Alters and schiff essential concepts for healthy living ebook pdf

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Pregnancy and Fetal Development The Birth Process Circumcision The Postpartum Period Infertility Factors That Affect Fertility Treating Infertility Contraception Abstinence and Natural Methods Chemical Methods Barrier Methods Hormonal Methods Intrauterine Devices Emergency Contraception Sterilization Abortion

139 140 144 145 146 146 147 148 148 151 151 154 156 157 157 158

Analyzing Health-Related Information

164

CHAPTER REVIEW

165

Chapter 6

Romantic Relationships and Sexuality

168

Human Sexual Behavior

171

The Biology of Sexual Behavior The Psychology of Sexual Behavior

171 172

The Sexual Response

172

Sexual Dysfunctions

175

Erectile Dysfunction (Impotence) Premature (Rapid) Ejaculation Hypoactive Sexual Desire Disorder Female Sexual Arousal Disorder Vaginismus

175 176 177 177 177

Culture, Gender, and Sexuality

180

Gender Identity and Roles Sexual Orientation Nature or Nurture?

Sexual Orientation and Society

180 184 185 186

Solitary Sexual Behavior Celibacy

188 188

Romantic Relationships

188

Defining Love Psychologists’ Theories About Love Love Attachments

188 189 190

Establishing Romantic Commitments Love Changes over Time Types of Romantic Commitments Communication in Relationships

192 192 193 195

Analyzing Health-Related Information

198

CHAPTER REVIEW

200

Chapter 7

Drug Use and Abuse

204

Drug Use, Misuse, and Abuse

206

Psychoactive Drugs: Effects on the Mind and Body

208

How Psychoactive Drugs Affect the Brain What Happens to Drugs in the Body?

208 209

Illicit Drug Use in the United States

209

Why Do People Use Psychoactive Drugs?

Patterns of Psychoactive Drug Use

210 210

Drug Dependence

212

Physiologic and Psychological Dependence Risk Factors for Drug Dependency Stimulants

212 212 213

Amphetamines and Methamphetamines Cocaine Caffeine

213 216 217

Depressants

218

Sedatives and Tranquilizers Rohypnol GHB and GBL

219 219 219 Contents

vii

Opiates Opium and Heroin OxyContin and Vicodin

220 221 221

Marijuana

222

Hallucinogens LSD Mescaline Psilocybin PCP Ketamine

223 223 223 224 224 224

Inhalants

224

Designer Drugs: Drugs with Mixed Effects Ecstasy K2 Bath Salts

225 226 226 227

Over-the-Counter Drugs Look-Alike Drugs Weight-Loss Aids Ephedrine/Ephedra

227 227 228 228

Drug Treatment and Prevention Treating Drug Dependency Antidrug Vaccines Preventing Drug Misuse and Abuse Analyzing Health-Related Information

229 229 230 230 234

CHAPTER REVIEW

235

Chapter 8

Alcohol and Tobacco Alcohol Use, Abuse, and Dependence Factors Related to Alcohol Abuse and Dependence Alcohol and College Students How the Body Processes Alcohol Consequences of Alcohol Abuse and Dependence Analyzing Health-Related Information Prevention How to Manage Alcohol Consumption viii

Contents

238 241 242 244 246 248 249 253 255

Diagnosis and Treatment of Alcoholism and Alcohol Abuse Tobacco Who Uses Tobacco and Why? Nicotine Addiction The Health Effects of Tobacco Use Environmental Tobacco Smoke Quitting Prevention CHAPTER REVIEW

255 257 258 259 260 266 266 270 274

Chapter 9

Nutrition

278

Basic Nutrition Principles What Are Nutrients?

What Are Non-nutrients?

Natural, Health, Organic, and Functional Foods What Happens to the Food You Eat?

281 281 281

Energy-Supplying Nutrients Carbohydrates Lipids Proteins

286 286 291 294

Non-Energy-Supplying Nutrients Vitamins Minerals Water

299 299 301 304

The Basics of a Healthful Diet Nutrient Requirements and Recommendations The Dietary Guidelines MyPlate Using Nutritional Labeling What About Foods Sold in Restaurants?

Do You Need Vitamin or Mineral Supplements?

Malnutrition: Undernutrition and Overnutrition Analyzing Health-Related Information

305

CHAPTER REVIEW

282 284

305 306 307 308 310 310 311 315 316

Chapter 10

Body Weight and Its Management

320

Overweight and Obesity 322 Body Mass Index 322 The Prevalence of Obesity 324 How Does Excess Body Fat Affect Health? 325 The Caloric Cost of Living Energy for Basal (Vital) Metabolism Energy for Physical Activity Energy for the Thermic Effect of Food The Basics of Energy Balance

325 325 326 328 328

Body Composition How Much Body Fat Is Healthy?

Estimating Body Fat

328

What Causes Obesity?

Biological Influences Environmental, Social, and Psychological Influences

332 332

Weight Management Weight Reduction Diets Physical Activity Surgical Procedures Medications Alternative Therapies Strategies for Successful Weight Loss Analyzing Health-Related Information

336 336 338 339 339 340 340 343

Weight Gain

343

CHAPTER REVIEW

329 329

335

347

Chapter 11

Physical Fitness

350

Principles of Physical Fitness The Body in Motion The Circulatory and Respiratory Systems Defining Physical Activity and Exercise

352 352 352 354

Physical Activity and Health

354

The Health-Related Components of Physical Fitness Cardiorespiratory Fitness Muscular Strength Muscular Endurance Flexibility Body Composition Analyzing Health-Related Information

355 356 359 360 361 363 365

Athletic Performance The Sports-Related Components of Fitness Diet and Performance Ergogenic Aids

367

Exercising for Health The Exercise Session Exercise Danger Signs

370 372 373

Preventing and Managing Common Exercise Injuries Strains and Sprains Dislocation Temperature-Related Injuries

373 373 373 374

367 367 367

Developing a Personal Fitness Program 376 Active for a Lifetime

378

CHAPTER REVIEW

384

Chapter 12

Cardiovascular Health

388

The Cardiovascular System and How It Works

390

Cardiovascular Diseases Atherosclerosis Coronary Artery Disease Stroke

393 393 394 400

Risk Factors for Cardiovascular Disease 402 Family Health History 403 Abnormal Blood Lipid Levels 403 Cigarette Smoking 405 High Blood Pressure 405 Physical Inactivity 406 Contents

ix

Obesity Diabetes Mellitus Anxiety and Stress Elevated C-Reactive Protein Maintaining Cardiovascular Health Smoking Cessation Maintaining a Healthy Weight Regular Exercise Lowering Blood Pressure Reducing Blood Cholesterol Aspirin Therapy Hormone Replacement Therapy Analyzing Health-Related Information CHAPTER REVIEW

407 407 407 409 409 410 410 410 410 411 412 412 414 418

Chapter 13

Cancer

422

What Is Cancer?

424

How Cancers Develop and Spread Genes and Cancer Development Metastasis

424 425 425

Cancer Detection and Staging

428

Cancer Treatment Surgery Radiation Chemotherapy Laser and Photodynamic Therapy Targeted Therapies Bone Marrow and Peripheral Blood Stem Cell Transplants

429 433 433 433 434 434 435

Prevalent Cancers in the United States 435 Cancers Caused by or Related to Tobacco 435 Cancers Related to Diet 443 Cancers Related to Hormone Function 445 Cancers Related to Viral Infection: Cervical Cancer 449 Cancers Related to Ultraviolet Radiation: Skin Cancers 451 Analyzing Health-Related Information 453 Cancers with Unknown Causes 454 x

Contents

Reducing Your Risk for Cancer CHAPTER REVIEW

458 460

Chapter 14

Infection, Immunity, and Noninfectious Disease

464

Noninfectious Diseases 466 Genetic Diseases 466 Noninfectious Disease and the Interaction of Genetic Factors with the Environment 469 Noninfectious Conditions with Environmental or Unknown Causes 471 Trends in Infectious Disease

472

The Chain of Infection Pathogens Transmission The Host

473 473 476 478

Immunity Nonspecific Immunity Specific Immunity Interactions Between Nonspecific and Specific Immunity

479 479 482 484

Protection Against Infectious Diseases

484

Drugs That Combat Infection

485

Sexually Transmitted Infections

488

Sexually Transmitted Infections Caused by Viruses Human Immunodeficiency Virus Genital Herpes Genital Warts Analyzing Health-Related Information Sexually Transmitted Infections Caused by Bacteria Syphilis Gonorrhea Chlamydial Infections

489 489 494 495 497 498 498 499 501

Other Sexually Transmitted Infections Trichomonas Vaginalis Infections Yeast Infections Pubic Lice Scabies

502 502 502 502 503

Protecting Yourself Against STIs

503

CHAPTER REVIEW

508

Chapter 15

Aging, Dying, and Death

512

Aging Life Expectancy The Characteristics of Aged Americans Why Do We Age? The Effects of Aging on Physical Health Analyzing Health-Related Information The Effects of Aging on Psychological Health The Effects of Aging on Social Health Successful Aging

514 516

Dying The Spiritual Aspects of Dying The Emotional Aspects of Dying Terminal Care: The Options

529 529 530 531

Death What Is Death?

