Health The Basics, 14th Edition Becky Donatelle Solution Manual

INSTRUCTOR RESOURCE AND SUPPORT MANUAL

Health: The Basics FOURTEENTH EDITION

Rebecca J. Donatelle

Table of Contents

CHAPTER 1

Health: Getting There—Staying There!

CHAPTER 1A

Focus On: Difference, Disparity, and Health: Achieving Health Equity16

CHAPTER 2

Promoting and Preserving Your Psychological Health

23

CHAPTER 2A

Focus On: Cultivating Mindfulness and Spiritual Well-Being

35

CHAPTER 3

Managing Stress and Coping with Life’s Challenges

41

CHAPTER 4

Improving Your Sleep

54

CHAPTER 5

Preventing Violence and Injury

63

CHAPTER 6

Connecting and Communicating in the Modern World

78

CHAPTER 6A

Focus On: Understanding Your Sexuality

89

CHAPTER 7

Considering Your Reproductive Choices

99

CHAPTER 8

Recognizing and Avoiding Addiction and Drug Abuse

118

CHAPTER 9

Drinking Alcohol Responsibly and Ending Tobacco Use

135

CHAPTER 10

Nutrition: Eating for a Healthier You

153

CHAPTER 11

Reaching and Maintaining a Healthy Weight

167

CHAPTER 11A

Focus On: Enhancing Your Body Image

179

CHAPTER 12

Improving Your Personal Fitness

187

CHAPTER 13

Reducing Your Risk of Cardiovascular Disease and Cancer

201

CHAPTER 13A

Focus On: Minimizing Your Risk for Diabetes

222

CHAPTER 14

Protecting against Infectious Diseases and Sexually Transmitted Infections

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229

CHAPTER 14A

Focus On: Reducing Risks for Chronic Diseases and Conditions

247

CHAPTER 15

Making Smart Health Care Choices

257

CHAPTER 15A

Focus On: Understanding Complementary and Integrative Health

267

CHAPTER 15B

Focus On: Aging, Death, and Dying

274

CHAPTER 16

Promoting Environmental Health

284

Preface

How to Use This Manual Preparing for a course can often be the most daunting part of teaching it! The Instructor Resource and Support Manual to accompany the fourteenth edition of Health: The Basics was designed to aid personal health and wellness instructors to prepare lectures, activities, and syllabi. It is especially helpful for teachers who are preparing and creating their personal health and wellness lecture materials for the first time. Each section of the manual offers advice and instruction on how to: • organize the content throughout the course, • prepare clear and informative materials in the least amount of time, and • provide the best interactive learning experience for your students.

The chapter outlines in Part 1 will help you easily incorporate key terms, discussion questions, critical thinking questions, student activities, PowerPoint lecture slides, ABC News video clips, and images and tables from the text. Chapter outlines are broken into the following parts to allow for easy accessibility and quick reference to all the available student and instructor resources.

Overview The overview provides background information pertinent to a topic in the chapter or suggestions for what to pay particular attention to during the course of instruction of the chapter.

Learning Outcomes The learning outcomes list the key concepts students should understand as they reach the conclusion of each chapter. These outcomes can be helpful in organizing lesson plans or lectures and come directly from the main text.

Lecture Outline The outlines for each chapter are helpful in formulating and structuring lectures.

Discussion Questions The discussion questions are presented to help students understand the material conceptually.

The questions integrate the information presented in the text with real life to facilitate better understanding.

Critical Thinking Questions These questions are meant to help students apply the information in each chapter directly to their everyday lives. They are intended to help students consider how to make reasoned, healthy decisions for their immediate futures and prompt them to consider the long-term consequences of their choices.

Student Activities Activities in and outside of the classroom help students apply their new knowledge. The different levels of activities (individual, community, and diverse population/nontraditional) help students understand the comprehensive aspects of health.

Additional References Additional references can be used as resources for expanding the information in the text. These current references are from various journals and can be useful for synthesis activities.

For Further Information There are many organizations that provide free or low-cost information that can help make lectures more interesting. Website addresses are provided for information requests. Many organizations have local chapters that can be great resources for guest speakers.

Additional Media Videos can enhance lectures and be used to promote discussion. Each suggested video should be previewed before use in class to make sure it is appropriate for specific audiences.

General best practices for teaching are covered in Teaching Tips in Part 2, and the sample syllabi and course outline in Part 3 will show you examples of how to organize your lectures given inevitable time constraints.

The tips in Getting Started with MasteringHealth are a valuable resource for any instructors with online components to their course, and can be found in Part 4.

We’ve also included the full set of our popular Great Ideas in Teaching Health and Wellness newsletters in Part 5, which have helped many professors add fun interactive activities to their classrooms.

Ready-to-Go Teaching Modules (RTGs) A personal health instructor’s resource guide to accompany Health: The Basics and My Health. These modules are designed to create a blueprint for using the Mastering Health online system and all of the ancillary tools that accompany the content. The goal of these modules is to provide an organized method of implementing Mastering Health assets along with in-class activities including Learning Catalytics questions and lecture presentations into your personal health class.

Each module is divided into segments:

Overview: an introduction listing the Learning Objectives with alignment to both Health: The Basics and My Health; and some core concepts to review with students.

Before Class: text readings with corresponding page numbers for both books, instructions on how to assign Mastering items that students can use prior to class, and a link to the appropriate Dynamic Study Modules (DSMs).

During Class: a list of common misconceptions surrounding the topic covered in the module, several inclass activities including items found in Great Ideas Active Way of Teaching Wellness, and new activities with downloadable instructions. There are also links to the Learning Catalytics questions that are aligned with the chapter, clicker questions, and a PowerPoint lecture presentation.

After Class: items in Mastering that are designed to reinforce the concepts from the chapter.

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PREFACE

CHAPTER

1

Health: Getting There—Staying There!

Overview This chapter will help lay the foundation for good health and positive behavior change. The terms health and wellness are used interchangeably to describe the entire dynamic process of fulfilling one’s potential in the physical, social, emotional, spiritual, intellectual, and environmental dimensions of life. Multiple factors contribute to the status of one’s health, many of which are within a person’s control. To be healthy, one must make decisions about when to maintain current healthy behaviors and when and how to change unhealthy ones.

Chapter 1 provides an understanding of how behavior change occurs and how one can improve their health behaviors. A major focus is the decision-making section and the selfassessment of one’s health. Chapter 1 sets the tone for the remainder of the book.

Learning Outcomes 1. Describe the immediate and long-term rewards of healthy behaviors and the effects that your health choices may have on others.

2. Compare and contrast the medical model of health and the public health model, and discuss the six dimensions of health.

3. Classify factors that today’s research and professional groups indicate are the major determinants of health and behaviors and that can be changed through your behaviors and social interactions, by policies and community action, and through global health initiatives.

4. Describe mindfulness, identifying its health benefits and ways to incorporate it into your life.

5. Compare and contrast commonly utilized models of health behavior change, such as the health belief model, the social cognitive model, and the transtheoretical model and explain how you might use them in making a specific behavior change.

6. Identify your own current risk behaviors, the factors that influence those behaviors, and the strategies you can use to change them.

Lecture Outline I. Why Health, Why Now? A. Choose Health Now for Immediate Benefits

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1. More than 73.6 percent of adults over the age of 20 were overweight or obese in 2019.

2. More than 71 percent of Americans gained weight in 2020, 7–8 pounds on average.

3. Many factors cause us to ignore the basic knowledge about the harmful effects of weight gain. a. These things can also lead to issues with immune functioning and predisposition to infectious disease, or longer-term issues with diabetes and other chronic diseases. b. Drinking alcohol can impair immediate health as well as increase the risk for unintentional injury.

4. When you’re nourished, fit, rested, and free from the influence of nicotine, alcohol, and other drugs, you’re more likely to avoid illness, succeed in school, maintain. supportive relationships, participate in meaningful work and community activities, and enjoy your leisure time.

5. Choosing to not wear masks during a pandemic can affect you, strangers, your friends and relatives as well as the health care workers charged with treating those infected.

B. Choose Health Now for Long-Term Rewards 1. The choices you make today are like seeds: Planting good seeds (health) and nurturing them along the way (healthful choices) mean you’re more likely to enjoy the fruits of a longer and healthier life. On the other hand, poor choices increase the likelihood of a shorter life, illness, addiction, and other limitations on quality and quantity of life.

2. Life Expectancy: A Key Measure of Health a. The United States tracks selected vital statistics such as current mortality rates and life expectancy at birth. b. Serve as indicators of how healthy we are as a nation and are used to compare the United States to other nations or much of the last century, life expectancy rates have risen steadily but plummeted by 1.5 years due to COVID-19 in 2020. c. The populations most affected by mortality in 2020 were non-Hispanic Blacks, Hispanics, and American Indian or Alaskan Native persons, particularly those living in persistent poverty, those who lacked resources to protect themselves, those who were geographically isolated, those who were distrustful of health care, the uninsured, and those living in environments where the virus spread unchecked. i. More than 30 percent of all deaths occurred in children under the age of 5 and as with COVID-19, disadvantaged populations were disproportionally affected overall.

3. Personal Choices Influence Healthy Years of Life a. According to current mortality rates, the average life expectancy at birth in the United States is projected to be 78.8 years for a child born in 2015. b. Life expectancy has increased significantly over the past 100 years, largely because our susceptibility to infectious disease has changed thanks to the development of vaccines and antibiotics.

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c. Leading causes of death have now shifted to chronic diseases such as heart disease, cerebrovascular disease, cancer, and chronic lower respiratory diseases. d. Advances in diagnostic technologies and medications have continued the trend of increasing life expectancy into the twenty-first century. e. Life expectancy in the United States is several years below that of many nations due to many complex factors, including obesity, tobacco and alcohol use, drug overdose, and health care.

4. Personal Choices Influence Healthy Life Expectancy a. Healthful choices increase your healthy life expectancy, the number of years of full health you enjoy, without disability, chronic pain, or significant illness. b. Health-related quality of life (HRQoL) is a multidimensional concept that includes elements of physical, mental, emotional, and social function. c. Closely related to HRQoL is well-being, which assesses the positive aspects of a person’s life, such as positive emotions and life satisfaction.

5. Health Choices Affect Others a. Our personal health choices affect the lives of others because they contribute to national health and the global burden of disease. b. For example, along with its associated health problems, obesity burdens the U.S. health care system and the U.S. economy with direct medical costs and indirectly through reduced tax revenues. i. Direct and indirect costs are also associated with smoking, the excessive consumption of alcohol, and the use of illegal drugs. c. At the root of this issue are ethical questions: To what extent should the public be held accountable for an individual’s unhealthy choices? Should we require individuals to somehow pay for their poor choices? i. We already tax cigarettes and alcohol at a higher rate, and some states tax sweetened soft drinks. ii. Others argue that smoking, drinking, and overeating should be treated behaviors that require treatment, not punishment.

Key Terms: mortality, life expectancy, chronic disease, healthy life expectancy, healthrelated quality of life (HRQoL), well-being Figure and Table: Figure 1.1 Top Ten Reported Impediments to Academic Performance—Past 12 Months Table 1.1 Leading Causes of Death in United States in ABC News: See It! Video: Helping Others Could Be Good for Your Health ABC News: See It! Video: Viola Davis Fights to End Child Hunger II. What Is Health?

1. Health means different things to different people—the antithesis of sickness, fitness, wellness, or well-being. As our understanding of illness has improved, so has our ability to understand health and its nuances. ..

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A. Models of Health 1. Our current model of health has broadened from a focus on the physical body to an understanding of health as a reflection not only of ourselves but also of our communities.

2. Medical Model a. The medical model focused primarily on the individual and his or her tissues and organs, and the surest way to improve health was to cure the individual’s disease.

3. Public Health Model a. The public health model views diseases and other negative health events as a result of an individual’s interaction with his or her social and physical environment. b. Recognition of the public health model enabled health officials to prioritize hygiene and sanitation as being integral to health. c. By the 1940s, public health officials began calling for even more policies, programs, and services to improve individual health and that of the population as a whole. d. The World Health Organization defines health as “the state of complete physical, mental, and social well-being, not just the absence of disease or infirmity.” e. Health promotion includes policies and programs that promote health behaviors known to support good health. f. Health promotion programs identify people engaging in risk behaviors (those that increase susceptibility to negative health outcomes) and create environments conducive to positive behavior change.

B. Wellness and the Dimensions of Health 1. René Dubos defined health as “a quality of life, involving social, emotional, mental, spiritual, and biological fitness on the part of the individual, which results from adaptations to the environment.” a. This concept of adaptability became key to our overall understanding of health.

2. Later, the concept of wellness enlarged Dubos’s definition of health by recognizing gradations of health. a. To achieve high-level wellness, a person must move progressively higher on a continuum of positive health indicators. Those who fail to achieve these levels may slip into illness.

3. Today health and wellness are often used interchangeably to describe the dynamic, ever-changing process of trying to achieve one’s potential in the six interrelated dimensions of health.

4. The dimensions of health include the following: a. Physical health (body size and shape; ability to perform activities of daily living) b. Social health (ability to have satisfying interpersonal relationships)

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c. Intellectual health (ability to think clearly, reason objectively, analyze critically, use brainpower to meet life’s challenges) d. Emotional health (the ability to express and control appropriate emotions) e. Spiritual health (having a sense of meaning and purpose in your life) f.

Environmental health (an appreciation of the external environment and the roles individuals play to protect and improve environmental conditions) 5. Achieving wellness means attaining the optimal level of well-being for your unique limitations and strengths.

Key Terms: health, medical model, ecological or public health model, disease prevention, health promotion, risk behaviors, wellness Figures: Figure 1.2 The Ten Greatest Public Health Achievements of the Twentieth Century Figure 1.3 The Wellness Continuum Figure 1.4 The Dimensions of Health III. What Influences Your Health?

1. If your built environment is affordable, safe, and has opportunities for access to health care, recreation, a quality education and other supports are available, you are more likely to thrive and achieve optimal health.

2. Where you live, socio-economic status, whether you have access to health care, have safe and stable housing, and a host of other factors can make all the difference in your ability to get healthy and stay healthy.

3. Public health experts refer to the factors that influence health as determinants of health, a term the U.S. Surgeon General has defined as “the range of personal, social, economic, and environmental factors that influence health status.”

4. Healthy People 2020 classifies health determinants into five large groupings: a. Individual behavior b. Biology and genetics c. Social factors d. Health services e. Policymaking 5. Healthy People 2020 has four overarching goals: a. Attain high-quality, longer lives free of preventable diseases b. Achieve health equity, eliminate disparities, and improve the health of all groups c. Create social and physical environments that promote good health for all d. Promote quality of life, healthy development, and healthy behaviors across all life stages A. Individual Behavior

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1. Individual behaviors can help you attain, maintain, or regain good health, or they can undermine your health and promote disease.

2. Modifiable determinants of health are things that you can change and include the following: a. A lack of physical activity b. Poor nutrition c. Excessive alcohol consumption d. Tobacco use B. Biology and Genetics 1. Biological and genetic determinants are nonmodifiable determinants and are things you can’t typically change or modify.

2. Biological and genetic determinants include inherited traits, conditions, and predispositions, as well as innate characteristics such as race, age, ethnicity, sex, metabolic rate, and body structure. a. Although we can’t influence the structure of our genes, the field of epigenetics looks at the ways aspects of our diet, physical activity, and other behavioral choices impact our cell’s ability to use our genes to build proteins that influence our health. b. You may develop immunity to certain infectious diseases by either contracting the disease or via immunization.

C. Social Factors 1. Many studies indicate that social determinants of health account for between 30 percent and 55 percent of negative health outcomes; potentially more important than health care or lifestyle in one’s overall health trajectory. a. The most comprehensive listing of social determinates includes the following: income and social protection, education, unemployment and job insecurity, working conditions, food insecurity, housing, basic amenities and the environment, early childhood development, social inclusion and nondiscrimination, structural conflict, and access to affordable health services of decent quality.

2. Social factors include the social and physical conditions of the environment in which people are born or live. a. Social factors include disparities in income and education, exposure to crime and violence, the availability of healthful foods, the state of buildings and roads, and the quality of air, soil, water, and climate.

3. Economic Factors a. People in lower socioeconomic brackets on average have substantially shorter life expectancies than those who are wealthy. b. Economic disadvantages exert their effects on human health within nearly all domains of life. c. Lacking access to high-quality education from early childhood through adulthood.

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d. Living in poor housing with potential exposure to asbestos, lead, dust mites, rodents and other pests, inadequate sanitation, unsafe drinking water, and high levels of violence and crime in neighborhoods. e. Being unable to pay for nourishing food, warm clothes, and sturdy shoes; heat and other utilities; medications and medical supplies; transportation; and counseling, fitness classes, and other wellness measures.

4. The Built Environment a. The built environment includes anything created or modified by human beings, from buildings to roads to recreation areas and transportation systems to electric transmission lines and communication cables. b. Changes to the built environment can improve the health of communities and individuals.

5. Pollutants and Infectious Agents a. When individuals and communities are exposed to toxins, radiation, irritants, and infectious agents via their environment, they can suffer significant harm. b. The recent pandemics of COVID-19, for example, is a grim reminder of the need for proactive international prevention policies, individual mandates for behavior change, and a uniform response for intervention and control.

D. Access to High-Quality Health Services 1. The health of individuals and communities is also determined by access to quality health care, including services for physical and mental health, as well as accurate and relevant information and products such as eyeglasses, medical supplies, and medications.

2. Although the 2010 Affordable Care Act had reduced the numbers of uninsured Americans by 20 million people by the end of 2016, by the end of 2020, a new administration in Washington led to devastating cuts to this insurance.

3. Individuals without health insurance or those with a high deductible may delay care or try other cost saving measures that may put their health at risk.

E. Policymaking 1. Public policies can have a powerful and positive effect on the health of individuals and communities.

2. Health policies serve a key role in protecting public health and motivating individuals and communities to change.

Key Terms: health disparities Figures: Figure 1.5 Healthy People 2020 Determinants of Health Figure 1.6 Four Leading Causes of Chronic Disease in the United States IV. How Does Mindfulness Influence Health?

A. Definitions of Mindfulness

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1. While definitions of mindfulness vary, most include the idea of being present in the moment through greater awareness of yourself and your environment. a. Key to mindfulness is focusing—bringing your complete attention to the present. b. While mindfulness has become increasingly popular, it is believed to have originated around 1500 bce or earlier, as an element of Hindu practices.

B. Health Benefits of Mindfulness 1. Studies associate mindfulness with pain relief, stress reduction, lower levels of anxiety and depression, improved memory and attention, weight loss, improved sleep, reduced risks for cardiovascular disease, and more satisfying relationships.

C. How to Practice Mindfulness 1. You can practice mindfulness at any time, in any place, but the path to mindfulness is different for everyone.

2. Cultivate Compassion a. Cultivating compassion is a recognition of another’s pain and a sincere desire to help. b. You might also take a vow to avoid engaging in negative thinking about yourself and others for a single day. Throughout that day, replace negativity with intentions of kindness. c. Meet other people’s eyes as you pass, acknowledging that you’re aware of their presence. Smile. When friends criticize others, try to listen fully to what’s behind the words, and respond with gentleness and honesty.

3. Start Each Day with Intention. a. Each morning, jot down some intentions. During the day, try to stay mindful of how your actions align with them.

4. Examine the Way You Deal with Life’s Challenges a. One method for confronting challenges with mindfulness is to acknowledge what you felt and then to try to determine why. b. It also helps to acknowledge that no one is perfect and to seek goodness rather than perfection.

Key Terms: mindfulness V. How Does Behavior Change Occur?

1. Over the years, social scientists and public health researchers have developed a variety of models to illustrate how individual behavior change occurs.

A. Health Belief Model 1. A belief is an appraisal of the relationship between some object, action, or idea and some attribute of that object, action, or idea.

2. Health Belief Model (HBM) describes the ways in which beliefs affect behavior change and holds that several factors must support a belief before change is likely: a. Perceived seriousness of the health problem b. Perceived susceptibility to the health problem c. Perceived benefits 8

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d. Perceived barriers e. Cues to action B. Social Cognitive Model 1. The social cognitive model (SCM) proposes that three factors interact in a reciprocal fashion to promote and motivate change: a. Social environment b. Thoughts or cognition c. Behaviors C. Transtheoretical (Stages of Change) Model 1. The transtheoretical (stages of change) model proposes that we must go through a series of changes to adequately prepare ourselves for change.

2. According the model, the likelihood of behavior change will be enhanced if we have proper reinforcement and help during each of the following phases: a. Precontemplation b. Contemplation c. Preparation d. Action e. Maintenance f. Termination 3. We do not necessarily go through these stages sequentially, but realizing where we are is useful so that we can consider the appropriate strategies to move us forward.

Key Terms: belief, health belief model (HBM), social cognitive model (SCM), transtheoretical model Figure: Figure 1.7 Transtheoretical Model VI. How Can You Improve Your Health Behaviors?

1. Change is not a singular event but instead is a process that requires preparation, has several steps or stages, and takes time to occur. A four-step plan integrates ideas from each of the behavior change models into a simple guide to moving forward.

A. Step One: Increase Your Awareness 1. Before you can decide what to change, you need to learn what researchers know about the behaviors that contribute and detract from your health.

2. This is a good time to take stock of the health determinants in your life.

B. Step Two: Contemplate Change 1. Examine Your Current Health Habits and Patterns a. Health behaviors involve elements of personal choice and are influenced by other determinants, including predisposing, enabling, and reinforcing factors.

2. Identify a Target Behavior a. What do I want? b. Which change is the greatest priority at this time? ..

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c. Why is this important to me?

3. Learn More about the Target Behavior a. Learn everything you can—positive and negative—about your target behavior.

4. Assess Your Motivation and Readiness to Change a. Motivation is not just a feeling but a social and cognitive force that directs your behavior. As you contemplate change, ask yourself, “Do you believe that your current pattern could lead to a serious problem?” and “Do you believe that you are personally likely to experience the consequences of your behavior?” b. Motivation must be combined with common sense, commitment, and a realistic understanding of how best to move from point A to point B. c. Readiness is the state of being that precedes a behavior change.

5. Develop Self-Efficacy a. Self-efficacy—the belief that you are capable of achieving your goals and influencing events in life—is a critical factor influencing your health status.

6. Cultivate an Internal Locus of Control a. People who have a stronger internal locus of control believe that they have power over their actions. b. They are more driven by their own thoughts and are more likely to state their opinions and be true to their own beliefs.

C. Step Three: Prepare for Change 1. Set SMART Goals a. Specific b. Measurable c. Action-oriented d. Realistic e. Time-orientated 2. Use Shaping a. Shaping involves starting slowly, keeping steps small and achievable, and mastering one step before moving on to the next.

3. Anticipate Barriers to Change a. General barriers to change include overambitious goals, self-defeating beliefs and attitudes, a lack of support and guidance, and emotions that sabotage your efforts and sap your will.

4. Enlist Others as Change Agents a. Modeling is learning by observing and imitating role models. b. Family members, friends, and professionals can all offer unique and valuable support in our efforts to make behavioral changes.

5. Sign a Contract a. A behavior change contract serves many purposes: a public declaration of intent, an organized plan, a list of barriers and ways to overcome them, and a reminder of the benefits of sticking with your program.

D. Step Four: Take Action to Change 10

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1. Visualize New Behavior a. Use imagined rehearsal to reach your goals.

2. Learn to “Counter” a. Substitute a desired behavior for an undesirable one.

3. Control the Situation a. Any behavior has antecedents (aspects of the situation that come beforehand) and consequences (the results of the behavior). b. Once you recognize the antecedents, you can use situational inducement to seek settings, people, and other circumstances that support your efforts to change, and avoid those likely to derail your change.

4. Change Your Self-Talk a. There is a close relationship between what people say to themselves and how they feel. b. Changing negative self-talk can help you recover from disappointment and take positive steps to correct the situation. c. Practice stopping and blocking negative thoughts, and concentrate on taking positive steps forward to positive behavior change.

5. Reward Yourself a. Positive reinforcement can increase the likelihood that a behavior will occur. b. Positive reinforcers are classified as consumable, activity, manipulative, possessional, and social.

6. Journal a. Write down your personal experiences, interpretations, ideas for improvement, and results; this is an important skill for behavior change.

7. Deal with a Relapse a. A relapse is a return to a previous pattern of negative behavior. b. To deal with a relapse you should: figure out what went wrong; use countering; consider getting help in making your change.

E. Let’s Get Started!

1. Create a behavior change contract that incorporates the goals and skills discussed in this chapter and put it where you can see it every day.

Key Terms: motivation, self-efficacy, locus of control, shaping, modeling, imagined rehearsal, countering, situational inducement, self-talk, positive reinforcement, relapse Figure: Figure 1.8 Example of a Completed Behavior Change Contract

Discussion Questions 1. What is your definition of health? What factors in your life have influenced this definition? How might these factors change in the future?

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2. How do you think the six dimensions of health relate to one another? How do they fit together in your life?

3. Discuss the major gender differences between men and women as they relate to health issues.

4. Describe the major contributors to health disparities in the United States.

5. Do you think the leading causes of death for Americans ages 15 to 24 are so different from the leading causes for all ages combined? What changes can you make to lower your risks for major diseases?

6. Provide examples of predisposing, enabling, and reinforcing factors that might influence the decision of a young college student deciding whether to drink and drive.

7. Describe how factors of the health belief model might affect a young woman deciding to smoke her first cigarette and her last cigarette.

8. Can you think of an example of how your family or significant others have affected your health behaviors? Was the influence positive or negative?

Critical Thinking Questions 1. Predict how advances in technology might influence morbidity and mortality rates in the United States and globally. How do technological advances influence each of the six dimensions of health? Provide one example of each.

2. What would happen to a person’s overall health and well-being if any one of the six dimensions of health was not a part of the person’s lifestyle and/or experiences?

3. Examine the Healthy People 2020 objectives, and select two of them. How does accomplishing these two objectives improve the overall health of individuals in the United States? Suggest two behavior changes that could support accomplishing the two objectives you’ve selected.

4. What are some of the effects of a lack of affordable and reliable health insurance for all?

5. Review the stages of the transtheoretical model of behavior change. Now, think of a behavior you’d like to change. At what stage do you belong in the process of changing your identified behavior? How can you go about adequately preparing yourself to move to the next step in the change process?

6. Which behavior change technique—shaping, visualization, modeling, controlling the situation, reinforcement, changing self-talk—do you think would be most effective for you personally if you were making a behavior change to improve your health? Why? Do you think this technique is the best technique for all behavioral changes you might make in a lifetime? Why or why not?

7. How would a person’s genetic predisposition influence that person’s health decisions?

Student Activities Individual

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1. Complete the How Healthy Are You? assessment, and pick a behavior you would like to change. Outline the steps you will take, and identify the factors that might influence this change. Write out three specific objectives for this change.

2. Conduct a search for websites that focus on health issues in your community or on your college campus. Identify three issues you consider the most important. Describe how you could participate or contribute to positive change.

Community 1. Go online and look over Healthy People 2020. Pick a national objective and find local or community statistics on that specific health problem. Find out if there are resources in the community to help achieve this objective on a local level.

2. Talk to your local elected officials about their views on important health issues in the community. Find out if they have specific plans to improve the health of local residents.

Diverse Population/Nontraditional 1. Use the Internet to research the leading causes of death by age in a different country or region of the world. Compare the statistics to the leading causes of death in the United States.

2. Countries such as Canada and Great Britain provide universal health care for all their citizens. Research the pros and cons of these health care systems, and propose a way in which a similar program might be implemented in the United States.

Additional References N. E. Adler and D. H. Rehkopf, “U.S. Disparities in Health: Descriptions, Causes, and Mechanisms.” Annual Review of Public Health, 29 (2008): 235–253.

R. J. DiClemente, R. A. Crosby, and M. C. Kegler, eds., Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health (San Francisco, CA: Jossey-Bass, 2002).

R. Dubos, So Human an Animal: How We Are Shaped by Surroundings and Events (New York: Scribner, 1968).

S. R. Hawks, T. Smith, H. G. Thomas, H. S. Christley, N. Meinzer, and A. Pyne, “The Forgotten Dimensions in Health Education Research,” Health Education Research, 23 (2008): 319–324, doi:10.1093/her/cym035.

J. Kabat-Zinn, Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life (New York: Hachette, 2014).

K. H. Mayer, J. B. Bradford, H. J. Makadon, R. Stall, H. Goldhammer, and S. Landers, “Sexual and Gender Minority Health: What We Know and What Needs to Be Done,” American Journal of Public Health, 98, no. 6 (2008): 989–995.

L. W. Nelms, E. Hutchins, D. Hutchins, and R. J. Pursley, “Spirituality and the Health of College Students.” Journal of Religion and Health, 46 (2006): 249–265.

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Organisation for Economic Co-operation and Development, Health at a Glance 2015, http://www.oecd.org/unitedstates/Health-at-a-Glance-2015-Key-Findings-UNITEDSTATES.pdf J. O. Prochaska, J. Norcross, and C. DiClemente, Changing for Good: A Revolutionary Six–Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward (New York: Avon Books, Inc., 1995).

B. J. Turnock, Public Health: What It Is and How It Works (Sudbury, MA: Jones and Bartlett Publishers, 2009).

U.S. Department of Health and Human Services. Healthy People 2020: The Road Ahead. https://www.healthypeople.gov/ Y. Wang, M. A. Beydoun, L. Liang, B. Caballero, and S. K. Kumanyika, “Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the U.S. Obesity Epidemic,” Obesity, 16 (2008): 2323–2330.

For Further Information Toll-Free Numbers for Health Information http://health.gov/nhic/pubs/tollfreenumbers/ Footprint Calculator www.footprintnetwork.org/en/index.php/GFN/page/calculators Go Ask Alice!

Health-Related Questions and Answers www.goaskalice.columbia.edu Healthy People www.healthypeople.gov Population Reference Bureau http://prb.org Health Topics A to Z http://healthfinder.gov/HealthTopics U.S. Department of Health and Human Services www.hhs.gov World Health Organization www.who.int/en

Additional Media “In Sickness and in Wealth,” 56 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “How does the distribution of power, wealth, and resources shape opportunities for health?”

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www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107 “Not Just a Paycheck,” 30 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “Why do layoffs take such a huge toll in Michigan but cause hardly a ripple in Sweden?” www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107 “Place Matters,” 29 minutes.

From the series Unnatural Causes: Is Inequality Making Us Sick?

This documentary examines the question, “Why is your street address such a strong predictor of your health?” www.unnaturalcauses.org California Newsreel 500 Third Street, Suite 505 San Francisco, CA 94107

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CHAPTER

1A

Focus On: Difference, Disparity, and Health: Achieving Health Equity

Overview Health equity, informed by the values of fairness and justice, is attainment of the optimal level of health for all people. Our society’s evolving diversity brings with it an increased potential for false assumptions, misperceptions, unrecognized biases, discrimination, and stereotyping. This chapter looks at important questions related to health equity, such as “Why has health equity become a critical issue in America?” “How do the social determinants of health influence health disparities in America?” “How can your actions contribute to health equity?” and “What kinds of systemic changes support health for all?”

Learning Outcomes 1. Explain why health equity has become a critical issue in twenty-first-century America, identifying the populations that are most vulnerable to health disparities and the costs to society.

2. Identify the social determinants of health that most strongly influence health disparities in the United States.

3. Discuss specific actions you can take to promote health equity on campus, in your community, and in your personal life, including how to use mindfulness to examine your biases and increase your respect for difference.

4. Describe the systemic changes required to enable the United States to progress toward good health for all and provide examples of national and community-based initiatives currently underway toward achieving this goal.

Lecture Outline I. Why Has Health Equity Become a Critical Issue in America?

1. The United States is one of the richest countries in the world but is ranked lowest in health equity of the world’s 11 wealthiest industrialized nations.

A. Health Equity is Attainment of the Highest Level of Health for All 1. Healthy People 2030 states that health equity is attainment of the optimal level of health for all people.

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a. Health disparities result from an unequal distribution of social resources, from education to housing to jobs that provide adequate health insurance and a living wage.

B. America: A Country of Increasing Diversity 1. America is diversifying in terms of ethnic background, age composition, selfidentity, and religious identity.

C. Our Response to Difference Can Lead to Disparities in Health 1. Any encounter with difference brings with it the potential for false assumptions.

Stereotyping and othering can contribute to discrimination and other social injustices, trigger struggles for power and control, increase the threat of violence, and reduce every American’s potential to thrive physically, emotionally, intellectually, and socially.

D. Certain Population Groups Are More Vulnerable to Health Disparities 1. Disparities occur between populations and between subgroups within populations.

They are also innumerable differences between people within groups.

2. Data from the CDC indicates that 34 percent of deaths due to COVID-19 in 2020 occurred among Black Americans, who represented only about 12 percent of the U.S. population that year.

E. Health Disparities Incur Enormous Costs 1. Racial and ethnic health disparities alone are estimated to cost the U.S. economy an estimated $35 billion in direct medical expenditures, $10 billion in lost productivity, and nearly $200 billion in premature deaths.

Key Terms: health equity, diversity, difference, stereotyping, othering Figure: Figure 1 Expected Increase in the Racial and Ethnic Diversity of the U.S. Population, 2016 and 2060 II. How Do the Social Determinants of Health Influence Health Disparities in America?

1. Indicators of health disparities are outcomes of a system that doesn’t value individuals equally.

2. Conditions that affect access to and distribution of health-related resources are known as the social determinants of health.

A. Economic Stability and Educational Attainment 1. Decades of research support a close association between poverty and poor health.

2. Poor Americans are more likely to live in food deserts, and communities with low walkability, lower-performing schools, poorer-quality health care facilities, and higher levels of pollution and violence.

3. Low educational attainment also increases with increasing poverty.

4. Poverty contributes to a number of different health problems, with striking disparities in life expectancy. a. More U.S. females than males live in poverty. In 2019, of the 34 million Americans living in poverty, 19 million, or 56 percent, were female.

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b. A contributing factor in female poverty is the wage gap: women earn $0.82 for every $1.00 earned by men. Also, women have less savings, greater student loan debt, more unpaid caregiver responsibilities(for both children and older generations), and are more likely than men to experience domestic violence.

B. Social Interactions and Community Context 1. Levels of social support, social norms and attitudes, cultural influences, language barriers and levels of literacy, incarceration rates, and availability of communitybased resources strongly influence our health.

C. Neighborhood and Built Environment 1. Neighborhood characteristics, such as walkability, the presence of food stores that offer plenty of healthy choices, and density of recreational facilities, also influence health.

Key Terms: othering, social determinants of health, food insecure, food desert, culture, health literacy Figure: Figure 2 Social Determinants of Health (SDOH) III. How Can Your Actions Contribute to Health Equity?

A. Use Mindfulness to Examine Your Assumptions and Biases 1. Cultivating mindfulness is a highly effective strategy for challenging the beliefs and attitudes that limit us, including raising awareness of unconscious biases, increasing insights into and understanding of the unconscious aspects of other people’s behavior, and adopting a less “us versus them” approach to interactions with others.

B. Affirm the Benefits of Diversity 1. Interacting with difference challenges your assumptions; exposes you to new ideas, values, and experiences; and generally expands your world.

C. Learn to Communicate across Differences 1. Effective communication across real and imagined differences involves the following: a. Establishing shared agreement about the values and goals of your communication b. Acknowledge the existence of any power differential c. Paying attention to what is said and how it’s said d. Aiming for full disclosure e. Hitting pause when things get tense f. Closing with dialogue about the dialogue D. Advocate for Yourself and Others 1. To advocate for yourself and others, it helps to be able to recognize othering and discrimination when it happens to you and to take action to protect your health and change your interactions in the future.

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IV. How Can Systemic Change Lead to Health for All? A. Increase Access to Health Care 1. Public health experts propose the following to achieve a more equitable distribution of health care: a. Increase diversity among providers b. Increase diversity training c. Increase preventive services d. Expand access to health insurance i.

Many who lost their jobs during the early months of the COVID-19 pandemic also lost their health insurance coverage.

ii. After 2016, the number of uninsured people began rising gradually, to an estimated 31–32 million in 2020. This is thought to be a result of policy changes during the Trump administration. (i) Reduced funding for outreach and enrollment, a more limited enrollment period, and changes to immigration policy that made it less likely that families would enroll in subsidized health insurance.

B. Reduce the Social Determinants that Contribute to Health Disparities 1. Specific strategies to reduce SDOH include a. Construction of affordable housing b. Remediating sources of pollution c. Increasing neighborhood walkability d. Establishing after-school programs e. Building community gardens f.

Facilitating meetings between community and law enforcement

C. Examples of Initiatives to Increase Health for All 1. National initiatives to increase health include Health People, the creation of the U.S. Department of Health and Human Services (DHHS) Task Force on Black and Minority Health, and new reports on health disparities from the Surgeon General.

2. City, county, and state initiatives include improvements in standards for public housing construction, changes to zoning ordinances, support for public transportation, policies to increase the minimum wage, and others.

3. National nongovernmental initiatives have organizations partnering to find solutions. a. Kaiser Permanente and the American Red Cross have partnered to develop “Check, Change, Control” whose goal is to reduce disparities in blood pressure control. b. In 2019, the American Heart Association also partnered with the American College of Cardiology to develop provider guidelines recommending that clinicians screen patients for “social risk.” c. 3rd Conversation, the program is directed by X4 Health, a social impact design firm, and is funded by the Andrew and Corey Morris-Singer Foundation.

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4. Colleges provide unique opportunities for students to develop more healthful habits via access to the student health center, healthy meal options, fitness facilities, and security services.

Discussion Questions 1. Why are life expectancy and wealth so closely correlated?

2. Why are certain groups of people more vulnerable to health disparities?

3. How are difference, stereotyping, and othering related?

4. What are the costs of health disparities, in economic terms and otherwise?

5. How can mindfulness help you examine your own assumptions and biases?

Critical Thinking Questions 1. Are there food deserts near you? What kind of risks are associated with living in a food desert?

2. What are some of the benefits of diversity? How might you most effectively communicate across boundaries of difference?

3. Why is it important to build trusting and respectful relationships between a community and local law enforcement?

4. What are some examples of national initiatives to increase health for all? Local initiatives? Initiatives on your campus?

5. What are some ways you can become your own advocate in the face of othering, stereotyping, or discrimination?

Student Activities Individual 1. Using the assessment at the end of the chapter, examine your own personal biases.

2. Use the Internet to explore different healthcare models in different countries. Compare life expectancy, accessibility, and cost; then determine which model might offer the greatest value to a consumer.

Community 1. What kind of impact can the built environment have on a community?

2. What kind of health initiatives exist in your school or community? How could they be more useful or reach more people?

3. What kind of public outreach might be beneficial in terms of raising awareness about the importance of reducing disparities in healthcare?

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Diverse Population/Nontraditional 1. Use the Internet to research the health disparities in another country. How do they compare to the United States?

2. Use the Internet to research gross domestic product (GDP) and life expectancy in another country. How do they compare, and what general conclusions might you draw?

Additional References World Health Organization, “Health Systems: Equity,” 2017, www.who.int/healthsystems/topics/equity/en U.S. Department of Health and Human Services, Health People 2020, www.healthypeople.gov/2020/ J. Z. Ayanian, “The Costs of Racial Disparities in Health Care,” Harvard Business Review, October 1, 2015, https://hbr.org/2015/10/the-costs-of-racial-disparities-in-health-care

For Further Information DHHS Office of Minority Health https://minorityhealth.hhs.gov/heckler30/ National Institute on Minority Health and Health Disparities www.nimhd.nih.gov/ CDC: Health Equity www.cdc.gov/minorityhealth/

Additional Media Project Implicit Bias Tests A variety of tests measuring implicit bias as it relates to race, age, sexuality, and a variety of other categories. https://implicit.harvard.edu/implicit/selectatest.html How Culture Connects to Healing and Recovery, 13 minutes A TEDx talk on culture and healing. https://www.youtube.com/watch?v=q9Tkb879dsY Minority Health Disparities, 6 minutes A firsthand look at health disparity, by Johns Hopkins Medicine. https://www.youtube.com/watch?v=vlVZKZNXYBA

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What Is Health Equity?, 3.5 minutes A video on the definition and causes of health inequity. https://www.youtube.com/watch?v=ZPVwgnp3dAc Health and Healthcare Disparities in the U.S., 4 minutes An overview. https://www.youtube.com/watch?v=7qAld9bGwlA

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CHAPTER

2

Promoting and Preserving Your Psychological Health

Overview Psychological health contributes significantly to our quality of life, and our ability to appreciate life is directly related to our psychological health. Chapter 2 discusses the mental, emotional, social, and spiritual qualities of health that make up the very heart of how we perceive our life experiences. This chapter discusses the keys to enhancing psychological health and explores the roles of self-efficacy and self-esteem, emotional intelligence, personality, and happiness in psychological well-being. The chapter also describes various psychological disorders and explains their causes and treatment. The risk factors and warning signs of suicide are discussed, helping the student to understand when to get help or how to recognize when friends need help. Tips for avoiding negative thoughts and focusing on the positive aspects of life are also provided in this chapter.

Learning Objectives 1. Describe what it means to be psychologically healthy and identify some of the characteristics that might indicate whether a person was psychologically well.

2. Discuss the roles of self-efficacy and self-esteem, emotional intelligence, personality, maturity, and happiness in psychological well-being.

3. Describe and differentiate psychological disorders, including mood disorders, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, personality disorders, and schizophrenia, and explain their causes and treatments.

4. Discuss risk factors and possible warning signs of suicide, as well as actions that can be taken to help a person contemplating suicide.

5. Explain the signs of mental illness, options for evaluation and treatment, as well as professional services available for people experiencing mental health problems.

Lecture Outline I. What Is Psychological Health?

A. DSM-V—Diagnostic and Statistical Manual of Mental Disorders 1. Not only did researchers develop and revise descriptions of mental disorders, they also spent many of the ensuing decades focused on what they believed had gone wrong in a person’s life that led to mental health problems and, by inference, what could be done to prevent mental illness from occurring. ..

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B. Psychological health is the sum of how we think, feel, relate, and exist in our day-to-day lives.

1. Psychologically healthy people share many basic elements: a. They feel good about themselves. b. They feel comfortable with other people and feel respect and compassion for others. c. They are “self-compassionate.” d. They control tension and anxiety. e. They meet the demands of life. f. They curb hate and guilt. g. They maintain a positive outlook. h. They value diversity. i.

They appreciate and respect the world around them.

2. Basic needs must be met before we can achieve the characteristics of psychologically healthy people. a. This idea is described by Abraham Maslow’s hierarchy of needs. b. Hierarchy of needs is composed of the following levels: i. Survival Needs: food, water, sleep, exercise, sexual expression ii. Security Needs: shelter, safety, protection iii. Social Needs: belonging, affection, acceptance iv. Esteem Needs: self-respect, respect for others, accomplishment v. Self-Actualization: creativity, spirituality, fulfillment of potential c. According to Maslow’s Hierarchy of Needs, a person’s needs must be met at each level before that person can be truly healthy.

C. Mental Health’s Evolution 1. Mental health has historically been described as the “thinking or rational” part of psychological health. a. A newer definition of mental health is much more comprehensive and closer to existing definitions of psychological health: i. “Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society.

Basic cognitive and social skills; ability to recognize, express, and modulate one’s own emotions as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium.”

D. Emotional Health 1. Emotional health refers to the feeling, or subjective, side of psychological health.

2. Emotions are intensified feelings or complex patterns of feelings we experience.

3. Emotionally healthy people are able to respond in a stable and appropriate manner to upsetting events. Emotionally unhealthy people are much more likely to let their feelings overpower them.

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E. Social Health 1. Social health includes your interactions with other people, your ability to use social resources and support in times of need, and your ability to adapt to a variety of social situations.

2. Families have a significant influence on psychological development.

3. Children raised in dysfunctional families may have a harder time adapting to life and run an increased risk of psychological problems.

4. Presence of key social support consists of networks or people and services with whom we share ties. a. This includes both tangible support (money to pay the bills) and intangible support (encouraging you to share your concerns).

5. Loneliness, a feeling of emptiness or hollowness causing people to feel alone and unwanted, is increasingly common among college students. a. Some health risks associated with loneliness include depression and suicide, increased stress levels, antisocial behavior, and alcohol and drug abuse. b. Although COVID-19 social distancing and quarantine measures undoubtedly accelerated feelings of loneliness, recent results of surveys assessing loneliness on campus by the American College Health Association have shown a pattern of dramatic increases in student loneliness in recent years overall.

F. Factors That Contribute to Social Isolation and Loneliness 1. Factors include such things as divorce and death; living longer and losing most of our close friends; connecting with more people on social media but having fewer really close friends; drug and alcohol use; declining face-to-face social relationships; a more mobile workforce, in which people may telecommute, lose jobs or change jobs and locations frequently; homelessness; and many other causes of social isolation.

2. During the recent pandemic, exercise patterns changed dramatically with gym closures and fear of exercising where others were exercising outdoors.

G. Spiritual Health 1. Spirituality is broader than religion and is defined as a person’s sense of peace, purpose and connection to others, and beliefs about the meaning of life.

2. Spiritual health refers to the sense of belonging to something greater than the purely physical or personal dimensions of existence. a. See Focus On: Cultivating Your Spiritual Health to explore your spiritual health.

Key Terms: Diagnostic and Statistical Manual of Mental Disorders (DSM-V), psychological health, Psychodynamic Diagnostic Manual (PDM), resiliency, mental health, emotional health, emotions, social health, dysfunctional families, social support, loneliness, social isolation, spiritual health Figures: Figure 2.1 Maslow’s Hierarchy of Needs Figure 2.2 Psychological Health Is a Complex Interaction…

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General Characteristics of Psychologically Healthy and Unhealthy People II. Keys to Enhancing Psychological Health A. Self-Efficacy and Self-Esteem 1. Self-efficacy refers to a person’s belief about whether he or she can successfully engage in and execute a specific behavior.

2. Self-esteem refers to one’s sense of self-respect or self-worth.

3. Learned Helplessness versus Learned Optimism a. Learned helplessness is a response to continued failure in which people give up and fail to take action to help themselves. b. It is thought that self-help programs can promote the principle of “learned optimism.”

4. Defense Mechanisms a. While defense mechanisms can become pathological if taken to an extreme, things like fantasizing about a vacation to cope with work stress can help relieve stress and disappointment.

B. Emotional Intelligence 1. Emotional intelligence (EI) is our ability to identify, use, understand, and manage our own emotions as well as those of others.

2. Your emotional intelligence quotient (EQ) is an indicator of social and interpersonal skills—your ability to successfully maneuver in emotionally changed settings. EI consists of the following: a. Self-awareness b. Self-regulation/self-management c. Internal motivation d. Empathy e. Social skills C. Personality 1. Your personality is the unique mix of characteristics that distinguishes you from others.

2. Heredity, environment, culture, and experience influence how each person develops.

3. A leading personality theory, the five-factor model, distills personality in five traits (the “Big Five”): a. b. c. d. e.

Agreeableness Openness Neuroticism Conscientiousness Extroversion

D. Happiness and the Mind–Body Connection 1. At the core of the mind–body connection is psychoneuroimmunology (PNI), or the study of the interactions of behavioral, neural, and endocrine functions and the functioning of the body’s immune system.

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2. According to Martin Seligman, the man seen as the founder of positive psychology, mentally health people have certain strengths and virtues in common: a. They have high self-esteem. b. They are realistic. c. They value close relationships with other people. d. They approach life with excitement and energy. e. They think things through and examine things from all sides.

3. Seligman suggests people can develop well-being by practicing positive psychological actions using PERMA: a. Positive emotion b. Engagement c. Relationships d. Meaning e. Accomplishment i. See the Skills for Behavior Change box for ways to incorporate PERMA principles into your own life.

4. Happy people share four characteristics: a. Health b. Intimacy c. Resources d. Competence Key Terms: self-efficacy, self-esteem, learned helplessness, learned optimism, emotional intelligence, psychoneuroimmunology (PNI), positive psychology, happiness III. When Psychological Health Deteriorates A. Mental illnesses are disorders that disrupt thinking, feeling, moods, and behaviors and cause a varying degree of impaired functioning in daily living.

1. They are believed to be caused by a variety of biochemical, genetic, and environmental factors. a. Most common risk factors are genetic or familial disposition and excessive, unresolved stress.

B. An estimated 17.9 percent of Americans aged 18 and older, slightly under 1 in 5 adults, suffer from a diagnosed mental disorder each year. Many suffer from more than one at a time.

1. Mental disorders are the leading cause of disability worldwide.

C. Mental Health Threats to College Students 1. Mental health problems are common among college students, and they appear to be increasing in number and severity.

2. The National College Health Assessment survey illustrates some of the difficulties college students face today. Anxiety and depression top the list of mental health problems faced by college students.

D. Mood Disorders

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1. Chronic mood disorders are disorders that affect how you feel, such as persistent sadness or feelings of euphoria. They include major depression, persistent depressive disorder, bipolar disorder, and seasonal affective disorder.

2. Major Depression a. Major depression (clinical depression) is the most common mood disorder, affecting approximately 9 percent of the U.S. population. b. Major depression is characterized by a combination of symptoms that interfere with work, study, sleep, appetite, relationships, and enjoyment of life. c. Depression in college students can be a major obstacle to academic success and healthy adjustment.

3. Persistent Depressive Disorder a. Persistent depressive disorder (PDD) is a less severe form of chronic, mild depression. Individuals may appear to function well but may lack energy, fatigue easily, or be short-tempered.

4. Bipolar Disorder a. Bipolar disorder (also known as manic-depressive illness) is often characterized by mood swings, ranging from extreme highs (mania) to extreme lows (depression).

5. Seasonal Affective Disorder a. Seasonal affective disorder (SAD) strikes during the winter months and is associated with reduced exposure to sunlight. People with SAD suffer from irritability, apathy, carbohydrate craving and weight gain, increased sleep time, and general sadness. b. Light therapy is the most beneficial treatment for SAD. E. What Causes Mood Disorders?

1. Mood disorders are believed to be caused by many factors, including biological differences, hormones, inherited traits, life events, and early childhood trauma.

F. Anxiety Disorders 1. Anxiety disorders are characterized by persistent feelings of threat and worry. a. Anxiety disorders are the largest mental health problem in the United States.

2. Generalized Anxiety Disorder a. Generalized anxiety disorder (GAD) is a common form of anxiety disorder; it can be severe enough to significantly interfere with daily life. b. To be diagnosed one most exhibit three of the following symptoms for more days than not during a six-month period: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and/or sleep disturbances.

3. Panic Disorder a. Panic disorders are characterized by the occurrence of panic attacks, a form of acute anxiety reaction that brings on an intense physical reaction.

4. Phobic Disorders a. Phobias involve a persistent and irrational fear of a specific object, activity, or situation, often out of proportion to the circumstances.

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b. Social anxiety disorder, or social phobia, is an anxiety disorder characterized by the persistent fear and avoidance of social situations.

5. What Causes Anxiety Disorders? a. There are no clear reasons as to why a person develops an anxiety disorder. b. The cause may be biological, environmental, or within cultural and social roles.

G. Obsessive-Compulsive Disorder 1. Obsessive-compulsive disorder (OCD) occurs when people feel compelled to perform rituals repeatedly; are fearful of dirt or contamination; have an unnatural concern about order, symmetry, and exactness; or have persistent intrusive thoughts that they cannot shake.

H. Post-Traumatic Stress Disorder 1. People who have experienced or witnessed a traumatic event may develop posttraumatic stress disorder (PTSD).

2. Symptoms of PTSD include dissociation of the mind from the body, intrusive recollections of the traumatic event, and acute anxiety or nervousness, insomnia and difficulty concentrating, and intense physiological reactions when something reminds the person of the traumatic event.

I. Personality Disorders 1. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a personality disorder is an “enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture and is pervasive and inflexible.”

2. Common types of personality disorders include the following: a. Paranoid personality disorder: pervasive, unfounded suspicion and mistrust of other people, irrational jealousy, and secretiveness b. Narcissistic personality disorders: exaggerated sense of self-importance and selfabsorption c. Antisocial personality disorder: long-term pattern of manipulation and taking advantage of other people, often in a criminal manner d. Borderline personality disorders (BPD): severe emotional instability, mood swings, impulsiveness, poor self-image, and erratic and risky behaviors J. Schizophrenia 1. Schizophrenia is characterized by the alteration of senses; the inability to sort out incoming stimuli and to make appropriate responses; an altered sense of self; and radical changes in emotions, movements, and behaviors.

2. Schizophrenia is treatable but not curable.

Key Terms: mental illness, chronic mood disorder, major depression, attention-deficit (hyperactivity) disorder (ADD/ADHD), dyslexia, dyscalculia, dysgraphia, autism spectrum disorder (ASD), Asperger syndrome, persistent depressive disorder, seasonal affective disorder (SAD), bipolar disorder, anxiety disorders, generalized anxiety disorder (GAD), panic attack, phobia, social anxiety disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), personality disorder, schizophrenia, self-injury Figure: Figure 2.4 ..

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The Ripple Effect of Mental Illness ABC News: See It! Video: What Are the Causes for Depression?

IV. Suicide: Giving Up on Life A. Suicide is the second leading cause of death for individuals between 15 and 29 years old.

B. Risk Factors for Suicide 1. Risk factors for suicide include previous suicide attempts, excessive drug and alcohol use, prolonged depression, financial difficulties, serious illness in oneself or a loved one, and loss of a loved one through death or rejection.

2. Lesbian, gay, bisexual, and transgender (LGBT) people are significantly more likely to have thought about or attempted suicide.

3. Nearly four times more men die by suicide than women.

4. The most common method for men is firearms; for women, poisoning.

C. Warning Signs of Suicide 1. In most cases, suicide does not occur unpredictably.

2. There are several common warning signs of suicide intent.

D. Preventing Suicide 1. Get involved if someone you know threatens suicide or displays warning signs. a. Monitor the warning signals. b. Take threats seriously. c. Let the person know how much you care. d. Ask directly. e. Take action. f. Help the person think about alternatives to suicide. g. Tell your friend’s spouse, partner, parents, siblings, or counselor.

V. Seeking Professional Help for Psychological Problems A. Although estimates show that 51.5 percent of adults have some kind of mental disorder, only 39 percent of adults use mental health services.

B. Mental Illness Stigma 1. Common stigmas around people with mental illness include being dangerous, irresponsible, and requiring of constant care.

2. The stigma of mental illness often leads to feelings of shame, guilt, loss of selfesteem, and a sense of isolation and hopelessness.

C. Getting Evaluated for Treatment 1. A thorough examination before receiving professional help for a psychosocial problem includes three parts: a physical checkup, a psychiatric history, and a mental status examination.

D. Mental Health Professionals 1. Several types of mental health professionals offer help and treatment for psychosocial problems. See Table 2.1.

E. What to Expect in Therapy

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1. The first visit serves as a sizing up between you and your therapist.

2. It is critical to the success of your treatment that you trust your therapist enough to be open and honest.

F. Treatment Models 1. Many different types of counseling exist, including psychodynamic therapy, interpersonal therapy, and cognitive therapy, behavioral therapy, and cognitivebehavioral therapy. a. Current research also shows that mindfulness may have a positive effect on mental health problems. See the Mindfulness and You box.

G. Pharmacological Treatment 1. Psychotherapeutic treatment often combines talk therapy with drug therapy. a. Psychoactive drugs are medicines that alter chemicals in the brain and affect mood and behavior such as antianxiety and antidepressants.

2. Potency, dosage, and side effects of drugs can vary greatly, and it is vital to talk with your health care provider and to completely understand the risks and benefits of the medication prescribed.

• Health Headlines: Homelessness on Campus: Hidden in Plain Sight Key Term: mindful-based stress reduction, mindful-based cognitive therapy Table: Table 2.1 Your Quick Guide to Mental Health Professionals ABC News: See It! Video: Psychological Disorders

Discussion Questions 1. What is psychological health? How do you know if you are psychologically healthy?

What areas in your life could use improvement? Why do you think the college environment may provide a challenge to your psychological health?

2. Do you know anyone who has high self-esteem? What characteristics does this person possess?

3. Why do you think the number of women with depression outnumbers that of men?

4. How do discrimination and stigma influence depression among LGBT youth? How are these things related to suicide rates among this population?

5. How might you know if a person is clinically depressed or temporarily sad, lonely, unhappy, or moody? What might you do?

6. How have psychological disorders been portrayed in movies? What are some specific examples? Do you think the media have helped remove some of the stigma surrounding these disorders?

7. What actions could you take if a close friend shows some of the warning signals of suicide?

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Critical Thinking Questions 1. Based on the examples given in the book showing an association between emotions and the immune system, substantiate whether or not you believe in this concept. Describe two separate situations when you think your emotions affected your health.

2. Consider Maslow’s Hierarchy of Needs. Explain how each lower level in the pyramid affects the next highest level. Describe how your needs are met at each level. From your personal experience, how does one level being out of balance affect other levels? How might not having needs met at any level influence depression?

3. From your personal experience, describe a situation in your life when you might have experienced learned helplessness. What situation caused you to feel this way? What did you do to overcome this situation?

4. Review the list of the “Big Five” personality traits. Which of these personality traits do you possess? Do you identify with more than one category of personality traits? Give evidence to support your responses.

5. Current research suggests that drugs might be more beneficial in treating a person with SAD than environmental methods such as light treatment. If you had a loved one who experienced SAD, what course of treatment would you encourage that person to follow?

What questions would you ask about the proposed pharmacological treatment?

6. What would be the first steps you would take if you suspected that a loved one was suffering from a psychosocial disorder?

Student Activities Individual 1. Make a list of five short-term goals to complete by the end of this term. Next to each goal, write the percentage (from 1–100 percent) of self-efficacy you feel toward that goal. If there are any goals with percentages under 80 percent, rework the goal until you have a high level of self-efficacy toward achievement of the goal.

2. Using the Internet, research ways to improve your own spiritual health. Write a short paragraph, and share it.

3. Research new drugs available to treat a category of mental illnesses of your choice.

Explain how the new drugs differ from previous drugs.

Community 1. What resources are available on campus for psychosocial health? Visit the counseling center, and write a short summary of services available and usage rates.

2. Find out how mental health services in your community are suffering from both state and federal budget cuts. What is being done to bridge the gap between need and services offered? What type of city/county legislation is being proposed to maintain adequate funding for mental health?

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Diverse Population/Nontraditional 1. How do people in different cultures regard and care for people with mental illness?

Conduct Internet research for a country of your choice. Find out the rates of psychosocial disorders such as depression, bipolar disorder, and schizophrenia, and compare them to rates in the United States.

2. Conduct Internet research to determine if women in other countries disproportionately suffer from depression. Suggest an explanation for your findings.

Additional References Ready-to-Go Teaching Module: Psychological Health Helpguide.org, “Improving Emotional Health, Strategies and Tips for Good Mental Health,” 2012, http://helpguide.org R. H. Aseltine Jr., A. James, E. A. Schilling, and J. Glanovsky, “Evaluating the SOS Suicide Prevention Program: A Replication and Extension,” BMC Public Health, 7 (2007): 161.

L. J. Cook, “Striving to Help College Students with Mental Health Issues,” Journal of Psychosocial Nursing and Mental Health Services, 45 (2007): 40–44.

S. J. Garlow, J. Rosenberg, J. D. Moore, A. P. Haas, B. Koestner, H. Hendin, and C. B. Nemeroff, “Depression, Desperation, and Suicidal Ideation in College Students: Results from the American Foundation for Suicide Prevention College Screening Project at Emory University,” Depression & Anxiety, 25 (2008): 482–488.

D. Eisenberg, M. F. Downs, E. Golberstein, and K. Zivin, “Stigma and Help Seeking for Mental Health among College Students,” Medical Care Research and Review, 66 (2009): 522–541.

M. D. Rudd, A. L. Berman, T. E. Joinder, Jr., M. K. Nock, M. M. Silverman, M. Mandrusiak, K. Van Orden, and T. Witte, “Warning Signs for Suicide: Theory, Research, and Clinical Applications,” Suicide and Life-Threatening Behavior, 36 (2006): 255–262.

D. L. Tosevski, M. P. Milovanevic, and S. D. Gajic, “Personality and Psychopathology of College Students,” Current Opinion in Psychiatry, 23 (2010): 48–52.

K. Zivin, D. Eisenberg, S. E. Gollust, and E. Golberstein, “Persistence of Mental Health Problems and Needs in a College Student Population,” Journal of Affective Disorders, 117 (2009): 180–185.

For Further Information American Association for Suicidology Prevention www.suicidology.org American Psychiatric Association www.psychiatry.org National Empowerment Center www.power2u.org

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Mental Health America www.mentalhealthamerica.net Schizophrenia Awareness Association www.schizophrenia.org.in SAVE: Suicide Awareness Voices of Education www.save.org

Additional Media Depression in College Students University of Wyoming, 3 minutes A video production of the University of Wyoming. The video discusses what depression is, the prevalence of depression among college students, and why college students may experience depression. www.youtube.com/watch?v=p0cVi3k2NAk Lidia Bernik on PBS Healthy Minds, 4 minutes A video of the National Suicide Prevention Lifeline. Lidia Bernik shares the story of her sister, who committed suicide while Lidia was in college. www.youtube.com/watch?v=rKZCeYo9gyM&feature=channel National Survivors of Suicide Day, 8 minutes A video of the American Foundation for Suicide Prevention. Eight people share how their lives have been affected by suicide. www.youtube.com/watch?v=MD7Odg3RnAg&feature=related WHO: Introduction to Mental Health, 5 minutes A video produced by the World Health Organization that discusses the prevalence of mental health issues, with an emphasis on an international perspective.

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CHAPTER

2A

Focus On: Cultivating Mindfulness and Spiritual WellBeing

Overview Spiritual health is one of the six key dimensions of health. And, just as individuals exercise to improve physical fitness, specific activities can strengthen the spiritual dimension of health as well. In this chapter, students begin to understand what spirituality is and how it is similar to and different from religion. Students learn that spirituality has three interconnected facets and that spirituality contributes to physical health, psychosocial health, and reduced stress.

Students learn how to focus on their spiritual health by being in tune with themselves and their surroundings, training their bodies, expanding their minds, and reaching out to others.

Learning Outcomes 1. Describe mindfulness, spirituality, and religion.

2. Discuss how mindfulness and spiritual well-being contribute to overall health.

3. Identify actions you can take to cultivate your spiritual well-being.

Lecture Outline 1. In the fall of 2019, of those surveyed, nearly 43 percent of incoming college freshman rated themselves as above average in spirituality.

2. Spiritual health is one of the six key dimensions of health.

I. Mindfulness, Spirituality, and Religion A. Mindfulness—an awareness of the present moment, a focused, thoughtful, and attentive way of perceiving the world with all of its flaws and beauty and refraining from judgment.

1. Mindfulness is a holistic sensation of being totally involved in the moment rather than thinking and worrying about something else.

2. The components of mindfulness include: a. Acceptance of things as they are b. Nonjudgement c. Present moment awareness d. Nonattachment ..

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e. Openness to experience f.

Compassion

g. Connection h. Intention i. j.

Gratitude Peace and equanimity

B. Spirituality and Religion 1. Spirituality is the personal search for meaning and answers about life, the sacred, or the transcendent.

2. Even though spirituality and religion share some common elements, they are not the same thing.

3. Religion is a set of rituals, beliefs, symbols, and practices intended to enable a feeling of connection to the holy or divine.

C. Spirituality and Relationships, Values, and Purpose 1. Three facets of human experience constitute the core of human spirituality. a. Relationships b. Values: the fundamental rules by which we conduct our lives. c. Purpose in life 2. Spirituality is about actively paying attention to our relationships, our community, and ourselves, emphasizing respect and awareness while considering the impact our actions have on our communities.

3. Common components of bringing spirituality in your own life, work and experiences a. Actively search for meaning in your life b. Give back c. Understand and foster the connections between humanity, nature, and the universe d. Nurture loving relationships live with intention every day e. Use your philosophy of life to guide your attitudes and decisions f. Accept your limitations and leverage your strengths Key Terms: spirituality, spiritual well-being Figure: Figure 1 Typical Components of Mindfulness Figure 2 Three Facets of Spirituality II. Mindfulness, Spiritual Well-Being, and Health A. Physical Health Benefits 1. An increasing number of studies examine how certain spiritual practices may improve health and promote healthy behaviors.

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2. When we get sick, spiritual or religious well-being may help restore health and restore quality of life in the following ways: a. By decreasing anxiety, depression, anger, discomfort, and feelings of isolation b. By decreasing alcohol and drug abuse c. By decreasing blood pressure and the risk of heart disease d. By increasing a person’s ability to cope with the effects of illness and with medical treatments e. By increasing feelings of hope and optimism, freedom from regret, satisfaction with life, and inner peace B. Psychological Benefits 1. Studies have found a benefit of spirituality in reducing levels of anxiety and depression. a. It may also protect against academic burnout.

2. People who have found a spiritual community also benefit from increased social support among members.

3. Stress reduction is one probable mechanism among spiritually healthy people for improved health and longevity and for better coping with illness.

Key Term: spiritual community Figure: Figure 3 Physical and Psychological Health Benefits of Spiritual Well-Being III. Cultivating Your Spiritual Health 1. Enhancing your spiritual side takes just as much work as becoming physically fit.

A. Tune In to Yourself and Your Surroundings 1. Inner wisdom is perpetually available to us, but if we fail to tune our “receiver,” we will not be able to hear it for all the “static” of our daily lives.

2. Four ancient practices still used throughout the world can help you to tune into yourself and your surroundings: a. Contemplation (studying): the practice of concentrating the mind on a spiritual or ethical question or subject, a view of the natural world, or an icon or other image representative of divinity b. Mindfulness (observing): a practice of focused, nonjudgmental observation in which we are fully present in the moment. Figure 2 shows the qualities of mindfulness. c. Meditation (quieting): a practice of cultivating a still or quiet mind. d. Prayer (communing with the divine): communication with a transcendent Presence B. Strengthen Your Mind-Body Connection 1. Traditional forms of yoga include controlled breathing and physical postures as well as meditation, chanting, and other practices believed to cultivate unity with the Atman, or spiritual life principle of the universe.

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2. There are several types of yoga including, but not limited to, hatha yoga and ashtanga yoga. Each type of yoga has its own unique techniques, and you can explore classes on campus, at the YMCA, or at a dedicated yoga center.

3. Eastern meditative movement practices like tai chi or qigong can also increase physical activity and mental focus.

4. Enhancing your mind-body connection to improve your spiritual health does not necessarily require you to engage in a formal practice. a. Any exercise you do every day can contribute to your spiritual health.

C. Reach Out to Your Communities 1. Altruism, the giving of oneself out of genuine concern for others, is a key aspect of a spiritually healthy lifestyle. a. Volunteering time, donating money or other resources to a food bank or other program, or even spending the afternoon picking up litter in your neighborhood are all ways to serve others and simultaneously enhance your own spiritual health.

