Access to Health, 12E Rebecca J Donatelle Solution Manuals

Type:

Solution Manual

Resource:

Access to Health

Edition:

12th Edition

Author(s):

Rebecca J. Donatelle

CHAPTER

1

Accessing Your Health

Overview Health and wellness are active states that are deeply affected by one’s style of living. Being healthy requires us to make choices about our lives. These choices include deciding which of our behaviors we should change and which of our behaviors should be maintained in order to maximize our health. Chapter 1 introduces us to a basic understanding of the concept of health, describing the six dimensions of health and helping the reader to understand how they relate to form a dynamic process of achieving one’s health potential. A major focus of Chapter 1 is the concept of healthy decision making. Several theories are discussed, including Prochaska and DiClemente’s “Stages of Change” model, and the Health Belief Model. These models are used throughout the text to help the student make healthy choices.

Learning Objectives 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. Identify several personal factors that influence your health and classify them as modifiable or nonmodifiable.

4. Explain how aspects of the social and physical environment influence your health.

5. Discuss the importance of a global perspective on health, and explain how gender, racial, economic, and cultural factors influence health disparities.

6. Compare and contrast three models of behavior change.

7. 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 1. The subtle choices you make daily influence your life, your future, and the well-being of others.

2. Health is intimately linked to—and influenced by—almost everything in the world.

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3. Identifying the health-related behaviors you’d like to change and moving toward that change can have immediate benefits.

B. Choose Health Now for Long-Term Rewards 1. Personal choices influence your life expectancy. a. Mortality statistics reflect the proportion of deaths in a population. b. Life expectancy is the expected number of years of life remaining at a given age, such as birth. The average life expectancy at birth in the United States is projected to be 78.3 years for a child born in 2010. c. Leading causes of death have shifted from infectious diseases to chronic diseases such as heart disease, cerebrovascular disease, cancer, and diabetes. d. It is thought that today’s newborns may be the first generation to have lower life expectancy than their parents.

2. Personal choices influence your healthy life expectancy. a. Healthy life expectancy is the expected number of years of full health you enjoy, without disability, chronic pain, or significant illness.

C. Choose Health Now to Benefit Others 1. Health choices influence the global burden of disease in the form of direct and indirect costs to the public as well as an individual.

2. The ethical dilemma is: individual health choices cost society, so to what extent should the public be accountable for an individual’s poor health choices?

Key Terms: mortality, life expectancy, chronic disease, healthy life expectancy Figures and Tables:

Figure 1.1 Top Ten Reported Impediments to Academic Performance—Past 12 Months

Table 1.1 Leading Causes of Death in the United States, 2007, Overall and by Age Group (15 and older)

Additional Instructor Resources: PPT slides: 1–8; Digital Transparency Masters: Figure 1.1, Table 1.1

II. What is Health?

A. The current model of health includes the ever-changing process of achieving individual potential in the physical, social, emotional, mental, spiritual, and environmental dimensions.

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B. Models of Health 1. Medical Model a. The medical model focuses primarily on the individual and a biological or disease organ perspective.

2. Public Health Model a. The ecological or 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. In 1947, the World Health Organization (WHO) defined health as “the state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” c. Alongside disease prevention, the public health model emphasizes health promotion, that is, polices and programs that promote behaviors known to support good health.

C. Wellness and the Dimensions of Health 1. In 1968, biologist, environmentalist, and philosopher 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.”

2. The word wellness further enlarged Dubo’s definition of health by recognizing levels—or gradations—of health within each category.

3. 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 move to the illness side of the continuum.

4. Today, the words health and wellness are often used interchangeably to mean the dynamic, ever-changing process of trying to achieve one’s potential in each of the six interrelated dimensions, which typically include the following: a. Physical health refers to such aspects as body functioning, resistance to disease, the ability to recuperate, and physical fitness. This includes our ability to perform normal activities of daily living (ADLs). b. Social health is the ability to have satisfying relationships and adapt to various social situations. c. Intellectual health is the ability to think clearly, reason objectively, analyze critically, and use brain power effectively to meet life’s challenges. d. Emotional health is the ability to express and control emotions appropriately. This includes self-esteem, self-efficacy, trust, and love. e. Environmental health is the appreciation of the external environment and working to preserve, protect, and improve it. f. Spiritual health is a feeling of oneness with others and nature, a sense of meaning or value in life, and a willingness to express one’s purpose and contribute to the world.

It may include experiencing love, joy, and wonder over life’s experiences.

5. Adapting a holistic approach means you are integrating a balance of mind, body, and spirit.

6. Mind–body health goal seekers actively work to improve other dimensions of life.

Key Terms: health, medical model, ecological or public health model, disease prevention, health promotion, risk behaviors, wellness Copyright © 2012 Pearson Education, Inc.

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Figures and Tables:

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

Additional Instructor Resources: PPT slides: 9–13; Digital Transparency Masters: Figure 1.2, Figure 1.3, Figure 1.4

III. What Influences Your Health?

A. Public health experts refer to the factors that influence health as determinants of health, a term the United States Surgeon General defines as “the array of critical influences that determine the health of individuals and communities.”

B. In 1990, the Surgeon General proposed a plan for improving health called Healthy People, which has been published every 10 years since, and outlines a series of long-term objectives.

C. Healthy People classifies health determinants into five groupings: 1. Individual biology and behavior 2. The social environment 3. The physical environment 4. Policies and interventions 5. Access to quality health care D. Individual Biology and Behavior 1. Biology refers to one’s genetics, age, ethnicity, genetics, and gender. For more information on physiological differences between men and women, please see page 11, Gender & Health box.

2. Biological determinants are things that one cannot change or modify, commonly referred to as nonmodifiable determinants.

3. Behaviors are our responses to internal and external conditions.

4. Behaviors are things you can change and are referred to as modifiable determinants.

5. Modifiable determinants are responsible for most illness, examples include: a. Lack of physical activity. b. Poor nutrition. c. Excessive alcohol consumption. d. Tobacco use.

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E. Social Environment 1. Your social environment includes your interactions with family, friends, coworkers, other students, and the people who make up your community.

2. Among the most influential social health determinants are economic factors.

F. Physical Environment 1. The built environment includes anything created or modified by human beings.

2. Pollutants and infectious agents can affect local communities and people around the world. For more information on how the global environment affects our health, please see page 13, Be Healthy, Be Green box. a. There are many benefits to the globalization of economic, social, behavioral, scientific, and technological factors; however, there are also drawbacks, including movement of infectious diseases across the globe (as in the newest strain of cold), contaminated foods, and so forth.

G. Policies and Interventions 1. Public policies and interventions are designed to enhance health among individuals and communities. Examples include: seat belt use, vaccination programs, and public funding for mental health services.

H. Access to Quality Health Care 1. Access to quality health care services, accurate information, and products significantly influence health.

2. Access to quality health care can be related to economics as well as public policies and interventions related to health insurance and sponsorship of health care.

I. Health Disparities 1. Central to the goal of reducing health disparities and achieving health for every person is Healthy People 2010 and the concept of cultural competency that focuses beyond the self and moves toward a more global sense of human existence. Healthy People 2020 sets similar goals for the nation as well as trying to improve on areas that were not as successful in Healthy People 2010. For more information about factors that can affect an individual’s ability to attain optimal health, please see page 14, Health in a Diverse World box.

Key Terms: determinants of health, health disparities Figures and Tables:

Figure 1.5 Four Leading Causes of Chronic Disease in the United States

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Lecture Launcher Video: A Difference Approach to Health Care Additional Instructor Resources: PPT slides: 14–21; Digital Transparency Masters: Figure 1.5

IV. How Can You Improve Your Health Behaviors?

A. Change is not always easy, but identification of a behavior to change and the development of a plan for change can help unlearn negative patterns and substitute positive ones.

B. Models of Behavior Change 1. Health Belief Model a. In 1966, psychologist I. Rosenstock developed a classic theory, the health belief model (HBM), to show when beliefs affect behavior change. b. A belief is an appraisal of the relationship between some object, action, or idea and some attribute of that object, action, or idea. Direct or indirect experiences affect our beliefs. c. According to the HBM, several factors must support a belief in order for change to be likely to occur: i. Perceived seriousness of health problem ii. Perceived susceptibility to the health problem iii. Cues to action d. The more consistent one’s attitude is toward an action, the more one is influenced by others to take the action, and the more likely a change in behavior will occur.

2. Social Cognitive Model (SCM) was developed from the work of several researchers, but most closely associated with the work of Albert Bandura. a. SCM proposes that three factors interact in a reciprocal fashion to promote and motivate change. i. Social environment ii. Inner thoughts and feelings (cognition) iii. Our behaviors 3. Transtheoretical Model (TTM): Stages of Change Model a. Drs. James Prochaska and Carlos DiClemente’s Transtheoretical Model of Health Behavior Change identifies six distinct stages people go through in altering behavior patterns: i. Precontemplation: No current plan or intention of change. ii. Contemplation: Recognition of a problem and contemplation of the need to change. iii. Preparation: Close to taking the needed action for change. iv. Action: Action taken to follow a plan for change. Publicly stating a desire to change a behavior can help ensure success. v. Maintenance: Requires vigilance, attention to detail, and long-term commitment. Awareness of the potential for relapse is key at this stage. vi. Termination: The new behavior has become an essential part of one’s life and a high level of vigilance may not be necessary.

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V. Step One: Increase Your Awareness A. To understand behavior change, we must first identify specific behavior patterns and try to understand the reasons for them. Making a list of all of the health determinants that affect you—both positively and negatively—should greatly increase our understanding of what you might want to change and how to make that change happen.

VI. Step Two: Contemplate Change A. Examine Your Current Health Habits and Patterns 1. The major factors influencing behavior change can be divided into three categories: a. Predisposing factors include life experiences, knowledge, cultural and ethnic inheritance, and current beliefs and values. b. Enabling factors include skills or abilities, resources, and accessible facilities that make behavior change more convenient or more difficult. c. Reinforcing factors include the presence or absence of support and encouragement that significant people in your life bring to a situation.

B. Identify a Target Behavior 1. To clarify your thinking about the various behaviors you might like to target, ask yourself these questions: a. What do I want? b. Which change is the greatest priority at this time? c. Why is this important to me?

C. Learn More about the Target Behavior 1. Once you’ve clarified exactly what behavior you’d like to change, get accurate and reliable information to learn more about that behavior.

D. Assess Your Motivation and Readiness to Change 1. Motivation—a social, cognitive, and emotional force that directs human behavior— and readiness to change involve daily choices.

2. Motivation must be combined with common sense, commitment, and a realistic understanding of how best to move from one place to the next.

3. Readiness is the state of being that precedes behavior change and those who are ready are more likely to make the actual effort.

E. Develop Self-Efficacy 1. Self-efficacy, or an individual’s belief he or she is capable of achieving certain goals, is one of the most important factors that influence health status.

2. If you suspect you have low self-efficacy, a technique of cognitive-behavior therapy called cognitive restructuring can help.

F. Cultivate an Internal Locus of Control 1. The locus of control is the location, external (outside oneself) or internal (within oneself), that an individual perceives as the source and underlying cause of events in his or her life.

2. Developing and maintaining an internal locus of control can help you take charge of your health behaviors.

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VII. Step Three: Prepare for Change A. Set a realistic goal, one that you can really achieve.

1. Use the SMART system. a. Successful goals are SMART (Specific, Measurable, Action-oriented, Realistic, Time-oriented).

2. Use shaping, which uses a series of small steps to get to a particular goal gradually.

All shaping involves the following: a. Starting slowly to avoid hurting yourself or causing stress. b. Keeping the steps small and achievable. c. Being flexible and ready to change if your original plan is too uncomfortable. d. Mastering one step before moving on to the next.

B. Anticipate Barriers to Change 1. Common barriers to change to anticipate: a. Overambitious goals b. Self-defeating beliefs and attitudes c. Failing to accurately assess your current state of wellness d. Lack of support and guidance e. Emotions that sabotage your efforts and sap your will C. Enlist Others as Change Agents 1. Modeling is learning specific behaviors by watching others perform them.

2. A healthy family provides the foundation for clear and necessary understanding of what is right and wrong, and what is positive and negative.

3. The social bonds and influence of friends can serve as a powerful social support for positive change.

4. Professional assistance can sometimes be essential for successful change. a. To find out more about how to use the Internet to find reliable health information, please see page 17, Consumer Health box.

D. Sign a Contract 1. Filling out a formal behavior change contract can help with commitment and followthrough for behavior change.

VIII. Step Four: Take Action to Change A. Visualize New Behavior 1. Visualization uses imagined rehearsal to mentally practice the planned action ahead of time to become better able to perform an event in actuality.

B. Learn to “Counter” 1. Countering involves substituting a desired behavior for an undesired behavior.

C. Control the Situation 1. Antecedents are the setting events for the behavior, stimulating a person to act in certain ways.

2. Consequences are the result of the behavior and affect whether it will be repeated.

3. Situational inducement attempts to influence a behavior through situations and occasions that are structured to exert control over that behavior.

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D. Change Your Self-Talk 1. Modifying self-talk, the way you think and talk to yourself, can be beneficial to behavior change. Cognitive procedures for changing self-talk include the following: a. Rational-emotive therapy, which is based on the connection between how people feel and what they say to themselves. By changing irrational self-talk into rational and positive statements about reality, positive behaviors are more likely to occur. b. Blocking and thought stopping, which involves purposely blocking negative thoughts in order to take positive steps to behavior change.

E. Reward Yourself 1. Positive reinforcement can increase the likelihood that a behavior will occur. Most positive reinforcers can be classified under five headings: a. Consumable reinforcers such as candy or gourmet meals. b. Activity reinforcers such as opportunities to watch TV or go on vacation. c. Manipulative reinforcers are incentives such as better grades from extra credit. d. Possessional reinforcers are tangible rewards such as a new car. e. Social reinforcers include loving looks, affectionate hugs, and praise.

F. Journal 1. Journaling and writing can help to monitor progress and provide insight.

Key Terms: belief, health belief model (HBM), social cognitive model, transtheoretical model, motivation, self-efficacy, locus of control, shaping, modeling, imagined rehearsal, countering, situational inducement, self-talk, positive reinforcement Tables and Figures:

Figure 1.6 Social Cognitive Model

Figure 1.7 Example of a Completed Behavior Change Contract

Lecture Launcher Video: Months to a Healthier Lifestyle Additional Instructor Resources: PPT slides: 22–33; Digital Transparency Masters: Figure 1.6, Figure 1.7

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Additional Chapter Activities Discussion Questions 1. What is your definition of health? What factors in your life have influenced this definition?

2. How do you think the six dimensions of health relate to one another?

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

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

5. Describe how factors of the Health Belief Model might affect a young woman’s decision to wear a helmet when snowboarding.

6. What types of influences do you consider critical in affecting your health behaviors?

7. Can you think of an example of how your family, coworkers, or significant others have affected your health behaviors? Was the influence positive or negative, why or why not?

Critical Thinking Questions 1. Predict how advances in technology might influence morbidity and mortality rates in the United States and globally.

2. Figure 1.4 illustrates the six dimensions of health. What would happen to a person’s overall health and well-being if any one of the dimensions were not a part of a person’s lifestyle and/or experiences?

3. Review the stages of the Transtheoretical Model of behavior change. What state do you think you belong to? How can you go about preparing yourself to achieve a behavior change for better health?

4. Which behavior change technique—shaping, visualization, modeling, controlling the situation, countering, 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? 5. How would a person’s genetic predisposition influence that person’s health decisions?

Student Activities Individual 1. Complete the How Healthy Are You? assessment on pages 24 to 26 of your textbook.

Identify the dimension of wellness that you would like to enhance. Identify a behavior that you might adopt or change to help you meet this goal. Outline the steps you will take and the factors that might influence this change, and write out three specific objectives for this change.

2. Complete the Your Plan for Change assessment on page 26 of your textbook. Given the status of your health, what can you do to take steps toward changing certain behaviors?

3. Conduct an Internet search of websites that focus on health issues in your community or college campus. Identify three issues that you consider to be the most important.

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Community 1. Look over Healthy People 2010. Pick a national objective and find out 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 or write 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. Choose one of the six dimensions of health and compare and contrast ways in which it differs in your culture compared to another. How might we need to address these differences in policy development like Healthy People 2020?

2. 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 as shown in Table 1.1.

Lecture Launcher Video Discussion Questions New! A Different Approach to Health Care 1. In what ways do you think Safeway’s use of prevention as a way to save on health care is a successful or unsuccessful model for health care?

2. What are the four things 25,000 Safeway employees have volunteered to measure in order to participate in their company’s health care plan? What happens when they score well on these tests and improve their test scores over time? How do you think these incentives encourage overall health?

3. Do you think Safeway’s health incentives program should be a model for the rest of the country? Why or why not?

New! Months to a Healthier Lifestyle 1. What are the steps that Dr. Oz recommends you take in order to improve your life expectancy in terms of food and exercise? What are some of the ways in which you can incorporate these steps into your daily life?

2. What are the six basic health numbers that Dr. Oz suggested that everyone should know?

What are some of the ways in which you can obtain and track these numbers?

3. Why is practicing your balance important? Explain how balance affects the brain.

4. Explain what you think Dr. Oz means by “putting it all together” at the end of this video.

What are some ways in which you can start to organize your life in order to improve your overall health?

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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).

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, doi:10.1093/her/cym035, (2007).

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, 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.

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.” http://healthypeople.gov/HP2020/default.asp 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 www.health.gov/NHIC/Pubs/2010tollfreenumbers/tollfreenumbers1.htm Baptist Memorial Health Care Interactive Health Quizzes www.bmhcc.org/health/quiz 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

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Quick Guide to Healthy Living www.healthfinder.gov/prevention 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?” 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

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Promoting and Preserving Your Psychological Health

Overview Being a healthy person involves more than biology. Psychological health is important because it contributes to our quality of life and our ability to enjoy ourselves, those around us, and our environment. Chapter 2 discusses the essential parts for overall psychological health: the mental, emotional, social, and spiritual qualities of health that make up the very heart of how we perceive all that we experience. This chapter also covers important issues such as depression and suicide, helping the student to understand when to get help or how to recognize when someone they know needs help.

Learning Objectives 1. Define each of the four components of psychological health, and identify the basic traits shared by psychologically healthy people.

2. Learn what factors affect your psychological health; discuss the positive steps you can take to enhance psychological well-being.

3. Identify psychological disorders, such as mood disorders, anxiety disorders, personality disorders, and schizophrenia, and explain their causes and treatments.

4. Discuss warning signs of suicide and actions that can be taken to help a suicidal individual.

5. Explain the different types of treatments and mental health professionals, and examine how they can play a role in managing mental health disorders.

Lecture Outline I. What Is Psychosocial Health?

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

1. Psychosocially healthy people are emotionally, mentally, socially, and spiritually resilient.

2. There are several basic elements shared by psychosocially healthy people, including that they feel good about themselves, they feel comfortable with other people and express respect and compassion toward others, they control tension and anxiety, they

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meet the demands of life, they curb hate and guilt, they maintain a positive outlook, they value diversity, and they appreciate and respect nature.

3. In the 1960s, human theorist Abraham Maslow developed a hierarchy of needs to describe the theory that certain basic needs must be met in order to achieve the characteristics of psychologically and socially healthy people. a. Survival needs include food, water, and sleep. b. Security needs include shelter, safety, and protection. c. Social needs, if met, provide a sense of belonging, affection, and acceptance. d. Esteem needs include self-respect, respect for others, and accomplishment. e. Self-actualization includes creativity, spirituality, or fulfillment of potential.

B. Mental Health 1. The term mental health describes the “thinking” or “rational” dimension of our health.

2. A mentally healthy person perceives life in realistic ways, can adapt to change, can develop rational strategies to solve problems, and can carry out personal and professional responsibilities.

3. A mentally healthy individual can intellectually sort through information, messages, and life events; attach meaning; and respond appropriately and make decisions, often referred to as intellectual health.

C. Emotional Health 1. The term emotional health refers to the feeling, or subjective, side of psychosocial health.

2. Emotions are intensified feelings or complex patterns of feelings that we experience on a regular basis.

3. Emotions are described as the interplay of four components: a. Physiological arousal, feelings, cognitive (thought) processes, and behavior reactions.

4. Emotionally healthy people are able to respond in a stable and appropriate manner to upsetting events.

5. Emotional health affects social and intellectual health.

D. Social Health 1. Social health refers to our interactions with others on an individual and group basis, and our ability to adapt to use social resources and support in times of need and to adapt to a variety of social situations.

2. Socially healthy people have a wide range of social interactions with family, friends, acquaintances, and intimate partners. a. Socially healthy individuals are able to: i. Listen ii. Express themselves iii. Form healthy relationships iv. Act in socially acceptable and responsible ways v. Find the best fit for themselves in society 3. Interactions with others help us to learn new skills and develop self-worth.

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4. Social bonding provides intimacy, feelings of belonging, opportunities for giving and receiving nurturance, reassurance of one’s worth, assistance and guidance, and advice.

5. Social support and community engagements are the most common social bonds.

6. Social support refers to networks of people and services with whom and which we interact and share social connections. a. Such services can be tangible support or intangible support. b. Common descriptions of strong social support include the following: i. Being cared for and loved, with the opportunity for shared intimacy ii. Being esteemed and valued; having a sense of self-worth iii. Sharing companionship, communication, and mutual obligations with others; having a sense of belonging iv. Having “informational” support—access to information, advice, community services, and guidance from others E. Spiritual health 1. Spiritual health refers to the aspect of psychosocial health that relates to having a sense of meaning and purpose to one’s life, as well as a feeling of connection with others and with nature.

2. According to the National Center for Complementary and Alternative Medicine (NCCAM), spirituality is broader in meaning than religion and is defined as an individual’s sense of purpose and meaning in life.

Key Terms: psychological health, mental health, emotional health, emotions, social health, social bonds, social support, spiritual health Figures and Tables:

Figure 2.1 Psychological Health

Figure 2.2 Characteristics of Psychologically Healthy and Unhealthy People People

Figure 2.3 Maslow’s Hierarchy of Needs

Additional Instructor Resources: PPT slides: 1–12; Digital Transparency Masters: Figure 2.1, Figure 2.2, Figure 2.3

II. Factors That Influence Psychosocial Health A. The Family 1. Healthy, nurturing families help develop the cognitive and social skills necessary for a person to solve problems, communicate emotions in socially acceptable ways, manage stressors, and develop both a sense of self-worth and purpose in life.

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2. Children brought up in dysfunctional families—in which there is violence; distrust; anger; dietary deprivation; drug abuse; parental discord; or sexual, physical, or emotional abuse—may have a harder time adapting to life.

B. Social Supports 1. Our initial social support may come from family members, but as we grow and develop the support of peers and friends become increasingly important.

2. Studies show that the availability of a social network, a sense of belonging, is a predictor of health.

C. Community 1. The communities we live in can influence our health.

2. A collective efficacy occurs when a group has an expectation that its members can successfully achieve an intended goal through collective action.

D. 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. Psychologist Martin Seligman has proposed that people who continually experience failure may develop a pattern of responding known as learned helplessness. a. Learned helplessness is a response to continued failure where people give up and fail to take action to help themselves. Seligman ascribes this response in part to society’s tendency toward victimology—blaming one’s problems on other people and circumstances. b. Today, many people have developed self-help programs that use elements of Seligman’s principle of learned optimism—teaching oneself to think positively.

E. Personality 1. Personality is not static; it changes as we move through our lives. Personality determines how we react to the challenges of life, interpret our feelings, and resolve conflicts.

2. In general, the following personality traits are often related to psychological well-being: extroversion, agreeableness, openness to experience, emotional stability, conscientiousness, and resiliency.

F. Life Span and Maturity 1. Our temperaments change as we grow, which is illustrated by the extreme emotions that children and many young teens experience. Most people learn to control emotions as they advance toward adulthood.

Key Terms: dysfunctional families, learned helplessness, learned optimism Additional Instructor Resources: PPT slide: 13

III. The Mind–Body Connection A. Researchers propose a connection between emotions and health.

B. Psychoneuroimmunology (PNI) is the study of how the brain and behavior affect the body’s immune system.

C. Happiness appears to reduce the risk or limit the severity of diseases and infections.

Likewise, laughter can enhance mental and emotional health.

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D. Subjective well-being refers to the uplifting feeling of inner peace, wonder, and happiness that gives us bursts of energy and satisfaction. It has three components: satisfaction with present life, relative presence of positive emotions, and relative absence of negative emotions.

1. People with subjective well-being are resilient and are able to look at the positive side of negative events.

E. Strategies such as developing gratitude, using capitalization and focusing on good things, knowing when to say “that’s enough,” and growing a signature strength can all enhance happiness and help one to employ a more positive outlook on life.

Key Terms: psychoneuroimmunology (PNI), subjective well-being Additional Instructor Resources: PPT slides: 14–15

IV. Strategies to Enhance Psychosocial Health A. Attaining self-fulfillment is a lifelong, conscious process that involves finding a support group or group of peers who share your values, completing required tasks, forming realistic expectations or setting small, incremental goals that are achievable, making time for yourself, maintaining your physical health, examining problems and seeking help when necessary, and getting adequate sleep.

Additional Instructor Resources: PPT slide: 16

V. When Psychosocial Health Deteriorates A. Mental illnesses are disorders that disrupt thinking, feeling, moods, and behaviors, and can cause varying degrees of impaired functioning in daily living.

B. Mental illnesses are believed to be caused by a variety of biochemical, genetic, and environmental factors. They can range from mild to severe.