Euthanasia and the Right to Die Preparing for Death Some Final Thoughts on Death

533 533 534 535 537

Grief

538

CHAPTER REVIEW

516 518 519 524 526 527 527

542

Chapter 16

Environmental Health

546

Environmental Health in and Around the Home Poisoning Inhalation of Asbestos Fibers Electromagnetic Radiation Analyzing Health-Related Information Irradiation of Food

548 549 554 555 556 557

Environmental Health in the Workplace 558 Pesticide Poisoning 558 Exposure to and Inhalation of Other Toxic Chemicals 559 Indoor Air Pollution 560 Environmental Health in the Outdoors Water Pollution Air Pollution Noise Pollution CHAPTER REVIEW

561 561 562 564 567

Appendix A The Mission, Vision, and Goals of Healthy People 2020

571

Appendix B Injury Prevention and Emergency Care

575

Appendix C Food Intake Patterns Based on MyPlate Recommendations

583

Student Workbook

589

Glossary

692

Index

702

Contents

xi

Features Diversity in Health Minority Health Status in the United States American Indians and Psychological Health Stress and Asian Americans Spouse Abuse: An International Problem Menopause The Perceived Virtue of Virginity Common Sexual Practices Between Partners Khat Tobacco Drinking?

Asian American Food The Plight of the Pima New Interest in an Ancient Approach to Fitness The Italian Gene: A Hope for Reversing Atherosclerosis?

Stomach Cancer: Variation in Mortality Among Countries Sickle Cell Disease: Why Does This Deleterious Gene Persist?

Hunting for Supercentenarians Hunger, the Environment, and the World’s Population

14 42 78 108 161 178 187 214 263 295 333 382

xii

85 115 139 174 228 262 312 342 380 408 432 486 532 554

407 441 467 515 566

Consumer Health Consumer Protection Locating and Selecting Mental Health Therapists

Healthy Technology and Social Media Consumption Natural Defense: Pepper Spray Home Pregnancy Tests Ginseng and Sexual Prowess Over-the-Counter Medicines: Safety and the FDA Electronic Cigarettes or E-Cigarettes Dietary Supplements Dietary Supplements: Weight-Loss Aids Choosing a Fitness Center Vitamin Pills for a Healthier Heart?

Alternative Cancer Therapies CAM Products and Colds Choosing a Long-Term Care Facility Carbon Monoxide Detectors: Are They Reliable?

21 50

Managing Your Health Routine Health Care for Disease Prevention: Adult Recommendations Resolving Interpersonal Conflicts Constructively A Technique for Progressive Muscular Relaxation Sexual Assault: Safety and Prevention Genetic Counseling and Prenatal Diagnosis Enlargement of the Prostate Minding Your Sexual Manners Falling Asleep Without Prescriptions

19 47 91 103 136 162 192 219

Drinking and Date-Rape Drugs: Safety Tips Guidelines for Safer Drinking How to Say No to Secondhand Smoke Tips for Quitters Trimming Unhealthy Fats from Your Diet General Features of Reliable Weight Reduction Plans Assessing the Intensity of Your Workout: Target Heart Rates Heart Attack and Stroke (Brain Attack) Symptoms: What to Do in an Emergency Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People Breast Self-Examination Testicular Self-Examination Reducing Your Risk for Cancer Cancer’s Seven Warning Signs Eliminating or Reducing Your Risk of HIV Infection and Other STIs After the Death of a Loved One Tips to Prevent Poisonings Avoiding ELF Radiation Reducing Pesticide Levels in the Food You Eat

247 255 269 271 296 344 357 401

430 446 456 458 459 493 539 552 557

Across the Life Span Health Psychological Health Stress Violence and Abuse Sexual Development Sexuality Drug Use and Abuse The Effects of Alcohol and Tobacco Use Nutrition Weight Management Physical Fitness Cardiovascular Health Cancer Infectious and Noninfectious Diseases Dying and Death Environmental Health

32 65 94 117 160 196 231 272 313 345 381 412 458 505 540 565

Features

xiii

560

Focus on Critical Thinking As the title suggests, Alters & Schiff Essential Concepts for Healthy Living was written to provide students with current information on how to live and age well. Our textbook combines evidence-based information with critical thinking activities to guide students toward healthy living through analysis of their own health behavior.

We challenge students to think seriously about healthrelated information by using critical-thinking strategies.

What Is Critical Thinking?

What Does a Critical-Thinking Textbook Do?

What Is New and Improved in This Edition?

The eighth edition is updated to provide the most current statistical data on a comprehensive array of health and wellness topics and issues. Updates to the new edition include: • Extensive changes to Chapter 4, “Violence and Abuse”

Critical thinking encompasses a variety of cognitive skills, such as: • • • •

Synthesizing Analyzing Applying Evaluating

•

Throughout the textbook, a critical-thinking icon identifies features that focus specifically on these skills. In the health sciences, critical-thinking skills are necessary to understand and evaluate health information as well as apply it to daily life. This book teaches critical thinking skills that help students develop expertise in important cognitive functions: • Differentiating between verifiable facts and value statements • Distinguishing relevant information from irrelevant information • Determining the factual accuracy of health claims • Making responsible health-related decisions To think critically, students need a solid foundation of personal health information. Alters & Schiff Essential Concepts for Healthy Living has been developed from the latest scientific and medical research, relying heavily on primary sources, which are cited in the text. Because understanding health involves understanding science, this text includes basic scientific information that relates to health and presents it in an easy-to-understand manner.

xiv

•

•

• •

• The Managing Your Health box, Sexual Assault: Safety and Prevention, has been heavily revised to avoid victim blaming.

• The definitions for key words such as sexual harassment have been updated.

• The section on Community Violence has new information to include gang violence.

• A new table, Safety Planning, has been added (Table 4.3).

Chapter 6, “Romantic Relationships and Sexuality,” has also been heavily revised.

• The section on Culture, Gender, and Sexuality was completely rewritten to reflect the evolving understanding of nontraditional gender identities.

• A new table lists Common Gender Identity Terms as well as Outdated, Inaccurate, or Offensive Gender Identity Terms (Table 6.1).

• The subsection Sexual Orientation now includes new definitions for various types of sexual orientation, including asexual, pansexual, and so on.

The chapter “Nutrition” (Chapter 9) includes updated Dietary Guidelines for Americans 2015–2020.

Table 13.3 in the chapter “Cancer” (Chapter 13) has been updated with 2018 estimates on new cancer cases and deaths.

A new Workbook activity for Chapter 6 has been added: the Couples Satisfaction Index.

New features appear throughout, including: • Consumer Health: Healthy Technology and Social Media Consumption in Chapter 3, “Stress and Its Management”

• Figure 4.3, Community Violence, is a photo of the memorial following the Las Vegas mass shooting (Chapter 4, “Violence and Abuse”).

How to Use This Book Analyzing Health-Related Information activities included throughout the text provide students with examples of common advertisement techniques and other forms of media and ask them to determine whether the information presented is valid. Because health information is readily available through many forms of media, we believe it is important for students to be able to distinguish evidence-based information from unreliable health information.

The organization of ideas is an integral part of learning comprehension. The chapters are structured with a consistent format throughout the text.

Each chapter begins and ends with a section that points out the key concepts and ties the information together.

We believe that students will find these activities and tools easy to use. If students read each chapter carefully and complete each activity thoroughly, they will gain a good understanding of major concepts of healthy living that can be applied to their personal lives as well as future health-related careers.

Key Features Alters & Schiff Essential Concepts for Healthy Living focuses on teaching behavior change, personal decision making, and up-to-date personal health concepts.

The critical-thinking approach encourages students to consider their own behaviors in light of the knowledge they are gaining. The pedagogical aids that appear in the chapters are described in the following pages.

Chapter-Opening Pedagogy Each chapter-opening spread shows students the organization of the chapter using a chapter overview and a list of the special boxed features. It also lists activities in the companion Student Workbook (included at the back of this text).

Focus on Critical Thinking

xv

Chapter Summaries Research says that students learn how to identify the key ideas of stories in elementary school, but they often have difficulty identifying key ideas in textbooks in their later schooling. Chapter summaries help students with this task. The chapter summaries follow the organization of the chapter.

How to Use This Book to Adopt Healthier Lifestyles Alters & Schiff Essential Concepts for Healthy Living, Eighth Edition, encourages students to adopt healthier lifestyles, and the boxed features throughout the text recommend practical ways to do so.

Healthy Living Practices Unique to this text, these short lists of bulleted statements throughout the chapters summarize key points and concisely state concrete yet simple actions students can take to improve their own health.

Managing Your Health This feature contains short essays or lists of tips that focus on ways to live a healthier life.

xvi

Focus on Critical Thinking

Consumer Health These commentaries and tips provide practical information and suggestions to help students become more careful consumers of health-related goods and services. In addition to being highlighted in this feature, consumer topics are integrated throughout the book and are the subject of scrutiny in the Analyzing HealthRelated Information activities.