Key Terms: contemplation, meditation, prayer, yoga, altruism Figure: ABC News: See It! Video: Meditation Becoming More Popular among Teens

Discussion Questions 1. What are the differences between spirituality and religion? Why is this distinction important?

2. What is mindfulness? Do you think it is important for each individual to become mindful? Describe one change you could make to become more mindful.

3. What are the differences between the various forms of meditation, such as mantra meditation, breath meditation, color meditation, and candle meditation?

4. What evidence supports the statement that spirituality and religion are not the same thing?

5. What is the role of altruism in a spiritually healthy lifestyle?

Critical Thinking Questions 1. Do you consider yourself a spiritual person? A religious person? How can a person be both spiritual and religious? In what ways do spirituality and religion play out in your life?

2. Which of the three facets of spirituality—relationships, values, and purpose in life— have you explored in your life? What prompted you to explore this aspect of your spirituality?

3. Have you ever used contemplation, mindfulness, meditation, or prayer in a situation from your life that was stressful or emotionally difficult? How did it help you deal with the situation? What are the benefits of these techniques?

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4. Which of the qualities of mindfulness illustrated in Figure 2 do you possess? What can you do to improve your qualities of mindfulness? Provide two strategies that you could use to improve qualities of mindfulness in your life.

5. Have you ever experienced a “helpers high” after volunteering? Why do you think altruism is a key component of spiritual health?

Student Activities Individual 1. Practice mindfulness while completing an everyday task or activity. Record your feelings and observations in a journal.

2. Use the Internet to explore one of the types of meditation discussed in the chapter.

Practice that type of meditation for two weeks to a month, and keep a journal about the way the meditation made you feel. Did you feel more relaxed? More peaceful? More focused? What were the tangible and intangible changes in your life?

3. Use the Internet to explore the many and varying yoga philosophies that are the foundation of the practices commonly offered in yoga studios and on campus.

Describe how these spiritual philosophies contribute to yoga as a spiritual practice.

Community 1. What kind of spiritual and/or religious programs and/or services are offered on your campus? Do these campus services have any connections to similar services offered in the community? Have you ever taken advantage of these programs or services?

2. What types of yoga classes are available on your campus? Attend a yoga class to see if this form of spirituality is appropriate for you. Talk with the instructor and other class participants to find out the benefits they gain from yoga.

3. Find out what kind of spiritual retreat centers are offered in your community or in your area. What services—meditation, yoga, or other—are offered at the center? How do you register to attend the center?

Diverse Population/Nontraditional 1. Use the Internet to research aspects of spirituality in a different culture or country.

How does that concept of spirituality compare to the concept in the United States?

2. Find books and sacred texts for a religion that interests you. Take the time to read these books and understand their approach to spiritual fulfillment.

Additional References Ready-to-Go Teaching Module: Psychological Health B. Seaward, Managing Stress: Principles and Strategies for Health and Well Being, 7th ed.

(Sudbury, MA: Jones and Bartlett, 2012).

A. N. Bryant and H. S. Astin, “The Correlates of Spiritual Struggle during the College Years,” The Journal of Higher Education, 79 (2008): 1–27. ..

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A. Chiesa and A. Serretti, “Mindfulness-based Stress Reduction for Stress Management in Healthy People: A Review and Meta-analysis,” The Journal of Alternative and Complementary Medicine, 15 (2009): 593–600.

E. Nagel and S. Sgoutas-Emch, “The Relationship between Spirituality, Health Beliefs, and Health Behaviors in College Students,” Journal of Religion and Health, 46 (2007): 141–154.

D. Oman, S. L. Shapiro, C. E. Thoresen, T. G. Plante, and T. Flinders, “Meditation Lowers Stress and Supports Forgiveness among College Students: A Randomized Controlled Trial,” Journal of American College Health, 56 (2008): 569–578.

S. L. Shapiro, D. Oman, C. E. Thoresen, T. G. Plante, and T. Flinders, “Cultivating Mindfulness: Effects on Well-being,” Journal of Clinical Psychology, 64 (2008): 840–862.

L. A. Taliaferro, B. A. Rienzo, R. M. Pigg, M. D. Miller, and V. J. Dodd, “Spiritual Wellbeing and Suicidal Ideation among College Students,” Journal of American College Health, 58 (2009): 83–90.

For Further Information Beliefnet www.beliefnet.com UCLA Mindful Awareness Research Center http://marc.ucla.edu

Additional Media Ready-to-Go Teaching Module: Psychological Health Mindfulness, Stress Reduction and Healing, 1 hour and 14 minutes A Google TechTalks presentation by Jon Kabat-Zinn, from the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School. www.youtube.com/watch?v=rSU8ftmmhmw Yoga Meditation Exercises: Yoga Breathing for Meditation, 2 minutes An ExpertVillage video in which Jennifer Kostel leads the viewer through yoga breathing for meditation. www.youtube.com/watch?v=8ljVqV5IDTo

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CHAPTER

3

Managing Stress and Coping with Life’s Challenges

Overview The powerful influence of stress in our lives and on our health is just becoming clear. The science of psychoneuroimmunology (PNI) is beginning to unravel the secrets of just how greatly stress affects our immune systems and, therefore, different disease processes. Chapter 3 informs students about stress, what stress is, when stress is healthy, and when it is not. After reading Chapter 3, students will have techniques for positive stress management that can alter life toward greater health and happiness.

Learning Outcomes 1. Define stress, and examine its potential impact on health, relationships, and success in college and life.

2. Explain key stress theories as well as the emotional, mental, and physiological changes that occur during the stress response.

3. Examine the physical health risks that may occur with chronic stress.

4. Examine the intellectual, social, and psychological effects of stress and their impacts on college students.

5. Discuss sources of stress and examine the unique stressors that affect young adults, particularly college students.

6. Explain key individual factors that may influence whether a person is able to cope with stressors.

7. Explore stress-management and stress-reduction strategies, ways you can cope more effectively with stress, and ways you can enrich your life experiences and reduce health risks.

Lecture Outline •

Being stressed out can take a major toll on people at all ages and stages of life (Figure 3.1)

I. What Is Stress?

A. Stress is the mental and physical response and adaptation by our bodies to real or perceived changes and challenges.

B. A stressor is a real or perceived physical, social, or psychological event or stimulus that causes our bodies to react or respond. ..

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C. Several factors influence one’s response to stressors: 1. Characteristics of the stressor 2. Biological factors 3. Past experiences D. Stress may be tangible (a failing grade) or intangible (angst about meeting your significant other’s parents for the first time).

E. Positive stress is called eustress and may present the opportunity for personal growth and satisfaction that can actually improve health.

F. Distress, or negative stress, is caused by events that result in debilitative tension and strain.

G. There are several types of distress: 1. Acute stress, the most common type of stress, comes from demands and pressures of the recent past and anticipated demands and pressures of the near future.

2. Episodic acute stress is described as the state of reacting with wild, acute stress about one thing or another.

3. Chronic stress may not appear as intense but can linger indefinitely and wreak havoc on your body systems.

4. Traumatic stress is often the result of witnessing or experiencing events like major accidents, war, shootings, sexual violence, assault, or natural disasters.

Key Terms: stress, stressor, distress, eustress, acute stress, episodic acute stress, chronic stress, traumatic stress Figure 3.1 Stress Levels by Age and Group II. Your Body’s Stress Response: What Really Happens A. Physiology/Systems Theory: The General Adaptation Syndrome 1. A body in homeostasis (balance) operates smoothly and maintains equilibrium.

2. An adaptive response is the body’s attempt to restore homeostasis following a trigger.

3. The general adaptive syndrome (GAS) has three phases: Alarm, resistance, and exhaustion.

4. Alarm Phase: The Body in “Protect Mode” a. When the body is exposed to a real or perceived stressor, the fight-or-flight response kicks in and triggers an autonomic nervous system (ANS) response. b. The ANS is made up of two branches: sympathetic and parasympathetic. c. The hypothalamus is a structure in the brain that functions as a control center of the sympathetic nervous system and determines the overall reaction to stressors. d. Epinephrine causes more blood to be pumped with each heartbeat, dilates airways in the lungs, increases breathing rate, stimulates the liver to release glucose, and dilates the pupils. e. Cortisol is a hormone that makes stored nutrients more readily available to meet energy demands. f. Other parts of the brain and body release endorphins, which can relieve the pain and anxiety that a stressor may cause.

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a. The body tries to return to homeostasis, but because some perceived stressor still exists, the body does not achieve complete calm or rest.

6. Exhaustion Phase: Body Resources Depleted a. A prolonged response leads to allostatic load, or exhaustive wear and tear on the body; the physical and emotional energy used to fight a stressor has been depleted. b. Over time, cortisol can reduce immunocompetence, or the ability of the immune system to respond to attack.

B. Psychological Theory: The Transactional Model of Stress and Coping 1. Richard Lazarus proposed that our reaction to stress is about the interaction between perception, coping ability, and the environment.

2. The Transactional Model of Stress and Coping consists of four stages: a. Appraisal b. Secondary appraisal c. Coping d. Post-assessment C. Minority Stress Perspective 1. According to the minority stress perspective, minority stress may be explained in large part by disparities and the chronic stress inherent in populations that experience persistent rejection, alienation, and hostility.

D. Yerkes-Dodson Law of Arousal 1. According to the Yerkes-Dodson Law of Arousal, when stress increases, performance improves—to a point. This stress response is often depicted as a bell-shaped curve.

E. Do Men and Women Respond Differently to Stress?

1. Research indicates that men and women may actually respond differently to stress. a. Men may be prone to fighting or fleeing. b. Women are more likely to “tend and befriend.”

Key Terms: homeostasis, adaptive response, general adaptation syndrome (GAS), fight-orflight response, autonomic nervous system (ANS), sympathetic nervous system, parasympathetic nervous system, hypothalamus, epinephrine, cortisol, allostatic load, immunocompetence, transactional model of stress and coping, minority stress perspective, Yerkes-Dodson law of arousal Figures: Figure 3.2 The General Adaptation Syndrome (GAS) Figure 3.3 Fight-or-Flight: The Body’s Acute Stress Response III. Physical Effects of Stress A. Stress is often described as a “disease of prolonged arousal” that leads to a cascade of negative health effects.

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2. The increased risk of CVD from chronic stress has been linked with arterial plaque buildup due to elevated cholesterol, hardening of the arteries, increases in inflammatory responses in the body, alterations in heart rhythm, increased and fluctuating blood pressure, and other CVD risks.

C. Stress and Weight Gain 1. Higher stress levels may drive us toward food because it may increase cortisol levels in the bloodstream. a. Cortisol seems to play a role in increased belly fat and increased eating behaviors.

D. Stress and Hair Loss: A Little-Known Fact 1. Too much stress can lead to thinning hair, and even baldness, in men and women.

E. Stress and Diabetes 1. Controlling stress levels for preventing type 2 diabetes, as well as for successful shortand long-term diabetes management. a. See Focus On: Minimizing Your Risk for Diabetes F. Stress and Digestive Problems 1. Stress can trigger nausea, vomiting, stomach cramps, and gut pain.

G. Stress and Impaired Immunity 1. Psychoneuroimmunology (PNI) analyzes the intricate relationship between the mind’s response to stress and the ability of the immune system to function effectively.

Key Term: cumulative adversity, psychoneuroimmunology (PNI) Figure: Figure 3.4 Common Physical Symptoms of Stress IV. When Overwhelm Strikes: Threats to Intellectual, Social, and Psychological Health •

Research indicates that 56 percent of college students felt overwhelmed with all that they had to do within the past two weeks.

A. Stress can play a huge role in whether students complete school, get good grades, and succeed on their career paths.

1. Stress, Memory, and Concentration 2. Animal studies provide compelling indicators of how stress hormones released from the adrenal cortex are believed to affect cognitive function and overall mental health.

B. Recent laboratory studies with rats have linked prolonged exposure to cortisol to actual shrinking of the hippocampus, the brain’s major memory center.

1. Psychological Effects of Stress 2. Stress may be one of the single greatest contributors to mental disability and emotional dysfunction in industrialized nations.

C. Studies have shown that chronic stress may cause structural degeneration and impaired function of the brain, leading to depression, dementia, and Alzheimer’s disease, as well as an overactive amygdala, which may increase rates of violence.

V. What Causes Stress?

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A. A 2015 survey found that concerns over money, work, family responsibilities, personal and family health, and the economy were the biggest reported causes of stress for Americans.

1. College students, in particular, face stressors that come from internal sources as well as external pressures to succeed in a competitive environment.

B. Hassles: Little Things that Bug You 1. Cumulative hassles tax the physiological systems of the body and cause stress-related wear and tear on the body.

2. See the Mindfulness and You box for more on technostress.

C. Stress: The Toll of Relationships 1. Relationships can trigger some of the biggest fight-or-flight reactions.

D. Money and Stress 1. Difficulties managing ever-increasing tuition, housing, and general expenses of college life are very stressful for students.

2. Relative deprivation is the inability of lower-income groups to sustain the same lifestyle as higher-income groups in the same community.

E. Stress, Frustration, and Conflict 1. Conflict occurs when we are forced to decide among competing motives, impulses, desires, and behaviors or when we are forced to face pressures or demands that are incompatible with our own values and sense of importance.

F. Overload 1. Overload occurs when we are overextended and there are not enough hours in the day to do what we must get done. Unrelenting stress and overload can lead to burnout.

G. Stressful Environments 1. For many college students, where they live and the environment around them cause significant levels of stress.

2. Background distressors in the environment, such as noise, air and water pollution, and environmental tobacco smoke, can contribute to stress.

H. Bias and Discrimination 1. Students come to campus from vastly different backgrounds and with very different life experiences. Often those perceived as dissimilar may become victims of subtle or not so subtle forms of bigotry, insensitivity, harassment, or hostility, or they may simply be ignored.

Key Terms: relative deprivation, overload, burnout, background distressors Figure: Figure 3.5 What Do We Say Stresses Us? VI. Individual Factors that Affect Your Stress Response A. Appraisal 1. Appraisal is defined as the interpretation and evaluation of information provided to the brain by the senses.

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1. Self-esteem refers to your sense of self-worth, or how you judge yourself in comparison to others. a. High stress and low self-esteem can significantly predict suicide ideation in you adults. b. You can improve your ability to cope with stress by increasing your self-esteem. c. Narcissism can be a dark side of self-esteem.

2. Self-efficacy refers to confidence in one’s skills and ability to cope with life’s challenges. a. Self-efficacy is critical to overcoming academic pressure and worries.

C. Type A and Type B Personalities 1. Personality can have an impact on whether you are happy and socially well-adjusted or sad and socially isolated.

2. Type A personalities are defined as hard-driving, competitive, time-driven perfectionists.

3. Type B personalities are described as relaxed, noncompetitive, and more tolerant of others.

4. Most researchers recognize that none of us are wholly Type A or Type B. D. Thriving Type A: Hardiness, Psychological Resilience, and Grit 1. Psychological hardiness may negate self-imposed stress associated with Type A behavior.

2. Psychologically hardy people are characterized by the following: a. Control: the ability to accept responsibility for their behaviors and work to change situation they discover to be debilitating. b. Commitment: have a healthy self-esteem and know their purpose in life c. Embrace challenge: see change as a stimulating opportunity for personal growth 3. Psychological resilience is a person’s capacity to maintain or regain psychological well-being in the face of adversity, trauma, tragedy, threats, or significant sources of stress.

4. In contrast to Type A individuals who thrive, those who are hostile are at increased risk for heart disease. a. Characteristics of hostility include disproportionate amounts of anger, distrust of others, and a cynical, glass-half-empty approach to life.

5. Broken heart syndrome is the very real heart damage experienced by some people as a result of chronic, debilitating stress; depression; loss; a breakup; betrayal; or another emotional blow.

E. Type C and Type D Personalities 1. Type C personality is described as stoic, with a tendency to stuff down feelings and conform to the wishes of others. a. May be more susceptible to diseases like asthma, multiple sclerosis, autoimmune disorders, and cancer.

2. Type D personality is characterized by a tendency toward excessive negative worry, irritability, gloom, and inability to express these feelings due to social inhibition. a. May be up to eight times more likely to die of a heart attack or sudden death.

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F. Shift and Persist 1. New research proposes that amid extreme, persistent adversity, youth are able to reframe appraisals of current stressors more positively (shifting) while persisting in focusing on the future.

Key Terms: appraisal, suicidal ideation, grit, hostility, psychological hardiness, psychological resilience, shift and persist VII. Managing Stress in College: Dealing with Overwhelm A. College students thrive under a certain amount of stress, but excessive stress can overwhelm many.

B. You can’t eliminate all life stressors, but you can train yourself to recognize the events that cause stress and to anticipate your reactions to them.

C. Coping is the act of managing events or conditions to lessen the physical or psychological effects of excess stress.

D. A Mindful Approach to Stress 1. Stress management requires getting a handle on what is going on in your life, taking a careful look at yourself, and developing a plan of action.

2. Assess Your Stressors to Solve Problems Mindfully a. Start a journal; track your worries and factors that trigger stress every day for one week. b. Examine the causes. c. Think about what is going on with you right now d. Take a ten-minute break e. Focus on your stressor 3. Change Your Inner Voice: Be Compassionate a. Several types of negative self-talk exist: pessimism, perfectionism, “should-ing,” blaming, and dichotomous thinking. b. To combat negative self-talk, we must become aware of it, stop it, and finally replace negative thoughts with positive ones—a process called cognitive restructuring. c. See the Skills for Behavior Change box for other suggestions to rethink your thinking habits.

E. Developing a Support Network 1. While developing a stress management program, do not underestimate the importance of social networks and social bonds. a. Studies of college students have demonstrated the importance of social support in buffering individuals from the effects of stress.

2. You must invest time and energy into developing a healthy social support network. a. Spend more time in face-to-face interactions.

F. Cultivating Your Spiritual Side 1. One of the most important factors in reducing stress in your life is taking the time and making the commitment to cultivate your spiritual side: finding your purpose in life and living your days more fully. ..

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2. See Focus On: Cultivating Your Spiritual Health.

G. Managing Emotional Responses 1. Stress management requires that you examine your emotional responses to interactions with others.

2. Fight the anger urge. a. Identify your anger style. b. c. d. e.

Learn to recognize patterns in your anger responses and how to de-escalate them.

Find the right words to de-escalate conflict.

Plan ahead.

Vent to your friends.

f.

Develop realistic expectations of yourself and others.

g. Turn complaints into requests. h. Leave past anger in the past.

3. Learn to laugh, be joyful, and cry. a. For ideas on how to find more joy and laughter in your daily life, see the Health Headlines box.

H. Taking Physical Action 1. Get Enough Exercise a. Exercise can “burn off” stress hormones by directing them toward their intended metabolic function.

2. Get Enough Sleep a. Adequate amounts of sleep allow you to refresh your vital energy, cope with multiple stressors more effectively, and be productive when you need to be.

Chapter 4 for more in-depth discussion of the benefits of sleep.

3. Eat Healthfully a. Eating a balanced, healthy diet will help provide the stamina you need to get through problems and will stress-proof you in ways that are not fully understood. b. It is important to avoid sympathomimetics, or substances in foods that mimic stress-like responses, such as caffeine.

I. Managing Your Time 1. Managing your time is an essential aspect of stress management.

2. Procrastination is defined as a voluntary delay in doing some task despite while expecting to be worse off for the delay.

3. Setting clear “implementation intentions,” a series of goals to accomplish toward a specific end, is key. a. Have a plan that has specific deadlines to help keep you on track.

4. Time management tips include taking on only one thing at a time; cleaning off your desk; prioritizing your tasks; finding a clean, comfortable place to work; avoiding interruptions; rewarding yourself for work completed; working when you’re at your best; breaking overwhelming tasks into smaller pieces and allocating time to each; and remembering that time is precious. a. See the Student Health Today for more on organizing to de-stress.

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J. Consider Downshifting 1. Downshifting involves a fundamental alteration in values and honest introspection about what is important in life.

2. It is important to move slowly and have a plan when contemplating any form of downshifting.

K. Relaxation Techniques for Stress Management 1. Yoga a. Yoga is an ancient tradition that combines meditation, stretching, and breathing exercises designed to relax, refresh, and rejuvenate (See Focus on: Cultivating Your Spiritual Health for additional information on yoga).

2. Qigong and Tai Chi a. Qigong is an ancient Chinese practice that involves becoming aware of and learning to control vital energy (qi) in your body. b. “Meditation in motion,” tai chi is another Chinese form of movement that provides stress reduction, greater balance, and increased flexibility.

3. Diaphragmatic or Deep Breathing a. This technique fills the lungs to maximum capacity.

4. Meditation

5.

6.

7.

8.

a. Mediation generally involves sitting quietly, focusing on your thoughts, blocking out the “noise,” controlling breathing, and ultimately relaxing.

Visualization a. Visualization involves using your imagination to create mental scenes. Recalling physical sensations of sight, sound, smell, taste, and touch can replace stressful stimuli with peaceful or pleasurable thoughts.

Progressive Muscle Relaxation a. Progressive muscle relaxation involves systematically contracting and relaxing the different muscle groups in your body.

Massage Therapy a. A growing body of evidence indicates that massage may ease back pain, reduce anxiety, and potentially improve quality of life for cancer patients and those with HIV/AIDS and depression.

Biofeedback a. Biofeedback is a technique in which a person learns to use the mind to consciously control bodily functions, such as heart rate, body temperature, and breathing rate.

Key Terms: coping, dispositional mindfulness, stress inoculation, cognitive restructuring, sympathomimetics, acculturation stress, procrastinate, implementation intentions, downshifting, biofeedback

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Figures: Figure 3.6 Diaphragmatic Breathing Figure 3.7 Progressive Muscle Relaxation

Discussion Questions 1. What major life events over the past year have been very stressful to you? How did you choose to cope with each situation? Pick one of the coping techniques discussed in the chapter. How would your coping have differed with this new technique?

2. Can you think of a situation where your perception of the event was quite different from the perception of one of your friends? Did your perception of the event lead to more or less stress in your life? How might you have perceived things differently?

3. Describe the daily hassles in your life that are stressful to you. Do you find these situations more stressful than major life events that you have dealt with? Considering the techniques discussed in this chapter, how might you minimize the daily hassles in your life?

4. Jack is taking too many classes, working part-time, and playing intramural sports. He is starting to have interpersonal problems, and his grades are starting to drop. What could Jack do to reduce his stress levels?

5. Why is college life so stressful? What preventive measures can college students take in order to reduce the chances of overload? How could students and professors work together to reduce the changes of overload?

6. Describe situations that involve conflict for college students. What can be done to resolve these conflicts?

7. Give an example of a situation where imagined stressors can invoke the stress response.

8. Have you ever tried any of the stress management techniques listed in the text? Which ones do you think work the best for you?

Critical Thinking Questions 1. Discrimination can be subtle or overt. What kinds of subtle and overt discrimination have you observed that might be stressful to people of minority groups in your community?

What can you do to reduce the discrimination and, as a result, reduce the stress levels for individuals within that group?

2. How does technostress affect you on a daily basis? How much time each day are you electronically “connected”? How does this amount of time compare to the amount of time you spend each day in face-to-face interactions with other individuals? Do you turn your devices off or at least not use them when you are in a social situation?

3. Think about a time of high stress in your life. What change caused the stress? Was the change good or bad? What behaviors did you adopt to reduce the stress? How did these behaviors influence your overall health?

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4. Do you think you suffer from overload? What are three behaviors you can adopt to minimize the feeling of being overwhelmed?

5. What mental skills do you have to deal with stress as it occurs? How often do you put them to work to diminish feelings of stress?

6. Are you guilty of negative self-talk? What steps can you take to reduce negative self-talk and make it more positive?

7. Are you a procrastinator or a good time manager? What steps can you take to improve your time management skills?

8. What type of personality do you think you are: A, B, C, or D? What characteristics do you exhibit that fit that personality type?

Student Activities Individual 1. Make a list of the primary stressors in your life. Give the list to a friend or significant other. Discuss the list, and ask your friend or significant other if he or she shares the same stressors. When you both realize your main sources of stress, make a stress management plan together. Social support in stress management can foster success.

2. Use the Internet to search for a stress management website that provides recommendations for ways to relax and bring calm to your life. Identify from this site five ways you can effectively reduce stress in your life.

3. Keep a daily journal of factors in your life that cause stress. At the end of a week, analyze your entries and identify the primary triggers that cause stress. Develop a stress management plan to avoid these triggers.

4. Attend a campus event for stress management.

Community 1. Identify at least three resources in the community that can help people with high stress levels. Resources can include counseling services, child-care services, massage therapists, or educational classes.

2. What resources that help with stress or time management are available on your campus?

What kinds of services are offered? How does one go about taking advantage of the services offered?

Diverse Population/Nontraditional 1. Do people in other cultures experience the same stressors as those in the United States? In your local community? How do people in other cultures manage their stress? What kinds of activities do they participate in to reduce stress? How does this relate to on-campus groups for minority students?

2. What different kinds of stressors do nontraditional college groups, such as mothers returning to college and adults who have lost their jobs, experience as students? What resources are available to help these individuals reduce their stress levels?

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Additional References American Psychological Association, “Stress in America: Our Health at Risk,” Monitor on Psychology, 43, no. 3 (2012): 18, www.apa.org.

E. Chiauzzi, J. Brevard, C. Thurn, S. Decembrele, and S. Lord, “MyStudentBody-Stress: An Online Stress Management Intervention for College Students,” Journal of Health Communication: International Perspectives, 13 (2008): 555–572.

M. R. Clark, “Negotiating the Freshman Year: Challenges and Strategies among First-year College Students,” Journal of College Student Development, 46 (2005): 296–316.

T. J. Connor, “Don’t Stress Out Your Immune System—Just Relax, Brain,” Behavior, and Immunity, 22 (2008): 1128–1129.

L. Dusselier, B. Dunn, Y. Wang, M. C. Shelley II, and D. F. Whalen, “Personal, Health, Academic, and Environmental Predictors of Stress for Residence Hall Students,” Journal of American College Health, 54 (2005): 15–24.

J. K. Giancola, M. J. Grawitch, and D. Borchert, “Dealing with the Stress of College: A Model for Adult Students,” Adult Education Quarterly, 59 (2009): 246–263.

K. Renk and T. Smith, “Predictors of Academic-related Stress in College Students: An Examination of Coping, Social Support, Parenting, and Anxiety,” Journal of Student Affairs Research and Practice, 44 (2007): 405–431.

M. Steinhardt and C. Dolbier, “Evaluation of a Resilience Intervention to Enhance Coping Strategies and Protective Factors and Decrease Symptomology,” Journal of American College Health, 56 (2008): 445–453.

For Further Information American Mental Health Counselors Association www.amhca.org American Psychological Association www.apa.org Association for Applied Psychophysiology and Biofeedback www.aapb.org Benson-Henry Institute for Mind Body Medicine www.massgeneral.org/bhi Mayo Clinic Biofeedback www.mayoclinic.com/health/biofeedback/MY01072

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Additional Media Ready-to-Go Teaching Module: Stress Dahn Yoga: ABC News, 7 minutes Dr. Sung Lee is interviewed in this ABC News clip and discusses the proven ability of Dahn Yoga to reduce stress. Dr. Lee also provides four techniques. www.youtube.com/watch?v=3kYyeijZKA8&NR=1 Health Benefits of Tai Chi, 2 minutes MSNBC program “The Mind-Body Connection” focuses on the research of the health effects of tai chi. www.youtube.com/watch?v=_cTlHy7D4uw Progressive Muscle Relaxation, 10 minutes Inner Health Studio production in which a script is used to guide a progressive muscle relaxation exercise. www.youtube.com/watch?v=HFwCKKa--18

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CHAPTER

Improving Your Sleep

4 Overview Sleep—we never seem to get enough, and we always need and want more. In this section you learn about sleep and why our bodies need sleep to maintain both our physical and psychosocial health. This section explains what happens when we sleep and describes the differences between REM and non-REM sleep. This chapter also describes how much sleep a person really needs for optimal health and daily performance and provides strategies on how to get the sleep you need to stay healthy.

Learning Outcomes 1. Describe the problem of sleep deprivation in the United States, including unique challenges of sleep deprivation on campus.

2. Explain why we need sleep and what happens if we don’t get enough sleep, including potential physical, emotional, social, and safety threats to health.

3. Explain the processes of sleep, including the two-stage model, circadian rhythm, and the sleep–wake cycle, as well as how they work and their importance for restful sleep.

4. Describe some common sleep disorders, including risk factors and what can be done to prevent or treat them.

5. Explore ways to improve your sleep through changing daily habits, modifying your environment, avoiding sleep disruptors, adopting mindfulness sleep strategies, and using other sound sleep hygiene approaches.

Lecture Outline I. Sleepless in America A. Sleepless on Campus: Tired and Dragged-Out Students?

1. According to a recent survey, only 10.6 percent of students reported getting a sufficient amount of sleep. a. Sixty-one percent said they often go to bed late and get up early, resulting in sleep deprivation—a condition that occurs when sleep is insufficient for a given age.

2. A lack of sleep leads to somnolence—drowsiness, sluggishness, and a lack of mental alertness that can affect daily performance 3. People likely to fall asleep unintentionally during the day are suffering from a condition known as excessive daytime sleepiness.

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B. Why so Sleep Deprived?

1. Several factors can lead to sleep deprivation: a. Shift work b. Long-haul driving c. Drugs and medications d. Pain e. Sleep habits f. Gender g. Sleep disorders Key Terms: somnolence, excessive daytime sleepiness or excessive sleepiness, sleep deprivation, primary idiopathic hypersomnia Figure: Figure 4.1 Effects of Short Term and Chronic Sleep Loss Table 4.1 Percentage of People in Each Age Group Who Are Sleep Deprived II. The Importance of Sleep A. Sleep serves to maintain your physical health, affects your ability to function effectively, and enhances your intellectual, social, emotional, and psychological health in several ways: 1. Sleep restores you both physically and mentally.

2. Sleep conserves body energy.

3. Sleep helps you cope with life’s challenges.

B. Sleep and Health 1. Sleep has beneficial effects on most body systems.

2. The physical effects of sleep include the following: a. Sleep helps maintain your immune system. b. Sleep helps reduce your risk for cardiovascular disease. c. Sleep contributes to a healthy metabolism. d. Short sleep increases the risk of type 2 diabetes. e. Sleep may be a factor in male reproductive health. f. Sleep contributes to neurological/mental/cognitive functioning. g. Sleep improves motor tasks, particularly driving. h. Sleep plays a role in stress management and mental health.

III. The Processes of Sleep A. Your normal circadian rhythm is the 24-hour biological clock by which you are accustomed to going to sleep, waking up, and performing daily tasks.

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B. There are two primary sleep states: 1. REM sleep: a state in which rapid eye movement and dreams occur, and brain-wave activity appears similar to that which occurs when you are awake.

2. Non-REM (NREM) sleep: a period of restful sleep with slow brain activity that is not characterized by rapid eye movement.

3. Throughout the night, you alternate through periods of NREM and REM sleep, repeating one full cycle about once every 90 minutes. a. You spend about 75 percent of each night in NREM sleep and 25 percent in REM sleep.

C. Non-REM Sleep Is Restorative 1. The body rests during NREM sleep. Body temperature is reduced, and energy use drops; sensation is dulled; and heart rate, breathing, and brain waves slow down.

2. You do not typically dream during NREM sleep.

3. Four characteristic stages occur during NREM sleep. a. Stage 1: This is the lightest stage of sleep that lasts only a few minutes. b. Stage 2: The eyes are closed, body movement slows, and you disengage from your environment. c. Stage 3 and 4: Your brain generates slow delta waves and blood pressure, heart rate, and respiration slow. Human growth hormone is released, signaling the body to repair worn tissues.

D. REM Sleep Energizes 1. Dreaming takes place primarily during REM sleep.

2. The brain waves of a person during REM sleep are almost undistinguishable from someone who is wide awake.

3. Deep phases of slow-wave sleep consolidate the day’s information, while REM sleep stabilizes consolidated memory.

E. Your Sleep Needs 1. Sleep patterns change over the life span, from 16 to 18 hours a day for newborns, to around 7 hours per night for adults.

2. Individual variations occur depending on age, gender, and other factors.

F. Sleep Debt 1. Sleep debt is the total number of hours of missed sleep you’re carrying around with you.

2. Some research shows you can catch up on sleep debt if you go about it sensibly. a. Take a power nap of about 20 minutes in the early afternoon. b. Sleep in on the weekends, but not more than 2 hours past the normal time you wake up. c. Go to bed a little earlier the next few nights.

G. Is Napping a Good Idea?

1. Naps cannot completely cancel sleep debt, but they can improve mood, alertness, and performance.

2. Regular naps may also improve immune function and help ward off infections.

3. It is best to nap early to midafternoon.

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4. Never nap in the late afternoon, as it could interfere with your ability to fall asleep at night.

5. Keep naps short to avoid sleep inertia, characterized by cognitive impairment, grogginess, and disoriented feelings.

H. The Rare “Short Sleeper” 1. Perhaps fewer than 1 percent of people seem to thrive on less than 6 hours of sleep per night.

2. Recent research points to a possible gene—the DEC2 gene—that accounts for this difference.

Key Terms: circadian rhythm, melatonin, REM sleep, non-REM (NREM) sleep, sleep debt, sleep inertia Figures: Figure 4.2 The Nightly Sleep Cycle Figure 4.3 Parts of the Brain Involved in Sleep IV. The Nightly Sleep Cycle A. Sleep Disorders 1. As many as 70 million Americans suffer from sleep-related disorders.

2. During a sleep study, sensors and electrodes record data that will be reviewed by a sleep specialist to determine the precise nature of your sleep problem. See Figure 4.4 for an example of a sleep diary.

B. Insomnia 1. Difficulty in falling asleep quickly, frequent arousals during sleep, or early morning awakening.

2. Symptoms and Causes a. Symptoms of insomnia include difficulty falling asleep, waking up frequently during the night, difficulty returning to sleep, waking up too early in the morning, unrefreshing sleep, daytime sleepiness, trouble focusing, and irritability. b. Insomnia can be related to stress and worry, to disruptions in the circadian rhythms, or as a side effect of certain medications.

3. Treatment for Insomnia a. Cognitive behavioral therapy for insomnia (CBT-I) is one of the best first-line defenses for people with insomnia b. Relaxation strategies like yoga and meditation can be helpful. c. Exercise done early in the day can also reduce stress and promote deeper sleep.

C. Sleep Apnea 1. A disorder in which breathing is briefly and repeatedly interrupted during sleep; breathing pauses last at least 10 seconds. a. Symptoms and Causes of Sleep Apnea b. Central sleep apnea occurs when the brain fails to tell the respiratory system to initiate breathing.

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c. Obstructive sleep apnea is more common and occurs when air cannot move in and out of a person’s nose or mouth. d. Risk factors include being overweight, smoking, alcohol use, being over 40, and ethnicity. Anatomical risk factors include a small upper airway, a recessed chin, small jaw or large overbite, and a large neck. Genetics may also play a role.

2. Treatment for Sleep Apnea a. Most commonly prescribed treatment is continuous positive airway pressure (CPAP), which consists of an airflow device, long tube, and mask that is worn during sleep. The Food and Drug Administration (FDA) also recently approved an implantable upper airway stimulator for people who can’t tolerate CPAP devices. b. Other methods include dental appliances and surgery to remove tissue in the upper airway.

3. Lifestyle changes like losing weight, avoiding alcohol, and quitting smoking are also ways to reduce symptoms.

D. Restless Legs Syndrome 1. Restless leg syndrome (RLS) is a neurological disorder characterized by unpleasant sensations in the legs when at rest combined with an uncontrollable urge to move in an effort to relieve these feelings.

2. Symptoms and Causes of RLS a. Restless legs syndrome sensations are often described as burning, creeping, or tugging or like insects are crawling inside the legs. b. A family history is seen in approximately 50 percent of the cases. RLS also appears to be related to other conditions, including Parkinson’s disease, kidney failure, diabetes, peripheral neuropathy, and anemia.

3. Treatment of RLS a. Treatment options include use of prescribed medications, decreasing tobacco and alcohol use, and applying heat to the legs. For some, practicing relaxation techniques or performing stretching exercises can help alleviate symptoms.

E. Narcolepsy 1. Narcolepsy is a neurological disorder caused by the brain’s inability to properly regulate sleep–wake cycles resulting in excessive, intrusive sleepiness and daytime sleep attacks.

2. Symptoms and Causes of Narcolepsy a. Characterized by overwhelming and uncontrollable sleepiness during the day. b. Sleep attacks can last from a few seconds to a few minutes. c. Other symptoms include cataplexy (sudden loss of voluntary muscle tone), hallucinations during sleep or upon waking, and brief episodes of paralysis during sleep–wake transitions. d. Appears to be caused by a deficiency of sleep-regulating chemicals in the brain.

3. Treatment for Narcolepsy a. Treatments include medications to improve alertness and antidepressants to treat cataplexy. Behavioral therapy and lifestyle changes may also help.

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F. Other Parasomnias 1. Among the most common parasomnias are circadian rhythm disorder, sleep phase disorder, sleep-related eating disorder, sleepwalking, night terrors, sexsomnia, bedwetting, and snoring.

G. Student Health Today looks at the truth about sleeping pills.

Key Terms: sleep study, insomnia, cognitive-behavioral therapy for chronic insomnia, sleep apnea, restless legs syndrome (RLS), narcolepsy, sleep disorders (somnipathy dyssomnia) Figure and Table: Figure 4.4 Continuous Positive Airway Pressure (CPAP) Device V. Getting a Good Night’s Sleep A. Create a Sleep-Promoting Environment 1. Chill.

2. Create a sleep “cave”—keep your bedroom quiet, cool, and dark; turn off your computer and cell phone.

3. Associate bed with sleep.

4. Go to bed only when you are tired.

5. Establish bedtime and waking rituals.

B. Adjust Your Daytime Habits 1. Get adequate daytime light exposure.

2. Exercise in the morning or afternoon.

3. Watch your diet, particularly in the hours before bed.

C. Avoid Common Sleep Disruptors 1. Go easy on the caffeine.

2. Avoid nicotine, alcohol, and liquids before bed.

3. Turn off screens.

4. Tune out conflict.

Key Terms: sleep hygiene, mindfulness-based stress reduction (MBSR), mindfulness meditation, narcolepsy, nocturia, parasomnias Figure: Figure 4.5 Proven Strategies for a Good Night’s Sleep

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Discussion Questions 1. Based on your reading of Chapter 4, explain the reasons why this statement is true: “When you don’t get enough sleep, your academic performance deteriorates.”

2. Describe how you feel in the morning if you do not get enough sleep at night. Do you feel better or worse as the day goes on? What changes would you need to make in order to get 7 to 8 hours of sleep every night?

3. How does your brain restore itself during REM sleep?

4. What behaviors do you follow to get a good night’s sleep?

Critical Thinking Questions 1. Many people have jobs that require them to work at night and sleep during the day. How do you think the circadian rhythms of these individuals are affected by their schedules?

What strategies would you suggest to help them get enough sleep?

2. Do you think a person who sleepwalks is getting the proper rest his or her body needs?

Why or why not?

3. What have you done in the past to help you fall asleep when you have insomnia? What behaviors described in the chapter will you try the next time you have difficulty falling asleep?

4. Have you ever fallen asleep during class? Describe three strategies and behaviors you can adopt to prevent falling asleep in class in the future.

5. How have your sleep patterns changed—for better or worse—since you have been at college? How do your current sleep patterns differ from those you had while living at home? What adjustments could you make to improve your sleep patterns?

Student Activities Individual 1. Conduct research on the Internet to find out how snoring affects sleep. Share your findings with your classmates.

2. Keep a sleep diary for two weeks. Calculate how much sleep you get each night and how much sleep debt you havCreate and follow a plan to help you reduce your sleep debt.

Community 1. Find out if your campus or community has a sleep cliniWhat kinds of services does the clinic provide? Who in your community can take advantage of these services?

2. Investigate automobile crashes in your community attributed to the driver falling asleep at the wheel. Does this number surprise you? What does the community do to prevent such accidents? What other steps might be taken to reduce the number of accidents even further?

3. Work with your dorm, student health center, or another organization to develop an awareness-raising campaign concerning the important aspects of sleep and health.

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Diverse Population/Nontraditional 1. Use the Internet to research the beds and bedding people use in different cultures. Are traditional designs for beds, pillows, and bedding still used? What materials are used in the traditional bedding? How do these materials and designs differ from modern bedding used in the United States?

2. Do people in other countries sleep as much or as little as people in the United States? Use the Internet to research sleep patterns of people in other cultures or countries.

Additional References American College Health Association, American College Health Association-National College Health Assessment II: Reference Group Data Report Fall 2012 (Hanover, MD: American College Health Association, 2013), www.acha-ncha.org Bailly, I. Bailly-Lambin, Querleu, R. Beuscart, and Collinet, “Sleep in Adolescents and its Disorders: A Survey in Schools,” Encephale, 30 (2004): 352–359.

W. Buboltz, J. Loveland, S. M. Jenkins, Brown, Soper, and J. Hodges, “College Student Sleep: Relationship to Health and Academic Performance,” in College Students: Mental Health and Coping Strategies, eM. V. Landow (New York: Nova Science Publishers, 2006), 1–29.

R. Jensen, “Understanding Sleep Disorders in a College Student Population,” Journal of College Counseling, 6 (2003): 25–34.

W. Kelly, K. Kelly, and R. Clanton, “The Relationship between Sleep Length and Gradepoint Average among College Students,” College Student Journal, 35 (2001): 84–86.

For Further Information Discovery Health Sleep Hygiene Test http://cl1.psychtests.com/take_test.php?idRegTest=2985 Mayo Clinic Insomnia www.mayoclinic.com/health/insomnia/DS00187

Additional Media Insomnia Consequences—Sleep, Sex, and Death (Health Guru Tip), 1 minute In this illumistream production, Mark Haltrecht, D.O., discusses the consequences of not meeting your daily sleep requirement. www.youtube.com/watch?v=P0mPWzLfLdU&feature=related Sleep Disorders Decoded (Sex Health Guru Health Tip), 1 minute In this illumistream production, Mark Haltrecht, D.O., demystifies sleep disorders, such as insomnia, and provides tips on what to do if you think you have a sleep disorder. www.youtube.com/watch?v=sO4hOQGh0zo&feature=related

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Understanding Sleep (Insomnia #1), 3 minutes In this illumistream health production, Mark Haltrecht, D.O., discusses the stages of sleep, the purpose of each stage, and common sleep disorders. www.youtube.com/watch?v=H9XtWxjkw2o What’s Keeping You Awake? (Insomnia #2), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses acute and chronic insomnia, circadian rhythm disorders, snoring, and sleep apne www.youtube.com/watch?v=0CKHA9iAwCQ&feature=channel Treating Sleep Disorders (Insomnia #4), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses behavioral and medical interventions used to treat sleep disorders. www.youtube.com/watch?v=xFUrw7g6Dw4&feature=channel Preventing Sleepless Nights (Insomnia #5), 3 minutes In this illumistream production, Mark Haltrecht, D.O., discusses sleep hygiene tips for preventing sleepless nights. www.youtube.com/watch?v=B9QWtAJwENM&feature=related

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CHAPTER

Preventing Violence and Injury

5 Overview Violence accounts for many of the health problems faced in the United States. Violence comes in many forms: abuse of spouses and children, homicide and other violent attacks on others, shootings in schools, or acts of terrorism. Interpersonal violence is a problem that has come to national attention. Chapter 5 focuses on the problems of violence in our culture. It provides data that are important in helping us understand the scope of the problem, as well as clues to the antecedents of violence and the knowledge that may help us to prevent it. This chapter also helps us to differentiate between intentional and unintentional injuries and to understand ways to minimize the risk and effect of unintentional injury.

Learning Outcomes 1. Differentiate between intentional and unintentional injuries and discuss trends in violence in American society and on college campuses.

2. List and explain factors that contribute to intentional acts of violence.

3. Discuss the prevalence of, common contributors to, and groups that are at risk for interpersonal and collective acts of violence and describe intimate partner violence (IPV) and the cycle of IPV. 4. Describe various types of sexual victimization, environmental and social contributors, and the effectiveness of strategies to prevent and respond to sexual victimization.

5. Discuss existing personal and community strategies for minimizing the risk of violence.

6. Discuss key strategies that are likely to minimize the risk of unintentional injuries.

Lecture Outline I. What Is Violence?

A. Violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”

B. The U.S. Public Health Service has categorized violence resulting in injuries into two categories: 1. Intentional injuries—those committed with intent to harm—typically include assaults, homicides, self-inflicted injuries, and suicides.

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2. Unintentional injuries—those committed without intent to harm, such as motor vehicle crashes, fires, and drownings.

C. Young adults are disproportionately affected by violence and injury.

1. Unintentional injuries are the number one cause of death among 15- to 44-year-olds.

2. Suicide and homicide are second- and third-leading causes of death in 15- to 34-year old people.

D. Violence Overview 1. How are crime rates determined? a. Federal Bureau of Investigation’s (FBI’s) Uniform Crime Reporting (UCR) Program b. Bureau of Justice Statistic’s National Crime Victimization Survey (NCVS) 2. Huge disparities in crime rates based on race, sex, age, socioeconomic status, location, crime type, and other factors.

3. Violent crime in the context of a pandemic a. Crime in America changed dramatically and varied significantly by source. Some crimes, such as homicide and arson, increased significantly, while others, such as rape, burglary, and robbery, decreased significantly compared to recent trends. i. COVID-19 Effect—fear anxiety, uncertainty, growing social and political pressure and civil unrest 4. Violent crime in the context of disparities a. Most violent crimes in the Unites States are not reported to police or the authorities i. Most that are reported are never solved E. Violence on U.S. Campuses 1. Relationship violence is one of the most prevalent problems on college campuses.

2. Fewer than 12.5 percent of rapes and 4.3 percent of sexual batteries are believed to have been reported to any authority.

3. Reasons campus crimes are not reported include concerns over privacy, fear of retaliation, embarrassment, a lack of support, a perception that the crime was too minor or they were somehow at fault, or an uncertainty that it was a crime.

Key Terms: meanness, violence, intentional injuries, unintentional injuries Figures: Figure 5.1 Changing Crime Rates Figure 5.2 Crime Clock II. Factors Contributing to Violence A. Several social, community, relationship, and individual factors increase the likelihood of violent acts: 1. Community contexts 2. Societal factors

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3. Religious beliefs and differences 4. Political differences 5. Breakdowns in the criminal justice system 6. Stress, depression, and other mental health issues B. What Makes Some People Prone to Violence?

1. Aggression and Anger a. Aggressive behavior is often a key aspect of violent interactions. b. Primary aggression is goal-directed, hostile self-assertion that is destructive in nature. c. Reactive aggression is more often part of an emotional reaction brought about by frustrating life experiences. i. See the Mindfulness and You box for tips on how to manage your own flareups. d. Anger is a well-known catalyst for violence. It typically occurs when there is a triggering event or when a person has learned that acting out in angry ways can get him or her what he or she wants. e. People who anger quickly often have a low tolerance for frustration. The cause may be genetic or environmental.

2. Macro and Micro Aggressions a. Two of the main forms of stigmatizing or discriminatory insults that negatively target a marginalized group of individuals based on race, gender, disability economic status, age, religion, or overall difference of an individual. i. Verbal, behavioral, and environmental b. Typically, individuals who are anger-prone come from families that are disruptive, chaotic, and unskilled in emotional expression and in which anger, domestic violence, and abuse occur regularly. c. People who have been bullied in school may also be prone to react violently and suffer from PTSD as adults.

3. Substance Abuse a. Forty percent of all violent crimes include alcohol as a factor. b. Research suggests higher rates of alcohol use and violence in some athlete populations compared to nonathlete populations. c. Suicide and suicide attempts are highly correlated to drug and alcohol intake.

C. How Much Impact Do the Media Have?

1. A recent meta-analysis indicates that playing violent games may increase risks of aggression and desensitize people when violence occurs.

2. Today’s youth are exposed to more media violence than any previous generation, yet rates of violent crime have declined over the decades.

Key Terms: primary aggression, reactive aggression, micro aggression, macro aggression ABC News: See It! Videos: Was a North Carolina Killing a Hate Crime?

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III. Interpersonal, Collective, and Structural Violence A. Interpersonal violence involves using “physical force or power, threatened or actual” to inflict harm on an individual that results in injury, death, or psychological harm.”

1. Examples include homicide, hate crimes, domestic violence, child abuse, elder abuse, and sexual victimization.

B. Structural violence is violence where an institution or a social structure may harm someone by preventing them from obtaining their basic needs or rightful status in society.

C. Collective violence refers to violence committed by groups against other groups.

1. Examples include gang violence, terrorism, and other violent acts related to political, governmental, religious, cultural, or social clashes.

D. Homicide 1. Homicide is defined as murder or nonnegligent manslaughter (killing of another human).

2. It is the 13th-leading cause of death in the United States.

3. It is among the top five causes of death for people aged 1 to 44 years.

4. Nearly half of all homicides occur among people who know one another.

5. Homicide rates reveal clear disparities across race, gender, and age.

E. Hate Crimes and Bias-Motivated Crimes 1. A hate crime is committed against a person, property, or group of people that is motivated by the offender’s bias against a race, religion, disability, sexual orientation, gender/gender identity, or ethnicity.

2. Hate crimes declined to 5,479 incidents in 2014 according to the FBI. 3. Ethnoviolence (bias-motivated crime) is violence based on prejudice and discrimination among ethnic groups in the larger society.

4. Prejudice is an irrational attitude of hostility directed against an individual, a group, a race, or the supposed characteristics of an individual, a group, or a race.

5. Discrimination constitutes actions that deny equal treatment or opportunities to a group of people, based on prejudice.

6. Common reasons given to explain bias-motivated and hate crimes include thrill seeking, feeling threatened, retaliating, and/or fearing the unknown or differences.

F. Gang Violence 1. Gangs are believed to be responsible for 48 percent of U.S. violent crime overall and as much as 90 percent in some locations. a. Gangs give members a sense of self-worth, companionship, security, excitement, as well as economic incentives. b. Risk factors include friendship with delinquent peers, lack of parental monitoring, negative life events, alcohol and drug use, low self-esteem, academic problems, low socioeconomic status, alienation from family and society, a history of family violence, and living in gang-controlled neighborhoods.

G. Cybercrime 1. Cyberattacks are becoming more commonplace 2. To protect your own cybersecurity, the FBI recommends the following: a. Keep your computer’s firewall turned on.

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b. Choose antivirus and antispyware software from reputable sources. c. Keep your operating system up to date. d. Be careful what you download or open as attachments. e. Turn off your computer when you aren’t using it.

H. Terrorism 1. Terrorism is the “unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof in furtherance of political or social objectives.”

2. Over the past decade, the Centers for Disease Control and Prevention (CDC) created the Emergency Preparedness and Response Division to monitor potential public health problems such as bioterrorism, chemical emergencies, radiation emergencies, mass casualties, national disaster, and severe weather; develop plans for mobilizing communities in case of emergency; and provide information about terrorist threats.

I. Intimate Partner and Domestic Violence 1. Domestic violence has historically referred to the use of force to control and maintain power over another person in the home environment. a. Domestic violence can occur between parent and child, between spouses or intimate partners, or between siblings or other family members and may involve emotional abuse, verbal abuse, threats of physical harm, and actual physical violence. b. The term domestic violence is slowly being replaced by more specific categories of violence—violence that may or may not occur in the home.

2. Intimate Partner Violence (IPV) a. IPV describes physical, sexual, or psychological harm done by a current or former partner or spouse and doesn’t have to occur within the home. b. Intimate partner abuse can take the form of constant criticism, humiliation, verbal attacks, displays of explosive anger meant to intimidate, and controlling behavior. c. The cycle of IPV, developed by psychologist Lenore Walker, consists of three major phases: tension building, incident of acute abuse, and remorse/reconciliation. d. Walker’s research has been expanded to focus on battered woman syndrome.

3. Child Abuse and Neglect a. Child maltreatment is defined as any act or series of acts of commission or omission by a parent or caregiver that results in harm, potential harm, or threat of harm to a child. b. Child abuse refers to acts of commission, which are deliberate or intentional words or actions that cause harm, potential harm, or threat of harm to a child. c. Neglect is an act of omission, meaning a failure to provide for a child’s basic physical, emotional, or education needs or to protect a child from harm or potential harm. d. Child abuse occurs at every socioeconomic level, across ethnic and cultural lines, within all religions, and at all levels of education.

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J. Each year, hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited.

1. Many victims don’t report abuse because they are embarrassed or don’t want the abuser to get in trouble or retaliate by putting them in a nursing home or escalating the abuse.

Key Terms: interpersonal violence, collective violence, structural violence, homicide, hate crime, ethnoviolence, prejudice, discrimination, terrorism, domestic violence, intimate partner violence (IPV), child maltreatment, child abuse, neglect, Figures: Figure 5.3 Number of Murders in the United States in 2019 by Weapon Used Figure 5.4 Number of Bias-Motivated Crimes, Single-Bias Incidence, 2019 IV. Sexual Violence A. Sexual victimization refers to any situation in which an individual is coerced or forced to comply with or endure another’s sexual acts or overtures; it can run the gamut from harassment to stalking to assault and rape.

B. Sexual Assault and Rape 1. Sexual assault is any act in which one person is sexually intimate (ranging from simple touching to forceful penetration) with another person without that person’s consent.

2. Considered to be the most extreme form of sexual assault, rape is defined as penetration without the victim’s consent. a. Aggravated rape is any rape involving one or multiple attackers, strangers, weapons, or physical beatings. b. Simple rape is a rape perpetrated by one person, whom the victim knows, and does not involve a physical beating or use of a weapon. c. Nearly 1 in 5 women and 1 in 59 men in the United States have been raped at some time in their lives, with nearly 80 percent of female rape victims experiencing their first rape before the age of 25.

3. Acquaintance Rape a. Acquaintance rape refers to any rape in which the rapist is known to the victim. b. Alcohol and rape-facilitating drugs like GHB, ketamine, and rohypnol are frequently involved in acquaintance rape.

4. Reducing Rape on U.S. Campuses a. The Clery Act (1990) requires institutions to collect and report sexual crimes on their campuses. It also required institutions to address victim’s rights, disciplinary procedures, and educational programs. b. The Campus Sexual Assault Victim’s Bill of Rights, known as the Ramstad Act, (1992) gave victims the right to call off-campus authorities to investigate serious campus crimes and required universities to develop educational programs and notify students of available counseling.

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c. The Campus Sexual Violence Elimination Act (2014) requires that intimate partner violence, dating violence, sexual assault, and stalking are reported on annual campus crime reports. Notification procedures and other requirements and assessments are also included. d. In 2014, California changed the definition of sexual consent to require “an affirmative, conscious, and voluntary agreement to engage in sexual activity” (“yes means yes”).

5. Marital Rape a. Marital rape is defined as any unwanted intercourse or penetration between spouses obtained by force, by threat of force, or when the spouse is unable to consent. b. Women raised in cultures wear male dominance is the norm, as well as pregnant, separated, and divorced women, all have higher rates of forced sex within the confines of marriage.

6. Social Contributors to Sexual Violence a. Trivialization b. Blaming the victim c. Pressure to be macho d. Male socialization e. Male misperceptions f. Situational factors C. Sexual Harassment 1. Sexual harassment is defined as unwelcome sexual conduct that is related to any condition of employment, education, or performance evaluation.

2. Faculty, students, and employees on U.S. campuses are protected from sexual harassment and other sexual offenses under Title IX of the Education Amendment of 1972, which prohibits discrimination based on sex in all education programs or activities that receive federal funds.

3. Most schools and companies have sexual harassment policies in place as well as procedures for dealing with harassment problems.

4. If you feel you are being harassed, the most important thing to do is be assertive: Tell the harasser to stop, document the harassment, try to make sure you aren’t alone in the harasser’s presence, complain to a higher authority, and remember that you have not done anything wrong.

D. Traditional and Tech-Facilitated Stalking 1. Stalking is defined as a course of conduct directed at a specific person that would cause a reasonable person to feel fear; it may include repeated visual or physical proximity, nonconsensual written or verbal communication, and implied or explicit threats. Stalking that occurs online is referred to as cyberstalking.

2. College students are more likely to be stalked than the general public by 200 percent.

E. Child Sexual Abuse

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1. Sexual abuse of children by adults or older children includes sexually suggestive conversations; inappropriate kissing; touching; petting; oral, anal, or vaginal intercourse; and other kinds of sexual interaction.

2. Girls are more commonly abused than boys, although boys are also frequent victims.

3. Ninety percent of child sexual abuse victims know their perpetrator in some way, with nearly 70 percent of children abused by family members, usually an adult male.

4. Children who experience sexual abuse are at increased risk for anxiety disorders, depression, eating disorders, post-traumatic stress disorder, and suicide attempts.

Key Terms: sexual assault, rape, aggravated rape, simple rape, acquaintance rape, marital rape, sexual harassment, stalking, cyberstalking Figure: Figure 5.5 Sexual Violence Pervasive Among 18–24 Year-Old-Women Compared to Women Overall ABC News: Lecture Launcher Video: Sexual Assaults on College Campuses: 95 Colleges under Federal Investigation V. Preventing Violence A. It is far better to prevent a violent act than to recover from it.

B. Self-Defense against Personal Assault and Rape 1. Assault can occur no matter what preventive actions you take.

2. Self-defense is a process that includes increasing your awareness, developing selfprotective skills, taking reasonable precautions, and having the judgment necessary to respond quickly to changing situations.

3. Do the following to let a potential assailant know that you mean what you say and are prepared to defend yourself: a. Speak in a strong voice. b. Maintain eye contact. c. Stand up straight, act confident, and remain alert.

If you are attacked, act immediate. Draw attention to yourself and your assailant.

Scream, “Fire!” as loudly as you can. (Passersby are more likely to respond if they hear the word fire than just a scream.)

4. What to Do If Rape Occurs a. If you are a rape victim, do the following: i. Call 9-1-1. ii. Do not bathe, shower, douche, clean up, or touch anything the attacker may have touched. iii. Save the clothes you were wearing, and do not launder them. iv. Contact the rape assistance hotline in your area, and ask for advice on counseling. b. If someone you know is assaulted, do the following: i. Believe the rape victim. ii. Encourage the victim to see a doctor immediately.

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iii. Encourage the victim to report the crime to the police. iv. Be understanding. v. Recognize that this is an emotional situation and that it may take time for the person to bounce back. vi. Encourage the person to seek counseling.

C. Campus-Wide Responses to Violence 1. Many college administrators have been proactive in establishing violence-prevention policies, programs, and services.

2. Prevention and early response efforts include emergency messaging systems, e-mail alerts, reverse 911 systems, and others.

3. There are many changes to the campus environment that can improve safety, including better campus lighting, parking lot security, emergency call boxes, the removal of overgrown shrubbery, safe ride programs, and stepped-up security.

4. Campus police are responsible for emergency responses, and they have the power to enforce laws with students in the same way they are handled in the general community.

D. Community Strategies for Preventing Violence 1. It is necessary to address the issues of violence and safety at a community level.

VI. Unintentional Injuries •

Unintentional injuries occur without planning or intention to harm.

•

The two types of unintentional injuries that cause the most deaths every year are drug overdoses and motor vehicle accidents.

A. Motor Vehicle Safety 1. Impaired Driving: Alcohol a. Nearly one-third of all motor vehicle accident fatalities involve a drunk or alcohol impaired driver. b. After alcohol, marijuana is the drug most often linked to impaired driving.

2. Impaired Driving: Drowsiness a. Many researchers contend that driving while sleep-deprived is as dangerous as driving drunk.

3. Impaired Driving: Distractions a. Three types of activities constitute distracted driving: taking your eyes off the road, taking your hands off the steering wheel, and taking your mind off driving. b. Texting is one of the most dangerous forms of distracted driving.

4. Vehicle Safety Issues a. Wearing a safety belt cuts the risk of serious injury in a crash by almost half. b. Vehicles with high crash safety ratings also make driving safer.

5. Improve Your Driving Skills a. Risk management driving techniques reduce the chances of being involved in a collision and include the following: i. Don’t use electronic devices while driving.

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ii. Don’t drink and drive. iii. Keep your eyes on the road. iv. Keep your mind on the road. v. Avoid aggressive driving. vi. Drive with your low-beam headlights on day and night. vii. Drive defensively. viii. all traffic laws. ix. Always wear a seat belt.

B. Cycling Safety 1. Most fatal cycling accidents occur at nonintersections between the hours of 4 pm and midnight. a. Alcohol plays a significant role in bicycle deaths.

2. Cyclists should wear a properly fitted bicycle helmet every time they ride.

3. Cyclists should also consider the following suggestions: a. Watch the road and listen for traffic sounds. b. Don’t drink and ride. c. Follow all traffic laws, signs, and signals. d. Ride with the flow of traffic. e. Wear light or brightly colored reflective clothing. f. Avoid riding after dark. g. User proper hand signals. h. Keep your bicycle in good condition. i. Use bike paths whenever possible. j. Stop at stop signs and traffic lights.

C. Staying Safe in the Water 1. Drowning Risk Factors a. A lack of swimming ability b. Unsupervised swimming areas c. A lack of skilled supervision around water locations d. A failure to wear life jackets e. Temperature extremes that cause hypothermia f.

Riptides and other hazardous conditions

g. Seizure disorders h. Excess alcohol use 2. Most drownings occur during water recreation when people unexpectedly find themselves in dangerous situations.

3. To be safe, take the following precautions around water: a. Learn how to swim. b. Learn CPR. c. Don’t drink alcohol or take drugs before swimming. d. Never swim alone, even if you are a skilled swimmer.

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e. Pay attention to water temperature. f.

Never leave a child unattended, even in shallow water.

g. Before entering the water, check the depth. h. Never swim in a river with currents that are too swift for easy, relaxed swimming i. Watch riptide warnings and beach conditions.

4. Boating a. Of those who died from drowning during a boating accident in 2015, 85 percent were not wearing a personal flotation device (lifejacket). b. Alcohol consumption was the leading factor in boating deaths. c. When boating, you should share the plans for your outing, check the weather ahead of time, make sure your boat is in good condition with proper safety equipment, and carry an emergency radio and cell phonAlways make sure to have enough life jackets for all who are on board.

D. Safety at Home 1. Injuries in the home typically occur in the form of poisonings, falls, or burns.

2. Prevent Poisoning a. A poison is any substance that is harmful to your body when ingested, inhaled, injected, or absorbed through the skin. b. Drug overdose is the leading cause of accidental death in the United States. c. For comprehensive precautions, talk with your doctor or pharmacist and read labels. If you have question, call poison control.

3. Avoid Falls a. Falls are the third-most-common cause of death from unintentional injury. b. Safety measures include keeping the floor and stairs clear from objects; avoiding use of small scatter rugs and mats; training pets to stay away from feet; installing slip-proof mats in showers, tubs, and stairs; and using appropriate step stools and ladders.

4. Reduce Your Risk of Fire a. The primary causes of fires in campus housing are cooking, use of candles, careless disposal of smoking materials, faulty wiring, and arson. Impaired judgment from alcohol is a major contributor. b. Tips to prevent fires include extinguishing all cigarettes before bed, setting lamps and candles away from combustibles, keeping hot pads and kitchen cloths away from stove burners, using caution when lighting barbecue grills, not overloading electrical circuits, having the proper fire extinguishers ready, and replacing batteries in smoke alarms.

Key Terms: impaired driving, distracted driving, personal flotation device, poison

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Discussion Questions 1. Explain how it could be possible for some news outlets to report an increase in crime rate while others report a decrease.

2. Discuss what you believe to be the top five societal factors that increase the likelihood of violent acts in the United States. In your discussion explain why you selected these five factors.

3. What is alcohol’s role in the occurrence of violence?

4. How do advertisements, television shows, and movies portray sexual assault? How is sexual assault portrayed through social media and social networking?

5. Describe the seriousness of relationship violence on college campuses.

6. What situations raise the risk of child sexual abuse in the home?

7. What campus-wide violence prevention programs do you think are the most effective at curbing violence?

8. How can the use of drugs or alcohol increase the likelihood of date rape? What can you do to prevent this increased risk?

Critical Thinking Questions 1. Have you ever personally experienced or witnessed an act of violence? What caused the violence? Was the violence intentional or unintentional? Was the violence physical, emotional, or psychological? How could you or the other person have avoided the violent act? How did you cope with your feelings after the experience?

2. What kind of information, programs, or support groups could officials and administrators on your campus provide to ensure campus crimes are reported?

3. Despite evidence to the contrary, why does the narrative persist that media violence is the main factor when it comes to societal violence?

4. Why do you think homicide is a leading cause of death for persons aged 15 to 24? What steps do you think could be taken to greatly reduce the number of deaths? What could be done on your campus to prevent homicide?

5. How has terrorism changed U.S. culture and economy?

6. What can you do as an individual to help a young person who has become involved with a gang to leave the gang and resist the gang’s influence?

7. Why do you think rape and other sexual assault crimes are sometimes trivialized and made the subject of jokes and ridicule? What do you think can be done to change this attitude?

8. How do you think you would react if a friend confided in you that he or she had been raped but was afraid to report the crime to the authorities? What could you say or do that would be supportive and not blaming?

Student Activities Individual

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1. Complete the assessment at the end of the chapter: Are You at Risk for Violence or Injury? What are your reactions to your score? Are there some behaviors in the assessment that you did not think were inappropriate?

2. Identify your most vulnerable times for an assault to occur at school, at work, and at your residence. Make an action plan to take steps to protect yourself.

3. Research self-protection programs available on campus or in the local community. How do these classes help a person to defend himself or herself in a potentially violent situation?

Community 1. Make a list of campus resources to decrease campus crime (e.g., student escort services).

On a campus map, find the locations of emergency call boxes. Share this information with friends and classmates.

2. Does your campus have a program similar to Neighborhood Watch? If so, what kind of services does this program provide? If your campus does not have such a program, what steps can you take to start one?

3. What resources does your campus or community provide for victims of sexual assault or domestic violence? Are shelters available for those in danger of violence? What support services are available for victims? How can you let people know that these services are available if needed?

4. Research the procedures your campus has in place to prevent a tragedy such as recent shootings on college campuses. Is this information readily available to everyone on campus? If not, how can the dissemination of this information be more efficient?

Diverse Population/Nontraditional 1. Use the Internet to research violent crime rates in other countries with large populations, such as China, India, and Mexico. How do these rates differ from that of the United States? What are the major causes of violent crime in the other country? What are the consequences of committing a violent crime in that country?

2. Make a list of reasons why someone unfamiliar with American culture might be at a greater risk for crime. Why might an American traveling in a foreign country be at a greater risk of violent crime?

3. How can people with disabilities protect themselves from crime? What resources exist to aid them?

Additional References Centers for Disease Control and Prevention, Injury Prevention and Control, “Ten Leading Causes of Injury and Deaths—2014” and “10 Leading Causes of Injury Deaths by Age Highlighting Violence-Related Injury Deaths, United States—2014,” www.cdc.gov World Health Organization, Global Status Report on Violence Prevention (Geneva: World Health Organization, 2014), www.undp.org Federal Bureau of Investigation, Crime in the United States, Preliminary Semiannual Uniform Crime Report for January-June 2016, 2016, www.fbi.gov K. Caird, R. Willness, P. Steel, and Scialfa, “A Meta-analysis of the Effects of Cell Phones on Driver Performance,” Accident Analysis & Prevention, 40 (2008): 1282–1293. ..