C. Mental disorders are the leading cause of disability in the United States and Canada for people aged 15 to 44.

D. Mental Health Threats to College Students 1. The most recent National College Health Assessment survey found that nearly 1 in 3 undergraduates reported “feeling so depressed it was difficult to function” at least once in the last year and just over 6 percent of students reported “seriously considering attempting suicide” in the past year.

2. For more information on mental health problems on college campuses, please see page 44, Student Health Today box. a. Studies indicate that almost half of all college students met the DSM-IV-TR criteria for at least one mental disorder in the previous year. b. The most common disorders among college students include mood disorders, anxiety disorders, personality disorders, and schizophrenia.

Key Terms: mental illnesses

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Figures and Tables:

Figure 2.4 Mental Health Concerns of American College Students, Past 12 Months

Additional Instructor Resources: PPT slides: 17–18; Digital Transparency Masters: Figure 2.4

VI. Mood Disorders A. Chronic mood disorders affect how you feel, such as persistent sadness or feelings of euphoria.

B. Approximately 10 percent of Americans aged 18 or older—or 20.9 million people— suffer from a mood disorder.

C. Major Depression 1. Major depression is the most common mood disorder affecting approximately 14.8 million American adults and is increasingly common among children. For more information on depression and gender, age, and ethnicity, please see page 42, Health in a Diverse World box.

2. Symptoms of depression include the following: a. Lack of interest in pleasurable activities b. Preoccupation with failures; overconcern with what others think c. Difficulty concentrating; indecisiveness; memory lapses d. Loss of sex drive or interest in close interactions with others e. Fatigue and loss of energy; slow reactions f. Sleep problems g. Feelings of agitation, hopelessness, or worthlessness h. Withdrawal from friends and family i. Diminished or increased appetite j. Significant weight loss or gain k. Recurring thoughts that life is not worth living; thoughts of death or suicide 3. In its most recent survey, the American College Health Association found that the number of students who reported “having been diagnosed with depression” was 11.1 percent.

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D. Dysthymic Disorder 1. Dysthymic disorder (dysthymia) is a less severe syndrome of chronic, mild depression and is harder to recognize than major depression.

2. Dysthymic disorder affects about 1.5 percent of the United States population aged 18 and older, or about 3.3 million American adults.

E. Bipolar Disorder 1. Bipolar disorder, also called manic depression, is manifested by severe mood swings.

2. Causes of bipolar disorder are unknown, but it can be treated through counseling and pharmaceutical options.

3. Bipolar disorder affects about 5.7 million adults in the United States, or approximately 2.6 percent of the population.

F. Seasonal Affective Disorder 1. Seasonal affective disorder (SAD) is a type of depression that strikes during the winter months and is associated with reduced exposure to sunlight.

2. People with SAD suffer from irritability, apathy, carbohydrate craving and weight gain, increased sleep time, and general sadness.

3. SAD is treated with light therapy, stress management, sleep restriction, psychotherapy, and prescription medication.

G. Causes of Mood Disorders 1. Depressive disorders are caused by interactions between biological differences, hormones, inherited traits, life events, and early childhood trauma.

2. The biology of mood disorders is related to individual levels of brain chemicals called neurotransmitters.

3. For more information on the common neurobehavioral disorder ADHD, please see page 41, Health Headlines box.

Key Terms: chronic mood disorder, major depression, dysthymic disorder (dysthymia), bipolar disorder, seasonal affective disorder (SAD) Additional Instructor Resources: PPT slides: 19–23

VII. Anxiety Disorders A. Anxiety disorders include many disorders and phobias that are associated with feelings of threat and worry in coping with everyday problems.

1. Anxiety disorders are the number one mental health problem in the United States, affecting more than 40 million people aged 18 and older each year, or about 18 percent of all adults.

2. In the past year, 9.4 percent of United States undergraduates were diagnosed with or treated for anxiety.

B. Generalized Anxiety Disorder 1. Generalized anxiety disorder (GAD) is a common form of anxiety disorder and can interfere with daily life.

2. Diagnosis of GAD includes exhibiting at least three of the following symptoms for more days than not during a 6-month period: a. Being restless or feeling keyed up or on edge, being easily fatigued having difficulty concentrating or mind going blank, being irritable, having muscle tension, and having sleep disturbances.

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C. Panic Disorders 1. Panic disorders are characterized by the occurrence of panic attacks, a form of acute anxiety reaction that brings on an intense physical reaction.

2. Approximately 6 million Americans aged 18 and older experience panic attacks each year.

3. Although highly treatable, panic attacks may become debilitating and destructive.

D. Phobic Disorders 1. Phobic disorders, or phobias, involve a persistent or irrational fear of a specific object, activity, or situation often out of proportion to the circumstances.

2. Social phobia is an anxiety disorder characterized by the persistent fear and avoidance of social situations, and about 7 percent of American adults suffer from it.

E. Obsessive-Compulsive Disorder 1. Obsessive-compulsive disorder (OCD) is an illness where people have obsessive thoughts or perform habitual behaviors that they cannot control.

2. OCD affects about 2 million people aged 18 and older in the United States.

3. Although the exact cause is unknown, genetics, biological abnormalities, learned behaviors, and environmental factors have all been considered with OCD. F. Post-Traumatic Stress Disorder 1. Post-traumatic stress disorder (PTSD) often affects soldiers returning home from war, rape victims, or victims of severe physical attacks, near-death experiences, or other major crises.

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

G. Causes of Anxiety and Phobic Disorders 1. Though anxiety disorders vary in complexity and degree, one’s biology, environment, and social and cultural roles are all factors that are often cited as possible causes.

Key Terms: anxiety disorders, generalized anxiety disorder (GAD), panic attack, phobia, social phobia, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) Lecture Launcher Video: Keeping Obsessive Compulsive Disorder in Check Additional Instructor Resources: PPT slides: 24–29

VIII. Personality Disorders A. According the DSM-IV-TR, 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.”

B. Common types of personality disorders include: 1. Paranoid personality disorders involve pervasive, unfounded suspicion and mistrust of people, irrational jealousy, and secretiveness.

2. Narcissistic personality disorders involve an exaggerated sense of self-importance and self-absorption.

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3. Borderline personality disorder (BPD) is characterized by impulsiveness and risky behaviors. a. Seventy to eighty percent of those diagnosed with BPD engage in self-injury, in which they deliberately cause harm to their own body as a way to cope with their emotions. For information on self-injury and prevention, please see page 47, Student Health Today box.

Key Terms: personality disorders, self-injury Lecture Launcher Video: The Hoarders Additional Instructor Resources: PPT slides: 30–31

IX. Schizophrenia A. 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.

B. Magnetic resonance imaging (MRI) and PET scans have led scientists to determine that schizophrenia is a biological disease of the brain.

1. Damage occurs early in life, possibly through fetal exposure to toxic substances, infections, or medications.

2. Hereditary links are being explored.

C. About 1 percent of the United States population suffers from schizophrenia. It is treatable through a combination of hospitalization, medication, and supportive therapy, but it is not curable.

Key Terms: schizophrenia Additional Instructor Resources: PPT slides: 32–33

X. Suicide: Giving Up on Life A. More lives are lost to suicide than to any other cause except cancer and cardiovascular disease—each year there are more than 33,000 reported suicides in the United States and college students are more likely than the average population to attempt suicide.

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

C. Warning Signs of Suicide 1. Recent loss and inability to let go of grief 2. History of depression 3. Change in personality 4. Change in behavior 5. Sexual dysfunction or diminished sexual interest 6. Expressions of self-hatred or excessive risk-taking 7. Change in sleep patterns and/or eating habits 8. A direct statement about committing suicide 9. An indirect statement about committing suicide 10. Final preparations

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11. Preoccupation with themes of death 12. Marked changes in personal appearance D. Preventing Suicide 1. Take action if someone you know threatens suicide. Specific actions you can take include monitoring the warning signals; taking threats seriously; letting the person know how much you care; listening; asking directly if s/he is thinking of hurting or killing themselves; not belittling the person’s feelings; helping the person think about alternatives to suicide; and telling that person’s spouse, partner, parents, siblings, or counselor.

Additional Instructor Resources: PPT slides: 34–37

XI. Seeking Professional Help A. Researchers view breakdowns in support systems, high societal expectations, and dysfunctional families as three major reasons that more people are asking for assistance than ever before.

B. Mental Illness Stigma 1. Stigmas are negative stereotypes about groups of people—often the stigma associated with mental illness can be more disabling than the illness itself.

C. Getting Evaluated for Treatment 1. Getting evaluated for treatment should begin with a complete evaluation with a credentialed health professional. The examination should include a physical checkup, psychiatric history, and a mental status examination.

D. Mental Health Professionals 1. Selecting a therapist should be based on feeling as though you can work together.

2. Questions to ask the therapist and yourself include the following: a. Can I interview the therapist before starting treatment? b. Do I like the therapist as a person? c. Is the therapist watching the clock or easily distracted? d. Does the therapist demonstrate professionalism? e. Will the therapist help me set my own goals and timetables?

E. Pharmacological Treatment 1. Drug therapy can also be an important adjunct in the treatment of psychological disorders as new generations of medications are continually being developed.

F. What to Expect in Therapy 1. Many different types of therapy exist, and the first trip to a therapist can be very difficult due to misconceptions about what therapy is and what it can do.

2. Treatment Models a. Treatment for mental disorders can include various cognitive-behavioral therapies.

Cognitive therapy focuses on the impact of thoughts and ideas on our feelings and behavior, and behavior therapy focuses on what we do, aiming to alter behavior patterns.

Key Terms: stigmas

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Figures and Tables:

Table 2.1 Mental Health Professionals

Table 2.2 Types of Medications Used to Treat Mental Illness

Additional Instructor Resources: PPT slides: 38–44; Digital Transparency Masters: Table 2.1, Table 2.2

Additional Chapter Activities Points of View Self-Help Books: Beneficial or Baloney? on page 51 of your textbook.

Self help books can be a useful and affordable strategy for receiving guidance about changing health behaviors. However, how does one determine if a self help book is really useful or a scam?

In Class Activity: Divide the class into groups. Assign the groups as either ‘for self help’ or ‘against self help’. Have each group discuss their side of the argument and develop three to five reasons that support their argument, and two specific examples for how their argument influences real people. These points and examples can be written on the board or on a large piece of paper that is taped to a classroom wall, or some other strategy for display. Finally, have each group explain their argument to the class.

Synthesis: After the groups have completed their presentations, ask students to take 3 to 5 minutes to write about where they stand on the issue as individuals.

Discussion Questions 1. What is psychosocial health? What indicates that you either are or are not psychosocially healthy? Why do you think the college environment may provide a real challenge to your psychosocial health?

2. Why do you think the number of women with depression is higher than the number of men with depression? How could cultural changes influence the rates of depression for men and women?

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

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

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5. How have psychosocial disorders been portrayed in movies? What are some specific examples? How do you think the media has influenced some of the stigma surrounding these disorders?

6. What are some of the warning signs of suicide? What actions could you take if someone you know shows warning signals of suicide?

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 any situations when you think your emotions affected your health.

2. Provide an example from your personal experience as to how a person’s psychosocial health benefits from good mental, emotional, social, and spiritual health.

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. Look at Maslow’s Hierarchy of Needs in Figure 2.2. Explain how each lower level in the pyramid affects the next highest level.

5. 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. Complete the How Psychologically Healthy are You? assessment on pages 55 to 56 of your textbook to explore your psychological health status.

2. 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%) 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.

Community 1. How is your university and wider community addressing mental health stigmas? Explore options to help reduce stigma in your community.

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

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

Research the rates of psychosocial disorders such as depression, bipolar disorder, and schizophrenia and compare them to rates in the United States.

2. How do people regard mentally ill women in other cultures? Conduct Internet research to determine if women in other countries disproportionately suffer from depression. Suggest an explanation for your findings.

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Lecture Launcher Video Questions New! Keeping Obsessive-Compulsive Disorder in Check 1. Fay says that deep down she knows a doorknob does not pose a risk. Then why do you think she still fights the urge to use hand sanitizer every time she opens a door?

2. What is “exposure” therapy and how does it work? Dr. Jonathan Grayson took Fay and a group of people on a virtual camping trip in the video. In what ways do you think this experience helped the participants with their OCD tendencies?

3. What are the benefits for someone with OCD who attends workshops and lectures at a convention like the one the OCD Foundation holds annually?

New! The Hoarders 1. Why might a person develop a hoarding compulsion? Give several reasons.

2. Some hoarders do not believe that they have a debilitating problem or that hoarding is such a problem. What does this say about the psychological mindset of a hoarder? Why do you think that simply “cleaning up the mess” is more difficult for a hoarder?

3. What are the consequences of being a hoarder? How does being a hoarder affect the hoarder and those around him or her negatively?

Additional References 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.

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For Further Information American Association for Suicidology Prevention www.suicidology.org American Psychiatric Association www.psych.org Depression and Related Affective Disorders Association www.drada.org National Empowerment Center www.power2u.org Mental Health America www.nmha.org 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 amongst 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 has been affected by suicide. www.youtube.com/watch?v=MD7Odg3RnAg&feature=related Understanding Schizophrenia, 4 minutes A video of the Health Science Channel. Health care providers and persons living with schizophrenia discuss the illness. www.youtube.com/watch?v=ZLhmD2UYEdc WHO: Mental Health, 5 minutes A video produced by the World Health Organization that discusses the prevalence of mental health, with an emphasis on an international perspective. www.youtube.com/watch?v=L8iRjEOH41c Copyright © 2012 Pearson Education, Inc.

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CHAPTER

2A

Focus On Cultivating Your Spiritual Health

Overview Spirituality is an important element in the six dimensions of health. In this chapter, students begin to understand what spirituality is, discover how it is similar to and different from religion, and learn that spirituality has three interconnected facets. Students will also begin to understand how spirituality contributes to physical health, psychosocial health, and stress reduction. In this chapter, students will learn how to attend to their spiritual health by training their bodies, expanding their minds, being in tune with themselves and their surroundings, and reaching out to others.

Lecture Outline I. Cultivating Your Spiritual Health A. The desire to find a sense of purpose, meaning, and harmony in life is shared by a majority of American college students.

B. More than half of all students surveyed have the following goals: 1. Attaining inner harmony 2. Developing a meaningful philosophy of life 3. Seeking beauty in life 4. Becoming a more loving person C. Researchers found that compared to freshmen, college juniors and seniors: 1. have more desire to reduce pain and suffering in the world.

2. are more thankful for all that had happened to them.

3. express higher levels of tolerance and respect for other religions and philosophies.

4. are committed to understanding other countries and cultures.

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

Additional Instructor Resources: PPT slides: 1–3

II. What Is Spirituality?

A. At some point many people realize that material possessions do not make them happy or improve their self-worth.

B. The National Center for Complementary and Alternative Medicine (NCCAM) defines spirituality as an individual’s sense of purpose and meaning in life, beyond material values.

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C. Religion and Spirituality Are Distinct Concepts 1. Spirituality may or may not lead to participation in organized religion. a. Religion is a system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent.

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

3. Most Americans consider spirituality important in their lives but not necessarily in the form of religion.

4. It seems that a majority of Americans recognize and respect the underlying unity of spiritual ideas expressed in different religious and spiritual practices.

D. Spirituality Integrates Three Facets 1. Professor and author Brian Luke Seaward identifies three facets of human existence that together constitute the core of human spirituality: a. Relationships—Healthy relationships are a sign of spiritual well-being when we treat ourselves and others with respect, honesty, integrity, and love. b. Values—Our values are the principles that influence our thoughts and emotions and guide the choices we make in our lives. c. Meaningful purpose in life—Healthy people are able to articulate their purpose and to make choices that manifest that purpose.

E. Spiritual Intelligence Is an Inner Wisdom 1. Our relationships, values, and sense of purpose together contribute to our overall spiritual intelligence (SI). a. Physicist and philosopher Danah Zohar defines SI as the intelligence of the deep self—including qualities such as self-awareness, spontaneity, and compassion.

Key Terms: spirituality, religion, values, spiritual intelligence (SI) Figures and Tables:

Table 1 Characteristics Distinguishing Religion and Spirituality

Figure 1 Three Facets of Spirituality

Additional Instructor Resources: PPT slides: 4–8; Digital Transparency Masters: Table 1, Figure 1

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III. How Is It Beneficial to Focus on Your Spiritual Health?

A. Spiritual Health Contributes to Physical Health 1. The emerging science of mind–body medicine is a research focus of NCCAM and evidence supports a positive influence of spirituality on health.

2. Some researchers believe that a key to understanding the improved health and longer life in spiritually healthy people is their greater self-control.

3. When we get sick, the National Cancer Institute (NCI) contends that 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. Spiritual Health Contributes to Psychosocial Health 1. The NCI and independent studies have found a benefit of spirituality in reducing levels of anxiety and depression.

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

C. Spiritual Health Contributes to Reduced Stress 1. Both the NCCAM and the NCI cite stress reduction as one probable mechanism among spiritually healthy people for improved health and longevity and for better coping with illness.

Lecture Launcher Video: The Study of Happy Brains Additional Instructor Resources: PPT slides: 9–14

IV. What Can You Do to Focus on Your Spiritual Health?

A. Enhancing your spiritual side takes just as much work as becoming physically fit or improving your diet.

B. Train Your Body 1. Traditional forms of yoga include controlled breathing and physical postures as well as meditation, chanting, and other practices that are believed to cultivate unity with the Atman, or Absolute.

2. Training your body to improve your spiritual health does not necessarily require you to engage in a formal practice such as yoga. a. Any exercise you do every day can contribute to your spiritual health.

3. You can cultivate spirituality through fully engaging your body’s senses. a. Vision, hearing, taste, smell, and touch are five portals to spiritual health. b. The flip side of cultivating your senses is depriving them. Closing your eyes and sitting in silence removes the distraction of visual and auditory stimuli, helping you to focus within.

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C. Expand Your Mind 1. For many people, psychological counseling is a first step toward improving their spiritual health.

2. Another way to expand your mind is to study the sacred texts of the world’s major religions and spiritual practices.

3. You can expand your awareness of different spiritual practices by exploring on-campus meditation groups, attending meetings of student religious organizations, going to different churches, attending public lectures, and exploring official websites of various spiritual and religious organizations on the Internet.

D. 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 can help you to tune into yourself and your surroundings. a. Contemplation is 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 is a practice of purposeful, nonjudgmental observation in which we are fully present in the moment. c. Meditation is the practice of emptying the mind and cultivating stillness. i. Experienced mediators show increased levels of empathy, the ability to understand and share another person’s experience. ii. Meditation improves the brain’s ability to process information, reduces stress, improves sleep, and relieves chronic pain. iii. Different schools of meditation include mantra meditation, breath meditation, color meditation, and object meditation. d. Prayer is defined as communication with a transcendent Presence.

E. Reach Out to Others 1. Altruism is the giving on oneself out of genuine concern for others. a. Volunteering to help others, choosing to work for a nonprofit organization, or donating money or other resources are ways to serve others and simultaneously enhance spiritual health. b. Community service can also take the form of environmental stewardship, which the Environmental Protection Agency (EPA) defines as the responsibility for environmental quality shared by all those whose actions affect the environment. c. To learn more about developing environmental mindfulness, please see page 67, Be Health, Be Green box.

Key Terms: yoga, contemplation, mindfulness, meditation, prayer, altruism, environmental stewardship

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Figures and Tables:

Figure 2 Qualities of Mindfulness

Additional Instructor Resources: PPT slides: 15–21; Digital Transparency Masters: Figure 2

Additional Chapter Activities Discussion Questions 1. What are the differences between spirituality and religion? How important are these distinctions to you and your health?

2. What is environmental mindfulness? What are the benefits for becoming environmentally mindful? Who benefits from becoming environmentally mindful?

3. What are the differences between the various forms of meditation, such as mantra meditation, breath meditation, color meditation, and object meditation? Which of the various forms are most appealing to you and why?

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

5. How does self-control help a spiritual person to maintain or improve his or her health?

Critical Thinking Questions 1. Do you consider yourself a spiritual person? A religious person? How can a person be both spiritual and religious?

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? How might each of these differ in how they help you deal with a stressful or difficult situation?

4. Which of the qualities of mindfulness illustrated in Figure 2 do you possess? What can you do to improve your qualities of mindfulness?

5. What activities do you practice in your daily life to promote environmental stewardship?

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Student Activities Individual 1. Practice mindfulness while completing an everyday task or activity, such as peeling an orange as described on page 66. Record your feelings and observations in a journal.

Consider asking a close friend to do the same and then discuss what you both notice and learn.

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?

Community 1. What kind of spiritual and/or religious programs and/or services are offered on your campus? Have you ever taken advantage of these programs or services? Have you ever attended a service or program that you hadn’t attended in the past?

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 doing 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 Populations/Nontraditional 1. Use the Internet to research aspects of spirituality in a different culture or country? How does that concept of spirituality compare to that in the United States?

2. Find books and sacred texts for a religion that interest you. Take the time to read these books and understand their approach to spiritual fulfillment. What similarities do you find in these texts and those that guide your life? If you do not incorporate spiritual texts into your life currently, what might change if you did?

Lecture Launcher Video Questions The Study of Happy Brains 1. Do you agree that life experiences account for only 10 percent of one’s total happiness?

Why or why not?

2. What do you do to make yourself happy?

3. In what ways can you work to increase your happiness level every day?

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Additional References 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.

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 Santa Barbara Institute For Consciousness Studies Cultivating Emotional Balance www.sbinstitute.com/research_CEB.html University of Maryland Medical Center Spirituality www.umm.edu/altmed/articles/spirituality-000360.htm University of California at Riverside Spiritual Wellness http://wellness.ucr.edu/spiritual_wellness.html UCLA Mindful Awareness Research Center http://marc.ucla.edu

Additional Media Amy Applebaum: Defining Spirituality, 2 minutes A video of PeopleJam. In the video, life coach Amy Applebaum shares her views on spirituality. www.youtube.com/watch?v=Oi391YzH05o

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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 Mediation Exercises: Guided Meditation for Yoga Exercises, 3 minutes An ExpertVillage video in which Jennifer Kostel leads the viewer through guided meditation. www.youtube.com/watch?v=k_G4o0EaR58 Yoga Meditation Exercises: Using Mantras for Yoga Meditation, 2 minutes An ExpertVillage video in which Jennifer Kostel teaches the viewer about mantras. www.youtube.com/watch?v=JU2e5n1FeMU 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 We have all personally experienced the sensations and consequences of feeling stress or being stressed out. But stress also affects our lives in ways that are only just becoming clear.

The links between stress and disease are increasingly evident, and the science of psychoneuroimmunology (PNI) is beginning to unravel the secrets of just how greatly stress affects our immune system and, therefore, different disease processes. Chapter 3 is devoted to helping the student understand what stress is and when it is healthy and when it is not. This chapter also helps us to explore ways that stress management can alter our lives toward greater health and happiness.

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

2. Explain the phases of the general adaptation syndrome and the physiological changes that occur during them.

3. Examine the physical, emotional, and social health risks that may occur with chronic stress.

4. Discuss sources of stress and examine the unique stressors that affect college students.

5. Explore stress-management techniques and ways to enrich your life with positive experiences and attitudes.

Lecture Outline I. What Is Stress?

A. Stress is a series of physiological responses and adaptations in response to a real or imagined threat to one’s well-being.

B. A stressor is any physical, social, or psychological event or condition that upsets homeostasis and produces a stress response.

1. Several factors influence one’s response to a stressor including characteristics of a stressor, biological factors, and past experiences.

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2. There are two major types of stress: a. Eustress is positive stress that presents the opportunity for growth and satisfaction and can actually improve health. b. Distress is negative stress that can result in debilitative tension or strain. i. Two kinds of distress include acute stress, short-term physiological responses, and chronic stress, the ongoing state of physiological responses.

Key Terms: stress, stressor, eustress, distress, acute stress, chronic stress Additional Instructor Resources: PPT slides 1–7

II. Your Body’s Response to Stress A. When the need to respond quickly to danger was a matter of life or death, the body’s physiological responses evolved to protect humans from harm.

B. The General Adaptation Syndrome 1. Homeostasis is a balanced physiological state in which all the body’s systems function smoothly.

2. The body attempts to return to homeostasis after responding to a stressor by means of an adaptive response.

C. The general adaptation syndrome (GAS) was first characterized in 1936 by Hans Selye and has three distinct phases.

1. The alarm phase occurs when homeostasis is disrupted and the body prepares for the fight-or-flight response—the physiological arousal response in which the body prepares to combat or escape a real or perceived threat. a. The stressor is interpreted by the cerebral cortex and triggers the autonomic nervous system (ANS) response that prepares the body for action. i. The sympathetic nervous system energizes the body for fight or flight by signaling the release of several stress hormones. ii. The parasympathetic nervous system slows the body down after stress reaction. b. The hypothalamus, a structure in the brain, determines the overall reaction to stressors. c. Epinephrine, also called adrenalin, secreted by adrenal glands causes more blood to be pumped with each beat of the heart, dilates the airways in the lungs, increases breathing rate, stimulates the liver to release more glucose, and dilates pupils to improve visual sensitivity. d. Adrenocorticotropic hormone (ACTH) signals adrenal glands to release cortisol, a hormone that makes stored nutrients more readily available to meet energy demands. e. Finally, other parts of the brain and body release endorphins to relieve pain that a stressor may cause.

2. The resistance phase begins almost immediately after the alarm phase starts. a. The body tries to return to homeostasis by resisting the alarm phase. b. However, because some perceived stressor still exists, the body does not achieve complete calm or rest and instead stays activated or aroused.