How to Use This Book to Enforce Critical Thinking The focus of education today is not simply to give students information but to teach them how to acquire and evaluate information. Unlike other personal health textbooks, the critical-thinking features in this text teach students higher order thinking skills and give them ways to practice these skills in every chapter.

Diversity in Health This feature cultivates an interest in and an appreciation for the health status and practices of various ­ethnic, ­cultural, and racial groups in the United States, as well as people around the world. Although the diversity essays focus specifically on multiculturalism, additional multicultural information is woven throughout the book.

Focus on Critical Thinking

xvii

Analyzing Health-Related Information This innovative feature teaches students the critical­ thinking skill of analysis. Students use this skill and the model provided to determine the reliability of healthrelated information in articles, advertisements, websites, and other sources. Learning such a skill and practicing it helps students become knowledgeable consumers of health-related information and products.

Applying What You Have Learned This unique end-of-chapter feature is a series of questions and activities that require critical thinking— application, analysis, synthesis, and evaluation. Each question is labeled with what type of critical thinking is required, and a key provides a brief explanation of the process students need to follow to complete the question or activity.

Reflecting on Your Health This end-of-chapter journal-writing activity stimulates students to consider what they have learned and to understand how their thoughts and feelings about health might have changed as a result of their new knowledge.

Compiling these activities and reviewing them from time to time, especially at the end of the semester, can offer tangible evidence of changes and psychological and intellectual growth.

xviii

Focus on Critical Thinking

The Integrated Teaching and Learning Package Integrating the text and ancillaries is crucial to deriving their full benefit. Based on feedback from instructors and students, the following supplements are offered with Alters & Schiff Essential Concepts for Healthy Living, Eighth Edition.

Instructor Resources Qualified instructors will receive a full suite of instructor resources, including the following: • A robust test bank, including chapter review questions, a midterm, and a final • Slides in PowerPoint format • Image bank • An updated instructor’s manual • Sample syllabus • Lecture outlines

Student Resources • • • •

An interactive eBook Warm-up activities Animations, now with audio and captions Revised Student Workbook with various healthrelated activities such as: Would a Behavior Change Improve Your Relationship? and How Much Energy Do You Use Daily?

Student Workbook In addition, the eighth edition contains a built-in critical thinking workbook that allows students to assess and improve their health-related behaviors and attitudes.

(See the Student Workbook at the end of this text for more information.)

Focus on Critical Thinking

xix

Reviewers M

any health teachers and researchers have made significant contributions to the development of this book. Our gratitude goes to the following reviewers whose expertise gave invaluable direction to the development of the eighth edition of Alters & Schiff Essential Concepts for Healthy Living: Brandy Hancock Adelsberger Fontbonne University St. Louis, Missouri Liza Allen Mesa Community College Mesa, Arizona Leigh Poirier Ball Orange Coast College Costa Mesa, California Amanda L. Divin Western Illinois University Macomb, Illinois Chris Eisenbarth Weber State University Ogden, Utah Bruce E. Ferguson Taft College Taft, California Jacqueline M. Franz Mercer County Community College West Windsor Township, New Jersey Linda J. Hoffman Community College of Allegheny County Pittsburgh, Pennsylvania

Regina M. Kay Mercer County Community College West Windsor Township, New Jersey Donna McGill-Cameron Woodland Community College Woodland, California Tony Monahan Queensborough Community College Bayside, New York J. Dirk Nelson West Texas A&M University Canyon, Texas David J. Pearson Baptist University Riverside, California Grace Pokorny Long Beach City College Long Beach, California Mikel Stone Shawnee University Portsmouth, Ohio Renee M. D. Swain Saint Augustine’s University Raleigh, North Carolina Nanette Tummers Eastern Connecticut State University Willimantic, Connecticut Julia VanderMolen Davenport University Grand Rapids, Michigan

Waltert Hook Eastern University St. Davids, Pennsylvania

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About the Authors A

lters & Schiff Essential Concepts for Healthy Living, Eighth Edition, was written by an author team with extensive credentials and backgrounds in health, exercise science, human sexuality, nutrition, health behavior, and education.

Jeff Housman Jeff Housman holds a doctorate degree in health education and a master’s degree in kinesiology and is a tenured associate professor in health and human ­ performance at Texas State University, where he teaches courses in community and public health, health behavior theory, and behavioral research and statistics. Understanding the importance of research, as well as remaining current with the industry, Dr. ­Housman’s research interests include health behavior, substance use, and program evaluation. He has authored multiple peer-reviewed articles and several textbook chapters, in addition to Alters & Schiff Essential Concepts for Healthy Living. He has also contributed to several professional publications, including A Competency-Based Framework for Health Education Specialists for the National Commission for Health Education Credentialing, Inc., and he has served as a consulting editor for the Journal of American ­College Health and The Health Educator. Dr. Housman is a member of multiple professional organizations, including the Eta Sigma Gamma Health Education Honorary, the American College Health Association, and the Society for Public Health Education. As the lead author on Alters & Schiff Essential Concepts for Healthy Living, Eighth Edition, Dr. Housman brings his education expertise, background in community and public health, exercise science, and health behavior, as well as his extensive writing experience, to this best-selling product and author team. xxii

Mary Odum Mary Odum holds a doctorate degree in health education, a master’s degree in health, exercise, and sport sciences, and a bachelor’s degree in psychology. She is an assistant professor in health and human ­performance at Texas State University, where she currently teaches courses in health education and promotion, program planning and evaluation, health behavior theory, and scientific writing. Dr. Odum’s research interests include health behavior, community-based health programs, and prepar­ ing students as writers, and she serves as a review editor for several academic journals, including the ­American Journal of Health Behavior. Dr. Odum is a member of multiple professional organizations, including the Eta Sigma Gamma Health Education Honorary, the Society for Public Health Educators, and the ­American ­Academy of Health Behavior.

Garden path: © Simon Marlow / EyeEm /Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/Getty Images.

Diversity in Health

Consumer Health

Managing Your Health

Across the Life Span

Minority Health Status in the United States

Consumer Protection

Routine Health Care for Disease Prevention

Health

Chapter Overview

Student Workbook

How the dimensions of health influence your well-being

Self-Assessment: Healthstyle | Personal Health History

The major health concerns of our nation

Changing Health Habits: Model Activity for Better Health

How your decisions affect your health How to analyze health-related information The differences between conventional and alternative treatment methods

Do You Know?

How your lifestyle affects your health?

How to make responsible health-related decisions?

How to analyze health-related information?

Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © aricvyhmeister/Shutterstock.

CHAPTER

1

© EyeEm/Getty Images.

Health: The Foundation for Life Learning Objectives After studying this chapter, you should be able to:

“A higher percentage of American adults report exercising during their leisure time …”

1. Identify trends in U.S. population health.

2. Describe the impact of lifestyle choices on one’s health.

3. Discuss different perspectives on health and wellness.

4. Describe the six components of health and discuss how each component affects one’s health.

5. Identify major causes of death for members of various age groups.

6. Explain why Americans’ life expectancy increased dramatically during the twentieth century.

7. Identify the purpose and four main goals of Healthy People 2020.

8. Describe factors that influence health behavior and health behavior change.

9. Describe the steps of the decision-making model and the stages of the behavior change model.

10. Explain how to analyze health information and assess information on the Internet.

11. Differentiate between conventional and complementary and alternative medicine.

12. Describe how to choose a conventional medical practitioner.

3

life expectancy The average number of years that an individual of a particular age can expect to live.

I

n the United States, there are some encouraging signs that more people are concerned about improving and protecting their health than in the past. A higher percentage of American adults met physical activity guidelines for aerobic physical activity (i.e., at least 150 minutes or more a week) in 2015 than in previous years.1 In 1995, 71% of adults reported that their blood cholesterol level had been checked. By 2015, that percentage had increased to 81.5% of adults.2 Between 1988 and 2016, the percentage of ­Americans wearing seat belts while riding in motor vehicles increased dramatically.3 In some respects, Americans have also improved their eating habits. Between 2005 and 2014, on average, adolescents consumed more than 16% of their total calories from added sugar, slightly above the recommended 15%. Most adults aged 20 or older, however, met recommended sugar consumption guidelines. In addition, Americans are consuming more calcium and more dietary fiber.4,5 In 2014, fewer Americans died of cancer than in 1999.6 Finally, Americans are living longer than in the 1980s.

Life expectancy is the average number of years that an individual of a particular age can expect to live. In 1990, the life expectancy of an infant in the United States was 75.4 years.7 By 2010, Americans’ life expectancy at birth had increased to 76 years for males and 81 years for females; however, life expectancy at birth decreased slightly between 2014 and 2016.7 Other findings about Americans’ current health status and health-related behaviors, however, are less encouraging. Although the overall rate of cigarette smoking has decreased slightly, consumption of cigars and loose-leaf tobacco (e.g., pipe tobacco) increased from 2000 to 2015. The greatest increase in loose-leaf tobacco consumption occurred after the federal tobacco excise tax increased in 2009, making cigarettes more expensive than loose-leaf tobacco.8 Recently, some laws aimed at tax avoidance strategies have resulted in a slight reduction in loose-leaf tobacco use. Additionally, alcohol abuse is a widespread behavior, particularly among young people.