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K. L. Chan, M. Straus, Brownridge, Tiwari, and W. Leung, “Prevalence of Dating Partner Violence and Suicidal Ideation among Male and Female University Students Worldwide,” Journal of Midwifery & Women’s Health, 53 (2008): 529–537.

S. Cramer, Mayer, and S. Ryan, “College Students Use Cell Phones While Driving More Frequently than Found in Government Study,” Journal of American College Health, 56 (2007): 181–184.

R. Gilber, Widom, K. Browne, Fergusson, Webb, and S. Janson, “Burden and Consequences of Child Maltreatment in High-income Countries,” The Lancet, 373 (2009): 68–81.

K. Heilbrun, Dvoskin, and Heilbrun, “Toward Preventing Future Tragedies: Mass Killings on College Campuses, Public Health, and Threat/Risk Assessment,” Psychological Injury and Law, 2 (2009): 93–99.

M. Herek, “Hate Crimes and Stigma-related Experiences among Sexual Minority Adults in the United States: Prevalence Estimates from a National Probability Sample,” Journal of Interpersonal Violence, 24 (2009): 54–74.

O. Laumann, S. Leitsch, and L. Waite, “Elder Mistreatment in the United States: Prevalence Estimates from a Nationally Representative Study,” The Journals of Gerontology: Series B, 63 (2008): S248–S254.

Q. Li, “New Bottle but Old Wine: A Research of Cyberbullying in Schools,” Computers in Human Behavior, 23 (2007): 1777–1791.

N. Pereda, Guilera, M. Forns, and Gomez-Benito, “The Prevalence of Child Sexual Abuse in Community and Student Samples: A Meta-analysis,” Clinical Psychology Review, 29 (2009): 328–338.

Rivers and N. Noret, ‘“I h8 u’: Findings from a Five-year Study of Text and E-mail Bullying,” British Educational Research Journal, 36 (2010): 643–671.

For Further Information American Red Cross www.redcross.org Centers for Disease Control and Prevention Injury and Violence Prevention & Control www.cdc.gov/injury/index.html National Committee for the Prevention of Elder Abuse http://preventelderabuse.org National Highway Traffic Safety Administration www.nhtsa.gov National Safety Council www.nsc.org National Sexual Violence Resource Center www.nsvrc.org Prevent Child Abuse America www.preventchildabuse.org 76

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Rape, Abuse, and Incest National Network (RAINN) www.rainn.org Stop the Hate http://stophate.org

Additional Media Ready-to-Go Teaching Module: Violence and Unintentional Injuries Bike Helmet Safety, 2 minutes In this Consumer Reports video, viewers are taught what to consider when selecting a bicycle helmet for themselves or their children. www.youtube.com/watch?v=7fE8TXUz6sY Emergency Health Tips: The Heimlich Maneuver: Conscious Choking Adult, 2 minutes In this Expert Village tutorial, the viewer learns how to administer the Heimlich Maneuver on a conscious choking adult. www.youtube.com/watch?v=Aj-XshIGI08&feature=channel Gail Rosseau, MD–Discusses Helmet Safety on Channel 5 News, 3 minutes In this news clip, Dr. Gail Rosseau provides an illustration of the importance of wearing a helmet and discusses the proper fit tips. www.youtube.com/watch?v=bkXTodtaQVc&NR=1 One in Four–How to Help a Sexual Assault Survivor, 3 minutes This video is provided by males, for males, and is designed to teach males how to help a female friend who has experienced sexual assault. www.youtube.com/watch?v=j0g14GUARh0 Red Cross on Water Safety, 20 seconds In this brief educational clip, water safety expert Connie Harvey, of the American Red Cross, discusses what to do if you see someone struggling in the water. https://www.youtube.com/watch?v=exhsd2YhO58 “Understanding Teen Bullying,” 7 minutes In this news clip from Good Morning Memphis, parenting expert Brian Housman discusses the prevalence of bullying, what teenagers are bullied about, and the most effective way to stop bullying. www.youtube.com/watch?v=KwUV28cUMOY Water Safety: Eating and Swimming, 30 seconds In this brief educational clip, water safety expert Connie Harvey, of the American Red Cross, discusses why you should wait to swim after eating. https://www.youtube.com/watch?v=qCfXyhbbl9cc

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CHAPTER

6

Connecting and Communicating in the Modern World

Overview Relationships are an important part of life. From the moment we enter the world, we are involved in relationships with others. In this chapter, we explore intimate relationships.

Students will learn to identify the types of committed relationships, the characteristics of successful relationships, and the importance of social networks. This chapter will also provide students with skills to improve their communication and conflict-management skills.

Learning Outcomes 1. Describe the types of social support available and the impact of social networks on health status.

2. Discuss the purpose and common forms of intimate relationships.

3. Discuss ways to improve communication skills and interpersonal interactions, particularly in the digital environment.

4. Identify the characteristics of successful relationships, including how to overcome common conflicts, and discuss how to cope when a relationship ends.

5. Compare and contrast the types of committed relationships and singlehood.

Lecture Outline I. The Value of Relationships A. Research shows that all types of healthy relationships are good for our health.

B. Friendships provide us with social support—the type of help we receive from contact with others—which is delivered in four forms: 1. Emotional support: displays of caring, love, trust, and empathy 2. Instrumental support: concrete help and service 3. Informational support: advice, suggestions, and information 4. Belonging support: sharing activities or a sense of belonging C. Another theory suggests that having friends can change your perspective on how challenging a task is.

D. Research also shows that, when it comes to health, it is the quality of friendships, not the quantity, that matters.

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E. The collective value of all the people in your social network—and the likelihood of those people providing social support when you need it—determine your social capital.

1. The more social capital that you have, the happier and healthier you are.

2. To build social capital, one must both strengthen existing ties and widen their existing network.

F. Relational connectedness comes from mutually rewarding face-to-face contact.

G. Collective connectedness comes from the feeling that you are part of a group beyond yourself.

Key Term: social support, social network, social capital, relational connectedness, collective connectedness II. Intimate Relationships: When Connecting Gets Personal A. Everyone needs people in their lives who affirm who we are and provide intimate connectedness.

B. Intimate relationships often include four characteristics: 1. Behavioral interdependence: the mutual impact that people have on each other as their lives intertwine 2. Need fulfillment: intimate relationships that fulfill our needs for intimacy, social integration, nurturance, assistance, and affirmation 3. Emotional attachment: strong bonds of love and intimacy 4. Emotional availability: the ability to give to and receive from others emotionally without fear of being hurt or rejected C. People with positive, fulfilling relationships with spouses, family members, friends, and coworkers are 50 percent more likely to survive over time than people with poor relationships.

D. A study of college students in committed relationships found that they reported fewer mental health problems and were less likely to be overweight or obese.

E. Caring for Yourself 1. Two personal qualities are especially important to any good relationship: a. Accountability means that both partners see themselves as responsible for their own decisions, choices, and actions; they do not hold the other person responsible for positive or negative experiences. b. Self-nurturance means developing individual potential through a balanced and realistic appreciation of self-worth and ability.

2. Important factors that affect your ability to nurture yourself and maintain healthy relationships with others include the way you define yourself (self-concept) and the way you evaluate yourself (self-esteem).

F. Family Relationships 1. A family is a recognizable group of people with roles, tasks, boundaries, and personalities whose central focus is to protect, care for, love, and socialize with one another.

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2. Although there is no “best” family type, we know that a healthy family’s key roles and tasks are to nurture and support. Healthy families foster a sense of security and feelings of belonging that are central to growth and development.

3. Our family of origin includes the people present in our household during our first years of life where we learn about feelings, problem-solving, and love, intimacy, and gender roles.

G. Friendships 1. Friendships are often the first relationships we form outside our immediate families.

2. Getting to know someone requires time, effort, and commitment.

H. Romantic Relationships 1. Romantic relationships typically include all the characteristics of friendship as well as fascination, exclusivity, sexual desire, giving the utmost, and being a champion or advocate.

2. Theories of Love a. Sternberg’s Triangular Theory of Love proposes three components of loving relationships: i. Intimacy is the emotional component, which involves closeness, sharing, and mutual support. ii. Passion is the motivational component, which includes lust, attraction, sexual arousal, and sharing. iii. Commitment is the cognitive component, which includes the decision to be open to love in the short term and the commitment to the relationship in the long term. b. Sternberg uses the term consummate love to describe a combination of intimacy, passion, and commitment. c. Anthropologist Helen Fisher suggests that there is a pattern of falling in love: i. Imprinting: in which our evolutionary patterns, genetic predispositions, and past experiences trigger a romantic reaction ii. Attraction: in which neurochemicals produce feelings of euphoria and elation iii. Attachment: in which endorphins—natural opiates—cause lovers to feel peaceful, secure, and calm iv. Production of the cuddle chemical: activity during which the brain secretes the hormone oxytocin, which stimulates sensations during lovemaking and elicits feelings of satisfaction and attachment 3. Choosing a Romantic Partner a. Attraction theory suggests that the following play strong roles in influencing with whom one falls in love: i. Proximity: being in the same place at the same time ii. Similarities in attitudes, values, intellect, interests, education, and socioeconomic status iii. Reciprocity: if a potential partner expresses interest, you may react with mutual regard iv. Physical attraction 80

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Key Terms: intimate connectedness, intimate relationships, accountability, self-nurturance, family of origin, consummate love Figure: Figure 6.1 Sternberg’s Triangular Theory of Love III. Building Communication Skills •

By adulthood each of us has developed a unique way of communicating to others with gestures, words, expressions, and body language.

•

Different cultures have different ways of expressing feelings and using body language.

A. Learning Appropriate Self-Disclosure 1. Self-disclosure is sharing personal information with others.

2. Self-disclosure is not only storytelling or sharing secrets; it is sharing emotions about what you are currently experiencing in life and giving any information about the past that is relevant to the other person’s understanding of your current reactions.

3. Do the following to overcome the fear of self-disclosure: a. Get to know yourself. b. Become more accepting of yourself. c. Be willing to talk about sex. d. Choose a safe context for self-disclosure. e. Be thoughtful about self-disclosure via social media.

B. Becoming a Better Listener 1. Listening is a vital part of interpersonal communication.

2. We listen best when we believe that the message is important and relevant to us, when the speaker holds our attention, and when we are in the mood to listen.

3. See the Mindfulness and You box for information on how mindfully listening can improve your relationships.

4. The Three Basic Listening Modes a. Passive listening: when one is listening but not providing any verbal or nonverbal feedback to the speaker b. Selective listening: when we are engaged but listening only for information that supports what we already believe c. Active listening: when one hears the words and tries to understand what is really being said. The listener confirms understanding by restating or paraphrasing the speaker’s message before responding.

C. Using Nonverbal Communication 1. Nonverbal communication includes all unwritten and unspoken messages, both intentional and unintentional.

2. Nonverbal communication can include the following: touch, gestures, interpersonal space, facial expressions, body language, and tone of voice.

D. Connecting Digitally

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1. Digital communication does allow us to have a more diverse social network and to easily keep in touch over long distances.

2. Users of social networking sites (SNS) seem to have larger and stronger social networks.

3. A recent meta-analysis found Facebook-based social support improved general health and well-being, as well as mental health, reducing symptoms of depression, anxiety, and loneliness; however, as usage levels shifted toward addiction, the social support received decreased.

4. We now have details about other people’s lives that, in the past, we would have known only about our closest friends. This can cause stress levels to increase and has been called the “cost of caring,”.

5. “Constant checkers” feel more stress than non-constant checkers because monitoring incoming information and our constant readiness to respond to it reduces our ability to cope with stressors.

6. The lack of nonverbal communication in text-based digital communication can lead to confusion and misunderstanding. a. Experts are concerned that reduced exposure to nonverbal communication may reduce people’s ability to read facial expressions—having an impact on their inperson communication skills.

E. Managing Conflict through Communication 1. Conflict is an emotional state that arises when the behavior of one person interferes with that of another. a. Not all conflict is bad; in fact, airing feelings and coming to some form of resolution over differences can sometimes strengthen relationships.

2. Conflict resolution and successful conflict management form a systematic approach to resolving differences fairly and constructively, rather than allowing them to fester. a. The goal of conflict resolution is to resolve differences peacefully and creatively. b. Strategies for conflict resolution include the following: identify the problem or issue, generate several possible solutions, evaluate the alternative solutions, decide on the best solution, implement the solution, and follow up.

Key Terms: self-disclosure, nonverbal communication, conflict, conflict resolution Figure: Figure 6.2 Nonverbal Communication That Indicates Romantic Interest ABC News: See It! Videos: One Woman’s Journey through 100 Dates IV. Relationships: For Better and Worse A. Characteristics of Healthy Relationships 1. Satisfying and stable relationships are based on good communication, intimacy, friendship and other factors.

2. A key ingredient is trust—the degree to which each partner feels he or she can rely on the integrity of the other. Without trust, intimacy will not develop.

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a. Predictability b. Dependability c. Faith 4. Figure 6.3 illustrates some of the factors that signal a healthy or unhealthy relationship.

5. Poor communication in relationships can weaken bonds and create mistrust. a. Breakdowns in relationships often begin with a change in communication, however subtle.

6. College students, particularly those who are socially isolated and far from family and hometown friends, may be particularly vulnerable to staying in unhealthy relationships.

B. Confronting Couples Issues 1. Couples seeking a long-term relationship must confront several issues: jealousy, sharing power and responsibility, and communication about unmet expectations.

2. Jealousy a. Jealousy is described as a negative reaction evoked by a real or imagined relationship involving one’s partner and another person. b. Jealousy often indicates underlying problems, such as insecurity or possessiveness—significant barriers to a healthy relationship. c. Other causes of jealousy include overdependence on the relationship, severity of the threat, high value on sexual exclusivity, low self-esteem, and fear of losing control. d. Although a certain amount of jealousy can occur in any loving relationship, it doesn’t have to threaten the relationship as long as partners communicate openly about it.

3. Sharing Power and Responsibilities a. Power can be defined as the ability to make and implement decisions. b. Our modern society has very few gender-specific roles. c. Rather than taking on traditional female and male roles, many couples find it makes more sense to divide tasks based on schedule, convenience, and preference. d. The division of labor at home, however, is not equal, with women more likely to do household chores. e. If couples fail to communicate how they feel about sharing power and responsibility to arrive at an equitable solution, the relationship is likely to suffer.

4. Unmet Expectations a. Expectations are an extension of our values, beliefs, hopes, and dreams for the future. b. When communicated and agreed on, expectations help relationships thrive. c. Partners in healthy relationships can communicate wants and needs and have honest discussions when things aren’t going as expected or as planned.

C. When and Why Relationships End 1. Reasons relationships may end include illness, financial concerns, career problems, geographical separation, and personality conflicts.

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a. Criticism b. Defensiveness c. Stonewalling d. Contempt 3. Contempt is the biggest predictor of divorce.

D. Coping with Failed Relationships 1. No relationship comes with a guarantee, and uncoupling can be very painful.

2. Consider the following tips for coping with a failed relationship: a. Acknowledge that you’ve gone through a rough spot. b. Let go of negative thought patterns and habits. c. Make a promise to yourself: no new relationships until you have moved past the last one.

Key Terms: jealousy, power Figure: Figure 6.3 Healthy versus Unhealthy Relationships V. Partnering and Singlehood •

Commitment in a relationship means that one intends to act over time in a way that perpetuates the well-being of the other person, oneself, and the relationship.

A. Marriage 1. In the United States, marriage means entering into a legal agreement that includes shared finances, property, and often the responsibility for raising children.

2. Historically, close to 90 percent of Americans married at least once during their lifetime. a. In recent years, however, Americans are becoming less likely to marry.

3. The divorce rate in the United States is declining. a. Reasons include the number of couples who cohabitate instead of marry, an increase in age at which people first marry, and a higher level of education among those who are marrying.

4. Many Americans believe that marriage involves monogamy, or exclusive sexual involvement with one person.

5. For many Americans, the pattern is one of serial monogamy, which means a person has a monogamous sexual relationship with one person before moving on to another monogamous relationship.

6. An open relationship involves agreement between partners that there may be sexual involvement for each person outside the relationship.

7. A small number of couples choose an open relationship, in which partners agree that there may be sexual involvement outside their marriage.

8. Lesbians and gay men have the same desire for intimacy as heterosexual partners do.

9. In addition to normal relationship challenges, gay and lesbian couples often must face discrimination and difficulties with social, legal, and religious issues.

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10. In 2015, the Supreme Court’s ruling in Obergefell v. Hodges made same-sex marriage legal in all 50 states.

11. Couples in healthy marriages live longer, feel happier, remain mentally alert longer, and suffer fewer physical and mental health problems.

B. Cohabitation 1. Cohabitation is defined as two unmarried people with an intimate connection who live in the same household.

2. In some states, cohabitation that lasts a designated number of years (usually seven) legally constitutes a common-law marriage for purposes of purchasing real estate and sharing other financial obligations.

3. Cohabitation can confer many of the same benefits as marriage and serves as a permanent alternative to marriage for some.

4. Disadvantages of cohabitation include lack of societal validation and lack of tax benefits, and legal issues over property and health care decision-making powers.

C. Staying Single 1. Increasing numbers of adults of all ages are electing to marry later or to remain single altogether.

2. Many singles live rich, rewarding lives and maintain a large network of close friends and family.

Key Terms: monogamy, serial monogamy, open relationship, cohabitation, common-law marriage Figure: Figure 6.4 Marital Status of the U.S. Population by Sex

Discussion Questions 1. Do you feel that falling in love follows the steps indicated by anthropologist Helen Fisher?

Why do you agree or disagree with her view of the chemistry of love? What other theory of love better fits your view and/or experiences?

2. How do you think men and women differ in the way they view relationships? What do you think contributes to these views?

3. How have gender roles changed over the past 20 years? How are the changes positive and negative for both men and women?

4. Discuss both healthy and unhealthy ways people cope with failed relationships. What areas for growth can you identify in your own dealings with failed relationships, or how might you adopt new coping strategies for the future?

Critical Thinking Questions 1. Drawing on your own life experiences, describe how today’s families have changed from the description of a traditional nuclear family with a male and a female parent and

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2.

3.

4.

5.

biological children. How do today’s families share the same love, commitment, and values as traditional families?

Explain the strengths and weaknesses of your communication skills with your family members. friends and roommates, and your boyfriend, girlfriend, or significant other. How do you vary your communication skills depending on with whom you are communicating?

What characteristics would your perfect life partner have? How have these characteristics changed over the years? Do you think it is realistic to believe you will meet such a person with all these characteristics?

Do you agree with Sternberg’s Triangular Theory of Love, as shown in Figure 6.1? Have you ever experienced consummate love?

In your last relationship with a significant other or close friend, which of the healthy and unhealthy behaviors from Figure 6.3 did you exhibit? How would you change the behaviors that are unhealthy in a relationship?

6. Why do you think good communication with your partner is a foundation for having a satisfying sexual relationship? How might you improve communication with your partner?

What are some of the barriers you feel and experience to improving communication with your partner?

Student Activities Individual 1. Discuss what you think would be an ideal division of work responsibilities around the home for a man and woman with two young children. How have these gender roles changed from those of your parents?

2. Talk to your sexual partner about how improving communication can improve sexual satisfaction. What are his or her experiences and opinions? Are your views close together or far apart? If you don’t have a sexual partner, discuss these topics with a friend and problem-solve how you might improve communication with a future sexual partner.

Community 1. List five ways you can improve the relationships you have with people in your surrounding community (i.e., dorm, sports team, classes).

2. Research the makeup of families in the community in which you live. Are most of the families traditional with two parents of opposite sexes with children? Or are there more single-parent families? What is the percentage of gay and lesbian families with children?

Create a pie chart that illustrates the results of your research.

Diverse Population/Nontraditional 1. Use the Internet to research gender roles in other cultures. How have traditional gender roles changed compared with modern gender roles in the culture? While doing your research, focus on traditional roles such as household responsibilities, raising and educating children, providing food and shelter, and other roles.

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2. Research how organizations such as Heifer International are helping to eliminate gender inequality, in terms of education and financial security, for women in communities around the world.

Additional References J. T. Cacioppo and S. Cacioppo, “Social Relationships and Health: The Toxic Effects of Perceived Social Isolation,” Social and Personality Psychology Compass, 8, no. 2 (2014): 58–72.

Obergefell v. Hodges, 576 U.S. (2015).

S. R. Braithwaite, R. Delevi, and F. D. Fincham, “Romantic Relationships and the Physical and Mental Health of College Students,” Personal Relationships, 17 (2010): 1–12.

V. M. Buote, S. M. Pancer, M. W. Pratt, G. Adams, S. Birnie-Lefcovitch, J. Polivy, and M. G. Wintre, “The Importance of Friends: Friendship and Adjustment among 1st-year University Students,” Journal of Adolescent Research, 22 (2007): 665–689.

A. J. Johnson, M. M. Haigh, J. A. H. Becker, E. A. Craig, and S. Wigley, “College Students’ Use of Relational Management Strategies in Email in Long-distance and Geographically Close Relationships,” Journal of Computer-Mediated Communication, 13 (2008): 381–404.

E. Marquardt et al., “The President’s Marriage Agenda for the Forgotten Sixty Percent,” The State of Our Unions: Marriage in America, 2012 (Charlottesville, VA: National Marriage Project and the Institute for American Values, 2012).

L. D. Pitman and A. Richmond, “University Belonging, Friendship Quality, and Psychological Adjustment during the Transition to College,” The Journal of Experimental Education, 76 (2008): 343–362.

R. Wise, “Family Environment as a Predictor of the Quality of College Students’ Friendships,” Journal of Family Issues, 29 (2007): 828–848.

For Further Information American Association for Marriage and Family Therapy www.aamft.org American Psychological Association Families and Relationships www.apa.org/helpcenter/family/index.aspx Conflict Resolution Information Source www.crinfo.org The Gottman Relationship Institute www.gottman.com

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Additional Media Nonverbal Communication, Body Language Expert Jan Hargrave, 9 minutes In this video, body language expert Jan Hargrave teaches the viewer how to use body language to gain a competitive advantage. www.youtube.com/watch?v=5X7fKZTmZa4

“Toxic Relationships,” 4 minutes A CBS Early Show news segment in which clinical psychologist Dr. Wendy Walsh speaks with Chris Wragge about when a relationship is so toxic, you have to leave. www.youtube.com/watch?v=s4YF2h_HWtE&feature=related

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CHAPTER

6A

Focus On: Understanding Your Sexuality

Overview This chapter explores sexuality, starting with the time of conception when our sexual identity begins. It explores how social constructs and gender roles play an important role in how we express our sexuality. Chapter 6A discusses the biological, physiological, psychological, and social determinants of our sexuality and explains the functions of the male and female reproductive anatomy. It also describes the stages of the human sexual response and the options available for expressing sexuality.

Learning Outcomes 1. Define sexual identity and discuss its major components, including biology, gender identity, gender roles, and sexual orientation.

2. Identify the primary structures of male and female reproductive anatomy, and explain the functions of each.

3. List and describe the stages of the human sexual response, and classify types of sexual dysfunctions.

4. Discuss the variety of sexual expression and their implications for sexual health and safety.

Lecture Outline I. Your Sexual Identity A. Sexual identity is a combination of the sex assigned at birth, the gender the person identifies as, and who the person is attracted to, both physically and emotionally.

B. The beginning of sexual identity begins at conception with the combining of chromosomes that determine sex.

C. All eggs carry an X chromosome; the sperm may carry either an X or a Y chromosome.

Females are XX; males are XY. D. The genetic instructions included in the sex chromosomes lead to the differential development of male and female gonads (reproductive organs) at about the eighth week of fetal life.

E. Sometimes chromosomes are added, lost, or rearranged in this process and the sex of the baby is not clear, a condition known as intersexuality, or disorders of sexual development (DSDs). ..

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1. About 1 in 2,000 babies (0.05 percent) are born with genitals that are ambiguous enough to lead to a recommendation of surgery.

2. Reconstructive surgery on infants has become controversial, as advocates argue surgery should be postponed until consent can be given.

F. The primary female sex hormones are estrogen and progesterone.

G. The primary male sex hormone is testosterone.

H. At the time of puberty, sex hormones again play major roles in development.

I. Hormones released by the pituitary gland, called gonadotropins, stimulate the testes and ovaries to make appropriate sex hormones.

J. The increase of estrogen production in females and testosterone production in males leads to the development of secondary sex characteristics like vocal pitch, body hair, and location of fat deposits.

K. Gender refers to the attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex.

L. Our sense of masculine and feminine traits is largely a result of socialization during our childhood.

M. Gender roles are the behaviors and activities we use to express our masculinity or femininity in ways that conform to society’s expectations.

1. Gender-role stereotypes can make it difficult to express one’s true sexual identity.

N. Androgyny is the combination of both masculine and feminine traits in a single person.

O. Gender identity is a person’s sense of awareness of being masculine, feminine, a blend of both masculine and feminine, or neither masculine nor feminine. a. This inner concept of one’s self impacts how a person sees themselves in the world and influences their use of gender pronouns (e.g., he she, they).

2. A person whose gender identity does not match his or her biological sex assigned at birth is said to be transgender.

P. When a person’s gender identity matches the sex assigned at birth, the person is cisgender.

Q. Sexual Orientation 1. Sexual orientation refers to a person’s enduring emotional, romantic, or sexual, attraction to others.

2. A person may be primarily attracted to members of the opposite sex (heterosexual), the same sex (homosexual), or both sexes (bisexual). a. Today, we talk about attraction as being far more diverse and includes, among others, people who are pansexual, asexual, androsexual, and gynosexual.

3. Many homosexuals prefer the terms gay, queer, and lesbian to describe their sexual orientation. Gay and queer apply to both men and women, but lesbian refers specifically to women.

4. Sexual prejudice refers to negative attitudes and hostile actions directed at a social group and its members.

Key Terms: intersexuality, gonads, puberty, pituitary gland, secondary sex characteristics, gender, socialization, gender roles, androgynous, gender identity, transgender, cisgender, sexual orientation, heterosexual, bisexual, gay, lesbian, sexual prejudice, disorders of sexual development (DSDs), gender role stereotypes, gender expression, transition 90

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II. Sexual and Reproductive Anatomy and Physiology A. Female Reproductive Anatomy and Physiology 1. The female reproductive system includes two major groups of structures: the external genitals and the internal organs. See Figure 1.

2. External female genitals are collectively known as the vulva and include all structures that are outwardly visible: a. The mons pubis is a pad of fatty tissue covering and protecting the pubic bone. b. The labia majora are folds of skin and erectile tissue that enclose the vaginal and urethral openings. c. The labia minora are folds of mucous membranes. d. The clitoris is located at the upper end of the labia minora and beneath the mons pubis, and its only known function is sexual pleasure. e. The urethral opening is right below the clitoris. f. The vaginal opening may be covered by a thin membrane (the hymen).

3. The internal female genitals include the following: a. The vagina is the passageway from the uterus to the outside of body. b. The uterus (womb) is a hollow, muscular, pear-shaped organ. c. The endometrium is the lining of the uterus. d. The cervix is the lower end of the uterus. e. The ovaries produce estrogen and progesterone, housing immature eggs. f. The fallopian tubes capture eggs as they are released from the ovaries during ovulation, and they are the site where sperm and egg meet and fertilization takes place.

4. The Onset of Puberty and the Menstrual Cycle a. With the onset of puberty, the female reproductive system matures, and the development of secondary sex characteristics transforms young girls into young women. i. About age 9½ to 11½ the hypothalamus receives the message to begin secreting gonadotropin-releasing hormone (GnRH). ii. The release of GnRH signals the pituitary gland to release gonadotropin hormones, especially follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which signal the ovaries to start producing estrogen and progesterone. b. Estrogen regulates the menstrual cycle, and progesterone helps the endometrium to develop in preparation to nourish a fertilized egg and helps maintain pregnancy. c. The normal age range for the onset of the first menstrual period, termed menarche, is 10 to 18 years, with the average age being 12 to 13 years. d. The average menstrual cycle lasts 28 days and consists of three phases: the proliferative phase, the secretory phase, and the menstrual phase. See Figure 2. e. The proliferative phase begins with the end of menstruation when the hypothalamus senses low blood levels of estrogen and progesterone. It increases secretion of GnRH, which triggers pituitary gland release of FSH.

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i.

f.

FSH signals several ovarian follicles to begin maturing during which time they begin producing estrogen and signal the endometrium to proliferate. ii. High estrogen levels increase the release of LH causing the mature ovarian follicle (Graafian follicle) to rupture releasing a mature ovum near a fallopian tube (around day14). This process is known as ovulation.

The secretory phase is the phase after ovulation, when the ruptured Graafian follicle is turned into corpus luteum and begins secreting large amounts of estrogen and progesterone. i. If fertilization and implantation take place, cells surrounding the developing embryo release a hormone called human chorionic gonadotropin (HCG), increasing estrogen and progesterone secretions that maintain the endometrium and signal the pituitary not to start a new menstrual cycle.

g. If no implantation occurs, the endometrium is sloughed off in the menstrual flow, and this begins the menstrual phase.

5. Menstrual Problems a. Premenstrual syndrome (PMS): a collection of physical, emotional, and behavioral symptoms that many women experience 7 to 14 days prior to menstruation. b. Premenstrual dysphoric disorder (PMDD): symptoms include severe depression, hopelessness, anger, anxiety, low self-esteem, difficulty concentrating, irritability, and tension. c. For severe cramping, your health care provider may recommend lower-dose oral contraceptives to prevent ovulation. Without ovulation there are fewer prostaglandins to trigger muscle contractions, thus reducing the severity of cramps. d. Dysmenorrhea: the medical term for menstrual cramps. e. Although toxic shock syndrome (TSS) is rare today, it is still something that women should be aware of. It is caused by a bacterial infection facilitated by tampon, diaphragm, or contraceptive sponge use.

6. Menopause a. Menopause is the permanent cessation of menstruation. It generally occurs after the age of 45 for women in the United States. i. Perimenopause refers to the four to six years preceding menopause when hormonal changes take place and menstrual cycles and flow can become irregular. b. Menopausal changes result in decreased estrogen levels causing symptoms such as decreased vaginal lubrication, hot flashes, night sweats, headaches, dizziness, and joint pain. c. Synthetic forms of estrogen and progesterone have been prescribed as hormone replacement therapy (HRT), also called menopausal hormone therapy. i. This treatment has been shown to increase the risk of stroke, blood clots, and breast cancer in some women. ii. Today, doctors only prescribe menopausal hormone therapy for women under the age of 60 and free of personal or family history of heart disease, high cholesterol, high blood pressure, breast cancer, or blood clots.

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1. The male reproductive system is also divided into internal and external genitalia. See Figure 3.

2. The penis and the scrotum make up the external genitalia. a. The penis is the male organ through which urine and semen are expelled from the body. b. Ejaculation expels the semen through the urethra out of the penis. c. The scrotum serves to control temperature and protects the testes, which manufacture sperm and testosterone.

3. The internal genitalia include many organs and glands. a. The testes are responsible for manufacturing sperm and for producing testosterone. b. Spermatogenesis is the development of sperm. c. Epididymides are where immature sperm are held until maturity. d. The vasa deferentia serve to store and move sperm. e. Seminal vesicles provide sperm with nutrients and other fluids that compose semen. f. The prostate gland adds chemicals to semen to help neutralize vaginal fluid. g. The Cowper’s glands secrete a fluid that lubricates the urethra and neutralizes acid. h. A small valve in the prostate gland prevents urine and semen from ever passing through the urethra at the same time.

4. The American Academy of Pediatrics and the Centers for Disease Control counsel that the benefits of newborn male circumcision outweigh the risks but that the benefits are not great enough for routine circumcision to be recommended in infants.

Key Terms: vulva, mons pubis, labia majora, labia minora, clitoris, urethral opening, hymen, perineum, vagina, uterus (womb), endometrium, cervix, ovaries, fallopian tubes, hypothalamus, estrogen, progesterone, menarche, ovarian follicles, Graafian follicle, ovum, ovulation, corpus luteum, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), dysmenorrhea, prostaglandin, menopause, menopausal hormone therapy, penis, ejaculation, scrotum, testes, testosterone, sperm, epididymis, vas deferens, seminal vesicles, semen, ejaculatory duct, prostate gland, Cowper’s glands, glans Figures: Figure 1 Female Reproductive System Figure 2 The Three Phases of the Menstrual Cycle Figure 3 Male Reproductive System III. Human Sexual Response A. The human sexual response generally follows a specific pattern. Both males and females exhibit four common stages.

1. Excitement/arousal stage: time during which vasocongestion occurs, the vagina lubricates, the penis becomes erect, and a “sex flush” may occur. ..

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2. Plateau phase: characterized by an intensification of initial responses.

3. Orgasmic phase: when vasocongestion and muscle tensions reach their peak, and rhythmic contractions occur throughout the genital regions.

4. Resolution phase: the organs return to their pre-arousal states, and a person experiences profound relaxation and deep feelings of well-being.

B. In males, the refractory period is the time it takes before subsequent arousal can occur.

C. Sexual Dysfunction 1. Sexual dysfunction is the term used to describe problems that can hinder sexual functioning.

2. Sexual dysfunction can be divided into four major categories (see Table 1): a. Desire disorders b. Arousal disorders c. Orgasmic disorders d. Pain disorders 3. Common causes of sexual dysfunction include biological/medical reasons, substanceinduced factors, psychological factors, and factors related to social context.

Key Term: vasocongestion Table: Table 1 Types of Sexual Dysfunction IV. Types of Sexual Dysfunction A. Sexual Expression and Behavior B. Every society sets standards and attempts to normalize sexual behavior.

C. Instead of making blanket judgments, we might consider the CERTS Model for Healthy Sexuality: 1. Consent 2. Equality 3. Respect 4. Trust 5. Safety D. Options for Sexual Expression 1. Celibacy and Abstinence a. Celibacy is the abstention from all sexual activities whatsoever, including masturbation. b. Abstinence is the avoidance of intercourse (oral, vaginal, or anal).

2. Autoerotic Behaviors a. Autoerotic behaviors involve sexual self-stimulation such as sexual fantasies and masturbation. b. Sexual fantasies are sexually arousing thoughts and dreams. c. Masturbation is self-stimulation of the genitals.

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3. Kissing and Erotic Touching a. Stimulation of erogenous zones can lead to sexual arousal. b. Manual stimulation is sexual arousal and orgasm through use of the hand or sex toys rather than through intercourse.

4. Oral–Genital Stimulation a. Cunnilingus refers to oral stimulation of a woman’s genitals. b. Fellatio is the oral stimulation of a man’s genitals. c. HIV and other sexually transmitted infections (STIs) can be transmitted via unprotected oral–genital sex.

5. Vaginal Intercourse a. Vaginal intercourse (coitus) is the insertion of the penis into the vagina. b. It can involve a variety of positions. c. Protection from unintended pregnancy and STIs is essential.

6. Anal Intercourse a. Anal intercourse is the insertion of the penis into the anus. b. Condom use is especially important, as the delicate tissues of the anus are more likely to tear than are vaginal tissues, increasing the risk of transmission of HIV and other STIs. 7. Sexual Variations a. Variant sexual behaviors are less common sexual activities that are considered outside the norm. They are legal when they involve consenting adults. Examples include the following: i. Group sex ii. Swinging (partner swapping) iii. Fetishism (using inanimate objects to heighten sexual arousal) iv. BDSM (bondage, discipline, domination, submission, sadism, and masochism) b. Some variant behaviors can be harmful to the individual, to others, or to both and are illegal in most circumstances: i. Exhibitionism (the exposure of one’s genitals to strangers in public places) ii. Voyeurism (observing other people for sexual gratification without their consent) iii. Pedophilia (any sexual activity involving a minor) E. Drugs and Sex 1. Alcohol and drugs do more harm than good to sexual behavior.

2. Alcohol reduces inhibitions but inhibits sexual response. The mind may be willing, but the body may not be.

3. When male erectile dysfunction drugs, such as Viagra, are used incorrectly and are combined with alcohol and other drugs, they can cause a sudden drop in blood pressure and possible cardiac arrest.

4. “Date rape” drugs are a growing concern on college campuses, where they are often combined with alcohol.

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5. An emerging issue is ChemSex, or intentional sex under the influence of drugs. This includes recreational use of drugs intended to treat erectile dysfunction. a. Also included in ChemSex is the use of stimulants, such as methamphetamine, which increase heart rate and blood pressure and trigger euphoria and arousal. b. Some sexual function supplements may contain potentially dangerous impurities or small amounts of hidden pharmaceutical drugs which can cause dangerous reactions.

F. Responsible and Satisfying Sexual Behavior 1. Healthy and responsible sexuality includes the following: good communication as the foundation, acknowledging that you are a sexual person, understanding sexual functions and safety, and accepting and embracing your gender identity and your sexual orientation.

Key Terms: celibacy, abstinence, autoerotic behaviors, sexual fantasies, masturbation, erogenous zones, cunnilingus, fellatio, vaginal intercourse, anal intercourse, sexual variations

Discussion Questions 1.

2.

3.

4.

5.

What are the similarities and differences in the female and male sexual response?

How do these differences influence sexual behavior between opposite-sex couples?

Describe three forms of variant sexual behavior.

How does drug use affect sexual performance?

Describe the main components of a person’s sexual identity.

Critical Thinking Questions 1. Review the differences between men and women in making decisions in terms of their sexuality and partnering behaviors. Do you agree with most of the behaviors for your sex?

What behaviors of the opposite sex, if any, have you exhibited when interacting with someone of the same or opposite sex?

2. Why do you think good communication with your partner is a foundation for having a satisfying sexual relationship? How might you improve communication with your partner?

What are some of the barriers you feel and experience to improving communication with your partner?

3. Have gender-role stereotypes negatively affected your life in any way? If so, how? If not, who do you know whose life has been impacted by gender-role stereotyping?

Student Activities Individual 1. Talk to your sexual partner about how improving communication can improve sexual satisfaction. What are his or her experiences and opinions? Are your views close together

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or far apart? If you don’t have a sexual partner, discuss these topics with a friend and problem-solve how you might improve communication with a future sexual partner.

Community 1. What is the policy in your local elementary, junior high, and high schools regarding sex education? Are there district policies restricting what teachers can and cannot say in class?

2. Find out if the use of date rape drugs is a problem on your campus. If so, what steps are being taken to eliminate the use of these drugs and to protect women from unwanted sex?

Diverse Population/Nontraditional 1. Use the Internet to research gender roles in other cultures. How have traditional gender roles changed compared with modern gender roles in the culture? While doing your research, focus on traditional roles such as household responsibilities, raising and educating children, providing food and shelter, and other roles.

2. Research how organizations such as Heifer International are helping to eliminate gender inequality, in terms of education and financial security, for women in communities around the world.

3. What types of challenges do people with disabilities face with regard to sexual expression?

Additional References Human Rights Campaign, “Sexual Orientation and Gender Identity Definitions,” 2017, www.hrc.org.

G. M. Herek, “Beyond ‘Homophobia’: Thinking More Clearly about Stigma, Prejudice, and Sexual Orientation,” American Journal of Orthopsychiatry, 85, no. 5S (2015): S29–S37.

E. Anastasakis, C. E. Kingman, C. A. Lee, D. L. Economides, and R. A. Kadir, “Menstrual Problems in University Students: An Electronic Mail Survey,” In Vivo, 22 (2008): 617–620.

K. A. Bogle, Hooking Up: Sex, Dating, and Relationships on Campus (New York: New York University Press, 2008).

C. M. Grello, D. P. Welsh, and M. S. Harper, “No Strings Attached: The Nature of Casual Sex in College Students,” Journal of Sex Research, 43 (2006): 255–267.

M. A. Lewis, C. M. Lee, M. E. Patrick, and N. Fossos, “Gender-specific Normative Misperceptions of Risky Sexual Behavior and Alcohol-related Risky Sexual Behavior,” Sex Roles, 57 (2007): 81–90.

M. P. Martens, J. C. Page, E. S. Mowry, K. M. Damann, K. K. Taylor, and M. D. Cimini, “Differences between Actual and Perceived Student Norms: An Examination of Alcohol Use, Drug Use, and Sexual Behavior,” Journal of American College Health, 54 (2006): 295–300.

E. M. Morgan and E. M. Thompson, “Process of Sexual Orientation Questioning among Heterosexual Men,” Men and Masculinities, 12 (2009): 425–443.

E. M. Morgan and E. M. Thompson, “Process of Sexual Orientation Questioning among Heterosexual Women,” Journal of Sex Research, (2009): 1–13.

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For Further Information American Society for Reproductive Medicine www.asrm.org National Library of Medicine—MedLinePlus Sexual Health www.nlm.nih.gov/medlineplus/sexualhealth.html Sexual Advice Association www.sda.uk.net

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CHAPTER

7

Considering Your Reproductive Choices

Overview Managing our fertility and making healthy reproductive decisions are among the most crucial behaviors for adults. This chapter provides an in-depth discussion concerning methods of contraception with information that will assist students in identifying the most appropriate options for them. This chapter also discusses emergency contraception. Once a couple decides to have a child, it is important that they understand what factors can lead to the best possible outcome. This chapter provides a thorough examination of appropriate diet and exercise and the harmful effects of drugs on a fetus, as well as other agents that can cause harm. Chapter 7 also deals with options for couples who are having difficulty conceiving or who may be infertile.

Learning Outcomes 1. Explain the process of conception and describe how the effectiveness of contraception is measured.

2. Compare and contrast the advantages, disadvantages, and effectiveness of different barrier methods in preventing pregnancy and sexually transmitted infections, and describe emergency contraception and its use.

3. List and explain factors that you should consider when choosing a method of contraception.

4. Summarize the political issues surrounding abortion and the various types of abortion procedures.

5. Discuss key issues to consider in planning a pregnancy, describe the process of pregnancy and fetal development, and explain the importance of prenatal care.

6. Explain the basic stages of childbirth and complications that can arise during pregnancy, labor, and delivery.

7. Review primary causes of and possible solutions for infertility.

Lecture Outline •

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Today we not only understand the intimate details of reproduction but also possess technologies that can control or enhance fertility.

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One measure of maturity is the ability to discuss reproduction and birth control with your sexual partner before engaging in sexual activity. o Failure to bring up the topic often leads to unprotected sex.

I. Basic Principles of Contraception A. Conception occurs when a sperm fertilizes an egg. The following conditions are necessary: 1. A viable egg 2. A viable sperm 3. Access to the egg by the sperm B. Contraceptive methods prevent contraception by interfering with one of these three conditions.

C. While contraception and birth control are often used interchangeably, contraceptives refer to devices, behaviors, or drugs that prevent conception, whereas birth control includes any method reducing the likelihood of pregnancy or childbirth, including contraception, contragestion (e.g., the morning-after pill), and abortion.

1. Without contraceptives, 85 percent of sexually active women would become pregnant within one year.

2. To evaluate the effectiveness of a particular contraceptive method, you must be familiar with two concepts: a. Perfect-use failure rate refers to a number of pregnancies that are likely to occur in the first year of use (per 100 users of the method) if the method is used absolutely perfectly—without any error. b. Typical-use failure rate refers to the number of pregnancies likely to occur during the first year of typical use—with the normal number of errors, memory lapses, and incorrect or incomplete use.

Key Terms: fertility, contraception, conception, birth control, perfect-use failure rate, typicaluse failure rate II. Contraceptive Methods A. Overview 1. Present methods of contraception fall into several categories, including the following: a. Barrier methods block the egg and sperm from joining. b. Hormonal methods prevent ovulation, thicken cervical mucus, or prevent a fertilized egg from implanting. c. Intrauterine methods interfere with sperm movement and egg fertilization. d. Behavioral methods involve temporary or permanent abstinence or planning intercourse around fertility patterns. e. Permanent methods surgically block the sperm’s ability to fertilize the egg.

2. Some contraceptive methods can also protect, to some degree, against sexually transmitted infections (STIs).

B. Barrier Methods 1. Barrier methods use a physical or chemical barrier to prevent an egg and sperm from joining during intercourse.

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2. The external condom is a thin sheath designed to cover the erect penis and catch semen, preventing it from entering the vagina. a. Most are made of latex, although condoms made of polyurethane, polyisoprene, or lambskin are also available. b. A new condom must be used for each act of vaginal, oral, or anal intercourse. c. See Figure 7.1 for how to use an external condom. d. Condoms come with or without spermicide or lubrication. i.

The most commonly used spermicide, nonoxynol-9 (N-9), can cause irritation and increase the likelihood of infection when used multiple times per day. e. Condoms are less effective and more likely to break during intercourse if they are old or improperly stored. f.

Condoms made of latex or polyurethane are the only barriers that effectively prevent the spread of some STIs and HIV.

g. External condoms do not require a prescription, are readily available and inexpensive, and have no negative health effects. h. Condoms have considerable potential for user error. i. Some people say that sex is not spontaneous; others claim condoms reduce sensation.

3. The internal condom is a single-use, soft, lubricated, loose-fitting polyurethane sheath meant for internal vaginal use. See Figure 7.2 for an illustration of the proper use of the internal condom. a. Internal condoms can prevent the spread of HIV and other STIs. b. They can be inserted in advance of intercourse. c. They are thin enough that less sensation is lost than with a external condom. d. Internal condoms do not require a prescription, are readily available and inexpensive, and cause no negative health effects. e. As with external condoms, there is potential for user error. f. Because of potential problems, the typical use effectiveness is 79 percent. g. Some people dislike using the internal condom because they feel it is disruptive, noisy, odd looking, or difficult to use.

4. Jellies, creams, foams, suppositories, and film are collectively called spermicides— substances designed to kill sperm. a. Jellies, creams, and foams must be inserted into the vagina far enough to cover the cervix, providing a chemical barrier that kills sperm and a physical barrier that stops sperm from continuing toward an egg. b. Suppositories are waxy capsules that are inserted deep into the vagina, where they melt. c. Vaginal contraceptive film infused with spermicidal gel is inserted into the vagina so that it covers the cervix. d. Spermicides are inexpensive and readily available. They do not require a prescription or pelvic examination. i.

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Spermicides are most effective when used in conjunction with another barrier method.

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ii. Spermicides can be messy and must be reapplied for each act of intercourse. iii. Some people experience irritation or allergic reactions. iv. Phexxi is a new contraceptive gel that does not contain N-9. v. They are not effective in preventing transmission of STIs. 5. The diaphragm is a soft, shallow cup made of thin latex rubber that snugly covers the cervix. a. Most diaphragms must be fitted by a physician, but the Food and Drug Administration (FDA) recently approved a new one-size-fits-most diaphragm, Caya. It is not yet widely available, but your health care provider or pharmacy can order it. b. Diaphragms must be used with spermicidal cream or jelly. See Figure 7.3 for an illustration for the proper use and placement of a diaphragm. c. Diaphragms have a higher typical-use effectiveness rate (88 percent) than other barrier methods. d. Some women find inserting a diaphragm awkward at first. e. Spermicide must be reapplied for each act of intercourse. f. It cannot be used during menstrual period or for longer than 48 hours because of the risk of toxic shock syndrome.

6. The cervical cap is a clear silicone cup that fits snugly over the entire cervix and has a ring on the back to assist with removal. a. It comes in three different sizes and must be fitted by a health care provider. b. It is designed for use with spermicidal jelly or cream. c. It can be inserted up to six hours prior to intercourse and must be left in place for six to eight hours after sex. d. They are reasonably effective when used consistently and correctly (86 percent effective with typical use). e. They are relatively inexpensive. f. They are somewhat difficult to insert compared to a diaphragm. g. They require an initial fitting by a physician. h. They pose some risk of toxic shock syndrome (TSS) when used during menstruation or for longer than 48 hours.

7. The contraceptive sponge is made of polyurethane foam and fits over the cervix. Prior to insertion, it is moistened with water to activate infused spermicide. It can be left in for up to 24 hours, and there is no need to reapply spermicide. It must be left in place for six hours after last intercourse. a. Contraceptive sponges are convenient, and protection begins immediately on insertion. b. They do not require a doctor’s visit for fitting. c. d. e. f.

They can be used for multiple acts of intercourse within 24 hours.

They are less effective for women who have previously given birth.

Allergic reactions and irritation can occur.

They may increase the risk of yeast infections and other STIs.

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1. Hormonal contraception refers to birth control that contains synthetic estrogen, progestin, or both—similar to the hormones estrogen and progesterone that a woman’s ovaries produce naturally for the process of ovulation and the menstrual cycle. a. Synthetic estrogen works to prevent the ovaries from releasing an egg. b. Progestin thickens mucus, which hinders the movement of the sperm, inhibits the egg’s ability to travel through the fallopian tubes, suppresses the sperm’s ability to unite with the egg, and thins the uterine lining, rendering the egg unlikely to implant in the uterine wall.

2. Today, oral contraceptives are second only to condoms as the most commonly used birth control method among college women. Birth control pills are highly effective a preventing pregnancy (91 percent with typical use). a. Pills have less room for user error. b. Taking pills is convenient and discreet. c. They do not interfere with lovemaking. d. Pills must be taken every day at the same time, without fail. e. The pill does not protect against HIV or STIs, and its effectiveness may be affected by certain medications.

3. Combination pills work through the combined effects of synthetic estrogen and progestin and are taken in a cycle. a. There is no known physiological need for a woman to have a monthly period, and there are no known risks associated with avoidance. b. Combination pills effectively prevent pregnancy and may lessen menstrual difficulties. c. Some combination pills have added benefits, such as lessening cramps and PMS and lowering the risk of several health conditions, including some cancers. d. Risks include increased risk for blood clots and higher risk for increased blood pressure, thrombotic stroke, and myocardial infarction. Risks increase with age and cigarette smoking. e. They can also cause spotting between periods, breast tenderness, moodiness, and nausea.

4. Progestin-only pills (minipills) contain small doses of progestin and no estrogen. a. Ovulation may occur, but the progestin prevents pregnancy by thickening the cervical mucus and interfering with the implantation of a fertilized egg. b. Good choice for women at high risk for estrogen-related side effects or who cannot take estrogen-containing pills. c. Can be used safely by women older than 35 or those who are currently breastfeeding. d. Highly effective at preventing pregnancy (91 percent with typical use). e. f. g. h.

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No estrogen-related cardiovascular risks.

Menstrual period generally becomes lighter or stops altogether.

Important to take at the same time each day.

Most common side effect is irregular menstrual bleeding or spotting.

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i.

Slynd is a new-to-market progestin-only pill that gives women the benefit of a progestin-only pill without the narrow time frame to take the pill.

5. Xulane is a square transdermal adhesive patch that works by delivering continuous levels of estrogen and progestin through the skin into the bloodstream. It should not be used by women who are over the age of 35 or who smoke. It is less effective for those women who weigh more than 198 pounds. a. b. c. d.

It is effective, low risk of error, and easy to use.

It may increase convenience and spontaneity.

It offers no protection against HIV and STIs. It has cardiovascular risks associated with estrogen.

e. There is some delay in the return to fertility after stopping to use. f.

Some medications may make Xulane less effective.

g. Twirla is a round patch about 2 inches in diameter, it retains many of the benefits and the convenience of Xulane, with lower exposure to hormones.

6. NuvaRing and Annovera are a soft, flexible plastic hormonal contraceptive ring the user inserts into the vagina and leaves in place for three weeks. It is removed for one week for menstruation. It can be 91 percent effective with typical use. a. It has a lower risk of user error than some other hormonal methods, with no pill to take daily or patch to change weekly. No fitting is required, and fertility rapidly returns when use is stopped. b. It exposes body to lower dosage of estrogen. c. It provides no protection against STIs. d. It can increase vaginal discharge and irritation or infection 7. Contraceptive injections Depo-Provera and Dep-subQ Provera are long-acting progestins injected every three months by a health care provider. They prevent ovulation, thicken the cervical mucus, and thin the uterine lining. a. Effective within 24 hours of the first shot b. Little room for user error; 6 percent failure rate with typical use c. No estrogen-related health risks d. No protection against STIs e. The main side effect is irregular bleeding, but most women stop having a period within a year. f.

After the final injection, it may take women who wish to get pregnant up to a year to conceive.

8. Nexplanon (formerly named Implanon) is a single-rod implantable contraceptive that offers a continual slow release of progestin for up to three years, suppressing ovulation during that time. a. Its advantages include discretion, high effectiveness, low user error, and reduction of estrogen-related side effects. b. Disadvantages include the need for insertion and removal by a clinician, minor side effects such as irritation and possibility of infection or complications with removal. They also offer no protection against STIs. D. Intrauterine Contraceptives 104

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1. The intrauterine device (IUD) is a small, plastic, flexible device with a nylon string attached that is placed in the uterus through the cervix and provides protection from pregnancy for 3 to 12 years. a. IUDs affect the ways sperm and eggs move, preventing fertilization and/or affecting the lining of the uterus to prevent a fertilized ovum from implanting. b. IUDs are again very popular with women around the world and are experiencing a resurgence of popularity among U.S. women.

2. Five IUDs are currently available in the United States. a. ParaGard is a T-shaped plastic device that does not contain hormones. It can be left in place for 12 years. b. Mirena is effective for five years and releases small amounts of progestin. c. Skyla and Kyleena are smaller versions of Mirena, designed for women who have not yet had a baby. Skyle is effective for three years, and Kyleena is effective for five years. d. Liletta is effective for three years and designed to be a more affordable choice. e. IUDs are safe, discreet, and effective, and must be inserted by a health care provider. f. ParaGard has the benefit of containing no hormones at all and thus has none of the potential negative health impacts of hormonal contraceptives. g. Mirena, Skyla, Kyleena, and Liletta, on the other hand, likely offer some of the potential health benefits of other progestin-only methods. h. IUDs are fully reversible, and there is no need to keep any supplies on hand. i.

Disadvantages include possible discomfort during insertion and removal, cost of insertion, and possible complications.

j.

In some women, Paraguard can cause heavy menstrual flows and severe cramping, acne, headaches, mood changes, uterine cramps, and backache.

E. Behavioral Methods 1. Behavioral methods require more self-control, diligence, and commitment than do barrier or hormonal methods.

2. Withdrawal, also called coitus interruptus, involves removing the penis from the vagina just before ejaculation. a. The amount of people who use this method is startlingly high considering the high risk of both pregnancy (78% effective with typical use) and STI transmission. b. Withdrawal is unreliable even with perfect use, especially since there is sperm in pre-ejaculation fluid. c. Timing of withdrawal is difficult, and it offers no protection against STI transmission.

3. Abstinence means deliberately avoiding oral, vaginal, and anal sex. “Outercourse” includes all sexual activity other than vaginal or anal sex. a. Abstinence is the only 100 percent certain way to avoid pregnancy and is the only method that is 100 percent effective against the transmission and contraction of STIs. b. Outercourse is not 100 percent effective against STIs. ..

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c. Both methods require discipline and commitment for couples to sustain over long periods of time 4. Fertility awareness methods (FAMs) rely on altering sexual behavior during certain times of the month and are rooted in an understanding of basic physiology. Some common forms include the cervical mucus method, body temperature method, and calendar method. a. Fertility awareness methods are the only forms of birth control that comply with certain religious teachings, including those of the Roman Catholic Church. b. They have a 76 percent effectiveness rate with typical use and offer no STI protection. They also may not work for women with irregular menstrual cycles.

F. Emergency Contraception 1. Emergency contraception is the use of a contraceptive to prevent pregnancy after unprotected intercourse, a sexual assault, or the failure of another birth control method. a. Combination pills and progestin-only types are two common types of emergency contraceptive pills (ECPs), sometimes referred to as “morning-after” pills. b. These pills must be taken before the woman’s next menstrual cycle starts; they are not effective for women who are already pregnant. c. Multiple types of ECPs that must be taken within 72 hours of unprotected intercourse are available in the United States. Ella, recently approved by the FDA, can prevent pregnancy when taken up to 120 hours (5 days) following unprotected intercourse. d. These pills prevent pregnancy the same way as other hormonal contraceptives—by delaying or inhibiting ovulation, inhibiting fertilization, or blocking implantation of the fertilized egg, depending on the phase of the woman’s cycle. e. Although not a suitable substitute for taking proper precautions, widespread availability has the potential to reduce rates of unintended pregnancies and abortions.

G. Permanent Methods of Birth Control 1. In the United States, sterilization has become the second most common form of contraception for women of all ages; it is the leading method of contraception among women over age 35.

2. Female sterilization can happen in a number of ways: tubal ligation, essure, and hysterectomy. a. Tubal ligation is a surgical procedure in which the fallopian tubes are sealed shut to block the sperms’ access to released eggs. See Figure 7.5. b. Essure involves the placement of small microcoils into the fallopian tubes via the vagina. These coils promote the growth of scar tissue around the coils and result in blocked fallopian tubes. c. Hysterectomy, the removal of the uterus, requires major surgery. d. While these methods are permanent and highly effective, disadvantages include potential complications of surgery.

3. Male sterilization takes the form of a vasectomy, the cutting and sealing of the vas deferens. See Figure 7.6.

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a. Advantages include ease, effectiveness, permanence, and no effect on sexual response Disadvantages include that it does not protect against STI transmission, and it is not immediately effective. In a small percentage of cases, serious complications occur, such as blood clots in the scrotum, infection, or inflammatory reactions.

Key Terms: barrier method, hormonal methods, intrauterine methods, behavioral methods, permanent methods, sexually transmitted infections (STIs), spermicide, external condom, internal condom, vaginal contraceptive film, diaphragm, toxic shock syndrome (TSS), cervical cap, contraceptive sponge, oral contraceptives, Xulane, contraceptive ring, Depo-Provera, Nexplanon (Implanon), intrauterine device (IUD), withdrawal, dental dam, fertility awareness methods (FAMs), emergency contraceptive pills (ECPs), sterilization, tubal ligation, hysterectomy, vasectomy Figures and Tables: Table 7.1 Contraception Effectiveness, STI Protection, Frequency of Use, and Cost Figure 7.1 How to Use an External condom Figure 7.2 How to Use an Internal condom Figure 7.3 The Proper Use and Placement of a Diaphragm Figure 7.4 The Fertility Cycle Figure 7.5 Female Sterilization: Tubal Ligation Figure 7.6 Male Sterilization: Vasectomy ABC News: See It! Video: Newer Birth Control Pills May Have Increased Risks of Blood Clots III. Choosing a Method of Contraception A. Ask these and other questions of yourself when trying to decide what method of contraception would be best for you: 1. How comfortable would I be using a particular method?

2. Will this method be convenient for my partner and me?

3. Am I at risk for the transmission of STIs? 4.

5.

6.

7.

8.

9.

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Do I want to have a biological child in the future?

How would an unplanned pregnancy affect my life?

What are my religious and moral values?

How much will the birth control method cost?

Do I have any health factors that could limit my choice?

Are there any additional benefits I’d like from my contraceptive?

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Table: Table 7.2 Contraception Methods Used by College Students or Their Partners the Last Time They Had Sex IV. Abortion A. Contraception Methods Used by College Students or Their Partners the Last Time They Had Sex 1. Abortion is the termination of a pregnancy by expulsion or removal of an embryo or fetus from the uterus.

2. Under the 1973 U.S. Supreme Court decision Roe v. Wade, women and their health care providers have the right to terminate a pregnancy through abortion during the first trimester of pregnancy without legal restriction. a. The decision allowed individual states to set conditions for second-trimester abortions. b. Third-trimester abortions were ruled illegal unless the mother’s life or health was in danger.

B. The Abortion Debate 1. Pro-choice individuals feel that it is a woman’s right to make decisions about her own body and health, including the right to continue or terminate a pregnancy.

2. In the more than 40 years since Roe v. Wade legalized abortion nationwide, hundreds of laws have been passed at the state and federal level to narrow or expand its limits.

New legislation has imposed certain restrictions on abortions.

3. While abortion remains legal in all 50 states, for many women its availability is limited as a result of difficulty accessing abortion services.

C. Emotional Aspects of Abortion 1. Among adult women who have an unplanned pregnancy, the risk of mental health problems is no greater if they have an abortion than if they deliver a baby. a. Researchers have found that the best predictor of a woman’s emotional well-being following an abortion was her emotional well-being prior to the procedur D. Methods of Abortion 1. The choice of abortion procedure is determined by how many weeks the woman has been pregnant.

2. Surgical Abortions a. Suction curettage (Figure 7.8) b. Dilation and evacuation (D&E) c. Intact dilation and extraction (D&X), often referred to as “partial-birth abortion,” is illegal in the United States, while several states do not enforce the law and allow the procedure when the mother’s life or health is at risk. d. Risks include infection, incomplete abortion, excessive bleeding, and cervical and uterine trauma.

3. Medication Abortions a. Medical abortions are performed without inserting an instrument into the uterus.

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b. Mifepristone is a steroid hormone that induces abortion by blocking the action of progesterone, the hormone that maintains the lining of the uterus. c. This pill has the nickname “abortion” pill, which may imply an easy process but the treatment actually involves more steps than a suction and curettage abortion. d. Effectiveness of a medication abortion depends on how far along the pregnancy is.

Key Terms: abortion, suction curettage, dilation and evacuation (D&E), intact dilation and extraction (D&X), medical abortion Figures: Figure 7.7 When Women Have Abortions (in weeks from the last menstrual period) Figure 7.8 Suction Curettage Abortion V. Pregnancy A. Planning for Pregnancy and Parenthood 1. Emotional Health a. Consider why you want to have a child. b. Then consider the responsibilities involved with becoming a parent.

2. Financial Evaluation a. The U.S. Department of Agriculture estimates that it will cost an average of $233,610 to raise a child born today to age 18, not including college tuition.

3. Maternal Age a. Statistically, the chances of having a baby with a birth defect rise after the age of 35, possibly because of a decline in the quality of eggs after this age. b. Two specific age-related risks are Down syndrome and miscarriage. c. Fertility also tends to decline with age. d. Some advantages to older mothers are that they more thoroughly follow medical advice during pregnancy, are more psychologically mature, are better prepared financially, and are more ready to care for an infant than some younger women.

4. Physical Health: Maternal Health a. Preconception care is medical care that is received prior to becoming pregnant that helps a woman assess and address potential issues. b. The key to promoting preconception health is to combine the best medical care, healthy behaviors, strong support, and safe environments at home and at work. c. Nutrition counseling is another important part of preconception care.

5. Physical Health: Paternal Health a. Fathers-to-be should practice the same healthy habits as mothers-to-be. b. Dozens of chemicals can damage sperm. c. A father’s age may play a role in the development of autism, attention-deficit hyperactivity disorder, bipolar disorder, and schizophrenia.

B. The Process of Pregnancy

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1. The process of pregnancy begins the moment a sperm fertilizes an ovum in the fallopian tubes. a. A single fertilized cell, a zygote, multiplies and becomes a sphere-shaped cluster of cells called a blastocyst that travels toward the uterus. b. Upon arrival in the uterus, the embryo implants into the endometrium and is nourished from the lining.

2. Pregnancy Testing

3.

4.

5.

6.

7.

a. A positive pregnancy test is based on the secretion of human chorionic gonadotropin (HCG), which is found in the woman’s urine. b. Home pregnancy tests vary, but some can be used as early as a week after conception, and many are 99 percent reliable. c. Common causes of a false negative include performing the test too early, unclean testing devices, use of certain drugs, and vaginal or urinary tract infections.

Early Signs of Pregnancy a. A woman’s body undergoes substantial changes during pregnancy. See Figure 7.9. b. Early signs of pregnancy include a missed menstrual period, breast tenderness, emotional upset, extreme fatigue, nausea, sleeplessness, and vomiting Pregnancy typically lasts 40 weeks and is divided into three phases, or trimesters, of approximately three months each.

The First Trimester a. During the first trimester, the mother sees few noticeable changes. She may urinate more frequently, experience morning sickness, swollen breasts, and undue fatigue. b. The first trimester is when various organ systems develop. c. During the first eight weeks after conception, the term used for the developing baby is embryo; at the start of the third month, the embryo is called a fetus. See Figure 7.10 for physical changes occurring during fetal development.

The Second Trimester a. During the second trimester, the mother sees more physical changes, and the placenta becomes well established.

The Third Trimester

a. The third trimester is the period of greatest fetal growtThe fetus depends entirely on its mother for nutrition.

C. Prenatal Care 1. Prenatal care is important for both infant and maternal health.

2. Early detection of fetal abnormalities, identification of high-risk mothers and infants, and screening for possible complications are the major purposes of prenatal care.

3. Regular prenatal checkups should occur throughout the pregnancy.

4. Nutrition and Exercise a. Nutrition and exercise are important parts of prenatal health. b. Increases in folic acid, iron, calcium, and fluids are important for healthy babies. c. Weight gain during pregnancy should be approximately 25 to 35 pounds. For overweight women, 15 to 25 pounds is recommended, and for obese women, 11 to 20.

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d. Exercise can help to control weight, make labor easier, and help with a faster recovery by contributing to increased strength and endurance.

5. Avoiding Drugs, Alcohol, Tobacco, and Other Teratogens a. A woman should consult with a health care provider regarding safety of any drugs she might use during pregnancy. b. The fetus is especially subject to teratogenic effects of drugs, X-rays, environmental chemicals, and diseases during the first trimester of pregnancy. The fetus can also develop an addiction to or tolerance for drugs the mother is using. c. Fetal alcohol syndrome (FAS) is a preventable birth defect caused by maternal use of alcohol while pregnant; total abstinence from alcohol is recommended. d. Women who smoke during pregnancy have a greater chance of miscarriage, complications, premature births, low birth weight infants, stillbirth, and infant mortality. e. Women should avoid exposure to X-rays, toxic chemicals, heavy metals, pesticides, gases, and other hazardous compounds. f. Women should also avoid cleaning cat-litter boxes, if possible, because cat feces can contain organisms that cause toxoplasmosis.

6. Prenatal Testing and Screening a. Ultrasonography, or ultrasound b. Chorionic villus sampling (CVS) c. Triple marker screen (TMS) d. Quad screen test e. Amniocentesis Key Terms: Down syndrome, preconception care, human chorionic gonadotropin (HCG), trimester, embryo, fetus, placenta, teratogenic, fetal alcohol syndrome (FAS), toxoplasmosis, ultrasonography (ultrasound), chorionic villus sampling (CVS), triple marker screen (TMS), amniocentesis, amniotic sac Figures: Figure 7.9 Changes in a Woman’s Body During Pregnancy Figure 7.10 Series of Fetoscopic Photographs Showing Development in the First, Second, and Third Trimesters of Pregnancy VI. Childbirth A. Labor and Delivery 1. During the few weeks preceding delivery, the baby normally shifts to a head-down position, the cervix begins to dilate, and the pelvic bones loosen.