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3. The exhaustion phase occurs after continuous alarm and resistance reactions. a. Adaptation energy stores are the physical and mental foundations of the ability to cope with stress. i. A prolonged effort to adapt to the stress response leads to allostatic load, or exhaustive wear and tear on the body. ii. In the exhaustion phase of GAS, the physical and emotional energy used to fight a stressor has been depleted. iii. Chronic, unresolved stress leads to the release of cortisol which can contribute to a reduction in the body’s immune function, immunocompetence, or the ability of the immune system to respond to attack.

Key Terms: homeostasis, adaptive response, general adaptation syndrome (GAS), fight-or-flight response, autonomic nervous system (ANS), sympathetic nervous system, parasympathetic nervous system, hypothalamus, epinephrine, cortisol, allostatic load, immunocompetence Figures and Tables:

Figure 3.1 The General Adaptation Syndrome (GAS)

Figure 3.2 The Body’s Acute Stress Response

Additional Instructor Resources: PPT slides: 8–11; Digital Transparency Masters: Figure 3.1, Figure 3.2

III. Effects of Stress on Your Life A. Stress is often described as “a disease of prolonged arousal” in which the body is susceptible to negative health effects.

B. Physical Effects of Stress 1. The list of ailments related to stress is extensive, and includes heart disease, diabetes, cancer, headaches, ulcers, low back pain, depression, and the common cold.

2. Studies show that 40 percent of deaths and 70 percent of diseases in the United States are related, in whole or in part, to stress.

C. Stress and Cardiovascular Disease 1. A summary of research studies has shown that cardiovascular disease and stress are often intertwined. a. Stress is one of the key modifiable risk factors for heart attack. b. Recent research has shown direct links between the incidence and progression of cardiovascular disease (CVD) and stressors such as job strain, care giving, bereavement, and natural disasters.

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D. Stress and Weight Gain 1. Higher stress levels may increase cortisol, contributing to increased hunger and fat-storing enzymes.

E. Stress and Hair Loss 1. Too much stress can lead to thinning hair, and even baldness, in both men and women.

F. Stress and Diabetes 1. Controlling stress levels is critical for preventing development of type 2 diabetes as well as successful short- and long-term diabetes management. a. People under stress often do not get enough sleep, do not eat well, and may drink or take drugs, all of which are behaviors that can alter blood sugar levels and promote development of diabetes.

G. Stress and Digestive Problems 1. Stress can be related to triggering nausea, vomiting, stomach cramps and related gut pain, or diarrhea.

H. Stress and Impaired Immunity 1. Psychoneuroimmunology (PNI) is a growing science that analyzes the relationship between the mind’s response to stress and the ability of the immune system to function effectively.

2. Several recent reviews of research linking stress to adverse health consequences suggest that too much stress over a long period can negatively affect various aspects of the cellular immune response.

I. Stress and Libido 1. Stress can lead to a lack of interest in sex at any age or stage of life. For more information on stress and your sex drive, please see page 79, Gender & Health box.

J. Intellectual Effects of Stress 1. Students under stress rated stress as their number one impediment to academic performance, followed by lack of sleep and anxiety.

K. Stress, Memory, and Concentration 1. Animal studies have provided compelling indicators of how glucocorticoids, stress hormones released from the adrenal cortex, are believed to affect memory.

2. In humans, acute stress has been shown to impair short-term memory, particularly verbal memory.

3. New studies linked prolonged exposure to cortisol (a key stress hormone) to actual shrinking of the hippocampus, the brain’s major memory center.

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

2. Stressful life events and inadequate sources of social support can contribute to mental disorders among people aged 15 to 24 more than among any other age group.

3. The high incidence of suicide among college students is assumed to indicate high personal and societal stress in the lives of young people.

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Figures and Tables:

Figure 3.3 Common Physical Symptoms of Stress

Additional Instructor Resources: PPT slides: 12–16; Digital Transparency Masters: Figure 3.3

IV. What Causes Stress?

A. A study conducted by the American Psychological Association in 2009 found that concerns over money, work, family, and housing were major sources of stress among American Adults.

B. Awareness of the sources of stress can do much to help you develop a plan to avoid, prevent, and control the things that cause you stress.

C. Psychosocial Stressors 1. Psychosocial stressors refer to the factors in our daily lives that cause stress. Key psychosocial stressors include adjustment to change, hassles, interpersonal relationships, academic and career pressures, and stressful environments.

2. Adjustment to Change a. Change always produces stress, whether good or bad. The more change experienced, the greater the stress.

3. Hassles: Little Things That Bug You a. Hassles are annoyances, irritations, and frustrations, such as losing keys, having a grocery bag rip, and so forth, that can build up and result in frustration, anger, and fight-or-flight responses. b. For many, the fast pace of technology creates new hassles and adds to stress. To learn more about stress created by a dependence on technology, please see page 81, Student Health Today box.

4. The Toll of Relationships a. Love relationships are the ones we often think of first, but friends, family members, and coworkers can be sources of overwhelming struggles. b. These relationships can make us strive to be the best we can be or they can diminish our self-esteem and leave us reeling from a destructive interaction.

5. Academic and Financial Pressure a. The competitive nature of academics and employment can cause mind-boggling amounts of pressure. b. Challenging classes and working to pay the bills can also cause stress.

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6. Frustrations and Conflict a. The disparity between our goals and our behaviors can cause frustration. b. Conflict occurs when we are forced to make difficult decisions concerning two or more competing motives, behaviors, or impulses or when forced to face incompatible demands, opportunities, needs, or goals.

7. Overload a. Overload is a condition in which a person feels overly pressured by demands. b. Unrelenting stress and overload can lead to a state of physical and mental exhaustion known as burnout.

8. Stressful Environments a. Where students live and their environment can cause significant levels of stress. b. Background distressors in the environment such as noise, air, and water pollution can be as damaging as one-time disasters such as earthquakes, flooding, and other natural disasters.

9. Bias and Discrimination a. Other forms of psychosocial stress include problems with discrimination, prejudice, inflation, unemployment, and poverty. b. Differences can cause isolation and affect stress levels. i. Evidence of excessive stress in minority groups and people who are socially disadvantaged abounds in our society. For more information on international student stress, please see page 83, Health in a Diverse World box.

D. Internal Stressors 1. Appraisal and Stress a. Appraisal is the interpretation and evaluation of information provided to the brain by the senses. b. As new information becomes available, appraisal helps us recognize stressors, evaluate them on the basis of past experiences and emotions, and decide how to cope with them.

2. Self-Esteem and Self-Efficacy a. Self-esteem refers to how you feel about yourself. b. Suicidal ideation, a desire to die and thoughts about suicide, may arise from low self-esteem and stressful life events. c. Self-efficacy is one of the most important personality traits that influences psychological and physiological stress responses and has been found to predict many health behaviors in college students.

3. Type A and Type B Personalities a. In 1974, physicians Meyer Friedman and Ray Rosenman identified Type A and Type B personalities. i. Type As are described as hard-driving, competitive, anxious, and time-driven perfectionists. ii. The “toxic core” or a collection of characteristics commonly referred to as hostility may make Type A people more vulnerable to self-imposed stress. iii. Type Bs are described as being relaxed, noncompetitive, and more tolerant of others.

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4. Type C and Type D Personalities a. Type Cs are described as stoic and tend to deny their feelings. b. Type Ds are described as characterized by a tendency toward excessive negative worry, irritability, and gloom.

5. Psychological Hardiness a. Psychological hardiness is a personality trait characterized by control, commitment, and the embrace of challenge. b. Those who embrace challenge see change as a stimulating opportunity for personal growth, and many researchers believe it is the foundation of an individual’s ability to cope with stress and remain healthy.

Key Terms: overload, background distressors, appraisal, suicidal ideation, hostility, psychological hardiness Figures and Tables:

Figure 3.4 What Stresses Us?

Lecture Launcher Video: Stress at Work and Home Additional Instructor Resources: PPT slides: 17–20; Digital Transparency Masters: Figure 3.4

V. Managing Stress in College A. There are many stressors associated with being a student.

1. Relationships, school events, safety, and feeling deviant from school norms are particularly distressful.

2. Students report using health enhancing methods to deal with stress, but research shows that students also resort to health-compromising behaviors to escape stress.

3. Stress in college is correlated with substance use, lack of physical activity, poor psychological and physical health, lack of social problem solving, and infrequent use of social support networks.

4. Coping is the act of managing events or conditions to lessen the physical or psychological effects of excess stress. One of the most effective ways to combat stressors is to build coping strategies and skills, known collectively as stress-management techniques.

B. Practicing Mental Work to Reduce Stress 1. Access your stressors and solve problems. a. Make a list of the major things that worry you. b. Examine the causes of the problems and worries.

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c. Consider how big each problem is and what the consequences are of doing nothing or taking action. d. List your options. e. Outline an action plan. f. Evaluate your actions. g. After you’ve identified your stressors, one useful way of coping with them is to practice stress inoculation—a technique in which a person consciously tries to prepare ahead of time for potential stressors.

2. Change the way you think and talk to yourself a. Our appraisal of people and situations is what makes things stressful, not the people or situations themselves. b. Several types of negative self-talk exist, but among the most common are pessimism, perfectionism, “should-ing,” blaming yourself, and dichotomous thinking. c. To stop negative self-talk, we must first become aware of it, then stop it, and finally replace the negative thoughts with positive ones—a process referred to as cognitive restructuring.

C. Developing a Social Network 1. Maintaining friendships offers support when stressors abound.

2. Invest in your loved ones. a. In order to have a healthy social support network, we have to invest time and energy.

3. Cultivate your spiritual side. a. Spiritual health and practices can link you to a community of like-minded individuals while giving you perspective on the things that truly matter in your life.

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

2. Learn to laugh, be joyful, and cry. For more information on how positive psychology can reduce stress, please see page 88, Health Headlines box. a. Research suggests that crying can have physiological effects in relieving tension while laughter and joy may increase endorphin levels, decrease stress levels, and enhance productivity.

3. Fight the anger urge. a. Anger usually results when we feel we have lost control of a situation or are frustrated by a situation we can do little about. b. Major sources of anger include perceived threats to self or others we care about, reactions to injustice, fear, faulty emotional reasoning, low frustration tolerance, unreasonable expectations, and people rating. c. To avoid an aggressive response: i. identify your anger style. ii. learn to recognize your anger responses and how to de-escalate them. iii. find the right words to de-escalate conflict. iv. plan ahead. v. develop a support system.

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vi. develop realistic expectations of yourself and others. vii. turn complaints into requests. viii. leave anger in the past.

E. Taking Physical Action 1. Exercise regularly.

2. Get enough sleep.

3. Learn to relax.

4. Eat healthfully. a. Avoid sympathomimetics, foods that produce (or mimic) stress-like responses, such as caffeine.

F. Managing Your Time 1. Avoid procrastination, the act of intentionally putting off doing something.

2. Time-management strategies are an important part of a stress-management program. a. Do one thing at a time. b. Clean off your desk. c. Prioritize your tasks. d. Find a clean, comfortable place to work, and avoid interruptions. e. Reward yourself for work completed. f. Work when you’re at your best. g. Break overwhelming tasks into small pieces, and allocate a certain amount of time to each. h. Remember that time is precious.

G. Managing Your Finances 1. Higher education can involve a huge financial burden on parents, students, and communities.

2. Thirty-five percent of college students report that their finances have been very difficult to handle during the past 12 months.

3. The recession, dwindling resources, and other factors, such as credit card debt, all converge to an increase in today’s students’ financial woes.

4. For more information on lessening your financial stress, please see page 93, Consumer Health box.

H. Consider Downshifting 1. Many people today are questioning whether “having it all” is worth it, and are taking a step back and simplifying their lives—a trend known as downshifting, or voluntary simplicity. a. Plan for health care costs. b. Determine your ultimate goal. c. Make both short- and long-term plans for simplifying your life. d. Complete a financial inventory. e. Select the right career. f. Consider options for saving money.

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I. Relaxation Techniques for Stress Management 1. Some common alternative stress management techniques include yoga, qigong, tai chi, deep breathing, meditation, visualization, progressive muscle relaxation, massage therapy, biofeedback, and hypnosis.

2. Yoga is an ancient practice that combines meditation, stretching, and breathing exercises to relax, refresh, and rejuvenate. a. There are various types of yoga that originate from India: i. Classical yoga involves the practice of breathing, poses, and verbal mantras. ii. Hatha yoga is a branch of classical yoga that is body focused. It involves the practice of breath control and asanas—held postures and choreographed movements.

3. Qigong is one of the fastest-growing and most widely accepted forms of mind–body health exercise. a. Qigong is an ancient Chinese practice that involves becoming aware of and learning to control qi, or vital energy in your body. According the Chinese medicine, a complex system of internal pathways called meridians carry qi throughout your body.

4. Tai chi is performed with a defined series of postures or movements in a slow, graceful manner, and is sometimes described as “meditation in motion.”

5. Diaphragmatic or deep breathing maximally fills the lungs by involving the movement of the diaphragm and lower abdomen. It is commonly used in yoga exercises and in other meditative practices.

6. Meditation has many different forms, and most involve sitting quietly and focusing on a particular word or symbol while practicing controlled breathing. Meditation can calm the body and quiet the mind, creating a sense of peace.

7. Visualization uses our imagination to create a mental image associated with peaceful thoughts.

8. Progressive muscle relaxation is designed to teach awareness of different feelings of muscle tension and muscle release.

9. Massage therapy is another way to relax, with varying techniques.

10. Biofeedback involves self-monitoring to control stress responses via a machine in hopes to eventually develop the ability to recognize and lower stress without using the machine.

11. Hypnosis is a process that requires a person to focus on one thought, object, or voice, thereby freeing the brain’s right hemisphere to become more active. While selfinduced or induced by someone else, hypnosis can reduce certain types of stress.

Key Terms: coping, stress inoculation, cognitive restructuring, sympathomimetics, procrastinate, meditation, visualization, biofeedback, hypnosis

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Figures and Tables:

Figure 3.5 How Do You Spend Your Time?

Figure 3.6 Diaphragmatic Breathing

Figure 3.7 Progressive Muscle Relaxation

Lecture Launcher Video: The Multi-Tasking Myth Additional Instructor Resources: PPT slides: 21–34; Digital Transparency Masters: Figure 3.5, Figure 3.6, Figure 3.7

Additional Chapter Activities 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? Did your coping strategies add more stress to the situation?

2. What are some situations that might be eustressors to one person but distressors to another? Can you think of examples when at different points in life eustressors can become distressors or that distressors can become eustressors?

3. Do you know anyone who fits the description of “psychologically hostile”? What characteristics does this person have?

4. Why is college life so stressful? What preventive measures can college students take in order to reduce the chance of overload?

5. What are some situations in which you felt environmental or background stressors? How did this change your perception or response to the situation at that time?

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

Critical Thinking Questions 1. What kinds of 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. Are you guilty of negative self-talk? What steps can you take to reduce negative self-talk and make it more positive?

3. Why are the college years often high-stress years for many? What factors increase stress risks? What actions can you take to manage your stressors?

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

5. 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. Think about the most stressful times during your academic year. What prevention measures could you put in place to reduce stress and maintain health during these times?

Discuss these stressful times with a friend or significant other to see whether you have any common stressors and make a stress management plan together.

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.

Community 1. Initiate a stress management campaign in your dorm or in collaboration with your campus’ student health services. Be creative to promote stress management techniques and support resources.

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

Diverse Populations/Nontraditional 1. Do people in other cultures experience the same stressors as those in the United States?

What are the stress management techniques emphasized in other cultures?

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?

Lecture Launcher Video Questions Stress at Work and Home 1. For those in class who work full or part time, share an extremely stressful work event and how it was resolved. How did you feel at that time?

2. In potentially stressful situations at home, how do you prevent issues from escalating to an uncontrollable level?

3. Name a few ways in which to reduce stress at school. Have you had success in any of these? What support systems need to be in place?

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The Multitasking Myth 1. Why isn’t multitasking as good an option as one might think? Do you agree that it can become a problem?

2. How do you multitask in your own life? Does it have an effect on the quality of the work you are doing simultaneously?

3. Translate the three steps outlined to be more productive to your own daily life. Could you follow them?

Additional References 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.

M. C. Nelson, K. Lust, M. Story, and E. Ehlinger, “Credit Card Debt, Stress, and Key Health Risk Behaviors among College Students.” American Journal of Health Promotion, 22, (2008): 400–407.

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 Psychiatric Association Healthy Minds. Healthy Lives. www.healthyminds.org American Psychological Association www.apa.org Association for Applied Psychophysiology and Biofeedback www.aapb.org 48

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Benson-Henry Institute for Mind Body Medicine www.mbmi.org Mayo Clinic Biofeedback www.mayoclinic.com/health/biofeedback/MY01072 National Mental Health Information Center Substance Abuse and Mental Health Services Administration http://mentalhealth.samhsa.gov/cmhs/

Additional Media 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 Health Matters: Stress Management, 29 minutes A UCTelevesion production in which doctors David Granet and Steven Hickman of UCSD School of Medicine discuss the mind-body connection. www.youtube.com/watch?v=lT17Jr1EEJQ&feature=related 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 Stress Relief Yoga: Yoga Breathing Techniques, 2 minutes This video, produced by Expert Village, has expert Elizabeth Cafferky teaching a breathing exercise designed to relieve stress. www.youtube.com/watch?v=W41V8w00E6o

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CHAPTER

3A

Focus On Improving Your Sleep

Overview Sleep is a vital part of reaching our health potential, and yet we never seem to get enough and always need more. This chapter, focused on sleep, explains why our bodies need sleep to maintain both our physical and psychosocial health. It explains what happens when we sleep and describes the differences between non-REM and REM sleep. This chapter also describes how much sleep a person really needs and provides strategies on how to get the sleep you need to stay healthy.

Lecture Outline I. Why Do You Need Sleep?

A. The American College Health Association (ACHA) reports that as many as 11 percent of college students do not get enough sleep during the week to feel rested and nearly 44 percent of college students say they don’t feel rested most days of the week.

1. One factor commonly implicated in reduced sleep time for college students is 24-hour access to the Internet.

2. Other things keeping students awake are academic pressures, an underlying sleep disorder, chronic pain or other disease symptoms, anxiety or depression, the use of drugs (including alcohol), and stress from a variety of sources.

3. A recent poll from the National Sleep Foundation (NSF) found that only about a third, 32 percent, of Americans report getting a good night’s sleep on only a few nights per month.

B. Sleep Maintains Your Physical Health 1. Sleep serves two biological purposes: a. It conserves body energy. b. It restores you both physically and mentally.

2. Sleep has beneficial effects on most body systems. a. Sleep helps maintain your immune system. b. Sleep helps reduce your risk for high blood pressure and cardiovascular disease. c. Sleep contributes to a healthy metabolism and body weight. i. The sum of your body’s cells reactions is called metabolism and studies suggest that sleep contributes to a healthy metabolism and thus helps you maintain a healthy body weight. ii. Inadequate sleep may play a role in our population’s increased prevalence of type 2 diabetes, a disorder of glucose metabolism, as well as obesity.

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C. Sleep Affects Your Ability to Function 1. Sleep contributes to neurological functioning. a. Restricting sleep can cause a wide range of neurological problems, including lapses of attention, slowed or poor memory, reduced cognitive ability, and a tendency for your thinking to get “stuck in a rut.”

2. Sleep improves motor tasks a. Sleep researchers contend that a night without sleep impairs your motor skills and reaction time as much as if you were driving drunk. b. The NSF reports that 37 percent of American drivers have admitted to falling asleep behind the wheel during the past year, and more than 1,500 Americans die in fatigue-related crashes annually.

D. Sleep Promotes Your Psychosocial Health 1. Research suggests that certain brain regions, including the cerebral cortex, can achieve some form of essential rest only during sleep.

2. One sign of brain fatigue is irritability.

3. Stress can cause or contribute to sleep problems, and sleep problems can cause or increase your levels of stress. This is also true of disorders such as anxiety and depression.

Additional Instructor Resources: PPT slides: 1–7

II. What Goes on When You Sleep?

A. Jet lag occurs because the new day/night pattern disrupts your normal circadian rhythm, the 24-hour cycle by which you are accustomed to going to sleep, waking up, and performing habitual daily tasks throughout the day.

B. Your circadian rhythm is regulated in part by a hormone called melatonin that is secreted by a small glad in your brain called the pineal body.

C. Sleep is clinically defined as a readily reversible state of reduced responsiveness to, and interaction with, the environment.

D. There are two primary sleep states: 1. Non-REM (NREM) sleep: a state that is not characterized by rapid eye movement 2. REM sleep: a state in which rapid eye movement occurs 3. Throughout the night, you slide through stages of NREM and REM sleep, a full cycle is repeated about once every 90 minutes.

4. You spend about 75 percent of each night in NREM sleep and 25 percent in REM. E. Non-REM Sleep Is Restorative 1. The body rests during NREM sleep. Body temperature is reduced; body temperature and energy use drop; sensation is dulled; and heart rate, breathing, and brain waves slow down.

2. You do not typically dream during NREM sleep.

3. Four distinct stages of NREM sleep have been distinguished by their characteristic brain-wave patterns. a. Stage 1: The lightest stage of sleep that lasts only a few minutes. b. Stage 2: Slightly deeper stage that lasts from 5 to 15 minutes. Eyes are closed and eye and body movement gradually cease.

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c. Stage 3: NREM sleep is also called slow-wave sleep, because during stages 3 and 4, a sleeper’s brain generates slow, large amplitude delta waves and your blood pressure, heart rate, and respiration slow. d. Stage 4: Deepest stage of sleep. Human growth hormone is released and signals the body to repair worn tissues.

F. REM Sleep Is Energizing 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. During REM sleep, your brain processes the experiences you’ve had and consolidates the information you learned during the day.

Key Terms: circadian rhythm, hormone, sleep, non-REM (NREM) sleep, REM sleep Figures and Tables:

Figure 1 The Nightly Sleep Cycle

Additional Instructor Resources: PPT slides: 8–9; Digital Transparency Masters: Figure 1

III. How Much Sleep Do You Need?

A. Sleep Need Includes Baseline Plus Debt 1. The average sleep time a person needs is 7 to 8 hours per day.

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

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

B. Do Naps Count?

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

2. It is best to nap early to mid-afternoon.

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

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

Key Terms: sleep debt, sleep inertia Additional Instructor Resources: PPT slides: 10–11

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IV. How Can You Get a Good Night’s Sleep?

A. Inadequate or poor quality sleep is characterized by difficulty waking up, difficultly staying awake in class, and nodding off behind the wheel of a car.

B. To Promote Restful Sleep, Try These Tips.

1. Let there be light—stay in sync with your circadian rhythm by spending time in the sunlight.

2. Stay active—get plenty of physical activity during the day.

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

4. Condition yourself into better sleep—establish a bedtime ritual; go to bed and get up at the same time each day.

5. Sleep tight—use proper, comfortable bedding.

6. Condition yourself into better sleep.

7. Breathe—take several deep breaths as soon as your head hits the pillow.

8. Don’t toss and turn—if you are not asleep after 20 minutes, try reading something relaxing, not stimulating, and once you feel sleepy, try going back to bed. a. To learn more about ecofriendly choices for bedding products, please see page 107, Be Healthy, Be Green box.

C. To Prevent Sleep Problems, Avoid These Behaviors 1. Don’t nap in the late afternoon or evening and don’t nap longer than 30 minutes.

2. Don’t engage in strenuous exercise within several hours before bedtime.

3. Don’t read, study, watch TV, use your laptop, talk on the phone, eat, or smoke in bed.

4. Don’t try to sleep if you’re starving or stuffed. Allow 3 hours between your evening meal and bedtime.

5. Don’t drink beverages with caffeine within several hours of bedtime.

6. Don’t drink alcohol within several hours of bedtime.

7. Don’t drink large amounts of any liquid before bedtime.

8. Don’t take sleeping pills or nighttime pain medications unless they are prescribed by your health care provider.

Additional Instructor Resources: PPT slides: 12–14

V. What If You’re Not Sleeping Well?

A. It is estimated that 50 to 70 million Americans have clinical sleep disorders.

B. 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.

C. The most common sleep disorders include the following: 1. Insomnia is characterized by difficulty in falling asleep quickly, frequent arousals during sleep, or early morning awakening. a. Cognitive behavioral therapy is often a part of any treatment for insomnia, and in some cases, hypnotic or sedative medications may be prescribed.

2. Sleep apnea: disorder in which breathing is briefly and repeatedly interrupted during sleep; apnea refers to a breathing pause that lasts at least 10 seconds. a. Central sleep apnea occurs when the brain fails to tell the respiratory system to initiate breathing.

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b. Obstructive sleep apnea (OSA) occurs when air cannot move in and out of a person’s nose or mouth.

3. Restless legs syndrome (RLS) is a neurological disorder characterized by overwhelming sensations in the legs when at rest combined by an uncontrollable urge to move in an effort to relieve these feelings.

4. Narcolepsy is an excessive, intrusive sleepiness in which a person can suddenly fall asleep while in class, while driving, or in any other situation.

5. A parasomnia is a disorder in which undesired events, such as REM sleep behavior disorder (RBD) or sleepwalking, occur while sleeping.

Key Terms: sleep study, insomnia, sleep apnea, restless legs syndrome (RLS), narcolepsy, parasomnia Figures and Tables:

Figure 2 Sample Sleep Diary

Table 1 Sleep Disorder Prevalence by Gender and Ethnicity

Lecture Launcher Video: Fatal Insomnia Additional Instructor Resources: PPT slides: 15–25; Digital Transparency Masters: Figure 2, Table 1

Additional Chapter Activities Discussion Questions 1. 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 types of strategies do you tend to use to get through the day? How might these influence your sleep schedule?

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? What strategies or behaviors would you recommend that they avoid?