Tobacco use remains the leading cause of preventable illness and death in the United States. In 2015, adults smoked fewer cigarettes than in 1985, but about 18% of Americans who were 18 years of age and older smoked cigarettes.8 U.S. public health officials are also concerned about Americans who use alcohol irresponsibly. In 2013, excessive alcohol consumption 4

Chapter 1 Health: The Foundation for Life

was the third leading cause of preventable deaths in the United States, including traffic-related fatalities.9 Approximately 17% of adult Americans reported binge drinking in 2016,10 and 18% of high school students reported that they engaged in binge drinking in 2015.11 Binge drinking is defined as consuming five or more alcoholic drinks per occasion for males and four or more drinks per occasion for females. Americans who are 18–24 years of age are more likely to binge drink than other members of the population. According to the results of one study, about one in four college students indicated that their drinking behaviors contributed to serious academic problems, including missing classes, performing poorly on exams, and lowering their grade point averages.12 The ­ typical American does not meet the federal government’s recommendations concerning healthy food choices.

The majority of the U.S. population does not eat enough vegetables, whole grains, fruits, milk, and oils (“healthy” fats).13 An important sign of Americans’ poor nutritional practices is the high prevalence of obesity in the United States. Between 1988 and 1994, 10% of children14 and almost 23% of adults14 were obese. By 2014, 17% of American children and more than 38% of American adults were obese.15 Between 1994 and 2014, the prevalence of obesity increased dramatically among all groups of Americans regardless of their age, sex, race, ethnicity, socioeconomic status, region of the country, and education level.

Excess body fat is associated with the development of many serious diseases, including high blood pressure, heart disease, certain cancers, and type 2 diabetes, a serious disorder characterized by the body’s inability to regulate blood sugar normally.

Although Americans are living longer than in the past, living longer is not always a sign that people are living better. Many older adults suffer from conditions that reduce their ability to enjoy life and perform important daily activities such as bathing and dressing. Heart disease, stroke, cancer, Alzheimer’s disease, impaired vision, hearing loss, osteoporosis, and depression create much misery not only for ­millions of older adults but also for the family members who struggle to care for their disabled relatives.

The results of many studies show that exercising regularly, eating a more nutritious diet, and avoiding smoking and excess alcohol consumption promote good health. Incorporating these and other healthy habits into your lifestyle while you are still young can improve your health and well-being and increase your chances of living a longer and healthier life than your parents and grandparents.

lifestyle A way of living, including behaviors that Lifestyle is a way of living. As a college student,

your lifestyle includes a variety of behaviors that promote or impair good health and longevity. Although you may be unable to prevent severe birth defects or inherited disorders from affecting your health, you can modify many health risk factors, reducing the likelihood that you will develop serious medical problems.

A risk factor is a characteristic that increases an individual’s chances of developing a health problem. For example, physical inactivity, tobacco use, emotional stress, and obesity are risk factors for heart disease, hypertension (persistent high blood pressure), and certain types of cancers. You can dramatically lower your chances of developing these conditions by incorporating exercise into your daily schedule, choosing not to use tobacco products, practicing relaxation techniques, and eating a more nutritious diet.

Are you concerned about your health? What are you doing to protect it? What steps can you take to enhance your state of health so that you can enjoy life more fully? Where can you find reliable information concerning health? This text presents findings from current scientific research for you to use in making choices that will improve your health.

What Is Health?

Most people can describe how it feels to be healthy or ill, but trying to define health is not an easy task.

In 1948, the World Health Organization (WHO)

promote or impair good health and longevity.

risk factor A characteristic that increases an individual’s chances of developing a health problem.

constitution defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”16 Some, however, consider this definition too limited and suggest that health cannot be a state because our health is ever changing. Consider the people in Figure 1.1. Although they are in wheelchairs, they are able to compete as athletes. If you judged their state of health using WHO’s 1948 definition, you might conclude that they are unhealthy. Many physically disabled people are able to function ­adequately in society and do not consider themselves ill or infirm.

The Ottawa Charter for Health Promotion defines health as “a resource for everyday life . . . a positive concept emphasizing social and personal resources, as well as physical capabilities.”17 According to this charter, health requires “peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity.” In addition to these conditions, most healthy adults want to function independently; enjoy eating, sexual, and physical activities; feel good about themselves; and enjoy being with family and friends.

Figure 1.1 Wheelchair Athletes. Many physically disabled people do not consider themselves ill or infirm because they can function well in society. According to Hochbaum’s definition of health, individuals with physical disabilities can be healthy and enjoy life. © Marek Slusarczyk/Shutterstock.

What Is Health?

5

good health The ability to function adequately and independently in a constantly changing environment.

optimal wellness A sense that one is functioning at his or her best level.

holistic (hole-IS-tic) A characteristic involving all aspects of the person.

signs Observable and measurable features of an illness.

symptoms Subjective complaints of illness. acute A condition or illness that tends to develop quickly and resolve within a few days or weeks.

chronic A condition or disease that often takes months or years to develop, progresses in severity, and can affect a person over a long period.

Behavioral scientist Godfrey Hochbaum proposed a simple definition for health: “Health is what helps me be what I want to be . . . do what I want to do . . . [and] live the way I would like to live.”18 Using Hochbaum’s definition, you might conclude that the wheelchair-bound athletes in Figure 1.1 are as healthy as people who are capable of running. In this text, we use concepts from all of these perspectives and define health as “a dynamic state or condition of the human organism that is multidimensional (i.e., physical, emotional, social, intellectual, spiritual, and occupational) in nature, a resource for living, and results from a person’s interactions with and adaptations to his or her environment.”19

Health and Wellness Health and wellness are related concepts. Good health enables one to function adequately and independently in a constantly changing environment; optimal wellness is a sense that one is functioning at one’s best level. Figure 1.2 illustrates the concept of health as a continuum; there are degrees of health.

The absence of functioning (premature death) is at

Premature Death

Loss of Interest in Living

Loss of Function

Signs and Symptoms of Illness

No Disease

one end of this continuum, and the highest level of functioning (optimal well-being) is at the other end.

Many people accept responsibility for the quality of their health and well-being. These people are willing to take various steps to improve their health, achieving a higher degree of wellness in the process.

Most health professionals agree that health and wellness are holistic; that is, they involve all aspects of the individual. Thus, the holistic concept of health encompasses not only the physical, psychological, and social aspects but also the intellectual, spiritual, and environmental dimensions of a person. Each dimension is an integral part of a person’s health, and any change in the quality of one component of health affects the others. For example, individuals who exercise with others to increase their level of physical health often report a sense of improved psychological and social health.

The Components of Health Physical Health Physical health refers to the overall condition of the organ systems, such as the cardiovascular system (heart and blood vessels), respiratory system (lungs), reproductive system, and nervous system. A healthy person’s systems function properly; the individual feels well and is free of disease. When organs do not function adequately, a person has various signs and symptoms of illness. Signs are the observable and measurable features of an illness, such as fever, rash, and abnormal behavior. S ­ ymptoms are the subjective complaints of an illness, such as reports of fatigue, headaches, and numbness. An acute condition or illness, such as the common cold or a foodborne infection, tends to develop quickly and resolve within a few days or weeks. A chronic condition or disease often takes months or years to develop, progresses in severity, and can affect a person over a longer period—in some cases, throughout his or her lifetime.

Personal Adjustment

Personal Growth

Enthusiasm for Living

Optimal Well-Being

Figure 1.2 A Health Continuum. Some people view health as a continuum; that is, there are degrees of health. Premature death is at one end of this continuum, and optimal well-being is at the other end.

Modified from Ebersole, P., & Hess, P. (1994). Toward healthy aging (4th ed.). St. Louis: Mosby.

6

Chapter 1 Health: The Foundation for Life

Psychological Health Psychological (mental) health involves the ability to deal effectively with the psychological challenges of life. Psychologically healthy people accept responsibility for their behavior, feel good about themselves and others, are comfortable with their emotions (feelings), and have positive, realistic outlooks on life. Although experiences such as losing a job or a family member cause stress or grief, psychologically healthy people are able to limit the extent to which crises affect their lives.

Social Health Social health is the sense of wellbeing that an individual achieves by forming emotionally supportive and intellectually stimulating relationships with family members, friends, and associates. Living in communities rather than in isolation, identifying with social groups, and belonging to organizations strengthen the social dimension of health. When social networks break down, health declines.

Intellectual Health Intellectual health is the ability to use problem-solving and other higher order thinking skills to deal effectively with life’s challenges.

Healthy people analyze situations, determine alternative courses of action, and make decisions. After making decisions, intellectually healthy individuals are able to judge the effectiveness of their choices and learn from their experiences. Effective intellectual skills enable people to feel in control of their lives.