2. The birth process has three stages. See Figure 7.11. a. b. c. d. ..

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3. Managing Labor a. Methods for managing labor include painkilling drugs and the Lamaze method.

4. Cesarean Section (C-Section) a. If labor lasts too long or if a baby is in physiological distress, a surgical procedure called a cesarean section (C-section) might be necessary. b. The rate of delivery by C-section has risen from 5 percent in the mid-1960s to almost one-third of all births in the U.S. today. Some critics, including the Centers for Disease Control and Prevention (CDC), think that C-sections are performed too often in the United States.

B. Complications of Pregnancy and Childbirth 1. Pregnancy and childbirth are not without risk. Some complications may result from a preexisting health condition of the mother, whereas others can develop during pregnancy and may result from physiological problems.

2. Preeclampsia and Eclampsia a. Preeclampsia is a condition characterized by high blood pressure, protein in the urine, and edema (fluid retention), which usually causes swelling of the hands and face. b. If preeclampsia is not treated, it can cause strokes and seizures, called eclampsia 3. Miscarriage a. Miscarriage is the loss of a fetus before it is viable; it is also called spontaneous abortion. b. Most miscarriages happen in during the first trimester. Reasons for miscarriage vary, but in most cases, the cause is unknown.

4. Ectopic Pregnancy a. Ectopic pregnancy is the fertilization of an egg outside the uterus, usually in the fallopian tubes.

5. Stillbirth a. Stillbirth is the death of a fetus after the twentieth week of pregnancy but before delivery.

C. The Postpartum Period 1. The postpartum period lasts six weeks after delivery.

2. One in seven new mothers experience postpartum depression characterized by mood swings, lack of energy, crying, guilt, and depression.

3. Breast-Feeding a. A mother’s milk does not begin to flow for two or more days after delivery, but her breast secrete a fluid called colostrum that contains vital antibodies that are important to all newborns. b. The American Academy of Pediatrics recommends that infants be breast-fed for at least 6 months and as a supplement for 12 months. c. Babies who are breast-fed have fewer illnesses and lower hospitalization rates. d. Breast milk contains maternal antibodies and immunological cells that stimulate the infant’s immune system. e. Breast-feeding has the added benefits of helping mothers lose weight after birth.

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4. Infant Mortality a. Infant mortality can be caused by birth defects, low birth weight, injuries, or other unknown causes. b. Sudden infant death syndrome (SIDS) is the unexpected death of a child younger than one year of age for no apparent reason.

Key Terms: cesarean section (C-section), preeclampsia, miscarriage, ectopic pregnancy, stillbirth, postpartum depression, sudden infant death syndrome (SIDS) Figure: Figure 7.11 The Birth Process VII. •

The Birth Process Infertility

• Infertility is defined as the inability to conceive after trying for a year or more.

A. Both partners should be tested; in one-third, of cases infertility involves the male partner, in another third, it is due to causes involving both partners or is of an unknown origin.

1. Causes in Women a. The most common cause of infertility is polycystic ovary syndrome (PCOS).

2. With PCOS, eggs mature within bunched, or cystic, follicles and then are unable to be released for fertilization.

3. Premature ovarian failure is when the ovaries stop functioning before natural menopaus 4. Endometriosis is when parts of the endometrial lining of the uterus implant outside the uterus and block the fallopian tubes.

B. Pelvic inflammatory disease (PID) is a serious infection that scars the fallopian tubes and blocks sperm migration.

1. Causes in Men 2. The leading cause of infertility among men is low sperm count.

3. It may be caused by environmental factors like heat or cold or even by wearing excessively tight underwear.

4. Mumps may also damage the cells that make sperm.

C. Varicocele (enlarged veins on a man’s testicle) can heat the testicles and damage the sperm.

1. Infertility Treatments a. Fertility Drugs b. Fertility drugs can stimulate ovulation 2. Alternative Insemination and Assisted Reproductive Technology a. Alternative insemination of a woman with her partner’s sperm (or by an anonymous donor) b. Assisted reproductive technology (ART) includes in vitro fertilization (IVF), in which eggs and sperm are mixed in a laboratory dish to fertilize and some of the fertilized eggs are then transferred to the woman’s uterus.

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3. Surrogate Motherhood a. With surrogacy, a woman is hired to carry another person’s pregnancy to term, at which time the intended parents gain custody. b. In traditional surrogacy, the gestational carrier is also the biological mother. In gestational surrogacy, the surrogate is not the biological mother.

4. Adoption a. Adoption is an option for couples who cannot have a child biologically. It also benefits children whose birth parents are unable or unwilling to raise them. b. There are two types: confidential (the birth parents and adoptive parents don’t know each other) and open (birth and adoptive parents have some level of knowledge about each other).

Key Terms: infertility, endometriosis, pelvic inflammatory disease (PID), low sperm count, alternative insemination, in vitro fertilization (IVF) ABC News: See It! Video: New Pill to Help Women Get Pregnant Soon to Be Available Over the Counter

Discussion Questions 1. Why do you or don’t you think that discussing contraception with a potential sexual partner is becoming more socially acceptable? How does the social acceptability of these conversations affect your behavior and conversations with sexual partners?

2. What advice would you give a friend about contraceptives?

3. In your opinion, what are the major issues that need to be discussed in a relationship before deciding to have a baby? How do you best ensure that the conversations occur before conception occurs?

4. What are some popular theories about the causes of low sperm count? Have they been proved?

5. Discuss the advantages and disadvantages of breast-feeding for baby and mother.

6. Describe three ways a father can actively participate in a pregnancy.

Critical Thinking Questions 1. Why do you or don’t you believe that a woman has the right to make a choice to have or not to have an abortion during the first trimester of her pregnancy? List the pros and cons of having the right to have an abortion.

2. What health decisions would you make if you found out you were pregnant? How would being pregnant change your lifestyle?

3. How would you advise a pregnant friend who continues to drink alcohol and to smoke occasionally? What health risks would you point out to her for her well-being and for the health of the baby?

4. Why do you think most contraceptive decisions are made by women rather than by men?

How could men become more involved in making these decisions?

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5. What factors in today’s society do you think contribute to the increased rates of infertility in couples wanting to have children?

6. After reading the information in the chapter, what type of birth control do you think you would use when faced with that decision? What factors influence your decision?

7. Why do you think so many women suffer from the “baby blues” or postpartum depression?

8. What do you think about nontraditional parents, such as single men or women or gay or lesbian parents, adopting children? Should the criteria for adoption be the same for these parents as for opposite-sex, male/female married parents?

9. What do you think is the optimal age for a married couple to have a child biologically?

What criteria did you use to decide on that age? What factors in addition to age did you take into consideration?

Student Activities Individual 1. Discuss what you think about the availability of the morning-after pill. Should it be available over the counter, only by pharmacist approval, or only by physician prescription?

2. You have a friend who is pregnant. She wants to learn more about childbirth options. Help her by searching the Internet for sites providing information. Use some of the sites identified in the text to begin.

3. Explore three types of birth control described in this chapter. Create a table or chart that identifies the advantages and disadvantages of each type of contraception. Based on this additional information, what type of birth control do you think you would choose?

4. Research the history of contraceptives. Answer questions such as the following: What was the first contraceptive used? When and where was it used? Is it still in use today?

Community 1. Find out the general political views on abortion in your community. Think about whether or not you agree with your elected officials on this subject. Call your local official and share your opinion on the topic or volunteer on their next reelection campaign.

2. What kind of reproductive services, such as availability of contraceptives, prenatal care, and care during pregnancy, are available to students on your campus? How do these services compare to those provided elsewhere in your community?

3. What kind of laws, if any, in your community regulate a woman’s right to breast-feed her baby in public?

Diverse Population/Nontraditional 1. Conduct online research on how abortion is viewed in countries outside the United States.

How do abortion laws in other countries differ from those in the United States? What sociocultural factors contribute to these laws?

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2. What birth control methods are accepted or widely used in other cultures? How do these methods compare to those commonly used in the United States? What cultural and economic factors contribute to the differences that you identify?

Additional References Abbey, M. R. Parkhill, P. O. Buck, and Saenz, “Condom Use with a Casual Partner: What Distinguishes College Students’ Use When Intoxicated?” Psychology of Addictive Behaviors, 21 (2007): 76–83.

R. Gleeson, Forde, S. Powell, Eadon-Jones, and Draper, “Medical Students’ Attitudes towards Abortion: A UK Study.” Journal of Medical Ethics, 34 (2007): 783–787.

R. Hatcher et al., Contraceptive Technology, 19th e(New York: Ardent Media, 2008).

W. L. Hellerstedt, N. Madsen, M. R. Gunnar, Grotevant, R. M. Lee, and Johnson, “The International Adoption Project: Population-based Surveillance of Minnesota Parents Who Adopted Children Internationally.” Maternal and Child Health Journal, 12 (2008): 162–171.

S. Kang and L. Moneyham, “Use of Emergency Contraceptive Pills and Condoms by College Students: A Survey.” International Journal of Nursing Studies, 45 (2008): 775–783.

M. Martinez, Chandra, Abma, Jones, and W. Mosher, “Fertility, Contraception, and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the 2002 National Survey of Family Growth.” Vital Health Statistics, 26 (2006): 1–142.

The National Campaign to Prevent Teen and Unplanned Pregnancy, “Unplanned Pregnancy among Unmarried Young Women,” 2012, www.thenationalcampaign.org.

Sanderson and Yopyk, “Improving Condom Use Intentions and Behavior by Changing Perceived Partner Norms: An Evaluation of Condom Promotion Videos for College Students.” Health Psychology, 26 (2007): 481–487.

Vahratian, Patel, K. Wolff, and X. Xu, “College Students’ Perceptions of Emergency Contraception Provision.” Journal of Women’s Health, 17, 103–111.

For Further Information American College of Nurse-Midwives www.midwife.org American Society for Reproductive Medicine www.asrm.org Bixby Center for Global Reproductive Health http://bixbycenter.ucsf.edu

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Additional Media Ready-to-Go Teaching Module: Reproductive Choices Birth Control Pills, 10 minutes In this Women’s Health production, Dr. Swartzman and Nurse Eunik address commonly asked questions related to the birth control pill. www.youtube.com/watch?v=qDo0mqrFvmY Condoms: Birth Control and Protection Against STDs, 1 minute 26 seconds In the Planned Parenthood production, the viewer is taught how a condom works and how to properly store, use, and discard of a condom. http://www.youtube.com/watch?v=XtvshMwnBuI How Do Fertility Awareness-Based Methods Prevent Pregnancy? 1 minute 45 seconds In this Planned Parenthood video, the viewer is taught about using fertility awareness-based methods as a way to track ovulation. http://www.youtube.com/watch?v=dBMMYcbElrQ The Business of Being Born, 85 minutes The film interlaces intimate birth stories with surprising historical, political, and scientific insights and shocking statistics about the current maternity care system.

Barranca Productions 151 First Avenue #58 New York, NY 10003 The Internal condom as a Form of Birth Control, 1 minute 23 seconds In this Planned Parenthood video, the viewer is taught about the internal condom and how to use the internal condom to protect against unintended pregnancy and sexually transmitted infections. http://www.youtube.com/watch?v=OOfZ6VfmQ_s What Are Abstinence and Outercourse? 1 minute 32 seconds In this Planned Parenthood Production, the viewer learns about the difference between abstinence and outercourse, as well as the effectiveness of these two methods in preventing unintended pregnancies and sexually transmitted infections. http://www.youtube.com/watch?v=RXjoLPss9ZI Why Is Affordable Birth Control Important? 2 minutes This Planned Parenthood video discusses the importance of affordable birth control. www.youtube.com/watch?v=s5Lil6Um0QQ&feature=related

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CHAPTER

8

Recognizing and Avoiding Addiction and Drug Abuse

Overview Chapter 8 provides students with a general introduction to the physiology of addiction and sets the stage for a deeper examination of addiction’s negative impact.

Process addictions are discussed, as are the six categories of drugs and how pharmaceutical, over-the-counter, and illicit drugs fit into these categories. The difference between drug misuse and drug abuse is explored. Treatment and recovery options and public health approaches to drug abuse prevention are also discussed.

Ultimately, this chapter is intended to help students become aware of the impacts and effects of drug use, misuse, and abuse.

Learning Outcomes 1. Define and outline the physiology,risk factors, and cycle of addiction.

2. Describe common process addictions involving technology, gambling, compulsive buying, sex and porn, exercise, and work behaviors.

3. Describe how drugs affect the brain and their routes of administration.

4. Outline the six categories of drugs and their interactions.

5. Evaluate problems associated with the misuse and abuse of over-the-counter prescription, and illegal drugs on and off campus.

6. Review common drugs of abuse, including stimulants, marijuana and other cannabinoids, depressants, opioids (narcotics), hallucinogens, inhalants, and anabolic steroids.

7. Discuss the impacts of addiction and drug abuse and approaches for reducing that impact on individuals and society.

8. Provide examples of effective treatment and recovery approaches for addictions.

Lecture Outline I. How Does Addiction Develop?

A. Addiction is the continued involvement with a substance or activity despite ongoing negative consequences.

1. The addictive behavior initially provides a sense of pleasure or stability beyond the addict’s power to achieve in other ways.

2. To be addictive, a substance or behavior must have the potential to produce positive mood changes such as euphoria, anxiety reduction, or pain reduction.

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3. People with physiological dependence on a substance experience tolerance when increased amounts of the drug are required to achieve the desired effect.

4. They also experience withdrawal, a series of temporary physical and psychological symptoms that occurs when substance abuse stops.

5. Psychological and physiological dependence are so intertwined that it is not really possible to separate the two.

B. Risk Factors for Addiction 1. Biological a. Studies show that drug addicts metabolize mood-altering substances differently than do nonaddicted people. b. Research also supports a genetic influence on addiction. i. Studies also show that half of the likelihood a person will develop an addiction is due to genetic factors.

2. Psychological a. People with low self-esteem, a tendency toward risk-taking behavior, or poor coping skills are more likely to develop addictive patterns.

3. Environmental a. Lack of family involvement, social isolation, and family disruptions are more commonly found in people who struggle with addiction. b. The accessibility of a substance such as the number of liquor stores or bars in a neighborhood or community also increases the risk of addiction. c. Social learning is particularly strong when it involves people who are important to us—parents, caregivers, and significant others. i. Our observations may lead to imitation behaviors as we try to achieve similar results or aim to belong to a social group that is important to us. d. Major stressful life events may trigger addictive behaviors as traumatized people seek to medicate their pain.

C. The Cycle of Addiction 1. Addictions are characterized by five common characteristics: a. Compulsion b. Loss of control c. Negative consequences d. Denial e. Inability to abstain 2. Addiction is a process that evolves over time. This pattern is known as nurturing through avoidance and is a maladaptive way of taking care of emotional needs.

See Figure 8.1.

Key Terms: addiction, physiological dependence, psychological dependence, neurotransmitters, tolerance, withdrawal, biopsychological model of addiction, compulsion, obsession, loss of control, negative consequences, denial, inability to abstain Figure: Figure 8.1 Risk Factors of Addiction Figure 8.2 The Cycle of Psychological Addiction

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II. Addictive Behaviors • Process addictions are addictions to certain behaviors that are addictive because they are mood altering. They are driven by a pathological pursuit of a reward or relief by an individual.

A. Technology and Internet Addictions 1. An estimated 9 percent of college students report that Internet use and computer games have interfered with their academic performance.

2. Internet addicts exhibit several signs and symptoms: a. General disregard for one’s health b. Sleep deprivation c. Neglecting family or friends d. Lack of physical activity e. Feeling of euphoria while online f. Lower grades in school g. Poor job performance B. Gambling Disorder 1. In the United States, more than 5 million people meet the criteria for having a gambling addiction.

2. The American Psychological Association (APA) now uses the term gambling disorder and recognizes it as an addictive disorder.

3. Characteristics of gambling disorder include preoccupation with gambling, unsuccessful efforts to cut back or quit, gambling when feeling distressed, and lying to family members to conceal the extent of gambling.

4. A gambling addiction typically progresses through four phases: a. Winning phase b. Losing phase c. Desperate phase d. Hopeless phase C. Compulsive Buying Disorder 1. Compulsive buyers are preoccupied with shopping and spending and exercise little control over their impulse to buy.

2. Compulsive buying has many of the same characteristics as alcoholism, gambling, and other addictions.

3. Warning signs include preoccupation with shopping and spending, buying more than one of the same item, shopping for longer periods than intended, repeatedly buying much more than he or she needs or can afford, and buying to the point that it interferes with social activities or work and creates financial problems.

D. Compulsive Sexual Behavior 1. Sexual addiction is compulsive involvement in sexual activity.

2. It may involve a normally enjoyable sexual experience that becomes an obsession, or it may involve fantasies or activities outside the bounds of culturally, legally, or morally acceptable behavior.

E. Exercise Addiction 1. Exercise addicts use exercise compulsively to try to meet needs—for nurturance, intimacy, self-esteem, and self-competency—that an object or activity cannot truly meet.

2. Warning signs of exercise addiction are as follows: injury and reinjury through excess or lack of proper rest, adhering to a rigid workout plan; fixation on weight

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loss or calories burned; skipping work, class, or social plans for exercise; and exercising to the point of pain.

F. Work Addiction 1. Work addiction is the compulsive use of work and the work persona to fulfill needs of intimacy, power, and success.

2. Work addiction is characterized by the following (Figure 8.2): a. Excessive time spent working b. Difficulty disengaging from work c. Going above and beyond what the job calls for d. A compulsive work style e. High levels of stress f. Low life satisfaction g. Marital conflict h. Work burnout Key Terms: process addiction, gambling disorder, Internet addiction, compulsive buying disorder, compulsive sexual behavior, exercise addiction, work addiction Figure: Figure 8.3 Warning Signs of Gambling Disorder III. Drug Actions and Administration A. Overview 1. Drugs are substances other than food that are intended to affect the structure or function of the mind or the body through chemical action.

2. Scientists divide drugs into six categories: a. Prescription drugs b. Over-the-counter drugs c. Recreational drugs d. Herbal preparations e. Illicit (illegal) drugs f. Commercial drugs B. How Drugs Affect the Brain 1. Pleasure, which scientists call reward, is a powerful biological force for survival. If the brain does something that feels pleasurable, the brain is wired to want to do it again.

2. One set of nerve cells that are devoted to producing and regulating pleasure sit at the very top of the brainstem and uses a chemical neurotransmitter called dopamine 3. All addictive drugs can activate the brain’s pleasure circuit, known as the mesolimbic dopamine system. a. Drug addiction is a biological, pathological process that alters the way in which the pleasure center, as well as other parts of the brain, functions.

4. Psychoactive drugs change the way the brain works by affecting chemical neurotransmission—either enhancing it, suppressing it, or interfering with it. a. See Figure 8.3 for an illustration of this process.

C. Routes of Drug Administration 1. Route of administration refers to the way in which a drug is taken into the body.

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b. Inhalation: has the most rapid effect c. Injection: is the most dangerous d. Transdermal: usually in patch form e. Suppositories: used anally or vaginally D. Drug Interactions 1. Polydrug use—taking several medications, vitamins, recreational drugs, or illegal drugs simultaneously—can frequently lead to dangerous health problems.

2. Synergism, also called potentiation, is an interaction of two or more drugs in which the effects of the individual drugs are multiplied beyond what would normally be expected if they were taken alone. a. You might think of synergism as 2 + 2 = 10.

3. Antagonism refers to two drugs working at the same receptor site so that one drug blocks the action of the other.

4. With inhibition, the effects of one drug are eliminated or reduced by the presence of another drug at the receptor site.

5. Intolerance occurs when drugs combine in the body to produce extremely uncomfortable reactions.

6. Cross-tolerance occurs when a person develops a physiological tolerance to one drug that also increases the body’s tolerance to other substances that act similarly on the body.

Key Terms: drugs, psychoactive drugs, oral ingestion, inhalation, injection, transdermal, suppositories Figure: Figure 8.4 The Action of Cocaine at Dopamine Receptors in the Brain IV. Drug Categories and Interactions A. Prescription Drugs 1. These drugs can be obtained only with a prescription from a licensed health practitioner.

2. Approximately 49 percent of Americans have reported using at least one prescription medication in the past month.

3. Thirteen percent of people are taking five or more prescriptions, and 74 percent of physician office visits involve receiving some drug therapy.

B. Over-the-Counter (OTC) Drugs 1. These can be purchased without a prescription in many locations such as grocery, drug, and convenience stores.

C. Recreational Drugs 1. Most of these drugs are legal even though they are psychoactive. a. Alcohol, tobacco, and caffeine are included in this category.

D. Herbal Preparations 1. Encompass approximately 750 substances, including teas and other products of botanical (plant) origin, that are believed to have medicinal properties.

E. Illicit Drugs (illegal) 1. Although laws governing their use, possession, cultivation, manufacture, and sale differ from state to state, illicit drugs are generally recognized as harmful and all are psychoactive.

2. Most notorious F. Commercial Drugs

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1. More than 1,000 exist, including those used in seemingly benign items such as perfumes, cosmetics, household cleaners, paints, glues, inks, dyes, and pesticides.

G. Drug Interactions 1. Polydrug use involves taking several medications simultaneously.

2. Synergism, also called potentiation, is an interaction of two or more drugs in which the effects of the individual drugs are multiplied beyond what would normally be expected if they were taken alone.

3. Antagonism, although usually less serious than synergism, can produce an antagonistic reaction. Some drugs work at the same receptor site and one drug blocks the other from working. This alters the absorption rate of the unattached drug.

Key Term: polydrug use, synergism, antagonism, inhibition, intolerance, cross-tolerance V. Drug Misuse and Abuse • Drug misuse involves using a drug for a purpose for which it was not intended.

• Drug abuse is the excessive use of any drug; it may cause serious harm.

A. Abuse of Over-the-Counter (OTC) Drugs 1. OTC drugs come in many different forms, including pills, liquids, nasal sprays, and topical creams.

2. Abuse of OTC drugs occurs when a drug is taken in more than the recommended dosage, combining it with other drugs, or taking it for longer than is recommended.

3. Several types of OTC drugs are subject to misuse and abuse: a. Caffeine pills and energy drinks b. Cold medicines (cough syrups and tablets) c. Diet pills d. Sleep aids B. Nonmedical Use or Abuse of Prescription Drugs 1. Today, the abuse of prescription drugs in the United States is at an all-time high. a. The latest data suggest that 6.4 million Americans aged 12 and older used prescription drugs for nonmedical reasons in the past month.

2. College Students and Prescription Drug Abuse a. The illicit use of prescription drugs is growing on college campuses. b. The most commonly abused prescription drugs on college campuses are stimulants—drugs that are intended to treat attention-deficit hyperactivity disorder (ADHD). c. Also of concern are the use of painkillers.

C. Use and Abuse of Illicit Drugs 1. Illicit Drug Use on Campus a. Close to 50 percent of college-age students nationwide have tried an illicit drug at some point; the vast majority of them reported using marijuana. b. Substance use among college students has many short- and long-term negative consequences.

D. Why Do Some College Students Use Drugs?

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Key Term: drug misuse, drug abuse Table: Table 8.1 Drug Use Prevalence, Full-Time College Students VI. Common Drugs of Abuse A. Stimulants 1. A stimulant is a drug that increases activity of the central nervous system; effects include increased activity, anxiety, and agitation.

2. Cocaine a. Cocaine is a powerful stimulant made from the leaves of the South American coca shrub and is one of the most powerful naturally occurring stimulants. b. Cocaine can be snorted, smoked, or injected. c. Cocaine is both an anesthetic and a stimulant of the central nervous system. d. In tiny doses, it can slow heart rate. In larger doses, it can increase heart rate and blood pressure, reduce appetite, and cause convulsions, muscle twitching, irregular heartbeat, and even death resulting from an overdose.

3. Amphetamines a. Amphetamines include a large and varied group of synthetic agents that stimulate the central nervous system. b. Small doses improve alertness, lessen fatigue, and elevate mood. c. Physical and psychological dependence develops with repeated use. d. High doses over long periods can produce hallucinations, delusions, and disorganized behavior. e. Certain types of amphetamines are used for medicinal purposes, such as those that are prescribed for ADHD. 4. Bath Salts a. Bath salts are a synthetic cathinones—drugs that are chemically related to the stimulate cathinone, which occurs naturally in the khat plant. b. This drug can have significant negative cardiovascular effects (rapid heart rate, increased blood pressure, and chest pain), psychiatric effects (anxiety, agitation, hallucinations, paranoia, and erratic behavior), and increased risk for depression and suicide.

5. Caffeine a. Caffeine is a legal stimulant, but excessive consumption is associated with addiction and certain health problems. b. Caffeine is found in plant products such as coffee, tea, and chocolate. c. Caffeine is derived from the chemical family called xanthines—mild central nervous system stimulants that enhance mental alertness, reduce feelings of fatigue, and increase heart muscle contractions, oxygen consumption, metabolism, and urinary output. d. Symptoms of excessive caffeine consumption include chronic insomnia, jitters, irritability, nervousness, anxiety, and involuntary muscle twitches. e. No strong evidence exists to suggest that moderate caffeine use produces harmful effects in healthy, nonpregnant people, and for most people caffeine poses few health risks and may actually have some benefit.

B. Marijuana and Other Cannabinoids 1. Today, marijuana is the most commonly used illicit drug in the United States.

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2. Methods of Use and Short-Term Physical Effects a. Marijuana is derived from cannabis sativa or cannabis indica (hemp) plants. b. The psychoactive substance in marijuana is tetrahydrocannabinol (THC). c. Hashish is derived from the plant resin and contains high concentrations of THC. d. The most noticeable effect of use is dilation of the eyes; users also experience coughing, dry mouth and throat, impaired body movement, increased heart rate, and changes in mood.

3. Marijuana and Driving a. Marijuana substantially reduces a driver’s ability to react and make quick decisions. b. Combining marijuana and alcohol enhances the impairing effects of both drugs.

4. Risks Associated with Chronic Marijuana Use a. Lung conditions such as chronic bronchitis, emphysema, and other lung disorders are associated with smoking marijuana b. Frequent and/or long-term marijuana use may significantly increase a man’s risk of developing testicular cancer. c. Chronic or heavy use of marijuana can decrease the quality of sleep. d. The link between marijuana and common mental health disorders is conflicting, but use is associated with a higher likelihood of drug dependence 5. Synthetic Marijuana (Spice or K2) a. A diverse family of herbal blends marketed under many names, which contain dried, shredded plant material and one or more synthetic cannabinoids, with results that mimic marijuana intoxication but with longer duration and poor detection on urine drug screens. b. People smoking Spice may experience several health effects such as hallucinations, severe agitation, elevated heart rate and blood pressure, coma, suicide attempts, and drug dependence, which is not common among cannabis users.

C. Depressants a. Depressants slow down neuromuscular activity and cause sleepiness or calmness.

If the dosage is high enough, brain function can slow to the point of causing death. b. Alcohol is the most widely used central nervous system depressant.

2. Benzodiazepines and Barbiturates a. Legalization of Marijuana and Medicinal Uses b. Although classified by the U.S. government as a dangerous drug, marijuana has been legalized for medicinal uses in 28 states and the District of Columbia. c. Although several states have legalized marijuana for medicinal and/or recreational purposes, its legal status continues to be hotly debated. d. Sedative drugs promote mental calmness and reduce anxiety. Hypnotic drugs promote sleep or drowsiness. e. Benzodiazepines, more commonly called tranquilizers, are the most common sedative-hypnotic drugs; they include Valium, Ativan, and Xanax. f. Barbiturates include Amytal and Seconal that have largely been replaced by benzodiazepines g. Sedative-hypnotic drugs combined with alcohol can lead to respiratory failure and even death. h. Cross-tolerance is a complication specific to sedatives. It occurs when users develop a tolerance for one sedative or become dependent on it and develop a tolerance for others as well. ..

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Rohypnol, or the “date rape” drug, produces a sedative effect, amnesia, muscle relaxation, and a slowed psychomotor response.

3. GHB a. GHB (gamma-hydroxybutyrate) is a central nervous system depressant with euphoric, sedative, and anabolic effects; like Rohypnol, it causes memory loss, unconsciousness, amnesia, and even death.

D. Opioids (Narcotics) 1. Opioids cause drowsiness, relieve pain, and induce euphoria; they are also called narcotics.

2. They are derived from opium, a dark, resinous substance made from the milky juice of the opium poppy seedpod, and they are highly addictive.

3. Some opioids are available by prescription for medical purposes, including morphine, codeine, Vicodin, Percodan, OxyContin, Demerol, and Dilaudid.

4. Physical Effects of Opioids a. Opioids are powerful depressants of the central nervous system. i. Side effects include drowsiness, mental confusion, nausea, and constipation. ii. Opioid-like hormones called endorphins are manufactured in the body and have multiple receptor sites in the central nervous system. When endorphins attach themselves to these sites, they create a feeling of painless well-beinThis same feeling occurs when opioids are active at the endorphin receptor sites.

5. Heroin a. Heroin is a depressant that produces drowsiness and a dreamy, mentally slow feeling. It can cause drastic mood swings, with euphoric highs and depressive lows. b. Symptoms of tolerance and withdrawal can appear within 3 weeks of first use. c. There has been an increasing amount of deaths due to heroin overdose as the drug becomes increasingly common in suburban and rural communities, with deaths skyrocketing, from 13,000 in 2015 to nearly 70, 630 in 2020. d. Heroin is usually injected intravenously (“mainlined”), but contemporary versions are so potent that users can get high by snorting or smoking it. e. Mainlining causes veins to scar and eventually collapse. f. Heroin addicts experience a distinct pattern of withdrawal: an intense desire for the drug, sleep disturbances, dilated pupils, a loss of appetite, irritability, goosebumps, and muscle tremors.

6. Fentanyl a. Fentanyl is a synthetic opioid narcotic that is like morphine but 50 to 100 times more potent, making it the most potent painkiller on the market. b. Fentanyl depresses the area of the brain that controls the breathing rate, and it decreases blood pressure and heart rate. c. Side effects similar to heroin and other opioids.

7. Naloxone (Narcan) is a medication that attaches to opioid receptors and blocks the effects of opioids, rapidly reversing the signs of an opioid overdose.

E. Hallucinogens 1. Hallucinogens, or psychedelics, are substances capable of creating auditory or visual hallucinations and unusual changes in mood, thoughts, and feelings.

2. The mixing of sensory messages that causes hallucinations is known as synesthesia.

Users may also become less inhibited or recall events long buried in the subconscious mind.

3. LSD (lysergic acid diethylamide) i.

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a. Known alternatively as “acid,” LSD is one of the most potent hallucinogenic drugs. b. LSD sometimes comes on small squares of blotter-like paper, in thin squares of gelatin, and in tablets. c. The psychological effects vary and include euphoria, dysphoria, distorted perception, and auditory and visual hallucinations.

Ecstasy a. Ecstasy is one of the most well-known club drugs. It creates feelings of extreme euphoria, openness, and warmth; an increased willingness to communicate; feelings of love and empathy; increased awareness; and heightened appreciation for music. b. Effects can last for three to six hours. c. Ecstasy users are at a greater risk for inappropriate or unintended emotional bonding and have a tendency to say things they may feel uncomfortable about later. d. Physical consequences include jaw clenching, tongue and cheek chewing, shortterm memory loss or confusion, increased body temperature heart rate, and blood pressure. e. When combined with alcohol, Ecstasy can be dangerous and sometimes fatal. f. The drug may cause long-lasting neurotoxic effects by damaging brain cells that produce serotonin. g. MDMA in powder or crystal form is known as “Molly.” Side effects include grinding one’s teeth, becoming dehydrated, feeling anxious, having trouble sleeping, fever, loss of appetite, uncontrollable seizures, elevated blood pressure and body temperature, and depression.

PCP (Phencyclidine) a. PCP was originally developed as a dissociative anesthetic—it was withdrawn from the legal market because of its unpredictability and drastic effects. b. On the illegal market, PCP is a white, crystalline powder that is often sprinkled onto marijuana cigarettes. c. The effects depend on the dose and range from slurred speech and impaired coordination to loss of sensitivity to pain to violent outbursts and deat d. Psychologically, PCP may produce either euphoria or dysphoria.

Ketamine a. The liquid form of ketamine (“Special K”) is used an anesthetic in some hospitals and veterinary clinics. For illicit use, it is stolen from hospitals or medical suppliers, dried, and ground into powder. b. It causes hallucinations by inhibiting the relay of sensory input. c. The effects of ketamine are similar to PCP but even less predictable.

Mescaline a. Mescaline comes from the peyote cactus and is both a powerful hallucinogen and a central nervous system stimulant. b. Users swallow buttons or soak them in liquid to create an intoxicating liquid c. Side effects include vomiting, dizziness, diarrhea, and headache. d. Synthetic chemical relatives are sold on the street as mescaline and can be toxic in small quantities.

Psilocybin a. Psilocybin and psilocin are the active chemicals in a group of mushrooms that are often called “magic mushrooms.”

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b. When consumed these mushrooms are hallucinogenic and have similar physical effects of LS 9. Salvia a. Salvia is an herb from the mint family. Its main ingredient causes hallucinations by changing the brain’s chemistry. b. Associated hallucinations are intense but are relatively short lasting F. Inhalants 1. Inhalants are vapor-producing chemicals that, when inhaled, can cause hallucinations and create intoxicating and euphoric effects.

2. Because they are inhaled, the volatile chemicals in these products reach the bloodstream within seconds, but the effects do not last long 3. An overdose of fumes from inhalants can cause unconsciousness and even death 4. Amyl Nitrite a. The drug is prescribed to alleviate chest pain in heart patients because it dilates small blood vessels and reduces blood pressure.

G. Anabolic Steroids 1. Anabolic steroids are artificial forms of testosterone that promote muscle growth and strength; they are also called ergogenic drugs.

2. They are available in two forms: injectable solutions and pills.

3. Physical Effects of Steroids a. Anabolic steroids produce a state of euphoria, diminished fatigue, and increased bulk and power in both sexes. b. Adverse side effects include becoming aggressive and violent, acne, liver damage, elevated cholesterol levels, kidney damage, and immune system disturbances. HIV and hepatitis transmission can occur with shared needles.

4. Steroid Use and Society a. The Anabolic Steroids Control Act (ASCA) of 1990 makes it a crime to possess, prescribe, or distribute anabolic steroids for any use other than the treatment of specific diseases.

Key Terms: stimulants, amphetamines, caffeine, marijuana, tetrahydrocannabinol (THC), hemp, cannabidiol (CBD), depressants, benzodiazepines, barbiturates, opioids, opium, endorphins, fentanyl, hallucinogens, club drugs, inhalants, anabolic steroids, ergogenic drugs Table and Figure: Table 8.2 Drugs of Abuse: Uses and Effects Figure 8.3 Caffeine Content Comparison ABC News: See It! Video: New Report Shows Surge in Heroin Deaths VII. Impacts of Addiction and Drug Abuse A. Costs of Addiction and Drug Use 1. Costs of addiction and risky substance use total more than $770 billion annually in health care expenses, crime-related costs, and lost workplace productivity.

2. Drug abuse and addictions cost U.S. companies 81 billion dollars every year; that money goes to cover health care costs, absenteeism, and lost worker productivity.

B. Multiple Addictions 1. People with addiction often depend on more than one chemical or behavior.

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C. Addiction Affects Family and Friends 1. Codependence, a self-defeating relationship pattern in which a person is controlled by an addict’s addictive behavior.

2. Enablers are people who knowingly or unknowingly protect addicts from the natural consequences of their behavior.

3. Codependents are the primary enablers of their addicted loved ones, although anyone who has contact with an addict can be an enabler and contribute to continuation of the addictive behavior D. Public Health Strategies for Addiction and Drug Use 1. Historically, the most popular antidrug strategy was total prohibition. Unfortunately, this approach proved to be ineffective, and in 1971 President Nixon proposed a “War on Drugs.”

2. Current strategies to address addiction and drug abuse problems include multimodal prevention strategies that focus on helping individuals develop the knowledge, attitudes, and skills to make good decisions.

3. Harm reduction is a set of practical approaches for reducing drug use consequences by incorporating strategies from safer drug use to abstinence.

4. The coronavirus pandemic affected every aspect of our society, including levels of addiction, drug abuse, and drug overdoses. The pandemic forced people to deal with job losses, addiction, and mental health struggles in isolation and severely reduced their access to health care and addiction treatment. This proved fatal to an already vulnerable population and resulted in a dramatic increase in overdose deaths.

5. The Biden-Harris Administration 2022 fiscal year budget included $41 billion for national drug program agencies, including a historically high 57 percent for reduction programs, including evidence-based treatment, harm reduction, prevention, and recovery services.

Key Term: codependence, enabler VIII. Recovery from Addiction and Drug Use A. Intervention 1. Intervention is a planned process of confrontation by people who are important to the addict, including spouses, parents, children, bosses, and friends.

2. Effective intervention includes (1) emphasizing care and concern for the addicted person; (2) describing the behavior that is the cause for concern; (3) expressing how the behavior affects the addict, each person taking part in the intervention, and others; and (4) outlining specifically what those participating in the intervention would like to see happen.

B. Treatment for Addiction 1. Abstinence—refraining from the addictive behavior.

2. Detoxification refers to an early abstinence period during which an addict adjusts physically and cognitively to being free from the addiction’s influence.

3. Treatment involves learning new ways of looking at oneself, others, and the world. It may require exploring a traumatic past so that psychological wounds can be healed.

C. Treatment Approaches 1. Outpatient behavioral treatment encompasses a variety of programs for addicts who visit a clinic at regular intervals.

2. Residential treatment programs can also be very effective and can include therapeutic communities that offer highly structured programs.

3. The Mindfulness and You box has more on mindfulness-based relapse prevention.

4. 12-Step Programs

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a. The 12-step program is nonjudgmental and is based on the idea that a program’s only purpose is to work on personal recovery. b. Working the 12 steps includes admitting to having a serious problem, recognizing there is an outside power that could help, consciously relying on that power, admitting and listing character defects, seeking deliverance from defects, apologizing to those individuals one has harmed in the past, and helping others with the same problem.

5. Recovery Coaching a. Recovery coaches provide four types of support: b. Emotional support c. Informational support d. Help in accessing health and social services e. Help in finding healthy social connections and recreational activities 6. Social Support Programs and Tools a. Social media, mobile health apps, and specific online recovery programs can provide social support to people in recovery.

7. Antidrug Vaccines a. A promising new cocaine vaccine is in development. It keeps the user from getting high by stimulating the immune system to attack the drug when it is taken. b. Vaccines against nicotine and methamphetamine are also in development.

8. Other Pharmacological Treatments a. Methadone maintenance is one treatment available for people addicted to heroin and other opioids; it is controversial because of the drug’s own potential for addiction. b. There are also a number of other new drug therapies emerging for opioid dependence.

9. Drug Treatment and Recovery for College Students a. Early intervention increases the likelihood of successful treatment. b. Treatment includes private therapy, group therapy, cognitive training, nutrition counseling, and health therapies. c. Many colleges and universities now offer special services to students recovering from alcohol and other drug addictions who want to stay in school without being exposed to excessive drinking or drug use.

10. Relapse a. Relapse is a return to an addictive behavior after a period of abstinence and is one of the defining characteristics of addiction. b. Relapse should not be interpreted as failure to change or lack of desire to stay well.

Remind addicts that they are addicted and redirect them to the strategies that have previously worked for them.

Key Term: intervention, abstinence, detoxification, relapse

Additional Chapter Activities Discussion Questions 1. What are the six categories of drugs, and what are some examples in each of the six categories?

2. Provide examples of synergistic effects of drugs. What physiological dangers might be involved with synergistic drug reactions?

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3. What population group do you think is most at risk for abusing OTC drugs? Explain your answer.

4. What is the history of cocaine use? Do you think anything could have been done differently in the control of early cocaine use that might have deterred it from being as popular as it is today?

5. Over the years, use of illegal drugs has grown to affect all aspects of life in the United States. What might have promoted this migration?

6. Describe reasons why treatment for heroin addiction has not been very successful.

7. What are the most popular drugs on college campuses? Why? 8. At what age should drug education begin? Is there any harm associated with telling kids about drugs?

9. Steroids are performance-enhancing drugs. How does the NCAA deter steroid use among collegiate athletes?

10. Do you think “date rape” drugs are a concern on your campus? Explain.

11. Do you think legalization of illicit drugs will decrease the drug problem in the United States? Why or why not?

Critical Thinking Questions 1. Why do you think individuals with lower levels of income are more likely to become compulsive gamblers than those with higher levels of income?

2. What are your thoughts about the legalization of marijuana for medical purposes?

What are the pros and cons?

3. Do you know anyone who has a behavioral addiction, such as shopping or gambling?

How does this addiction influence the person’s life? Does the person have any control over the addiction?

4. How do you think that the legalization of marijuana would influence other drug use in the United States?

5. What would you do if you observed illegal drug use while attending a party on campus? What if you observed your friend, or the person you attended the party with, using illegal drugs? How would your response change?

6. How would you react if you found out that a sibling or close friend was experimenting with meth? What advice would you offer them?

7. How would you describe the difference between a compulsive behavior and an addiction? Do you think they are one and the same?

8. Do you know anyone who has an addiction to technology? How do you know that he or she has an addiction and how is it influencing his or her everyday life? What advice would you offer this person to help in overcoming the addiction?

9. What strategies would you recommend to help a college student recover from an addiction?

Student Activities Individual 1. Keep a record for one week of all the time you spend using technology. What devices do you use most and how are you using them? Based on this information, do you think you have a technology addiction?

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2. Make a list of all the OTC and prescription drugs you have in your home. What are the drugs used for? Are the drugs current (not past their expiration date)? Are the drugs stored in a safe place so that they are not available to children or other possible users?

Community 1. What kind of support is offered on your campus to help students who are struggling with addiction? How would you help a friend if you knew that he or she had a substance abuse problem?

2. Is medical marijuana available in your community? What criteria must a person meet to be able to receive medical marijuana?

3. Locate a list of campus rules about illegal drug use. Interview someone in the campus police department and find out the rates of drug violations on campus. What occurs on your campus if a student is found using illegal drugs? What if a student athlete is found to be using illegal drugs? Should different rules apply to different groups of students? Why or why not?

Diverse Population/Nontraditional 1. Many drugs considered to be prescriptions are available over the counter in other countries. Why do you think a physician in the United States must prescribe these drugs? Do you think the medicines available without a prescription in other countries are safe to use?

2. What are some substitutes for OTC drugs in other cultures?

3. Research prescription drug use in other countries. Are the same kinds of drugs used?

Are they used in the same amounts?

Additional References U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and HealtNovember, 2016, Washington, DC: HHS. M. Arria, K. M. Caldeira, K. E. O’Grady, K. Vincent, Fitzelle, E. P. Johnson, and E. Wish, “Drug Exposure Opportunities and Use Patterns among College Students: Results of a Longitudinal Prospective Cohort Study.” Substance Use, 29 (2008): 19–38.

M. Barnes, J. W. Welte, J. Hoffman, and M. O. Tidwell, “Comparisons of Gambling and Alcohol Use among College Students and Noncollege Young People in the United States.”

Journal of American College Health, 58 (2010): 443–452.

M. Herman-Stahl, P. Krebs, L. Kroutil, and Heller, “Risk and Protective Factors for Methamphetamine Use and Nonmedical Use of Prescription Stimulants among Young Adults Aged 18 to 25.” Addictive Behaviors, 32 (2007): 1003–1015.

J. Hoffman and S. Froemke, eds., Addiction: Why Can’t They Just Stop? (New York: Rodale Books, 2007).

L. Johnston, P. M. O’Malley, J. Bachman, and J. E. Schulenberg, “Monitoring the Future: National Survey Results on Drug Use, 1975–2008,” in Volume II: College Students and Adults Ages 19–50, NIH Publication No. 09-7403 (Bethesda, MD: National Institute on Drug Abuse, 2009), www.monitoringthefuture.org/pubs/monographs/vol2_2008.pdf.

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S. E. McCabe, T. West, and Wechsler, “Trends and College-level Characteristics Associated with the Non-medical Use of Prescription Drugs among US College Students from 1993 to 2001.” Addiction, 102 (2007): 455–465.

Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey, 2012, NSDUH Series H-46, HHS Publication No. (SMA) 12-4795 (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012).

J. L. Thome and L. Espelage, “Obligatory Exercise and Eating Pathology in College Females: Replication and Development of a Structural Model.” Eating Behaviors, 8 (2007): 334–349.

K. Vincent, K. M. Caldeira, K. E. O’Grady, E. Wish, and M. Arria, “The Impact of Positive and Negative Ecstasy-related Information on Ecstasy Use among College Students: Results of a Longitudinal Study.” Drugs: Education, Prevention, and Policy, 17 (2010): 232–247.

E. M. Wickwire, J. P. Whelan, R. West, Meyers, McCausland, and J. Leullen, “Perceived Availability, Risks, and Benefits of Gambling among College Students.” Journal of Gambling Studies, 23 (2007): 395–408.

J. Yen, Ko, Yen, C-S. Chen, and C-Chen, “The Association between Harmful Alcohol Use and Internet Addiction among College Students: Comparison of Personality.” Psychiatry and Clinical Neurosciences, 63 (2009): 218–224.

Yusko, J. Buckman, R. White, and R. Pandina, “Alcohol, Tobacco, Illicit Drugs, and Performance Enhancers: A Comparison of Use by College Student Athletes and Nonathletes.” Journal of American College Health, 57 (2008): 281–290.

For Further Information Al-Anon Family Groups www.al-anon.org American Academy of Addiction Psychiatry www.aaap.org Community Anti-Drug Coalitions of America www.cadca.org Faces & Voices of Recovery www.facesandvoicesofrecovery.org National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov SMART Recovery www.smartrecovery.org

Additional Media Ready-to-Go Teaching Module: Addiction and Drug Abuse NIDA Scientist Ruben Baler Talks about the Dangers and Consequences of Steroid Abuse, ..

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1 minute 49 seconds In this production of the NIDA, NIDA scientist Ruben Baler discusses the negative health effects of steroid abuse. https://www.youtube.com/watch?v=z9Ynf2kPNIc NIH, on the Inside: Gambling Addiction, 7 minutes 26 seconds In this production of the National Institute of Health (NIH), persons addicted to gambling share their personal struggles. Later in the segment, Dr. Jim Bjork of the NIH discusses what the brain of someone with an addiction resembles. www.youtube.com/watch?v=8-IrXyNZbww

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Drinking Alcohol Responsibly and Ending Tobacco Use

Overview Alcohol and tobacco use are important issues for today’s students. To promote responsible alcohol use, it is extremely important that college students understand the significant risks of using alcohol. Many college students binge drink, diminishing their abilities to succeed in school and possibly negatively influencing their futures. Young people are at the greatest risk of injury and death associated with drinking and driving. Research indicates that even “moderate” drinking carries health risks and that one or two drinks a day are all that the human body can handle without problems. Tobacco use is the single most preventable cause of death in the United States. Although tobacco use is legal in this country, it is currently a hotly debated topic. Tobacco use carries with it numerous health problems. After reading Chapter 9, students will understand health problems and social consequences of tobacco use.

Today’s college student must be aware that the longer one uses tobacco, the harder it is to quit and the greater the cost to one’s health.

Learning Outcomes 1. Explain the physiological and behavioral effects of alcohol, including absorption, metabolism, and blood alcohol concentration.

2. Identify short-term and long-term effects of alcohol consumption.

3. Describe alcohol use patterns of college students, practical strategies for drinking responsibly, and ways to cope with campus and societal pressures to drink.

4. Describe alcohol use disorder and its risk factors, causes, and costs to society, and discuss options for treatment.

5. Discuss the rate of tobacco use in the United States, in general, and among college students, in particular, and explain the social and political issues involved in tobacco use and prevention.

6. Identify different types of tobacco products and the chemicals they contain, and explain their effects on the body.

7. Describe the health risks and physical impact associated with using tobacco products, as well as with environmental tobacco smoke.

8. Describe methods and benefits of smoking cessation.

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Lecture Outline I. Alcohol: An Overview A. Alcohol has been used throughout history for everything from social gatherings to religious ceremonies.

1. Very low levels of alcohol consumption, particularly wine, may lower some health risks in older adults.

2. Alcohol is a drug and, when not used responsibly, can be dangerous.

3. More than half of Americans consume alcoholic beverages regularly, and about 21 percent abstain from drinking alcohol.

B. The Chemistry and Potency of Alcohol 1. The intoxicating substance in beer, wine, and liquor is ethyl alcohol, or ethanol. a. It is produced through a process called fermentation. b. Hard liquors go through another process called distillation. c. Proof is a measure of the percentage of alcohol in the beverage and therefore the strength of the drink. Alcohol percentage is half the given proof (i.e., 80 proof whiskey is 40 percent alcohol by volume).

2. A standard drink is any drink that contains about 14 grams of pure alcohol. See Figure 9.1.

C. Absorption and Metabolism 1. Alcohol molecules are sufficiently small and fat soluble to be absorbed throughout the entire gastrointestinal system.

2. How quickly your body absorbs alcohol is influenced by several factors: a. The alcohol concentration of the drink b. The amount of alcohol you consume c. The amount of food in your stomach d. Your metabolism, weight, and body mass index e. Your mood 3. The higher the concentration of alcohol in your drink, the more rapidly it will be absorbed in your digestive tract.

4. Carbonated beverages and drinks with mixers are absorbed more rapidly. a. These drinks cause the pyloric valve to relax thereby emptying stomach contents more rapidly into the small intestine.

5. The more alcohol you consume, the longer absorption takes.

6. Mood affects how long it takes for the contents of the stomach to empty into the intestine. a. Alcohol is absorbed much more rapidly when people are tense than when they are relaxed.

7. Alcohol contains 7 calories per gram, meaning that the average beer contains about 150 calories. a. Mixed drinks may contain more calories if they are combined with sugary soda or fruit juice.

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8. The breakdown of alcohol in the body occurs at a fairly constant rate of 0.5 ounce per hour—this is slightly less than one standard drink.

D. Blood Alcohol Concentration 1. Blood alcohol concentration (BAC) is the ratio of alcohol to total blood volume.

2. It is used to measure the physiological and behavioral effects of alcohol. See Figure 9.2.

3. As BAC increases, the drinker suffers increased negative physiological and psychological effects.

4. legal limit for driving a vehicle is .08 percent in all states.

5. A drinker’s BAC depends on weight and percentage of body fat, the water content in body tissues, the concentration of alcohol in the beverage consumed, the rate of consumption, and the volume of alcohol consumed. a. A woman will be more intoxicated than a man will be after drinking the same amount of alcohol.

6. Body fat is not the only contributor to the differences in alcohol’s effects on men and women. Compared with men, women have half as much alcohol dehydrogenase, the enzyme that breaks down alcohol in the stomach before it reaches the bloodstream and the brain.

7. Both breath analysis and urinalysis are used to determine BAC, but blood tests are the most accurate. a. Physical and psychological tolerance can occur with regular use.

8. Learned behavior tolerance is when an individual can modify their behavior to appear sober.

Key Terms: ethyl alcohol (ethanol), fermentation, distillation, proof, standard drink, blood alcohol concentration (BAC) Figures: Figure 9.1 What Is a Standard Drink?

Figure 9.2 The Psychological and Physical Effects of Alcohol Figure 9.3 Approximate Blood Alcohol Concentration (BAC) and the Physiological and Behavioral Effects II. Alcohol and Your Health •

The immediate and long-term effects of alcohol vary greatly. See Figure 9.4.

A. Short-Term Effects of Alcohol Use 1. The most dramatic effects occur within the central nervous system (CNS). a. CNS depression can affect vital functions and even cause death. b. Alcohol is a diuretic that increases urinary output, which can lead to dehydration of the cerebrospinal fluid. c. Alcohol irritates the gastrointestinal system and can affect the heart.

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2. Hangover a. Symptoms of a hangover include headache, muscle aches, upset stomach, anxiety, depression, diarrhea, and thirst. b. It usually takes 12 hours to recover from a hangover. c. Congeners, forms of alcohol that are metabolized more slowly than ethanol and are more toxic, are thought to play a role in the development of a hangover. i. The body metabolizes the congeners after the ethanol is gone from the system, and their toxic by-products may contribute to the hangover.

3. Alcohol and Injuries a. Alcohol use plays a significant role in accidental injuries. b. It is also a key risk factor for suicide.

4. Alcohol and Sexual Decision Making a. Because it lowers inhibitions, alcohol influences a person’s ability to make good decisions about sex. b. Intoxicated people are less likely to practice safe sex.

5. Alcohol and Rape, Sexual Assault, and Dating Violence a. Alcohol use is associated with sexual assault and dating violence on campus.

6. Alcohol Poisoning a. Alcohol poisoning occurs when blood alcohol level reaches the lethal range. b. Death can be caused by central nervous system and respiratory system depression or by inhaling vomit or fluid into the lungs.

B. Drinking and Driving 1. Traffic accidents are the leading cause of accidental death for all age groups from 1 to 35. a. Alcohol-impaired drivers are involved in about 28 percent of traffic deaths, resulting in more than 10,500 deaths a year—roughly one traffic fatality every 50 minutes.

2. Over the past 20 years, the percentage of intoxicated drivers involved in fatal crashes decreased for all age groups. See Figure 9.5.

3. All states have zero-tolerance laws for driving while intoxicated.

4. The risk of being involved in an alcohol-related crash is still substantial. a. Alcohol-related fatal crashes occur more often at night than during the day.

C. Long-Term Effects of Alcohol 1. Effects on the Nervous System a. People who drink even moderately experience shrinkage in brain size and weight and a loss of some degree of intellectual ability. b. Developing brains in adolescents are much more prone to damage than previously thought.

2. Alcohol and Weight Gain a. By drinking an extra 150 calories a day, you can gain 1 pound a month and up to 12 pounds a year.

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a. Numerous studies have associated light to moderate alcohol consumption (no more than two drinks per day) with a reduced risk of coronary artery disease. b. Alcohol consumption causes many more cardiovascular health hazards than benefits. c. Drinking too much alcohol contributes to high blood pressure, increasing the risk of a stroke and heart attack in some people.

4. Liver Disease a. One result of heavy drinking is that the liver begins to store fat—a condition known as fatty liver. b. Continued drinking can cause a further stage of liver deterioration called fibrosis.

At this stage, cell function can be partially restored with proper nutrition and abstinence from alcohol. If not, cirrhosis of the liver results. c. Alcoholic hepatitis is a serious condition resulting from prolonged use of alcohol.

5. Cancer a. Alcohol is considered a carcinogen. b. Prolonged alcohol use has been linked to cancer of the esophagus, colon, rectum, breast, stomach, oral cavity, and liver. i. For women who drink, breast cancer is the leading alcohol-related cancer. ii. For men, it is colon cancer. c. Evidence indicates that women consuming high levels of alcohol have a higher risk of breast cancer compared with abstainers.

6. Other Effects a. Alcohol abuse is a major cause of chronic inflammation of the pancreas. b. Drinking alcohol can block the absorption of calcium, a nutrient that strengthens the bones.

D. Alcohol and Pregnancy 1. Alcohol is one of the most common and most dangerous teratogenic substances for pregnant women.

2. Alcohol consumed during the first trimester poses the greatest threat to organ development of the fetus.

3. Fetal alcohol syndrome (FAS) is associated with alcohol consumption during pregnancy. a. Symptoms of FAS include small head size, tremors, and abnormalities of the face, limbs, heart, and brain.

4. Children with fewer than the full physical or behavior symptoms of FAS may have a disorder that falls under the umbrella term fetal alcohol spectrum disorders (FASD).

Key Terms: learned behavior tolerance, dehydration, hangover, congeners, alcohol poisoning (acute alcohol intoxication), cirrhosis, alcoholic hepatitis, fetal alcohol syndrome (FAS) Figures: Figure 9.4 Effects of Alcohol on the Body and Health Figure 9.5 ..

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Percentage of Fatally Injured Drivers with BACs Greater Than 0.08 Percent, by Driver Age, 1982–2015 Figure 9.6 Comparison of a Healthy Liver with a Cirrhotic Liver III. Alcohol Use in College •

Alcohol is the most popular drug used on college campuses.

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Over 53 percent of college students report having consumed alcoholic beverages in the past 30 days. See Figure 9.7.

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Approximately 33 percent of all college students engage in binge drinking.

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A significant number of college students experience negative consequences because of their alcohol consumption. See Figure 9.8.

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Many students report practicing preventive behaviors to reduce the risk of negative consequences associated with alcohol consumption. o See the Skills for Behavior Change box for strategies for drinking responsibly.

A. High-Risk Drinking and College Students 1. A recent study reports that 1,825 college students die each year because of alcoholrelated, unintentional injuries, including car accidents.

2. College students are at particularly high risk for alcohol-related problems for several reasons: a. Alcohol exacerbates their already high risk for suicide, automobile crashes, and falls. b. Many college and university students’ customs and celebrations encourage dangerous practices and patterns of alcohol use. c. The alcoholic beverage industry heavily targets university campuses. d. Drink specials enable students to consume large amounts of alcohol cheaply. e. College students are particularly vulnerable to peer influence. f. College administrators deny alcohol problems on their campuses.

3. Pre-gaming involves planned heavy drinking with friends over brief periods prior to going out to a bar, party, or sporting event.

4. Drinking games have been associated with blacking out, regrettable sexual experiences, and alcohol-related injuries and deaths from alcohol poisoning.

5. “Drunkorexia” is a colloquialism currently being used to describe the combination of two dangerous behaviors: disordered eating and heavy drinking.

6. A dangerous alternative is alcohol inhalation; risks include liver and brain damage.

B. Efforts to Reduce Student Drinking 1. Programs addressing the problem of drinking that have proven particularly effective use cognitive-behavioral skills training with motivational interviewing, a nonjudgmental approach to working with students to change behavior.

2. E-interventions and web interventions have shown promise in reducing alcohol-related problems among first-year students.

Key Terms: binge drinking, pre-gaming, drunkorexia

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Figures: Figure 9.7 College Students’ Patterns of Alcohol Use in the Past 30 Days Figure 9.8 Prevalence of Negative Consequences of Drinking Among College Students, Past Year IV. Alcohol Abuse and Dependence •

The Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) has integrated alcohol abuse and alcohol dependence into a single disorder: Alcohol use disorder (AUD). o Any person who meets two or more criteria is diagnosed with AUD. o Severity falls along a spectrum from mild to severe. o

See Figure 9.9.

A. Identifying an Alcoholic 1. As with other drug addictions, craving, loss of control, tolerance, psychological dependence, and withdrawal symptoms must be present to qualify a drinker as an addict.

2. Recognizing and admitting the existence of an alcohol problem is often extremely difficult. a. See Skills for Behavior Change for tips on cutting down on drinking.

3. Functional alcoholics are typically educated, have a steady job, have a family, and have made it to middle age.

B. The Causes of Alcohol Use Disorder 1. Alcoholism is a disease with biological and social/environmental components.

2. Biological and Family Factors a. Alcohol use disorders are approximately 60 percent heritable. b. No single gene causes addiction, but multiple genes can affect the possibility of developing an addiction.

3. Social and Cultural Factors a. Some people begin drinking as a way to dull the pain of an acute loss or an emotional or social problem. b. Family attitudes toward alcohol may play a role. i.

See Health in a Diverse World box.

c. The amount of alcohol a person consumes seems to be directly related to the drinking habits of his or her social group.

C. Alcohol Use Disorder in Women 1. Women tend to become alcoholics at a later age and after fewer years of heavy drinking than do male alcoholics.

2. Women get addicted faster with less alcohol use and suffer the consequences more profoundly.

3. Risk factors for female alcoholism include the following: a. Unmarried but living with a partner

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b. In their 20s or early 30s c. Have a husband or partner who drinks heavily d. A family history of drinking problems e. Pressure to drink from a peer or spouse f. Depression g. Stress D. Alcohol and Prescription Drug Abuse 1. When alcohol and prescription drugs are taken together, severe medical problems can result, including alcohol poisoning, unconsciousness, respiratory depression, and death.

E. Costs to Society 1. Estimated alcohol-related costs to society are well over $249 billion when health insurance, criminal justice costs, treatment costs, and lost productivity are considered.

2. Alcoholism is directly or indirectly responsible for more than 25 percent of the nation’s medical expenses and lost earnings.

F. Treatment and Recovery 1. Only a very small percentage of alcoholics in the United States receive any care.

Factors contributing to this low figure include the following: a. inability or unwillingness to admit to an alcohol problem b. the social stigma attached to alcoholism c. the fact that seeking treatment would require abstinence d. the desire to deal with alcohol problems on one’s own 2. Alcoholics who decide to quit drinking experience detoxification, the process by which addicts end their dependence on a drug. a. Symptoms of detoxification include hyperexcitability, confusion and agitation, sleep disorders, convulsions and tremors, depression, headache, and seizures. b. Some people experience delirium tremens (DTs) characterized by confusion, delusions, agitated behavior, and hallucinations.

3. Treatment for alcoholics ready for help includes the following: a. Psychologists and psychiatrists specializing in the treatment of alcoholism b. Private treatment facilities c. Hospitals specifically designed to treat alcoholics d. Community mental health facilities e. Support groups such as Alcoholics Anonymous (AA) 4. Private Treatment Facilities a. Private treatment facilities are expensive, but some insurance programs or employers will assume most of this expense.

5. Therapy a. There are several types of therapy available to alcoholics including family therapy, individual therapy, and group therapy to help them overcome their addiction. b. Many campuses recognize the need to create recovery-friendly space and supportive environments for students engaged in recovery.

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6. Relapse a. Only about one-third of people who are abstinent less than a year will remain abstinent. b. People who are seeking to regain a healthy lifestyle must guard against the tendency to relapse.

Key Terms: alcohol use disorder, delirium tremens (DTs), Alcoholics Anonymous (AA) Figure: Figure 9.9 Alcohol Use Disorder (AUD) Criterion V. Tobacco Use in the United States A. Tobacco use is the single most preventable cause of death in the United States.

1. Nearly a half a million Americans die each year of tobacco-related diseases.

2. Tobacco is known to cause about 20 diseases, and about half of all regular smokers die of smoking-related diseases. a. Table 9.1 shows the percentages of Americans who smoke, by demographic group.

B. Tobacco and Social Issues 1. The production and distribution of tobacco products involve many political and economic issues.

2. Advertising a. The tobacco industry spends an estimated $26 million per day on advertising and promotional materials. b. Advertisements in women’s magazines imply that smoking is the key to financial success, desirability, beauty, independence, social acceptance, and being “cool”— and they have apparently been working. c. Cigarette advertising targeted toward men appeals to a need to feel and appear masculine. d. Minorities are targeted where studies have shown a higher concentration of tobacco advertising in magazines aimed at African Americans.

3. Financial Costs to Society a. Estimates show that the annual costs attributed to smoking in the United States are between $289 and $333 billion.

C. College Students and Tobacco Use 1. College students are the targets of heavy tobacco marketing and advertising campaigns.

2. Smoking among college students has decreased slightly in recent years. See Figure 9.10.

3. Why Do College Students Smoke? a. The main reason students give for their smoking is to relax or reduce stress.

4. Social Smoking a. Many college students identify themselves as social smokers—those who smoke only when they are with people rather than when alone.

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b. Smoking just one to five cigarettes per day has been shown to damage blood vessels and to increase the risk of heart disease and cancer.

D. Tobacco Use and Prevention Policies 1. The government began warning that tobacco use is hazardous to the health of the nation more than 40 years ago.

2. In 1998, the tobacco industry reached a Master’s Settlement Agreement with 46 states to pay approximately $206 billion over 25 years to support antismoking education and other measures. a. Unfortunately, most of the money designated for tobacco control and prevention at the state level has not been used for this purpose.

3. The Family Smoking Prevention and Tobacco Control Act signed in 2009 allows the Food and Drug Administration (FDA) to forbid advertising to children, lower the amount of nicotine in products, ban sweetened cigarettes, prohibit labels that use “light” and “low tar,” and place more prominent health warnings on advertising of tobacco products and the products themselves.

Figure and Table: Table 9.1 Percentage of Population That Smokes (Age 18 and Older) among Select Groups in the United States VI. Tobacco and Its Effects •

Smoking is the most common form of tobacco use and delivers directly to the lungs a strong dose of nicotine as well as 7,000 other chemicals, including arsenic, formaldehyde, and ammonia.

A. Nicotine 1. Nicotine is a highly addictive chemical stimulant and the major psychoactive substance in tobacco.

2. Nicotine is a powerful stimulant of the central nervous system that produces a variety of physiological effects.

B. Tar and Carbon Monoxide 1. Tar is the thick, brownish sludge from particulate matter that condenses in the lungs. It contains various carcinogenic agents, such as benzopyrene, and chemical irritants, such as phenol.

2. The cleansing function of the cilia in the lungs is damaged by nicotine. See Figure 9.11 for how tobacco smoke damages the lungs.

3. Tobacco smoke also contains poisonous gases, the most dangerous of which is carbon monoxide.

C. Tobacco Use Disorder 1. The APA defines tobacco use disorder as a “problematic pattern of tobacco use leading to clinically significant impairment or distress,” characterized by 2 of 11 symptoms in a 12-month period.

D. Tobacco Products

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1. Filtered cigarettes are designed to reduce the levels of gases such as hydrogen cyanide and carbon monoxide, but may actually deliver more hazardous gases to the user than do nonfiltered brands. a. Clove cigarettes contain about 40 percent ground cloves and about 60 percent tobacco and contain higher levels of tar, nicotine, and carbon monoxide than do regular cigarettes—and the numbing effect of eugenol, the active ingredient in cloves, allows smokers to inhale the smoke more deeply. b. The throat-numbing effect of menthol cigarettes also allows for deeper inhalation.

2. E-Cigarettes a. Electronic cigarettes, or e-cigarettes, deliver nicotine, flavorings, and other additives as vapor instead of smoke. b. Beyond exposing users to chemicals such as nicotine, carbonyl compounds, and volatile organic compounds, the health effects and harmful doses of heated and aerosolized constituents of e-cigarette fluids including solvents, flavorings, and toxicants are not fully understood.

3. Cigars a. Many people believe that cigars are safer than cigarettes, when, in fact, nothing could be further from the truth. b. Cigars have higher levels of carcinogens, more tar per gram of tobacco smoked, and higher levels of toxins than do cigarettes.

4. Bidis a. Bidis are small, hand-rolled cigarettes that come in a variety of flavors. b. Bidis are far more toxic than cigarettes.

5. Pipes and Hookahs a. Pipes have had a long history of use throughout the world, and hookahs—a type of water pipe with a long hose for inhaling—have become particularly popular among young adults in the United States. b. Many of the same harmful toxins found in cigarettes are also found in hookah smoke.

6. Smokeless Tobacco a. Smokeless tobacco is just as addictive as cigarettes and contains more nicotine. b. Chewing tobacco comes in three forms: loose leaf, plug, or in a pouch. Dipping rapidly releases nicotine into the bloodstream. c. Snuff is a finely ground form of tobacco that can be inhaled, chewed, or placed against the gums.