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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? What strategies and behaviors can you adopt to prevent falling asleep in class in the future?

5. How have your sleep patterns changed—for the good or bad—since you have been at college? How do your current sleep patterns differ from those you had while living at home? How do you think these changes are influencing your health and academic performance?

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 have. Create and follow a plan to help you reduce your sleep debt.

Community 1. Create a program with your roommates or dorm to track your sleep debt. How much can each person or group reduce their debt weekly?

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

3. Investigate automobile crashes in your community that are 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?

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.

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Lecture Launcher Video Questions New! Fatal Insomnia 1. In the video, footage is shown of Silvano, a man who suffered from fatal familial insomnia (FFI). What happens to someone who has FFI? How can FFI eventually lead to death?

2. How does insomnia affect someone after just a single night without sleep? Have you ever experienced sleep deprivation? If so, describe the ways in which it affected you both physically and mentally.

Additional References D. Bailly, I. Bailly-Lambin, D. Querleu, R. Beuscart, and C. Collinet, “Sleep in Adolescents and Its Disorders: A Survey in Schools,” Encephale, 30, (2004): 352–359.

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

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

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

For Further Information Sleep Treatment Chronic Insomnia Assay http://sleeptreatment.com/assess-your-sleep/chronic-insomnia-assay Mayo Clinic Insomnia www.mayoclinic.com/health/insomnia/DS00187 Discovery Health Sleep Hygiene Test http://discoveryhealth.queendom.com/sleep_hygiene_abridged_access.html University of Florida Sleeping in the Swamp www.healthygators.hhp.ufl.edu/sleep.shtml Sleep Treatment Sleep Quality Index http://sleeptreatment.com/assess-your-sleep/sleep-quality-index

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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 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 apnea. 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

4

Building Healthy Relationships and Communicating Effectively

Overview Communication is an important aspect of our daily lives. We spend most of our time communicating with others, making our ability to communicate and listen significantly contribute to our social, mental, spiritual, and physical health. Good communication is also a key to healthy relationships and many, some say most, of the breakdowns that we have in our relationships with others have to do with poor communication. Chapter 4 explains the communication process, including all components such as nonverbal communication and listening.

This chapter also deals with the newest forms of communication including online dating and social networking websites. Communicating in our global society means that we must have greater tolerance for differences between ourselves and others. This chapter also discusses the language differences that exist between men and women and helps us to understand what can be done to improve our communication with others. In this chapter, intimacy, love, commitment, and passion are explored. A variety of possible relationships are examined. Examples include relationships with parents, friendships, lovers, and others. It is important that we understand what factors build strong relationships. The different types of committed relationships are explored as well.

Learning Objectives 1. Identify the characteristics of successful relationships, including how to maintain them and overcome common barriers.

2. Discuss ways to improve communication skills and interpersonal interactions.

3. Examine what determines the success of an intimate relationship and where to get help when a relationship has problems.

4. Examine relationship factors that affect life decisions, for example, whether to have children.

5. Discuss when and why relationships end, and how to cope when they do.

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Lecture Outline I. Characteristics and Types of Intimate Relationships A. Intimate relationships are those relationships with another person in which you offer, and are being offered, validation, understanding, and a sense of being valued intellectually, emotionally, and physically.

1. They are usually defined in terms of four characteristics: a. Behavioral interdependence refers to the mutual impact that people have on each other as their lives and daily activities intertwine. b. Need fulfillment refers to our psychological needs including intimacy, social integration, nurturance, assistance, and affirmation of our worth. c. Emotional attachment means strong bonds of love. d. Emotional availability is being able to give and receive from others emotionally without fear of being hurt or rejected.

2. Intimate relationships are not necessarily sexual, and the intimacy level two people experience in a relationship cannot be easily judged by those outside the relationship.

B. Family Relationships 1. 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.

2. Because the family is a dynamic institution that changes as society changes, the definition of family changes over time as well.

3. Family of origin, the people present in our household during our first years of life, are those who teach us our earliest lessons about feelings, problem solving, love, intimacy, and gender roles, and who have a significant impact on relationships established outside the family.

C. Relating to Yourself 1. Must one love oneself before loving someone else? This is a lifelong task, and intimate relationships should not be postponed to achieve this, but a certain level of individual maturity can help maintain a committed relationship.

2. Accountability entails recognizing that you are responsible for your own decisions, choices, and actions.

3. Self-nurturance means developing individual potential through a balanced and realistic appreciation of self-worth and ability.

4. The way that we define ourselves (self-concept) and evaluate ourselves (self-esteem) influences our ability to nurture ourselves and maintain healthy relationships with others.

D. Friendships 1. Friendships are often the first relationships we form outside of our immediate families and they can be some of our lives’ most stable and enduring relationships.

2. Investing in friendships is important because friends provide emotional stabilities throughout our lives.

3. Being able to establish and maintain strong friendships may be a good predictor of your success in establishing love relationships.

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E. Romantic Relationships 1. Most people eventually choose to enter into an intimate sexual relationship with another person.

2. Romantic relationships typically include the characteristics of friendship, as well as the following characteristics related to passion and caring: a. Fascination—Exclusive preoccupation with the other person b. Exclusiveness—Exclusion of a relationship with a third party, making the relationship take priority of all others c. Sexual desire—Wanting to have physical intimacy and to engage in sexual activities with the other person d. Giving the utmost—Caring enough to give when the other is in need, sometimes to the point of extreme sacrifice e. Being a champion or advocate—Actively championing each other’s interests and attempting to ensure that the other partner succeeds F. Theories of Love 1. Love is usually characterized in one of two ways: a. Companionate love is when two people are attracted to each other, have much in common, care about each other’s well-being, and express reciprocal liking and respect. b. Passionate love is a state of high arousal, filled with the ecstasy of being loved and the agony of being rejected.

2. Psychologist Robert Sternberg’s Triangular Theory of Love proposes the following three key components to loving relationships: a. Intimacy is the emotional component, which involves closeness, sharing, and mutual support. b. Passion is the motivational component, which includes lust, attraction, sexual arousal, and sharing. c. 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.

3. The quality of love relationships is reflected by the level of intimacy, passion, and commitment each person brings to the relationship over time.

4. Sternberg uses the term consummate love to describe a combination of intimacy, passion, and commitment.

5. According to anthropologist Helen Fisher and many others, there is a predictable pattern of falling in love: a. Imprinting—Our genetics as well as past experiences trigger romantic reactions. b. Attraction—Neurochemicals produce feelings of euphoria and elation. c. Attachment—Endorphins cause lovers to feel peaceful, secure, and calm. d. Production of the hormone oxytocin (the cuddle chemical)—When released, it elicits feelings of satisfaction and attachment.

Key Terms: intimate relationships, family of origin, accountability, self-nurturance

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Tables and Figures:

Figure 4.1 Sternberg’s Triangular Theory of Love

Additional Instructor Resources: PPT slides: 1–12; Digital Transparency Masters: Figure 4.1

II. Strategies for Success in Relationships A. Characteristics of Healthy Relationships 1. Satisfying and stable relationships share certain identifiable traits, such as good communication, intimacy, friendship and other factors.

2. Without trust, another key ingredient, intimacy will not develop, and the relationship will likely fail. Trust includes the following elements: a. Predictability b. Dependability c. Faith B. Choosing a Romantic Partner 1. The partner selection process is influenced by more than just chemical and psychological processes. a. One important factor is proximity, or being in the same place at the same time. The more you see a person, the more likely you are to interact with each other. b. Similarities, in attitudes, values, intellect, interests, education, and socioeconomic status, can add to partner selection. c. Mutual regard or reciprocity occurs when expressions of interest or liking are shared. d. Physical attraction also plays a role in partner selection. Males and females have different criteria, which are complex and influenced by social, biological, and cultural factors. i. To learn about meeting people online, please see page 123, Consumer Health box.

C. Confronting Couple Issues 1. Having a long-term relationship requires that couples confront issues that either enhance or diminish their chances of success.

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2. Jealousy is an adverse reaction evoked by a real or imagined relationship involving your partner and a third person. It can inhibit intimacy and destroy relationships.

Causes of jealousy typically include the following: a. A past relationship in which an individual experienced deception and loss. b. Overdependence on the relationship. c. Severity of threat. d. High value on sexual exclusivity. e. Low self-esteem. f. Fear of losing control.

3. Women and men take on various roles in relationships and gender roles are changing. a. In modern society there are fewer gender-specific roles. Many couples find that it makes the most sense to divide tasks along the lines of schedule, convenience, and preference. b. In relationships where a couple is unable to communicate how they feel about performing certain tasks, the relationship tends to suffer.

4. Sharing power, or the ability to make and implement decisions, is an important element of a stable relationship.

5. Communicating our expectations about our lives and our desires within a relationship is necessary for a stable, long-term relationship.

Key Terms: jealousy, power Figures and Tables:

Figure 4.2 Healthy Versus Unhealthy Relationships

Additional Instructor Resources: PPT slides: 13–17; Digital Transparency Masters: Figure 4.2

III. Communicating: A Key to Good Relationships A. Many cultures differ in their communication styles.

B. All of us can learn to be better communicators. By understanding how to deliver and interpret information, we can enhance our relationships. For more information on how men and women differ in the way they communicate, please see page 126, Gender & Health box.

C. Learning Appropriate Self-Disclosure 1. Self-disclosure is the sharing of personal information with others.

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2. Self-disclosure involves taking a risk for rejection or alienation but improves social health. Also, without self-disclosure, there will be a lack of close relationships.

3. Improving self-disclosure involves several things: a. Getting to know yourself. b. Becoming more accepting of yourself. c. Being willing to discuss your sexual history. d. Choosing a safe context for self-disclosure.

D. Becoming a Better Listener 1. Being a better listener enhances relationships, improves our grasp on information, and allows us to interpret more effectively what others say.

2. We listen best when: a. We believe that the message is somehow important to us. b. We are interested in what is being said. c. We are in the mood to listen.

3. There are three main ways in which we listen: a. Competitive, or combative, listening—More self-centered rather than being an active listener. b. Passive, or attentive, listening—Listening with interest but not responding with questions or comments to clarify. c. Active, or reflective, listening—Genuine interest in the speaker and responding with clarifying statements.

E. Using Nonverbal Communication 1. Nonverbal communication includes all unwritten and unspoken messages, both intentional and unintentional, including the following: a. Touch b. Gestures c. Interpersonal space d. Facial expressions e. Body language f. Tone of voice F. Managing Conflict through Communication 1. A conflict is an emotional state that arises when the behavior of one person interferes with that of another.

2. Conflict resolution and successful conflict management form a systematic approach to resolving differences fairly and constructively. a. Most conflict revolves around two message components: content, or the subject of the participants’ sentences, and relationship, which embodies the interactions between the people concerned and usually involves issues that are much more deeply rooted.

3. Prolonged conflict can destroy relationships, but there are several strategies used for conflict resolution: a. Identify the problem or issues. b. Generate several possible solutions.

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c. Evaluate the alternative solutions. d. Decide on the best solution. e. Implement the solution. f. Follow up.

Key Terms: self-disclosure, nonverbal communication, conflict, conflict resolution Lecture Launcher Videos: For Richer or For Poorer, Unwanted Advances Additional Instructor Resources: PPT slides: 18–25

IV. Committed Relationships A. Commitment in a relationship means that there is an intent to act over time in a way that perpetuates the well-being of the other person, oneself, and the relationship.

B. Marriage 1. In many societies, marriage is the traditional form of a committed relationship. Close to 90 percent of Americans marry at least once during their lifetime, and at any given time, close to 60 percent of Americans are married.

2. Many Americans believe that marriage involves monogamy, an exclusive sexual involvement with one person.

3. 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 the same type of relationship with another person.

4. An open relationship involves agreement between partners that there will be sexual relationships outside their relationship.

5. Healthy marriages provide emotional support and stability, and often longer life, less stress, and better overall health. However, marriage is not the only path to a successful, committed relationship. To learn more about marriage myths and facts, please see page 131, Health Headlines box.

C. Cohabitation 1. Cohabitation is defined as two people who have an intimate connection with each other and who live in the same household.

2. Cohabitation lasting a designated number of years (usually seven) constitutes as a common-law marriage in some states for the purposes of real estate and other financial obligations.

3. Advantages include not being legally committed and sharing expenses.

4. Disadvantages include lack of societal validation and lack of tax deductions, health insurance, and other benefits.

D. Gay and Lesbian Partnerships 1. Those in gay and lesbian partnerships have the same desire for intimate, committed relationships as heterosexual couples.

2. Challenges to gay and lesbian couples include discrimination and dealing with social, legal, and religious doctrines. The United States’ Defense of Marriage Act (DOMA) is a law that states no state can treat a relationship between persons of the same sex as a marriage, even if the relationship is considered a marriage in another state.

3. Worldwide, the number of countries that have legalized same-sex marriages or who approve civil unions or registered domestic partnerships for same-sex couples continues to grow.

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Key Terms: monogamy, serial monogamy, open relationship, cohabitation, common-law marriage Figures and Tables:

Figure 4.3 Marital Status of the U.S. Population by Sex

Digital Transparency Masters: Figure 4.3

V. Staying Single A. Today, large numbers of people are choosing to stay single or to delay marriage.

1. Data from 2008 indicate that 52.8 percent of women aged 20 to 34 have never been married and the number of unmarried men is also increasing, with 62.8 percent remaining unmarried in 2008.

2. Although sexual intimacy may or may not be present, the intimacy achieved through other interactions with loved ones is a key aspect of the single lifestyle.

VI. Choosing Whether to Have Children A. When couples have children, their relationship changes. Money, time, and energy are diverted to the children and the couple may not have each other’s undivided attention.

B. No matter what the family structure looks like, the well-being of the family unit depends on consistency, communication, affection, and mutual respect.

C. Changing patterns in family life affect the way children are raised. More and more children are becoming part of blended families when their parents remarry; in addition, increasing numbers of individuals are choosing to have children in a family structure other than a heterosexual marriage.

D. Finally, it is important for potential parents to consider the financial implications to having a child. It is estimated that a family that had a child in 2009 will spend between $200,000 and $475,000 for food, clothing, shelter, education, and other necessities for the child over the next 17 years.

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Figures and Tables:

Table 4.1 Common Parenting Styles

Additional Instructor Resources: PPT slides: 26–28; Digital Transparency Masters: Table 4.1

VIII. When Relationships Falter A. There are many warning signs that signal the oncoming breakup of a relationship.

1. A change in communication is usually the first sign.

2. A change in level of autonomy, or the ability to care for oneself, is often a signal of trouble in a relationship.

3. College students may be particularly vulnerable to staying in unhealthy relationships.

4. Most communities have trained therapists who specialize in relationship difficulties, and most student health centers offer services at reduced fees for students.

5. Honesty and verbal affection are usually positive aspects of a relationship. In a troubled relationship, however, they can be used to cover up irresponsible or hurtful behavior. To learn more about recognizing your partner as a potential abuser, please see page 136, Student Health Today box.

B. When and Why Relationships End 1. The divorce rate in the United States has declined from previous decades, and has never exceeded 41 percent.

2. Relationships may end for a variety of reasons such as illness, financial concerns, or career problems.

3. Other breakups arise from unmet expectations. Under stress, communication and cooperation between partners can break down.

C. No relationship comes with a guarantee, but the uncoupling process can be very painful.

Remembering that knowing, understanding, and feeling good about oneself before entering the relationship is very important. Tips for coping with a failed relationship include: 1. Recognize and acknowledge your feelings.

2. Find healthful ways to express your emotions, rather than turning them inward.

3. Spend time with current friends, or reconnect with old friends.

4. Do not rush into a “rebound” relationship.

Additional Instructor Resources: PPT slides: 29–33

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Additional Chapter Activities Points of View The Defense of Marriage Act: For Better or For Worse? on page 133 of your textbook.

1. The federal Defense of Marriage Act (DOMA) is a United States law requiring that no state can treat a relationship between persons of the same sex as marriage, even if the relationship is considered marriage in another state.

2. DOMA denies gay couples the federal protections and benefits afforded to heterosexual couples.

In Class Activity: Have students spend 3 to 5 minutes writing about the arguments to keep DOMA. Then have students turn their paper over and spend 3 to 5 minutes writing about the arguments to repeal DOMA. Synthesis: Have students get into small groups and share both sides of their argument.

Finally, have students come together as a class and list the rights, responsibilities, and protections granted to married couples at the federal level that are unavailable to same sex couples.

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?

2. Do you think men and women differ in the way they view relationships?

3. Do you think cohabitating couples should have the same legal advantages as married couples? Why or why not?

4. Discuss both healthy and unhealthy ways people cope with failed relationships.

5. Discuss common parenting styles. Which styles most closely reflect the way you were parented? What type of parenting might be best suited to you in the future?

Critical Thinking Questions 1. Explain the strengths and weaknesses of your communication and listening skills with your family members; friends and roommates; or significant other. Do you vary your communication skills depending on with whom you are communicating?

2. What can you do to become a more active listener?

3. Have you or your friends used the Internet to meet or date? How did the experience work out? What safety mechanisms do you use or your friends use?

4. Do you agree with Sternberg’s triangular theory of love, as show in Figure 4.1? Have you ever experienced consummate love?

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Student Activities Individual 1. Assess how well you communicate with the Assess Yourself activity on page 138 of your textbook, then ask a close friend to do the same. Compare your strengths and areas for growth and talk about how to make a plan for change.

2. Have you ever gone through a breakup? Analyze the past relationship and identify the main problems that caused the breakup. What coping strategies helped you to get through it?

Community 1. List five ways that you can improve the relationships you have with people in your surrounding community (i.e., dorm, sports team, classes).

2. Interview a marriage counselor. What types of problems are common in his or her practice?

3. 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?

Diverse Population/Nontraditional 1. Use the Internet to research gender roles in other cultures. How have traditional gender roles changed compared to 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. Explore organizations that deal with the prevention of sexual prejudice against LGBT populations in your community.

Lecture Launcher Video Questions New! For Richer or Poorer 1. Why do you think money is the number one problem in marriages and the number one reason cited for divorces in America? How do you think the current economy might cause stress and tension in a relationship?

2. In what ways do you think finance expert Ellie Kay’s 60-minute-money workout would help a relationship involving money-related tension?

3. List three money-saving techniques that a family might use in order to spend their money more wisely.

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New! Unwanted Advances 1. Why do you think people respond differently to witnessing an unwanted sexual advance?

What reasons can you think of that a man would respond differently than a woman, a single person differently than a group, etc.?

2. How would you react if you saw a man relentlessly flirting with a woman who clearly showed signs of being bothered? What would you personally classify as “crossing the line” in regard to unwanted advances, and why?

3. If you were the person being bothered, what are some things you could do to remove yourself from the uncomfortable situation while also ensuring your safety?

Additional References 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. Criag, and 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.

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.

J. Vézina, and M. Hérbert, “Risk Factors for Victimization in Romantic Relationships of Young Women: A Review of Empirical Studies and Implications for Prevention,” Trauma Violence Abuse, 8, (2007): 33–66.

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 Conflict Resolution Information Source www.crinfo.org American Psychological Association Families and Relationships www.apa.org/helpcenter/family/index.aspx The Gottman Relationship Institute www.gottman.com Human Rights Campaign www.hrc.org

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Additional Media Friendship Skills: How to End a Toxic Friendship, 2 minutes Expert Village recruited Dr. Felicia Ferrara to narrate a series on friendship skills. The series of 15 videos provides tips on how to make friends, how to end a friendship, and how to cope with the end of a friendship. The link below is a narration on how to end a toxic friendship. www.youtube.com/watch?v=2vjylxXvmo8&feature=channel Handling Heartache Health Guru is an organization that posts videos narrated by health experts on various health topics. College Health Guru, a subsection of Health Guru, provides videos that cover various topics. The link below has to do with coping with the end of an intimate relationship. http://college.healthguru.com/content/video/watch/100515/Handling_Heartache Health Guru Media, Inc. 494 Broadway 4th Floor New York, NY 10012 information@fullturnmedia.com 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 Self-Improvement Tips: How to Improve Communication Skills, 2 minutes Expert Village recruited Dr. Paul Verhorn to narrate a series on self-improvement tips. The series of videos provides tips on how to overcome shyness, how to small talk, and how to make friends. The link below is a narration on how to improve communication skills. www.youtube.com/watch?v=htbNbmVLvkU&feature=channel 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

5

Understanding Your Sexuality

Overview We are sexual beings from the time of conception. Our identity begins at that time. How our caregivers treat us will help us to determine what behaviors are appropriate for our gender.

Social constructs play an important role in how we express our sexuality. Chapter 5 discusses the biological, physiological, psychological, and social determinants of our sexuality. This chapter will help students identify behaviors that feel comfortable and will also explain what may be happening when problems occur.

Learning Objectives 1. Identify major features and functions of male and female sexual anatomy and physiology.

2. Discuss the stages of the human sexual response and what factors may influence these during your life.

3. Define sexual identity, and discuss its major components, including biology, gender identity, gender roles, and sexual orientation.

4. Discuss the options available for the expression of one’s sexuality.

5. Classify sexual dysfunctions, and describe major disorders.

6. Examine the effects of various drugs on sexual behavior.

Lecture Outline I. Sexual Anatomy and Physiology A. Sexuality is all of the thoughts, feelings, and behaviors associated with being male or female, experiencing attraction, being in love, and being in relationships that include sexual intimacy and activity. The interwoven elements of sexuality include sensuality, intimacy, sexual identity, sexual health and reproduction, and sexualization.

B. Female Sexual Anatomy and Physiology 1. The female reproductive anatomy includes two major groups of structures: external genitals and internal organs. a. External female genitalia, the vulva, include all structures that are outwardly visible. b. The mons pubis is a pad of fatty tissue covering the pubic bone. c. The labia majora, “outter lips,” are folds of skin and tissue that enclose the vaginal and urethral openings.

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d. The labia minora, “inner lips,” are folds of mucous membranes. e. The clitoris is a sexual organ whose only known function is sexual pleasure. f. The urethral opening, through which urine is expelled, is right below the clitoris. g. The vaginal opening is covered by a thin membrane called the hymen. h. The perineum is the area between the vulva and the anus.

2. The internal female genitals include the following: a. The vagina is the passageway from the uterus to the outside of the body. b. The uterus (womb) is a hollow, pear-shaped organ whose function is to contain the developing fetus. c. The endometrium is the lining of the uterus that prepares for implantation and fertilization. d. The cervix is the lower end of the uterus that opens into the vagina; its actual opening is referred to as the cervical os. e. The ovaries produce estrogen and progesterone and house immature eggs. f. The fallopian tubes connect the ovaries to the uterus and are the site of fertilization and passageway for fertilized eggs; also called oviducts.

3. With the onset of puberty, the female reproductive system matures, and the development of secondary sex characteristics signals the transition of young girls into young women. a. The hypothalamus and the pituitary gland secrete hormones to begin the process of puberty. b. Gonadotropin-releasing hormone (GnRH) signals the pituitary gland to release gonadotropin hormones, especially follicle-stimulating hormone (FSH) and luteinizing hormone (LH). c. FSH and LH signal ovaries to start producing estrogen and progesterone. d. These hormones cause menarche, or the first menstrual cycle at approximately 9 to 17 years of age. e. The average menstrual cycle lasts 28 days and consists of three phases: the proliferative phase, the secretory phase, and the menstrual phase. f. During the proliferatory phase, hormones signal the matural of ovarian follicals, eventually resulting in the graafian follicle which is a mature ovarian follicle that contains a fully developed ovum, or egg. g. The release of a mature ovum from the ovarian follicle is a process called ovulation. h. After ovulation, the ovarian follicle is turned into corpus luteum (called secretory phase). i. If fertilization takes place, human chorionic gonadotropin (HCG) is released by the developing embryo. j. If fertilization does not occur, the egg disintegrates. k. As hormones decline if fertilization does not occur, the endometrium is sloughed off and the menstrual phase begins.

4. Menstrual Problems a. Premenstrual syndrome (PMS) comprises the mood changes and physical symptoms that occur in some women during the 1 or 2 weeks prior to menstruation.

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b. Premenstrual dysphoric disorder (PMDD) is a collective name for a group of negative symptoms simliar to more severe than PMS, including severe mood disturbances. c. Dysmenorrhea is a condition that causes discomfort in the lower abdomen just before or after menstruation. d. Toxic shock syndrome (TSS), although rare today, is caused by a bacterial infection facilitated by tampon and diaphragm use.

5. Menopause is the permanent cessation of menstruation generally occurring between the ages of 40 and 60, with age 51 being the average in the United States. a. It results in decreased estrogen levels, which can cause vaginal dryness, hot flashes, headaches, dizziness, joint pain, and in some women a decline in libido. b. Menopausal women may have an increased risk of heart disease and osteoporosis. i. Hormone replacement therapy (HRT), or menopausal hormone therapy, has long been prescribed to reduce menopausal symptoms and the risk of heart disease and osteoporosis in susceptible women. ii. Recent studies and the results from the Women’s Health Initiative (WHI) suggest that hormone therapy may do more harm than good by increasing the risk of breast cancer, heart attack, stroke, blood clots, and other health problems.

C. Male Sexual Anatomy and Physiology 1. The male reproductive system is also divided into internal and external genitalia. The penis and the scrotum make up the external genitalia. a. The penis is the organ that deposits sperm in the vagina during intercourse. b. Ejaculation expels the semen through the urethra (which also acts as a passageway for urine) out of the penis. c. There is much debate over the practice of circumcision, or the surgical removal of the foreskin. i. Circumcision may be associated with increased hygiene, and reduced risk for HPV and HIV transmission. d. The scrotum serves to control temperature and protect the testes, which is vital to sperm production, known as spermatogenesis.