Spiritual Health Spiritual health is the belief that one is a part of a larger scheme of life and that one’s life has purpose. Identifying with a religion and

having religious beliefs influence the spiritual health of many people. However, spirituality is not confined to those who belong to organized religious groups or have religious beliefs. People can develop spirituality without practicing a particular religion or believing in the power of a supreme being. Whatever the nature of their spirituality, many individuals achieve a sense of inner peace and harmony, as well as emotional fulfillment, by believing that their lives have a purpose.

As in the other wellness dimensions, a breakdown in spiritual health can have a negative impact on one’s well-being.

Environmental Health Nothing affects the quality of wellness components as much as the state of the environment—the conditions in which people live, work, and play. Environmental concerns that influence wellness include the provision of clean water and air, the management of wastes, and the control of distressing social problems such as crime and family violence. Humans cannot achieve a high degree of wellness if their environment is polluted or unsafe (Figure 1.3).

Figure 1.4 is a model that illustrates how these six components of health are related and integrated into a holistic approach to understanding wellness.

This model has the physical and psychological health components at the core of the larger environmental component. The social, intellectual, and spiritual components involve thought processes; therefore, they are found in the psychological health dimension.

Note how the physical and psychological spheres

Figure 1.3 Environmental Health. The state of the environment in which people live, work, and play affects the quality of their health. People cannot achieve a high degree of wellness if their environment is polluted or unsafe. © Hung Chung Chih/Shutterstock.

What Is Health?

7

Figure 1.4 The Components of Health. The components of health are interrelated. According to this model, the social, intellectual, and spiritual components of health are in the larger spheres of physical and psychological health, which are in the largest sphere of environmental health.

Environmental

Physical

Ps yc h

Social

ua

l

l

l ica og ol

Spirit ua

I n te l l e c

t

of the gross domestic product.20 Americans generally rely on themselves and their employers, as well as private and public health insurance programs, to pay for some of their health care; approximately 10% of Americans younger than 65 years of age were not covered by health insurance in 2015.20 A major illness, serious accident, or hospitalization can quickly exhaust a person’s financial resources and create enormous personal debt; therefore, it is important to have adequate health insurance to cover such expenses. The Affordable Care Act is projected to reduce the number of uninsured A ­ mericans by 30 million by 2022.20

Tracking the Nation’s Health The U.S. government, particularly the Public Health Service of the Department of Health and Human Services, monitors the nation’s health in a variety of ways. One way is by recording cases of certain diseases and causes of death. Table 1.1 shows data for the 10 leading causes of death for all Americans in

Table 1.1 The 10 Major Causes of Death in the United States (2017) overlap to illustrate how the body and mind are closely integrated. When the components of health function well together, the individual has a sense of well-being.

Th e Nation’s Health Health involves more than just personal health— health is a national concern, too. Many of the crucial social, political, and economic issues facing this country are health related, such as domestic violence, terrorism, care of the aged, and access to health care and insurance.

Lack of health insurance and the high cost of health care are major barriers to obtaining routine preventive medical care and proper treatment. The United States spends more on health-related care per person than any other country.7 According to the U.S. Department of Health and Human Services, total healthcare costs reached $3.2 trillion in 2015, or 17.8% of the United States gross domestic product.

By, 2025, healthcare costs are expected to increase by an annual ­average rate of 5.6%, or approximately 20% 8

Chapter 1 Health: The Foundation for Life

Rank

Cause

Approx.

Percentage of Deaths

1

Heart disease

23.4

2

Cancer

22.0

3

Chronic lower respiratory diseases

5.7

4

Accidents/unintentional injuries

5.4

5

Stroke

5.2

6

Alzheimer’s disease

4.1

7

Diabetes mellitus

2.9

8

Pneumonia/influenza

2.1

9

Nephritis

1.8

10

Suicide

1.6

—

Other causes

25.8

Modified from Murphy, S. L., Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015.

National Vital Statistics Reports, 66(6), 1–74.

2015. In the United States, heart disease was the leading cause of death, followed by cancer, chronic lower respiratory disease, and stroke.21 The major causes of death differ for members of various age groups. Table 1.2 shows preliminary data concerning the leading causes of death in two age categories: 15–24 years and 25–44 years. In 2009, unintentional injuries (accidents), homicide, and suicide were the top three leading causes of death of people between 15 and 24 years of age. Note that unintentional injuries, cancer, and heart disease were the top three leading causes of death of people between 25 and 44 years of age.

Over the past 100 years, Americans made great progress toward improving their health, wellbeing, and longevity. In 1900, the life expectancy of a newborn baby was less than 50 years. Compared to people who lived in the first half of the twentieth century, many Americans can now expect to live

Table 1.2 Causes of Death: All Races, Selected Age Groups of Americans (Preliminary Data, 2017) Ages 10–24 Rank

Cause

1

Unintentional injuries

2

Suicide

3

Homicide

4

Cancer

5

Heart disease

longer lives. This progress occurred largely because various government agencies provided greater access to health care, promoted preventive healthcare efforts, funded health education and research programs, and regulated the safety of the environment. For example, childhood vaccination programs have removed the threat of polio and controlled other infectious diseases such as measles, diphtheria, rubella, and tetanus. Food fortification programs have nearly eliminated nutritional deficiency diseases such as goiter, rickets, and pellagra.

Efforts to educate the public concerning the importance of early and routine prenatal care (medical care for pregnant women) have helped reduce the infant death rate.

Although the life expectancy of Americans has increased, many people still die prematurely, that is, before they reach 75 years of age. According to health experts at the Centers for Disease Control and Prevention in Atlanta, actual causes of death are the underlying reasons that are not reported on death certificates. In 2015, for example, about 17% of all deaths were the result of drug use, and alcohol and firearm-related incidents accounted for about 20% of deaths.21 However, tables that list leading causes of death, such as Table 1.1, integrate those deaths with the number of deaths resulting primarily from heart disease, cancer, chronic lower respiratory diseases, and stroke. Health experts predict that the combination of poor diet and physical inactivity will soon replace tobacco use as the leading actual cause of death in the United States. In many instances, actual causes of death are associated with lifestyle choices, such as tobacco use or physical inactivity. By changing these and other health-related behaviors, people may avoid dying prematurely.

Rank

Cause

1

Unintentional injuries

2

Cancer

3

Heart disease

4

Suicide

5

Homicide

Courtesy of James Gathany/Judy Schmidt/CDC.

Ages 25–44

Modified from Murphy, S. L., Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015.

National Vital Statistics Reports, 66(6), 1–74.

The Nation’s Health

9

Health Promotion: Development of Healthy People 2020 Health promotion is the practice of helping people become healthier by encouraging them to take more control over their health and change their lifestyles.

Health promotion efforts strive to prevent rather than treat disease and injury. Federal, state, and local governments can help the population develop healthy lifestyles by funding and providing educational programs and preventive medical care services. When planning effective health promotional programs, public health experts and government officials need to identify which aspects of the population’s health should receive the most attention. How does the federal government identify serious health concerns and monitor the health of its citizens? What is being done to improve the nation’s health?

In the late 1980s, a team of concerned health experts, health educators, and U.S. government officials analyzed the results of reports, recommendations, and studies that provided data concerning the health status of Americans. In 1991, these experts published their findings in a report called Healthy People 2000.22 Healthy People 2000 had three general goals: increase the healthy life span of Americans, improve the health status of American minorities, and extend the accessibility of preventive health services to all Americans. Healthy People 2000 also established numerous health-related objectives that related to each goal, such as increasing the percentage of children who engaged in 20 minutes or more of vigorous physical activity at least 3 days a week. The overall aim was for Americans to achieve the health objectives by the year 2000; as more Healthy People 2000 objectives were met, the overall health status of Americans would improve. By 2000, public health experts had collected and analyzed information about the population’s progress toward achieving the health objectives, and the data were used for the publication of a revised set of goals and objectives. This process would be repeated approximately every 10 years. In 2000, the federal government released the second edition of the plan, Healthy People 2010. The analysis of data obtained from Healthy People 2010 led to the publication of Healthy People 2020, the third and latest edition of the national health goals and objectives.

Table 1.3 indicates the four main goals of Healthy People 2020 and factors that will be measured to monitor progress toward meeting those goals.

Healthy People 2020 identifies 42 “objective topic 10

Chapter 1 Health: The Foundation for Life

Table 1.3 Healthy People 2020: Foundation Health Measures Main Goals of Healthy People 2020

Measures of Progress

General Health Status Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death

Life expectancy; healthy life expectancy Years of potential life lost Physically and mentally unhealthy days Self-assessed health status Limitation of activity Chronic disease prevalence

Disparities and Inequity Achieve health equity, eliminate disparities, and improve the health of all groups

Race/ethnicity Socioeconomic factors Natural and built environments Policies and programs

Social Determinants of Health Create social and physical environments that promote good health for all

Social and economic factors Natural and built environments Policies and programs

Health-Related Quality of Life and Well-Being Promote quality of life, healthy development, and healthy behaviors

Self-reports of well-being and satisfaction Quality of life Participation in common activities

Modified from U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy People 2020. Available at: http://www.healthypeople.gov/2020/about /Foundation-Health-Measures.

areas,” including “physical activity” and “injury and violence prevention,” as well as nearly 600 health objectives. An objective identifies target populations and a specific health concern. One of the physical activity objectives, for example, is, “Increase the proportion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle strengthening activity.”