Key Terms: nicotine, tar, carbon monoxide, nicotine poisoning, bidis, chewing tobacco, dipping, snuff, leukoplakia Figure: Figure 9.10 Lung Damage from Chemicals in Tobacco Smoke ABC News: See It! Video: GMA Investigates Liquid Nicotine

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VII. •

Health Hazards of Tobacco Products

Each day, cigarettes contribute to approximately 1,200 deaths from cancer, cardiovascular disease, and respiratory disorders. o Tobacco use can negatively impact the health of almost every system in your body. o Figure 9.12 summarizes some of the physiological and health effects of smoking.

A. Cancer 1. Lung cancer is the leading cause of cancer deaths in the United States.

2. It is estimated that smoking causes 90 percent of lung cancer in men and 78 percent in women.

3. If you are a smoker, the risk of developing lung cancer depends on several factors: a. Amount smoked per day b. When you started smoking c. How deeply you inhale when you smoke 4. A major health risk of chewing tobacco is leukoplakia, a condition characterized by leathery white patches inside the mouth. a. Smokeless tobacco users have significantly higher rates of oral cancer than do nonusers. b. The lag time between first use and contracting cancer is shorter for smokeless tobacco users than for smokers because absorption through the gums is the most efficient route of nicotine administration.

5. Other cancers associated with tobacco use include cancers of the larynx, esophagus, nasal cavity, pancreas, colon, kidney, and bladder.

B. Cardiovascular Disease 1. Smoking is a major risk factor for cardiovascular disease and stroke.

2. Smoking ages the arteries. a. Smoking decreases high-density lipoprotein levels.

3. It contributes to platelet adhesiveness, which increases the risk of blood clots.

4. Smoking contributes to strokes by raising blood pressure, which increases the stress on vessel walls, and platelet adhesiveness contributes to blood clot formation.

C. Respiratory Disorders 1. Smoking quickly impairs the respiratory system.

2. Chronic bronchitis is caused by inflamed lungs producing excess mucus.

3. Emphysema is a chronic condition in which alveoli are destroyed and oxygen intake is impaired.

D. Sexual Dysfunction and Fertility Problems 1. Studies have found that male smokers are much more likely to experience erectile dysfunction than are nonsmokers.

2. In women, smoking can lead to infertility and problems with pregnancy.

E. Unique Risks for Women 1. Women who smoke also have higher rates of osteoporosis, depression, and thyroidrelated disease.

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F. Other Health Effects 1. Studies have shown tobacco use to be a serious risk factor in the development of gum disease.

2. Smoking increases the chance of macular degeneration, one of the most common causes of blindness in older adults.

3. Smoking ages the skin, stains teeth yellow, yellows fingernails, and causes bad breath.

4. Heavy smokers might be at higher risk for developing Alzheimer’s disease.

G. Environmental Tobacco Smoke 1. Environmental tobacco smoke (ETS) is divided into two categories: a. Mainstream smoke refers to smoke drawn through tobacco while inhaling. b. Side-stream, or secondhand, smoke, refers to smoke from the burning end of a cigarette or smoke inhaled by a smoker. c. People who breathe smoke from someone else’s smoking product are said to be involuntary or passive smokers.

H. Risks from Environmental Tobacco Smoke 1. Secondhand smoke contains hundreds of chemicals known to be toxic or carcinogenic.

2. Every year, ETS is estimated to be responsible for 3,400 lung cancer deaths, 46,000 coronary and heart disease deaths, and a higher risk of death in newborns from sudden infant death syndrome.

3. The Environmental Protection Agency has designated secondhand smoke as a known carcinogen.

Key Terms: platelet adhesiveness, emphysema, environmental tobacco smoke (ETS), mainstream smoke, sidestream smoke Figure: Figure 9.11 Effects of Smoking on the Body and Health VIII. •

Quitting

Quitting is often a lengthy process involving several unsuccessful attempts before success is finally achieved.

A. Benefits of Quitting 1. Many tissues damaged by smoking can repair themselves. a. See Figure 9.13 for an illustration of the repair process.

2. The body begins to repair itself almost as soon as the smoker stops.

3. Another benefit from quitting smoking is saving money.

B. How Can You Quit?

1. Smoking cessation programs include short-term programs, treatment centers, community outreach plans sponsored by a local medical clinic, telephone quit lines, one-on-one with a physician, and, of course, going “cold turkey” on your own.

2. Programs that combine several approaches have shown the most promise.

C. Breaking the Nicotine Addiction

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1. Symptoms of nicotine withdrawal include irritability, restlessness, nausea, vomiting, and intense cravings for tobacco. a. See Table 9.2.

2. Nicotine Replacement Products a. Nicotine replacement products are one way to help smokers break the addiction. b. Two most common products: nicotine gum or lozenges and the nicotine patch. c. The nasal spray requires a prescription and is much more powerful and delivers nicotine to the bloodstream faster than gum or the patch. The nicotine inhaler also requires a prescription and consists of a mouthpiece and cartridge.

3. Smoking Cessation Medications a. Bupropion, an antidepressant, is FDA approved as a smoking-cessation aid. b. Varenicline reduces nicotine cravings and the urge to smoke and blocks the effects of nicotine at nicotine receptors in the brain.

Key Term: nicotine withdrawal Figure and Table: Figure 9.12 When Smokers Quit Table 9.2 Coping Strategies for Common Smoking Withdrawal Problems

Discussion Questions 1. Discuss several reasons for the popularity of alcohol on college campuses. How do you think that this influences the wider campus culture?

2. Explain how alcohol use is related to motor vehicle accidents. How would stricter penalties or random checkpoints affect the number of people who drive after drinking? What ideas do you have to curb drinking and driving among young adults?

3. Explain the effects of nicotine, and describe why it is so difficult to break the addiction.

What could be done on college campuses to support smoking cessation?

4. What are some possible reasons for the increasing number of teen smokers? What are the gender differences, if any? Support your answer with a discussion of gender- and smokingrelated issues.

5. How is cigarette smoking related to lung cancer? How is smokeless tobacco related to oral cancer? What other forms of cancer does tobacco use influence?

6. Why are companies promoting smoke-free workplaces? How do these restrictions save the company money?

Critical Thinking Questions 1. Have you or your friends ever driven while under the influence of alcohol? How did you feel about this behavior? Do you condone this behavior? What do you do if your designated driver has been drinking?

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2. Why do you think the incidence of alcohol use and abuse by women has risen to the same levels as in men? What are two suggestions for curbing this rise in abuse?

3. Discuss three ways that tobacco use is costly to society. How could some of these costs be reduced or eliminated with reduced tobacco use? To reduce the greatest costs to society, what age demographic should be targeted for eliminating tobacco use and why?

4. Do you think there is a problem with alcohol use and abuse on your campus? What do you think needs to be done to address this problem with students? What policies are in place on your campus to limit the use and abuse of alcohol?

5. What would you do if a friend or acquaintance at a party exhibits signs of alcohol poisoning?

6. Do you think people who smoke should pay higher rates for health insurance? Why or why not?

7. Why do you think more women smoke today than in the past? What specific things do you think can be done to educate women about the dangers of smoking?

Student Activities Individual 1. Observe a public place for one hour. Tally the number of people who smoke, breaking down for gender and age. How does this compare with the national average?

2. Discuss with a friend what actions you would take if a mutual friend exhibited signs of alcohol abuse or alcoholism. What would you say to your friend about his or her situation?

What campus or community resources would you tell your friend about?

Community 1. Find out what the penalties are for driving while intoxicated (DWI) or driving under the influence (DUI) in your community and state. Do you agree with these penalties? Do you think the penalties should be more or less severe?

2. What kinds of laws are enforced on your campus or in your community to provide smokefree environments at work, study, and meeting places; restaurants and bars; motels and hotels; and other public places? What are the penalties for breaking these laws?

3. Find out what is being done on your campus or in your community to support the idea of having designated drivers to avoid alcohol-related automobile accidents. Have you ever been a designated driver? Have you ever asked a friend to be a designated driver?

Diverse Population/Nontraditional 1. Use the Internet to research how print and other advertising of alcoholic beverages has changed over the years. Are similar changes reflected in how cigarette advertising has changed over the years?

2. What is the percentage of cigarette smoking and other forms of tobacco use in other countries? How do these figures compare by age with similar figures in the United States?

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Additional References R. S. Caraballo, S. L. Yee, J. Gfroerer, and S. A. Mirza, “Adult Tobacco Use among Racial and Ethnic Groups Living in the United States, 2002–2005.” Preventing Chronic Disease, 5 (2008): A78, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483561/.

V. Cokkindes, P. Brandi, C. McMahan, A. Jemal, T. Glynn, and E. Ward, “Tobacco Control in the United States—Recent Progress and Opportunities.” CA: A Cancer Journal for Clinicians, 59 (2009): 352–365.

F. M. Costa, R. Jessor, and M. S. Turbin, “College Student Involvement in Cigarette Smoking: The Role of Psychosocial and Behavioral Protection and Risk.” Nicotine & Tobacco Research, 9 (2007): 213–224.

K. Fromme, R. R. Wetherill, and D. J. Neal, “Turning 21 and the Associated Changes in Drinking and Driving after Drinking among College Students.” Journal of American College Health, 59 (2010): 21–27.

R. Hingson, T. Heeren, M. Winter, and H. Wechsler, “Magnitude of Alcohol-related Mortality and Morbidity among U.S. College Students Ages 18–24: Changes from 1998 to 2001.” Annual Review of Public Health, 26 (2005): 259–279.

J. G. Lee, A. O. Goldstein, K. D. Kramer, J. Steiner, M. M. Ezzell, and V. Shah, “Statewide Diffusion of 100% Tobacco-free College and University Policies.” Tobacco Control, 19, no.

4 (2010), doi:10.1136/tc.2009.032888.

M. C. Mackey, S. H. McKinner, and A. Tavakoli, “Factors Related to Smoking in College Women.” Journal of Community Health Nursing, 25 (2008): 106–121.

National Advisory Council on Alcohol Abuse and Alcoholism, A Call to Action: Changing the Culture of Drinking at U.S. Colleges (Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, National Advisory Council on Alcohol Abuse and Alcoholism, Task Force on College Drinking, 2005).

National Advisory Council on Alcohol Abuse and Alcoholism. High-Risk Drinking in College: What We Know and What We Need to Learn: Final Report of the Panel on Contexts and Consequences (Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, National Advisory Council on Alcohol Abuse and Alcoholism, Task Force on College Drinking, 2002).

P. M. O’Malley and L. D. Johnston, “Epidemiology of Alcohol and Other Drug Use among American College Students.” Journal of Studies on Alcohol, 14 (2002): 23–29.

J. R. Sanem, C. J. Berg, L. C. An, M. A. Kirch, and K. A. Lust, “Differences in Tobacco Use among Two-year and Four-year College Students in Minnesota.” Journal of American College Health, 58 (2009): 151–150.

G. K. Sing, M. Siahpush, and M. D. Kogan, “Disparities in Children’s Exposure to Environmental Tobacco Smoke in the United States, 2007.” Pediatrics (2010), doi:10.1542/peds.2009-2744.

R. R. Staten and S. L. Ridner, “College Students’ Perspective on Smoking Cessation: ‘If the Message Doesn’t Speak to Me, I Don’t Hear It.’” Issues in Mental Health Nursing, 28 (2007): 101–115.

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S. T. Walters, B. S. Roudsari, A. M. Vader, and T. R. Harris, “Correlates of Protective Behavior Utilization among Heavy-drinking College Students.” Addictive Behaviors, 32 (2007): 2633–2644.

H. Wechsler, J. E. Lee, M. Kuo, M. Seibring, T. Nelson, and H. Lee, “Trends in College Binge Drinking during a Period of Increased Prevention Efforts: Findings from Four Harvard School of Public Health College Alcohol Study Surveys: 1993–2001.” Educational Administration Abstracts, 38 (2003): 147–282.

For Further Information Al-Anon Family Groups www.al-anon.org American Cancer Society www.cancer.org/index Americans for Nonsmokers’ Rights www.no-smoke.org Campaign for Tobacco-Free Kids www.tobaccofreekids.org/index.php National African American Tobacco Prevention Network www.naatpn.org National Cancer Institute www.cancer.gov/cancertopics/tobacco/smoking National Cancer Institute Tobacco Control Research Branch http://cancercontrol.cancer.gov/brp/tcrb/ National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov Smokefree.gov www.smokefree.gov State Tobacco Activities Tracking and Evaluation (STATE) System http://www.cdc.gov/statesystem/ Substance Abuse and Mental Health Services Administration www.samhsa.gov

Additional Media Ready-to-Go Teaching Module: Alcohol and Tobacco Alcohol: A Women’s Health Issue, 13 minutes 6 seconds In this National Institutes of Health video, seven women discuss their struggles with alcohol. www.youtube.com/watch?v=N0X2aRnYL4E&feature=related Alcohol Abuse and Addiction (College Health Guru), 2 minutes 28 seconds ..

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Dr. Morgan Rabach discusses the signs of alcohol abuse and distinguishes alcohol abuse from alcoholism, as well as what happens when alcohol abuse becomes alcoholism. www.youtube.com/watch?v=FdAu5HcMuBs&feature=related End Result of Alcoholism (College Health Guru), 2 minutes 31 seconds Dr. Morgan Rabach discusses the negative effects of drinking, alcohol-related deaths, and the long-term health effects of alcohol use. www.youtube.com/watch?v=wavDf59t1YE What Is Alcoholism? (College Health Guru), 2 minutes 18 seconds Dr. Adam J. Flisser of College Health Guru discusses alcoholism, alcohol abuse, and alcohol dependence. Dr. Flisser also discusses factors that increase the risk of alcoholism and what to do if you or someone you know exhibits the signs of alcoholism. www.youtube.com/watch?v=gTPjlN7VR7c&feature=channel What Is Alcohol Poisoning? (College Health Guru), 1 minute 56 seconds Dr. Morgan Rabach discusses what causes alcohol poisoning, signs of alcohol poisoning, and what to do if you observe these symptoms. www.youtube.com/watch?v=6E_T_NQjJDo Alternative Therapies to Help You Quit (Smoking Cessation 4), 3 minutes 38 seconds In this illumistream production, Dr. Joshua Fink discusses various nonnicotine strategies that can be used to help a person quit smoking. www.youtube.com/watch?v=aNgox9EPha0&p=14F5DEF25590476C&index=15 How to Quit Smoking (Health Guru), 3 minutes 25 seconds In this Health Guru educational clip, Dr. Joshua Fink outlines a plan to help smokers quit.

Tips including keeping a smoking journal, identifying triggers, and setting a quitting date. www.youtube.com/watch?v=_tGzsX0borM&feature=channel Medications That Help You Quit (Smoking Cessation #3), 3 minutes In this illumistream production, Dr. Joshua Fink discusses nicotine replacement therapies available to help current smokers kick their habit. www.youtube.com/watch?v=nASxOVKjciY&feature=channel Nicotine and Tobacco Addiction Video, NIDA, 1 minute 43 seconds In this production of the National Institute of Drug Abuse, NIDA scientists Gaya Dowling and Redonna Chandler discuss the negative health effects of nicotine and smoking. www.youtube.com/watch?v=DqLA2sW_thw&feature=channel Smoking Cigarettes—Not So Smart (College Health Guru), 2 minutes In this College Health Guru educational clip, Dr. Robert Gorski discusses factors affecting the increasing rates of cigarette use among college students. www.youtube.com/watch?v=oB8AvqeOcZM The Real Cost of Smoking (Smoking Cessation #1), 3 minutes In this illumistream production, Dr. Joshua Fink discusses the health effects of smoking.

Additionally, Dr. Fink examines the biological effects on the human body. www.youtube.com/watch?v=3aIeF5LjaDk&feature=channel 152

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Nutrition: Eating for a Healthier You

10 Overview

In order to reduce the prevalence of many costly and debilitating diseases, proper nutrition must be a primary concern in the United States. This chapter introduces students to basic nutrition information and provides strategies for making healthy dietary decisions even under the restrictions of campus dining. It also helps the student to understand the effect that a diet high in fat can have on one’s health. Students will complete this chapter with skills in label reading and understanding how to calculate proper amounts of fat for their own health. Chapter 10 stresses the importance of raising the intake of fruits and vegetables, including fiber, as an important aspect of sound nutrition. It also discusses the importance of safe food handling practices. Finally, the end of the chapter provides students with important introductions to two of the hottest nutrition debates: organically grown foods and genetically modified foods. This chapter is designed to help students become more educated about nutrition and dietary behaviors and more skilled in making healthy food choices.

Learning Outcomes 1. List the six classes of nutrients and explain the primary functions of each.

2. Explain how the Dietary Guidelines for Americans and the MyPlate food guidance system can help you follow a healthful eating pattern.

3. Discuss strategies for healthful eating, including how to read food labels, the role of vegetarian diets and dietary supplements, how to eat mindfully, and how to choose healthful foods on and off campus.

4. Explain food safety concerns facing Americans and people in other regions of the world.

Lecture Outline

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•

Hunger occurs when our brains initiate a physiological response that prompts us to seek food for the energy and nutrients that our bodies require to maintain proper functioning.

•

Appetite is a learned psychological desire to consume food.

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o

•

Many factors influence our physiological drive to eat, including cultural factors, food advertising, perceived nutritional value, social interaction, emotions, and financial means.

Nutrition is the science that investigates the relationship between physiological function and the essential elements of the food we eat.

I. Essential Nutrients for Health •

Our bodies cannot synthesize certain essential nutrients, so we must obtain them from foods.

•

The nutrients we need in the largest amounts—water, carbohydrates, fats, and proteins—are called macronutrients.

•

Other nutrients—the vitamins and minerals—are needed in smaller amounts, so they are called micronutrients.

•

Before the body can use foods, the digestive system must break down the larger food particles into smaller, more usable forms; this is the digestive process.

A. Recommended Intakes for Nutrients 1. Dietary Reference Intakes are umbrella guidelines and include the following categories: a. Recommended Dietary Allowances (RDAs) b. Adequate Intakes (AIs) c. Tolerable Upper Intake Levels (ULs) d. Acceptable Macronutrient Distribution Ranges (AMDRs) B. Calories 1.

A kilocalorie (shortened to calorie on labels) is a unit of measurement that quantifies the amount of energy in food sources.

2. Energy is defined as the capacity to do work; we derive energy from the energycontaining nutrients in the foods we eat (proteins, carbohydrates, and fats).

C. Water: A Crucial Nutrient 1. Humans can survive much longer without food than without water. a. Dehydration, the abnormal depletion of body fluids, can cause serious problems. b. Too much water, hyponatremia, can also pose a serious health risk.

2. The human body consists of 50 to 70 percent water by weight.

3. Individual needs for water vary drastically according to dietary factors, age, size, overall health, environmental temperature and humidity levels, and exercise. a. General recommendations for women are approximately 9 cups of total water from all beverages and foods each day; for men, an average of 13 cups. b. Caffeinated drinks, including coffee, tea, and soda, also count toward total fluid intake for those who regularly consume them.

4. There are situations in which a person needs to take in additional fluids in order to stay properly hydrated. These include illness, experiencing warmer weather, working out, and other factors.

D. Proteins

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1. Proteins are major components of every cell. a. They help repair tissue and assist in antibody production and hormone formation. b. They are also called “body builders.”

2. Your body breaks down proteins into smaller nitrogen-containing molecules known as amino acids. a. Nine of the 20 different amino acids must be obtained from the diet and are called essential amino acids. b. Eleven amino acids are considered nonessential because the body can make them. c. Complete protein is a dietary protein that supplies all the essential amino acids; it usually comes from animals. d. Proteins from plant sources are incomplete; they lack one or two of the essential amino acids. Quinoa and soy are complete plant proteins. e. Eating complementary plant proteins can supply all the essential amino acids.

See Figure 10.1.

3. Few Americans suffer from protein deficiencies. a. The average American consumes more than 83 grams of protein daily, and much of this comes from high-fat animal flesh and dairy products. b. The typical protein recommendation is that 10 to 35 percent of calories should come from lean protein. c. A person might need additional protein if pregnant, fighting off a serious infection, recovering from surgery, or recovering from burns.

E. Carbohydrates 1. Carbohydrates supply us with the energy needed to sustain normal daily activity; for a quick source of energy, the human body metabolizes carbohydrates faster and more efficiently than protein.

2. There are two major types of carbohydrates: simple and complex.

3. Simple Carbohydrates a. They include simple sugars such as glucose and fructose—also called monosaccharides and found primarily in fruits and vegetables. b. Two single sugars combined are referred to as a disaccharide. Examples include sucrose (granulated table sugar), lactose (milk sugar), and maltose (malt sugar).

4. Complex Carbohydrates: Starches and Glycogen a. There are three main types of complex carbohydrates: starches, glycogen, and fiber. b. Starches from flours, breads, pasta, rice, corn, oats, barley, potatoes, and related foods make up the majority of complex carbohydrates. c. The body breaks these complex carbohydrates into glucose, which can be used as energy or stored in the muscles and liver as glycogen. Glycogen is broken down into glucose when the body needs a sudden burst of energy.

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a. Fiber, often called “bulk” or “roughage,” is the indigestible portion of plant foods that helps move foods through the digestive system, delays absorption of cholesterol and other nutrients, and softens stools by absorbing water. b. Dietary fiber is found in plant foods. c. Fiber is either soluble (which can be dissolved in water and digested by bacteria in the colon) or insoluble (cannot be dissolved in water and cannot be fermented by bacteria in the colon). d. The AMDR for carbohydrates is 45 to 65 percent of total calories, the majority of which should be fiber-rich. e. Fiber is associated with a reduced risk for obesity, heart disease, constipation, and possibly even type 2 diabetes and colon and rectal cancers.

F. Fats 1. Fats are the most energy-dense source of calories in our diet. a. Fats play a vital role in insulating organs against cold and shock, as well as maintaining healthy skin and hair.

2. Triglycerides make up the majority of our body fat. a. The remaining fat in our bodies is composed of substances like cholesterol— a type of sterol—and lipoproteins. b. Whereas low-density lipoproteins (LDLs) transport cholesterol to the body’s cells, high-density lipoproteins (HDLs) transport circulating cholesterol to the liver for metabolism and elimination from the body.

3. Types of Dietary Fat a. Saturated fats generally come from animal sources and are solid at room temperature. b. Unsaturated fats come from plants and are liquid at room temperature; they include most vegetable oils. c. See Figure 10.3 for a breakdown of the types of fats in common vegetable oils. d. Omega-3 and omega-6 fatty acids are classified as essential fatty acids.

4. Avoiding Trans Fatty Acids a. Just a 2 percent caloric intake of trans fats was associated with a 23 percent increased risk for heart disease b. Trans fats, including partially hydrogenated oils (PHOs), are fatty acids produced by adding hydrogen molecules to liquid oil to make the oil into a solid. c. In 2015, the Food and Drug Administration (FDA) ruled that PHOs are no longer generally recognized as safe for consumption. d. If you see the words partially hydrogenated oils, fractioned oils, shortening, lard, or hydrogenation on a food label, trans fats are present.

5. Fat Intake Recommendations a. AMDR for fats is 20 to 35 percent of total calories. A number of guidelines can help you add more healthful fats to your diet, including the following: b. Eat fatty fish at least twice weekly.

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c. Use soy, olive, peanut, and canola oils for instead of lard and butter. d. Add healthy doses of green leafy vegetables, walnuts, walnut oil, and ground flaxseed to your diet. e. Read nutrition facts panels. f.

Chill meat-based soups and stews, scrape off any fat that hardens on top, and then reheat to serve. g. Fill up on fruits and vegetables. h. Hold the creams and sauces. i. Avoid all products with trans fatty acids. j. Choose lean meats, fish, or skinless poultry. k. Choose fewer cold cuts, bacon, sausages, hot dogs, and organ meats. l. Select nonfat and low-fat dairy products.

G. Vitamins 1. Vitamins are organic compounds that promote growth and are essential for maintaining life and health.

2. Vitamins are classified as either fat soluble or water soluble. a. The fat-soluble vitamins are vitamins A, D, E, and K. b. The water-soluble vitamins are vitamin C and the B-complex vitamins. c. See Table 10.2 for functions, recommended intake amounts, and food sources of specific vitamins.

3. Vitamin D 4. Vitamin D is formed in the skin when exposed to ultraviolet light. For people who can’t get enough sunshine, Vitamin D needs to be obtained through foods. a. Vitamin D is essential for the body’s regulation of calcium. A deficiency in Vitamin D can result in osteoporosis, rickets, and osteomalacia. b. Adequate levels of vitamin D may reduce the risk for cardiovascular disease, diabetes, and some forms of cancer. c. Excess vitamin D can be dangerous.

5. Folate a. Folate is needed for the production of compounds necessary for DNA synthesis in body cells. b. Folate deficiencies in the first few weeks of pregnancy can cause neural tube defects.

H. Minerals 1. Minerals are inorganic, indestructible elements build body tissues and assist body processes.

2. There are two different types of minerals. a. Major minerals are needed by the body in large amounts. b. Trace minerals are needed by the body in only very small amounts. i. See Table 10.3 for more on minerals.

3. Sodium

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a. Sodium is necessary for the regulation of blood and body fluids, transmission of nerve impulses, heart activity, and certain metabolic functions. b. The majority of sodium in our diet comes from highly processed foods that are enhanced with sodium to enhance flavor and preservation. c. Many experts believe there is a link between sodium intake and hypertension.

4. Calcium a. Calcium is the primary mineral component of bones and teeth. It is also essential for muscle contraction, blood clotting, nerve pulse transmission, and acid-base balance. b. Most Americans do not consume enough calcium in their diets. c. Calcium is available in dairy products or calcium-fortified products such as orange juice; many green leafy vegetables contain calcium. d. Consuming carbonated soft drinks can cause you to excrete extra calcium, which can cause calcium loss from your bones.

5. Iron a. Iron deficiency is the most common nutrient deficiency worldwide and in the United States. b. Iron deficiency frequently leads to iron-deficiency anemia—which results from the body’s inability to produce hemoglobin. c. Iron overload or toxicity due to ingesting too many iron-containing supplements is the leading cause of poisoning among small children in the United States.

I. Beneficial Non-Nutrient Components of Foods 1. Functional foods are foods that may confer health benefits beyond the nutrients that they contribute to the diet. a. Antioxidants are substances that appear to protect against oxidative stress by combatting free radicals. b. Phytochemicals are potent antioxidants that are thought to protect against ultraviolet radiation, pests, and other threats. Common examples are the carotenoids and polyphenols.

Key Terms: hunger, nutrients, appetite, nutrition, digestive process, Dietary Reference Intake (DRI), calorie, dehydration, proteins, amino acids, essential amino acids, complete proteins, incomplete proteins, carbohydrates, simple carbohydrates, monosaccharides, disaccharides, complex carbohydrates, starches, glycogen, fiber, whole grains, fats, triglycerides, cholesterol, high density lipoproteins (HDLs), low density lipoproteins (LDLs), saturated fats, unsaturated fats, trans fatty acids, vitamins, minerals, anemia, functional foods, antioxidants, phytochemicals Figures and Tables: Figure 10.1 Foods Providing Complementary Amino Acids Figure 10.2 Anatomy of a Whole Grain Figure 10.3

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Percentages of Saturated, Polyunsaturated, Monounsaturated, and Trans Fats in Common Vegetable Oils Table 10.1 Estimates Daily Calorie Needs Per Day by Age, Sex, and Physical Activity Table 10.2 A Guide to Vitamins Table 10.3 A Guide to Minerals II. Nutritional Guidelines • Americans today consume about 900 more calories per day than they did 50 years ago. See Figure 10.4.

A. Dietary Guidelines for Americans 1. The 2020–2025 Dietary Guidelines are recommendations for eating a healthy, nutritionally adequate diet. They include five key guidelines: a. Follow a healthy eating pattern across the life span. b. Customize and enjoy food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations. c. Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits. d. Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.

B. MyPlate Food Guidance System 1. The MyPlate food guidance system takes into consideration the dietary and caloric needs for a wide variety of individuals. See Figure 10.5. a. Enjoy food, but eat less—every bite counts, so avoid oversized portions. b. Make half your plant fruits and vegetables. c. Drink water instead of sugary drinks. d. Switch to fat free or low fat (1 percent) milk. e. Watch your sodium. Compare amounts in different foods and snacks—no more than 2,300 mg/day! f. Make at least half of your grains whole grain. g. Vary protein sources (from seafood; meat, poultry, and eggs; beans, peas, and lentils; and nuts).

Figures: Figure 10.4 Trends in Per Capita Nutrient Consumption Figure 10.5 The MyPlate System III. How Can I Eat More Mindfully Healthfully?

A. Read Food Labels

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1. To help consumers evaluate the nutritional values of packaged foods, the % Daily Value tells you how a serving of food will contribute to the nutrient levels in your diet. a. Figure 10.6 walks you through the old and new Nutrition Facts labels.

2. The FDA allows for three types of health-related claims on food and dietary supplements: a. Health claims describe a relationship between a food product and health promotion or disease prevention. When the current scientific evidence supports risk reduction, the FDA approves the health claim. b. Nutrient content claims indicate that a specific nutrient is present at a certain level, that is, “High in fiber.” c. Structure and function claims describe the effect that a component of the food product has on the body; that is, “Calcium builds strong bones.”

B. Understand Serving Sizes 1. Understanding serving sizes is important for meeting dietary needs. a. A serving is the recommended amount you should consume. b. A portion is the amount you choose to eat at any one time. c. See Figure 10.7 for a guide with tips for recognizing serving sizes.

C. Vegetarianism: A Healthy Diet?

1. The word vegetarian means different things to different people. a. Strict vegetarians, or vegans, avoid all foods of animal origin including dairy products and eggs. This diet is based on legumes, grains, nuts, seeds, and vegetables. b. Lacto-vegetarians eat dairy products but avoid flesh foods and eggs. c. Ovo-vegetarians eat eggs, and lacto-ovo-vegetarians consume dairy and eggs but avoid flesh foods. d. Pesco-vegetarians eat fish, dairy, and eggs. e. Semi-vegetarians eat chicken, fish, dairy, and eggs.

2. People become vegetarians for a variety of reasons including concern for animal welfare, environmental concerns, food safety, personal health, weight loss, and weight maintenance.

3. Vegetarian diets can meet all of the recommendations for nutrient needs if they combine the right types of foods and eat a variety of different foods to ensure proper nutrient intake.

D. Supplements: Research on the Daily Dose 1. Dietary supplements are products such as vitamins and minerals that are taken by mouth and are intended to supplement existing diets.

2. Dietary supplements are not regulated by the FDA. 3. The Academy of Nutrition and Dietetics recommends that, whereas there are benefits for some people in taking supplements, a healthy diet is the best way to give your body what it needs.

E. Eating Well in College 1. College students often face a challenge when trying to eat healthy foods.

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2. Mindful eating can help you avoid processed foods and unhealthy food and beverage choices.

3. If you eat fast food, try the following tips to have a more nutritious meal: a. Ask for a nutritional analysis of the items. b. Order salads. c. Try baked “fries.” d. Avoid giant sizes and extra sauces. e. Limit beverages that are high in added sugars. f. Substitute a vegetable-based meal at least once per week.

4. If eating in the dining hall, try these ideas: a. Choose lean meats, grilled chicken, fish, or vegetable dishes. b. Hit the salad bar first to load up on fresh greens, beans, tuna, and tofu. c. Ask the preparer to hold mayonnaise, oils, and butter- or cream-based sauces. d. Avoid going back for seconds and consuming large portions. e. Speak with the food service manager and make suggestions for vegetarian options. f. Pass on high-calorie, low-nutrient foods.

5. Between classes, avoid vending machines. Pack healthy snacks like fruit or dried nuts.

Key Terms: % Daily Values (%DVs), vegetarian, dietary supplements, mindful eating Figures: Figure 10.6 Reading the New Nutritional Facts Label Figure 10.7 Serving Size Card ABC News: See It! Videos: Changes Coming to Nutrition Labels IV. Food Safety: A Growing Concern •

The Food Safety Modernization Act of 2011 includes new requirements for food processors to take to prevent food contamination and gives the FDA greater authority to inspect food manufacturing facilities and to recall contaminated food.

A. Choosing Organic or Locally Grown Foods 1. Organic foods and beverages are developed, grown, or raised without the use of toxic pesticides or fertilizers, antibiotics, or hormones.

2. Today, any food sold as organic has to meet criteria set by the U.S. Department of Agriculture (USDA) and carry a USDA seal verifying products as “certified organic.”

3. The market for organics has been increasing faster than food sales for many years. a. Research on whether organic food is more nutritious is conflicting.

4. Locavores are people who eat only food grown or produced locally.

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1. Foodborne illnesses from 31 pathogens cause 9.4 million illnesses, 55,961 hospitalizations, and 1,351 deaths in the United States annually.

2. Symptoms of foodborne illnesses include diarrhea, nausea, cramping, and vomiting.

3. Several factors contribute to the increase in foodborne illnesses, including the following: a. Inadequate oversight of both foreign and domestic suppliers by uncoordinated and underfunded federal agencies C. Avoiding Risks in the Home 1. About 9 percent of foodborne illnesses result from unsafe handling of food at home.

2. You can take several steps to prevent food contamination: a. Wash your hands. b. Use separate cutting boards and utensils for meats and produce. c. Pay attention to food temperature. d. Eat leftovers within three days. e. When in doubt, throw it out.

3. See Figure 10.9 for four basic steps to reduce the likelihood of contaminating your food.

D. Food Sensitivities, Allergies, and Intolerances 1. A food allergy, or hypersensitivity, is an abnormal response to a food triggered by the immune system. a. Symptoms are varied and include a tingling sensation in the mouth; swelling of the lips, tongue, and throat; difficulty breathing; hives; vomiting; abdominal cramps; and diarrhea.

2. Anaphylaxis is a severe and potentially deadly reaction to a food allergen that causes widespread inflammation and cardiovascular problems, such as a sudden drop in blood pressure.

3. The eight major food allergens are milk, eggs, peanuts, wheat, soy, tree nuts, fish, and shellfish.

4. Celiac disease is an inherited autoimmune disorder that causes malabsorption of nutrients from the small intestine.

5. A food intolerance can cause gastric upset but is not an immune system response. a. Lactose intolerance is an example of food intolerance.

E. Genetically Modified Food Crops 1. Genetic modification involves the insertion or deletion of genes into the DNA of an organism.

2. The long-term safety of genetically modified foods is still in question. a. For more on the debate about GM foods, see the Points of View box.

Key Terms: organic, locavore, food allergy, celiac disease, food intolerance, genetically modified (GM) foods Figure: Figure 10.8 162 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e

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The Four Core Practices

Discussion Questions 1. What are some challenges to eating healthy when away at college? Describe two ways that you cope with these challenges.

2. How do you think food labels could be made easier to understand?

3. Describe why you think MyPlate is easy or difficult to follow.

4. What are some ways that you add fruits and vegetables to your diet? If you don’t add these items, list two adjustments that you could make to increase your fruit and vegetable consumption.

5. Explain five practices you as a consumer can adopt that will allow you to eat nutritionally while eating fast foods.

6. How do you think American restaurants are responding to demands for healthy choices? Cite four examples.

7. In your opinion, should genetically modified foods be allowed in the United States?

Why or why not?

8. How has vegetarianism changed in the past few decades? Do you think there is a stigma attached to being a vegetarian? Why or why not? Where does this stigma stem from?

9. What three manageable dietary changes could you suggest to your parents if they want to decrease their fat intake?

Critical Thinking Questions 1. What are some of your favorite “unhealthy” food choices? What kinds of healthy foods could you eat to replace your unhealthy favorites? How could you modify unhealthy food choices to make them healthier?

2. What kinds of vitamin or other food supplements do you take on a regular basis?

What benefits do you think you are getting from the supplements? Do you think eating a more nutritious diet could eliminate your need for taking dietary supplements? Why or why not?

3. Who in your community is struggling most with hunger? What kinds of things can you, your friends, and your college or university do to help prevent hunger on your campus or in your community?

4. A friend tells you that she is going on a diet that eliminates all carbohydrates. What advice would you give your friend about this diet? Why is it important to include carbohydrates as part of a nutritious diet? What types of carbohydrates should your friend include in her diet?

5. How has the “no fat” or “low fat” diet trend influenced American overweight and obesity? What role do fats play in a healthy diet?

6. What do you think is the hardest part in following the recommendations for the MyPlate Plan? What are the strengths and weaknesses of this plan?

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7. How frequently do you look at food labels when you shop for food? What kinds of information included on food labels are the most important to you when selecting nutritious foods? What additional kinds of information would you like to see included on food and supplement labels?

8. What practices for food safety described in the chapter do you follow regularly at home? What additional practices for food safety should you adopt to reduce the risk of foodborne illnesses?

Student Activities Individual 1. Find out what kind of nutrition information and software is available for your computer. Using the software and information you find, analyze your dietary intake for three days. Identify three changes you can make to eat healthier.

2. Write down each item of your favorite dinner at your favorite fast-food restaurant.

Then use the Fast Food Finder website at www.healthieryou.com/food2.html to find the total calories, fat calories, and simple sugar calories for the meal. Consider alternative, healthier options at this restaurant for the future.

3. Keep a food diary for one week. Record all the foods and beverages you consume, paying particular attention to unhealthy food choices such as junk food, foods high in sugar and fat, and eating at fast-food restaurants. At the end of the week, analyze your food diary. What healthy choices could you have made when you made unhealthy food and beverage choices?

Community 1. Make a list of restaurants in town that offer “healthy” options. Find out which menus or items have been approved by the American Heart Association.

2. Research the quality of drinking water on your campus or in your community. What is the source of the drinking water? What chemicals, if any, are added to the water to make it safe for drinking? What problems are associated with ensuring a constant and adequate supply of drinking water?

3. Find out if your community has a green or farmers’ market. What are the days and hours of operation? How many farmers or growers participate? What kinds of fruits, vegetables, breads, cheeses, meats, and other products are available? Find out if a farmers’ market could come to campus.

Diverse Population/Nontraditional 1. Select a country to which you have traveled or that you would like to visit in the future. Research the typical diet of that country. What are the main sources of protein? What kinds of grains are consumed? How does the typical diet of that country compare with that in the United States?

2. List ways eating habits change throughout the lifespan. How can attending college, living alone, working long hours, and so on influence the way people eat?

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3. Use the Internet to research how food is handled safely in other countries. What kinds of preservation methods are used? How is fresh food transported and stored?

4. Caloric needs are based on several factors. Does the average person have the knowledge to accurately assess caloric intake needs? What more can be done in terms of educating the public regarding caloric needs?

5. What practical methods can the consumer employ to decrease calorie intake at restaurants?

Organic Produce 1. Americans may be confused about the nutritional value of organic foods and the benefits of eating organic. How can we get the word out about the nutritional value of organic and conventional foods?

2. What is the justification for the higher cost of organic foods? Describe reasons you think organic food is or is not worth the higher price tag.

3. Describe the benefits of eating organic foods.

FDA Proposed New Food Safety Rules 1. How might the new food regulations impact the health of the consumer?

2. Why do you think food was not previously tested prior to leaving fields?

3. If foods are tested prior to the food being shipped, packaged, or processed after leaving fields and farms, what will be the economic impact?

Additional References L. Boyd, The Complete Guide to Healthy Cooking and Nutrition for College Students: How Not to Gain 17 Pounds at College (Ocala, FL: Atlantic Publishing Group, Inc, 2010).

K. Bradley, K. Silliman, and M. N. Morris, “Evaluation of a Peer-led Nutrition Education Intervention among College Students.” The FASEB Journal, 22 (2008): 681– 687.

K. Fawkes, J. Levy, K. Terry, and S. Edelstein, “Female College Students’ Attitudes about Body Image and Food Labels and How They Affect Purchasing Behavior.”

Topics in Clinical Nutrition, 25 (2010): 165–171.

L. Huffman and D. S. West, “Readiness to Change Sugar Sweetened Beverage Intake among College Students.” Eating Behaviors, 8 (2007): 10–14.

J. Kolodinsky, J. R. Harvey-Berino, L. Berlin, R. K. Johnson, and T. W. Reynolds, “Knowledge of Current Dietary Guidelines and Food Choice by College Students: Better Eaters Have Higher Knowledge of Dietary Guidance.” Journal of the American Dietetic Association, 197 (2007): 1409–1413.

K. L. Morse, and J. A. Driskell, “Observed Sex Differences in Fast-food Consumption and Nutrition Self-assessments and Beliefs of College Students.” Nutrition Research, 29 (2009): 173–179.

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For Further Information American Council on Science and Health www.acsh.org American Society for Nutrition www.nutrition.org Center for Food Safety and Applied Nutrition http://www.fda.gov/AboutFDA/CentersOffices/OfficeofFoods/CFSAN/default.htm Food Allergy Research & Education www.foodallergy.org International Food Information Council www.foodinsight.org The Vegetarian Resource Group Sports Nutrition Guidelines for the Vegetarian www.vrg.org/nutshell/athletes.htm The Vegetarian Resource Group www.vrg.org U.S. Department of Agriculture Food and Nutrition Information Center www.nal.usda.gov/fnic

Additional Media Ready-to-Go Teaching Module: Nutrition How to Reduce Your Salt Intake, 1 minute 40 seconds This video goes through quick tips for reducing your salt intake. https://www.youtube.com/watch?v=pzsvXoxH8rM Nutrition 101 (College Health Guru), 3 minutes 19 seconds In this College Health Guru production, Dr. Robert Gorski, MD, provides a brief Nutrition 101 tutorial. www.youtube.com/watch?v=7jEf82sejtw What Not to Do in the Kitchen, 5 minutes 38 seconds This video shows a person breaking lots of food safety rules while cooking in the kitchen. Try to spot them all! https://www.youtube.com/watch?v=IA8IW5abQTg

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CHAPTER

11

Reaching and Maintaining a Healthy Weight

Overview Weight management is a hot topic in the United States. Chapter 11 discusses several theories on what causes some people to become obese. Research on heredity and genetic influences is included. It also discusses weight management techniques. This is a very important component for college students who may be setting up lifestyles that are not conducive to healthy body weights. Chapter 11 provides important information concerning the role of exercise and healthy diet planning as components for maintaining a healthy weight over one’s lifetime. This chapter also addresses stigma issues related to obesity. After reading this chapter, students will understand the components that influence body weight and weight management. Students will also have a better understanding of the social issues experienced by overweight and obese Americans.

Learning Outcomes 1. Describe the current epidemic of overweight and obesity in the United States and globally, and demonstrate an understanding of health risks associated with excess weight.

2. Describe factors that put people at risk for problems with obesity, distinguishing between controllable and uncontrollable factors.

3. Discuss reliable methods for determining a healthy weight and body fat percentage.

4. Explain the effectiveness and potential pros and cons of various weight control strategies, including maintaining a healthy eating pattern, engaging in physical activity, using supplements and diet drugs, undergoing surgery, and other options.

Lecture Outline I. Overweight and Obesity: A Growing Health Threat

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The United States has the dubious distinction of being the fattest developed nation on Earth.

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Americans today are fatter than virtually all previous generations, making American society obesogenic, or an environment that promotes increased food intake, nonhealthful foods, and physical inactivity.

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Obesity refers to a body weight that is more than 20 percent above recommended levels for health or a body mass index (BMI) over 30. o Class 1 obesity = BMI ≥30 but less than 35 167

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Class 2 obesity = BMI ≥35 but less than 40

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Class 3 obesity (morbidly obese) = BMI ≥40

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Overweight is a body weight that is more than 10 percent above healthy levels or a BMI between 25 and 29.

A. Overweight and Obesity in the United States 1. Figure 11.1 illustrates the increasing levels of obesity in the United States. a. Research points to higher obesity risks among adults of some ethnicities; most notably, non-Hispanic black women and Hispanic women are more likely to be overweight or obese than are non-Hispanic white women.

B. An Obesogenic World 1. The global epidemic of overweight and obesity in multiple regions of the world has come to be known as globesity.

C. Health Risks of Excess Weight 1. Obesity increases the risks of cardiovascular disease, stroke, cancer, hypertension, depression, digestive problems, gallstones, sleep apnea, osteoarthritis, and other ailments. a. See Figure 11.2 for a summary of health risks associated with obesity.

2. Strongly associated with overweight and obesity, diabetes is also a major concern.

3. There are many social and quality of life issues also associated with obesity.

Key Terms: overweight, obesogenic, obesity, body mass index (BMI), globesity, weight stigma Figures: Figure 11.1 Obesity in the United States Figure 11.2 Potential Negative Health Effects of Overweight and Obesity II. Factors Contributing to Overweight and Obesity A. Genes, Hormones and Metabolism 1. FTO, Ghrelin, and Leptin: Genes and Hormones at Work? a. Some people may inherit a lower sensitivity to satiety, or feeling full. b. FTO and ghrelin may play a role in metabolism, specifically in determining appetite and food intake control. i.

Much research has centered on the role of genes such as FTO on regulating ghrelin, a hormone synthesized in the stomach that has sometimes been called the “hunger hormone” because it stimulates appetite and food intake. c. Leptin is an appetite regulator produced by fat cells in mammals. d. A healthy lifestyle may be able to override “obesity genes.”

2. The Role of Thrifty Genes a. Researchers have proposed the existence of several “thrifty genes,” key among them a gene called PTEN (for “phosphatase and tensin homolog deleted on chromosome 10”), which plays multiple roles in human metabolism.

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b. Ease or difficulty with weight loss may be influenced by individual biology. c. Individuals with a thrifty metabolism may have a metabolism that slows down significantly in response to caloric restriction. d. On the other end of the spectrum, those with a spendthrift metabolism may have metabolisms that continue to burn calories despite caloric restriction, meaning they lose weight faster.

3. The Role of Metabolic Rate a. Several aspects of your metabolism help determine whether you gain, maintain, or lose weight. b. Basal metabolic rate (BMR) is the minimum rate at which the body uses energy to maintain basic vital functions. c. Resting metabolic rate (RMR) is the measure of the BMR plus any additional energy expended through daily sedentary activities such as food digestion, sitting, studying, or standing. d. Exercise metabolic rate (EMR) refers to the energy expenditure that occurs during physical activity. e. Adaptive thermogenesis is the process whereby the body slows metabolic activity and energy expenditure as a form of defensive protection against starvation. f. Yo-yo diets refer to when people cycle between periods of weight loss and gain. g. On the other side of the BMR equation is the set point theory, which suggests that our bodies fight to maintain our weight around a narrow range or at a set point.

4. The Set Point Theory a. AKA the Compensatory Theory i.

It suggests that our bodies fight to maintain weight around a narrow range or set point, and that is why going on a drastic diet triggers the physiological compensations, such as decreased BMR and increased appetite. b. Not all research supports this theory.

5. Fat Cells and Predisposition to Fatness a. Some obese people may have excessive numbers of fat cells, or hyperplasia. b. Hypertrophy is the swelling or increase in size of a cell.

B. Environmental Factors 1. Greater Access to High-Calorie Foods a. Environmental factors play a large role in weight maintenance. b. There are more high-calorie, low-nutrient-density foods today compared to the past and many environmental factors that prompt us to consume them.

2. Reduced Opportunities for Physical Activity a. According to data from the 2018 Physical Activity Guidelines for Americans, only half of adults in the United States meet the minimum recommended guidelines for regular aerobic activity and only 20 percent meet the minimum guidelines for both aerobic and muscle strengthening activity. b. The increasingly high rate of overweight and obesity in today’s society is largely due to the way we live our lives.

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c. Americans are eating more and moving less than ever before and are becoming overweight as a result.

C. Psychosocial and Socioeconomic Factors 1. Eating tends to be a focal point in peoples’ lives. a. Comfort food is used to help us feel good when other things in our lives are not going well.

2. Socioeconomic factors can have a significant effect on risk for obesity. a. When economic times are tough, people tend to eat more inexpensive high-calorie processed foods and may not have time, ability, or access to cook or exercise.

D. Emerging Theories on Obesity Risks 1. There is much emerging research on factors that may increase obesity risk.

2. Pathogens, Toxins, and the Gut Microbiome a. Several researchers have studied the role of viruses and other pathogens in a form of infectobesity. b. Gut microbiome—that is, the bacteria and other microorganisms that reside in the human gastrointestinal tract. i. People with obesity have different types and numbers of resident bacteria in their gut microbiome as compared to people with a healthy weight. ii. The profile of bacterial species more commonly found in people with obesity has been shown to increase the harvesting of calories from food in the gastrointestinal tract. c. Researchers are also examining how the gut microbiome can be disturbed upon exposure to toxic chemicals, including in ways that predispose people to obesity.

3. Drugs a. Several studies have examined the role of prescription drugs in increased weight gain and weight fluctuation.

4. Sleep Deprivation a. Sleep deprived people tend to have significant drops in leptin, which plays a role in metabolism, insulin sensitivity, and other weight-related changes.

Key Terms: basal metabolic rate (BMR), resting metabolic rate (RMR), exercise metabolic rate (EMR), adaptive thermogenesis, set point theory, yo-yo diets, satiety, hyperplastic obesity, hypertrophy, gut microbiome III. Assessing Body Weight and Body Composition •

Everyone has his or her own ideal weight, based on individual variables such as body structure, height, and fat distribution.

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Accurate measures of evaluating healthy weight and disease risk focus on a person’s percent body fat and how that fat is distributed in his or her body.

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Fat regulates body temperature, cushions and insulates organs and tissues, and is the body’s main source of stored energy. o

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Body fat is composed of two types: essential fat and storage fat.

Being underweight can cause a host of problems including hair loss, visual disturbances, skin problems, a tendency to fracture bones easily, and others.

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A. BMI 1. BMI is a description of the relationship of body weight relative to height—numbers that are highly correlated with your total body fat.

2. BMI is calculated by dividing a person’s weight in kilograms by height in meters squared.

3. See Figure 11.3 for body mass index.

4. Desirable BMI levels may vary with age and by sex.

5. Healthy weights are defined as those with BMIs of 18.5 to 24.9. a. A BMI of 25 to 29.9 indicates overweight. b. A BMI of 30 to 39.9 is classified as obese. c. A BMI of 40 to 49.9 is morbidly obese.

6. A new category for BMIs of 50 or higher is known as super obese.

B. Limitations of BMI 1. Although they are useful, BMI levels do not account for the fact that muscle weighs more than fat.

2. BMI levels can be inaccurate for those under five feet tall, highly muscled, or older and have little muscle mass.

3. Youth and BMI a. There is growing concern about the effects of stigma. b. Children and teens with BMI ranges above normal weight are labeled as “at risk of overweight” and “overweight.”

C. Waist Circumference and Ratio Measurements 1. Waist circumference measurement is a useful tool to assess abdominal fat, which is considered more health threatening than fat in other regions of the body.

2. Waist circumference-to-hip ratio and waist circumference-to-height ratio have been used to measure abdominal fat as an indicator of obesity and health risk.

D. Clinical Measures of Body Fat 1. There are other ways to measure body fat (see Figure 11.4).

Key terms: underweight, healthy weight Figures and Table: Figure 11.3 Body Mass Index (BMI) Figure 11.4 Overview of Various Body Composition Assessment Methods Table 11.1 Weight Classifications Based on BMI, Waist Circumference, and Associated Risks IV. Managing Your Weight: Individual Roles •

Weight loss failure is often related to thinking about weight loss as a short-term “diet” rather than as adjusting long-term eating behaviors.

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Maintaining a healthful body takes constant attention and nurturing.

A. Understanding Calories and Energy Balance ..

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1. A calorie is a unit of measure indicating the amount of energy obtained from food or expended through activity.

2. Each time you consume 3,500 calories more than your body needs, you gain a pound of storage fat.

3. To lose weight, lower caloric intake and increase exercise.

4. See Figure 11.5 for an example of the concept of energy balance. a. Has significant limitations b. The equation fails to account for differences in individuals’ weight gain and loss even when their food intake and physical activity are tightly controlled in laboratory experiments, such as those investigating the thrifty/spendthrift gene theory.

B. Maintaining a Healthy Eating Pattern 1. Being Mindful of Your Eating Triggers a. Mindless eating may be a key contributor to excess calorie consumption. b. Triggers are cues that make us want to eat, but they can be modified. c. See Figure 11.6 for ways you can adjust your eating triggers and snack more healthfully in order to manage your weight.

C. Choosing a Healthy Eating Plan 1. Once you have determined your triggers, you can begin to devise a plan for improved eating and nutrition.

2. Any diet that requires radical behavior changes or prepackaged meals that don’t teach you how to eat healthfully is likely to fail.

D. Engaging in Physical Activity 1. Any increase in the intensity, frequency, and duration of exercise can lead to an increase in muscle mass, which can impact total calorie expenditure.

2. The key is that lean tissue (muscle) is more metabolically active than fat tissue.

3. The number of calories spent during exercise depends on three factors: a. The number and proportion of muscles used b. The amount of weight moved c. The amount of time the activity takes 4. A new study suggests that, in addition to burning calories, working out enhances the body’s response to leptin, thereby reducing hunger and food intake—but only among people who exercise for enough time to burn at least 3,000 calories a week. a. The number of minutes that this represents differs according to the individual’s body weight and type of activity, but among the study participants, it amounted to about 300 minutes a week of brisk walking, which the researchers suggest be performed in six sessions a week of nearly one hour per session.

E. Keeping Weight Control in Perspective 1. Weight loss is difficult for many people and may require lots of effort.

2. It is unrealistic and dangerous to lose weight in a short period.

3. Making permanent changes to your lifestyle by adding exercise and cutting back on calories to expend about 500 more calories than you consume each day will help you lose weight at about 1 pound per week.

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F. Considering Weight-Loss Supplements or Over the Counter drugs?

1. Dramatic weight loss may be recommended in cases of extreme health risk but should be considered carefully and discussed with several knowledgeable health professionals.

G. Treatments for Obesity 1. Very-Low-Calorie Diets (VLCDs) a. In severe cases of obesity that are not responsive to traditional dietary strategies, medically supervised very-low-calorie diets are given to patients. b. Problems associated with severe calorie restriction include blood sugar imbalance, cold intolerance, constipation, decreased BMR, dehydration, and others. c. One particularly dangerous complication of a VLCD is ketoacidosis. d. about 30 percent of fats consumed to pass through the body undigested. e. In a recent study, patients on medically supervised VLCDs lasting as long as 4 months did not develop or even approach ketoacidosis; thus, the researchers concluded that VLCDs are safe, inducing significant weight loss without altering the patient’s acid-base balance.

2. Prescription Weight Loss Drugs a. Today, there are nearly 65 prescription, over-the-counter, alternative, and off-label options. b. When used as part of a long-term, comprehensive weight-loss program, weightloss drugs can potentially help those who are severely obese lose weight and maintain the loss. c. Few drugs are without side effects. i.

Wegovy, for example, can cause nausea, vomiting, diarrhea, constipation, and several other gastrointestinal side effects, as well as headache and fatigue; moreover, the prescribing information includes a boxed warning that it may increase the risk of certain thyroid tumors.

3. Surgery a. Weight-loss surgery can be one of two types: restrictive surgeries and malabsorption surgeries. i. Restrictive surgeries, such as gastric banding or lap banding, limit food intake. ii. Malabsorption surgeries, such as gastric bypass, decrease the absorption of food into the body. b. In gastric banding, the surgeon uses an inflatable band to partition off part of the stomach. i. Although the bands are designed to stay in place, they can be removed surgically. c. Gastric bypass—the surgeon cuts across the top of the stomach, leaving a small pouch that on average can hold only about 1 ounce of food. d. Sleeve gastrectomy is one of the most common forms of weight-loss surgery. i. About 80 percent of the stomach is removed. The portion left intact—a “sleeve” about the size of a banana—is contiguous with the duodenum of the small intestine. ..

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e. A new technique, biliopancreatic division or duodenal switch procedure, combines the elements of restrictive and malabsorption surgeries. It is highly effective for rapid weight loss, but it carries a higher risk than the other types of surgeries. f.

While weight loss tends to be maintained with surgery, there are many risks, including nutritional deficiencies, blood clots, and leaks, among others. i.

Remission of type 2 diabetes, even before weight loss, has been an unexpected result of gastric surgeries. g. Bariatric arterial embolization is a new, nonsurgical alternative to gastric bypass in which a catheter is inserted through the wrist or groin and targets blood vessels in the stomach where ghrelin is produced. h. Another surgery, liposuction, is more of a cosmetic surgery in which fat cells are actually removed from specific areas of the body.

H. Trying to Gain Weight 1. For some people, trying to gain weight is a challenge.

2. People who are underweight need to examine diet and exercise behaviors and take steps to achieve and maintain a healthy weight. a. A first step is to increase consumption of healthy foods not only at mealtimes but in several snacks throughout the day. b. A small amount of alcohol with meals can modestly increase your appetite, but avoid excessive intake, since alcohol can displace your intake of healthy foods. c. Avoid smoking, which suppresses appetite, increases BMR, and increases your risk for cancer, heart disease, and many other health problems.

Key Term: very-low-calorie diets (VLCDs) Figures and Table: Figure 11.5 The Energy Balance Equation Figure 11.6 Avoid Trigger-Happy Eating Table 11.2 The Top Five Healthy Diets in 2021 ABC News: See It! Videos: Fast-Paced Movies, Television Shows May Lead to More Snacking; Experiment Shows Portion Control is the Key to Healthy Eating; Low-Carb Diet Trumps Low Fat in Weight-Loss Study

Discussion Questions 1. Why do you think Americans are increasingly more overweight?

2. What are some social stigmas attached to being overweight? Do you think these have changed over the past few decades? Why or why not?

3. How does heredity or environment play a role in the determination of obesity? Which is more influential? Why? Support your answer.

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4. What would you suggest to someone who wants to lose weight? How would your recommendations differ for male or female friends? Why would your recommendations differ?

5. What concerns should you have when choosing a commercial weight loss plan?

6. How do the media portray overweight people? Cite specific examples. Now, make suggestions for two alternative portrayals.

7. What are common eating triggers for college students, and how can they be modified?

How does the college environment increase eating triggers?

8. How can we get young girls to understand that the weight of supermodels is often unhealthy and highly unachievable for the average person? Make two suggestions for changing this view.

Critical Thinking Questions 1. Identify three triggers in your daily life that make you want to eat, even if you are not hungry. Have you had these triggers since childhood? Or have they developed while you have been in college? What do you think causes these triggers?

2. What are five specific things you can do to become more physically active? How will increasing your overall activity affect your overall calorie intake and weight?

3. Why do you think that today more men are suffering from weight gain than before? How does culture play a role in this change?

4. What would you advise an overweight friend who yo-yo diets to do to achieve a healthy weight and maintain it?

5. What factors other than those discussed in the chapter do you think contribute to the increased rates of overweight and obesity in the United States?

6. Childhood obesity in the United States is increasing at an alarming rate. What do you think should be done to prevent childhood obesity?

7. People in other parts of the world, in the Mediterranean region, for example, eat diets rich in flavor and variety and maintain healthy weights. What can Americans learn from the diets in these regions to reduce the rate of obesity in this country?

Student Activities Individual 1. Visit My Heart Central at www.heartinfo.org and search for the Diet and Weight Loss/Fitness Home Page. Gather healthy tips on how to shed unwanted pounds for yourself or a friend.

2. Keep a food diary. At the end of one week, two weeks, and one month, analyze the foods recorded in your diary. When did you make healthful food choices? When did you make unhealthy food choices?

3. Research your family history to find out if any family members suffered from being overweight or obese. When did these people live? What did they do for a living? What correlations can you make between their lifestyles and their weight?

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Community 1. What kinds of weight loss services are available on your campus? Interview a weight loss counselor to find out about the special weight loss needs of college students. Are these services geared toward the general student population? Are the services geared more toward women than men?

2. Find out what the needs are for a local food bank on your campus or in the community.

What kinds of foods are provided to people who lack a reliable source of food? Is the food nutritious? What physical activity programs are linked with food banks in your community?

Diverse Population/Nontraditional 1. Many countries perceive someone who is overweight as happy and wealthy. Research the differences in societal views of overweight and obesity in other cultures. Compare these attitudes and perceptions with those in the United States. Are they very different? Why do you think these differences exist?

2. Many Native American societies are experiencing increases in the rate of obesity and obesity-related diseases such as hypertension and diabetes. Compared with their historical diets, research how the diet of contemporary Native Americans has changed. How has this change influenced the higher rates of obesity? Explain the differences.

Additional References E. J. Benjamin et al., “Heart Disease and Stroke Statistics—2017 Update: A Report from the American Heart Association.” Circulation, 135, no. 10 (2017): e146–e603.

M. N. Desai, W. C. Miller, B. Staples, and T. Bravender, “Risk Factors Associated with Overweight and Obesity in College Students.” Journal of American College Health, 57 (2008): 109–114.

T. Kelly, W. Yang, C. S. Chen, K. Reynolds, and J. He, “Global Burden of Obesity in 2005 and Projections to 2030.” International Journal of Obesity, 32 (2008): 1431–1437.

L. MacLean, N. Edwards, M. Garrard, N. Sims-Jones, K. Clinton, and L. Ashley, “Obesity, Stigma, and Public Health Planning.” Health Promotion International, 24 (2009): 88–93.

T. F. Nelson, S. L. Gortmaker, S. V. Subramanian, L. Cheung, and H. Wechsler, “Disparities in Overweight and Obesity among U.S. College Students,” American Journal of Health Behavior, 31 (2007): 363–373.

D. M. Nguyen and H. B. El-Serag, “The Epidemiology of Obesity.” Gastroenterology Clinics of North America, 39 (2010): 1–7.

B. J. Rolls, L. S. Roe, and J. Meengs, “Larger Portion Sizes Lead to a Sustained Increase in Energy Intake over 2 Days.” Journal of the American Dietetic Association, 106 (2006): 543– 549.

C. L. Ogden et al., “Trends in Obesity Prevalence among Children and Adolescents in the United States, 1998 through 2013–2014.” Journal of the American Medical Association, 315, no. 21 (2016): 2292–2299.

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N. Sira and C. P. White, “Individual and Familial Correlates of Body Satisfaction in Male and Female College Students.” Journal of American College Health, 58 (2010): 507–514.

Y. Wang and T. Lobstein, “Worldwide Trends in Childhood Overweight and Obesity.”

International Journal of Pediatric Obesity, 1 (2006): 11–25.

J. A. Watkins, C. Christie, and P. Chally, “Relationship between Body Image and Body Mass Index in College Men.” Journal of American College Health, 57 (2008): 95–100.

For Further Information Academy of Nutrition and Dietetics www.eatright.org National Heart, Lung, and Blood Institute, National Institutes of Health Aim for a Healthy Weight www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm We Can! Ways to Enhance Children’s Activity & Nutrition www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm Obesity Research at the National Institutes of Health www.obesityresearch.nih.gov/ Obesity Society www.obesity.org

Additional Media Ready-to-Go Teaching Module: Nutrition Dangers of Childhood Obesity, 2 minutes 30 seconds In this CBS News clip, Travis Stork, MD, goes over the risks associated with childhood obesity. Drawing on a recent study, Stork also provides factors associated with the increased prevalence of childhood obesity. www.youtube.com/watch?v=gBBLYczdMLs&NR=1 Healthy Body Measurements: Weight vs. BMI vs. Body Comps, 9 minutes 34 seconds In this Synergenix Fitness production, Astrid Whiting discusses the distinction between body weight and body composition, as well as which assessment tools are best. www.youtube.com/watch?v=cUdKqA0JrUA&feature=related Human Physiology: What Is Body Composition? 1 minute 46 seconds In this eHow production, science teacher Janice Creneti provides a basic understanding of body composition and body mass index. www.youtube.com/watch?v=0cQLfx1SAUQ&feature=fvw Katie Couric’s Notebook: Obesity in America (CBS News), 58 seconds ..

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In this CBS News clip, Katie Couric succinctly explains why obesity in America is everyone’s issue. www.youtube.com/watch?v=P_1u_RVaULE Notebook: The Severely Obese (CBS News), 1 minute 5 seconds In this CBS News clip, Katie Couric succinctly discusses the growing prevalence of severe obesity in America and Canada and why everyone should be concerned. www.youtube.com/watch?v=egI2Fi4j0AE&feature=channel Obesity and Heart Risk, 1 minute 38 seconds In this CBS News clip, reporter Bill Whitaker goes over a study that states even being slightly overweight increases the risk for heart failure. www.youtube.com/watch?v=z-R_dZTxihU&feature=channel Winning at Weight Loss (College Health Guru), 2 minutes 12 seconds In this College Health Guru production, Robert Gorski, MD, provides tips on how college students can attain and maintain weight loss. www.youtube.com/watch?v=xIc_0FiCqXM

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CHAPTER

11A

Focus On: Enhancing Your Body Image

Overview One’s body image is influenced by a wide range of cultural, individual, and interpersonal factors. Our body image, or the way we perceive our own body, can be either positive or negative. An individual with a positive body image is pleased with what he or she sees when looking into a mirror. A negative body image results when a person is frustrated, disappointed, or even angry when viewing himself or herself in a mirror. Individuals with a negative body image are at risk of unhealthy behaviors such as eating disorders and possibly exercise disorders. This chapter provides important information about the causes of negative body images. It also discusses the common types of eating disorders and the negative physiological and psychological consequences of eating disorders. After reading this chapter, students will have a better idea of what to do when they think a friend has an eating disorder.

The dangers and negative health consequences of exercise disorders are also discussed.

Learning Outcomes 1. Define body image, list the factors that influence it, and identify the difference between being dissatisfied with your appearance and having body dysmorphic disorder.

2. Describe the signs and symptoms of disordered eating, as well as the physical effects and treatment options for anorexia nervosa, bulimia nervosa, orthorexia nervosa, and bingeeating disorder.

3. List the criteria, symptoms, and treatment for exercise disorders and syndromes such as muscle dysmorphia and female athlete triad.

Lecture Outline I. What Is Body Image?

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Body image refers to what you believe or emotionally feel about your body’s shape, weight, and general appearance. There are several components to body image: o How you see yourself in your mind o What you believe about your own appearance o

How you feel about your body—including your height, shape, and weight

o o

How you sense and control your body as you move How you behave in relation to your thoughts and feelings about your body

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A negative body image is a distorted perception of your shape or feelings of discomfort, shame, or anxiety about your body.

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A positive body image is a true perception of your appearance, seeing yourself as you truly are.

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Researchers have developed a body image continuum that may help you decide if you have a positive or negative body image. See Figure 1.

A. Many Factors Influence Body Image 1. The Media and Popular Culture a. Media images tend to set the standard for what we find attractive, and changing our bodies and body parts to better achieve what current society feels is beautiful has long been a part of American culture. b. Social media popularity has also increased concerns regarding negative body images. c. In a culture where more than two-thirds of adults older than 20 years old are overweight or obese, a significant disconnect exists between the media’s idealized images and the typical American body.

2. Family, Community, and Cultural Groups a. The people with whom we most often interact strongly influence the way we see ourselves. b. Peer harassment (teasing and bullying) is widely acknowledged to contribute to a negative body image. c. Associations with one’s cultural group appear to influence body image.