2. The internal genitalia include many organs and glands. a. The seminal vesicles, the prostate gland, and Cowper’s gland are collectively called accessory organs. b. The testes are responsible for manufacturing sperm and for producing testosterone. c. Spermatogenesis is governed by the pituitary gland, which releases FSH. d. Epididymidis is where immature sperm are held until maturity. e. The vas deferens is a tube that stores and transports sperm toward the penis. f. Seminal vesicles provide sperm with nutrients and other fluids that compose semen. g. The vasa deferentia eventually connect each epididymus to the ejaculatory ducts, which pass through the prostate gland and empty into the urethra. h. The prostate gland adds chemicals to semen to help neutralize vaginal fluid which helps sperm to fertilize an ovum. i. The Cowper’s glands secrete a fluid that lubricates the urethra and neutralizes any acid that may remain in the urethra after urination.

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3. Andropause is a term used to describe age-related hormone changes among men.

These changes can result in changes in sexual function, changes in sleep patterns, physical changes, and/or emotional changes Key Terms: sexuality, vulva, mons pubis, labia majora, labia minora, clitoris, urethral opening, hymen, perineum, vagina, uterus (womb), endometerium, cervix, ovaries, fallopian tubes (oviducts), secondary sex characteristics, pituitary gland, hypothalamus, estrogens, progesterone, menarche, ovarian follicles, graafian follicles, ovum, ovulation, corpus luteum, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), dysmenorrhea, menopause, libido, hormone replacement therapy (HRT) or menopausal hormone therapy, penis, ejaculation, scrotum, testes, testosterone, spermatogensis, epididymis, vas deferens, seminal vesicles, semen, ejaculatory duct, prostate gland, Cowper’s glands Figures and Tables:

Figure 5.1 Female Reproductive System

Figure 5.2 The Three Phases of the Menstrual Cycle

Figure 5.3 Hormonal Control and Phases of the Menstrual Cycle

Figure 5.4 Male Reproductive System

Additional Instructor Resources: PPT slides: 1–19; Digital Transparency Masters: Figure 5.1, Figure 5.2, Figure 5.3, Figure 5.4

II. The Human Sexual Response A. The human sexual response generally follows a specific pattern. Both males and females exhibit four common stages.

1. During the excitement/arousal stage, vasocongestion (increased blood flow that causes swelling in the genitals) occurs; the vagina lubricates, penis becomes erect, and “sex flush” may occur.

2. The plateau phase is characterized by an intensification of initial responses.

3. The orgasmic phase is when vasocongestion and muscle tensions reach their peak and rhythmic contractions occur throughout the genital regions.

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4. The resolution phase is where organs return to normal and the person experiences profound relaxation and deep feelings of well-being.

B. Sexual Responses among Older Adults 1. Older adults are commonly stereotyped as being incapable of or being uninterested in sexual realtions, but the truth is while older adults do experience some physical changes with age, they generally do not stop enjoying sex.

2. In women, the most significant physical changes follow menopause.

3. Men experience a decrease in firmness of erection, require more stimulation to achieve an erection, and their refractory period is longer.

Key Terms: vasocongestion Figures and Tables:

Figure 5.5 Comparison of Male and Female Sexual Response

Additional Instructor Resources: PPT slides: 20–23; Digital Transparency Masters: Figure 5.5

III. Your Sexual Identity: More Than Biology A. Sexual identity, the recognition and acknowledment of oneself as a sexual being, is determined by the interaction of genetic, physiological, environmental, and social factors.

1. Intersex is a general term for a variety of conditions in which a person is born with reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. For more information on disorders of sexual development, please see page 153, Health in a Diverse World box.

2. Disorders of sexual development (DSDs) is a term that has been recommended to refer to intersex conditions.

3. Differential development of male and female gonads (testes and ovaries) occurs at about the eighth week of fetal life. a. Testosterone is the primary male sex hormone. b. Estrogen and progesterone are the primary female sex hormones.

4. Puberty is a period of sexual maturation. a. It begins with the release of gonadotropins by the pituitary gland. b. Gonadotropins are responsible for secondary sex characteristic development.

5. Gender refers to your sense of masculinity or femininity as defined by the society in which you live. a. Socialization is the process by which we learn gender.

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b. Gender roles are expressions of maleness or femaleness in everyday life. c. Gender-role stereotypes are generalizations concerning how males and females should express themselves. d. Androgyny refers to the combination of traditional masculine and feminine traits in a single person. e. Gender identity is the personal sense or awareness of being masculine or feminine, a male or a female. f. Transgendered occurs when a person’s gender identity does not match his or her biological sex. g. A transsexual is a person who is psychologically of one sex but physically of the other.

B. Sexual Orientation 1. Sexual orientation refers to a person’s enduring emotional, romantic, sexual, or affectionate attraction to other persons.

2. There are several types of sexual orientation: a. Heterosexuality refers to emotional and sexual attraction to the opposite sex. b. Homosexuality refers to emotional and sexual attraction to persons of the same sex. c. Bisexuality refers to emotional and sexual attraction to persons of both the opposite and same sex. d. The term gay or queer applies to men or women who are attracted to the same sex and the term lesbian is applied only to women who are attracted to each other.

3. Sexual prejudice refers to negative attitudes and hostile actions directed at sexually identified social groups; also referred to as sexual bias.

4. Sexual orientation is often viewed as a concept based entirely on whom one has sex with, but this is an inaccurate and overly simplistic idea. a. Researcher Fritz Klein developed a questionnaire that aids in analyzing sexual preferences.

Key Terms: sexual identity, intersex, gonads, puberty, gender, socialization, gender roles, gender-role stereotypes, androgyny, gender identity, transgendered, transsexual, sexual orientation, heterosexual, homosexual, bisexual, gay, lesbian, sexual prejudice Lecture Launcher Videos: Gender Transition, Homophobia Additional Instructor Resources: PPT slides: 24–32

IV. Expressing Your Sexuality A. Sexual Behavior: What is “Normal”?

1. Some common sociocultural standards for sexual behavior in Western culture today include the following: a. The coital standard—Penile–vaginal intercourse is considered the ultimate sex act. b. The orgasmic standard—Sexual interaction should lead to orgasm. c. The two-person standard—Sex is an activity that is experienced by two people. d. The romantic standard—Sex should be related to love. e. The safer-sex standard—Choosing to be sexually active brings responsibility to prevent unintended pregnancy and prevent disease transmission.

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2. To decide if a behavior is normal for you, ask yourself whether the sexual behavior is healthy and fulfilling for a particular person, whether it’s safe, whether it leads to the exploitation of others, and whether it takes place between responsible, consenting adults.

B. Options for Sexual Expression 1. There are many forms of sexual expression. Everything from cultural norms to upbringing to personal comfort level to physical limitations influences how sexuality is expressed.

2 Accepting yourself as a sexual person with individual desires and preferences is the first step in achieving sexual satisfaction.

3. Celibacy is the avoidance or abstention from sexual activities.

4. Autoerotic behaviors involve self-stimulation and includes masturbation and sexual fantasies. a. Sexual fantasies are sexually arousing thoughts and dreams. b. Masterbation, or self-stimulation of the genitals, is a common way to seek sexual pleasure.

5. Kissing and erotically touching erogenous zones can lead to sexual arousal.

6. Manual stimulation of the genitals by a partner can cause sexual arousal and for many women, orgasm is more likely to be achieved through manual stimulation than through intercourse. a. Sex toys include a wide variety of objects that can be used for sexual stimulation alone or with a partner.

7. Oral–genital stimulation refers to cunnilingus, a term used for oral stimulation of a woman’s genitals and fellatio, a term used for oral stimulation of man’s genitals.

8. Vaginal intercourse (coitus) refers to insertion of the penis into the vagina and is the most commonly practiced form of sexual expression by most couples.

9. Anal intercourse is the insertion of the penis into the anus.

C. Variant Sexual Behavior 1. Variant sexual behavior describes sexual behaviors that most people do not engage in, for example: a. Group sex is sexual activity with more than two people. Participants in group sex run a higher risk of exposure to HIV and other STIs. b. Transvestism is wearing clothing of the opposite sex. Most transvestites are male, heterosexual, and married. c. Fetishism describes arousal by looking at or touching inanimate objects.

2. Some variant sexual behaviors can be harmful to the individual, to others, or to both.

Many of the following activities are illegal in at least some states: a. Exhibitionism is the exposure of one’s genitals to strangers in public places. b. Voyeurism is observing other people for sexual gratification. c. Sadomasochism involves sexual activities in which gratification is received by inflicting pain either physically or verbally. A sadist inflicts pain; a masochist experiences pain. d. Pedophilia is sexual activity or attraction between an adult and a child. Any sexual activity involving a minor, including possession of child pornography, is illegal.

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e. Autoerotic asphyxiation is an unsafe practice of reducing or eliminating oxygen to the brain, usually by tying a cord around one’s neck while masturbating to orgasm.

Key Terms: celibacy, autoerotic behavior, sexual fantasies, masturbation, erogenous zones, cunnilingus, fellatio, vaginal intercourse, anal intercourse, variant sexual behavior Additional Instructor Resources: PPT slides: 33–39

V. Sexual Dysfunction A. Sexual dysfunction is a term used to describe problems that hinder sexual functioning.

Research indicates that it is quite common.

B. Sexual Desire Disorders 1. Inhibited sexual desire is a lack of sexual appetite or lack of interest and pleasure in sexual activity and is the most frequent reason people seek out a sex therapist.

2. Sexual aversion disorder includes sexual phobias and anxiety about sexual contact.

C. Sexual Arousal Disorders 1. Erectile dysfunction (ED) is difficulty in achieving or maintaining a penile erection sufficient for intercourse.

D. Orgasmic Disorders 1. Premature ejaculation occurs prior to or soon after the penis is inserted into the vagina.

2. Female orgasmic disorder can be treated by first ruling out organic causes, then using masturbation to help a woman become orgasmic, and teaching her how to communicate her needs to her partner.

E. Sexual Performance Disorders 1. Both men and women can experience sexual performance anxiety when they anticipate some sort of problem in the sex act.

F. Sexual Pain Disorders 1. Dyspareunia is pain experienced by a female during intercourse. Causes include disease or tissue damage or it may be psychological.

2. Vaginismus is a state where vaginal muscles contract so forcefully that penile insertion is painful or impossible.

G. The first step in getting help for sexual dysfunction is to research and choose a means of seeking help, for example, certified counselors, sex therapists, and clinics that treat sexual dysifunctions.

H. To learn about sexuality and disability, please see page 156, Health in a Diverse World box.

Key Terms: sexual dysfunction, inhibited sexual desire, sexual aversion disorder, erectile dysfunction (ED), premature ejaculation, female orgasmic disorder, sexual performance anxiety, dyspareunia, vaginismus Additional Instructor Resources: PPT slides: 40–41

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VI. Drugs and Sex A. Drug and alcohol use can lead to undesired sexual acitvity, as well as a tendency to blame the drug for negative behavior or unsafe sexual activities. For information on misperceptions about sex on campus, please see page 157, Student Health Today box.

B. A sexually mature person will carefully examine risks and benefits and make decisions about their sex behaviors accordingly.

1. Alcohol reduces inhibitions but inhibits sexual response. The mind is willing, but the body is not.

2. The greatest danger in using drugs is making them the reason for negative behavior.

3. “Date-rape” drugs, such as Rohypnol (referred to as “roofies”), GHB (also called “liquid X”), and ketamine (also known as “K”), have been used to facilitate rape. When combined with alcohol, they greatly increase drunkenness and are often used on unsuspecting females to render them unconscious, making them vulnerable to rape.

Additional Instructor Resources: PPT slide: 42

VII. The Sex Industry A. Pornography refers to any visual or literary depictions of sexual activity intended to be sexually arousing.

1. The pornography industry generates revenues of $13.33 billion annually in the United States, $2.8 billion of which is from online sources.

2. There is no reliable evidence to suggest that pornography leads to sexual violence or predatory behavior in normal, healthy adults, but in those individuals who have preexisting negative attitudes toward women, it may be a legitimate problem.

B. Prostitution is the practice of engaging in sexual acts for money.

1. Several countries have legalized prostitution, but most prostitution in the United States is illegal.

Key Terms: pornography, prostitution Additional Instructor Resources: PPT slide: 43

VIII. Responsible and Satisfying Sexual Behavior A. Making responsible and informed choices includes good communication as the foundation, acknowledging that you are a sexual person, understanding sexual structures and their functions, and accepting and embracing your gender identity and your sexual orientation.

Additional Instructor Resources: PPT slides: 44–45

Additional Chapter Activities Points of View Circumcision: Risks versus Benefit, on page 149 of your textbook.

1. Circumcision is a controversial issue for many parents.

2. Approximately 56 percent (1.1 million) of all newborn boys are circumcised in the United States each year.

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In Class Activity: As a class, review and discuss the arguments in favor and against circumcision. Next, have students take out a page of paper and write for four minutes about their view of circumcision (no names on papers). After four minutes is over, have students pass the page to their right. Have students read what was written, to themselves, and take four minutes to write a response to the prior opinion. Repeat one more time. After the third pass, have students pass once more. This time have students read what was written in the three prior writing exercises.

Synthesis: Have another discussion about what students learned and wrote about. Ask the students who ended up with the final paper to share the opinions that were written down.

Discussion Questions 1. What are the similarties and differences in the female and male sexual response?

2. What is “normal” sexual behavior? What criteria should we use to determine healthful sexual practice?

3. How does our society view variant sexual behaviors? How is variant sexual behavior portrayed in the media? Does this support or resist stereotypes and biases?

4. What are factors that may influence sexual aversion disorders?

5. Do you think prostitution should be legal? Provide two reasons why you think prostitution should or should not be illegal.

6. How do you think pornography affects society? Do you think it should it be regulated?

Why or why not, and in what way(s) and by whom?

Critical Thinking Questions 1. Consider your own gender identity and sexual orientation. How did you know you were one sexuality over another? When did these decisions take place?

2. How have you dealt with stereotypes or biases in your life? Have these been related to your sexual orientation or sexual identity? If not, what biases and stereotypes might be faced by someone who identifies as homosexual or transgender? What biases and stereotypes do you hold?

3. How can we address and remove the stigma that surrounds sexual dysfunction so that individuals feel more comfortable seeking help? Are men and women influenced the same or differently by the stigma associated with sexual dysfunction?

4. Why do you think good communication with your partner is a foundation for having a satisfying sexual relationship?

Student Activities Individual 1. Think about your own sexual maturation. How were you told about “the birds and the bees”? When did you “come out” as heterosexual or homosexual? Did you “come out” at all, why or why not?

2 Go to the website www.siecus.org, The Sexuality Information and Education Council of the United States website, and read from the “What’s New” section. Briefly describe what you learned.

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Community 1. What do grade schools in your area teach about sex? Are there laws that mandate what teachers can and cannot say in class?

2. How do stereotypes influence sexuality in assisted living environments for the elderly?

What risks might be posed? What do assisted living facilities in your community do to address healthy sexuality among residents?

Diverse Population/Nontraditional 1. How do gender-role stereotypes differ in other cultures? Describe typical characteristics of the female and male roles.

2. What types of problems do people with disabilities face with regard to sexual expression?

Lecture Launcher Video Questions New! Gender Transition 1. What challenges do you think a family as a whole would face if one parent decided that he or she wanted to have a sex change operation?

2. How do the boys react when interviewed about how their daddy became their other mommy? Do you think Rene and Chloe’s honesty with the boys was a good approach to explaining their new situation? Why or why not?

3. What kind of conversation would you have with your child in discussing gender transition?

New! Homophobia 1. Why do you think people responded so differently to the “gay basher” during his different bashing tactics—male bonding, making jokes, and being offensive?

2. What do you think the actor means when he says he’s used to having to “negotiate in order to avoid violence” in public? Do you think it is fair that a gay couple would feel the need to modify their behavior in public in order to avoid conflict?

3. In what ways can you promote tolerance as an American value and end negative gay stereotypes?

Additional References 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.

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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.

S. D. Longerbeam, K. K. Inkelas, D. R. Johnson, and Z. S. Lee, “Lesbian, Gay, and Bisexual College Student Experiences: An Exploratory Study,” Journal of College Student Development, 48, (2007): 215–230.

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.

For Further Information American Psychological Association Sexuality www.apa.org/topics/sexuality/index.aspx American Society for Reproductive Medicine www.asrm.org Human Rights Campaign www.hrc.org National Library of Medicine Sexual Health www.nlm.nih.gov/medlineplus/sexualhealth.html National Sexuality Resource Center http://nsrc.sfsu.edu Sexual Advice Association www.sda.uk.net

Additional Media Health Matters: Sexual medicine, 28 minutes In this UC Television production, show host David Granet, M.D., discusses sexual medicine and sexual dysfunction with medical expert, Irwin Goldstein, M.D. www.youtube.com/watch?v=M-mrO6JiFeU Human Rights, Not Special Rights: Understanding the LGBTQAC, 1 hour 46 minutes A panel discussion hosted by the USC School of Social Work aimed to provide understanding of the LGBT community. www.youtube.com/watch?v=3P50AquPiNg

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Intersex 20/20, Part 1 of 2, 7 minutes Intersex 20/20, Part 2 of 2, 3 minutes A 20/20 special from ABC television that discusses the social and medical controversies that have arisen around people born with ambiguous genitalia. Features interviews with Kenneth Glassberg, M.D., and Hida Viloria, an intersex woman who did not have corrective surgery.

Cheryl Chase discusses her experience discovering that she was operated on as an infant. www.youtube.com/watch?v=xv1yk2Va9qc (Part 1) www.youtube.com/watch?v=oHbBTEeayEU&feature=related (Part 2) Let’s Talk about Sex: The State of Modern Sexuality, 66 minutes A panel discussion on modern sex hosted by The Commonwealth Club of California. Topics covered including: Hooking Up, The New Taboos, Pop Culture, and Changes in Porn Over the Past 25 Years. http://fora.tv/2008/05/05/Lets_Talk_about_Sex_The_State_of_Modern_Sexuality Sex Health Guru Health Guru is an organization that posts videos narrated by health experts on various health topics, including sexual health. The link below will lead students to brief video clips such as: Sex and Relationships, Sex: Am I Normal?, Sex Education, and STDs on Campus. http://sex.healthguru.com Health Guru Media, Inc. 494 Broadway 4th Floor New York, NY 10012 information@fullturnmedia.com

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CHAPTER

6

Considering Your Reproductive Choices

Overview Chapter 6 is packed full of vital information for college student’s sexual and reproductive health. Managing our fertility and making sure we make choices that maximize opportunities to plan for healthy offspring are among the most crucial behaviors for adults. Methods of birth control are discussed in detail, allowing the student to decide which option is safest and most desirable. This chapter also discusses emergency contraception for those times when unprotected sex occurs. Deciding to have a child requires that individuals and couples understand the factors that lead to the best possible outcome. Preconception and prenatal behaviors for men and women are also addressed in this chapter including the importance of appropriate diet and exercise for men and women. The harmful effects of drugs on the fetus as well as other agents that can cause harm are thoroughly examined. This chapter also deals with options for couples who are having difficulty conceiving or may be infertile.

Learning Objectives 1. Compare the different types of contraceptive methods and their effectiveness in preventing pregnancy and sexually transmitted infections.

2. Summarize the legal decisions surrounding abortion and the various types of abortion procedures.

3. Discuss key issues to consider when planning a pregnancy.

4. Explain the importance of prenatal care and the physical and emotional aspects of pregnancy.

5. Describe the basic stages of childbirth, and the methods and complications that can arise during labor and delivery.

6. Review primary causes of and possible solutions to infertility.

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Lecture Outline I. Basic Principles of Birth Control A. It is important to discuss reproduction and birth control with one’s sexual partner before engaging in sexual activity.

1. Today, we possess technologies that can control or enhance our fertility—a person’s ability to reproduce.

2. The term birth control, or contraception, refers to methods of preventing conception.

The following conditions are necessary for conception: a. A viable egg b. A viable sperm c. Access to the egg by the sperm 3. Two measures of effectiveness include the following: a. Perfect-use failure rate refers to the 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 that are likely to occur in the first year of use with the normal number of errors; a much more practical measure.

4. When choosing a contraception method, one must consider protection—including barrier methods, hormonal methods, and others—against sexually transmitted infections (STIs).

Key Terms: fertility, conception, contraception (birth control), perfect-use failure rate, typical-use failure rate, barrier methods, hormonal methods, sexually transmitted infections (STIs) Figures and Tables:

Table 6.1 Top Reported Means of Contraception Sexually Active College Students or Their Partner Used the Last Time They Had Intercourse

Additional Instructor Resources: PPT slides: 1–7; Digital Transparency Masters: Table 6.1

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II. Barrier Methods A. The Male Condom 1. The male condom is a single-use sheath of thin latex or other material designed to fit over an erect penis and to catch semen upon ejaculation.

2. Condoms come with or without spermicide—substances designed to kill sperm.

3. Condoms are less effective and more likely to break during intercourse if they are old or improperly stored.

4. When used consistently and correctly, condoms can be up to 98 percent effective; latex and polyurethane condoms are the only barriers that can effectively prevent the spread of some STIs and HIV. 5. Some complain that the easy availability of condoms is accompanied by considerable potential for error, while others report that the condom decreases sensation and can be an inconvenience during sex.

B. The Female Condom 1. The female condom is a single-use polyurethane sheath for internal use during vaginal or anal intercourse to catch semen on ejaculation.

2. When used consistently and correctly, the female condom can be up to 95 percent effective and can prevent the spread of HIV and other STIs. 3. Some women choose to use the female condom because it gives them more personal control over pregnancy prevention and STI protection, because they cannot rely on their partner to use the male condom, or because it is relatively inexpensive and available without prescription.

4. As with the male condom, there is potential for user error. Some people dislike using the female condom because they feel it is a disruption and odd looking. There is also the risk of rectal bleeding, which increases risk of contracting HIV. C. Jellies, Creams, Foams, Suppositories, and Film 1. Jellies, creams, foams, suppositories, and film are referred to as spermicides, and like condoms, do not require a prescription.

2. Spermicides are most effective when used in conjunction with another barrier method—alone offering only 71 to 82 percent effectiveness at preventing pregnancy— and are inexpensive and simple to use.

3. Spermicides can be messy and must be reapplied for each act of intercourse. They are not effective in the prevention of transmission of STIs and have been associated with irritation and increased risk of urinary tract infection.

D. The Diaphragm with Spermicidal Jelly or Cream 1. A diaphragm is a latex, cup-shaped device designed to cover the cervix and block access to the uterus; it should always be used with spermicide.

2. When used consistently and correctly, they can be 94 percent effective in preventing pregnancy and when used with spermicidal jelly can possibly protect the cervix against some STIs and the human papillomavirus (HPV).

3. Disadvantages include difficulty and awkwardness placing it in as well as it being difficult to remove and slipping out of place.

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E. The Cervical Cap with Spermicidal Jelly or Cream 1. A cervical cap is a small latex or silicone cup that is designed to fit snugly over the entire cervix.

2. The currently available cervical cap called the FemCap can be reasonable effective (86 percent with typical use), may offer some protection of STIs, and is relatively inexpensive.

3. The FemCap is somewhat more difficult to insert than a diaphragm, can become dislodged during intercourse, and cannot be used during the menstrual period for longer than 48 hours because of toxic shock syndrome (TSS) risk—a potentially lifethreatening disease.

F. The Sponge 1. The Today Sponge is a contraceptive device, made of polyurethane foam and containing nonoxynol-9, that fits over the cervix to create a barrier against sperm.

2. It is fairly effective (between 91 percent perfect use; 84 percent typical use) and is convenient.

3. It is less effective, however, for women who have previously given birth, and some cases of TSS have been reported in women using the sponge.

Key Terms: male condom, spermicides, female condom, diaphragm, cervical cap, toxic shock syndrome (TSS), Today Sponge Figures and Tables:

Table 6.2 Contraceptive Effectiveness, STI Protection, Frequency of Use, and Cost

Figure 6.1 How to Use a Male Condom

Figure 6.2 How to Use a Female Condom

Figure 6.3 The Proper Use and Placement of a Diaphragm

Additional Instructor Resources: PPT slides: 8–18; Digital Transparency Masters: Table 6.2, Figure 6.1, Figure 6.2, Figure 6.3 Copyright © 2012 Pearson Education, Inc.

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III. Hormonal Methods A. The term hormonal contraception refers to birth control that contains synthetic estrogen and/or progesterone.

1. All forms of hormonal contraception (transdermal, injection, oral) require a prescription from a health care provider.

2. In hormonal contraception, a woman’s biochemistry is altered, preventing ovulation or making it difficult for sperm to reach an egg if ovulation does occur.

B. Oral Contraceptives 1. Oral contraceptives are pills containing synthetic hormones that prevent ovulation by regulating hormones.

2. Most modern oral contraceptive pills are up to 99 percent effective at preventing pregnancy with perfect use and are the most commonly used contraception method among college women.

3. Combination pills are highly effective at preventing pregnancy, are indiscreet, and have the potential to lessen menstrual difficulties.

4. The estrogen in combination pills is associated with the risk of health problems such as blood clots and high blood pressure as well as other varying minor side effects. The pill must also be taken daily, does not protect against STIs, and can be high in price. a. For more information on the fight for affordable birth control on college campuses, please see page 179, Consumer Health box.

C. Progestin-Only Pills 1. Progestin-only pills (or minipills) contain only small doses of progestin and no estrogen.

2. Minipills may be a good option for women at risk for estrogen-related side effects or who cannot take estrogen containing pills for other health reasons and can be taken by women over the age of 35 and by women who are breast-feeding.