Staff of various federal, state, and local agencies are responsible for developing and implementing health education efforts, such as community and

genes Segments of DNA that code for specific

school-based programs to reduce the prevalence of childhood obesity, that support Healthy People 2020 objectives. In addition, staff will monitor Americans’ progress in meeting these health objectives. You can learn more about Healthy People 2020 by visiting the government’s web site: www.healthypeople.gov/2020 /default.aspx.

Minority Health Status For hundreds of years, immigrants from around the world have been changing the face of the United States as they settle in this country. Each new group of immigrants brings different cultural traditions and various ethnic identities with them (Figure 1.5). Culture consists of the unique social characteristics of a population, such as its customs, rituals, and health beliefs and practices, which are passed down from generation to generation. An ethnic group is one in which members share a common national, religious, racial, or ancestral identity. According to the U.S. Department of Health and Human Services, the major

Figure 1.5 An American Family. Culture consists of the unique social characteristics of a population, such as its customs, rituals, and health practices. Immigrants who settle in the United States contribute much to the racial, ethnic, and cultural diversity of the population. © digitalskillet/Shutterstock.

proteins.

American racial/ethnic subpopulations are Caucasians (Whites), African Americans (Blacks), Latinos (Hispanics), American Indian/Alaska Natives, and Asian/Pacific Islanders. The same terms, however, are not used by all agencies. Throughout this text, terms such as Caucasian may be used in one context and Whites in another when reporting statistics or results of research studies; the text reflects the language of the agency or researcher.

In the United States, the majority of Americans have European ancestry, particularly northern European.

The National Center for Health Statistics refers to this population as “White, non-Hispanic.” In 2017, 61.3% of the U.S. population identified itself as “White, not Hispanic”; 13.3% identified as Black or African ­American; and 17.8% identified as Hispanic or Latino.23 Differences in death and illness rates between the nation’s men and women, as well as among its diverse ethnic and racial groups, are major public health concerns. For example, American men generally do not live as long as American women and are more likely to die from each of the 10 leading causes of death.

More African Americans die of cancers and diseases of the heart and blood vessels than do members of other ethnic and racial groups. The reasons for these differences are unclear, but socioeconomic status, environmental conditions, and lifestyle choices are major contributing factors. The term minority, however, is not strictly limited to race or ethnicity. In the United States, minority groups also include religious minorities (e.g., Mormons, Muslims), sexual minorities (e.g., lesbian, gay, bisexual, and transgender), age minorities (e.g., the very young or very old), and people with disabilities (e.g., those with autism).

The Diversity in Health essay addresses topics that concern a variety of populations in the United States and around the world. The Diversity in Health essay in this chapter, “Minority Health Status in the United States,” discusses differences in the overall health of major minority groups in the United States.

Genetics and Genomics Your lifestyle and environment influence your health status, but your genes also play a role in determining your health. With the exception of red blood cells, all cells in your body contain genes. Genes are segments Genetics and Genomics

11

genomics (JEE-nom-iks) The scientific study of an organism’s entire set of genes.

of DNA, a complex chemical compound that codes for the production of proteins. Cells use proteins for a variety of functions, including building, maintaining, and repairing structures, such as bones and other tissues. Mistakes in the genetic code can result in the production of faulty proteins that can cause disease and even death. Genes are inherited, that is, their coded instructions for protein synthesis are passed on to subsequent generations.

Genetics is the scientific study of genes and the way they pass certain traits, such as the risk of breast cancer, or medical conditions, such as birth defects, from one generation to another. Thus, genetics can help people understand how certain life-threatening medical conditions, including sickle cell anemia and cystic fibrosis, tend to “run in families.” Scientists have developed tests to identify the gene or genes for hundreds of diseases, most of which are rare genetic disorders, such as Duchenne muscular dystrophy and certain breast and ovarian cancers.

Most of the 10 leading causes of death in the United States, particularly heart disease, cancer, stroke, diabetes, and Alzheimer’s disease, have a

A gene is a segment of DNA. © Hemera/Thinkstock.

12

Chapter 1 Health: The Foundation for Life

genetic component. Unlike cases of rare genetic conditions, these common chronic diseases generally develop partly as a result of multiple genes interacting with behavioral and environmental risk factors, such as poor food choices, lack of physical activity, and exposure to tobacco smoke.

Genomics is the study of all of a person’s genes (genome), including the complex ways the genes interact with each other and the environment to influence the individual’s health. A person’s genome can provide medical researchers with important biological clues about the individual’s health status, disease risk, and responses to treatments. Scientific analysis of individual genomes may help explain why people who share similar environments or healthrelated behaviors do not always develop the same health conditions.

Genes play roles in a person’s ability to achieve and maintain good health. Medical researchers use genetics to learn more about diseases that are caused by genes. Researchers use genomics to understand how multiple genes contribute to the development of ­complex diseases and how these particular genes interact with other factors, such as lifestyle and environment. As a result of such analyses, medical researchers can develop better ways to prevent, diagnose, and treat diseases.

Genomics is a relatively new science, and genomic testing, which involves combinations of biochemical and molecular methods to analyze a cell’s genes, has the potential to improve the health of individuals. However, the value of genomic testing for diagnosing, predicting, and treating common chronic diseases has not been established. Public health experts are concerned about personal genomic tests that are directly marketed to consumers through the Internet and other media outlets. At present, very little scientific evidence supports the validity and usefulness of the results of such direct-to-consumer genomic tests.

More research is needed to establish the usefulness of adding information obtained by genomic testing to the standard medical history that healthcare practitioners routinely collect from their patients. Maintaining a record of your health history can help you make a positive contribution to your medical care. How? When you share this information with your physicians, the medical practitioners can consider inherited factors to predict your risk of certain chronic diseases and develop ways (interventions) to help you prevent or forestall those diseases.

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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least the Newala of to-day does; there was once another Newala in a lovely valley at the foot of the plateau. I visited it and found scarcely a trace of houses, only a Christian cemetery, with the graves of several missionaries and their converts, remaining as a monument of its former glories. But the surroundings are wonderfully beautiful. A thick grove of splendid mango-trees closes in the weather-worn crosses and headstones; behind them, combining the useful and the agreeable, is a whole plantation of lemon-trees covered with ripe fruit; not the small African kind, but a much larger and also juicier imported variety, which drops into the hands of the passing traveller, without calling for any exertion on his part. Old Newala is now under the jurisdiction of the native pastor, Daudi, at Chingulungulu, who, as I am on very friendly terms with him, allows me, as a matter of course, the use of this lemon-grove during my stay at Newala.

FEET MUTILATED BY THE RAVAGES OF THE “JIGGER” (Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley, some 1,600 feet lower down. The way is not only long and fatiguing, but the water, when we get it, is thoroughly bad. We are suffering not only from this, but from the fact that the arrangements at Newala are nothing short of luxurious. We have a separate kitchen—a hut built against the boma palisade on the right of the baraza, the interior of which is not visible from our usual position. Our two cooks were not long in finding this out, and they consequently do—or rather neglect to do—what they please. In any case they do not seem to be very particular about the boiling of our drinking-water—at least I can attribute to no other cause certain attacks of a dysenteric nature, from which both Knudsen and I have suffered for some time. If a man like Omari has to be left unwatched for a moment, he is capable of anything. Besides this complaint, we are inconvenienced by the state of our nails, which have become as hard as glass, and crack on the slightest provocation, and I have the additional infliction of pimples all over me. As if all this were not enough, we have also, for the last week been waging war against the jigger, who has found his Eldorado in the hot sand of the Makonde plateau. Our men are seen all day long—whenever their chronic colds and the dysentery likewise raging among them permit—occupied in removing this scourge of Africa from their feet and trying to prevent the disastrous consequences of its presence. It is quite common to see natives of this place with one or two toes missing; many have lost all their toes,

or even the whole front part of the foot, so that a well-formed leg ends in a shapeless stump. These ravages are caused by the female of Sarcopsylla penetrans, which bores its way under the skin and there develops an egg-sac the size of a pea. In all books on the subject, it is stated that one’s attention is called to the presence of this parasite by an intolerable itching. This agrees very well with my experience, so far as the softer parts of the sole, the spaces between and under the toes, and the side of the foot are concerned, but if the creature penetrates through the harder parts of the heel or ball of the foot, it may escape even the most careful search till it has reached maturity.

Then there is no time to be lost, if the horrible ulceration, of which we see cases by the dozen every day, is to be prevented. It is much easier, by the way, to discover the insect on the white skin of a European than on that of a native, on which the dark speck scarcely shows. The four or five jiggers which, in spite of the fact that I constantly wore high laced boots, chose my feet to settle in, were taken out for me by the all-accomplished Knudsen, after which I thought it advisable to wash out the cavities with corrosive sublimate. The natives have a different sort of disinfectant—they fill the hole with scraped roots. In a tiny Makua village on the slope of the plateau south of Newala, we saw an old woman who had filled all the spaces under her toe-nails with powdered roots by way of prophylactic treatment. What will be the result, if any, who can say?