3. Physiological and Psychological Factors a. Body image disorders have been linked with the brain’s ability to regulate neurotransmitters, which are linked with mood.

B. Building a Positive Body Image 1. To develop a positive body image, you need to challenge these four myths: a. Myth 1: How you look is more important than who you are. b. Myth 2: Anyone can be slender and attractive if he or she works at it. c. Myth 3: Extreme dieting is an effective weight-loss strategy. d. Myth 4: Things will go better for you after you achieve the perfect body.

C. Body Image Disorders 1. Body Dysmorphic Disorder (BDD) a. Persons with body dysmorphic disorder are obsessively concerned with their appearance and have a distorted view of their own body shape, size, weight, perceived lack of muscles, facial blemishes, size of body parts, and so on. b. Although the exact cause is unknown, BDD is often accompanied by an anxiety disorder or obsessive-compulsive disorder.

Key Terms: body dysmorphic disorder (BDD) Figure: Figure 1 Body Image Continuum 180 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e ..

II. Disordered Eating and Eating Disorders 1. Disordered eating is a pattern of atypical behaviors used to achieve or maintain a lower body weight; behaviors include chronic dieting, abuse of diet pills and laxatives, selfinduced vomiting, and many others. a. Eating issues occur along a continuum. See Figure 2.

2. A small number of people who exhibit disordered eating patterns progress to a clinical eating disorder. a. Eating disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorder (OSFED). b. Eating disorders are on the rise among men, who currently represent up to 25 percent of anorexia and bulimia patients. c. Many people with eating disorders feel disempowered in other aspects of their lives and try to gain a sense of control through food; many have psychiatric problems.

A. Anorexia Nervosa 1. Anorexia nervosa is a persistent, chronic eating disorder characterized by deliberate food restriction and severe, life-threatening weight loss.

2. It involves self-starvation motivated by an intense fear of gaining weight along with an extremely distorted body image.

3. See Figure 3 for the physical symptoms and negative health consequences associated with anorexia nervosa.

4. The causes of anorexia nervosa are complex and variable.

B. Bulimia Nervosa 1. Bulimia nervosa is characterized by binge eating followed by compensatory behavior (vomiting, taking laxatives, excessive exercise) to lose calories that were just consumed.

2. People with bulimia are obsessed with their bodies, weight gain, and appearance but are often hidden from the public eye because their weight may fall within a normal range or they may be overweight.

3. See Figure 4 for the physical symptoms and negative health consequences associated with bulimia.

4. A combination of genetic and environmental factors is thought to cause bulimia nervosa.

C. Binge-Eating Disorder (BED) 1. Individuals with BED gorge like those with bulimia but do not take excessive measures to lose the weight that they gain; they are often clinically obese.

D. Other Specified Feeding or Eating Disorder 1. Some patterns of disordered eating qualify as a legitimate psychiatric illness but don’t fit into the strict diagnostic criteria for either anorexia, bulimia, or binge-eating disorder.

2. If this is the case, the disordered eating is called OSFED, which includes five subtypes: ..

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a. Night eating syndrome b. Purging disorder c. Binge-eating disorder of low frequency/limited duration d. Bulimia nervosa of low frequency/duration e. Atypical anorexia nervosa E. Orthorexia Nervosa 1. Orthorexia nervosa is an unhealthy obsession with what would otherwise be healthy eating.

2. People become fixated on food quality and purity and consumed with what and how much to eat.

3. Eventually food choices become so restrictive that health suffers.

F. Treatment for Eating Disorders 1. There are no quick or simple solutions for disordered eating or eating disorders.

2. Treatment often focuses first on reducing the threat to life.

3. Once the patient is stabilized, therapy focuses on the psychological, social, environmental, and physiological factors that have led to the problem.

4. Through therapy, the patient works on adopting new eating behaviors, building selfconfidence, and finding other ways to deal with life’s problems.

G. Helping Someone with Disordered Eating 1. Know the facts about weight and nutrition.

2. Recognize that eating disorders are more than the eating patterns.

3. Be honest 4. Be caring, but be firm.

5. Compliment.

6. Be a good role model.

7. Tell someone.

Key Terms: disordered eating, eating disorder, anorexia nervosa, bulimia nervosa, bingeeating disorder, other specified feeding or eating disorders (OSFED), orthorexia nervosa Figures: Figure 2 Eating Issues Continuum Figure 3 What Anorexia Nervosa Can Do to the Body Figure 4 What Bulimia Nervosa Can Do to the Body III. Can Too Much Exercise Be Unhealthy?

A. Compulsive Exercise 1. Also called anorexia athletica, compulsive exercise is characterized not by a desire to exercise but by a compulsion to do so. a. The person struggles with guilt and anxiety if he or she doesn’t work out.

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2. People overexercise compulsively to feel more in control of their lives.

3. Disordered eating or a true eating disorder is often part of the picture.

4. Compulsive exercise can lead to a variety of injuries, including significant stress on the heart.

B. Muscle Dysmorphia 1. Muscle dysmorphia is a body image disturbance and exercise disorder in which a person (usually male) believes that his or her body is insufficiently lean or muscular.

2. Behaviors characteristic of this disorder include comparing oneself unfavorably to others, checking one’s appearance in the mirror, and camouflaging one’s appearance. a. They are also more likely to abuse anabolic steroids and dietary supplements.

C. The Female Athlete Triad 1. The female athlete triad has three interrelated problems. See Figure 5. a. Low energy intake—typically prompted by disordered eating behaviors b. Menstrual dysfunction (amenorrhea) c. Poor bone density D. Health at Every Size (HAES) 1. HAES posits that well-being and healthy eating and exercise habits are more important than any number on a scale, so all of us, no matter our size, should accept our size and not wait to be a different weight to begin self-acceptance.

Key Terms: compulsive exercise, muscle dysmorphia, female athlete triad, amenorrhea Figure: Figure 5 The Female Athlete Triad

Discussion Questions 1. Why do you think so many women in the United States report dissatisfaction with their appearance? What factors do you think contribute to this dissatisfaction?

2. How are negative and positive body image interrelated with a person’s self-esteem?

3. List the factors that influence one’s body image. Which of these factors do you think is most important? Why? 4. Do you think women as well as men can suffer from a body image disorder? Explain why you think this has been historically and mistakenly thought of as a “women’s issue.”

5. Why do you think the number of men with eating disorders is on the rise? Do you think treatments for men with eating disorders should be different from treatment for women? If so, how? If not, why not?

Critical Thinking Questions 1. How do the media (television, magazines, movies) influence how both women and men perceive their body image?

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2. The chapter discussed four myths a person must overcome to develop a more positive body image. What other myths can you add to this list? Make three suggestions for undoing and changing these myths.

3. Where do you think you fit in the body image continuum? Where do you fit in the eating disorder continuum? Are there changes you would like to make? Describe two steps toward improving your body image.

4. In this chapter, suggestions are made if you suspect that a friend has an eating disorder.

What three things could you add to this list? Why did you add these suggestions?

5. What personal behaviors can you adopt to lessen our cultural obsession with slenderness?

Student Activities Individual 1. Create a collage of images from magazines or newspapers that reinforce our cultural obsession with slenderness in females or muscular physiques in males. You may want to work together with other students to create a mural for your classroom.

2. Conduct research on the Internet to find out more about the eating and exercise disorders described in the chapter. Look at how the number of people afflicted with these disorders has changed over the years. What are the underlying causes of these disorders, and how have the causes changed as the numbers of afflicted individuals has increased?

Community 1. Find out what kind of support your campus offers to students with eating disorders. Are counselors available? Are group therapy sessions available for the person with the eating disorder? Are support groups available for family and friends?

2. Does your campus offer any support for individuals with exercise disorders? How can students become aware of these services? Can you help to make a connection between your student health center and your student gym facility for individuals in need of support?

Diverse Population/Nontraditional 1. Do Internet research to find out if the prevalence of eating disorders is as high in European and Asian countries compared with the United States. What about Africa, Latin America, and other parts of the world? What factors do you attribute to the differences?

2. In some cultures, acceptable and positive body image is very different from the American perception that being thin for women or muscular for men is desirable. Describe the different types of body images deemed acceptable in different cultures or races.

Additional References E. T. Barker and N. L. Galambos, “Body Dissatisfaction, Living Away from Parents, and Poor Social Adjustment Predict Binge Eating Symptoms in Young Women Making the Transition to University.” Journal of Youth and Adolescence, 36 (2007): 904–911.

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K. Y. Z. Forrest and W. L. Stuhldreher, “Patterns and Correlates of Body Image Dissatisfaction and Distortion among College Students.” American Journal of Health Studies, 22 (2007): 18–25.

J. R. Grossbard, C. M. Lee, C. Neighbors, and M. E. Larimer, “Body Image Concerns and Contingent Self-esteem in Male and Female College Students.” Sex Roles, 60 (2009): 198– 207.

H. A. Harring, K. Montgomery, and J. Hardin, “Perceptions of Body Weight, Weight Management Strategies, and Depressive Symptoms among US College Students.” Journal of American College Health, 59 (2010): 43–50.

N. Sira and C. P. White, “Individual and Familial Correlates of Body Satisfaction in Male and Female College Students.” Journal of American College Health, 58 (2010): 507–514.

J. A. Watkins, C. Christie, and P. Chally, “Relationship between Body Image and Body Mass Index in College Men.” Journal of American College Health, 57 (2008): 95–100.

For Further Information Academy for Eating Disorders http://www.aedweb.org/ Academy of Nutrition and Dietetics www.eatright.org Beyond Ana and Mia: Support for Those Struggling with Eating Disorders https://sites.google.com/a/kenyon.edu/beyond-ana-and-mia-support-for-those-strugglingwith-eating-disorders Obesity Society www.obesity.org

Additional Media Dying to Be Thin: Anorexia (College Health Guru), 2 minutes 33 seconds In this College Health Guru production, Dr. Adam Flisser discusses anorexia nervosa and the negative health effects that make this condition fatal. Dr. Flisser also discusses factors related to anorexia and what to do if you think you or a friend is suffering from this disorder. www.youtube.com/watch?v=jENeKOdhpGo&NR=1 Eating Disorder Indicators (College Health Guru), 2 minutes In this College Health Guru production, Dr. Adam Flisser discusses how all eating disorders stem from an unhealthy, unrealistic body image. Additionally, Dr. Flisser provides signs that you or a friend may have an eating disorder and who to reach out to for help. www.youtube.com/watch?v=zfnRBd9TT74&feature=channel Healthy Body Image (College Health Guru), 1 minute 40 seconds

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In this College Health Guru production, Dr. Adam Flisser discusses the factors that influence body image and how images of beauty have changed across time. Dr. Flisser also discusses resources to reach out to if you are struggling with body image issues. www.youtube.com/watch?v=r1An2lpb1RE&feature=channel “Man-orexia” on the Rise, 4 minutes 32 seconds In this CBS News production, experts discuss the rise of eating disorders and body dissatisfaction among males. www.youtube.com/watch?v=RFvb1Hxz4To&feature=fvsr Understanding Bulimia (College Health Guru), 2 minutes 6 seconds In this College Health Guru production, Dr. Adam Flisser discusses bulimia nervosa, which is the most common eating disorder on college campuses. www.youtube.com/watch?v=4zuDNSzO3zA&feature=related

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Improving Your Personal Fitness

Overview Physical activity is an essential component for good health and longevity. After reading Chapter 12, students will know more about why physical activity is one of the best ways to prevent the risk of early disease and death. It is important to establish good exercise habits as soon as possible and to make regular aerobic exercise and strength training an integral part of one’s life. Chapter 12 provides the student with the information necessary to develop an exercise program that can prevent injury and improve or maintain his or her level of fitness throughout life.

Learning Outcomes 1. Describe the health benefits of being physically active.

2. Outline the key components of fitness for optimal health, wellness, and physical functioning.

3. Plan a safe and effective fitness program using the FITT (frequency, intensity, time, and type) principle.

4. Identify obstacles to physical activity and implement your fitness program.

5. Create a strategy for optimal food and fluid consumption for exercise and recovery.

6. Explain how to prevent and treat exercise injuries.

Lecture Outline I. Physical Activity for Health A. Physical activity refers to all body movements produced by the skeletal muscles that result in substantial increases in energy expenditure.

1. Physical activity can vary by intensity: light, moderate, or vigorous.

2. There are three general categories of physical activity defined by the purpose for which they are done: leisure-time physical activity, occupational physical activity, and lifestyle physical activity.

3. Exercise is a planned, structured, and repetitive body movement to improve or maintain one or more components of fitness.

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a. See Table 12.1 for the 2018 Physical Activity Guidelines for Americans. b. See Figure 12.1 to identify the health-related benefits of regular exercise.

B. Reduced Risk of Cardiovascular Diseases 1. Regular exercise makes the cardiovascular and respiratory systems more efficient.

2. Regular physical activity can reduce hypertension, a significant risk factor for other coronary heart diseases and stroke, and can improve the blood lipid profile.

C. Reduced Risk of Metabolic Syndrome and Type 2 Diabetes 1. Regular physically active reduces the risk of metabolic syndrome, a combination of risk factors that produces a synergistic increase in risk for heart disease and diabetes.

2. Research also indicates that a healthy dietary intake combined with sufficient physical activity could prevent many of the current cases of type 2 diabetes. a. For more on diabetes prevention and management, see Focus On: Minimizing Your Risk for Diabetes.

D. Reduced Cancer Risk 1. Most cancer epidemiologists believe that 25 to 37 percent of cancers are preventable and can be avoided by a healthier lifestyle and environmental choices.

E. Improved Immunity 1. Regular, consistent exercise promotes a healthy immune system, but more extreme levels can negatively affect your immune system.

2. Improved Mental Health and Stress Management 3. Psychological benefits include feeling better about oneself and an overall sense of well-being.

4. Exercise can improve one’s physical appearance, further increasing self-esteem.

5. Regular exercise improves cognitive function across the lifespan.

F. Reduced Risk of Low Bone Mass and Osteoporosis 1. A common affliction for older people is osteoporosis, a disease characterized by low bone mass and deterioration of bone tissue, which increases fracture risk.

2. Regular weight-bearing and strength-building physical activities are recommended to maintain bone health and prevent osteoporotic fractures.

G. Better Weight Control 1. Physical activity uses calories, and if calories expended exceed calories consumed over a span of time, the net result will be weight loss.

2. In addition, being regularly physically active has a direct positive effect on metabolic rate, keeping it elevated for several hours following vigorous physical activities.

H. Improved Mental Status and Reduced Stress 1. Recent data show that the factors with the biggest impact on academic performance reported by college students include stress, anxiety, sleep difficulties, and depression.

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2. Physical activity and exercise can positively impact mental health by helping you sleep better, enhancing mood and positive affect, and preventing depression.

I. Improved Cognitive Function and Reduced Dementia Risk 1. There is increasing evidence that regular physical activity positively affects cognitive function across the life span.

2. Every 500-kcal increase in exercise calorie expenditure per week results in an average decrease in the risk of dementia by 10 percent and Alzheimer disease by 13 percent.

3. This exciting area of research is expanding, and additional studies are needed to better describe the relationship among exercise, cognitive function, and dementia risk.

J. Longer Life Span 1. Several studies indicate significant decreases in long-term health risk and increases in years lived, particularly among those who have several risk factors and use physical activity as a means of risk reduction.

Key Terms: physical activity, exercise, sedentary Figures and Table: Figure 12.1 Selected Health Benefits of Regular Exercise Figure 12.2 Calories Burned in 1 Hour for Activities of Varying Intensities Table 12.1 2018 Physical Activity Guidelines for Americans ABC News: See It! Videos: New Study Shows Exercise May Build Brain Power II. Physical Activity for Fitness and Performance •

Physical fitness refers to a set of attributes that are either health or skill related.

A. Health-Related Components of Physical Fitness 1. The health-related attributes of physical fitness allow you to perform moderateto vigorous-intensity physical activities on a regular basis. a. See Figure 12.3 to identify the health-related components of physical fitness.

2. Cardiorespiratory Fitness a. Cardiorespiratory fitness refers to the ability of the heart, lungs, and blood vessels to function efficiently. b. The word aerobic means “with oxygen” and describes any type of exercise that requires oxygen to make energy for prolonged activity. c. Cardiorespiratory fitness is measured by determining aerobic capacity (power) or the volume of oxygen the muscles consume during exercise. d. Maximal aerobic power (commonly written as VO2max) is defined as the volume of oxygen that the muscles consume per minute during maximal exercise. i.

VO2max is most commonly tested by a walk or run test on a treadmill.

3. Muscular Strength a. Muscular strength refers to the amount of force a muscle or group of muscles can generate in one contraction.

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b. The most common way to assess muscular strength is to measure the maximum amount of weight you can move at one time in one repetition maximum (1 RM).

4. Muscular Endurance a. Muscular endurance is the ability of a muscle or group of muscles to exert force repeatedly without fatigue or the ability to sustain muscular contraction. b. The more repetitions you can perform successfully or the longer you can hold a certain position, the greater your muscular endurance.

5. Flexibility a. Flexibility refers to the range of motion or the amount of movement possible at a particular joint or series of joints. b. The greater the range of motion, the greater the flexibility.

6. Body Composition a. Body composition describes the relative proportions and distributions of fat and fat-free (muscle, bone, water, organs) tissues in the body.

B. Skill-Related Components of Physical Fitness 1. The skill-related components are attributes that improve one’s ability to perform athletic tasks. They help exercisers increase their fitness level and their ability to perform daily tasks.

2. The skill-related components of physical fitness are agility, balance, coordination, power, speed, and reaction time.

3. Some skill-related fitness components, such as balance and coordination for older adults, can impact health.

Key Terms: physical fitness, cardiorespiratory fitness, aerobic exercise, aerobic capacity (power), muscular strength, one repetition maximum (1 RM), muscular endurance, flexibility, body composition Figure: Figure 12.3 Health-Related Components of Physical Fitness III. Using “FITT” to Create Your Fitness Program A. Set SMART goals 1. A SMART goal would be as follows: a. Specific b. Measurable c. Action-Oriented d. Realistic e. Time-Oriented B. Use the FITT Principle 1. The FITT principle should be used to define your exercise program (see Figure 12.4).

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a. Frequency: the number of times of week b. Intensity: how hard your workout must be c. Time: how many minutes or repetitions d. Type: what kind of exercise should be performed C. The FITT Principle for Cardiorespiratory Fitness 1. The FITT principle includes three to five days a week of vigorous, rhythmic, continuous activity at 64 to 96 percent of your maximal heart rate for at least 20 minutes. a. The most effective aerobic exercises for building cardiorespiratory fitness are whole-body activities.

2. Frequency a. The frequency of your program is related to your intensity. b. If you do moderate-intensity exercises, you should aim for a frequency of five days a week; frequency drops to three days with vigorous-intensity activities.

3. Intensity a. The most common methods for determining the intensity of cardiorespiratory endurance exercises are target heart rate, the rating of perceived exertion, and the talk test. b. The exercise intensity to improve endurance is a heart rate between 64 and 96 percent of your maximum heart rate (moderate to vigorous intensity). c. Your target heart rate is the range of aerobic exercise that leads to improved cardiorespiratory fitness. i. Use an activity tracker, or take your pulse during your workout to determine how close you are to your target heart rate. ii. See Figure 12.5 for an illustration of taking a pulse. d. Borg’s rating of perceived exertion scale refers to how hard you feel you are working, which you might base on your heart rate, breathing rate, sweating, and level of fatigue. i. This scale uses a rating from 6 (no exertion at all) to 20 (maximal exertion). ii. An RPE of 12 to 16 is recommended for training the cardiorespiratory system. e. The easiest method for measuring cardiorespiratory exercise intensity is the “talk test.” i. A heart rate of 64 to 76 percent of maximum is also called the “conversational” level of exercise because you are able to talk to a partner while exercising.

4. Time a. The American College of Sports Medicine (ACSM) recommends vigorous activities be performed for at least 20 minutes at a time and moderate activities for at least 30 minutes.

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a. Any sort of rhythmic, continuous, and physical activity that can be done for 20 minutes or more will improve cardiorespiratory fitness.

D. The FITT Principle for Muscular Strength and Endurance 1. The FITT prescription for muscular strength includes two to three days per week of exercises that train the major muscle groups.

2. Frequency a. Training the major muscle groups two to three days a week is recommended. b. Resistance training should include at least one day of rest between workouts before the same muscles are overloaded again. i. Overloading the muscles causes microscopic tears in the muscle fibers. ii. The rebuilding process that increases muscle size and capacity takes 24 to 48 hours. c. Reversibility means that if you stop exercising, then the body responds by deconditioning. Within two weeks the muscles begin to revert to their untrained state.

3. Intensity a. To determine the intensity of exercise needed to improve strength and endurance, you need to know the maximum amount of weight you can lift (or move) in one muscle contraction, known as one repetition maximum (1 RM). b. Muscular strength is improved when resistance loads are greater than 60 percent of your 1 RM. Muscular endurance is improved using loads less than 50 percent of your 1 RM. c. To become stronger you must overload your muscles—regularly create a degree of tension in your muscles that is greater than what they are accustomed to.

4. Time a. The time recommended for muscular strength and endurance exercises is measured in repetitions and sets. b. To increase muscular strength, you need higher intensity and fewer repetitions and sets. i. Use a resistance at least 60 percent of your 1RM, performing 8 to 12 repetitions per set. c. If improving endurance is your goal, use less resistance and do more repetitions. i. Perform one or two sets of 15 to 25 repetitions using resistance that is less than 50 percent of your 1 RM. d. Resting between exercises is crucial to reduce fatigue and help with performance and safety in subsequent sets. i.

A rest period of two to three minutes is recommended but varies depending on the muscle group being exerted.

5. Type a. Specificity principle: The effects of resistance training are specific to the muscles exercised.

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i.

To improve muscular strength or endurance, you must include exercises for all the major muscle groups. b. Exercise selection: Select exercises that meet your goals. i.

Eight to ten exercises that target all major muscle groups is generally recommended.

c. Exercise order: Complete large-muscle group exercises before small-muscle group exercises, multiple-joint before single-joint exercises, and highintensity exercises before low-intensity exercises.

E. The FITT Principle for Flexibility 1. Inflexible muscles are susceptible to injury. Improved flexibility means less tension and pressure on joints, resulting in less joint pain and joint deterioration.

2. Frequency a. A minimum of two to three days a week 3. Intensity a. Perform or hold stretching positions at an individually determined “point of mild tension.”

4. Time a. Hold at the point of tension for 10 to 30 seconds for each stretch, and repeat two to four times in close succession.

5. Type a. The most effective exercises for improving flexibility involve stretching of the major muscle groups, when the body is warm, as it is after cardiorespiratory activities. b. Static stretching techniques are the safest and involve slowly and gradually lengthening the muscle group.

Key Terms: FITT, frequency, intensity, time, type, target heart rate, perceived exertion, static stretching Figures: Figure 12.4 The FITT Principle Applied to Cardiorespiratory Fitness, Muscular Strength and Endurance, and Flexibility Figure 12.5 Taking a Pulse Figure 12.6 Determine Your Perceived Exercise Intensity Figure 12.7 Stretching Exercises to Improve Flexibility IV. Overcome Obstacles and Implement Your Fitness Program A. What If I Have Been Inactive for a While?

1. Consider consulting a personal trainer or fitness instructor to help you get started.

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B. People have real and perceived barriers that prevent regular physical activity. Table 12.2 provides suggestions on overcoming obstacles for physical activity.

C. Incorporating Physical Activity into Your Life, Mindfully 1. When designing your fitness program, there are several factors to consider: 2. Be mindful of your own preferences.

3. Be mindful of your current fitness level.

4. Be mindful of opportunities to increase your activity levels.

5. Green your routine.

D. Develop a Progressive Physical Activity Plan 1. Experts recommend that you begin an exercise regimen by gradually increasing the frequency or time of your workouts, then make gradual increases in exercise intensity.

2. Find a variety of exercises to reduce the risk of overuse injuries.

3. Reevaluate your fitness goals and action plan monthly.

E. Design Your Exercise Session 1. Warm-Up a. The primary purpose of the warm-up is to prepare the body physically and mentally for the cardiorespiratory and/or resistance training that is to follow. b. A warm-up should include large body movements, generally using light cardiorespiratory activities, followed by range-of-motion exercises of the muscle groups to be used during the exercise session. c. A warm-up usually lasts 5 to 15 minutes and provides a transition from rest to physical activity by slowly increasing the heart rate, blood pressure, breathing rate, and temperature.

2. Cardiorespiratory and/or Resistance Training a. Following your warm-up, move into the next phase of your workout, involving either cardiorespiratory training or resistance training, or a little of both. b. If performing aerobic and resistance exercise in the same session, it is recommended to perform the aerobic exercise first.

3. Cool-down and Stretching a. The cool-down involves another 10 to 15 minutes of activity time. b. It should start with 5 to 10 minutes of moderate- to low-intensity activity followed by 5 to 10 minutes of stretching exercise. c. The cool-down period is also an excellent time to stretch to improve flexibility.

F. Explore Activities that Develop Multiple Components of Fitness 1. Some forms of activity can improve several components of physical fitness and improve everyday functioning.

2. Core Strength Training a. The body’s core muscles are the foundation for all movement. A weak core results in poor posture, lower back pain, and muscle injuries.

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b. You can develop core strength by doing various exercises, including calisthenics, yoga, or Pilates.

3. Yoga a. Yoga blends the mental and physical aspects of exercise. It focuses attention on controlled breathing as well as physical exercise and incorporates a complex array of static stretching and strengthening exercises expressed as postures or asanas. b. When done regularly, yoga can improve flexibility, vitality, posture, agility, balance, coordination, and muscular strength and endurance.

4. Tai Chi a. Tai chi is an ancient Chinese form of exercise that combines stretching, balance, muscular endurance, coordination, and meditation. b. It increases range of motion and flexibility while reducing muscle tension.

5. Pilates a. Pilates is an exercise style that combines stretching with movement against resistance, frequently aided by devices such as tension springs or heavy rubber bands. b. It teaches body awareness, good posture, and easy, graceful body movements while improving flexibility, coordination, core strength, muscle tone, and economy of motion.

Key Terms: dynamic stretches Figures: Figure 12.8 A 60-minute Workout Plan Tables: Table 12.3 Overcoming Obstacles to Physical Activity V. Taking in Proper Nutrition for Exercise A. Foods for Exercise and Recovery 1. To make the most of your workouts, follow the recommendation from the MyPlate plan and make sure that you eat a sufficient amount of carbohydrates.

2. When you eat is almost as important as what you eat.

3. After a large meal, wait three to four hours before exercising.

4. Smaller snacks can be eaten about an hour before activity.

5. After your workout, help your muscles to recover by eating a snack with plenty of carbohydrates and a little protein.

B. Fluids for Exercise and Recovery 1. Staying hydrated is crucial. The ASCM recommends five to seven milliliters per kilogram of body weight four hours prior to exercise.

2. For exercise sessions lasting less than one hour, plain water is sufficient for hydration.

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3. If your exercise session is more than one hour—and you sweat profusely— consider a sports drink containing electrolytes, which are important for proper functioning of your nervous and muscular systems.

4. Chocolate milk is a good choice for hydrating after and recovering from exercise.

Key Terms: hyponatremia, water intoxication VI. Preventing and Treating Fitness-Related Injuries •

•

Two basic types of injuries stem from fitness-related activities. o

Traumatic injuries occur suddenly and usually by accident.

o

Overuse injuries occur because of cumulative, day-after-day stresses placed on body parts during exercise.

The three most common overuse injuries are runner’s knee, shin splints, and plantar fasciitis.

•

Rest, variation of routine, and stretching are the first lines of treatment for overuse injuries.

A. Preventing Injuries 1. There are steps you can take to reduce your risk of overuse or traumatic injuries.

2. Use common sense and the proper gear, vary your physical activities throughout the week, set appropriate goals, and listen to your body.

3. Appropriate Footwear a. Proper footwear, replaced in a timely matter, can decrease the likelihood of foot, knee, hip, or back injuries. b. Running shoes should be replaced after 300 to 500 miles of use, which is typically between three and nine months. c. It is essential for a shoe to absorb shock and provide a good fit for maximal comfort and performance. d. See Figure 12.7 for the anatomy of a running shoe.

4. Appropriate Protective Equipment a. Using well-fitted, appropriate protective equipment will help prevent certain fitness-related injuries. b. Always wear a helmet while riding your bike, skateboarding, skiing, in-line skating, snowboarding, playing contact sports, or using kick-scooters.

5. Exercising in the Heat a. Exercising in hot or humid weather increases your risk of a heat-related illness. b. Heat cramps are the least serious problem and can be prevented by adequate fluid replacement and dietary intake of electrolytes lost during sweating. c. Heat exhaustion is a mild form of shock caused by excessive water loss. d. Heatstroke, often called sunstroke, is life-threatening and occurs when the body’s heat production significantly exceeds its cooling capacities. e. To prevent heat stress when exercising, acclimatize your body, stay hydrated, wear appropriate clothing, and use common sense.

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6. Exercising in the Cold a. Hypothermia is a potentially fatal condition of low body core temperature. b. To prevent hypothermia, analyze weather conditions and your risk before you undertake an outdoor physical activity. Have a friend join you for safety; wear layers of appropriate clothing; keep your head, hands, and feet warm; and stay hydrated.

B. Treating Injuries 1. First-aid treatment for virtually all fitness-training related injuries involves RICE: a. Rest: to avoid further irritation of the injured body part b. Ice: to relieve pain and constrict the blood vessels c. Compression: apply pressure to injured body part d. Elevation: elevate the injury above the level of your heart to control internal or external bleeding by making the blood flow upward to reach the injured area.

Key Terms: traumatic injuries, overuse injuries, heat cramps, heat exhaustion, heatstroke, hypothermia, RICE Figure: Figure 12.9 Anatomy of a Running Shoe

Discussion Questions 1. Which of the fitness components do you think you are strongest in? Which do you feel you could improve?

2. How does exercise influence your immune system? How does excessive exercise or overtraining influence immune function? Why? 3. What motivates people to exercise? How can we use these motivational factors on people who don’t exercise?

4. What three tips would you give someone starting an exercise program?

5. How can focusing on just one aspect of physical fitness (e.g., muscle strength) cause health problems? What would you recommend to achieve balanced physical fitness?

6. Explain how lack of proper equipment in fitness activities can result in injuries. Give three examples.

Critical Thinking Questions 1. Do you own any popular fitness gadgets or equipment? What do you like about that piece of equipment? What do you dislike? Is the device easy to use? Do you use it regularly?

2. What obstacles are keeping you from becoming physically fit? Describe two solutions.

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3. Brandy is a 20-year-old female who never exercised before in her life. She is interested in beginning an exercise program. What would you suggest to her? Provide four specific suggestions.

4. Describe the benefits of getting enough physical activity. Are you getting enough physical activity in your daily life? What can you do to increase the amount of physical activity you get each day?

5. How does your level of weekly physical activity compare with the 2008 guidelines listed in Table 12.1? What changes could you make to improve your physical activity levels?

6. What steps can you take to avoid injuries while exercising? Give examples of what can be done in the heat and cold. What are other things you can do to reduce the chances of injury while physically active?

7. Which of the components of physical fitness do you address on a regular basis? What other components would you like to include in your daily routine of physical activity?

8. What is your target heart rate? What heart rate do you try to maintain while doing physical activity?

9. Based on the information about the calories burned by different activities shown in Figure 12.2, how many calories do you think you burn while studying? What might you do to burn more calories while you study?

Student Activities Individual 1. The ACSM has published guidelines for safe and proper fitness programs. Select a cardiorespiratory activity, and determine the proper frequency, intensity, and time as recommended by the ACSM for a healthy person who is your age.

2. Record your physical activities each day for one week. Do you meet the ACSM guidelines for exercise frequency, intensity, and duration? If not, what changes can you make in your daily routine to meet the guidelines?

3. There are four phases of a workout (warming up and stretching, resistance training, cardiorespiratory training, cooling down and stretching). Choose an activity, and set up a routine based on these four phases. Give examples of what you are doing during each phase of the workout. Do the workout with friends. Record how you feel physically and emotionally before and after completing the workout.

Community 1. What options for physical activity are available on your campus? Make a list of available activities. Are these activities free or very affordable? Are they open to all students for participation? Are there places to go for fitness assessments?

2. Find out what your campus or community does to encourage and support individuals who walk or ride bicycles to work. Are safe walking and riding paths available? Are traffic signs clearly marked for pedestrians and bicycle riders? What else could be 198 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e ..

done on campus or in your community to encourage more people to walk or ride their bikes?

Diverse Population/Nontraditional 1. What exercises are popular in other cultures? Do people participate in formal exercise programs, or is there more movement involved in daily activity than in the United States?

2. People who are physically challenged often are able to participate in sports and other activities to gain physical fitness. What have organizations such as Special Olympics done to foster physical activity in individuals with both physical and mental disabilities?

Additional References American College Health Association, “Healthy Campus 2020,” Accessed February 2018, https://www.acha.org/HealthyCampus.

American College Health Association, National College Health Assessment II (ACHANCHA II): Reference Group Executive Summary, Spring 2016 (Hanover, MD: American College Health Association, 2016).

J. Buckworth and C. Nigg, “Physical Activity, Exercise, and Sedentary Behavior in College Students.” Journal of American College Health, 53 (2004): 28–34.

B. J. Cardinal and S. S. Levy, “Factors Associated with Transitional Shifts in College Students’ Physical Activity Behavior.” Research Quarterly for Exercise and Sport, 77 (2006): 476–485.

E. M. Jackson and A. Howton, “Increasing Walking in College Students Using a Pedometer Intervention: Differences According to Body Mass Index.” Journal of American College Health, 57 (2008): 159–164.

X. D. Keating, J. Guan, J. C. Piñero, and D. M. Bridges, “A Meta-analysis of College Students’ Physical Activity Behaviors.” Journal of American College Health, 54 (2005): 116–125.

M. Kilpatrick, E. Hebert, and J. Bartholomew, “College Students’ Motivation for Physical Activity: Differentiating Men’s and Women’s Motives for Sport Participation and Exercise.” Journal of American College Health, 54 (2005): 87–94.

J. L. Maglione and L. L. Hayan, “Correlates of Physical Activity in Low Income College Students,” Research in Nursing & Health, 32 (2009): 634–646.

American College of Sports Medicine, ACSM’s Guidelines for Exercise Testing and Prescription, 10th ed. (Baltimore, MD: Lippincott, Williams, & Wilkins, 2018).

American Cancer Society, “Diet and Physical Activity: What’s the Cancer Connection?,” April 2017, https://www.cancer.org/cancer/cancer-causes/diet-physicalactivity/diet-and-physical-activity.html

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For Further Information Mayo Clinic Fitness Basics https://www.mayoclinic.org/healthy-lifestyle/fitness/basics/fitness-basics/hlv-20049447 eHow Muscular Strength & Endurance Exercises www.ehow.com/way_5407559_muscular-strength-endurance-exercises.html Exercise Is Medicine www.exerciseismedicine.org President’s Council on Fitness, Sports, & Nutrition www.fitness.gov WebMD How to Start an Exercise Program www.webmd.com/fitness-exercise/features/how-start-exercise-program

Additional Media Ready-to-Go Teaching Module: Fitness Beginner’s Guide to Exercise, 3 minutes 30 seconds In this illumistream production, Certified Fitness Coach Kendra provides tips to beginners looking to increase their fitness. The video includes sample exercises. www.youtube.com/watch?v=M7fwAOS__wc Exercise is MedicineTM – Exercise and Your Health, 2 minutes 52 seconds In this clip of the American College of Sports Medicine (ACSM), the reader learns about the ACSM’s new campaign, as well as the benefits of exercise on overall health, and talking to your health care provider to get on the health track. www.youtube.com/watch?v=GYBLR7DhjVY&NR=1 Quick Ab Workout: Trim ’n Tone Your Core, 4 minutes 36 seconds In this diet.com production, a fitness expert leads the viewer through four nontraditional abdominal exercises designed to strengthen the core muscles. www.youtube.com/watch?v=eTjRpZjh0kE&feature=rec-LGOUT-exp_stronger_r2-2r12-HM

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CHAPTER

13

Reducing Your Risk of Cardiovascular Disease and Cancer

Overview This chapter explains how the heart works and then details the different types of heart disease and their consequences. Cardiovascular disease (CVD) is a major cause of death, and many of the risk factors are preventable. Consequently, it is extremely important for the student to gain a clear understanding of the risk factors, how they relate to CVD, and what they can do now or in the future to reduce their risk. After reading this chapter, students should have a clear understanding that their risk for CVD begins early in life and that they must make healthy choices now to protect their future. Another topic of vital importance in this chapter is learning to recognize the signals of heart attack and stroke.

The chapter also examines cancer. There are many different types of cancers, each with its own risk factors. Students should understand the nomenclature and treatments for cancer so they can make sound health decisions regarding screening and treatment for themselves and their loved ones. Students need to be able to relate directly to controllable risk factors, such as smoking, fat in the diet, exposure to the sun, and so forth. Students also need to understand the early warning signs of these deadly diseases.

Learning Outcomes 1. Discuss the social, physical, and economic burden of cardiovascular disease in the United States and globally, as well as the importance of ideal cardiovascular health.

2. Describe the anatomy and physiology of the heart and circulatory system and the importance of healthy heart function.

3. Review major types of cardiovascular disease, their symptoms, and their prevalence.

4. Describe the modifiable and nonmodifiable risk factors for cardiovascular disease and methods of prevention.

5. Examine current strategies for diagnosis and treatment of cardiovascular disease.

6. Describe cancer and how it develops, as well as its impact compared to other major health problems in terms of morbidity/mortality, costs, and overall effectiveness of prevention and control.

7. Explain key risk factors for cancer, and identify which risks are preventable, given current knowledge in the field. ..

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8. Describe symptoms, populations at risk, and key methods of prevention for the most common types of cancer.

9. Discuss the most current and effective methods of cancer detection and treatment, including areas of significant progress and future challenges.

Lecture Outline Overview A. Among the largest groups of chronic diseases that contribute to the greatest global burden of disease (GBD) are cardiovascular disease and cancer.

1. GBD is a method of quantifying the burden of premature morbidity, disability, and death in a given disease or disease group.

2. GBD is measured in disability-adjusted years (DALYs), or years lived in ill health or disability.

B. Both CVD and cancer are chronic diseases, meaning they are prolonged, do not resolve spontaneously, and are rarely cured completely.

C. Cardiovascular diseases and cancer (to a lesser extent) are closely related to lifestyle factors such as obesity, sedentary behavior, poor nutrition, stress, a lack of sleep, tobacco use, and excessive alcohol use.

Key Term: global burden of disease (GBD), disability-adjusted for life years (DALYs), chronic disease I. Cardiovascular Disease in the United States A. More than one in three adults suffers from one or more types of CVD. B. See Figure 13.1 for the prevalence of cardiovascular disease in adults 20 years and older.

C. CVD continues to be the leading cause of death in the world.

D. Recognizing select risk factors is the key to changing the course of CVD. E. The American Heart Association (AHA) focuses on ideal cardiovascular health (ICH) rather than mortality rates and the disease process.

F. ICH is the absence of clinical indicators of CVD and the presence of seven behavioral and health factor metrics: 1. Not smoking 2. Sufficient physical activity 3. A healthy diet 4. An appropriate energy balance and normal body weight 5. Optimal total cholesterol without medication 6. Optimal blood pressure without medication 7. Optimal fasting blood glucose without medication G. Only 13 percent of U.S. adults meet five or more metrics with ideal levels; fewer than 1 percent meet all seven Key Terms: global burden of disease (GBD), disability-adjusted life years (DALYs), chronic disease, cardiovascular disease (CVD), ideal cardiovascular health (ICH) 202 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e

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Figure: Figure 13.1 Prevalence of Cardiovascular Diseases (CVDs) in Adults Aged 20 and Older by Age and Sex II. Understanding the Cardiovascular System •

The cardiovascular system is the network of organs and vessels through which blood flows as it carries oxygen and nutrients to all parts of the body. o It includes the heart, arteries, arterioles, veins, venules, and capillaries.

A. The Heart: A Mighty Machine 1. The heart is a muscular pump roughly the size of your fist. It usually contracts 100,000 times per day.

2. The body contains approximately 6 quarts of blood. a. Blood transports nutrients, oxygen, waste products, hormones, and enzymes throughout the body. b. It also regulates body temperature, cellular water levels, and acidity, and defends against toxins and harmful microorganisms. c. An adequate supply of blood is essential to health and well-being.

3. The heart has four chambers that work together to circulate blood constantly throughout the body. a. The two upper chambers are atria; they receive blood from the rest of the body. b. The two lower chambers are ventricles; they pump blood out again.

4. Heart Function a. Heart activity depends on a complex interaction of biochemical, physical, and neurological signals and involves four basic steps. See Figure 13.2. i.

Deoxygenated blood enters the right atrium after having been circulated through the body. ii. From the right atrium, blood moves to the right ventricle and is pumped through the pulmonary artery to the lungs to receive oxygen. iii. Oxygenated blood from the lungs then returns to the left atrium. iv. Blood from the left atrium moves into the left ventricle, which pumps the blood through the aorta to all body parts.

5. Arteries, except for the pulmonary arteries, and arterioles carry oxygenated blood away from the heart. a. Pulmonary arteries carry deoxygenated blood to the lungs. b. As the arteries branch off from the heart, they branch into smaller blood vessels called arterioles and then into even smaller blood vessels known as capillaries.

6. Veins and venules carry carbon dioxide and waste products to the lungs and kidneys.

7. The sinoatrial node (SA node), located in the right atrium, keeps the heartbeat regular. ..

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8. The average adult heart beats 70 to 80 times per minute, although a wellconditioned heart may only beat 50 to 60 times per minute to achieve the same results. a. A healthy heart functions more efficiently and is less likely to suffer damage from overwork.

Key Terms: cardiovascular system, atria, ventricles, arteries, arterioles, capillaries, veins, venules, sinoatrial node (SA node) Figure: Figure 13.2 Blood Flow within the Heart III. The Major Cardiovascular Diseases A. Hypertension 1. Hypertension refers to sustained high blood pressure and is known as a silent killer.

2. Blood pressure is measured by two numbers. a. Systolic blood pressure (the top number) refers to the pressure of blood in the arteries when the heart muscle contracts, sending blood to the rest of the body. b. The bottom number, diastolic blood pressure, refers to the pressure of blood on the arteries when the heart muscles relaxes as blood is reentering the heart chambers.

3. High blood pressure is usually diagnosed when systolic pressure is 140 or above. a. When only systolic pressure is high the condition is known as isolated systolic hypertension (ISH).

4. More and more people are considered to be prehypertensive, which means that their blood pressure is above normal but not yet in the hypertensive range.

B. Atherosclerosis 1. Arteriosclerosis is a thickening and hardening of arteries; it is an underlying condition in many cardiovascular health problems.

2. Atherosclerosis is a type of arteriosclerosis characterized by deposits of fatty substances, cholesterol, cellular waste products, calcium, and fibrin (a bloodclotting material) in the inner lining of the artery. a. Hyperlipidemia is a key factor in this process, and the resulting buildup is referred to as plaque. b. As plaque accumulates, it adheres to the inner lining of blood vessels causing pressure within the arteries to build.

3. Atherosclerosis is the most common form of CVD. It occurs as plaques are deposited in vessel walls and restrict blood flow and oxygen to the body’s main coronary arteries, often eventually resulting in a heart attack. See Figure 13.4.

4. When circulation is impaired and blood flow to the heart is limited, the heart may become starved for oxygen, a condition commonly referred to as ischemia.

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1. Peripheral artery disease (PAD) is atherosclerosis in the upper and lower extremities (feet, calves, legs, or arms). a. It is most often characterized by pain and aching in the legs, calves, or feet upon walking/exercise and relieved by rest—known as intermittent claudication.

2. Risk factors include inflammation, smoking, high blood pressure, and high cholesterol, and diabetes.

D. Coronary Heart Disease 1. Of all the major types of cardiovascular disease, coronary heart disease (CHD) is the single greatest killer.

2. A heart attack is also called a myocardial infarction. a. It involves an area of the heart that suffers permanent damage because its normal blood supply has been blocked. b. It is often brought on by a blood clot in a coronary artery or an atherosclerotic narrowing that blocks an artery.

3. When heart blockage is severe, the body is unable to adapt and outside lifesaving support is critical. See Skills for Behavior Change to learn what to do in the case of a heart attack.

E. Arrhythmias 1. Arrhythmias are irregularities in heart rhythm that occur when the electrical impulses in your heart don’t work properly.

2. The following are the opposite ends of the arrhythmia continuum: a. Tachycardia: abnormally fast heartbeat b. Bradycardia: abnormally slow heartbeat 3. Fibrillation is the beating of the heart in a sporadic, quivering pattern that results in extreme inefficiency in moving blood.

4. Not all arrhythmias are life-threatening; they are sometimes triggered by stress, a lack of sleep, or excessive caffeine or nicotine consumption.

F. Angina Pectoris 1. Angina pectoris is a symptom of CHD that occurs when not enough oxygen supplies the heart muscle and is an indicator of underlying heart disease.

2. There are several ways to treat angina: a. Rest for some mild cases b. Nitroglycerin c. Drugs called calcium channel blockers d. Beta-blockers G. Cardiomyopathy and Heart Failure 1. Cardiomyopathy occurs when the heart muscle is damaged or overworked and lacks the strength to keep blood circulating normally through the body, blood and fluids begin to back up into the lungs and other body tissues and continue on to the feet, ankles, and legs, resulting in swelling.

2. Shortness of breath and tiredness may occur as the disease progresses, garnering a diagnosis of congestive heart failure. ..

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3. Most cases of heart failure respond well to treatment that includes the following: a. Diuretics to relieve fluid accumulation b. Drugs like digitalis that increase the pumping action of the heart c. Vasodilators that expand blood vessels and decrease resistance H. Stroke 1. Stroke, or cerebrovascular accident, occurs when the blood supply to the brain is interrupted.

2. Strokes can be one of two types: a. Ischemic: caused by plaque formation that narrows blood flow or an obstructive clot b. Hemorrhagic: caused by a weakened blood vessel that bulges or ruptures 3. An aneurysm is a widening or bulge in a blood vessel that becomes hemorrhagic and is the most well known of the hemorrhagic strokes.

4. Some strokes are mild and cause only temporary dizziness or slight weakness or numbness; more serious interruptions in blood flow may impair speech, swallowing, memory, or motor control in the long term.

5. Traumatic brain injury (TBI) has been noted as a risk factor for stroke development, particularly among younger adults. a. Stroke risk in the four months after a TBI playing sports, having an auto accident, taking a fall, or engaging in military conflict is on the increase, and stroke risk continues years post-surgery.

6. Transient ischemic attacks (TIAs) are brief interruptions of the blood supply to the brain that cause only temporary impairment. a. TIAs often indicate an impending major stroke.

7. The earlier a stroke is recognized and treatment started, the more effective the treatment will be. a. See Skills for Behavior Change for tips on recognizing a stroke.

8. Stroke deaths have declined due to greater awareness of symptoms and faster medical attention, improvements in emergency medicine and protocols, and a greater emphasis on rehabilitation and therapy.

9. New treatments include tissue plasminogen activator, which improves blood flow to affected areas; intra-arterial treatment (IAT), where a catheter delivers clotdissolving drugs directly to the site of injury; and stent retriever therapy, which involves inserting a catheter into the groin and snaking it through the body to the blocked artery.

Key Terms: systolic blood pressure, diastolic blood pressure, arteriosclerosis, atherosclerosis, plaque, ischemia, peripheral artery disease (PAD), coronary heart disease (CHD), myocardial infarction (MI; heart attack), thrombus, embolus, angina pectoris, arrhythmia, fibrillation, cardiomyopathy, congestive heart failure (CHF), stroke, aneurysm, transient ischemic attacks (TIAs), preventricular contractions (PVCs) Figures and Table: Figure 13.3 206 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e ..

Major Cardiovascular Disease Age-Adjusted Death Rates by State Figure 13.4 Atherosclerosis and Coronary Heart Disease Table 13.1 Blood Pressure Classifications IV. Reducing Your Risks •

Suboptimal diet, smoking, high body mass index, high blood pressure, high fasting plasma glucose, and physical inactivity are all contributors to CVD. o

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In addition to associated CVD issues, hypertension may also eventually lead to a slowing of cognitive function and increased risk for Alzheimer’s disease.

Cardiometabolic risk refers to the combined risks that indicate physical and biochemical changes that can lead to both CVD and type 2 diabetes.

A. Metabolic Syndrome: Quick Risk Profile 1. Metabolic syndrome (MetS) is a group of metabolic conditions occurring together that increase a person’s risk of heart disease, stroke, and diabetes.

2. To be diagnosed with a metabolic syndrome, a person would have three or more of the following: a. b. c. d.

Abdominal obesity Elevated blood fat (triglycerides) Low levels of high-density lipoproteins (HDL, or “good”) cholesterol Elevated blood pressure

e. Elevated fasting glucose B. Modifiable Risks for CVD 1. Avoid tobacco. a. Cigarette smokers are two to four times more likely to develop CVD than nonsmokers. b. Cigarette smoking doubles a person’s risk for stroke. c. Smokers are more than ten times more likely than nonsmokers to develop peripheral vascular disease. d. Nicotine increases heart rate, output, blood pressure, and oxygen use. The chemicals in smoke damage and inflame the lining of the coronary arteries, allowing cholesterol and plaque to accumulate more easily.

2. Changing Fat and Cholesterol Recommendations a. Cholesterol is a fatty, waxy substance found in the bloodstream and in body cells. b. Cholesterol plays an important role in the production of cell membranes and hormones and in other body function. c. Too much blood cholesterol, however, escalates one’s risk of CVD. d. Seventy-five percent of blood cholesterol is produced by your body and out of your control. Twenty-five percent comes from the food you eat, meaning you can improve your overall cholesterol by making improvements in your diet. ..

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e. As a result of years of study, the new 2015–2020 Dietary Guidelines for Americans eased recommendations focused on cutting cholesterol, moving eggs and other cholesterol-rich foods to the “eat in moderation” list.

Low-density lipoproteins (LDLs) are referred to as “bad” cholesterol and are believed to build up on artery walls. g. High-density lipoproteins (HDLs) are referred to as “good” cholesterol and appear to remove cholesterol from artery walls. h. Triglycerides continue to be a focus of attention as a key factor in CVD risk. i. To reduce risk, the goal is to manage the ratio of HDL to total cholesterol by lowering LDL levels, raising HDL, or both. f.

3. Strive for a Heart-Healthy Diet a. Reduce salt intake. b. Consume 5 to 10 mg per day of soluble fiber. c. Consume about 2 g per day of plant sterols.

4. Maintain a Healthy Weight a. People who are overweight are more likely to develop heart disease and stroke, even if they have no other risk factors.

5. Exercise Regularly a. Even modest levels of physical activity are beneficial if done regularly and over the long term.

6. Control Diabetes a. Heart disease rates among adults with diabetes are two to four times higher than the rates of those without diabetes.

7. Control Your Blood Pressure a. In general, the higher your blood pressure, the greater your risk for CVD. 8. Manage Stress and Get More Sleep a. Both acute and chronic stress may trigger acute cardiac events or even sudden cardiac death, as well as increase the risks of hypertension, stroke, and elevated cholesterol levels. b. Sleep deprivation may increase risks.

C. Nonmodifiable Risks 1. Some risk factors for CVD cannot be prevented or controlled. a. Race and ethnicity b. Heredity c. Age d. Gender 2. Other Risk Factors Being Studied a. Inflammation and C-reactive Protein b. Inflammation may play a major role in atherosclerosis development. c. During an inflammatory reaction, C-reactive proteins tend to be present in higher levels.

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a. When present at high levels, homocysteine may be related to higher risk of coronary heart disease, stroke, and peripheral artery disease.

Key Terms: C-reactive protein (CRP), homocysteine Figure and Table: Figure 13.5 The DASH Eating Plan Table 13.2 Recommended Cholesterol Levels for Lower/Moderate Risk Adults V. Diagnosing and Treating Cardiovascular Disease •

Today, CVD patients have many diagnostic, treatment, prevention, and rehabilitation options.

A. Techniques for Diagnosing Cardiovascular Disease 1. Electrocardiogram (ECG): a record of the electrical activity of the heart a. Patients may undergo a stress test or a nuclear stress test 2. Angiography (cardiac catheterization): a procedure in which dye is injected into the heart to discover any areas that are blocked 3. Positron emission tomography (PET): three-dimensional images of the heart as blood flows through it 4. Magnetic resonance imaging (MRI): the use of powerful magnets to look inside the body 5. Ultrafast computed tomography (CT): an especially fast form of X-ray imaging of the heart 6. Cardiac calcium score: measures the amount of calcium-containing plaque in the coronary arteries B. Surgical Options: Bypass Surgery, Angioplasty, and Stents 1. In a coronary bypass graft, a blood vessel is taken from another site in the patient’s body and implanted to “bypass” blocked coronary arteries and transport blood to heart tissue.

2. In an angioplasty, a thin catheter is threaded through blocked heart arteries. A balloon at the tip is inflated to flatten fatty deposits, allowing blood to flow more freely.

3. A stent (a mesh-like stainless steel tube) may be inserted to prop open an artery and, while highly effective, can cause future blockage and problems.

4. Today, newer forms of laser angioplasty and atherectomy, a procedure that removes plaque, are being done in several clinics.

C. Changing Aspirin Recommendations and Other Treatments 1. Although aspirin has been touted for its blood-thinning qualities and possibly reducing risks for future heart attacks among those who already have had MI events, the benefits of an aspirin regimen for otherwise healthy adults has been controversial.

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2. Thrombolysis involves injecting an agent such as tissue plasminogen activator to dissolve the clot and restore some blood flow to the heart, thereby reducing the amount of tissue that dies from ischemia.

Key Terms: electrocardiogram (ECG), angiography, coronary bypass surgery, angioplasty, thrombolysis VI. Cancer: An Epidemiological Overview •

Cancer is the name given to a large group of diseases characterized by the uncontrolled growth and spread of abnormal cells. It is the second leading cause of death in the United States.

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Five-year relative survival rates are the relative rates for survival in persons who are living five years after diagnosis; they are up dramatically over the past decades.

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Remission is when cancer is responding to treatment and under control.

A. How Does Cancer Develop?

1. Uncontrolled growth and abnormal cellular development, serving no physiological function, is called neoplasm. a. A tumor is a clumping of cells formed from the neoplastic mass.

2. Malignant tumors are cancerous, with abnormal-looking cells that are not enclosed in a protective capsule and can spread to other organs. a. Benign tumors are noncancerous, normal-looking cells that are enclosed in a fibrous shell and do not spread to other parts of the body. b. To determine if a tumor is malignant, a biopsy is done.

3. Benign and malignant tumors differ in several key ways. a. Benign tumors are enclosed in a fibrous shell or capsule that prevents their spreading to other body areas. b. Malignant tumors are not enclosed in a protective capsule and can spread to other areas of the body. This is known as metastasis.

B. How Is Cancer Classified?

1. Cancer staging is a classification system that describes how much a cancer has spread at the time it is diagnosed. a. Cancers are often staged based on the TNM system (Tumor, Node, and Metastasis). b. The most commonly known staging system assigns the numbers zero to four.

See Table 13.3.

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VII.

What Causes Cancer?

1. Causes of cancer are generally divided into two categories of risk factors: hereditary and acquired (environmental).

2. Many factors are believed to contribute to cancer development.

a. Carcinogens are cancer-causing agents, such as chemicals in our foods, the air we breathe, the water we drink, and the homes in which we live.

A. Lifestyle Risks 1. Lifetime risk refers to the probability that an individual, over the course of a lifetime, will develop cancer.

2. Relative risk is a measure of the strength of the relationship between risk factors and a particular cancer. a. Certain actions are clearly associated with a greater than average risk for cancer.

3. Tobacco Use a. Smoking is associated with increased risk of at least 15 different cancers.

4. Alcohol and Cancer Risk a. Countless studies have implicated alcohol as a risk factor for cancer.

5. Poor Nutrition, Physical Inactivity, and Obesity a. Dietary choices and physical activity are some of the most important modifiable determinants of cancer risk.

6. Stress and Psychosocial Risks a. People under chronic, severe stress or who suffer from depression or other persistent emotional problems show higher rates of cancer than their healthy counterparts.

B. Genetic and Physiological Risks 1. Scientists believe that between 5 and 10 percent of all cancers are strongly hereditary.

2. Suspected cancer-causing genes are called oncogenes.

3. Certain cancers, particularly those of the breast, stomach, colon, prostate, uterus, ovaries, and lungs, appear to run in families.

4. Reproductive and Hormonal Factors a. Increased risk factors for breast cancer include increased numbers of fertile or menstrual cycle years, not having children or having them later in life, recent use of birth control pills or hormone replacement therapy, and opting not to breast-feed all appear to increase the risk for breast cancer.

5. Inflammation and Cancer Risks a. Chronic inflammation can lead to increased risks for cancer, particularly of the colon and digestive system.

C. Occupational and Environmental Risks 1. Some occupational and environmental hazards are known to cause cancer and depend on the concentration, intensity, and duration of exposure.

2. Radiation

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a. Ionizing radiation is the only form of radiation proven to cause human cancer. b. Non-ionizing radiation, produced by radio waves, cell phones, and computer screens, has not been shown to increase the risk of cancer. One 2017 study showed a relationship between radio frequency exposure and malignant brain and heart tumor development in rats.

3. Many of the concerns about chemicals in foods center on the possible harm caused by pesticide and herbicide residues.

D. Infectious Diseases and Cancer 1. According to experts, over 10 percent of all malignancies in the United States are caused by viruses, bacteria, and parasites. a. Viruses are believed to inject their genes into host cells and cause them to grow uncontrollably.

2. Hepatitis B, Hepatitis C, and Liver Cancer a. Viruses such as hepatitis B and C are believed to stimulate the growth of cancer cells in the liver because they are chronic diseases that cause inflammation of liver tissue.

3. Human Papillomavirus and Cervical Cancer a. Cervical cancer has been associated with the human papillomavirus (HPV).

4. Helicobacter Pylori and Stomach Cancer a. More than half of all cases of stomach cancer are thought to be linked to H. pylori infection.

Key Terms: carcinogens, lifetime risk, oncogenes VIII.

Types of Cancers 1. There are four broad classifications of cancer according to the type of tissue from which the cancer arises. a. Carcinomas affect the epithelial tissue and metastasize through the circulatory or lymph system. b. Sarcomas occur in the mesodermal, or middle, layer of tissues and metastasize via the blood. While less common, these are more virulent than carcinomas. c. Lymphomas develop in the lymphatic system and metastasize through the lymphatic system. Hodgkin’s disease is one type of lymphoma.

d. Leukemias occur in the blood-forming parts of the body, such as bone marrow and spleen. They are nonsolid tumors and are characterized by an abnormal increase in white blood cells.

2. Figure 13.7 shows the most common sites of cancer and the number of new cases and deaths from each type in 2015.

A. Lung Cancer 1. Lung cancer is the leading cause of death from cancer for men and women.

2. Detection, Symptoms, and Treatment

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a. Symptoms include a persistent cough, blood-streaked sputum, chest pain, and recurrent attacks of pneumonia or bronchitis.

3. Surgery, radiation, and chemotherapy are all treatment modes, though it depends on the type and stage of the cancer.

4. Risk Factors and Prevention a. Smokers, those exposed to secondhand smoke, and people who have been exposed to industrial carcinogens are at the highest risk.

B. Breast Cancer 1. Women have about a one in eight chance lifetime risk of developing breast cancer.

2. Detection, Symptoms, and Treatment a. The earliest signs of breast cancer are usually observable on mammograms, often before lumps can be felt. A newer form MRI is now available and appears to be more accurate. b. The new guidance on breast self-exams is “learn how to do them, and if you desire, do them to know your body and be able to recognize changes.” c. Symptoms include breast changes such as a lump, thickening, dimpling, skin irritation, distortion, retraction or scaliness of the nipple, and nipple tenderness or discharge. d. Treatments range from simple lumpectomy to radical mastectomy to various combinations of radiation or chemotherapy.

3. Risk Factors and Prevention a. The incidence of breast cancer increases with age. b. Risk factors include family history of breast cancer, menstrual periods that started early and ended late in life, weight gain after age 18, obesity after menopause, recent use of oral contraceptives or postmenopausal hormone therapy, never having children or having a first child after age 30, consuming two or more alcoholic drinks a day, and physical inactivity. c. International differences in breast cancer incidence correlate with variations in diet, especially fat intake, although a causal role for these dietary factors has not been firmly established.

C. Colon and Rectal Cancers 1. Colorectal cancer is the third-most common cancer.

2. Detection, Symptoms, and Treatment a. Colorectal cancers usually have no early symptoms. In later stages, symptoms include stool changes, bleeding, cramping, and pain in the lower abdomen, and unusual fatigue. b. Colonoscopies and other screening tests should begin at age 50 for most people. c. Treatment often consists of radiation or surgery and, in some cases, chemotherapy.

3. Risk Factors and Prevention

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a. People who are older than 50, who are obese, who smoke, who have a family history, who have a personal or family history of polyps, or who have type 2 diabetes or inflammatory bowel problems are at increased risk. b. Protective factors include regular exercise; a diet with lots of fruits, vegetables, and grains; limiting consumption of red and processed meats; maintaining a healthy weight; avoiding tobacco products; and moderation in alcohol consumption.

D. Skin Cancer 1. Skin cancer is the most common form of cancer in the United States today. a. Malignant melanoma is the deadliest form of skin cancer, though basal cell and squamous cell carcinoma are highly curable.

2. Detection, Symptoms, and Treatment a. Many people don’t know what to look for when examining themselves for skin cancer. b. A simple ABCDE rule outlines the warning signs of melanoma (see Figure 13.9 for a comparison of melanoma to basal cell and squamous cell carcinomas): i. Asymmetry ii. Border irregularity iii. Color iv. Diameter v. Evolving c. Treatment of skin cancer depends on the seriousness and can include surgery, radiation therapy, electrodessication, and cryosurgery.

3. Risk Factors and Prevention 4. Anyone who overexposes himself or herself without adequate protection from the sun is at risk for skin cancer. a. Preventing skin cancer is a matter of limiting exposure to harmful ultraviolet rays found in sunlight.

E. Prostate Cancer 1. Cancer of the prostate is the most frequently diagnosed cancer in American males today, excluding skin cancer.

2. Detection, Symptoms, and Treatment a. Symptoms include a weak or interrupted urine flow, difficulty starting or stopping urination, feeling the urge to urinate frequently, pain upon urination, blood in the urine, and pain in the lower body. b. Men over the age of 40 should have an annual digital rectal prostate examination. c. Another method of screening is the prostate-specific antigen (PSA) test, which is a blood test that screens for an indicator of prostate cancer.

3. Risk Factors and Prevention a. Chances of developing prostate cancers increase dramatically with age.

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b. Race is a factor, and having a father or brother with prostate cancer more than doubles a man’s risk. c. Eating more fruits and vegetables, particularly those containing lycopene, may lower the risk of prostate cancer.

F. Ovarian Cancer 1. Ovarian cancer causes more deaths than any other cancer of the reproductive system because women tend not to discover it until the cancer is at an advanced stage.

2. Symptoms include an enlargement of the abdomen, feeling of bloating, having pain in the pelvic area, feeling full quickly, or feeling the need to urinate more frequently.

3. Risk factors include a family or personal history of ovarian, breast, or colon cancer, never having been pregnant, and the use of fertility drugs.

4. Research shows that a healthy diet, exercise, sleep, stress management, and weight control will lower risk. a. Women should get an annual pelvic examination and those over 40 should have a cancer-related checkup every year.

G. Cervical and Endometrial (Uterine Corpus) Cancer 1. Most uterine cancers develop in the endometrium; the rest develop in the cervix.

2. Pap tests screen for cervical (early-stage) cancer but are less effective in detecting endometrial cancer.

3. The primary cause of cervical cancer is infection with certain types of the HPV. a. Increased risk comes from having sex at a young age, having multiple partners, and unprotected sex.

4. Men and women now have the option of getting vaccinated against two types of HPV that cause most types of cervical cancers.

H. Testicular Cancer 1. Testicular cancer is one of the most common types of solid tumors found in young men.

2. Risk factors include undescended testicles, HIV, and a family history of testicular cancer.

3. Symptoms include enlargement of one or both of the testis, a lump or thickening of testicular tissue, and a dull or heavy feeling in the lower abdomen and groin area.

4. This is the most curable form of cancer and can be easily detected by performing regular testicular self-examinations.

I. Pancreatic Cancer: Deadly and on the Rise 1. Pancreatic cancer is one of the deadliest forms of cancer, with most patients dying within one year of diagnosis and only 8 percent surviving five years.

2. Risk factors include tobacco use, obesity, consumption of high levels of red meat, and a high-fat diet, family history, chronic inflammation of the pancreas over the years (pancreatitis), diabetes, those who have had infections with hepatitis B and C, and the Helicobacter bacteria.

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3. Because pancreatic cancer has few early symptoms, there is no reliable test to detect it in its early stages.

Key Terms: malignant melanoma, prostate-specific antigen (PSA), Pap test Figures: Figure 13.7 Leading Sites of New Cancer Cases and Deaths, 2021 Estimates Figure 13.8 Breast Awareness and Self-Exam Figure 13.9 Types of Skin Cancers Figure 13.10 Testicular Self-Exam ABC News: See It! Videos: How Effective Is Breast Cancer Early Detection?

IX. Facing Cancer A. The earlier cancer is diagnosed, the better the prospect for survival.

B. See Table 13.4 for screening guidelines for early detection of cancer in average-risk asymptomatic people.

C. Several high-tech tools to detect cancer have become standard: 1. MRI 2. CT scan 3. Prostatic ultrasound is being investigated as a means to increase the early detection of prostate cancer.

D. Cancer Treatments 1. Cancer treatments vary based on the type of cancer and stage in which it’s detected.

2. Common forms of treatment include the following: a. Surgery to remove the tumor and surrounding tissues i. Stereotactic radiosurgery (gamma knife surgery) b. Radiotherapy c. Chemotherapy d. Combinations of some or all of the above forms of treatment 3. New ways of killing tumors and new chemotherapeutic drug cocktails are being developed regularly. Promising areas of research include the following: a. Immunotherapy b. Cancer-fighting vaccines c. Gene therapy d. Stem cell research Key Terms: magnetic resonance imaging (MRI), computed tomography scan (CT scan), stereotactic radiosurgery, radiotherapy, chemotherapy Table:

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Table 13.4 Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People

Discussion Questions 1. Even though we know heart disease has been the number one killer in the United States for decades, why haven’t we made more headway in decreasing the rates?

2. Do you think people tend to view heart surgeries such as angioplasty and bypass as “quick fixes” for a lifetime of bad habits? Justify your answer. Describe a potential solution for the quick fix myth.