3. Minipills must be taken at the same time every day, and the most common side effect of progestin-only pills is irregular menstrual bleeding.

D. Contraceptive Skin Patch 1. Ortho Evra is a patch that releases hormones similar to those in oral contraceptives; each patch is worn for one week.

2. Ortho Evra is 99.7 percent effective with perfect use, it may be easier to remember than taking a daily pill, and offers the same potential health benefits as combination pills.

3. Like other hormonal methods of birth control, the patch offers no protection from HIV and other STIs, and in April 2010, the FDA released its second warning for users, indicating more conclusive evidence of an increased risk of blood clots among regular users.

E. Vaginal Contraceptive Ring 1. The NuvaRing is a soft, flexible ring inserted into the vagina that releases hormones, preventing pregnancy.

2. It is 99.7 percent effective when used properly, and advantages include less likelihood of user error, no requirement to use spermicide, rapid return of fertility when use is stopped, among other benefits.

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3. The ring poses possible minor side effects as well as potentially more serious health risks—including increased risk of vaginal discharge or vaginal irritation or infection.

F. Contraceptive Injections 1. Depo-Provera is an injectable method of birth control that lasts for three months.

2. There is little room for user error with the shot (as it is administered by a clinician every three months) and with perfect use it is 99.7 percent effective.

3. Drawbacks include possible irregular bleeding, slight weight gain, dizziness, nervousness, headache, and it cannot be stopped immediately if problems arise. People also report it can take up to a year to conceive after use has been halted.

G. Contraceptive Implants 1. Implanon (a single-rod implantable contraceptive) can be implanted just beneath a woman’s upper arm skin by a health care provider.

2. It is generally not visible and can be highly effective (99.95 percent).

3. Implanon has a higher initial cost, offers no protection against transmission of STIs, and also has the possibility of other minor side effects.

Key Terms: oral contraceptives, Ortho Evra, NuvaRing, Depo-Provera Figures and Tables:

Figure 6.4 Early Warning Signs of Medical Complications for Users of the Birth Control Pill

Lecture Launcher Video: Surging Cost of Birth Control Additional Instructor Resources: PPT slides: 19–27; Digital Transparency Masters: Figure 6.4

IV. Interuterine Contraceptives A. The intrauterine device (IUD) is a device, often T-shaped, that is implanted in the uterus to prevent pregnancy.

B. Two IUDs are currently available in the United States, Paragard (left in place for 10 years) and Mirena (in place for 5 years).

1. The IUD is a safe, discreet, and highly effective method of birth control (99.4 percent).

2. Disadvantages of IUDs include possible discomfort, cost of insertion, and potential complications. IUDs do not protect against STIs and women using IUDs have a higher risk of benign ovarian cysts.

C. To learn about the most environmentally friendly forms of contraceptives, please see page 182, Be Healthy, Be Green box.

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Key Terms: intrauterine device (IUD) Additional Instructor Resources: PPT slides: 28–29

V. Emergency Contraception A. Emergency contraceptive pills (ECPs) are drugs taken after unprotected intercourse to prevent fertilization or implantation.

1. A women taking ECPs does so to prevent pregnancy; the method will not work if she is already pregnant. In contrast, Mifeprex or mifepristone, the early abortion pill, is used to terminate a pregnancy.

2. Use of ECPs within 24 hours of intercourse reduces the risk of pregnancy by 95 percent, although the effectiveness decreases when taken up to 5 days later.

3. The FDA approved the over-the-counter sale of Plan B emergency contraceptive pills in the United States to women aged 17 and older, but for younger women a prescription is still required.

Key Terms: intrauterine device (IUD), emergency contraceptive pills (EPCs) Additional Instructor Resources: PPT slide: 30

VI. Behavioral Methods A. Withdrawal 1. Withdrawal involves withdrawing the penis from the vagina just prior to ejaculation, also called the coitus interruptus. a. Although withdrawal can be practiced when there is no other contraceptive available, it is highly unreliable and offers no protection against transmission of STIs. B. Abstinence and “Outercourse” 1. Abstinence means “deliberately avoiding intercourse” while engaging in activities such as oral—genital sex and mutual masturbation are sometimes said to be engaging in “outercourse.” a. Abstinence is the only method of avoiding pregnancy that is 100 percent effective.

Outercourse can be 100 percent effective against pregnancy, but is not 100 percent effective against STIs. C. Fertility Awareness Methods 1. Fertility awareness methods (FAMs) are several types of birth control that require alteration of sexual behavior rather than chemical or physical intervention in the reproductive process. a. The cervical mucus method requires women to examine the consistency and color of normal vaginal secretions. b. The body temperature method relies on the fact that a woman’s basal body temperature rises after ovulation. The woman must chart her temperature for months to understand her body’s fluctuations and avoid intercourse preceding the temperature rise until several days after her temperature rise was first noted. c. The calendar method requires women to record the exact number of days in her menstrual cycle to predict fertile times.

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2. While the success of these methods has increased with understanding of physiology, FAMs are less reliable and classes are encouraged to better understand how these methods work. People untrained in these techniques run a high risk of unwanted pregnancy.

3. For more information on safe sex, please see page 188, Student Health Today box.

Key Terms: withdrawal, fertility awareness methods (FAMs) Figures and Tables:

Figure 6.5 The Fertility Cycle

Additional Instructor Resources: PPT slides: 31–32; Digital Transparency Masters: Figure 6.5

VII. Surgical Methods A. Sterilization is permanent fertility control achieved through surgical procedures.

B. Female Sterilization 1. Female sterilization includes tubal ligation and hysterectomy. a. Tubal ligation is a method where surgery either ties shut or cuts and cauterizes the uterine tubes closed. This blocks the sperm’s access to released eggs. b. A hysterectomy, or removal of the uterus, is a method of sterilization requiring major surgery; it is only done when a women’s uterus is diseased or damaged.

2. The main advantage to female sterilization is that it is highly effective for pregnancy prevention and is permanent. There is no further cost or ongoing action required, and it does not negatively impact a woman’s sex drive.

3. Although rare, possible complications include infection, pulmonary embolism, hemorrhage, anesthesia complications, and ectopic pregnancy. Risks are lesser known with new techniques including Essure and Adiana.

C. Male Sterilization 1. Male sterilization is called a vasectomy which is a procedure that involves the cutting and tying off of both vasa deferentia. a. It is less complicated than female sterilization. b. Testicular function is not affected.

2. A vasectomy is a highly effective and permanent means for preventing pregnancy. It is a simple outpatient procedure that requires minimal recovery time.

3. Disadvantages include the initial expense, the fact that it offers no protection against STIs, and as with any surgery, possible complications.

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Key Terms: sterilization, tubal ligation, hysterectomy, vasectomy Figures and Tables:

Figure 6.6 Female Sterilization: Tubal Ligation

Figure 6.7 Male Sterilization: Vasectomy

Additional Instructor Resources: PPT slides: 33–35; Digital Transparency Masters: Figure 6.6, Figure 6.7

VIII. Choosing a Method of Contraception A. Selecting a method of contraception is a personal choice that takes time to research. Ask questions of your health care provider, and be honest with yourself about your own preferences.

1. Questions to ask yourself include the following: a. How comfortable would I be using a particular method? b. Will this method be convenient for me and my partner? c. Am I at risk for the transmission of STIs? d. Do I want to have a biological child in the future? e. How would an unplanned pregnancy affect my life? f. What are my religious and moral values? g. How much will the birth control method cost? h. Do I have any health factors that could limit my choice? i. Are there any additional benefits I’d like to get from my contraceptive?

Additional Instructor Resources: PPT slide: 36

IX. Abortion A. Abortion is the termination of a pregnancy by expulsion or removal of an embryo or fetus from the uterus.

1. The 1973 U.S. Supreme Court decision in Roe v. Wade maintained that women have the right to have a pregnancy terminated through the first trimester without legal restrictions, maintained the right of individual states to set limits on second trimester abortions, and set limits on third trimester abortions based on risk to the mother’s life or health.

B. The Debate over Abortion 1. Abortion is a highly contested issue in the United States. a. Pro-choice individuals feel that it is a women’s right to make decisions about her own body and health, including abortion.

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b. Pro-life individuals believe the embryo or fetus is a human being with rights that must be protected.

2. To learn more about the incidence of abortion worldwide, please see page 191, Health in a Diverse World box.

C. Emotional Aspects of Abortion 1. Although a variety of feelings are present after an abortion, there is no evidence that it causes long-term psychological trauma. a. The best predictor of a woman’s emotional well-being following an abortion was her emotional well-being prior to the procedure.

D. Methods of Abortion 1. Surgical abortions are performed in low-risk, first trimester pregnancies with a local anesthetic or a mild tranquilizer. Most abortions occur during the first 12 weeks of pregnancy. a. The most commonly used method of first trimester abortion is suction curettage. b. Second trimester pregnancies may be terminated through a method called dilation and evacuation (D&E). c. Other methods used in second-trimester abortions are prostaglandin or saline induction abortions, hysterotomy, and a controversial method known as intact dilation and extraction (D&X), sometimes referred to as partial-birth abortion. d. Risks associated with surgical abortions include infection, incomplete removal of placenta from the uterus, missed abortion, excessive bleeding, and cervical and uterine trauma. i. The risk of death does exist but is very small (1 in 1,000,000 during the first 8 weeks of pregnancy) and increases with the length of pregnancy.

2. Medical abortions are performed without entering the uterus. a. The abortion pill, Mifepristone (RU-486), currently sold under the brand name Mifeprex in the United States, is a steroid hormone that induces abortion by blocking the action of progesterone, which maintains the lining of the uterus during pregnancy. This causes the fetus and placenta to be expelled through contractions. b. Ninety-two percent of women using this method during the first 9 weeks of pregnancy will experience a complete abortion, and side effects are similar to those experienced during heavy menstruation (although 1 in 1,000 women experience severe bleeding, necessitating a blood transfusion).

Key Terms: abortion, suction curettage, dilation and evacuation (D&E), induction abortion, hysterotomy, intact dilation and extraction (D&X), medical abortion

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Figures and Tables:

Figure 6.8 When Women Have Abortions (in weeks from the last menstrual period)

Figure 6.9 Suction Curettage Abortion

Additional Instructor Resources: PPT slides: 37–40; Digital Transparency Masters: Figure 6.8, Figure 6.9

X. Planning a Pregnancy A. Emotional Health 1. Emotional health is important when planning a pregnancy. Ask yourself why you want a child and whether you are prepared for the sacrifices necessary to care for a child. If you feel that you are ready to be a parent, the next step is preparation.

B. Maternal Health 1. Maternal health includes having a thorough medical examination before becoming pregnant.

2. Preconception care should include an assessment of potential complications that could occur during pregnancy.

C. Paternal Health 1. Paternal health is an important consideration when planning a pregnancy.

2. New research suggests that a man’s exposure to chemicals influences not only his ability to father a child, but also the future health of his child.

3. To learn more about increasing men’s involvement in reproductive and sexual health, please see page 170, Gender & Health box.

D. Financial Evaluation 1. Financial evaluations should be done to assess the affordability of having a baby; it is crucial to consider medical insurance, parental leave, possible family assistance, and childcare.

E. Contingency Planning 1. Contingency planning is a process of planning provisions for your child in the event of your death. Prearranged plans can help transition children into new families.

Key Terms: preconception care Additional Instructor Resources: PPT slides: 41–42

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XI. Pregnancy A. Preconception Care 1. Preconception health focuses on the conditions and risk factors that could affect a woman if she becomes pregnant.

B. The Process of Pregnancy 1. The process of pregnancy begins the moment a sperm fertilizes an ovum in the fallopian tubes. From there, a single fertilized cell, now called a zygote, multiples and becomes a blastocyst. a. Pregnancy tests detect levels of human chorionic gonadotropin (HCG), in a women’s urine. b. Home pregnancy tests are about 85 to 95 percent reliable. c. Blood tests administered and analyzed by medical laboratories are more accurate.

2. Early signs of pregnancy include a missed period, breast tenderness, extreme fatigue, sleeplessness, emotional upset, nausea, and vomiting. a. A woman’s body undergoes substantial changes during the course of pregnancy. b. Pregnancy lasts 40 weeks and is divided into three trimesters.

3. The first trimester is when various organ systems develop. During the first 2 months, the term used for the developing baby is embryo and at the start of the third month, the baby is called a fetus, which indicates that all the organ systems are in place.

4. During the second trimester, the mother sees more physical changes and the placenta becomes well developed.

5. The third trimester is when respiratory organs and digestive organs develop. The fetus gains most of its weight during this period.

6. Emotional changes occur from the onset of pregnancy and include fear of complications and anxiety about becoming a parent as well as wonder and excitement over the developing baby.

C. Prenatal Care 1. A successful pregnancy includes good nutrition and exercise, avoidance of drugs, alcohol, and other harmful substances, and regular medical checkups, for a healthy outcome.

2. Nutrition and exercise are an important part of prenatal health. a. Pregnant women need additional protein, calories, vitamins, and minerals, particularly folic acid, iron, calcium, and fluids and special attention should be paid to getting enough folic acid. b. Weight gain for normal weight women before pregnancy should be around 25 to 35 pounds during pregnancy. Gaining too much or too little weight can lead to complications. c. Exercise has been shown to have positive effects on overall maternal health, birth weight, and infant health. Pregnant women should consult their health care providers before beginning an exercise program.

3. Drugs and alcohol have detrimental effects, teratogenic effects, on a developing fetus. a. Fetal alcohol syndrome (FAS) is a preventable birth defect caused by maternal use of alcohol while pregnant. b. Total abstinence from alcohol during pregnancy is recommended.

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4. Smoking and tobacco use also has negative effects on developing babies. This includes use of cigarettes, smokeless tobacco, and secondhand smoke. a. There is a greater chance of premature births, low-birth-weight infants, stillbirth, cleft lip and palate, and infant mortality.

5. Other teratogens pregnant women should avoid exposure to are X rays, toxic chemicals, heavy metals, pesticides, gases, and other hazardous compounds. a. They should also avoid cleaning cat-litter boxes due to a risk of toxoplasmosis (causing an infant to be stillborn or to suffer birth defects). b. Women with STIs may need to make special arrangements for the birth. c. According to new research, caffeine can significantly increase the risk of miscarriage, and should also be avoided during pregnancy.

6. A woman’s reproductive years last approximately 40 years. a. Down syndrome is the most common birth defect in babies born in the United States, and the risk of having a baby with Down syndrome increases with the mother’s age.

7. Prenatal testing and screening can help detect health defects in a fetus. a. Ultrasound and ultrasonography use high-frequency sound waves to create a sonogram, which helps determine the size and position of the fetus. b. In chorionic villus sampling (CVS), tissue is snipped from the fetal sac and analyzed. This can be done at 10 to 12 weeks into the pregnancy, during the first trimester. c. The triple marker screen (TMS) is a maternal blood test that is used to identify certain birth defects and genetic abnormalities in growing fetuses. d. Amniocentesis, in which amniotic fluid from the amniotic sac is analyzed for abnormalities, is strongly recommended for women over age 35.

8. If any tests reveal a severe birth defect, parents are advised to undergo genetic counseling to educate themselves and discuss their options.

Key Terms: human chorionic gonadotropin (HCG), trimester, embryo, fetus, placenta, teratogenic, fetal alcohol syndrome (FAS), toxoplasmosis, Down syndrome, ultrasonography (ultrasound), chorionic villus sampling (CVS), triple marker screen (TMS), amniocentesis, amniotic sac Figures and Tables:

Figure 6.10 Fertilization

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Figure 6.11 Changes in a Woman’s Body during Pregnancy

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Figure 6.12 Series of Fetoscopic Photographs Showing Development in First, Second, and Third Trimesters of Pregnancy

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Table 6.3 Choosing a Prenatal Care Practitioner

Figure 6.13 Amniocentesis

Additional Instructor Resources: PPT slides: 43–49; Digital Transparency Masters: Figure 6.10, Figure 6.11, Figure 6.12, Table 6.3, Figure 6.13

XII. Childbirth A. Labor and Delivery 1. There are three stages in the birth process which can last from several hours to more than a day, these include Stage 1: dilation of the cervix and transition, Stage 2: expulsion, and Stage 3: delivery of the placenta.

2. Natural childbirth is an option for those who do not want the side effects from painkillers. However, some women prefer to use drugs to take the edge off the pain of birthing. Several options are available and should be discussed with the medical practitioner both before and during the delivery. a. The Lamaze method is the most popular technique of childbirth preparation in the United States, teaching women proper breathing to control pain.

3. Surgical extraction of the baby is called a cesarean section (C-section). a. The procedure involves making an incision across the mother’s abdomen and through the uterus to remove the baby. b. It may be performed due to wrong positioning or long labor. c. Recovery takes longer after a C-section.

B. Complications of Pregnancy and Childbirth.

1. Preeclampsia is a condition related to high blood pressure, protein in the urine, and edema. a. Eclampsia can occur if preeclampsia is left untreated, which could cause strokes and seizures.

2. Miscarriage (spontaneous abortion) is defined as the loss of a fetus before it is viable and most often happens during the first trimester.

3. A blood incompatibility between a mother and a fetus can result in Rh factor problems, and can result in miscarriage. a. Women with Rh-negative blood should be injected with a medication called RhoGAM within 72 hours of birth, miscarriage, or abortion to prevent Rh-negative women from developing Rh antibodies.

4. Ectopic pregnancies (implantation of a fertilized egg outside the uterus) must be terminated surgically or miscarriage will occur. a. Should an ectopic pregnancy go untreated, the woman is put at great risk of hemorrhage, peritonitis, or death.

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5. Stillbirth is the death of a baby after the twentieth week of pregnancy, but before delivery. With a stillbirth, a baby is born dead, often for no apparent reason.

C. The Postpartum Period 1. The postpartum period is the time when the woman’s body recovers to a nonpregnant state, lasting 4 to 6 weeks after birth. a. “Baby blues” are experienced by many new mothers, manifesting as sadness, anxiety, headache, sleep disturbances, and irritability. Symptoms in most of these women disappear after a short while. b. About 10 percent of new mothers experience postpartum depression any time within the first year after childbirth.

2. Scientific studies indicate that breast-feeding has many advantages. a. Colostrum, containing vital antibodies to help the baby fight infection, is secreted from the breast the first two days prior to breast milk production. b. Breast-feeding is recommended by the American Pediatrics Association for at least 6 months and ideally for 12 months for the following reasons: i. Breast milk is perfectly suited to babies’ nutritional needs. ii. Breast-fed babies have fewer illnesses and much lower hospitalization rates. iii. They are less likely to be obese than babies fed on formulas. They also have fewer allergies. iv. When breast-fed babies get sick, they have faster recovery times. v. It is possible that the longer a baby is breast-fed, the higher the IQ in adulthood. vi. Compounds found in baby bottles are under scrutiny due to research suggesting they can lead to health problems. c. Some women are unable or unwilling to breast-feed. i. Bottle-feeding with prepared formulas can provide proper nourishment for the baby.

3. Sudden infant death syndrome (SIDS) is defined as the death of an infant under the age of one for no apparent reason. a. It is the leading cause of death for babies aged 1 month to 1 year. b. Placing babies on their backs or sides, not stomach, reduces risk by as much as half. c. Babies should sleep on a firm surface without any fluffy pillows or blankets.

Key Terms: cesarean section (C-section), preeclampsia, miscarriage, Rh factor, ectopic pregnancy, stillbirth, postpartum depression, sudden infant death syndrome (SIDS) Figures and Tables:

Figure 6.14 The Birth Process

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Additional Instructor Resources: PPT slides: 50–55; Digital Transparency Masters: Figure 6.14

XIII. Infertility A. About 10 to 20 percent of the reproductive-age population suffer from infertility and are unable to conceive for a year or more.

B. High levels of infertility in the United States can be due to factors including delaying childbirth, endometriosis, pelvic inflammatory disease, low sperm count, environmental contaminants known as endocrine disrupters, stress, anxiety, obesity, and diabetes.

C. Causes in Women 1. The most common cause of female infertility is polycystic ovary Syndrome (PCOS).

2. Another disorder called endometriosis, the leading cause of infertility in women, causes parts of the endometrial lining of the uterus to establish iteself outside the uterus.

3. Pelvic inflammatory disease (PDI) can cause blockage in the uterine tubes, preventing sperm from reaching the egg. It can result from infection (including STIs such as gonorrhea and chlamydia) that spreads to the uterine tubes or ovaries.

D. Causes in Men 1. Men can also contribute to infertility, with a low sperm count being the single largest fertility problem. Low sperm count may be attributed to environmental factors or even wearing excessively tight clothes.

2. The mumps virus and varicose veins above one or both testicles can also render men infertile.

E. Infertility Treatments 1. Treatments for infertility include various methods and can be done after extensive evaluation of the couple’s level of motivation and fertility workups. a. Fertility drugs are an option for many women trying to conceive. There are numerous side effects, and women treated with fertility drugs have a one in ten chance of having multiple births. b. Alternative insemination, also known as artificial insemination, is an option chosen by many infertile couples. A woman can be inseminated with her partner’s sperm or that of a sperm donor. c. Assisted reproductive technology (ART) describes several different types of me dical procedures that help a woman get pregnant. i. In vitro fertilization (IVF) is the most common form of ART and includes testtube fertilization before implantation in a woman. ii. Intracytoplasmic sperm injection (ICSI) involves injecting a sperm cell into an egg. iii. Gamete intrafallopian transfer method (GIFT) is when an egg is harvested from the woman’s ovary and placed in the uterine tube with the man’s sperm. iv. Zygote intrafallopian transfer combines IVF with GIFT; eggs and sperm are mixed outside the body and then fertilized zygotes are returned to the fallopian tubes.

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2. Nonsurgical embryo transfer is when a donor egg is fertilized by the man’s sperm and implanted in the women’s uterus. In embryo transfer, an ovum from a donor is artificially inseminated by the man’s sperm, allowed to stay in the donor’s body for a time, and then transplanted into the women’s body.

3. Ethical and moral questions about experimental infertility treatments abound. It is important to ask hard questions and be realistic about the options and outcomes.

F. Surrogate Motherhood 1. It is an option for infertile couples to “hire” a woman to have a baby for them. The surrogate mother is inseminated by the male partner and then turns over the child at birth. These couples should consult a lawyer regarding contracts.

G. Adoption 1. Adoption provides an alternative to couples who want children and for whom biological childbirth is not an option.

2. It is estimated that about 2 percent of the adult population has adopted children. a. Confidential adoption ensures the birth parents and adoptive parents never know each other, although medical information is provided so the adoptive parents can care for the child. b. Open adoptions allow more information about both birth and adoptive parents, but the amount of information can vary. Both parties need to agree, and it is not available in every state.

3. More couples are going international to adopt children, particularly those who want an infant rather than an older child.

Key Terms: infertility, endometriosis, pelvic inflammatory disease (PID), low sperm count, alternative insemination, in vitro fertilization (IVF) Additional Instructor Resources: PPT slides: 56–58

Additional Chapter Activities Discussion Questions 1. Do you think discussing contraception with a potential sexual partner is becoming more socially acceptable?

2. What advice about contraceptives would you give to a younger sibling?

3. Why do you think there are so many more methods of contraception for women than men? Is it solely the woman’s responsibility? What could men do to become more involved?

4. Compare and contrast the different infertility methods. Why are some of the methods under ethical scrutiny?

5. Discuss the advantages and disadvantages of breast-feeding for the baby and the mother.

6. Describe ways a father can actively participate in a pregnancy.

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Critical Thinking 1. Do you believe a woman has the right to make a choice 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. Should same-sex couples discuss barrier methods? How might this be more or less difficult than the conversations about barrier methods had between opposite-sex partners?

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. What factors in today’s society do you think contribute to the increased rates of infertility in couples wanting to have children?

5. Why do you think so many women suffer from the “baby blues” or postpartum depression?

6. 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?

7. Do you think the morning-after pill should be available over-the-counter, only by pharmacist approval, or only by physician prescription? Why?

Student Activities Individual 1. You have a friend who has just discovered she is pregnant. She is interested in learning about her childbirth options. Help her identify her options by using this book and the Internet to research her options.

2. Explore three types of birth control described in this chapter. Identify 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?

Community 1. What birth control methods are available at your student health center? How much do they cost? Compare these costs with the costs of treating a sexually transmitted infection or an unwanted pregnancy.

2. Find out the political view on abortion in your community. Think about whether or not you agree with your elected officials’ stand on this subject.

3. Contact your student health center to ask about programs that involve males in sexual and reproductive health. What services and/or educational programs are available? Share these with your male roommates or friends.

Diverse Population/Nontraditional 1. Research how abortion is viewed in countries outside the United States. How do abortion laws in other countries differ from those in the United States?

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?

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Lecture Launcher Video Questions Surging Cost of Birth Control 1. If college students have trouble purchasing birth control pills, what are their other options?

2. Should state or government money be used to subsidize birth control for college students? For people on welfare? For people without insurance?

3. What effect may taking birth control pills unevenly (such as every other month, or when the budget allows) have on the body?

Additional References A. Abbey, M. R. Parkhill, P. O. Buck, and C. Saenz, “Condom Use with a Casual Partner: What Distinguishes College Students’ Use When Intoxicated?” Psychology of Addictive Behaviors, 21, (2007): 76–83.

R. Gleeson, E. Forde, S. Powell, E. Eadon-Jones, and H. Draper, “Medical Students’ Attitudes towards Abortion: A UK Study,” Journal of Medical Ethics, 34, (2007): 783–787.