The rest of the many trifling ills which trouble our existence are really more comic than serious. In the absence of anything else to smoke, Knudsen and I at last opened a box of cigars procured from the Indian store-keeper at Lindi, and tried them, with the most distressing results. Whether they contain opium or some other narcotic, neither of us can say, but after the tenth puff we were both “off,” three-quarters stupefied and unspeakably wretched. Slowly we recovered—and what happened next? Half-an-hour later we were once more smoking these poisonous concoctions—so insatiable is the craving for tobacco in the tropics.

Even my present attacks of fever scarcely deserve to be taken seriously. I have had no less than three here at Newala, all of which have run their course in an incredibly short time. In the early afternoon, I am busy with my old natives, asking questions and making notes. The strong midday coffee has stimulated my spirits to

an extraordinary degree, the brain is active and vigorous, and work progresses rapidly, while a pleasant warmth pervades the whole body. Suddenly this gives place to a violent chill, forcing me to put on my overcoat, though it is only half-past three and the afternoon sun is at its hottest. Now the brain no longer works with such acuteness and logical precision; more especially does it fail me in trying to establish the syntax of the difficult Makua language on which I have ventured, as if I had not enough to do without it. Under the circumstances it seems advisable to take my temperature, and I do so, to save trouble, without leaving my seat, and while going on with my work. On examination, I find it to be 101·48°. My tutors are abruptly dismissed and my bed set up in the baraza; a few minutes later I am in it and treating myself internally with hot water and lemon-juice.

Three hours later, the thermometer marks nearly 104°, and I make them carry me back into the tent, bed and all, as I am now perspiring heavily, and exposure to the cold wind just beginning to blow might mean a fatal chill. I lie still for a little while, and then find, to my great relief, that the temperature is not rising, but rather falling. This is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment, that it has fallen below 98·6°, and I feel perfectly well. I read for an hour or two, and could very well enjoy a smoke, if I had the wherewithal—Indian cigars being out of the question.

Having no medical training, I am at a loss to account for this state of things. It is impossible that these transitory attacks of high fever should be malarial; it seems more probable that they are due to a kind of sunstroke. On consulting my note-book, I become more and more inclined to think this is the case, for these attacks regularly follow extreme fatigue and long exposure to strong sunshine. They at least have the advantage of being only short interruptions to my work, as on the following morning I am always quite fresh and fit.

My treasure of a cook is suffering from an enormous hydrocele which makes it difficult for him to get up, and Moritz is obliged to keep in the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy from somewhere in the bush, knows still less of cooking than Omari; consequently Nils Knudsen himself has been promoted to the vacant post. Finding that we had come to the end of our supplies, he began by sending to Chingulungulu for the four sucking-pigs which we had

bought from Matola and temporarily left in his charge; and when they came up, neatly packed in a large crate, he callously slaughtered the biggest of them. The first joint we were thoughtless enough to entrust for roasting to Knudsen’s mshenzi cook, and it was consequently uneatable; but we made the rest of the animal into a jelly which we ate with great relish after weeks of underfeeding, consuming incredible helpings of it at both midday and evening meals. The only drawback is a certain want of variety in the tinned vegetables. Dr. Jäger, to whom the Geographical Commission entrusted the provisioning of the expeditions—mine as well as his own—because he had more time on his hands than the rest of us, seems to have laid in a huge stock of Teltow turnips,[46] an article of food which is all very well for occasional use, but which quickly palls when set before one every day; and we seem to have no other tins left. There is no help for it—we must put up with the turnips; but I am certain that, once I am home again, I shall not touch them for ten years to come.

Amid all these minor evils, which, after all, go to make up the genuine flavour of Africa, there is at least one cheering touch: Knudsen has, with the dexterity of a skilled mechanic, repaired my 9 × 12 cm. camera, at least so far that I can use it with a little care.

How, in the absence of finger-nails, he was able to accomplish such a ticklish piece of work, having no tool but a clumsy screw-driver for taking to pieces and putting together again the complicated mechanism of the instantaneous shutter, is still a mystery to me; but he did it successfully. The loss of his finger-nails shows him in a light contrasting curiously enough with the intelligence evinced by the above operation; though, after all, it is scarcely surprising after his ten years’ residence in the bush. One day, at Lindi, he had occasion to wash a dog, which must have been in need of very thorough cleansing, for the bottle handed to our friend for the purpose had an extremely strong smell. Having performed his task in the most conscientious manner, he perceived with some surprise that the dog did not appear much the better for it, and was further surprised by finding his own nails ulcerating away in the course of the next few days. “How was I to know that carbolic acid has to be diluted?” he mutters indignantly, from time to time, with a troubled gaze at his mutilated finger-tips.

Since we came to Newala we have been making excursions in all directions through the surrounding country, in accordance with old habit, and also because the akida Sefu did not get together the tribal elders from whom I wanted information so speedily as he had promised. There is, however, no harm done, as, even if seen only from the outside, the country and people are interesting enough.

The Makonde plateau is like a large rectangular table rounded off at the corners. Measured from the Indian Ocean to Newala, it is about seventy-five miles long, and between the Rovuma and the Lukuledi it averages fifty miles in breadth, so that its superficial area is about two-thirds of that of the kingdom of Saxony. The surface, however, is not level, but uniformly inclined from its south-western edge to the ocean. From the upper edge, on which Newala lies, the eye ranges for many miles east and north-east, without encountering any obstacle, over the Makonde bush. It is a green sea, from which here and there thick clouds of smoke rise, to show that it, too, is inhabited by men who carry on their tillage like so many other primitive peoples, by cutting down and burning the bush, and manuring with the ashes. Even in the radiant light of a tropical day such a fire is a grand sight.

Much less effective is the impression produced just now by the great western plain as seen from the edge of the plateau. As often as time permits, I stroll along this edge, sometimes in one direction, sometimes in another, in the hope of finding the air clear enough to let me enjoy the view; but I have always been disappointed.

Wherever one looks, clouds of smoke rise from the burning bush, and the air is full of smoke and vapour. It is a pity, for under more favourable circumstances the panorama of the whole country up to the distant Majeje hills must be truly magnificent. It is of little use taking photographs now, and an outline sketch gives a very poor idea of the scenery. In one of these excursions I went out of my way to make a personal attempt on the Makonde bush. The present edge of the plateau is the result of a far-reaching process of destruction through erosion and denudation. The Makonde strata are everywhere cut into by ravines, which, though short, are hundreds of yards in depth. In consequence of the loose stratification of these beds, not only are the walls of these ravines nearly vertical, but their upper end is closed by an equally steep escarpment, so that the

western edge of the Makonde plateau is hemmed in by a series of deep, basin-like valleys. In order to get from one side of such a ravine to the other, I cut my way through the bush with a dozen of my men.

It was a very open part, with more grass than scrub, but even so the short stretch of less than two hundred yards was very hard work; at the end of it the men’s calicoes were in rags and they themselves bleeding from hundreds of scratches, while even our strong khaki suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR MAHUTA

I see increasing reason to believe that the view formed some time back as to the origin of the Makonde bush is the correct one. I have no doubt that it is not a natural product, but the result of human occupation. Those parts of the high country where man—as a very slight amount of practice enables the eye to perceive at once—has not yet penetrated with axe and hoe, are still occupied by a splendid timber forest quite able to sustain a comparison with our mixed forests in Germany. But wherever man has once built his hut or tilled his field, this horrible bush springs up. Every phase of this process

may be seen in the course of a couple of hours’ walk along the main road. From the bush to right or left, one hears the sound of the axe— not from one spot only, but from several directions at once. A few steps further on, we can see what is taking place. The brush has been cut down and piled up in heaps to the height of a yard or more, between which the trunks of the large trees stand up like the last pillars of a magnificent ruined building. These, too, present a melancholy spectacle: the destructive Makonde have ringed them— cut a broad strip of bark all round to ensure their dying off—and also piled up pyramids of brush round them. Father and son, mother and son-in-law, are chopping away perseveringly in the background—too busy, almost, to look round at the white stranger, who usually excites so much interest. If you pass by the same place a week later, the piles of brushwood have disappeared and a thick layer of ashes has taken the place of the green forest. The large trees stretch their smouldering trunks and branches in dumb accusation to heaven—if they have not already fallen and been more or less reduced to ashes, perhaps only showing as a white stripe on the dark ground.

This work of destruction is carried out by the Makonde alike on the virgin forest and on the bush which has sprung up on sites already cultivated and deserted. In the second case they are saved the trouble of burning the large trees, these being entirely absent in the secondary bush.

After burning this piece of forest ground and loosening it with the hoe, the native sows his corn and plants his vegetables. All over the country, he goes in for bed-culture, which requires, and, in fact, receives, the most careful attention. Weeds are nowhere tolerated in the south of German East Africa. The crops may fail on the plains, where droughts are frequent, but never on the plateau with its abundant rains and heavy dews. Its fortunate inhabitants even have the satisfaction of seeing the proud Wayao and Wamakua working for them as labourers, driven by hunger to serve where they were accustomed to rule.