3. Describe the cardiovascular risks you can control. Which habits can you concentrate on changing first, and why?

4. Discuss the societal implications of new cardiovascular diagnosis and treatment technology.

5. What type of cardiovascular risk education should be given in schools? At what age should this education begin? How often should it be discussed (once yearly, every other grade, and so on)? Justify your answer.

6. Compare and contrast how occupational, social, and psychological factors contribute to the causes of cancer.

7. Describe four ways to reduce your risk of developing cancer.

Critical Thinking Questions 1. Which risk factors do you or anyone in your family have for cardiovascular disease?

What steps can you or your family member take to minimize these risks?

2. What is your blood pressure? What are your total cholesterol, LDL/HDL ratio, and triglycerides levels? What do these numbers tell you about your overall health? What steps can you take in your daily life to improve these numbers?

3. How does knowing the effects of alcohol and tobacco use on the risk of cardiovascular disease influence your use of these products?

4. What can you do to decrease your risk of developing cancer at any point in your life?

What steps do you take for early detection of certain types of cancer (skin, testicular, breast, and so on)?

5. Smoking has been directly linked to the development of cancer. Why do you suppose people still use tobacco products knowing that they are risking their health? Do you think the warning labels on tobacco products are strong enough? How could they be strengthened?

6. Do you think all forms of cancer-causing products, such as cigarettes, should be made illegal in our country? Why or why not?

7. Do you believe that secondhand smoke exposes people to the same cancer risk as those who smoke? What do you do to reduce your exposure to secondhand smoke?

Does your campus have a smoking ban? Do you think it should or should not?

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8. Do you apply sunscreen when you are doing activities outside? Do you use it yearround or just in the summer? Do you wear a hat or protective eyewear? What else can you do to reduce your chances of developing skin cancer?

9. A big part of wellness is prevention. What types of cancer prevention practices do you regularly perform? Do you do self-exams? Do you schedule screenings? How often do you have a physician determine your risks? If you do not participate in any prevention practices, please explain your reasoning.

Student Activities Individual 1. Use the Internet to answer the following questions about cancer: Which cancer has the greatest chance for recovery, which is the most painful, and which is the most dangerous? Also, what are the best ways to decrease risks for cancer, and what are the most common unconventional methods of treatment?

2. Keep a diary or journal in which you keep track of your daily activities that both reduce and increase the risk of cardiovascular disease. After one week, analyze your entries. Make note of changes you can incorporate into your daily life to help to reduce your risk of CVD. 3. Talk to a cancer patient or survivor. Find out how this person feels about having or recovering from cancer. Find out what you can do to help someone else who is suffering from cancer.

Community 1. Find out if smoking cessation programs are available on your campus. Are these programs free to students? What specific services do they provide?

2. Visit a support group for heart attack and cancer survivors in your community to gain insight into their experiences.

3. Visit a tanning salon in your community. What safety guidelines do they practice?

What additional steps could be taken to ensure safety and minimize the risks of skin cancer?

Diverse Population/Nontraditional 1. Use the Internet to research statistics about cardiovascular diseases and different types of cancers in different countries. How do these rates compare with those in the United States? What are the possible causes for these differences?

2. How do rates of cardiovascular diseases and different types of cancers differ across races? What factors might contribute to these differences?

Additional References American Heart Association, “2020 Cardiovascular Impact Goals,” 2013, www.heart.org.

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C. Day, “Metabolic Syndrome, or What You Will: Definitions and Epidemiology” Diabetes & Vascular Disease Research, 4 (2007): 32–38.

M. Felts, S. C. Burke, K. Vail-Smith, and L. M. Whetstone, “College Students’ Knowledge, Attitudes and Perceptions of Risks Regarding Intentional Sun Exposure: A 17-Year Follow-up.” American Journal of Health Education, 41 (2010): 274–283.

R. T. Greenlee and H. L. Howe, “County-level Poverty and Distant Stage Cancer in the United States.” Cancer Causes & Control, 20 (2009): 989–1000.

S. M. Grundy, “Metabolic Syndrome Pandemic.” Arteriosclerosis, Thrombosis, and Vascular Biology, 28 (2008): 629–636.

N. Howlader, S. F. Altekruse, and B. K. Edwards, “Monitoring the Burden of Cancer in the United States.” Bioactive Compounds and Cancer, 1 (2010): 3–23.

A. Jemal, R. Siegel, J. Xu, and E. Ward, “Cancer Statistics, 2010.” CA: A Cancer Journal for Clinicians, 60 (2010): 277–300.

American Cancer Society, Cancer Facts & Figures 2017 (Atlanta, GA: American Cancer Society, 2017).

D. Lloyd-Jones, et al. “Heart Disease and Stroke Statistics—2009 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.” Circulation, 119 (2009): 21–181.

S. McMahan, M. Cathorall, and D. R. Romero, “Cardiovascular Disease Risk Perception and Knowledge: A Comparison of Hispanic and White College Students in a Hispanic-serving Institution.” Journal of Hispanic Higher Education, 6 (2007): 5–18.

J. C. Orri, S. R. Carter, and E. B. Howington, “Gender Comparison of C-reactive Protein and Cardiovascular Disease Risk in College and Intercollegiate Students.”

Journal of Sports Medicine & Physical Fitness, 50 (2010): 72–78.

D. R. Romero, S. McMahan, and M. Cathorall, “Cardiovascular Disease (CVD) Risk: Should We Target College Women?” Californian Journal of Health Promotion, 3 (2005): 117–129.

K. Schenck-Gustafsson, “Risk Factors for Cardiovascular Disease in Women.”

Maturitas, 63 (2009): 186–190.

R. A. Smith, V. Cokkinides, and H. J. Eyre, “Cancer Screening in the United States, 2007: A Review of Current Guidelines, Practices and Prospects,” CA: A Cancer Journal for Clinicians, 57 (2007): 90–104.

For Further Information American Cancer Society www.cancer.org American Heart Association www.heart.org American Institute for Cancer Research

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www.aicr.org Centers for Disease Control and Prevention National Center for Health Statistics—Cancer www.cdc.gov/nchs/fastats/cancer.htm American Heart Association Healthy for Good https://healthyforgood.heart.org/ Go Red for Women www.goredforwomen.org International Agency for Research on Cancer www.iarc.fr National Stroke Association www.stroke.org Power to End Stroke http://powertoendstroke.org World Health Organization Cancer www.who.int/cancer/en

Additional Media Ready-to-Go Teaching Module: CVD and Cancer Understanding Cholesterol (Heart Basics #5), 3 minutes 3 seconds In this illumistream production, Dr. Michael Farkouh defines cholesterol, explains what happens when the body has too much cholesterol, differentiates good from bad cholesterol, and explains how to interpret your cholesterol levels. www.youtube.com/watch?v=hjv5OnbcjE8&feature=channel Understanding Heart Disease (Heart Basics #1), 2 minutes 55 seconds In this illumistream production, Dr. Michael Farkouh discusses how the heart works, as well as the various forms that heart disease can take. www.youtube.com/watch?v=3cW8__wFXDA&NR=1&feature=fvwp What Is a Heart Attack? (Heart Basics #2), 2 minutes 40 seconds In this illumistream production, Dr. Michael Farkouh discusses the distinctive symptoms associated with a heart attack and what to do if you think you may be experiencing a heart attack. www.youtube.com/watch?v=JtFV1EGI3B4&feature=channel What Is Angina? (Heart Basics #3), 3 minutes 11 seconds In this illumistream production, Dr. Michael Farkouh provides an overview of angina and discusses the three types of angina.

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www.youtube.com/watch?v=RXuPBaKzmfM&feature=channel What Is Congestive Heart Failure? (Heart Basics #4), 3 minutes 7 seconds In this illumistream production, Dr. Michael Farkouh provides an overview of congestive heart failure, the common causes of congestive heart failure, and how to live with congestive heart failure. www.youtube.com/watch?v=XFmFpwOvcn8&feature=channel Effects of Cancer (Cancer #3), 3 minutes 40 seconds In this educational clip, Dr. Suzanne Phillips discusses how cancer harms a person, symptoms of localized cancer growths, and symptoms that are present as cancer spreads to other parts of the body. www.youtube.com/watch?v=BMctKampdpU Identifying Melanoma (Health Tip), 1 minute In this brief yet informative illumistream production, Dr. Hadley King provides tips on identifying melanoma, the deadliest kind of skin cancer. www.youtube.com/watch?v=QOoRaFKLIbQ&p=B63D777C3F749DD5&index=1 Identifying Basal Cell Carcinoma (Health Guru Short), 1 minute In this brief yet informative illumistream production, Dr. Hadley King discusses how to identify basal cell carcinoma, the most common form of skin cancer. www.youtube.com/watch?v=NUhGoWmJeVI Recognizing Squamous Cell Carcinoma (Health Short), 1 minute In this brief yet informative illumistream production, Dr. Hadley King discusses factors that increase the risk for squamous cell carcinoma. www.youtube.com/watch?v=Lhi3lBwm2JQ&p=B63D777C3F749DD5&index=3 Smart Sun Protection (Sex Health Guru), 1 minute In this brief yet informative illuminstream production, Dr. Hadley King discusses what to consider when choosing sunscreen and the steps to follow when applying sunscreen. www.youtube.com/watch?v=Hp_jvEAQGLk Treating Cancer (Cancer #4), 3 minutes 47 seconds In this educational clip, Dr. Suzanne Phillips discusses advances in modern medicine used to treat cancer patients. www.youtube.com/watch?v=KasKe1P__7Q&feature=related

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CHAPTER

13A

Focus On: Minimizing Your Risk for Diabetes

Overview Diabetes kills more Americans each year than breast cancer and AIDS combined.

This chapter describes the causes of diabetes and the distinct types of the disease.

Students are made aware of both the nonmodifiable and modifiable risk factors for type 2 diabetes. They are also introduced to prediabetes and its relationship with type 2 diabetes. This chapter informs students about how making healthy lifestyle choices can eliminate or reduce the risk of prediabetes and diabetes.

Learning Outcomes 1. Explain trends in diabetes, describe the effect of diabetes on the body, and differentiate among types of diabetes and their risk factors.

2. Describe the symptoms of, and complications associated with, and main tests for diabetes.

3. Explain how diabetes can be prevented and treated.

Lecture Outline Overview A. At current rates, more than one in three Americans will have diabetes by 2050.

1. Diabetes kills more Americans each year than breast cancer and AIDS combined. a. See Figure 1 for the percentage of the U.S. population with diabetes from 1958 to 2014. b. Diabetes rates increase as age and weight increase. c. The combined economic burden of all types of diabetes was more than $322 billion in 2012.

I. What Is Diabetes?

A. Diabetes mellitus is a group of diseases, each with its own mechanism, but all characterized by a persistently high level of sugar—technically, glucose—in the blood.

1. Hyperglycemia is an elevated blood glucose level.

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B. In a healthy person, the digestive system breaks carbohydrates down into glucose, which it then releases into the bloodstream for use by cells 1. Glucose is one of the main sources of energy for living organisms.

2. When glucose levels drop below normal, certain mental functions, like concentration, may be impaired C. To become available for cells to use, glucose must first be able to cross cell membranes.

1. Insulin, a hormone secreted by the pancreas, stimulates cells to take up glucose from the bloodstream and carry it into the cell, where it is used or stored.

D. Type 1 Diabetes 1. Type 1 diabetes is an autoimmune disease in which the individual’s immune system attacks and destroys normal insulin-making cells in the pancreas; it is also called insulin-dependent diabetes. a. Destruction of these cells causes a dramatic reduction, or total cessation, of insulin production. b. Without insulin, cells cannot take up glucose, and blood glucose levels become permanently elevated.

2. Risk factors include European ancestry, genetic predisposition, those living in cold climates, children who are not breastfed, and people with a history of certain viral infections.

3. People with type 1 diabetes require daily insulin injections or infusions and must carefully monitor their diet and exercise levels.

E. Type 2 Diabetes 1. Type 2 diabetes (noninsulin-dependent diabetes) accounts for 90 to 95 percent of all diabetes cases and develops slowly.

2. In type 2 diabetes, the pancreas does not make sufficient insulin or body cells are resistant to its effects; this condition is called insulin resistance.

3. See Figure 2 for an illustration of how diabetes develops.

4. Development of Type 2 Diabetes a. An overabundance of free fatty acids concentrated in fat cells inhibit glucose uptake by body cells and suppress the liver’s sensitivity to insulin. b. The liver’s ability to self-regulate the conversion of glucose to glycogen begins to fail and blood levels of glucose begin to rise. c. The pancreas tries to compensate by producing more insulin, but it cannot maintain the hypoproduction of insulin indefinitely. d. Pancreatic insulin-producing cells become nonfunctional, insulin output declines, and blood glucose levels rise enough to warrant a diagnosis of type 2 diabetes.

5. Nonmodifiable Risk Factors a. Nonmodifiable risk factors include age, ethnicity, family history, and genetic and biological factors. b. Nearly 26 percent of adults older than 65 has type 2 diabetes.

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c. Most experts believe type 2 diabetes is caused by a complex interaction between environmental factors, lifestyle, and genetic susceptibility d. Having a close relative with type 2 diabetes is another significant risk factor. e. According to the most recent study by Magliano et al., rates of T2D are up significantly among youth ages 10 to 19, particularly among members of minorities. i.

Younger onset T2D has a greater risk of complications than type 1 diabetes, probably due in part to longer years with the disease. ii. Adolescent girls appear to have a greater risk than adolescent boys of early onset T2D. 6. Modifiable Risk Factors a. Body weight (especially around the waistline) b. Dietary choices c. Level of physical activity d. Sleep patterns e. Stress levels F. Prediabetes 1. Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough to be classified as diabetes.

2. Prediabetes is clearly linked to lifestyle, including overweight and obesity profiles constituting metabolic syndrome—a cluster of risk factors that contribute to several health problems.

3. A diagnosis of prediabetes represents a tremendous opportunity to take actions that could prevent diabetes or at least delay its onset.

G. Gestational Diabetes 1. Gestational diabetes is a state of high blood glucose levels during pregnancy that poses risks for both mother and child.

2. Between 40 and 50 percent of women with gestational diabetes develop type 2 diabetes later in life.

Key Terms: diabetes mellitus, hyperglycemia, pancreas, insulin, type 1 diabetes, type 2 diabetes, insulin resistance, prediabetes, gestational diabetes Figures: Figure 1 Percentage of U.S. Population with Diagnosed Diabetes, 1958–2018 Figure 2 Diabetes: What It Is and How It Develops II. What Are the Symptoms of Diabetes?

A. The following are among the most common symptoms of both type 1 and type 2 diabetes: 1. Thirst 2. Excessive urination

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3. Increased hunger 4. Weight loss 5. Fatigue 6. Nerve damage 7. Poor wound healing and increased infections B. Complications of Diabetes 1. The main complications of poorly controlled diabetes are: a. b. c. d.

Diabetic coma (diabetic ketoacidosis) Cardiovascular disease Kidney disease Amputations

e. Eye disease and blindness f. Infectious diseases (particularly influenza and pneumonia) g. Tooth and gum diseases h. Other complications including diabetic neuropathy and depression C. Diagnosing Diabetes 1. Diabetes and prediabetes are diagnosed when a blood test reveals elevated blood glucose levels.

2. A physician will generally order one of the following blood tests: a. Fasting plasma glucose test (FPG) b. Oral glucose tolerance test (OGTT) c. A1C or glycosylated hemoglobin test (HbA1C; tests the estimated average glucose [eAG] over the past two to three months) 3. People with diabetes need to check their own blood glucose level several times each day to make sure they stay within their own target range.

Key Term: estimated average glucose (eAG) Figures: Figure 3 Complications of Uncontrolled Diabetes: Amputation and Eye Disease Figure 4 Blood Glucose Levels in Prediabetes and Untreated Diabetes III. Treating Diabetes A. Lifestyle Changes 1. Studies have shown that lifestyle changes can prevent or delay the development of type 2 diabetes by up to 58 percent.

2. Losing Weight a. A loss of as little as 5 to 7 percent of current body weight and regular physical activity significantly lowers the risk of progressing to diabetes.

3. Adopting a Healthy Diet

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a. It is also important for people with diabetes to pay attention to the glycemic index and glycemic load of foods to prevent surges in blood sugar. b. Foods that may reduce type 2 diabetes risks include low-fat dairy, nuts, whole grains, high-fiber foods, and fatty fish.

4. Increased Physical Fitness a. Increasing physical fitness increases sensitivity to insulin and improves the body’s efficiency in using glucose for fuel.

B. Medical Interventions 1. Oral Medications a. When lifestyle changes fail to control type 2 diabetes, oral medications may be prescribed.

2. Weight Loss Surgery a. Recent findings show that people who have undergone gastric bypass surgery can often stop taking medications for diabetes symptoms altogether.

C. Insulin Injections 1. Insulin injections are absolutely essential for those with type 1 diabetes.

2. People with type 2 diabetes whose blood glucose levels are not adequately controlled with other treatment options also require insulin injections.

3. Today, many diabetics use an insulin infusion pump.

D. New Research in the Battle to Cure Type 2 Diabetes 1. Although there is no cure for type 2 diabetes yet, a new drug is showing promising results when given to mice with insulin resistance. Clinical trials in humans will test whether this is the next step in finding a cure for type 2 diabetes.

ABC News: See It! Video: Two Meals a Day Could Help Diabetics Control Blood Sugar

Discussion Questions 1. Explain the differences among the types of diabetes.

2. How does the body use glucose?

3. What modifiable risk factors can you change to reduce your risk for prediabetes and diabetes?

4. How can prediabetes lead to type 2 diabetes?

5. How does gestational diabetes differ from type 1 and type 2 diabetes? How does gestational diabetes influence risk for type 2 diabetes?

Critical Thinking Questions 1. What types of behavior modification would you recommend for an overweight, sedentary workaholic with an unhealthy diet who has type 2 diabetes?

2. Diabetes is quickly becoming the number one noninfectious disease in our country.

What are the controllable and uncontrollable risk factors of diabetes? What can you do to help minimize your chances of becoming diabetic?

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3. Which of the key steps to begin reducing your risk for diabetes do you follow? Why do you think following these steps is effective? Which steps are the easiest, and which are the hardest for you to follow?

4. Why do you think the percentage of adults with diagnosed diabetes has increased so dramatically over the past three decades?

5. How has the development of the insulin pump altered the lives of people with type 1 diabetes?

Student Activities Individual 1. Research your family history for diabetes. If diabetes is present in your family medical history, what type of diabetes is it?

2. Make up a weekly menu of healthy foods based on recommendations provided by the American Diabetes Association. How does this menu differ from what you normally eat? How can you change your daily diet to reflect the recommendations of the American Diabetes Association? Which changes will be the most difficult? What barriers will you have to address?

3. Find out your blood glucose level. Is it normal? Are you a prediabetic? If so, what lifestyle changes can you make to reduce your risk of diabetes?

Community 1. What kinds of diabetes treatment and education centers are available on your campus or in your community? Are these services readily available to all who need them? If services are not available, what can you do to encourage school administrators or public officials to provide these services?

Diverse Population/Nontraditional 1. Use the Internet to research the incidence of diabetes among Native Americans, especially those over the age of 40. What are the primary causes for this rate of diabetes? What are Native American tribes doing to educate their populations about the prevention and treatment of diabetes?

Additional References A. T. Ahmed, V. P. Quinn, B. Caan, B. Sternfeld, R. Haque, and S. K. Van Den Eeden, “Generational Status and Duration of Residence Predict Diabetes Prevalence among Latinos: The California Men’s Health Study.” BMC Public Health, 9 (2009): 392.

A. Ferrara, et al. “Sex Disparities in Control and Treatment of Modifiable Risk Factors among Patients with Diabetes—Translating Research into Action for Diabetes (TRIAD) Study.” Diabetes Care, 31 (2008): 69–74.

R. W. Grant, J. C. Hivert, J. C. Pandiscio, J. C. Florez, D. M. Nathan, and J. B. Meigs, “The Clinical Application of Genetic Testing in Type 2 Diabetes: A Patient and Physician Survey.” Diabetologia, 52 (2009): 2299–2305. ..

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R. W. Grant, A. F. Moore, and J. C. Florez, “Genetic Architecture of Type 2 Diabetes: Recent Progress and Clinical Implications.” Diabetes Care, 32 (2009): 1107–1114.

D. J. Magliano et al., “Lifetime Risk and Projected Population Prevalence of Diabetes,” Diabetologia, 51 (2008): 2179–2186.

K. L. Ong et al., “Prevalence, Treatment, and Control of Diagnosed Diabetes in the U.S. National Health and Nutrition Examination Survey 1999–2004.” Annals of Epidemiology, 18 (2008): 222–229.

C. S. Owens, “Diabetes and Obesity Risks in African American Young Adult Freshmen Attending a Historically Black College/University.” Journal of Health Care for the Poor and Underserved, 19 (2008): 1096–1118.

For Further Information Diabetes Action: Research and Education Foundation www.diabetesaction.org Diabetes Digest www.diabetesdigest.com Joslin Diabetes Center www.joslin.org

Additional Media Symptoms of Diabetes (Diabetes #2), 2 minutes 56 seconds In this illumistream video, Dr. Melanie Jay reviews the signs and symptoms of diabetes and what to do if you exhibit signs. www.youtube.com/watch?v=7TA5UGY3Joc&feature=channel Consequences of Diabetes (Diabetes #3), 2 minutes 55 seconds In this illumistream video, Dr. Melanie Jay discusses the negative health effects associated with diabetes and explains why diabetes causes these complications. www.youtube.com/watch?v=p7rO2mugexc&feature=channel Gestational Diabetes (Pregnancy Health Guru), 2 minutes 14 seconds In this Pregnancy Health Guru educational clip, Dr. Adam Flisser discusses gestational diabetes, how health care providers test for gestational diabetes, and negative health effects associated with gestational diabetes. www.youtube.com/watch?v=155uGwYOuO4

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CHAPTER

14

Protecting against Infectious Diseases and Sexually Transmitted Infections

Overview Infectious disease is not the leading cause of death as it once was. However, it is still necessary for students to have an understanding of the process of infection. Knowledge about the importance of adequate sleep, proper nutrition, exercise, and good hygiene will help students know how to resist and prevent colds and the flu. This chapter also describes the rates of sexually transmitted infections in the United States and informs students how to focus on behaviors that will protect them at a vulnerable time in their lives from sexually transmitted infections (STIs), which are known to run rampant on college campuses. Chapter 14 also discusses the transmission, symptoms, testing, and treatment of HIV/AIDS. Students are introduced to the stages in the course of these STIs. This understanding can help the student to be aware of how treatment and intervention efforts work to break the cycle of infection.

Learning Outcomes 1. Describe the process of infection and the factors that increase your risk for infectious diseases.

2. Explain how your immune system protects you, factors that diminish its effectiveness, and what you can do to boost its effectiveness.

3. Describe the most common pathogens infecting humans today, key diseases caused by each, and the threat of growing antimicrobial resistance as well as individual- and community-based strategies for prevention and control of infectious diseases.

4. Explain the risk factors for sexually transmitted infections and actions that can prevent their spread.

5. Describe common types of sexually transmitted infections, including their symptoms and treatment methods.

6. Discuss human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), trends in infection and treatment, and the impact of these diseases on special populations.

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Lecture Outline Overview A. Pathogens—disease-causing agents—are everywhere.

B. Some infectious diseases, like the common cold, are endemic—occurring at expected prevalence rates in virtually all populations. An epidemic is a disease outbreak that affects many people in a community or region at the same time.

C. A pandemic is a global epidemic.

D. The more virulent an organism, the greater the chance that it can gain entry into the body, sustain itself in the host, and cause disease.

I. The Process of Infection A. Most infectious diseases are multifactorial, or caused by the interaction of several factors inside and outside the person.

B. For an infection to occur, three conditions, the epidemiological triad of disease, must be met. See Figure 14.1.

1. The host must first come into contact with a pathogen (infectious agent) that is able to overcome the body’s defenses.

2. The host must be susceptible, or in some way vulnerable to infection; that is, the pathogen must be virulent enough to overcome a healthy immune system, or as in the case of an opportunistic infection, the immune system is in a weakened condition (immunocompromised).

3. The environment must be hospitable to the pathogen in terms of temperature, light, moisture, and other requirements.

C. Routes of Transmission: How Do Pathogens Gain Entry?

1. Pathogens may be transmitted through direct contact or by indirect contact.

2. You can also autoinoculate yourself, or transmit a pathogen from one part of your body to another. a. See Table 14.1 for routes of disease transmission.

3. Dogs, cats, livestock, and wild animals can be the source of animal-borne (zoonotic) infections by spreading disease through bites and feces or by carrying infected insects into living areas. a. Interspecies transmission can occur, and vaccination, basic hygiene, and care in contact with animal fluids are important parts of prevention.

D. Risk Factors You Can Control 1. There are some things you can do to eliminate, reduce, or change your susceptibility to various pathogens. a. Too much stress, poor diet, low fitness level, lack of sleep, misuse or abuse of drugs, poor personal hygiene, and high-risk behaviors significantly increase the risk for many diseases.

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b. Age c. Environmental conditions d. Organism virulence and resistance Key Terms: pathogen, endemic, epidemic, pandemic, virulent, infection, epidemiological triad of disease, opportunistic infection, immunocompromised, autoinoculate, interspecies transmission Figure and Table: Figure 14.1 Epidemiological Triad of Disease Table 14.1 Routes of Disease Transmission II. Your Body’s Defenses Against Infection •

For pathogens to gain entry into your body, they must overcome a multitude of effective barriers. See Figure 14.2 for a summary of the body’s defenses that help protect against invasion.

A. Physical and Chemical Defenses 1. Our single most critical early defense system is the skin.

2. Pathogens enter through the skin only when cracks or breaks occur.

3. Internal linings of the body and bodily secretions provide additional protection. a. Mucous membranes, cilia, nose hairs, tears, earwax are all examples.

B. The Immune System: Your 24/7 Protector 1. Immunity is a condition of being able to resist a particular disease by counteracting the substance that produces the disease. a. substance capable of triggering an immune response is called an antigen. b. The body’s response to an antigen is the formation of antibodies. c. Humoral immunity is the body’s major defense against many bacteria and the poisonous substances, called toxins, they produce. d. In cell-mediated immunity, specialized white blood cells, lymphocytes, attack and destroy the foreign invader. i. Lymphocytes are the body’s main defense against viruses, fungi, parasites, and some bacteria, and are found in the blood, lymph nodes, bone marrow, and certain glands. ii. Figure 14.2 provides a summary of the cell-mediated immune response. e. Other key players in this immune response are macrophages (a type of phagocytic, or cell-eating, white blood cell).

2. Damage to the Microbiome a. Unnecessary antibiotics can disrupt the microbiome, the community of naturally occurring bacteria in and on the body. b. When a patient takes antibiotics with the intention of killing infection causing bacteria, they need to remember that it takes months to restore normal healthy bacteria colonies. ..

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3. When the Immune System Misfires: Autoimmune Diseases a. Although the immune system response generally works in our favor, the body sometimes makes a mistake and targets its own tissue as the enemy; this is known as autoimmune disease.

4. Inflammatory Response, Pain, and Fever a. The four cardinal signs of inflammation are redness, swelling, pain, and heat. b. Pain is often one of the earliest signs that an injury or infection has occurred. c. Fever is another frequent indicator of infection.

C. Vaccines Bolster Immunity 1. Vaccination is based on the principle that once people have been exposed to a specific pathogen and had a successful immune response, subsequent attacks will activate their “immune memory” and allow them to fight the pathogen in the future.

2. Vaccines consist of killed or weakened versions of disease-causing microorganisms typically given orally or by injection to cause the body to develop immunity against the organism. a. Artificially acquired active immunity is gained by vaccination.

3. Specific vaccination schedules have been established for various population groups. a. See Table 14.2 for recommended vaccines for teens and college students.

Key Terms: drug resistance, antigen, antibodies, humoral immunity, toxins, cellmediated immunity, lymphocyte, antibiotic/antimicrobial resistance, macrophage, microbiome, autoimmune disease, vaccination Figures and Table: Figure 14.2 The Body’s Defenses against Disease-Causing Pathogens Figure 14.3 The Cell-Mediated Immune Response Figure 14.4 Recommended Adult Immunization Schedule, by Vaccine and Age Group, 2015 Table 14.2 Checklist for Incoming Student Vaccines III. Types of Pathogens and the Diseases They Cause •

There are six major types of pathogens: bacteria, viruses, fungi, protozoans, parasitic worms, and prions.

•

See Figure 14.5 for examples of these pathogens.

A. Bacteria 1. Bacteria are single-celled organisms. a. Three main types are cocci, bacilli, and spirilla. b. Diseases caused by bacteria are often easily treatable with antibiotics.

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c. Antibiotic-resistant bacteria, or “superbugs,” result when successive generations of bacteria mutate to develop resistance to specific drugs. d. Antibiotic/antimicrobial resistance is one of the world’s most pressing problems.

2. Staphylococcal Infections a. Staphylococci are present on the skin or in the nostrils of 20 to 30 percent of us at any given time and usually don’t cause a problem. b. The presence of bacteria on or in a person without infection is called colonization. c. Acne, boils, styes, or infected wounds are examples of “staph” infections. d. Methicillin-resistant Staphylococcus aureus (MRSA) is a dangerous, resistant form of staph. e. Health care-associated or health care-acquired MRSA is contracted in health care facilities such as hospitals, nursing homes, or clinics and has been one of the leading health care–associated infections (HAIs). f. Today, MRSA infection is on the rise between family members, in the home, and in workplaces and communities—known as community-acquired MRSA (CA-MRSA). g. Another type of MRSA appears to be spread among people who work closely with livestock and is known as livestock-associated MRSA, or LA-MRSA. 3. Clostridium difficile a. difficile is a bacterial disease that leads to major inflammation of the colon. b. Long-term antibiotic use, which kills the good bacteria in the gut, is the major cause. c. The elderly are at particular risk.

4. Streptococcal Infections a. At least five types of Streptococcus microorganism are known to cause bacterial infections. b. Group A streptococci (GAS) cause most common diseases including strep throat and scarlet fever. One virulent group of GAS causes necrotizing fasciitis (“flesh-eating strep”). c. Group B streptococci can cause illness in newborn babies, pregnant women, older adults, and adults with illness such as diabetes or liver disease. d. The species Streptococcus pneumoniae causes thousands of cases of bacterial meningitis and pneumonia every year and is a primary culprit in most ear infections.

5. Meningitis a. Meningitis is an infection and inflammation of the membranes that surround the brain and spinal cord. A virulent form prevalent on college campuses, meningococcal meningitis, is among the most serious. b. Bacterial meningitis progresses rapidly, is life-threatening, and needs immediate medical attention.

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c. Viral meningitis is much less dangerous and symptoms usually diminish in three to five days in otherwise healthy people. d. Vaccines are available for some types of meningitis. e. The signs of meningitis are sudden fever, severe headache, and stiff neck, particularly causing difficulty touching your chin to your chest.

6. Pneumonia a. Pneumonia is a general term for a wide range of conditions that result in inflammation of the lungs and difficulty breathing. b. Pneumonia can be bacterial, viral, fungal, or caused by occupational exposure to chemicals, or trauma. Bacterial pneumonia is readily treated with antibiotics.

7. Tuberculosis (TB) a. Only HIV/AIDS is a greater infectious agent killer than tuberculosis in the global population. b. Symptoms include wasting/weight loss, persistent coughing, fever, and spitting up blood. It was historically known as consumption. c. Airborne transmission via the respiratory tract is the primary mode of infection. d. Multidrug-resistant TB (MDR-TB) is a form of TB that is currently resistant to at least two of the best anti-TB drugs in use today. e. Extensively drug-resistant TB (XDR-TB) is resistant to nearly all first- and second-line drug defenses against it and is extremely difficult to treat.

8. Tickborne Bacterial Diseases a. Tickborne bacterial diseases have become major health threats in the United States and include Lyme disease, babesiosis, ehrlichiosis, and rickettsia. b. Symptoms of Lyme disease range from none to a rash or bull’s-eye lesion and flulike symptoms to chronic arthritis, blindness, and long-term disability. c. Babesiosis symptoms mimic the flu and include headache, fatigue, and nausea. It attacks and destroys red blood cells, potentially causing anemia. d. Ehrlichiosis also has flulike symptoms that may progress to respiratory symptoms and even death. Antibiotics given early in the disease are effective. e. Rickettsia are small tickborne bacteria that produce toxins that multiply within small blood vessels; two forms of rickettsial disease are Rocky Mountain spotted fever and typhus. f. Prevention measures include staying out of woods and grass during times that ticks are most active, using insect repellent with DEET, wearing long sleeves and pants, and doing tick checks.

9. Escherichia coli O157:H7 a. coli O157: H7 is a foodborne illness that causes severe bloody diarrhea and kidney failure. b. Causes of infection include undercooked ground beef, unpasteurized milk or juice, or swimming in sewage-contaminated water.

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B. Viruses 1. Viruses are the smallest known pathogens. a. Viruses are incapable of carrying out any life processes on their own. To reproduce they must invade and inject their own DNA or RNA into a host cell and force it to make copies. b. Viral diseases can be difficult to treat because many viruses can withstand heat, formaldehyde, and large doses of radiation with little effect on their structure. c. Some viruses have incubation periods that last for years, which delays diagnosis. d. Drug treatment for viral infections is also limited.

2. The Common Cold a. The common cold is an example of a viral infection. b. Ten to 40 percent of all colds are caused by a rhinovirus; 20 percent of all colds are caused by the coronavirus. c. Colds are endemic (always present) throughout the world and increase in prevalence when the weather turns cold and people spend more time indoors.

3. Influenza a. Influenza, or flu, is a contagious respiratory illness that includes fever and chills along with other cold symptoms. b. Once a person gets the flu, treatment is palliative—focused on relief symptoms rather than cure. c. The best way to avoid the flu is to get an annual vaccination against it. d. Flu shots take two to three weeks to become effective, so people at risk should get these shots before the season begins.

4. Hepatitis a. Hepatitis is a virally caused inflammation of the liver. b. Hepatitis symptoms include fever, headache, nausea, loss of appetite, skin rashes, pain in the upper right abdomen, dark yellow urine, and jaundice. c. There are several known forms: Hepatitis A, B, C, D, and E, with A, B, and C having the highest rates of incidence. d. Hepatitis A is contracted from eating food or drinking water contaminated with human feces. Vaccination is available. e. Hepatitis B is spread through bodily fluids, during unprotected sex, or via contact with blood of an infected person (i.e., through sharing needles or during birth). f.

Hepatitis C is on the rise in many regions of the world, and resistant forms of this strain are emerging. It becomes chronic in 75 to 85 percent of cases.

5. Zika a. Zika is a mosquito-borne virus that poses a threat to pregnant women and their offspring, sometimes causing microcephaly—a condition in which a

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baby’s head is unusually small at birth because of a lack of development of brain tissue.

C. Other Pathogens 1. Fungi a. Fungi can cause diseases such as candidiasis (vaginal yeast infection), athlete’s foot, ringworm, jock itch, toenail fungus, and valley fever. b. Fungal diseases usually transmit via physical contact.

2. Protozoans a. Protozoans—microscopic single-celled organisms—cause diseases like giardiasis, malaria, and African sleeping sickness.

3. Parasitic Worms a. Parasitic worms like pinworms and tapeworms are more of a nuisance than a threat. b. Of special note are worm infestations that are associated with eating raw fish.

4. Prions a. Prions are self-replicating protein-based agents that can infect humans and other animals; one prion is the cause of “mad cow disease.”

D. Emerging and Resurgent Diseases 1. Within the past decade, rates for many infectious diseases have increased. a. This can be attributed to a combination of economic development and land use, human behaviors, and the proliferation of international travel.

2. There has also been a significant increase in vaccine-preventable diseases as some families opt out of vaccinations.

3. Measles and Mumps a. Mumps is the swelling of the salivary glands, which in severe cases can cause hearing loss or male sterility. b. Measles is known for its high fever and itchy red rash. c. Cases of measles and mumps have become increasingly common because people mistakenly believe that the diseases are gone and the risk of vaccination is greater than the risk of disease.

4. West Nile Virus a. The West Nile Virus is spread by the bite of an infected mosquito. b. Symptoms are flulike and can include a form of encephalitis. c. Today only Alaska and Hawaii remain free of the disease in the United States. d. The best way to avoid infection is through mosquito eradication programs, wearing mosquito repellent, and avoiding mosquito-infested areas.

5. Avian (Bird) and Swine (Pig) Flu a. Avian influenza is an infectious disease of birds. Strains capable of crossing the species barrier can cause severe illness in humans who come in contact with bird droppings or fluids. b. The virus has yet to mutate into a form highly infectious to humans.

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c. The swine flu (H1N1) is a respiratory infection that was believed initially to be found primarily in pigs but that eventually combined with a human flu virus.

6. Powassan Virus a. Powassan is a tick borne virus that attacks the brain of those infected, causing encephalitis. b. Infection can occur when a tick is attached to the person for less than an hour..

E. Mindfulness: A New Ally in Bolstering Defenses?

1. An emerging body of research indicates that mindfulness may be a weapon in your arsenal against infectious and chronic diseases.

Key Terms: bacteria (singular: bacterium), antibiotics, staphylococci, colonization, methicillin-resistant Staphylococcus aureus (MRSA), health care-associated infections (HAIs), Clostridium Difficile (C. Diff), Streptococcus, meningitis, pneumonia, tuberculosis (TB), multidrug-resistant TB (MDR-TB), extensively drugresistant TB (XDR-TB), Lyme disease, rickettsia, Rocky Mountain Spotted Fever, Ehrlichiosis, Powassan, Babesiosis, viruses, incubation period, influenza, hepatitis, Zika virus, fungi, protozoans, parasitic worms, prion, mumps, measles Figure: Figure 14.4 Recommended Adult Immunization Schedule, by Vaccine and Age Group, 2021 Figure 14.5 Examples of Five Major Types of Pathogens Figure 14.6 How Antibiotic Resistance Spreads ABC News: See It! Video: A Brief History: Measles in America IV. Sexually Transmitted Infections (STIs) •

Every year there are at least 20 million new cases of STIs, only some of which are curable.

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Early symptoms of STIs are often mild and unrecognizable.

A. What’s Your Risk?

1. The more sexual partners a person has, the greater the risk for contracting an STI. 2. Several reasons have been proposed to explain the present high rates of STIs: a. Shame and embarrassment b. Our culture’s casual attitude toward sex c. Ignorance about the infections, their symptoms, and their spread 3. See Figure 14.7 for a continuum of disease risk for various sexual behaviors.

B. Routes of Transmission 1. STIs generally are spread by some form of intimate sexual contact.

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2. STIs have both pathogen-specific incubation periods and periods of communicability—times during which transmission is most likely.

Key Term: sexually transmitted infections (STIs) Figure: Figure 14.7 Continuum of Disease Risk for Various Sexual Behaviors V. Common Types of Sexually Transmitted Infections • There are more than twenty known types of STIs. A. Chlamydia 1. Chlamydia is the most common STI reported in the United States.

2. Signs and Symptoms a. Early symptoms for men might include painful and difficult urination, frequent urination, and watery, pus-like discharge from the penis. b. Early symptoms for women include a yellowish discharge, spotting between periods, and occasional spotting after intercourse.

3. Complications a. Men can suffer injury to the prostate gland, seminal vesicles, and bulbourethral glands and can suffer from arthritis-like symptoms, inflammatory damage to the blood vessels and heart, and epididymitis. b. Women can experience injury to the cervix or fallopian tubes, causing sterility and pelvic inflammatory disease (PID). c. Chlamydia may also be responsible for conjunctivitis, an eye infection, which can pass from a mother to an infant during delivery.

4. Diagnosis and Treatment a. Diagnosis of chlamydia is determined through a laboratory test of a urine or fluid sample. b. If diagnosed early, chlamydia is easily treatable with antibiotics.

B. Gonorrhea 1. Gonorrhea is one of the most common STIs in the United States.

2. Signs and Symptoms a. Symptoms for males include a white, milky discharge and painful urination two to nine days after contact. See Figure 14.8. b. Most women do not experience any symptoms, but others may have vaginal discharge or a burning sensation during urination.

3. Complications a. If untreated in the male, it can spread to the prostate, testicles, urinary tract, kidneys, and bladder. b. If untreated in women, it can spread to the fallopian tubes and ovaries, causing sterility or severe inflammation and PID. 4. Diagnosis and Treatment

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a. If detected early, gonorrhea is treatable with antibiotics, but it has also begun to develop resistance. b. Frequently chlamydia and gonorrhea occur at the same time, but different antibiotics are needed to treat each separately.

C. Syphilis 1. Syphilis is generally transferred only through direct sexual contact or from mother to fetus. a. The incidence of syphilis is highest in adults aged 20 to 39.

2. Signs and Symptoms a. Syphilis is known as the “great imitator” because its symptoms resemble those of several other infections. b. Syphilis occurs in four distinct stages: i.

Primary syphilis: characterized by the development of a chancre

ii. Secondary syphilis: secondary symptoms include a rash, white patches on skin or mucous membranes, loss of hair, enlarged lymph nodes, fever, or headache iii. Latent syphilis: development of lesions (gummas) iv. Tertiary/late syphilis: heart and central nervous damage, blindness, deafness, paralysis, and dementia 3. Complications a. Pregnant women with syphilis can experience premature births, miscarriages, stillbirth or can transmit the infection to their unborn children.

4. Diagnosis and Treatment a. Diagnosis is made with a blood test or analyzing a sample from a chancre. b. The early stages of syphilis can easily be treated with antibiotics.

D. Herpes 1. Herpes is the general term for a family of diseases characterized by sores or eruptions on the skin.

2. There are two types of herpes simplex virus: herpes simplex type 2 virus (HSV2) and the herpes simplex type 1 virus (HSV-1).

3. Signs and Symptoms a. The precursor to infection is characterized by a burning sensation and redness. b. By the second phase, a blister filled with a clear fluid that contains the virus forms. c. The blister will crust over, dry up, and disappear, but the virus remains in certain nerve cells for life and can flare up or cause symptoms when the body’s ability to maintain itself is weakened.

4. Complications a. Many physicians recommend cesarean deliveries for pregnant women who are infected with herpes, as it can be passed to the baby during birth.

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a. Although there is no cure for herpes at present, certain drugs can be used to treat symptoms and reduce viral shedding.

E. Human Papillomavirus (HPV) and Genital Warts 1. Genital warts are caused by a group of viruses called human papillomavirus (HPV). The human papillomavirus is among the most common STIs in the United States today.

2. HPV affects almost all sexually active men and women during their lives, even though most don’t realize that they are infected.

3. Signs and Symptoms a. Low-risk types of HPV may develop into genital warts, a series of bumps or growths on the genitals. See Figure 14.11.

4. Complications a. Infection with high-risk types of HPV poses a significant risk for cervical cancer in women. They may lead to dysplasia. b. HPV can also result in oropharyngeal cancer—around the tonsils or base of the tongue.

5. Diagnosis and Treatment a. Genital warts can be treated with topical medications or removed by being frozen with liquid nitrogen. Large warts may require surgical removal. b. Two vaccines have been licensed by the U.S. Food and Drug Administration and recommended by the Centers for Disease Control and Prevention.

F. Candidiasis (Moniliasis) 1. Candidiasis, also called moniliasis or yeast infection, is caused by a fungus normally found in a woman’s vaginal tract, which multiplies when the normal chemical balance of the vagina is disturbed.

2. Signs and Symptoms a. Symptoms include severe itching and burning of the vagina and vulva and a cheesy, white vaginal discharge. b. When the microbe infects the mouth, it is referred to as thrush.

3. Diagnosis and Treatment a. It is treated with antifungal drugs.

G. Trichomoniasis 1. Trichomoniasis is caused by a protozoan.

2. It can be spread sexually or by contact with items that have discharged fluid on them.

3. Signs and Symptoms a. Symptoms in women include a foamy, yellowish, unpleasant-smelling discharge accompanied by a burning sensation, itching, and painful urination.

4. Most men do not experience symptoms.

5. Diagnosis and Treatment a. It is diagnosed by collecting fluid samples from the penis or vagina. b. Treatment includes oral medication given to both sexual partners to avoid the “ping-pong” effect of repeated cross-infection.

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H. Pubic Lice 1. Pubic lice (crabs) are small parasites usually transmitted during sexual contact.

2. They attach themselves to the base of pubic hair, where they deposit their eggs (nits). a. One to two weeks later, the nits develop into adults that lay eggs and migrate to other body parts.

3. Signs and Symptoms a. Symptoms include itchiness in the area covered by pubic hair, bluish-gray skin color in the pubic region, and sores in the genital area.

4. Diagnosis and Treatment a. Diagnosed by identification of eggs in the genital area. b. Treatment includes washing clothing, furniture, and linens that may harbor the eggs.

Key Terms: chlamydia, pelvic inflammatory disease (PID), gonorrhea, syphilis, chancre, genital herpes, genital warts, human papillomavirus (HPV), genital warts, candidiasis, trichomoniasis, pubic lice Figures: Figure 14.8 Gonorrhea Figure 14.9 Syphilis Figure 14.10 Herpes Figure 14.11 Genital Warts Figure 14.12 Pubic Lice ABC News: See It! Video: Oral HPV VI. HIV/AIDS •

Acquired immunodeficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), was first recognized more than 37 years ago.

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Since its discovery, approximately 78 million people worldwide have become infected.

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Because of improved treatments, more people are living with HIV than ever before.

A. How HIV Is Transmitted 1. HIV is transmitted when an infected person’s body fluids (blood, semen, vaginal secretions, etc.) gain entry into another person’s body through a breach in the body’s defenses. a. Despite some myths, HIV is not highly contagious.

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2. Engaging in High-Risk Behaviors a. HIV infection is related to certain high-risk behaviors rather than groups of people. b. See Figure 14.13 for a breakdown of sources of HIV infection among U.S. men and women. c. The majority of HIV infections arise from the following high-risk behaviors: i. Exchange of bodily fluids ii. Contaminated needles 3. Mother-to-Child (Perinatal) Transmission a. Without antiretroviral treatment, 15 to 45 percent of pregnant women will transmit the virus to their infant.

B. Signs and Symptoms of HIV/AIDS 1. The incubation period for HIV before symptom development varies greatly from person to person. a. For adults who receive no medical treatment, it takes an average of eight to ten years for the virus to cause the slow, degenerative changes in the immune system. b. During this time, a person may experience many opportunistic infections.

2. Colds, sore throats, fever, tiredness, nausea, night sweats, and other generally non-life-threatening conditions commonly appear and are described as pre-AIDS symptoms.

3. Other symptoms of progressing HIV infection include wasting syndrome, swollen lymph nodes, and neurological problems.

C. Testing for HIV: Newer Options 1. Today, three categories of tests exist for people who are concerned they may be infected with HIV: a. Antibody tests b. Combo or Fourth-Generation Tests c. Nucleic Acid Tests (NAT) and HIV p24 Antigen Test D. New Hope and Treatments 1. New, high-powered anti-HIV drugs have slowed the progression from HIV to AIDS and have prolonged life expectancies for most AIDS patients.

E. Preventing HIV Infection a. The only way to prevent HIV infection is through the choices you make in sexual behaviors and drug use and by taking responsibility for your own health and the health of your loved ones. b. Studies have shown promising results from preexposure prophylaxis (PrEP) for HIV. c. If you are concerned about your risk or a friend’s risk, arrange a confidential meeting with a health educator or other health professional.

Key Terms: acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), preexposure prophylaxis (PrEP) Figures: 242 INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR HEALTH: THE BASICS, 14e

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Figure 14.13 Estimates of New HIV Diagnoses in the United States for Most Affected Subpopulations, 2018

Discussion Questions 1. Discuss the differences between a cold and the flu. How should each be treated?

2. What are some of the diseases that are easily treatable but, if left untreated, can cause serious secondary problems?

3. What are some of the reasons why people don’t seek treatment for STIs? Provide two potential solutions for each reason.

4. Describe three ways to improve sexual communication to prevent diseases.

5. Why does it seem that more women are infected by HIV today than in the past?

Critical Thinking Questions 1. Why do you think the incidence of syphilis is highest in adults aged 20 to 39? What practices in the lifestyles of women and men in these age groups might cause this increased risk of syphilis?

2. Why do you think some people are against immunization? Should immunizations be mandated by law to decrease the incidence of dangerous childhood diseases?

3. What do you do to protect yourself from STIs? Are there additional things you can do to If vaccines were available for STIs, do you think they should be required for sexually active people? Why or why not?

Student Activities Individual 1. Look up organizations such as Nothing But Nets (www.nothingbutnets.net) on the Internet to find out what you can do to help prevent the spread of infectious diseases such as malaria.

2. Write out your “medical” family tree. Identify any disorders of family members that might put you at a greater risk due to genetic links.

3. Write out a list of five ways you can speak with a sexual partner about his or her past and five ways to insist that you and your partner practice safe sex.

Community 1. Find out the HIV/AIDS rate in your area. Compare this with the state and national averages. What types of resources (or lack of resources) contribute to these rates?

Find out which STIs are most prevalent in your community. Make a list of campus and community resources for STI treatment. Distribute the list to the class.

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2. What steps have your campus and your community taken to prevent the spread of flu should an outbreak occur in your area? What additional steps could be taken on your campus to protect students from this highly contagious disease?

3. Find out what vaccinations, if any, are required on your campus. What vaccinations are required by public schools in your community?

Diverse Population/Nontraditional 1. Compare the rates of infectious diseases such as malaria and HIV/AIDS in countries around the world. Compare the rates to those in the United States. Are these diseases more common in certain parts of the world? Why do you think this is so?

2. When it was first identified, AIDS was considered to be a “gay disease.” How have perceptions of AIDS changed as knowledge about the disease has increased? How do you think the label of being a “gay” disease influenced how people addressed their own exposure to the disease?

3. Use the Internet to research international health organizations that fight infectious diseases. What can you do as an individual to support the work of these organizations?

4. What courses of action should the principal take to make students and families aware of the staph outbreak?

Additional References J. B. Adelbert, T. Simpson, and W. Chamberlain, “Chlamydia Prevalence among College Students: Reproductive Public Health Implications.” Sexually Transmitted Diseases, 35 (2008): 529–532.

E. R. Buhi, S. L. Marhefka, and M. T. Hoban, “The State of the Union: Sexual Health Disparities in a National Sample of U.S. College Students.” Journal of American College Health, 58 (2010): 337–346.

J. K. Freburger et al., “The Rising Prevalence of Chronic Low Back Pain.” Archives of Internal Medicine, 169 (2009): 251–258.

D. P. Gilkey, T. J. Keefe, J. L. Peel, O. M. Kassab, and C. A. Kennedy, “Risk Factors Associated with Back Pain: A Cross-Sectional Study of 963 College Students.” Journal of Manipulative and Physiological Therapeutics, 33 (2010): 88–95.

E. Hazard, J. Munakata, M. E. Bigal, M. F. T. Rupnow, and R. B. Lipton, “The Burden of Migraine in the United States: Current and Emerging Perspectives on Disease Management and Economic Analysis.” Value in Health, 12 (2008): 55–64.

E. Scott and K. Vanick, “A Survey of Hand Hygiene Practices on a Residential College Campus.” American Journal of Infection Control, 35 (2007): 694–696.

P. D. Smith and C. M. Roberts, “American College Health Association Annual Pap Test and Sexually Transmitted Infection Survey: 2006.” Journal of American College Health, 57 (2009): 389–394.

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A. Unlap, E. Dirik, and S. Kurul, “Prevalence and Clinical Findings of Migraine and Tension-type Headache in Adolescents” Pediatrics International, 49 (2007): 943–949.

H. R. Weiner, “Methicillin-resistant Staphylococcus Aureus on Campus: A New Challenge to College Health.” Journal of American College Health, 56 (2008): 347– 350.

J. R. Williams, J. Zenilman, J. P. Nanda, and H. Mark, “Recruitment Strategies and Motivations for Sexually Transmitted Disease Testing among College Students.”

Journal of American College Health, 57 (2008): 357–360.

L.T. Wu, C. L. Ringwalt, A. A. Patkar, R. L. Hubbard, and D. G. Blazer, “Association of MDMA/ecstasy and other Substance Use with Self-reported Sexually Transmitted Diseases among College-aged Adults: A National Study.” Public Health, 123 (2009): 557–564.

For Further Information Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention www.cdc.gov/nchhstp Centers for Disease Control and Prevention National Prevention Information Network www.cdcnpin.org National Foundation for Infectious Diseases www.nfid.org

Additional Media Ready-to-Go Teaching Module: Infectious Disease and Sexually Transmitted Infections Sex and the STD Test (Sex Health Guru Survey), 2 minutes 13 seconds In this educational clip produced by Sex Health Guru, columnist Jamye Waxman shares results of a survey regarding STI testing. https://www.youtube.com/watch?v=s-fjg7Stgb4&t=7s The Flu Vaccine: Fact & Fiction (College Health Guru), 3 minutes 12 seconds In this College Health Guru educational clip, Dr. Robert Gorski discusses what influenza is, why a new flu vaccine is developed annually, the purpose of a flu shot/nasal spray, and who should get a flu vaccine. www.youtube.com/watch?v=MubPD5HmxVc Mono: The Makeout Disease (College Health Guru), 2 minutes 17 seconds Infectious mononucleosis is discussed by Dr. Adam Flisser. Specifically, Dr. Flisser discusses how mononucleosis is transmitted, its symptoms, and what to do if you think you may have mononucleosis. www.youtube.com/watch?v=atA5LmigZjM ..

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Top 10 Herpes Facts (Sex Health Guru Tip), 2 minutes 51 seconds In this illumistream health video, Dr. Alice Ko discusses the ten most common herpesrelated myths. https://www.youtube.com/watch?v=NbEGIidxqqQ&t=10s When HIV Becomes AIDS (HIV #2), 3 minutes 52 seconds In this illumistream educational clip, Dr. Alice Ko distinguishes HIV from AIDS and discusses what happens when HIV becomes AIDS. https://www.youtube.com/watch?v=68I7JlVhuhY

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CHAPTER

14A

Focus On: Reducing Risks for Chronic Diseases and Conditions

Overview Focus On: Reducing Risks and Coping with Chronic Diseases and Conditions provides the student with an overview of noninfectious conditions such as chronic lung diseases, allergies, headaches, digestion-related disorders, and musculoskeletal conditions.

Students learn the causes of these diseases and lifestyle changes that can lessen their chances of developing these diseases.

Learning Outcomes 1. Describe the prevalence and symptoms of key respiratory diseases such as bronchitis, emphysema, and asthma, including their risk factors and impact on society.

2. Describe the allergic response, as well as key types of allergy, potential complications, and susceptibility.

3. Explain common neurological disorders, including headaches and seizure disorders, risk factors, possible causes, and methods of prevention and control.

4. Summarize key digestive disorders, their risks, symptoms, and strategies for prevention.

5. Explain the risk factors and symptoms of major musculoskeletal diseases, including arthritis and low back pain, and suggest strategies for prevention.

Lecture Outline •

Chronic diseases and conditions take time to develop, cause progressive damage to the body, and are not easily cured.

I. Chronic Lower Respiratory (Lung) Diseases 1. Chronic lower respiratory diseases are the third-leading cause of death in the United States.

2. Any disease or disorder in which lung function is impaired is considered a lung disease.

3. When the lungs are impaired, a condition known as dyspnea, or a choking type of breathlessness, can occur even with mild exertion. ..

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4. Chronic Obstructive Pulmonary Disease 5. Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that gradually makes it more difficult for a person to breathe.

6. COPD includes chronic bronchitis and emphysema, which often occur together and can lead to problems with inhalation and exhalation.

7. There is no cure for COPD, but there is much that can be done to prevent it, i.e., not smoking, proper ventilation, etc.

A. Bronchitis 1. Bronchitis refers to an inflammation and eventual scarring of the lining of the bronchial tubes.

2. Acute bronchitis is the most common bronchial disease, and symptoms often improve in a week or two.

3. Chronic bronchitis is when the symptoms of bronchitis last for at least three months of the year for two consecutive years.

4. Poverty, lack of education, and higher smoking rates are likely contributors to the prevalence of chronic bronchitis.

B. Emphysema 1. Emphysema involves the gradual, irreversible destruction of the alveoli of the lungs.

2. As the alveoli are destroyed, it becomes more and more difficult to exhale.

C. Asthma 1. Asthma is a long-term, chronic inflammatory disorder that inflames and blocks lung airflow.

2. It is characterized by attacks of wheezing, difficulty breathing, shortness of breath, and coughing spasms.

3. There are two types: extrinsic (or allergic) and intrinsic (nonallergic).

4. Asthma can occur at any age and is now the most common chronic illness in children.

Key Terms: dyspnea, chronic obstructive pulmonary diseases (COPDs), bronchitis, emphysema, asthma Figure: Figure 1 Asthma Is an Inflammation of the Airways in the Lungs II. Coping with Allergies A. An allergy occurs as part of the body’s attempt to defend itself against a specific antigen or allergen by producing specific antibodies.

1. In some people, the immune system overreacts and develops an overly elaborate protective mechanism against relatively harmless substances.

2. Once excessive antibodies to allergens are produced, they trigger the release of histamine, a chemical that dilates blood vessels, increases mucous secretions, causes tissues to swell, and produces rashes, difficulty breathing, and sometimes anaphylaxis.

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3. Treatments may be as simple as quickly washing off the substance you came into contact with, taking antihistamines, or getting shots to avoid serious reactions, and working with your doctor to come up with a treatment regimen.

4. Hay Fever B. Hay fever, or allergic rhinitis, is one of the most common chronic diseases in the United States.

1. It is most common when ragweed and flowers bloom.

2. Hay fever is characterized by sneezing and itchy, watery eyes and nose.

3. Typical over-the-counter treatment consists of antihistamines.

4. An allergist can help determine if you have a pollen allergy.

Key Terms: allergy, allergen, histamine Figures: Figure 2 Steps in an Allergic Response III. Coping with Neurological Disorders A. Headaches 1. Tension headaches are experienced by up to 80 percent of the population. a. Causes are unknown, but possible triggers include stress, depression and anxiety, jaw clenching, poor posture, drinking red wine, lack of sleep, extreme fasting, hormonal changes, and certain food additives and preservatives. b. They are most often prevented by reducing triggers. Aspirin, ibuprofen, acetaminophen, and naproxen sodium can also help relieve pain.

2. Migraines are inherited neurological disorder characterized by overexcitability of specific areas of the brain, particularly the vascular network. a. Symptoms vary and can last from 4 to 72 hours. b. About one-third of migraine sufferers can predict an attack based on a sensory warning sign called an aura. c. Because triggers vary, treatment varies. When true migraines occur, relaxation is only minimally effective. Often, prescription pain relievers are necessary.

3. Cluster headaches are relatively rare, though adults between the ages of 20 and 40 tend to be particularly susceptible. a. These headaches cause stabbing pain on one side of the head, behind the eye, or in one defined spot. b. They can last for weeks and disappear quickly, though they commonly last for 40 to 90 minutes and often occur in the middle of the night during REM sleep.

B. Seizure Disorders 1. Seizure disorders are generally caused by abnormal electrical activity in the brain and are characterized by loss of control of muscular activity and unconsciousness.

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a. Risk factors include taking certain drugs, drug withdrawal, having a high fever and abnormal blood levels of sodium or glucose, or experiencing physical, chemical, or temperature trauma.

Key Term: migraines, seizure disorders IV. Coping with Digestion-Related Disorders and Diseases A. Irritable Bowel Syndrome (IBS) 1. IBS is a functional bowel disorder—affecting how the bowel, including the colon and rectum, works.

2. Often, because symptoms are so similar to those of other gastrointestinal conditions, IBS is diagnosed only after all other potential causes are ruled out.

3. Treatment focuses on relieving symptoms. Stress management, relaxation techniques, regular activity, and diet changes can help.

B. Inflammatory Bowel Disease 1. Ulcerative colitis is a condition that occurs when the lining of the large intestine becomes inflamed. a. Possible causes include environment, pathogens, stress, smoking, and genetics. b. Treatment focuses on decreasing foods that are hard to digest, taking probiotics, and taking anti-inflammatory drugs.

2. Crohn’s disease can affect any area of the gastrointestinal tract from the mouth to the anus. It causes major pain, inflammation, and bleeding and can lead to tears in the gastrointestinal tract. a. Genes, environmental exposures, and an autoimmune reaction are among the culprits. b. Those diagnosed must carefully monitor their diet and nutrition, be tuned in to their body, see a doctor if symptoms develop, and take medications to reduce inflammation and prevent infection. c. Surgery to remove damaged or obstructed portions of the bowel can be necessary.

Key Terms: inflammatory bowel disease (IBD), ulcerative colitis, Crohn’s disease V. Coping with Musculoskeletal Diseases •

Musculoskeletal diseases can exact a heavy toll on quality of life as well as ability to work and perform activities of daily living.

A. Arthritis 1. Arthritis consists of more than 100 conditions that affect joints, bones, muscles, organs, cartilage, and connective tissue leading to disability and pain.

2. Osteoarthritis (OA), or degenerative joint disease, is the most common form of arthritis and has been associated with the wear-and-tear theory of aging. a. Other risk factors may include heredity, abnormal joint use, diet and excess weight, abnormalities in joint structure, and impaired blood supply to the joint.

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3. Rheumatoid arthritis is a disabling form of arthritis in which a person’s immune system attacks body tissues, causing pain and disability.

B. Low Back Pain 1. Eighty-five to 90 percent of all Americans will experience low back pain (LBP) at some point.

2. The following factors contribute to LBP and suggest areas for prevention: a. Age b. Body type c. Posture d. Strength and fitness e. Psychological factors f. Occupational risk C. Repetitive Strain/Motion Injuries 1. Repetitive strain/motion disorders include carpal tunnel syndrome, bursitis, tendonitis, ganglion cysts, and others.

2. Twisting of the arm or wrist, overextension, and incorrect posture or position are usually contributors Key Term: arthritis, osteoarthritis (OA), rheumatoid arthritis, low back pain (LBP), carpal tunnel syndrome

Discussion Questions 1. Discuss the differences between a cluster headache and a migraine. How should each be treated?

2. What are some chronic diseases that are easily treatable but, if left untreated, can cause serious secondary problems?

3. What are some of the reasons people get carpal tunnel syndrome? Provide two potential solutions for each reason.

4. Why might a person’s allergies be worse at different times of the year than others?

5. What are the direct and indirect financial impacts on society from low back pain?

Critical Thinking Questions 1. Do you suffer from hay fever? If so, what triggers your hay fever? What do you do to lessen the symptoms? Are these techniques effective?

2. Do you or any of your loved ones have allergies? How do you or they cope?

3. Do you think it’s important to use green cleaning products? Why or why not?

4. What are some effective ways of preventing asthma attacks?

5. What can you do to protect yourself from chronic lung disease? What changes could you make in your habits, dorm room, or living area?

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Student Activities Individual 1. Look up organizations such as Crohn’s and Colitis Foundation of America (http://www.crohnscolitisfoundation.org/) on the Internet to find out what you can do to help raise awareness about these debilitating conditions.

2. Write out your “medical” family tree. Identify any chronic disorders of family members that might put you at a greater risk due to genetic links.

3. Write out a list of five ways you can reduce your risk of developing chronic illness.

Community 1. Find out the rate of chronic respiratory disease in your area. Compare this with the state and national averages. What types of resources (or lack of resources) contribute to these rates? Find out which diseases are most prevalent in your community.

2. What environmental steps have your campus and your community taken to reduce the risk of developing a chronic respiratory disease? What additional steps could be taken on your campus to protect students from environmental factors?

Additional References J. K. Freburger et al., “The Rising Prevalence of Chronic Low Back Pain.” Archives of Internal Medicine, 169, (2009): 251–258.

D. P. Gilkey, T. J. Keefe, J. L. Peel, O. M. Kassab, and C. A. Kennedy, “Risk Factors Associated with Back Pain: A Cross-Sectional Study of 963 College Students.” Journal of Manipulative and Physiological Therapeutics, 33 (2010): 88–95.

E. Hazard, J. Munakata, M. E. Bigal, M. F. T. Rupnow, and R. B. Lipton, “The Burden of Migraine in the United States: Current and Emerging Perspectives on Disease Management and Economic Analysis.” Value in Health, 12 (2008): 55–64.

A. Unlap, E. Dirik, and S. Kurul, “Prevalence and Clinical Findings of Migraine and Tension-type Headache in Adolescents,” Pediatrics International, 49 (2007): 943–949.

H. R. Weiner, “Methicillin-resistant Staphylococcus Aureus on Campus: A New Challenge to College Health.” Journal of American College Health, 56 (2008): 347–350.

For Further Information American Headache Society www.americanheadachesociety.org American Lung Association www.lung.org Crohn’s & Colitis Foundation http://www.crohnscolitisfoundation.org/

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Additional Media Is It a Migraine? (Migraine #1), 3 minutes 6 seconds In this illumistream production, Dr. Stephen Silberstein, Professor of Neurology, provides a historical perspective on migraine headaches, symptoms associated with migraine headaches, and treatment options. www.youtube.com/watch?v=CeWHTM7d_-k&feature=channel Managing Chronic Conditions, 1 minute 12 seconds In this brief educational video, psychologist Dr. Josh Klapow discusses five steps that can be taken to manage any chronic disease. www.youtube.com/watch?v=xFOS9qr0_tA The Basics of Back Pain (Back Pain #1), 3 minutes 41 seconds In this illumistream production, Dr. Vijay Vad discusses the basics of back pain, such as why it is so prevalent, the biology of the back, and natural aging processes that contribute to the epidemic. www.youtube.com/watch?v=sSCZ1yJtges&feature=channel Treating Back Pain (Back Pain #2), 3 minutes 11 seconds In this illumistream video, Dr. Vijay Vad provides tips for short-term relief of back pain. www.youtube.com/watch?v=GyLAKw8j7As&feature=channel

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CHAPTER

Making Smart Health Care Choices

15 Overview

Part of our overall health includes becoming educated consumers of the health care system. Chapter 15 discusses the importance of self-care and discusses when it is most appropriate to look for professional help. After reading this chapter, students will know what to look for when selecting a health care provider, including credentials the provider has, how the provider is funded, and what patients’ rights and responsibilities are. Knowledge about what motivates hospitals and insurance companies will be useful to students when they are faced with making these choices. The chapter also discusses the issues facing today’s health care system.

Learning Objectives 1. Explain why it is important to be a responsible health care consumer, and identify several factors to consider in making health care decisions.

2. Discuss conventional health care, including types of practitioners and the health care products and treatments available.

3. Describe the U.S. health care system in terms of types of insurance, the changing structure of the systems, and issues of cost, quality, and access to services.

4. Explain key issues facing our health care system today and possible actions that could improve the system.

Lecture Outline I. Taking Responsibility for Your Health Care A. Self-Care 1. Self-care consists of knowing your body, paying attention to its signals, and taking appropriate action to stop the progression of illness and injury.