R. A. Hatcher, et al. Contraceptive Technology, 19th ed. (New York: Ardent Media, 2008).

W. L. Hellerstedt, N. J. Madsen, M. R. Gunnar, H. D. Grotevant, R. M. Lee, and D. E. Johnson, “The International Adoption Project: Population-based Surveillance of Minnesota Parents Who Adopted Children Internationally,” Maternal and Child Health Journal, 12, 162–171.

H. 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.

G. M. Martinez, A. Chandra, J.C. Abma, J. Jones, and W. D. 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.

C. A. Sanderson and J. A. 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.

A. Vahratian, D. A. 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.acnm.org/about.cfm American Society for Reproductive Medicine www.asrm.org Association of Reproductive Health Professionals www.arhp.org

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Discovery Health Birth Control: Many Methods, One Goal http://health.howstuffworks.com/sexual-health/contraception/birth-control-ga.htm Bixby Center for Global Reproductive Health http://bixbycenter.ucsf.edu International Consortium for Emergency Contraception www.emergencycontraception.org National Adoption Center www.adopt.org/assembled/home.html Emedicine Understanding Birth Control Medications (Contraceptives) www.emedicinehealth.com/understanding_birth_control_medications_contrace/ article_em.htm

Additional Media 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. 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. www.youtube.com/user/plannedparenthood#p/c/A46DFCD237A38D37/15/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. www.youtube.com/user/plannedparenthood#p/c/A46DFCD237A38D37/1/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.

Baranca Productions 151 First Avenue #58 New York, NY 10003 The Female Condom. 1 minute, 23 seconds In this Planned Parenthood video, the viewer is taught about the female condom, and how to use the female condom to protect against unintended pregnancy and sexually transmitted infections. www.youtube.com/user/plannedparenthood#p/c/A46DFCD237A38D37/0/OOfZ6VfmQ_s Copyright © 2012 Pearson Education, Inc.

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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. www.youtube.com/user/plannedparenthood#p/c/A46DFCD237A38D37/16/ 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

7

Eating for a Healthier You

Overview Proper nutrition and healthy food choices are important goals in the United States. Many chronic and disabling diseases can be reduced or even eliminated by making a lifetime of healthy food choices. This chapter introduces basic nutrition information in addition to valuable information on organic foods, genetically modified foods, and food politics. It also helps the student to understand the USDA’s MyPyramid Plan and the effect that a diet high in fat can have on health. Students will leave this chapter with skills in food label reading and understanding how to calculate proper amounts of fat for their own health.

Learning Objectives 1. Understand the factors that influence decisions about nutrition.

2. List the six classes of nutrients, and explain the primary functions of each and their roles in maintaining long-term health.

3. Discuss how to eat healthfully, including what is a healthful diet, how to use the MyPyramid Plan, information about supplement use, and reading food labels.

4. Discuss the unique challenges that college students face when trying to eat healthy foods and the actions they can take to eat healthfully.

5. Explain food safety concerns facing Americans and people in other regions of the world.

Lecture Outline I. Essential Nutrients for Health A. Nutrition is the science that investigates the relationship between physiological function and the essential elements of the foods we eat.

1. There are several factors involved in the way we eat. a. Hunger is the physiological impulse to seek food, prompted by the lack or shortage of basic foods needed to provide the energy and nutrients that support health. b. Nutrients are the constituents of food that sustain humans physiologically: proteins, carbohydrates, fats, vitamins, minerals, and water. c. Appetite is a learned psychological desire to eat and may not accompany true hunger.

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B. Essential Nutrients for Health 1. Food provides the chemicals we need for activity and body maintenance. Our bodies cannot synthesize certain essential nutrients—we must obtain them from the foods we eat.

2. The sequence of functions by which the body breaks down foods and either absorbs or excretes them is known as the digestive process.

C. Calories 1. A kilocalorie is a unit of measure used to quantify the amount of energy in food that the body can use.

2. A calorie is also a unit of measure—1 kilocalorie is equal to 1,000 calories.

3. We derive energy—the capacity to do work—from energy-containing nutrients, which include protein, carbohydrate, and fat.

D. Water: A Crucial Nutrient 1. Too little water can lead to dehydration, and too much water can lead to hyponatremia.

2. Water needs vary drastically by person, and we often get the water we need through the food we eat. a. Fruits and vegetables are 80 to 95 percent water, and meats are more than 50 percent water.

3. Intake should be increased in hot climates or if sweating profusely or ill. Some diseases and their treatments cause the body to require a higher fluid intake, and the elderly and very young also may have increased water needs. a. To learn more about the environmental impacts of drinking bottled water, please see page 214, Be Healthy, Be Green box.

E. Proteins 1. Next to water, proteins are the most abundant substances in the human body and are major components of every cell.

2. They help repair tissue, assist in antibody production and hormone formation, and help transport nutrients to cells.

3. Whenever you consume proteins, your body breaks them down into smaller molecules known as amino acids, the building blocks of proteins. a. There are nine essential amino acids, meaning the body cannot make them; they must be ingested through diet. b. Eleven other amino acids can be produced by the body. c. Complete (high-quality) proteins contain all essential amino acids in sufficient quantity and proportion. They typically come from animal sources. d. Proteins from plant sources are often incomplete proteins, missing one or two of the essential amino acids. e. Eating combined plant food sources of protein can help maintain an adequate intake of complete protein. Plant sources of protein fall into three general categories: legumes, grains, and nuts and seeds.

4. A person might need to eat extra protein if she is pregnant, or if he or she is fighting off a serious infection for example, but otherwise Americans rarely suffer from protein deficiencies.

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F. Carbohydrates 1. Carbohydrates supply us with energy for sustaining daily activity.

2. There are two major types of carbohydrates. a. Simple carbohydrates or simple sugars are found naturally in fruits and many vegetables. b. Complex carbohydrates are found in grains, cereals, and certain vegetables.

3. Simple carbohydrates are consumed in large amounts by Americans. a. Glucose and fructose are monosaccharides. b. Disaccharides are combinations of two monosaccharides.

4. Complex carbohydrates, or polysaccharides, are formed by long chains of monosaccharides. Polysaccharides can also be stored in body muscles and the liver as glycogen. a. Starches make up the majority of the complex carbohydrate group. b. Fiber, a complex carbohydrate, is the indigestible portion of plant foods that helps move foods through the digestive system. i. Dietary fiber is the nondigestible parts of plants. ii. Functional fiber is the nondigestible forms of carbohydrates. iii. Total fiber is the sum of dietary fiber and functional fiber in a diet. c. Fiber is either soluble or insoluble. Soluble fiber can easily be digested by bacteria in the colon. Insoluble fiber typically cannot be dissolved in water. For more information about the importance of fiber, please see page 219, Student Health Today box.

G. Fats 1. Fats play a vital role in maintaining healthy skin and hair, insulating our organs, maintaining body temperature, and promoting healthy cell function.

2. Fats make foods taste better and carry the fat-soluble vitamins A, D, E, and K to the cells.

3. Triglycerides make up 95 percent of total body fat and are the most common form of fat circulating in the blood.

4. Cholesterol is a form of fat that can accumulate on the inner walls of arteries and cause narrowing of the channel through which blood flows. a. High-density lipoproteins (HDLs) are compounds that transport circulating cholesterol to the liver. Higher HDL levels are a benefit. b. Low-density lipoproteins (LDLs) play a role in clogging arteries. Lower LDL levels are a benefit.

5. Types of Dietary Fats a. Saturated fats are solid at room temperature and usually come from animals. b. Unsaturated fats are liquid and come from plant sources. i. Monounsaturated fats (MUFAs) and polyunsaturated fats (PUFAs) refer to the relative number of hydrogen atoms that are missing in a fatty acid chain. ii. PUFAs come in two forms: omega-3 fatty acids and omega-6 fatty acids.

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6. Avoiding Trans Fatty Acids a. Trans fats are fatty acids produced when polyunsaturated oils are hydrogenated to make them more solid. b. In January 2006, the FDA began requiring labeling that tells consumers how much trans fat is in a particular food. c. Some fats are actually healthy, including fats from fish, seeds, and nuts. Moderation continues to be key, along with switching to beneficial fat.

H. Vitamins 1. Vitamins are essential organic compounds that promote growth and help maintain life and health. Fat-soluble vitamins include A, D, E, and K, and B-complex vitamins and vitamin C are water soluble.

2. Antioxidants, found in functional foods, offer protection from oxidative stress and resultant tissue damage at the cellular level (free radicals). To learn more about functional foods and their health claims, please see page 224, Health Headlines box. a. Carotenoids are fat-soluble plant pigments with antioxidant properties.

3. Folate is a form of vitamin B that is critical for DNA production. a. Questions continue to circulate around folate’s potential to decrease homocysteine and to protect against cardiovascular disease.

I. Minerals 1. Minerals are inorganic, indestructible elements that aid physiological processes within the body. a. Macrominerals are the minerals that the body needs in fairly large quantities and trace minerals are only needed in small amounts.

2. Sodium is necessary for regulation of blood and body fluids, transmission of nerve impulses, heart activity, and certain metabolic functions. a. Most Americans consume an excess of sodium, and many experts believe there is a link between sodium and hypertension.

3. Calcium plays a vital role in the building of strong bones and teeth, muscle contraction, blood clotting, nerve impulse transmission, the regulation of heartbeat, and fluid balance within cells. a. The issue of calcium consumption has gained national attention with the rising incidence of osteoporosis among older adults. Most Americans do not consume the recommended amount of calcium per day.

4. Iron deficiency is the world’s most common nutrient deficiency, affecting more than 2 billion people, nearly 30 percent of the world’s population. For more information on global nutrition, please see page 217, Health in a Diverse World box. a. Iron-deficiency anemia results from the body’s inability to produce hemoglobin, causing iron-deficient people to feel tired and run down.

Key Terms: hunger, nutrients, appetite, nutrition, digestive process, calorie, dehydration, proteins, amino acids, essential amino acids, complete (high-quality) proteins, incomplete proteins, carbohydrates, simple carbohydrates, complex carbohydrates, monosaccharides, disaccharides, polysaccharides, starch, glycogen, fiber, whole grains, fats, triglycerides, cholesterol, high-density lipoproteins (HDLs), low-density lipoproteins (LDLs), saturated fats, unsaturated fats, trans fats (trans fatty acids), vitamins, functional foods, antioxidants, carotenoids, minerals, macrominerals, trace minerals, anemia 108

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Figures and Tables

Figure 7.1 The Digestive Process

Table 7.1 Estimated Daily Calorie Needs

Figure 7.2 Complementary Proteins

Figure 7.3 Anatomy of a Whole Grain

Figure 7.4 Percentages of Saturated, Polyunsaturated, Monounsaturated, and Trans Fats in Common Vegetable Oils

Table 7.2 A Guide to Water-Soluble Vitamins

Table 7.3 A Guide to Fat-Soluble Vitamins

Table 7.4 A Guide to Major Minerals

Table 7.5 A Guide to Trace Minerals

Lecture Launcher Video: How Much Sugar?

Additional Instructor Resources: PPT slides: 1–38; Digital Transparency Masters: Figure 7.1, Table 7.1, Figure 7.2, Figure 7.3, Figure 7.4, Table 7.2, Table 7.3, Table 7.4, Table 7.5

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II. How Can I Eat More Healthfully?

A. What is a Healthful Diet?

1. Generally speaking, a healthful diet provides the combination of energy and nutrients needed to sustain proper function. A healthful diet should be: a. Adequate, moderate, balanced, varied, and nutrient dense.

2. Americans today eat more than ever before and it is not surprising that we have seen a dramatic rise in obesity with the rise in calorie consumption.

3. For more information on healthy food choices, please see page 237, Consumer Health box.

B. Use the MyPyramid Food Guide 1. The MyPyramid Plan replaced the former Food Guide Pyramid and takes into consideration the various dietary and caloric needs of a variety of individuals and activity levels of those individuals.

2. Understanding serving sizes is an important part of the MyPyramid Guide. a. A serving is the recommended amount you should consume. A portion is the amount you choose to eat at any one time, and it may be more or less than a serving.

3. There are large caloric, fat, and energy differences between foods within a given food group. It is important to eat nutrient-dense foods for the high nutritional values.

4. Discretionary calories may be left over at the end of the day, once all nutritional needs have been met. These can be spent on foods that do not provide a significant amount of nutritional value.

5. Physical activity is encouraged for at least 30 minutes daily. The activity can include anything that gets your heart pumping (e.g., gardening, dancing, and playing basketball).

C. Vegetarianism: A Healthy Diet?

1. According to a 2009 poll, more than 3 percent of U.S. adults are vegetarians.

2. Generally, people who follow a balanced vegetarian diet weigh less and have better cholesterol levels, fewer digestive issues, and a lower risk of heart disease than nonvegetarians.

3. Most vegetarians today are adept at combining the right types of foods and eating a variety of different foods to ensure proper nutrient intake. Strict vegans should also pay more attention to what they eat to ensure proper nutrient intake.

D. Reading Food Labels 1. Recommended Dietary Allowances (RDAs) are guidelines with recommended intake levels to meet nutritional needs. a. Dietary Reference Intakes (DRIs) are a list of 26 nutrients essential to maintaining health. b. The U.S. Recommended Dietary Allowances (USRDAs) outlines standard intake levels to meet the nutritional needs of most healthy individuals. c. Adequate Intake (AI) is the recommended average daily intake when there is not enough research to determine the full RDA.

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d. Tolerable Upper Intake Level (UL) is the highest amount of a nutrient an individual can consume daily without risking adverse effects. e. Together, RDIs and DRVs make up Daily Values (DVs) found on labels to aid in understanding the percentage of vitamins, minerals, and macronutrients in the food.

E. Supplements: Research on the Daily Dose 1. Dietary supplements are products taken by mouth and intended to supplement existing diets.

2. It is important to note that these dietary supplements are not regulated like other food and drug products by the FDA. 3. In 2006, the National Institutes of Health concluded there was not sufficient evidence to recommend either for or against the use of multivitamins and minerals by the American public to prevent chronic diseases.

F. Eating Well in College 1. Healthy eating can be a challenge for college students for many reasons, including financial and time concerns. a. Eating a complete breakfast and lunch, trying to avoid fast food, and planning your meals, are all critical in adopting better eating habits and in saving money.

G. Is Organic for You? 1. Concerns about food safety, genetically modified foods, and health impacts of chemicals have led many people to organic foods.

2. According to the 2002 National Organic Rule set by the USDA, foods sold as organic in the United States must meet specific criteria. a. Food must be produced without hormones, antibiotics, herbicides, insecticides, chemical fertilizers, genetic modification, or germ-killing radiation.

3. Locavore refers to people who only eat food grown or produced locally, usually within close proximity to their homes.

4. To learn about eating for a healthy environment, please see page 238, Be Healthy, Be Green box. For information on sustainable food, please see page 221, Be Healthy, Be Green box.

Key Terms: vegetarian, Recommended Daily Allowances (RDAs), Daily Values (DVs), dietary supplements, organic, locavore Figures and Tables:

Figure 7.5 Trends Per Capita Nutrient Consumption

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Figure 7.6 MyPyramid Plan

Figure 7.7 Serving Size Card

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Figure 7.8 Nutritional Needs for Different Groups

Table 7.6 Types of Vegetarians

Figure 7.9 Reading a Food Label

Lecture Launcher Video: You Are What You Eat Additional Instructor Resources: PPT slides: 39–53; Digital Transparency Masters: Figure 7.5, Figure 7.6, Figure 7.7, Figure 7.8, Table 7.6, Figure 7.9

III. Food Safety: A Growing Concern A. Foodborne Illnesses 1. Foodborne illness is one of the most serious concerns about food safety and is caused by several common types of bacteria and viruses. a. Signs of food-borne illnesses vary but usually include one or several symptoms: diarrhea, nausea, cramping, and vomiting. b. For certain populations, foodborne diseases can be fatal.

2. Several factors are associated with the increasing spread of foodborne diseases: a. Globalization of the food supply b. Inadvertent introduction of pathogens into new geographic regions c. Insufficient education about food safety d. Climate change and global warming B. Avoiding Risks in the Home 1. Part of the responsibility for preventing foodborne illness lies with consumers. a. Among the most basic precautions are to wash your hands and to wash all produce before eating it, avoid cross-contamination in the kitchen, maintain temperature control, and refrigerate food when needed.

C. Food Irradiation 1. Food irradiation is a process that involves treating foods with invisible waves of energy that damage microorganisms without leaving any radioactive residue. a. Irradiation can lengthen the shelf-life of produce, prevent the spread of microorganisms, and potentially reduce costs for consumers. b. Food irradiation is now common in over 40 countries, and treated food is marked with the “radura” logo.

D. Food Additives 1. Additives are substances added to food to reduce risk of foodborne illness, prevent spoilage, enhance the way foods look and taste, and enhance nutrient value.

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2. As a general rule, the fewer chemicals, colorants, and preservatives there are, the better the food is. Examples of common additives include the following: a. Antimicrobial agents b. Antioxidants c. Artificial colors, nutrient additives, and flavor enhancers, such as MSG (monosodium glutamate) d. Sulfites E. Food Allergy or Food Intolerance?

1. Only 4 to 8 percent of children and 2 percent of adults in the United States have a true food allergy.

2. A food allergy is an overreaction by the body to normally harmless proteins, which are perceived as allergens. In response, the body produces antibodies, triggering allergic symptoms.

3. In 2004, Congress passed the Food Allergen Labeling and Consumer Protection Act (FALCPA) which requires clear labeling of ingredients that are common allergens.

4. Celiac disease is an inherited autoimmune disorder that affects digestive activity in the small intestine, affecting over 3 million Americans.

5. Food intolerance can cause symptoms of gastric upset but is not the result of an immune system response.

F. Genetically Modified Food Crops 1. Genetically modified (GM) foods involve genetic cutting and pasting to enhance production.

2. Concerns about seed control, engineering, and fear of allergens and antibiotic resistance all make GM organisms highly controversial.

3. According to the WHO, no effects on health have been shown from consumption of GM foods in countries that have approved their use. However, a number of organizations would like to see greater regulation of GM foods.

Key Terms: food irradiation, food allergy, celiac disease, food intolerance, genetically modified (GM) foods Figures and Tables:

Table 7.7 Common Foodborne Illnesses

Figure 7.10 The USDA’s Fight BAC!

Additional Instructor Resources: PPT slides: 54–61; Digital Transparency Masters: Table 7.7, Figure 7.10

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Additional Chapter Activities Points of View Genetically Modified Foods: Boon or Bane? on page 243 of your textbook.

1. As the population continues to expand, there are valid concerns about the Earth’s ability to supply us with healthy foods due to soil depletion and overconsumption. Some have proposed that genetically modified foods could help solve these problems of matching food supply to demand, but researchers and other advocates are opposed to further development of the widespread use of genetically altered foods.

In Class Activity: First, ask student to raise their hands if they are in favor of GM foods (count the hands raised) and then ask students to raise their hands if they are against GM foods (count hands raised). Next, have students read each of the arguments in favor and against GM foods on page 243. Ask students to take out a sheet of paper and to select one argument from each of the opposing sides. On one side of the paper, ask students to build an argument in support of GM foods, and on the other side of the paper, build the second argument opposing GM foods.

Synthesis: Have students get into groups of 3 or 4 and discuss what they wrote on each side of the paper. Finally, take a second vote. Did the number of students in favor or opposition to GM foods change? If so, why does the class think that there were changes? If the class is comfortable enough, consider asking a few students who changed their vote to explain their change with the class.

Discussion Questions 1. In what ways do hunger and appetite affect your daily life?

2. What are some challenges to eating healthy when away at college?

3. What suggestions can you come up with for eating healthfully, considering your budget and your schedule?

4. How does the MyPyramid differ from the older Food Guide Pyramid? Do you think it is easier to follow?

5. Do you think food labels are easy to understand? Why or why not?

6. How has vegetarianism changed in the last few decades? Do you think there is a stigma attached to being a vegetarian?

7. In your opinion, should food irradiation be used in the United States? Why or why not?

8. Why are organic foods worth searching out? How has the trend toward organic foods changed the way people shop for food?

Critical Thinking Questions 1. How does your cafeteria assist students in pursuing a healthy diet? What kinds of healthy foods could you eat to replace your unhealthy favorites when at college?

2. What kinds of vitamins 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?

3. 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?

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4. What do you think is the hardest part in following the recommendations for the MyPyramid dietary guidelines?

5. 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?

6. What practices for food safety described in the chapter do you follow regularly at home?

What additional practices for food safety should you adopt?

Student Activities Individual 1. Write down each item of your favorite dinner at your favorite fast-food restaurant. Then use the Fast Food Fact Finder at www.healthieryou.com/food2.html to find out the total calories, fat calories, and simple sugar calories for the meal.

2. Would you like to see changes in food offerings at your cafeteria? Consider writing a letter to the cafeteria director at your school or leave a comment card after your next meal.

3. Take the Assess Yourself survey on pages 244–245 in your textbook. How healthy are your eating habits? What are your strengths and what areas could use attention for improvement?

Community 1. Find out if your community has a green or farmer’s market. What are the days and hours of operation? How many farmers or growers participate? What kinds of fruit, vegetables, breads, cheeses, meats, and other products are available?

2. Make a list of restaurants in your town that offer healthy choices. Find out which menus have been approved by the American Heart Association.

Diverse Population/Nontraditional 1. What are some major differences in the way people eat in the United States versus other countries? Select a country to which you have traveled or 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 to one in the United States?

2. List ways that eating habits can change throughout life. How can attending college, living alone, working long hours, and so forth, influence the way people eat? What can you do to prevent barriers to healthy food choices now and in the future?

Lecture Launcher Video Questions New! How Much Sugar?

1. What is the triple threat from consuming too much added sugar?

2. What are three tips for cutting out added sugar in your diet?

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3. What are the health benefits of cutting out extra sugar from your diet?

You Are What You Eat 1. Is posting calorie counts on menus helpful? What other dietary information would help people make the healthiest choices?

2. Should more restaurants be required to follow this trend?

3. Is it up to a restaurant or up to a consumer to make people aware of dietary information and healthy choices?

4. Are you surprised by some of the calorie counts? Does seeing calorie counts affect your food choices?

Additional References L. Boyd, The Complete Guide to Healthy Cooking and Nutrition for College Students: How Not To Gain 17 Pounds At College, (Atlantic Publishing Group, Inc: Ocala, FL, 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.

L. Neuhauser, R. Rothschild, and F. M. Rodriguez, “MyPyramid.gov: Assessment of Literacy, Cultural and Linguistic Factors in the USDA Food Pyramid Web Site,” Journal of Nutrition Education and Behavior, 39, (2007): 219–225.

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 www.fda.gov/AboutFDA/CentersOffices/CFSAN/default.htm Food Allergy and Anaphylaxis Network www.foodallergy.org 116

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International Food Information Council www.foodinsight.org The Vegetarian Resource Group Sports Nutrition Guidelines for the Vegetarian www.vrg.org/nutshell/athletes.htm U.S. Department of Agriculture Food, and Nutrition Information Center www.nal.usda.gov/fnic Vegetarian Resource Group www.vrg.org

Additional Media Being a Vegan: Understanding the Vegan Lifestyle. 1 minute, 37 seconds.

In this ExpertVillage production, Robert Cheeke, President of Vegan Bodybuilding and Fitness, provides insight on why people choose the vegan lifestye. www.youtube.com/watch?v=0M4N1K1fag4 Being a Vegan: Protein in a Vegan Diet. 1 minute, 37 seconds.

In this ExpertVillage production, Robert Cheeke, President of Vegan Bodybuilding and Fitness, provides tips on how to get the recommended daily amount of protein in a vegan diet. www.youtube.com/watch?v=9BZlrCq7uho&feature=channel Cutting Back on Salt in Your Diet. 2 minutes.

In this production of the American Dietetics Association, Registered Dietitian, Marisa Moore, provides tips on how to reduce the amount of salt in your diet. www.youtube.com/watch?v=42DYoElO-0E Home Food Safety 101. 2 minutes.

In this production of the American Dietetics Association, Registered Dietitian, Marisa Moore, provides food safety tips to help reduce risk of foodborne illness. www.youtube.com/watch?v=pEG4EqZMVrI&NR=1 Nutrition 101 (College Health Guru). 3 minutes.

In this College Health Guru production, Dr. Robert Gorski, M.D., provides a brief Nutrition 101 tutorial. www.youtube.com/watch?v=7jEf82sejtw Tips on Canned and Frozen Produce. 2 minutes.

In this production of the American Dietetics Association, Registered Dietitian, Marisa Moore, provides tips on the dos and don’ts of buying canned or frozen fruits and vegetables. www.youtube.com/watch?v=KPTDjTwtTu4&feature=related

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CHAPTER

8

Reaching and Maintaining a Healthy Weight

Overview As rates of obesity and overweight steadily increase nationally and internationally, weight management is a growing priority. Weight management can be a difficult task for many Americans. Chapter 8 discusses several theories on what causes some people to become overweight or obese. Research on the obesity gene, Leptin, GLP-protein, and Leptin receptors in the brain is included in the discussion presented here. Weight management techniques, an important component for college students who may be setting up lifestyles that are not conducive to healthy body weights, are also discussed. It is important for students to understand the role that exercise and a low-fat diet play in maintaining their health now and in the long term.

Learning Objectives 1. Define overweight and obesity, describe the current epidemic of overweight/obesity in the United States, and understand risk factors associated with these weight problems.

2. Describe factors that place people at risk for problems with obesity. Distinguish between factors that can and cannot be controlled.

3. Discuss reliable options for determining percentage of body fat and a healthy weight for yourself.

4. Discuss the roles of exercise, diet, lifestyle modification, fad diets, and other strategies of weight control, and which methods are most effective.