But the light, sandy soil is soon exhausted, and would yield no harvest the second year if cultivated twice running. This fact has been familiar to the native for ages; consequently he provides in time, and, while his crop is growing, prepares the next plot with axe and firebrand. Next year he plants this with his various crops and

lets the first piece lie fallow. For a short time it remains waste and desolate; then nature steps in to repair the destruction wrought by man; a thousand new growths spring out of the exhausted soil, and even the old stumps put forth fresh shoots. Next year the new growth is up to one’s knees, and in a few years more it is that terrible, impenetrable bush, which maintains its position till the black occupier of the land has made the round of all the available sites and come back to his starting point.

The Makonde are, body and soul, so to speak, one with this bush.

According to my Yao informants, indeed, their name means nothing else but “bush people.” Their own tradition says that they have been settled up here for a very long time, but to my surprise they laid great stress on an original immigration. Their old homes were in the south-east, near Mikindani and the mouth of the Rovuma, whence their peaceful forefathers were driven by the continual raids of the Sakalavas from Madagascar and the warlike Shirazis[47] of the coast, to take refuge on the almost inaccessible plateau. I have studied African ethnology for twenty years, but the fact that changes of population in this apparently quiet and peaceable corner of the earth could have been occasioned by outside enterprises taking place on the high seas, was completely new to me. It is, no doubt, however, correct.

The charming tribal legend of the Makonde—besides informing us of other interesting matters—explains why they have to live in the thickest of the bush and a long way from the edge of the plateau, instead of making their permanent homes beside the purling brooks and springs of the low country.

“The place where the tribe originated is Mahuta, on the southern side of the plateau towards the Rovuma, where of old time there was nothing but thick bush. Out of this bush came a man who never washed himself or shaved his head, and who ate and drank but little.

He went out and made a human figure from the wood of a tree growing in the open country, which he took home to his abode in the bush and there set it upright. In the night this image came to life and was a woman. The man and woman went down together to the Rovuma to wash themselves. Here the woman gave birth to a stillborn child. They left that place and passed over the high land into the valley of the Mbemkuru, where the woman had another child, which

was also born dead. Then they returned to the high bush country of Mahuta, where the third child was born, which lived and grew up. In course of time, the couple had many more children, and called themselves Wamatanda. These were the ancestral stock of the Makonde, also called Wamakonde,[48] i.e., aborigines. Their forefather, the man from the bush, gave his children the command to bury their dead upright, in memory of the mother of their race who was cut out of wood and awoke to life when standing upright. He also warned them against settling in the valleys and near large streams, for sickness and death dwelt there. They were to make it a rule to have their huts at least an hour’s walk from the nearest wateringplace; then their children would thrive and escape illness.”

The explanation of the name Makonde given by my informants is somewhat different from that contained in the above legend, which I extract from a little book (small, but packed with information), by Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my results agree exactly with the statements of the legend. Washing?

Hapana—there is no such thing. Why should they do so? As it is, the supply of water scarcely suffices for cooking and drinking; other people do not wash, so why should the Makonde distinguish himself by such needless eccentricity? As for shaving the head, the short, woolly crop scarcely needs it,[49] so the second ancestral precept is likewise easy enough to follow. Beyond this, however, there is nothing ridiculous in the ancestor’s advice. I have obtained from various local artists a fairly large number of figures carved in wood, ranging from fifteen to twenty-three inches in height, and representing women belonging to the great group of the Mavia, Makonde, and Matambwe tribes. The carving is remarkably well done and renders the female type with great accuracy, especially the keloid ornamentation, to be described later on. As to the object and meaning of their works the sculptors either could or (more probably) would tell me nothing, and I was forced to content myself with the scanty information vouchsafed by one man, who said that the figures were merely intended to represent the nembo—the artificial deformations of pelele, ear-discs, and keloids. The legend recorded

by Pater Adams places these figures in a new light. They must surely be more than mere dolls; and we may even venture to assume that they are—though the majority of present-day Makonde are probably unaware of the fact—representations of the tribal ancestress.

The references in the legend to the descent from Mahuta to the Rovuma, and to a journey across the highlands into the Mbekuru valley, undoubtedly indicate the previous history of the tribe, the travels of the ancestral pair typifying the migrations of their descendants. The descent to the neighbouring Rovuma valley, with its extraordinary fertility and great abundance of game, is intelligible at a glance—but the crossing of the Lukuledi depression, the ascent to the Rondo Plateau and the descent to the Mbemkuru, also lie within the bounds of probability, for all these districts have exactly the same character as the extreme south. Now, however, comes a point of especial interest for our bacteriological age. The primitive Makonde did not enjoy their lives in the marshy river-valleys.

Disease raged among them, and many died. It was only after they had returned to their original home near Mahuta, that the health conditions of these people improved. We are very apt to think of the African as a stupid person whose ignorance of nature is only equalled by his fear of it, and who looks on all mishaps as caused by evil spirits and malignant natural powers. It is much more correct to assume in this case that the people very early learnt to distinguish districts infested with malaria from those where it is absent.

This knowledge is crystallized in the ancestral warning against settling in the valleys and near the great waters, the dwelling-places of disease and death. At the same time, for security against the hostile Mavia south of the Rovuma, it was enacted that every settlement must be not less than a certain distance from the southern edge of the plateau. Such in fact is their mode of life at the present day. It is not such a bad one, and certainly they are both safer and more comfortable than the Makua, the recent intruders from the south, who have made USUAL METHOD OF good their footing on the western edge of the CLOSING HUT-DOOR plateau, extending over a fairly wide belt of country. Neither Makua nor Makonde show in their dwellings anything of the size and comeliness of the Yao houses in the plain, especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a Makonde hamlet not far from Newala, on the road to Mahuta, is the

most important settlement of the tribe I have yet seen, and has fairly spacious huts. But how slovenly is their construction compared with the palatial residences of the elephant-hunters living in the plain.

The roofs are still more untidy than in the general run of huts during the dry season, the walls show here and there the scanty beginnings or the lamentable remains of the mud plastering, and the interior is a veritable dog-kennel; dirt, dust and disorder everywhere. A few huts only show any attempt at division into rooms, and this consists merely of very roughly-made bamboo partitions. In one point alone have I noticed any indication of progress—in the method of fastening the door. Houses all over the south are secured in a simple but ingenious manner. The door consists of a set of stout pieces of wood or bamboo, tied with bark-string to two cross-pieces, and moving in two grooves round one of the door-posts, so as to open inwards. If the owner wishes to leave home, he takes two logs as thick as a man’s upper arm and about a yard long. One of these is placed obliquely against the middle of the door from the inside, so as to form an angle of from 60° to 75° with the ground. He then places the second piece horizontally across the first, pressing it downward with all his might.

It is kept in place by two strong posts planted in the ground a few inches inside the door. This fastening is absolutely safe, but of course cannot be applied to both doors at once, otherwise how could the owner leave or enter his house? I have not yet succeeded in finding out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe Chauro, however, have a much more complicated, solid and original one. Here, too, the door is as already described, except that there is only one post on the inside, standing by itself about six inches from one side of the doorway. Opposite this post is a hole in the wall just large enough to admit a man’s arm. The door is closed inside by a large wooden bolt passing through a hole in this post and pressing with its free end against the door. The other end has three holes into which fit three pegs running in vertical grooves inside the post. The door is opened with a wooden key about a foot long, somewhat curved and sloped off at the butt; the other end has three pegs corresponding to the holes, in the bolt, so that, when it is thrust through the hole in the wall and inserted into the rectangular opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second showed me on the spot the action of this greatest invention of the Makonde Highlands. To both with an admiring exclamation of “Vizuri sana!” (“Very fine!”). I expressed the wish to take back these marvels with me to Ulaya, to show the Wazungu what clever fellows the Makonde are. Scarcely five minutes after my return to camp at Newala, the two men came up sweating under the weight of two heavy logs which they laid down at my feet, handing over at the same time the keys of the fallen fortress. Arguing, logically enough, that if the key was wanted, the lock would be wanted with it, they had taken their axes and chopped down the posts—as it never occurred to them to dig them out of the ground and so bring them intact. Thus I have

two badly damaged specimens, and the owners, instead of praise, come in for a blowing-up.

The Makua huts in the environs of Newala are especially miserable; their more than slovenly construction reminds one of the temporary erections of the Makua at Hatia’s, though the people here have not been concerned in a war. It must therefore be due to congenital idleness, or else to the absence of a powerful chief. Even the baraza at Mlipa’s, a short hour’s walk south-east of Newala, shares in this general neglect. While public buildings in this country are usually looked after more or less carefully, this is in evident danger of being blown over by the first strong easterly gale. The only attractive object in this whole district is the grave of the late chief Mlipa. I visited it in the morning, while the sun was still trying with partial success to break through the rolling mists, and the circular grove of tall euphorbias, which, with a broken pot, is all that marks the old king’s resting-place, impressed one with a touch of pathos.

Even my very materially-minded carriers seemed to feel something of the sort, for instead of their usual ribald songs, they chanted solemnly, as we marched on through the dense green of the Makonde bush:—