2. Examples of self-care include the following: a. Diagnosis of symptoms or conditions that occur frequently but may not require a physician visit b. Using over-the-counter remedies to treat mild, infrequent, and unambiguous pain and other symptoms c. Performing first aid for common, uncomplicated injuries and conditions 254

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d. Having periodic checks for blood pressure, blood glucose, blood lipids, or other levels as prescribed by a physician e. Scheduling routine and special vaccinations, such as an annual flu vaccine, and an initial vaccination or booster for COVID-19 f. Learning from reliable self-help books, websites, and videos g. Performing meditation and other relaxation techniques h. Maintaining a healthful diet, getting adequate rest, and exercising B. When to Seek Help 1. Generally, you should consult a physician if you experience any of the following: a. A serious accident or injury b. Sudden or severe chest pains, especially if they cause breathing difficulties c. Trauma to the head or spine accompanied by persistent headache, blurred vision, loss of consciousness, vomiting, convulsions, or paralysis d. Sudden high fever or recurring high temperature (over 102 ºF for children and 103 ºF for adults) and/or sweats e. Tingling sensation in the arm accompanied by slurred speech or impaired thought processes f. Adverse reactions to a drug or insect bite (shortness of breath, severe swelling, dizziness) g. Unexplained sudden weight loss h. Persistent or recurrent diarrhea or vomiting i. Blue-tinted lips, eyelids, or nail beds j.

Any lump, swelling, thickness, or sore that does not subside or that grows for over a month k. Any blood in the stool or urine, or significant pain, or marked, persistent change in bowel or bladder habits l. Yellowing of the skin or the whites of the eyes m. Sudden severe pain that has no apparent cause n. Any symptom that is unusual, persists, or recurs over time o. Pregnancy C. Assessing Health Professionals 1. The most satisfied patients are those who feel their health care provider explains diagnosis and treatment options thoroughly and demonstrates competency as well as genuine concern.

2. Consider the following questions when selecting health care providers: a. Do they listen to you, respect you as an individual, and give you time to ask questions? b. What professional educational training have they had, and what are their credentials? c. Are they affiliated with an accredited medical facility or institution? d. Are they open to complementary or integrative strategies?

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e. Do they communicate possible treatment options clearly, the pros and cons of each, and the effectiveness of a given treatment in the short and long term? f. Do they make alternate arrangements for your care when on vacation or off call? g. Are there professional reviews and information on any lawsuits against them available online?

3. Asking the right questions at the right time allows you to work in partnership with your health care provider.

4. Active participation in your treatment is the only sensible course in a health care environment that encourages defensive medicine. a. Providers may take certain actions primarily to avoid a malpractice claim, but these actions don’t necessarily help the patient.

D. Your Rights as a Patient 1. The right of informed consent means that before receiving any care, you should be fully informed of what is planned, including the risks and potential benefits, and possible alternative forms of treatment.

2. You are entitled to know whether the treatment you are receiving is standard or experimental.

3.

4.

5.

6.

7.

a. You have the right to know if the study is one in which some people receive a placebo.

You have the right to make decisions regarding the health care that is recommended by the physician.

You have the right to confidentiality, which includes the source of payment for treatment and care.

You have the right to receive adequate health care, as well as to refuse treatment at any time.

You are entitled to have access to all of your medical records and to have those records remain confidential.

You have the right to continuity of health care.

8. You have the right to seek the opinions of other health care professionals regarding your condition.

9. You have the right to courtesy, respect, dignity, responsiveness, and timely attention to health needs.

Key Terms: malpractice, informed consent, placebo II. Conventional Health Care A. Overview 1. Allopathic medicine is traditional Western medical practice, generally believed to be based on scientifically validated methods and procedures. a. Recommended treatments may change dramatically as new technologies and medical advances replace older practices.

2. One way health care providers ensure the quality of care they provide is by practicing evidence-based medicine.

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a. Decisions regarding patient care are based on clinical expertise, patient values, and current best scientific evidence.

B. Conventional Health Care Practitioners 1. Selecting a primary care practitioner, a physician you can visit for routine ailments, preventative care, general medical advice, and referrals is not an easy task.

2. Medical doctors (MDs) undergo rigorous training before they can begin practicing. a. Four years of undergraduate work, 4 years of medical school, and up to 8 years of additional training depending on the specialty.

3. Osteopaths (DOs) are general practitioners who receive training similar to that of medical doctors but who place special emphasis on the skeletal and muscular systems.

4. Eye care specialists can be either ophthalmologists or optometrists. a. An ophthalmologist holds a medical degree and can perform surgery and prescribe medications. b. An optometrist evaluates visual problems and prescribes glasses but is not a trained physician. c. If you have an eye infection or some other eye condition requiring diagnosis and treatment, you need to see an ophthalmologist.

5. Dentists diagnose and treat diseases of the teeth, gums, and oral cavity. They can receive a doctor of medical dentistry (DMD) or a doctor of dental surgery (DDS).

6. Dental specialists include orthodontists, periodontists, and oral surgeons. a. Nurses are highly trained and strictly regulated health professionals who provide a wide range of services for patients and their families.

7. Registered nurses (RNs) have a higher level of education or certification.

Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) complete a one- or two-year training program. a. Nurse practitioners (NPs) are nurses with advanced training through either a master’s degree program or a specialized nurse practitioner program.

8. They have the authority to conduct diagnostic tests and prescribe medications (in some states). a. Physician assistants (PAs) are licensed to examine and diagnose patients, offer treatment, and write prescriptions under a physician’s supervision.

C. Conventional Medication 1. Prescription Drugs a. In about three-fourths of doctor visits, the physician administers or prescribes at least one medication. b. Consumers have a variety of resources available to determine the risks of various prescription medicines and can make educated decisions about whether to take a certain drug.

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i.

The Food and Drug Administration’s Center for Drug Evaluation and Research website provides current information for consumers about the risks and benefits of prescription drugs.

c. Generic drugs are medications sold under a chemical name rather than a brand name and contain the same active ingredient as brand-name drugs but at lower cost. i.

Always note any reactions you have to medications and tell your doctor about them.

2. Over-the-Counter Drugs a. Over-the-counter drugs (OTCs) are medications available without a prescription. b. The most commonly used OTCs are pain relievers, medications for cough, cold, and allergy symptoms, stimulants, sleeping aids and relaxants, and dieting aids. c. Indiscriminate use and abuse of OTC drugs can occur if they are not taken properly. i. See Figure 15.1 for information about how to read the over-the-counter medicine label.

Key Terms: allopathic medicine, evidence-based medicine, primary care practitioner (PCP), osteopath, ophthalmologist, optometrist, dentist, nurse, nurse practitioner (NP), physician assistant (PA), generic drugs Figure: Figure 15.1 Over-the-Counter Medicine Label ABC News: See It! Video: Real Money: Saving Big on Dental Bills III. Health Insurance A. Overview 1. When you seek medical care from your physician or specialist or are preparing for a hospital visit, you will most likely be using some form of health insurance to pay for your care.

2. The fundamental principle of insurance underwriting is that the cost of health care can be predicted for large populations. a. This is how health care premiums are determined, where holders pay into a pool from which companies pay claims. b. Health insurance is based on the idea that policyholders pay affordable premiums so that they never have to face catastrophic bills.

B. Private Health Insurance 1. Health insurance originally consisted of hospital coverage only, called major medical.

2. It was gradually extended to cover routine physicians’ treatment and other areas such as dental services, vision care, and pharmaceuticals.

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3. This system provided no incentive to contain costs, limit the number of procedures, or curtail capital investment in redundant equipment or facilities.

4. Private insurance companies have employed several mechanisms to control consumer use of insurance and limit potential losses, including the following: a. Deductibles i.

Payments you make for health care services before insurance coverage kicks in.

b. Co-payments i. The set amounts that you pay per service received, regardless of the cost of the service. c. Coinsurance i.

The percentage of the bill that you must pay throughout the course of treatment.

d. Waiting period before coverage commences e. Limits on the types of covered services f. Preexisting condition clauses i. The Patient Protection and Affordable Care Act (ACA) forbids discrimination based on a preexisting condition. g. Annual upper limit or lifetime limit after which coverage would end. i. The ACA makes this practice illegal.

C. Managed Care 1. Managed care describes a health care delivery system consisting of three elements: a. A network of physicians, hospitals, and other providers and facilities linked contractually to deliver health benefits within a predetermined budget. b. A budget based on an estimate of the annual cost of delivering health care for a given population. c. An established set of administrative rules regarding how services are to be obtained from participating health care providers under the terms of the health plan 2. Types of managed care plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS).

3. Many managed care plans pay their contracted health care providers through capitation, a fixed amount paid for each enrolled patient without regard for the type or number of services provided. a. Doctors are motivated to keep their patient pool healthy and avoid preventable catastrophic ailments.

4. Health Maintenance Organizations a. HMOs provide a wide range of covered health benefits for a fixed amount prepaid by the patient, employer, Medicare, or Medicaid. b. There are low or no deductibles or coinsurance, but patients are required to use the plan’s doctors and hospitals.

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c. The plan’s PCP serves as a gatekeeper, coordinating care and providing referrals.

5. Preferred Provider Organization a. PPOs are networks of independent doctors and hospitals that contract to provide care at discounted rates. b. Patients have more choice of providers but they are less likely to coordinate a patient’s care.

6. Point of Service a. POS is a hybrid of the HMO and PPO plans—members select an in-network PCP, but they can go to nonnetwork providers for care without a referral and must pay the extra cost.

7. Other Types of Managed Care a. Independent practice associations (IPAs) are composed of independent physicians who maintain their own offices, but also agree to enroll members of an organization for a negotiated fee for each assigned patient, or a negotiated fee-for-service basis. b. Exclusive provider organizations (EPOs) are a type of managed health care organization in which no coverage is typically provided for services received outside the EPO. D. Government-Funded Programs 1. The federal government, through programs like Medicare and Medicaid, currently funds about 45 percent of U.S. health care spending.

2. Medicare a. Medicare is a federal insurance program that employees and employers pay into over the course of a person’s working life, a form of long-term savings plan for health insurance and care rather than an “entitlement” program. b. The funds are used to cover a broad range of services, except long-term care. c. As medical costs have risen, Medicare has placed limits on the amount of reimbursement to providers. d. Medicare currently is divided into two parts: Part A and Part B e. Part A is the hospital insurance portion and helps pay for care while in the hospital, skilled nursing facilities, hospice care, and some health care. f.

Part B covers services and supplies needed to diagnose and treat you and the preventative exams and services recommended based on your age and symptoms. i. Part B requires a monthly payment and covers most of one’s care as long as his or her provider or facility “accepts assignment”—meaning it agrees to only charge what Medicare says it should charge and will pay for.

g. Diagnosis-related groups (DRGs) were set up to control hospital costs for Medicare. i. DRGs are based on the assumption that people with similar health status and conditions require a similar amount of hospital resources.

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3. Medicare Supplemental Plans a. If providers charge more than Medicare allows, either the patient or a supplement/Medigap plan must make up for the differences. b. Advantage plans are private plans (often called Medicare Part C) that contract with Medicare, which funds their coverage of Medicare Part A and B. c. Original Medicare typically covers only minimal drugs, making the purchase of an additional drug plan (Part D) necessary.

4. Medicaid a. Medicaid is a federal–state matching funds welfare program that provides health insurance for people who are defined as low-income, including many who are pregnant women, blind, disabled, and elderly. b. The Children’s Health Insurance Program provides health insurance coverage to more than 8 million uninsured children.

5. Insurance Coverage by the Numbers a. In 2020, the average family’s annual health insurance premium was more than $21,000. b. More than 28 million Americans are uninsured. c. A lack of health insurance has been associated with delayed health care and increased mortality. d. Underinsurance is not having the ability to pay out-of-pocket expenses despite having health insurance; it may also result in adverse health consequences. e. People without health care coverage are less likely to have their children immunized, seek early prenatal care, obtain annual blood pressure checks, or seek attention for symptoms of health problems. f. Foregoing preventative care because of cost, causes people to rely on more expensive emergency care at later stages of illness.

Key Terms: premium, managed care, capitation, Medicare, Medicaid IV. Issues Facing Today’s Health Care System •

The ACA was enacted in 2010 for the purpose of increasing access to care, addressing the high cost of care, and improving the overall quality of care.

A. Access to Providers, Facilities, and Treatments 1. Access to care is determined by many factors including supply the of providers and facilities in the area and availability of insurance coverage.

2. Managed care health plans determine access on the basis of participating providers, health plan benefits, and administrator rules.

3. The ACA and other government investments have helped to train many new health care providers, as well as encouraged primary care providers to set up their practices in high-need areas.

B. Access to Quality Health Insurance

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1. Key provisions in the ACA aim to increase access to quality health insurance among Americans. They include the following: a. Insurers are now required to cover preventive services. b. Insurers are required to cover young adults on a parent’s plan through age 26. c. Coverage for prescription medications, including psychotropic medications, is required. d. Americans with preexisting conditions cannot be denied coverage. e. No annual and lifetime limits on benefits are allowed. f. An online insurance marketplace helps consumers shop for and enroll in plans as well as apply for federal subsidies that lower the cost of premiums for many Americans. g. An online insurance marketplace helps consumers shop for and enroll in plans as well as apply for federal subsidies that lower the cost of premiums for many Americans. Under the American Rescue Plan Act of March 2021, these subsidies increased. In addition, before passage, eligibility for subsidies had ended for anyone with an income at or above 400 percent of the federal poverty level. The American Rescue Plan removed this so-called “subsidy cliff,” making more middle-income Americans eligible for subsidized coverage in the online marketplace. h. Small businesses now qualify for special tax credits to help fund insurance plans.

2. Employees who change jobs have the option of continuing their insurance for up to eighteen months at group rates under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

3. One group that has been left behind, however, are immigrants who lack documentation of their right to remain in the United States. Many are families with children who were born in the United States and are therefore citizens. Undocumented immigrants are not eligible for Medicaid, Medicare, CHIP, or insurance in the ACA marketplace; moreover, they are more likely to work in low-wage industries that do not offer employer-sponsored coverage.

A. Cost 1. Americans spend more on health care than any other nation.

2. Many factors contribute to the rising cost of health care: a. Duplication of services b. An aging population c. Growing rates of obesity d. Inactivity and related health problems e. Demand for new diagnostic and treatment technologies f. An emphasis on crisis-oriented care instead of prevention g. Physician overtreatment h. Inappropriate use of services 3. Our system has more than 2,000 health insurance companies, each with different coverage structures and administrative requirements. a. This system prevents the achievement of economies of scale and administrative efficiency found in a single-payer delivery system.

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b. See Figure 15.3 for a breakdown of how health care dollars are spent.

B. Quality 1. In the United States, health care providers are assessed according to education, licensure, certification/registration, accreditation, peer review, and the legal system of malpractice litigation.

2. Although our health care spending far exceeds any other nation, we rank far below many nations in key indicators of quality.

Figures: Figure 15.2 Health Care Spending per Person, 2018 (in thousands of U.S. dollars) Figure 15.3 Where Do We Spend Our Health Care Dollars?

Discussion Questions 1. Based on your thoughts and using the chapter as a guide, list four questions that you think a person should ask when looking into the qualifications of a nonallopathic practitioner.

2. List three reasons that delay an individual from seeking help until a disease is too far progressed.

3. Describe the difference between the need for self-care versus medical care.

4. What types of things do you look for when you choose a physician? Is your list consistent with the study results cited in the text? What are the differences? Explain.

5. Discuss the advantages and disadvantages of belonging to an HMO.

Critical Thinking Questions 1. List the over-the-counter drugs that you take or use regularly. Now read the labels for these drugs. Do you use these drugs properly? Do you misuse or abuse these drugs?

How do you know? Explain your answer.

2. Do you think that extending Medicare coverage to people younger than 65 is a good solution to providing health insurance to the uninsured in America? Why or why not?

3. What are the strengths of a single-payer plan? Weaknesses? How do you think the media have shaped these views?

4. What do you think about the options that have been made available to people since enacting health care reform? What are the strengths and weaknesses of the ACA? How could it be improved?

5. Have you ever consulted a medical website instead of visiting a health care professional? Why? What was your experience? What types of illnesses or health concerns are suited for website consultation, and what types of health concerns are not well suited to such consultation?

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7. Describe how managed care aims to reduce the rising costs of health care. What are the negative and positive consequences of this approach? What other options are available to reduce these ever-rising costs?

8. Many pharmaceutical companies advertise prescription drugs on television. The advertisements often include warnings for possible side effects. Do you think the American consumer is knowledgeable enough to weigh the benefits and potential dangers of these medicines? What impact do you think these advertisements have on the overall rising costs of health care?

Student Activities Individual 1. There are many ways of treating the same problem without the use of drugs. Go to the National Center for Complementary and Alternative Medicine website (http://nccam.nih.gov) and find alternative methods of treating muscle pain, arthritis, constipation, and stress. List the possible alternative solutions for each.

2. Is individual health care available to you as a student on your campus? If so, what kind of coverage is provided? What is the cost? If not, is there anything you can do to help make health insurance coverage available on your campus?

Community 1. What types of health care services are offered by your student health center? Do they treat only people affiliated with the college? What complementary and alternative medicine services does the student health center offer? Are they available to all students?

2. Ask five of your friends what they think should be done to improve the health care system in the United States. Compare and contrast their answers.

Diverse Population/Nontraditional 1. What do you know about health care coverage in other cultures? Compare and contrast it with coverage in the United States.

2. Countries such as Canada and Great Britain provide universal health care to their citizens. Look up the benefits and costs of these health care programs. Do you think such a program should be made available to American citizens?

3. Look up health product advertisements in magazines from 30 years ago. Compare and contrast these advertisements with those of today.

4. Look up the costs of hospital procedures such as human heart surgery in countries such as India and Thailand. Compare the quality of care and the costs of those procedures with the same procedures in the United States. Given a choice, where would you have these procedures done if you needed them?

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Additional References A. Birenbaum, Wounded Profession: American Medicine Enters the Age of Managed Care (Westport, Connecticut: Praeger Publishers, 2002).

J. Geyman, Health Care in America: Can an Ailing System Be Healed? (London, England: Butterworth-Heinemann, 2001).

H. W. Griffith and S. Moore, Complete Guide to Prescription and Nonprescription Drugs 2010 (New York: Perigree Trade, 2009).

G. Halvorsen, Health Care Will Not Reform Itself: A User’s Guide to Refocusing and Reforming American Health Care (New York: Productivity Press, 2009).

I. Kawachi and B. Kennedy, The Health of Nations: Why Inequality Is Harmful to Your Health (New York: New Press, 2006).

L. Klosterman, The Facts about Over-the-Counter Drugs (New York: Benchmark Books, 2006).

P. Lee and C. Estes, The Nation’s Health, 7th ed. (Sudbury, MA: Jones and Bartlett, 2003).

T. R. Reid, The Healing of America: The Global Quest for Better, Cheaper, and Fairer Health Care (New York: The Penguin Press, 2009).

P. D. R. Thompson, The PDR Pocket Guide to Prescription Drugs (New York: Pocket Books, 2007).

For Further Information Agency for Healthcare Research and Quality www.ahrq.gov U.S. Food and Drug Administration (FDA) www.fda.gov Health Grades www.healthgrades.com HealthCare.gov www.healthcare.gov National Committee for Quality Assurance www.ncqa.org National Library of Medicine www.nlm.nih.gov The Leapfrog Group www.leapfroggroup.org

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Additional Media Who Lives Who Dies: Rationing Health Care, 58 minutes The documentary shows how our health care system is failing a large part of the population.

Filmmakers Library 124 40th Street, Suite 901 New York, NY 10016 Healthwise Video This video describes medical self-care practices.

Healthwise, Inc. P.O. Box 1989 Boise, ID 83701

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CHAPTER

15A

Focus On: Understanding Complementary and Integrative Health

Overview Complementary health approaches have been practiced around the world for centuries.

In recent decades, they have been gaining in popularity in the United States. In Chapter 15A, approaches to self-care and health promotion that encourage the use of complementary health therapies will be explored. This chapter describes various complementary health approaches, providing evidence concerning their effectiveness and their benefits to health. Students will learn about complementary medical systems, mind and body practices, and natural products and will be given tips on how to evaluate each.

Learning Objectives 1. Distinguish between complementary health approaches, alternative health approaches, and integrative health care.

2. Describe four complementary medical systems practiced in the United States.

3. Discuss several psychological and physical approaches to healing, including manipulative therapies, movement and relaxation therapies, and energy therapies.

4. Explain why caution is particularly important when using nutritional approaches to healing.

Lecture Outline I. What Art Complementary, Alternative, and Integrative Health Approaches?

A. Complementary health approaches are non-mainstream practices and products that are used together with conventional medicine.

B. Alternative health approaches are used in place of conventional medicine.

C. When those who practice conventional health care incorporate complementary therapies in a coordinated, purposeful way it is known as integrative medicine.

1. Many people who incorporate these therapies seek a holistic approach to medicine that focuses on the mind and whole body rather than just an isolated symptom or body part.

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D. Before you consider using any kind of complementary therapy, visit the website of the NCCIH, a division of the National Institutes of Health (NIH).

E. NCCIH groups complementary health approaches into three general categories of practice.

1. Natural products 2. Mind and body practices 3. Other complementary health approaches (complementary medical systems) Key Terms: complementary health approaches, alternative health approaches, integrative medicine, holistic Figure: Figure 1 The Ten Most Common Complementary Therapies among U.S. Adults II. Complementary Medical Systems A. Complementary medical systems reflect specific theories of physiology, health, and disease that have developed outside the influence of conventional medicine.

B. Traditional Chinese Medicine 1. Traditional Chinese medicine (TCM) emphasizes the proper balance or disturbances of qi, or vital energy. An imbalance of qi results in disease.

2. Diagnosis is based on personal history, observation of the body (especially the tongue), palpitation, and pulse diagnosis.

3. Approaches include acupuncture, herbal medicine, massage, and qigong.

4. Practitioners must complete a graduate program, a clinical internship, and a certification and licensing exam.

C. Ayurveda 1. Ayurveda (Ayurvedic medicine) is an alternative medical system that evolved over thousands of years in India.

2. It seeks to integrate and balance the body, mind, and spirit and to restore harmony in the individual.

3. Techniques include questioning, observing, and pulse palpitation to determine which of three vital energies, or doshas, is dominant in the patient.

4. The goal is to bring the doshas into balance to reduce symptoms.

5. Treatments include dietary modification, herbal remedies, yoga, meditation, massage, steam baths, changes in sleep patterns and sun exposure, and controlled breathing.

6. Practitioner training varies and there is no national certification.

D. Homeopathy 1. Homeopathy (homeopathic medicine) is an unconventional Western system that is based on the principle that “like cures like.” Substances that cause symptoms of an illness in large doses can cure the illness in small doses.

2. Practitioner training varies from diploma programs to correspondence courses.

Licensing requirements vary by state.

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E. Naturopathy 1. Naturopathy (naturopathic medicine) emphasizes the power of nature to restore health.

2. Naturopathic physicians view their role as supporting the body’s innate ability to maintain and restore health, typically by identifying and removing obstacles to these innate processes.

3. Approaches to care include diet; dietary supplements; homeopathy; spine and soft-tissue manipulation; detoxification using fasting, juice, diets, colon cleansing, or other means; and therapeutic counseling.

4. Several major schools confer a naturopathic doctor (ND) degree on students who have completed a 4-year graduate program.

Key Terms: complementary medical systems, traditional Chinese medicine (TCM), Ayurveda (Ayurvedic medicine), homeopathy (homeopathic medicine), naturopathy (naturopathic medicine) III. Psychological and Physical Approaches •

Mind and body practices are a large and diverse group of complementary health approaches administered or taught by a trained practitioner or teacher.

A. Manipulative Therapies 1. Chiropractic medicine focuses on disorders of the muscular and skeletal system and the use of various modalities to reduce health effects from these disorders. a. It is based on the idea that a life-giving energy flows through the nervous system, including the spinal cord. b. If the spinal cord is misaligned or dislocated, that force is disrupted. c. Chiropractors use a variety of techniques to manipulate the spine into proper alignment. d. The average chiropractic training program includes intensive courses, and the practice is licensed and regulated in all fifty states.

2. Massage therapy is defined as soft-tissue manipulation by trained therapists for relaxation and healing. a. Therapists manipulate muscles and connective tissue to loosen the fibers and break up adhesions, improve the body’s circulation, and remove waste products. b. Research shows that it is effective in relieving musculoskeletal pain, and it may help to promote relaxation and relieve depression. c. Many states require at least 500 hours of training and a passing grade on a national certification exam before licensing.

B. Movement and Relaxation Therapies 1. A broad range of Eastern and Western complementary health approaches use movement to promote physical, mental, emotional, and spiritual well-being. a. Alexander Technique—movement education method designed to release harmful tension in the body to improve ease of movement, balance, and coordination

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b. Feldenkrais Method—a system of gentle movements and exercises C. Energy Therapies 1. Energy medicine therapies focus either on energy fields originating with the body (biofields) or on fields from other sources (electromagnetic fields).

2. Acupuncture a. In acupuncture, the therapist stimulates various points on the body with a series of precisely placed needles. b. The stimulation of these acupuncture points is thought to increase the flow of qi through the meridians, or energy pathways, in the body. c. Acupuncturists in the United States are state licensed, and each state has specific requirements regarding training programs.

3. Acupressure a. Acupressure is based on the same principles of energy flow as acupuncture but does not use needles; the practitioner applies pressure to critical points.

4. Other Forms of Energy Therapy a. Qigong brings together movement, meditation, and regulation of breathing to increase the flow of qi, enhance blood circulation, and improve immune function. b. Reiki is a non-touch form of energy therapy that is based on the belief that by channeling ki to the patient, the practitioner facilitates healing. c. Two other non-touch energy therapies are therapeutic touch and healing touch in which the therapist attempts to perceive, through his or her hands held just above the body, imbalances in the patient’s energy. i.

The therapist promotes healing by increasing the flow of the body’s energies and bringing them into balance.

Key Terms: manipulative therapies, chiropractic medicine, massage therapy, energy therapies, acupuncture, acupressure ABC News: See It! Video: Acupuncture Wonders IV. Natural Approaches A. Natural products are perhaps the most controversial category of complementary health approaches because of the number of products available, the number of claims that have been made about their effects, and their lax regulation B. The U.S. Food and Drug Administration has not developed a definition for the term natural and cautions consumers to avoid assuming that any food or dietary supplement claiming to be “natural” is safe.

C. When buying a dietary supplement look for the United States Pharmacopeia (USP) mark on the label, which means that what it says on the bottle is in the bottle, that the supplement doesn’t contain unsafe levels of contaminants, and that the product was created through well-controlled, sanitary manufacturing processes.

D. The NCCIH “Alerts and Advisories” web page releases notifications of natural products that are contaminated or contain hidden drug ingredients.

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E. Individuals must take an active role in their health care, which means staying educated.

F. Table 1 provides an overview of some of the common dietary supplements on the market.

Table: Table 1 Common Dietary Supplements: Benefits, Research, and Risks

Discussion Questions 1. What types of questions should a person ask when investigating the qualifications of a nonallopathic practitioner?

2. Compare and contrast the theory underlying acupuncture, in particular, and Chinese medicine, in general.

3. What are some of the potential risks and benefits of complementary health approaches? Why are complementary health therapies growing in popularity?

4. What can you do to ensure you are receiving accurate information regarding complementary health treatments or therapies?

Critical Thinking Questions 1. Have you ever taken advantage of any form of complementary health therapy? What was your experience? Did you have positive or negative results? Have any of your friends or family members used complementary health approaches? What were their results? How did their results compare with your results and experiences?

2. What functional foods do you currently incorporate into your daily diet? Have you noticed any benefits from eating these foods? What additional incorporations can you make? What will be the anticipated benefit to your health?

3. Have you or anyone you know ever used any of the common dietary supplements listed in Table 1? What benefits did you experience from taking the supplement? Did you experience any negative side effects from taking the supplement?

4. Do you think more health insurance companies should cover complementary health approaches? Why or why not?

5. Why do you think the terms natural and safe are not synonymous when referring to herbal supplements?

6. Do you think more should be done to regulate “natural” products, or that “natural” should be given a universal definition as it relates to things like supplements and other “natural” products? Why or why not?

7. Do you think the mind can affect bodily functions, symptoms, and overall health?

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Student Activities Individual 1. Make an appointment with a practitioner of homeopathy or naturopathy in your community. Explain that you are a student and would like to interview him or her about the principles of his or her medical practice. Write a brief summary of your interview. How does this form of alternative medicine compare with what you know about traditional Western medical practices?

2. Make an appointment to have a massage. How did you feel after the massage compared with how you felt before the massage?

3. Schedule an appointment with an energy worker. How did you feel after the work was done as compared with how you felt before you arrived? What, if any, were the lasting benefits?

Community 1. Is a massage therapy program of courses offered on your campus? If so, what kinds of classes are included in the program? What is the length of the program? If no program is offered on your campus, is a program offered in your community?

2. Assess complementary health providers in your community. What kinds of treatments are available? Which practitioners use reputable products and services?

3. Write to congressional leaders to support insurance provisions that allow consumers to choose complementary health approaches that are scientifically proved to be safe and effective.

Diverse Population/Nontraditional 1. Use the Internet to research traditional medical practices of Native American, Aboriginal, African, Middle Eastern, and South American cultures. How do these traditional practices compare with today’s scientific medical practices?

2. Research the history of acupuncture. Where was acupuncture first used? How long ago?

3. Acupuncture is now often offered as part of veterinary medicine. Is there a veterinary practice in your community that offers acupuncture? What kinds of services are provided? For what kinds of ailments is acupuncture used for pets? What is the cost of acupuncture compared to traditional medical treatments?

Additional References R. L. Nahin, P. M. Barnes, B. J. Stussman, and B. Bloom, “Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007.” National Health Statistics Report, 18 (2009): 1–14.

J. Rayner, H. L. McLachlan, D. A. Forster, and R. Cramer, “Australian Women’s Use of Complementary and Alternative Medicines to Enhance Fertility: Exploring the Experiences of Women and Practitioners.” BMC Complementary and Alternative Medicine, 9 (2009): 52–62.

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C. Wang, C. H. Schmid, R. Rones, R. Kalish, J. Yinh, D. Goldenberg, Y. Lee, and T. McAlindon, “A Randomized Trial of Tai Chi for Fibromyalgia.” The New England Journal of Medicine, 363 (2010): 743–754.

G. Wyatt, A. Sikorskii, C. E. Wills, and H. A. Su, “Complementary and Alternative Medicine Use, Spending, and Quality of Life in Early Stage Breast Cancer.” Nursing Research, 59 (2010): 58–66.

K. Yang, L. M. Bernardo, S. M. Sereika, M. Conroy, J. Balk, and L. Burke, “Utilization of a 3-month Yoga Program for Adults at High Risk for Type 2 Diabetes: A Pilot Study.” Evidence-based Complementary and Alternative Medicine (2009): Article ID 257891, doi:10.1093/ecam/nep117.

For Further Information American Academy of Medical Acupuncture http://medicalacupuncture.org American Association of Naturopathic Physicians www.naturopathic.org American Massage Therapy Association www.amtamassage.org/index.html American Herbal Products Association www.ahpa.org U.S. Food and Drug Administration www.fda.gov North American Society of Homeopaths www.homeopathy.org

Additional Media Naturopathy vs. Homeopathy, 3 minutes 4 seconds In this ihealthtube video, Naturopathic Doctor Todd Ferguson distinguishes naturopathy from homeopathy. www.youtube.com/watch?v=yMWhaLDR2hU

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CHAPTER

15B

Focus On: Aging, Death, and Dying

Overview The issues associated with aging are increasingly important as more and more people live past the age of 65. Chapter 15B outlines theories on aging and discusses many of the changes that occur as we age. The chapter’s emphasis on prevention of many of the health problems, and a slowing of the aging process through long-term lifestyle choices, will prepare the student for a long and healthy life. To age healthfully and successfully, people need something to do, someone who cares about them, money to live on, and a place to live. Spending the time now to ensure that these things are in place when we are older is of vital importance.

The second part of Chapter 15B examines the end stage of the life cycle. We all eventually lose something or someone of great importance to us. Knowing the stages of dying will help us to understand what our loved ones are going through when they find out they are going to die. Grieving is a normal process we go through on our way to recovery from loss. It also is important for the student to know all of the legal consequences of living wills, regular wills, and not having a will. The loss of someone important to us will go more smoothly if we understand what is happening.

Learning Objectives 1. Define aging, describe the physical and mental changes associated with aging, and explain how the growing population of older adults will affect society, including considerations of economics, health care, and living arrangements.

2. List strategies for successful and healthy aging.

3. Define death, and discuss strategies for coping with loss.

4. Explain the ethical concerns that arise from the concepts of the right to die and rational suicide.

5. Review the decisions that need to be made when someone is dying or has died, including hospice care, funeral arrangements, wills, and organ donation.

Lecture Outline I. Aging •

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Aging has traditionally been described as the patterns of life changes that occur in all members of a species as they grow older. ..

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Gerontology is the study of individual and collective aging processes that explores the reasons for aging and the ways in which people cope with and adapt to this process.

A. Older Adults: A Growing Population 1. The United States and much of the developed world are on the brink of a longevity revolution that will have many effects on society. a. The life expectancy of a child born in 2016 is more than 30 years longer than for a child born in 1900.

B. Health Issues for an Aging Society 1. Health Care Costs a. Older Americans averaged $5,756 per year in out-of-pocket medical expenses in 2016, an increase of 37 percent since 2005. b. Most older adults have at least one chronic condition.

2. Housing and Living Arrangements a. Most older adults never live in a nursing home. b. An increasing number, though, do opt for some type of assisted living. c. There are many options for care during your later years, but they come at a cost. Tremendous income-based disparities exist in caring for the elderly; those without means are more likely to be shut out of all but the most meager care situations.

C. Physical and Mental Changes of Aging 1. Although the physiological consequences of aging can differ in severity and timing, certain standard changes occur as a result of the aging process.

2. The Skin a. The skin becomes thinner and loses elasticity; fat deposits under skin tend to diminish. b. Age spots become more numerous.

3. Bones and Joints a. By the third or fourth decade of life, mineral loss from bones becomes more prevalent, resulting in diminished density of bone tissue. b. Osteoporosis is a disease characterized by low bone density and structural deterioration of bone tissue. c. Osteoarthritis is the progressive breakdown of joint cartilage that becomes more common with age and is a major cause of disability in the United States.

4. The Urinary Tract a. For most, the thirties and forties bring about a gradual decrease in the size and weight of the kidneys, effectively reducing blood filtering and other functions. b. Some changes, including hormonal changes in women, may lead to urinary incontinence, which can cause major social, physical, and emotional problems.

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i.

Most cases are caused by persistent infections, medications, treatable neurological problems that affect the central nervous system, weakness in the pelvic floor, or other problems. With treatment, incontinence is usually resolved.

5. The Senses a. With aging, the senses (vision, hearing, touch, taste, and smell) become less acute. i. Eyesight worsens, and cataracts (clouding of the lens) and glaucoma (elevated pressure within the eyeball) become more likely. ii. Macular degeneration is the breakdown of the light-sensitive part of the retina, and its effects can be devastating. b. Presbycusis, or age-related hearing loss, is one of the most common conditions of the elderly. c. Ear structure also changes with age. i. Changes in the inner ear can affect balance. ii. Can be difficult to maintain balance. iii. The ability to hear high-frequency consonants also diminishes.

6. Sexual Function a. As people age, they experience noticeable changes in sexual function. b. Sexual changes in men include the following: i. Slowed ability to obtain an erection ii. Diminished ability to maintain an erection iii. Decline in the angle of the erection iv. Longer refractory period between orgasms v. Shortened duration of orgasm c. Sexual changes in women include the following: i. Hormonal changes occur with the onset of menopause. ii. The walls of the vagina become less elastic. iii. Vaginal secretions diminish. iv. The breasts become less firm, and body contours change. d. Sex remains an essential part of the lives of those in their mid-fifties and older, and many people remain sexually active throughout their entire adult lives.

7. Mental Function and Memory a. Dementias and Alzheimer’s disease i. The term dementia is used to describe either reversible symptoms or progressive forms of brain malfunctioning. ii. One of the most common forms of dementia is Alzheimer’s disease (AD). (i) Alzheimer’s is a degenerative illness in which areas of the brain develop “tangles” that impair the way nerve cells communicate with one another, eventually causing them to die.

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(ii) The disease progresses in stages, each of which is marked by increasingly impaired memory and judgment. (iii) Possible causes include genetic predisposition, malfunction of the immune system, a slow-acting virus, chromosomal or genetic defects, chronic inflammation, uncontrolled hypertension, and neurotransmitter imbalance. (iv) There is no treatment that can stop the progression, but some medications can prevent some symptoms from progressing for a short period.

Key Terms: aging, gerontology, osteoporosis, urinary incontinence, cataracts, glaucoma, macular degeneration, dementia, Alzheimer’s disease (AD) Figures: Figure 1 Number of Americans 65 and Older (in millions), Years 1900–2008, and Projected 2010–2050 Figure 2 Living Arrangements of Americans Age 65 and Older Figure 3 Normal Effects of Aging on the Body II. Strategies for Healthy Aging A. Improve Fitness 1. Just about any moderate-intensity exercise that gets your heart beating faster and increases strength and/or flexibility will maximize your physical health and functional years.

2. Both aerobic and muscle-strengthening activities are critical for healthy aging.

3. See Table 1 for a list of basic recommendations for exercise among older adults.

4. Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account.

B. Eat for Longevity 1. As one ages, there exists a greater need for the following nutrients.

2. Calcium a. Adequate consumption of calcium throughout one’s life can help prevent bone loss.

3. Vitamin D a. Necessary for adequate calcium absorption 4. Protein a. Necessary to help maintain muscle mass 5. Other nutrients including vitamin E, folic acid, iron, potassium, and vitamin B12 are important to the aging process.

C. Develop and Maintain Healthy Relationships

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1. Social bonds lend vigor and energy to life.

D. Enrich the Spiritual Side of Life 1. Cultivating a relationship with nature, the environment, a higher being, and yourself is a key factor in personal growth.

Table: Table 1 Exercise Recommendations for Adults over Age 65 III. Understanding the Final Transitions: Dying and Death A. Defining Death 1. Death can be defined as “a permanent cessation of vital functions: the end of life.”

2. The legal and ethical issues surrounding death, especially in cases where life is prolonged through medical advancements, led to the Uniform Determination of Death Act, which is the law in several states.

3. Brain death is defined as the irreversible cessation of all functions of the entire brainstem and occurs when the following criteria are met: a. Unreceptivity and unresponsiveness b. No movement for a continuous hour and no breathing after three minutes off a respirator c. No reflexes, including brainstem reflexes; fixed and dilated pupils d. A “flat” electroencephalogram e. All of these tests repeated at least twenty-four hours later with no change f. Certainty that conditions are not caused by drugs or hypothermia B. The Process of Dying 1. Dying is the process of decline in body functions that results in the death of an organism.

2. Thanatology is the study of death and dying.

3. Kübler-Ross and the Stages of Dying a. Elizabeth Kübler-Ross was a pioneer in thanatology, the study of death and dying. b. Her pioneering work encouraged the development of death education as a discipline. c. Kübler-Ross identified five psychological stages (see Figure 4) that people coping with death experience: i. Denial (“Not me, there must be a mistake.”) ii. Anger (“Why me?”) iii. Bargaining (“If I’m allowed to live, I promise . . . ”) iv. Depression (“It’s really going to happen to me, and I can’t do anything about it.”) v. Acceptance (“I’m ready.”)

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d. Although subsequent research shows that the experience of people dying does not fit easily into the specific stages, Kübler-Ross’s theory still offers valuable insight for those seeking to understand or deal with the process of dying.

4. Social Death a. Social death is a situation in which a person is not treated like an active member of society. b. A decrease in meaningful social interaction often strips dying and bereaved people of their identity as valued members of society.

C. Coping with Loss 1. Coping with the loss of a loved one is extremely difficult.

2. Bereavement is generally defined as the loss or deprivation that a survivor experiences when a loved one dies.

3. Survivors may experience a “hole” left by the loved one and inevitable changes.

4. Grief occurs in reaction to significant loss, including one’s own impending death, the death of a loved one, or a quasi-death experience.

5. May be experienced as a mental, physical, social, or emotional reaction 6. Disenfranchised grief occurs when a person experiences a loss that cannot be openly acknowledged, publicly mourned, or socially supported.

7. Because of the contagion risk to family and friends, many COVID-19 victims died without family in attendance and without an in-person funeral service. a. COVID-19 was a uniquely swift, widespread, and traumatic bereavement for millions of Americans.

8. Symptoms of grief vary in severity and duration depending on the situation and the individual.

9. Mourning refers to culturally prescribed and accepted time periods and behavior patterns for the expression of grief.

D. What Is “Typical” Grief?

1. Grief responses vary widely from person to person.

2. Grief work is the process of integrating the reality of the loss into everyday life and learning to feel better.

E. Worden’s Model of Grieving Tasks 1. Worden’s model of grieving includes four developmental tasks that a grieving person must complete in the grief work process: 2. Accept the reality of the loss.

3. Work through the pain of grief.

4. Adjust to an environment in which the deceased is missing.

5. Emotionally relocate the deceased and move on with life.

Key Terms: death, brain death, dying, thanatology, social death, bereavement, grief, mourning, grief work Figure: Figure 4

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Kübler-Ross’s Stages of Dying ABC News: See It! Video: Opting Out of Old Age? ABC News: See It! Video: The Conversation: A Family’s Private Decision IV. Life-and-Death Decision Making A. The Right to Die 1. Many people today believe that they should be allowed to die if their situation is terminal.

2. Artificial life support techniques may be legally refused by competent patients.

3. Living wills and other advance directives are indications of a person’s wishes with regard to receiving artificial life support.

4. Take the following steps to ensure that your wishes are carried out. a. Be specific. b. Name a health care proxy. c. Discuss your wishes. d. Deliver the directive.

5. The Five Wishes document allows you to outline personal, emotional, and spiritual needs as well as medical needs.

B. Rational Suicide and Euthanasia 1. Rational suicide is the decision to kill oneself rather than endure constant pain and slow decay.

2. Euthanasia is often referred to as “mercy killing.” a. Active euthanasia ends the life of a person who is suffering greatly and has no chance of recovery, for example, by lethal injection. b. Passive euthanasia refers to the intentional withholding of treatment that would prolong life. c. Advance directives, such as “do not resuscitate” (DNR) orders, can provide legal justification for various forms of passive euthanasia.

Key Terms: living will, advance directive, rational suicide, active euthanasia, passive euthanasia I. Making Final Arrangements A. Hospice Care: Positive Alternatives 1. Hospice programs are a form of palliative care that focuses on reducing pain and suffering and attending to the emotional and spiritual needs of dying individuals and their caregivers.

2. Hospice programs help relieve the person’s pain, and offer emotional support to the dying person and loved ones.

B. Making Funeral Arrangements 1. Anthropological evidence indicates that all cultures throughout human history have developed some sort of funeral ritual.

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2. Social interaction associated with funeral and memorial services is valuable in helping survivors cope with their losses.

C. Wills 1. Many people die intestate, or without a will.

D. Organ Donation 1. The number of patients waiting for organ donations greatly outnumbers available organs.

Key Terms: hospice, palliative care, intestate

Discussion Questions 1. Promoting health and preventing secondary problems are important aspects of decreasing health care costs. What are some health promotion areas we should be focusing on for the elderly?

2. Describe the relationship between physical and mental health. How does this relationship affect the way a person ages?

3. What factors do you think contribute to the differences in life expectancy between men and women?

4. Describe the different stages a dying person may experience. How can family and friends assist the dying person in his or her passage though these stages?

5. How does our society foster social death? Describe several situations that promote social death.

6. What role does a funeral play in the mourning process?

7. Compare and contrast hospice care with traditional hospital care.

8. Describe the struggles that caregivers of Alzheimer’s patients might experience.

Critical Thinking Questions 1. Have you experienced the death of a family member, close friend, or other loved one? If so, which of the five psychological stages of coping with death described by Kübler-Ross did your loved one experience? Did he or she experience the stages in the order in which they are presented in the text? Did you experience the same stages?

2. What is your opinion on the right to die? Does your state have any laws regarding the right to die? Do you agree or disagree with these laws? Why? 3. Do you have a will, a living will, or another advanced directive? What do you think is the appropriate age to have these documents?

4. Have you talked to family members or friends about what kind of funeral or other memorial service you want to have when you die? Do you think it is important to make these kinds of decisions and make them known to family or friends? Why or why not?

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decision to be an organ donor? What are the ethical pros and cons associated with organ donation?

6. Are you responsible in any way for the care of an elderly parent or other family member? If so, how do these responsibilities alter your daily life? What kind of help would you like to have to continue to provide this care as your parents or other family members grow older?

7. What do you think about death? Is it something you think about often? Do you think it is healthy to think about aging and death?

Student Activities Individual 1. Write a one-page paper on what you will be like when you are 60. Reflect on past accomplishments, describe yourself physically, and explain the plan for your future.

2. Make a list of ten things you can do now to ensure your health and memory as you age.

3. Visit a hospice facility in your community or research hospice care online. What specific kinds of treatment are provided to dying individuals and their family and friends by hospice organizations?

4. Research cryogenics on the Internet. Is this a process you think you might want to have done when you die? Why or why not?

Community 1. Find out what laws your state has regarding rational suicide and physician-assisted suicide. Do you agree with these laws? How do you think these laws should be changed? In what ways can you influence changing these laws?

2. Visit a mortuary in your community to find out what kind of green burial options are available.

Diverse Population/Nontraditional 1. Compare and contrast funeral rites in the United States and other countries. Compare and contrast different cultures within the United States with regard to funerals. Focus on the types of funerals and memorial services, the duration of mourning, the typical type of dress and ornamentation during mourning, and the types of food served.

2. Many Latin American cultures celebrate the Day of the Dead (El Día de los Muertos). Research this day of celebration and share with friends the primary types of preparation, activities, and foods associated with this day.

Additional References K. Christensen, G. Doblhammer, R. Rau, and J. W. Vaupel, “Aging Populations: The Challenges Ahead.” The Lancet, 374, no. 9696 (2009): 1196–1208.

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B. M. Kuehn, “Effort Under Way to Prepare Physicians to Care for Growing Elderly Population.” The Journal of the American Medical Association, 302 (2009): 727–728.

J. S. Linebarger, O. J. Z. Sahler, and K. A. Egan, “Coping with Death.” Pediatrics in Review, 30 (2009): 350–356.

F. Oswald, et al. “Relationships between Housing and Healthy Aging in Very Old Age.” The Gerontologist, 47 (2007): 96–107.

M. G. Parker and M. Thorslund, “Health Trends in the Elderly Population: Getting Better and Getting Worse.” The Gerontologist, 47 (2007): 150–158.

R. G. J. Westendorp, “What Is Healthy Aging in the 21st Century?” American Journal of Clinical Nutrition, 83 (2006): 404S–409S.

For Further Information American Geriatrics Society www.americangeriatrics.org Death with Dignity www.deathwithdignity.org Our Everyday Life How to Plan a Funeral https://oureverydaylife.com/how-to-plan-a-funeral-12077773.html Mental Health America Coping with Loss: Bereavement and Grief www.nmha.org/index.cfm?objectid=C7DF9618-1372-4D20-C807F41CB3E97654 National Association of State Long-Term Care Ombudsman Programs www.nasop.org

Additional Media The Aging Brain, 3 minutes 10 seconds In this U.S. News and World Report clip, the importance of creativity and challenging your brain in promoting healthy brain aging is discussed. www.youtube.com/watch?v=YtNI3Rrqb_0&feature=fvw The Science of Healthy Aging: Living Better, Not Just Longer, 84 minutes 15 seconds In this presentation of the University of California San Francisco Osher Center for Integrative Medicine, Dr. Ellen Hughes discusses healthy living and aging. www.youtube.com/watch?v=jQrkioHOJLs

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CHAPTER

Promoting Environmental Health

16 Overview With the increasing pollution, population growth, and other global burdens, environmental health has become a major concern. Even if we take care of our own health through many of the means discussed previously in this text, if we do not have clean water to drink, clean air to breathe, and uncontaminated land to grow our crops and animals, we cannot be healthy.

Chapter 16 describes in detail many of the problems our planet is experiencing. Several boxes in the chapter discuss specific actions we can take and changes that we can make to contribute to positive environmental change. After reading this chapter, students should have an increased sense of personal responsibility and empowerment to engage in behaviors that benefit and avoid behaviors that harm the environment. It must be understood that individual and community behaviors are essential if we are to make a positive difference in environmental health.

Learning Objectives 1. Explain the environmental impact associated with global population growth and out global ecological footprint.

2. Discuss climate change and global warming, the underlying causes of each, impacts on health, and how alternative energy and individual actions can reduce risks.

3. Identify major causes, components, and consequences of outdoor and indoor air pollution.

4. Discuss key causes of water scarcity and sources of water pollution.

5. Distinguish between municipal solid waste and hazardous waste, and list strategies for reducing land pollution.

6. List and explain key health concerns associated with ionizing and nonionizing radiation.

Lecture Outline I. Overpopulation: The Planet’s Greatest Threat 1. At the current rate, the world’s population will grow to 9.7 billion by 2050 and to over 11 billion by 2100.

2. Tomorrow’s population will consume more resources, produce more waste and emissions than did previous generations.

A. Global Population Growth 1. Key indicators of growth patterns are life expectancy, childhood mortality, fertility rates and migration.

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2. Fertility rate refers to how many births a woman has by the end of her reproductive life. a. Globally, fertility rates are declining, women are having fewer children. b. The global fertility rate is expected to drop below the replacement-level fertility rate by 2100 but will continue to swell in countries where the fertility rate remains high.

3. Mortality rates from both chronic and infectious diseases have declined worldwide. a. As people live longer, they add more years of resource consumption and add to the overall human footprint on the environment. b. Over half of our ecological footprint is from carbon dioxide emissions (carbon footprint).

B. Measuring the Impact of People 1. Due to the growth in demand for finite resources, experts are analyzing the carrying capacity of the earth—the largest population that can be supported indefinitely, given the resources available in the environment.

2. Evidence of unchecked population growth includes: a. Impact on other species b. Impact on ecosystems c. Impact on the food supply d. Land degradation and contamination of drinking water e. Energy consumption Key Terms: fertility rate replacement-level fertility rate, carrying capacity of the earth, ecosystem, fossil fuel, ecological footprint Table: Table 16.1 Selected Total Fertility Rates Worldwide, 2019 ABC News: See It! Video: Actress Rosario Dawson’s Mission for Sustainable Fashion II. Climate Change 1. Climate change refers to a shift in typical weather patterns across the world, and global warming is a type of climate change where average temperatures increase.

2. Global warming is a type of climate change in which average temperatures increase.

The greenhouse effect is a phenomenon in which greenhouse gasses such as carbon dioxide (CO2) form a layer in the atmosphere trapping some of the heat close to the surface, where it warms the planet.

3. The enhanced greenhouse effect is caused by the increase in greenhouse gases caused by human activities that raise the planet’s temperature higher than normal by trapping excess heat.

A. Scientific Evidence of Climate Change 1. Recent evidence points to unusual changes in climate that go beyond predictable natural causes.

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2. Studies indicate that large changes in climate can occur in decades rather than centuries or thousands of years.

B. Health Risks of Climate Change 1. The health effects of climate change are already being felt in communities worldwide.

2. More frequent and more intense extreme weather events can cause or increase existing disease. a. Also expected to increase our exposure to insects that carry harmful bacteria and viruses.

3. Drought and other extreme weather events will reduce global crops yields that will also be affected by rising CO2 levels, lower their nutritional value.

C. Reducing the Threat of Global Warming 1. Climate change problems are rooted in our energy, transportation, and industrial practices.

2. Increased CO2 production and rapid deforestation contribute to the rise in greenhouse gases, as do population increases and the destruction of natural resources.

3. Keys to slowing climate change include: reducing consumption of fossil fuels, shifting to alternative energy sources, using mass transportation, improving energy efficiency, and increasing governmental regulation.

4. Sustainable development is development that meets the needs of the present without compromising the needs of future generations.

5. In 2015, 190 nations adopted the Paris Agreement, allowing countries to come up with their own intended nationally determined contributions. The United States, under President Trump, became the only country to leave the agreement in 2017. a. Cap and trade policies are designed to set limits, or caps, on how much carbon large industrial polluters can emit.

6. Large emitters are issued permits for allowable levels of pollutants and are then taxed on the overages.

7. Many communities and campuses have established plans to reduce their carbon footprint, or the amount of CO2 emissions contributed to the atmosphere on a daily basis.

Key Terms: climate change, global warming, greenhouse gases, enhanced greenhouse effect, global warming potential (GWP), nationally determined contributions (INDCs), cap and trade, carbon tax, carbon footprint.

III. Air Pollution 1. The term air pollution refers to the presence of substances not found in perfectly clean air.

2. In general, air pollutants are either naturally occurring or anthropogenic (human caused). a. Naturally occurring pollutants include particulate matter, such as from volcanic eruptions, soil, and dust. b. Anthropogenic sources include those caused by stationary sources (e.g., power plants, factories, and refineries) and mobile sources such as vehicles.

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A. Health Effects of Common Air Pollutants 1. The Clean Air Act of 1970 (amended several times since then) established standards for six of the most widespread air pollutants that seriously affect health: sulfur dioxide, particulates, carbon monoxide, nitrogen dioxide, ground-level ozone, and lead. a. See Table 16.2 for an overview of the sources and effects of these pollutants.

2. Smog a. Smog is a brownish haze produced by a mixture of pollutants, mainly groundlevel ozone and particulate matter. b. Ozone in the earth’s upper atmosphere is protective, but ozone near the ground is formed when pollutants react chemically in the presence of sunlight. c. It tends to form in areas that experience a temperature inversion, in which a cool layer of air is trapped under a layer of warmer air, preventing the air from circulating. d. The most noticeable health effects include respiratory irritation, reduced lung function, aggravation of asthma, and inflammation and damage to the lining of the lungs.

3. Air Quality Index a. Air Quality Index (AQI) is a measure of daily air quality. b. It focuses on health effects that can happen within a few hours or days after breathing polluted air. c. The Environmental Protection Agency (EPA) has divided the AQI into six categories corresponding with color codes; the higher the AQI value, the greater the level of air pollution and associated risks. i. See Figure 16.1 for a summary.

4. Acid Deposition a. Acid deposition refers to the deposition of wet and dry acidic components that fall to the earth in dust or smoke. b. Acid deposition aggravates and may even cause bronchitis, asthma, and other respiratory problems, and people with emphysema or heart disease may suffer from exposure. It may also be harmful to fetuses. c. Acid deposition can cause metals such as aluminum, cadmium, lead, and mercury to leach out of the soil.

5. Indoor Air Pollution a. Mounting evidence indicates that air pollution levels within homes and other buildings may be two to five times higher than outdoor pollution levels. i.

Sources of indoor air pollution include cooking stoves and furnaces, woodstoves and space heaters, household cleaners and solvents, mold, pesticides, asbestos, formaldehyde, radon, and lead.

ii. Recently, accumulation of ash and smoke from wildfires has emerged as a potent source of indoor air pollution.

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b. Multiple factors contribute to a person’s risk of being affected by indoor air pollution. Those with allergies may be particularly vulnerable. See Table 16.3 for sources of indoor air pollution and possible health effects. c. Preventing indoor air pollution should focus on the following: i. Source control ii. Ventilation improvements iii. Air cleaners 6. Ozone Layer Depletion a. The ozone layer protects our planet and its inhabitants from ultraviolet B (UVB) radiation, a primary cause of skin cancer. i. UVB radiation also damages DNA and weakens the immune system. ii. Chlorofluorocarbons (CFCs) are chemicals that deplete the ozone layer. b. CFCs were banned in the United States after the discovery of an ozone “hole” over Antarctica, which led to a series of treaties between 1985 and 2016. i. The United States and other nations agreed to phase out the use of all CFCs and many other ozone-depleting substances (ODS). ii. These include hydrofluorocarbons (HFCs), which had initially been used as a replacement for CFCs, but are now recognized as potent GHGs. c. As a result of these measures, emissions of ODS are falling, and the ozone layer is expected to be fully healed by the middle of this century.

Key Terms: pollutant, smog, hydrocarbons, temperature inversion, acid deposition Figure and Tables: Figure 16.1 Air Quality Index (AQI) Table 16.2 Sources, Health Effects, and Environmental Impacts of Six Major Air Pollutants Table 16.3 Selected Indoor Air Pollutants, Their Sources, and Health Effects ABC News: See It! Video: China Smog Creates What Some Call a Kind of Respiratory Nuclear Winter IV. Water Scarcity and Pollution A. Water Scarcity 1. Just 3 percent of the world’s entire water supply is fresh and drinkable water. a. One-sixth of that water is available for use, which includes lakes, ground ice, swamps, marshes, rivers, and soil moisture, and groundwater, from layers of underground rock called aquifers.

2. Climate change has increased the threat of drought—and increased water scarcity—in many regions of the world, including the United States.

3. Research published in the spring of 2021 concluded that human activities—especially the release of GHGs—had increased drought frequency, duration, and intensity in large regions of Africa, Asia, and the Americas.

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a. That summer, over 47 percent of the United States experienced some form of drought—with nearly 60 percent of the western United States experiencing extreme or exceptional drought. b. The UN estimates that by 2025, two-thirds of the world’s population will live in water-stressed areas, increasing competition for scarce reserves and posing a major risk to global food supplies, energy supplies, and survival of all living things.

4. Drought conditions in the United States have forced rationing, and other efforts to conserve water by industry, agriculture, communities, and individuals.

B. Water Pollution 1. Tap water in the United States is among the safest in the world. a. This is because of the Safe Drinking Water Act; the EPA sets standards for drinking water in the United States.

2. Point source pollutants enter a waterway at a specific point through a pipe, ditch, culvert, or other such conduit. a. Two sources include sewage treatment plants and industrial facilities.

3. Nonpoint source pollutants (runoff and sedimentation) drain or seep into waterways from broad areas of land rather than through a discrete pipe or conduit.

4. Table 16.4 presents some of the pollutants causing the greatest potential harm.

Figure and Table: Figure 16.2 Individual Water Usage Table 16.4 Selected Water Pollutants and Their Health and Ecosystem Effects V. Land Pollution A. Solid Waste 1. Each day, every person in the United States generates nearly 4.9 pounds of municipal solid waste (MSW). a. Although experts believe that up to 90 percent of our trash is recyclable, we still fall short of this goal.

2. We recycle only about 32 percent of the waste we generate. a. Instead of being recycled, about 12 percent of our MSW is burned at combustion facilities, and 50 percent is disposed of in landfills.

3. Strategies to reduce solid waste include the following: a. Source reduction b. Recycling c. Composting d. Combustion with energy recovery B. Hazardous Waste 1. Hazardous waste has properties that make it capable of harming human health or the environment.

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2. The Superfund was enacted to provide funds for cleaning up chemical dump sites that endanger public health and land.

3. The EPA has developed protective requirements for land disposal facilities, such as double liners, detection systems for substances that may leach into groundwater, and groundwater monitoring systems.

Key Terms: municipal solid waste (MSW), hazardous waste, Superfund Figure: Figure 16.3 How Much Do We Recycle?

VI. Radiation A. Nonionizing Radiation 1. Nonionizing radiation is radiation at the lower end of the electromagnetic spectrum. a. Moves in relatively long wavelengths and has enough energy to move atoms around or to cause them to vibrate, but not enough to move electrons or alter molecular structure.

2. Examples include radio waves, TV signals, microwaves, infrared waves, and visible light.

B. Ionizing Radiation 1. Ionizing radiation is caused by the release of particles and electromagnetic rays from atomic nuclei during the normal process of disintegration. a. Has enough energy to remove electrons from the atoms it passes through. b. The sun emits ionizing radiation in the form of high-frequency ultraviolet rays.

2. Exposure to radiation is measured in radiation absorbed doses, or rads. a. Recommended safe dosages range from 0.5 to 5 rads per year.

C. Nuclear Power Plants 1. Proponents say it is a safe and efficient way to produce electricity and could help slow global warming.

2. Disadvantages include the following: a. Disposal of nuclear waste b. Potential reactor core meltdown 3. A nuclear meltdown occurs when the temperature in the core of a nuclear reactor increases enough to melt both the nuclear fuel and its containment vessel.

4. Nuclear accidents, such as those at Chernobyl and the Fukushima Daiichi Nuclear Power Station, can be devastating.

Key Terms: nonionizing radiation, ionizing radiation, radiation absorbed dose (rad), nuclear meltdown

Discussion Questions 1. What are some of the challenges that come along with population growth? What strategies would you suggest to address the preference for large families in developing countries?

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2. What impact could the popularity of new hybrid cars that operate on electricity and gas have on reducing air pollution? List and describe three other ways to reduce the dependence on automobiles as a source of transportation.

3. Describe four strategies you can personally engage in to reduce environmental pollution to protect your own health. What are the barriers for implementing these strategies?

4. Should we increase the use of nuclear reactors as sources of electricity? Explain.

5. What products in your home are sources of pollution? Are there viable alternatives?

6. Discuss the consequences of global warming. How can we emphasize the severity of this problem to the American public? Why do you think many are convinced that global warming is a myth? What is the influence of personal convenience in this controversial problem?

7. What are the physical effects of indoor air pollution? What can be done to reduce these effects?

8. How can we promote recycling as a way to reduce the amount of waste in landfills?

9. What is a sustainable solution for states that have no more room in landfills for their trash?

Critical Thinking Questions 1. Imagine a world in which you have no water for a shower, not enough electricity to turn on your lights or run your refrigerator, and little or no gas for your car. Why do you or don’t you believe this situation is possible in the future? If so, what can you, as an individual, do to prevent this hypothetical situation? What changes should occur at the community level?

How can you contribute to these community-level changes?

2. How does the low educational and economic status of women in poor developing countries contribute to population growth? What can be done to create an environment in which women are allowed to make different reproductive choices?

3. Why do you think population size in the United States continues to increase in contrast to static or declining population size in other wealthy countries?

4. As an individual, what are ten things you can do to reduce your personal carbon footprint on the environment? Identify and describe the barriers to five of these ten things and solutions for each barrier.

5. Identify five things you, as an individual, can do to reduce the impact of global warming.

Why do you think it is important for each individual to assume responsibility for his or her contribution to global warming?

6. What are some techniques to waste less water? Do you follow any of these techniques on a daily basis? If you do not follow any of these water-saving practices, why not? What changes could you make?

7. On a daily basis, what conscious choices do you make to protect your hearing? What are three things you can do to prevent damage from noise pollution?

8. What materials do you recycle on a daily basis? What additional materials could you recycle easily? Do you and your friends make recycling a part of your daily lives? Why or why not?

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Student Activities Individual 1. Keep a diary for 2 weeks. List everything you have done in your home, your classes, and your place of work that reduced your carbon footprint. Document your reactions and feelings to your efforts. What worked well, and what was inconvenient? How can you improve the inconveniences so that they become habits? What other changes could you make to reduce your carbon footprint even more?

2. Do an assessment of possible indoor air pollutants in your home. Make changes where possible.

3. Implement some strategies to waste less food and keep a journal of your efforts. Were some strategies more difficult to implement in some settings over others?

4. Use the website www.niehs.nih.gov and others to find out what you can do to help the environment and reduce your own risk for health problems.

Community 1. Find out what type of recycling program your campus has. List ways the program is promoted, and find out what percentage of trash is recycled.

2. What is the average daily Air Quality Index for your community? What was the highest AQI, and when did it occur? How is the public made aware of the daily AQI? What additional measures are taken to let the public know when the AQI reaches unhealthy to hazardous levels?

3. Does your campus or community have any type of water restrictions? If so, what are they?

Are they implemented only at certain times of the year? If so, when? What is the average daily water consumption on your campus or in your community?

4. Find out the local government’s stand on environmental issues. What are the topics of debate in your community?

Diverse Population/Nontraditional 1. Look up Potters for Peace at www.pottersforpeace.org. What does this organization do to ensure that children around the world have clean drinking water?

2. Research organizations that help developing countries supply safe drinking water. What can you do to help these organizations provide safe drinking water?

3. How is trash managed in other countries? Find out if recycling programs are available in other countries and if they recycle more or less than in the United States.

4. Describe changes in environmental awareness in the past 25 years. How have consumer products changed to become more “environmentally friendly”?

Additional References The Paris Agreement http://unfccc.int/paris_agreement/items/9485.php M. Bahar, H. Bag, and O. Bozkurt, “Pre-service Science Teachers’ Understanding of an Environmental Issue: Ozone Layer Depletion,” Ekoloji, 18 (2008): 51–58.

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M. L. Bell, K. Ebisu, and K. Belanger, “Ambient Air Pollution and Low Birth Weight in Connecticut and Massachusetts,” Environmental Health Perspectives, 115 (2007): 1118– 1124.

D. E. Hun, J. A. Siegel, M. T. Morandi, T. H. Stock, and R. L. Corsi, “Cancer Risk Disparities between Hispanic and Non-Hispanic White Populations: The Role of Exposure to Indoor Air Pollution,” Environmental Health Perspectives, 117 (2009): 1925–1931.

M. Jerrett, et al. “Traffic-related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement,” Environmental Health Perspectives, 116 (2008): 1433–1438.

S. H. Linder, D. Marko, and K. Sexton, “Cumulative Cancer Risk from Air Pollution in Houston: Disparities in Risk Burden and Social Disadvantage,” Environmental Science Technology, 42 (2008): 4312–4322.

E. McLeish, Overcrowded World (Pleasantville, New York: Gareth Stevens Publishing, 2009).

For Further Information Indoor Air Quality Association www.iaqa.org National Ground Water Association www.ngwa.org National Oceanic and Atmospheric Administration www.noaa.gov Superfund www.epa.gov/superfund

Additional Media A Breath of Air, 30 minutes In this documentary co-directed by Andrea Hricko, Associate Professor of Preventive Medicine at USC’s Keck School of Medicine, the acute and chronic health effects of air pollution on children are explored. www.youtube.com/watch?v=FnR_uM4IQ6s Air Quality 101: The Basics, 7 minutes In this production of the Utah Department of Transportation, viewers are provided with a basic understanding of air quality. www.youtube.com/watch?v=Hx_yWFQvJT4&feature=related Indoor Air Pollution, 3 minutes In this news segment, the topic of indoor air quality and its effect on one’s health are discussed, with emphasis on what can be done to improve indoor air quality. www.youtube.com/watch?v=6QrC_o4b8dE&feature=related

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Global Warming 101, 3 minutes The purpose of this educational clip, produced by National Geographic, is a basic explanation of global warming. www.youtube.com/watch?v=oJAbATJCugs&ob=av3e

Ozone Depletion, 4 minutes In this Spot Films production, an explanation and animation of ozone depletion are presented.

Additionally, human factors affecting ozone depletion are discussed as well as actions being taken to achieve change, such as The Montreal Treaty. www.youtube.com/watch?v=PXV6ppONgUk

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