Lecture Outline A. The United States is among the fattest nations on Earth.

1. Our society has increasingly become obesogenic, meaning “characterized by environments that promote increased food intake, nonhealthful foods, and physical inactivity.”

2. More than 68 percent of adults overall are considered to be overweight or obese and nearly 19 percent among children under age 4.

B. Obesity is the second-to-top preventable cause of death in the United States, after smoking.

1. Obesity and inactivity increase the risks of three of the leading killers: heart disease, cancer, and cerebrovascular ailments, including strokes.

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C. Short- and long-term health consequences of obesity are not our only concern: The estimated annual cost of obesity in the United States exceeds $147 billion in medical expenses and lost productively.

D. Obesity is also influencing regions around the globe; there are more than 1.6 billion overweight adults, at least 400 million of them obese. To learn more about combating “Globesity,” please see page 254, Health in a Diverse World box.

I. Factors Contributing to Overweight and Obesity A. Genetic and Physiological Factors 1. Body type and size run in families. Children whose parents are obese also tend to be overweight.

2. There is evidence that genes play some role in weight gain and that genetic variation, along with environmental influences, may increase the risks of obesity. a. Experts believe that genes probably play less of a role than originally believed.

3. The “thrifty gene” theory is one genetic basis for obesity that continues to gain traction and comes from observational studies of certain Indian and African tribes. a. Researchers note higher body fat and obesity levels in some tribes today than in the general population. This could be caused by historical struggle with centuries of famine where survival occurred through metabolic adaptation. This genetic change may have been passed down making losing fat more difficult.

4. The metabolism rate (the rate the body processes nutrients) and the hormones that regulate it play important roles in our propensity to gain weight and to lose it. a. Basal metabolic rate (BMR) is the amount of energy your body uses at complete rest. b. Resting metabolic rate (RMR) is the energy expenditure of the body under BMR conditions plus other daily sedentary activities. c. The exercise metabolic rate (EMR) accounts for the remaining percentage of all daily expenditures. d. Your BMR (and RMR) can fluctuate considerably, but generally the younger a person is, the higher the BMR. 5. Theories abound concerning the mechanisms that regulate metabolism and food intake. a. One theory is that thin people send more effective messages to the hypothalamus, called adaptive thermogenesis, meaning they can consume large amounts of food without gaining weight because the appetite center of their brains speeds up metabolic activity to compensate for the increased consumption. b. The set point theory suggests that a person’s body has a set point weight at which it is programmed to be comfortable, and if we go on a drastic diet or fast, our bodies slow down our BMR to conserve energy. c. Yo-yo diets are ineffective largely due to BMR; when one’s BMR is set lower, it makes it almost certain that they will regain the pounds they lost in the diet.

6. Hormones potentially impact a person’s ability to lose weight, control appetite, and sense fullness—called satiety. a. Ghrelin, a hormone produced in the stomach, is being studied for its role in appetite stimulation and eating cues.

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b. Another hormone gaining increased attention and research is leptin, which scientists believe serves as a form of satiety signal, telling the brain when you are full.

7. The number of fat cells a person has and their predisposition to fatness are other factors that contribute to obesity. a. Hyperplasia is a condition where a person has an excessive number of fat cells. b. It is believed that the number of fat cells remains constant during adulthood, but each of the cells has the ability to shrink or swell, known as hypertrophy. c. Weight gain may be tied to both the number of fat cells and the capacity of individual cells to enlarge.

B. Environmental Factors 1. Environmental factors have come to play a large role in weight maintenance. There is a long list of environmental factors believed to trigger our “eat” responses. a. Advertising designed to increase energy intake b. Pre-packaged high-fat meals, including fast food and soft drinks c. Greater consumption of restaurant meals, fast foods, and convenience foods d. Bottle feeding e. Misleading food labels f. Increased opportunities and locations for eating g. Larger dishes, cups, and serving utensils 2. Today’s youth tend to eat larger portions and exercise less than previous generations.

For more information about portion inflation, please see page 257, Consumer Health box. a. Epidemiological studies suggest that maternal undernutrition, obesity, and diabetes during gestation and lactation are strong predictors of obesity in children. b. Obese kids not only suffer from the physical problems of obesity, but they also often face weight-related stigma which can negatively affect their emotional health.

To learn more about obesity stigma, please see page 259, Health Headlines box.

C. Psychosocial and Economic Factors 1. There are many psychosocial factors that influence the way we eat, such as using food as a reward for good behavior, to feel better, for comfort, or as social rituals.

2. Socioeconomic factors also come into play. New research suggests that the more educated you are, the lower your BMI and overall obesity profile are likely to be.

D. Lifestyle Factors 1. The way we live our lives, including the relationship between activity level and calorie intake, has a large impact on our country’s increasingly high rates of overweight and obesity.

2. According to a National Health Interview Survey, 4 in 10 adults in the United States never engage in exercise, sports, or physically active hobbies in leisure time. a. To learn more about whether a sedentary lifestyle increases obesity, please see page 260, Health Headlines box.

3. People who include a high level of activity in daily life, without making exercising feel like a chore, have the best chance of eating what they want without gaining weight.

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Key Words: obesogenic, basal metabolic rate (BMR), resting metabolic rate (RMR), exercise metabolic rate (EMR), adaptive thermogenesis, set point theory, yo-yo diets, satiety, hyperplasia, hypertrophy Figures and Tables:

Figure 8.1 Obesity Trends among U.S. Adults, 1988, 1998, and 2008

Figure 8.2 Potential Negative Health Effects of Overweight and Obesity

Figure 8.3 One Person at Various Stages of Weight Loss

Additional Instructor Resources: PPT slides: 1–12; Digital Transparency Masters: Figure 8.1, Figure 8.2, Figure 8.3

II. Assessing Body Weight and Body Composition A. Overweight and Obesity 1. Many people worry about becoming fat, but it is important to know the difference between good fat and bad fat. Essential fat is the fat necessary for maintenance of life and reproductive functions, and storage fat is the nonessential fat that many of us try to get rid of.

2. In general, overweight refers to increased body weight due to excess fat, whereas obesity refers to body weight that greatly exceeds health recommendations. a Overweight is defined as being 1 to 19 percent above one’s ideal weight. b. Obese is defined as being 20 percent or more above ideal weight. c. Morbidly obese people are 100 percent or more above their ideal weight.

B. Underweight 1. Underweight is having a body weight more than 10 percent below healthy recommended levels; in an adult, having a BMI below 18.5. a. Extremely low body fat can cause a host of problems including hair loss, visual disturbances, skin problems, a tendency to fracture bones, among other serious problems.

C. Body Mass Index 1. Body mass index (BMI) is a number calculated from a person’s weight and height that is used to assess risk for possible present or future health problems.

2. BMI = weight (kg)/height squared (m2) a. Healthy weights are associated with BMIs of 18.5 to 25, the range of lowest statistical health risk.

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3. There is a growing concern about the long-term consequences of pinning potentially stigmatizing labels (obese and morbidly obese) on children. a. BMI ranges for children and teens are defined so that they can take into account normal differences in body fat between boys and girls and the differences in body fat that occur at various ages.

D. Waist Circumference and Ratio Measurements 1. Waist circumference measurement is increasingly recognized as a useful tool for assessing abdominal fat, which is considered more threatening to health than fat in other regions of the body. a. A waistline greater than 40 inches in males and 35 inches in females indicates greater health risk. b. The waist-to-hip ratio measures regional fat distribution. i. A waist-to-hip ratio greater than 1 in men and 0.8 in women indicates increased health risks.

E. Measures of Body Fat 1. There are numerous ways besides BMI calculations and waist measurements to assess whether your body fat levels are too high. Looking in the mirror to see how your clothes fit, underwater (hydrostatic) weighing, skinfolds, bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), and the Bod Pod are all techniques that aim to measure body fat levels.

Key Words: overweight, obesity, morbidly obese, underweight, body mass index (BMI), waist-to-hip ratio Figure and Tables:

Table 8.1 Body Fat Percentage Recommendations for Men and Women

Figure 8.4 Body Mass Index (BMI)

Figure 8.5 Overview of Various Body Composition Assessment Methods

Additional Instructor Resources: PPT slides: 13–21; Digital Transparency Masters: Table 8.1, Figure 8.4, Figure 8.5

III. Managing Your Weight A. Improving Your Eating Habits 1. At some point in life, almost all of us decide to lose weight or modify our diet to reduce risks from chronic disease.

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2. Failure is often related to thinking about losing weight in terms of short-term dieting rather than adjusting for long-term lifestyle and changing one’s eating behaviors. a. Learn what triggers an eating behavior. Triggers are situations that make us want to eat. Keeping a chart of eating behaviors can help pinpoint problem issues.

3. Before engaging in any weight-loss program consult reliable, reputable sources when selecting a nutrition plan. a. Any diet that promises “miracle” results, requires radical behavior change, or prepackaged meals without teaching healthful eating behaviors is likely to fail.

B. Understanding Calories and Energy Balance 1. A calorie is a unit of measure that indicates the amount of energy gained from food or expended through activity. a. One pound of fat is equal to 3500 extra calories.

C. Including Exercise 1. Any increase in the intensity, frequency, and duration of daily exercise levels can have a significant impact on total calorie expenditure.

2. The number of calories spent during physical activity depends on three factors: a. the number and proportion of muscles used, b. the amount of weight moved, c. the length of time the activity takes.

D. Keeping Weight Control in Perspective 1. Weight loss is difficult for many people and may require supportive friends, relatives, and community resources.

2. People the same age, sex, height, and weight can have differences of as much as 1,000 calories in a day in RMR. 3. To reach and maintain the weight at which you will be healthy and feel your best, you must develop a program of exercise and healthy eating behaviors that will work for you now and over the long term.

E. Considering Drastic Weight-Loss Measures 1. Sometimes people are willing to take great risks to lose weight.

2. Very-low-calorie diets (VLCDs), diets with a daily caloric value of 400 to 700 calories, should never be taken without strict medical supervision. a. VLCDs can cause ketosis, a dangerous potential complication where the body turns fat reserves into fuel for the brain.

3. Drugs are sometimes used for weight loss, and FDA approval is not needed for overthe-counter supplements and “diet aids.” a. In general, diet pills have not been proven to be all that effective when used alone, though drugs can potentially help those who are severely obese. b. Diet drugs and supplements can have dangerous side effects. i. Drugs to be viewed with caution include Sibutramine (Meridia), Hoodia gordonii, and herbal weight-loss aids.

4. Surgery should be a last resort as it is one of the riskier weight-loss solutions. a. Restrictive surgeries limit food intake. b. Malabsorption surgeries decrease the absorption of food into the body, such as gastric bypass.

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5. Each type of surgery comes with its own risks and benefits that are best discussed with a doctor before surgery.

6. Surgery is not a guarantee for long-term weight loss, as those who have gone through surgery still need to be educated in healthy eating practices. Many who have had these drastic surgeries have regained their weight.

7. Liposuction is another surgical procedure and is often considered cosmetic rather than weight-loss surgery.

F. Trying to Gain Weight 1. For some people, trying to gain weight is a challenge for a variety of metabolic, hereditary, psychological, and other reasons.

2. People who are too thin need to take the same steps as those who are overweight or obese to find out what their healthy weight is and attain that weight.

Key Words: very-low-calorie diets (VLCDs) Figures and Tables:

Figure 8.6 Avoid Trigger-Happy Eating

Table 8.2 Analyzing Popular Diet Books

Figure 8.7 The Concept of Energy Balance

Figure 8.8 Weight-Loss Surgery Alters the Normal Anatomy of the Stomach

Lecture Launcher Videos: Food Diary Diet Writing, Miscounting Calories Report Additional Instructor Resources: PPT slides: 22–39; Digital Transparency Masters: Figure 8.6, Table 8.2, Figure 8.7, Figure 8.8

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Additional Chapter Activities Points of View Obesity: Is It a Disability? on page 272 of your textbook.

In Class Activity: Have students read the Points of View box. Next, have half of the students in class each write a short essay in favor of disability status for obese people with a minimum of three supporting points. Have the other half of students in class each write a short essay in opposition to disability status for obese people with a minimum of three supporting points. Neither half of the class is permitted to use any weight stigmatizing language or arguments (review how to avoid negative language with examples of positive language prior to beginning the assignment).

Next, have favoring essays be exchanged with opposing essays. Have students read the essay composed by their fellow students and pose arguments in opposition to the essay’s content.

Synthesis: Have a positive discussion about the experience and ask students to verbally share two new ways of considering this problem that they learned. Finally, discuss with students what the public health perspective might be on this issue. What might a public health professional or agency argue on this topic and why?

Discussion Questions 1. What factors do you think are driving the United States obesity epidemic? Why? 2. How does heredity or environment play a role in the determination of obesity?

3. What are some social stigmas attached to being overweight? How are these stigmas damaging to individuals and society?

4. What concerns should you have when choosing a commercial weight-loss plan?

5. How does the media portray overweight people? Cite specific examples.

6. What are common eating triggers for college students, and how can they be modified?

7. What would you suggest to someone who wants to lose weight?

Critical Thinking Questions 1. Statistics on obesity and associated health problems and costs are startling, but is there anything you personally can do about this? What can you do to increase public awareness without elevating stigma?

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. What would you advise an overweight friend who yo-yo diets to do to achieve a healthy weight and maintain it?

4. What factors, other than those discussed in this chapter, do you think contribute to the increased rates of overweight and obesity in the United States?

5. 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?

6. Childhood obesity in the United States is increasing at an alarming rate. What do you think should be done to prevent childhood obesity?

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Student Activities Individual 1. Create a plan to help someone prevent gaining the ‘freshman 15’. What healthy food choices and physical activity options do you suggest?

2. Many environmental factors contribute to weight gain and one’s risk for obesity and overweight. Identify five environmental factors that can influence college student’s body weight negatively? Generate two solutions for each environmental factor that work in your own environment.

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?

Community 1. What weight-loss options are available on your campus? Find out what services are available on campus or at your health center. Interview a counselor to find out special weight-loss needs of college students.

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?

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 to those in the United States. Are they very different? Why do you think these differences exist?

Lecture Launcher Video Questions New! Miscounting Calories 1. What is the misconception about the number of calories reported on the labels of some popular diet foods?

2. Why is more than one sample of a particular food tested to determine the correct calorie count?

3. Why does the FDA allow such a wide range of labeling of calories on prepared foods?

Food Diary Diet Writing 1. How does keeping a good diary improve your chances of doubling your weight loss?

2. What else did the dieters do to lose weight?

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Additional References 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 Leads to a Sustained Increase in Energy Intake over 2 Days,” Journal of the American Dietetics Association, 106, (2006): 543–549.

B. J. Rolls, L. S. Roe, and J. Meengs, “Reductions in Portion Size and Energy Density of Foods are Additive and Lead to a Sustained Decrease in Energy Intake,” American Journal of Clinical Nutrition, 83, (2006): 11–17.

Y. Wang and T. Lobstein, “Worldwide Trends in Childhood Overweight and Obesity,” International Journal of Pediatric Obesity, 1, (2006): 11–25.

For Further Information 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 National Institute of Health Obesity Research http://obesityresearch.nih.gov/index.htm U.S. Department of Health and Human Services SmallStep (Adult & Teen) www.smallstep.gov/index.html National Heart Lung and Blood Institute, National Institute of Health WE CAN (Ways to Enhance Children’s Activity & Nutrition) www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm Federal Trade Commission Weight loss & Fitness www.ftc.gov/bcp/menus/consumer/health/weight.shtm

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Additional Media Dangers of Childhood Obesity. 2 minutes, 31 seconds.

In this CBS News clip, Travis Stork, M.D., 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). 1 minute.

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.

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.

In this College Health Guru production, Robert Gorski, M.D., provides tips on how college students can attain and maintain weight loss. www.youtube.com/watch?v=xIc_0FiCqXM

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CHAPTER

8A

Focus On Enhancing Your Body Image

Overview Body image, or the way we perceive our own body, can be either positive or negative. Developing a positive body image can be challenging for many college students. Having a positive body image means that an individual is pleased with what he or she sees when looking into a mirror, while 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 disordered eating, eating disorders, and possibly exercise disorders. This chapter focuses on the causes of negative body images. It also discusses the common types of eating disorders and offers students advice on how to seek help if they think a friend has an eating disorder. The dangers of exercise disorders are also discussed.

Lecture Outline I. What Is Body Image?

A. Body image, most fundamentally, is how you see yourself when you look in a mirror or picture yourself in your mind and how you feel about your body.

1. The National Eating Disorders Association (NEDA) identifies a negative body image as either a distorted perception of your shape, or feelings of discomfort, shame, or anxiety about your body.

2. There are several components to body image: a. How you picture yourself in your mind b. What you believe about your own appearance c. How you feel about your body d. How you sense and control your body as you move 3. Researchers have developed a body image continuum that may help you decide your body image.

B. Many Factors Influence Body Image 1. Several factors play a role in the development of your body image. a. The media and popular culture i. The images and celebrities in the media set standards for what we find attractive, leading some people to go to dangerous extremes to look like them.

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b. Family, community, and cultural groups i. The members of society with whom we most often interact influence the way we see ourselves. c. Physiological and psychological factors i. Research indicates that people who have been diagnosed with a body image disorder also show differences in the brain’s ability to regulate neurotransmitters, which are linked to mood.

C. How Can I Build a More Positive Body Image?

1. To develop a positive body image, you need to bust 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 they work at it. c. Myth 3: Extreme dieting is an effective weight-loss strategy. d. Myth 4: Appearance is more important than health.

D. Some People Develop Body Image Disorders 1. Two clinical body image disorders are common. a. Body dysmorphic disorder (BDD) is when a person is obsessively concerned with their appearance; approximately 1 percent of people in the United States suffer from BBD. b. Social physique anxiety (SPA) is an emerging problem, seen in both young men and women, in which the desire to “look good” is so strong that it has a disabling effect on the person’s ability to function effectively.

Key Terms: body image, body dysmorphic disorder (BDD), social physique anxiety (SPA) Figures and Tables:

Figure 1 Body Image Continuum

Additional Instructor Resources: PPT slides: 1–9; Digital Transparency Masters: Figure 1

II. What Is Disordered Eating?

A. Eating Issues Occur along a Continuum 1. Disordered eating is a pattern of atypical eating behaviors that is used to achieve or maintain a lower body weight.

2. Some people channel their anxiety about weight into self-defeating thoughts and harmful behaviors.

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B. Some People Develop Eating Disorders 1. An eating disorder is a psychiatric disorder characterized by severe disturbances in body image and eating behaviors; eating disorders include anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified (EDNOS). a. In the United States, as many as 24 million people of all ages have eating disorders. b. In 2009, 3.2 percent of college students reported that they were dealing with either anorexia or bulimia. c. Many people with eating disorders feel disenfranchised in other aspects of their lives and try to gain a sense of control through food; many have psychiatric problems.

2. Anorexia nervosa is a persistent, chronic eating disorder characterized by deliberate food restriction and severe, life-threatening weight loss. a. It involves self-starvation motivated by an intense fear of gaining weight along with an extremely distorted body image. b. The criteria for anorexia nervosa include the following: i. Refusal to maintain body weight at or above a minimally normal weight for age and height ii. Intense fear of gaining weight or becoming fat iii. Disturbance in the way in which one’s body weight or shape is experienced 3. Bulimia nervosa is characterized by binge eating followed by inappropriate measures, such as vomiting, to prevent weight gain. a. It often involves binging on huge amounts of food and then engaging in some kind of purging, such as vomiting, taking laxatives, or exercising excessively. b. The criteria for bulimia nervosa include the following: i. Recurrent episodes of binge eating ii. Eating a larger amount of food than most people would eat during a similar period of time under similar circumstances c. A combination of genetic and environmental factors is thought to cause bulimia.

4. Binge-eating disorder is a type of eating disorder characterized by binge eating twice a week or more, but not typically followed by a compensatory behavior. a. It involves eating large amounts of food rapidly, even when not feeling hungry, and feeling guilty or depressed after overeating. b. Individuals with binge-eating disorder are often clinically obese. c. A recent study showed that 3.5 percent of women and 2 percent of men experience binge-eating disorder at some point in their lives.

5. Eating disorders not easily classified (EDNOS) are those that do not fit into the strict diagnostic criteria for either anorexia or bulimia, but are legitimate psychiatric illnesses.

6. Treatment for eating disorders can lead to recovery, though there are no quick or simple solutions for disordered eating or eating disorders. a. Therapy focuses on the psychological, social, environmental, and physiological factors that have led to the problem. b. Therapy allows the patient to focus on adopting new eating behaviors, building selfconfidence, and finding other ways to deal with life’s problems.

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C. How Can You Help Someone with Disordered Eating?

1. Learn as much as possible about eating disorders before talking to the person.

2. Know the differences between facts and myths about weight, nutrition, and exercise.

3. Be honest.

4. Be caring, but be firm.

5. Compliment your friend’s personality, successes, or accomplishments.

6. Be a good role model in regard to healthy eating, exercise, and self-acceptance.

7. Tell someone about your concerns.

Key Terms: disordered eating, eating disorder, anorexia nervosa, bulimia nervosa, bingeeating disorder, eating disorder not otherwise specified (EDNOS) Figures and Tables:

Figure 2 Eating Issues Continuum

Figure 3 Factors that Contribute to Eating Disorders

Figure 4 What Anorexia Can Do to the Body

Figure 5 What Bulimia Nervosa Can Do to the Body.

Lecture Launcher Video: Normal-Weight Obesity Additional Instructor Resources: PPT Slides: 10–23; Digital Transparency Masters: Figure 2, Figure 3, Figure 4, Figure 5

III. Can Exercise be Unhealthy?

A. Some People Develop Exercise Disorders 1. Compulsive exercise, also called anorexia athletica, is characterized by a compulsion to exercise; and feelings of guilt or anxiety if the level of exercise is perceived as inadequate. a. People often overexercise to feel more in control of their lives.

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b. Compulsive exercise can lead to the following: i. Injuries to joints, ligaments, tendons, and cartilage ii. Broken bones iii. Significant stress on the heart 2. Muscle dysmorphia is a body image disorder in which men believe that their body is insufficiently lean or muscular. a. Men with muscle dysmorphia believe that they look “puny,” when in reality they look normal or may even be unusually muscular.

3. The female athlete triad is a syndrome of three interrelated health problems seen in some female athletes including low-energy intake typically prompted by disordered eating behaviors, menstrual dysfunction, such as amenorrhea, and poor bone density. a. Female athlete triad is prevalent in women who participate in highly competitive individual sports or activities that emphasize leanness and require the wearing of body-contouring clothes.

Key Terms: compulsive exercise, muscle dysmorphia, female athlete triad Figures and Tables:

Figure 6 The Female Athlete Triad

Lecture Launcher Video: Extreme Healthy Eating Additional Instructor Resources: PPT Slides: 24–28; Digital Transparency Masters: Figure 6

Additional Chapter Activities Discussion Questions 1. Why do you think that 80 percent of women in the United States are dissatisfied with their appearance? What factors do you think contribute to this dissatisfaction? List two ways we could begin changing these factors.

2. How does a positive or negative body image relate to a person’s self-esteem? How might we address self-esteem to reduce or prevent body image problems?

3. Which of the factors that influence our body image do you think is most important in your own life?

4. Why do you think the number of men with eating disorders is on the rise?

5. How might we reduce the number of individuals experiencing eating disorders?

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Critical Thinking Questions 1. How does the media (television, magazines, movies) influence how both women and men perceive their body image?

2. Page 283 identifies four myths a person must overcome to develop a more positive body image. Add three more myths to this list. What could you do to help reduce the presence of these myths?

3. Where do you think you fit in the body image continuum shown in Figure 1 on page 282? Where do you fit in the eating issues continuum shown in Figure 2 on page 285?

4. Pages 289–290 list things you can do if you suspect that a friend has an eating disorder.

What other things could you add to this list?

5. What personal behaviors can you adopt to lessen our cultural obsession with thinness?

Student Activities Individual 1. Create a collage of images from magazines or newspapers that reinforce our 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?

3. Work with an RA in your dorm or a health education person in your student health center to implement a body image myth-busting campaign.

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 to 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 than 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.

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Lecture Launcher Video Questions New! Normal-Weight Obesity 1. How can a person who is “normal” weight be at risk for obesity-related diseases?

2. What are health risks of women who are normal-weight obese?

3. In addition to increased percentage of body fat, what characteristic of body fat points to increased health risks?

New! Extreme Healthy Eating 1. What is orthorexia? What kinds of food does a person with orthorexia eat?

2. Why can eating “too much healthy” food be a bad thing?

3. What are the five warning signs of orthorexia?

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.

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 www.aedweb.org//AM/Template.cfm?Section=Home American Dietetic Association www.eatright.org American Obesity Association www.obesity.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 Copyright © 2012 Pearson Education, Inc.

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Binge Eating Disorder Association www.bedaonline.com Body Image Health www.bodyimagehealth.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). 2 minutes.

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, 33 seconds.

In this CBS News production, experts discuss the rise of eating disorders and body dissatisfaction amongst males. www.youtube.com/watch?v=RFvb1Hxz4To&feature=fvsr Understanding Bulimia (College Health Guru). 2 minutes.

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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CHAPTER

9

Improving Your Physical Fitness

Overview Physical activity is one of the best ways to reduce the risk of early disease and premature death. Regular physical activity reduces the risk of heart attack, some cancers, hypertensions, and type 2 diabetes. However, a recent survey indicated that 60 percent of college women and 50 percent of college men do not meet recommended guidelines for engaging in moderate or vigorous physical activity. It is important to establish good exercise habits while still young.

Chapter 9 provides students with basic information necessary to begin developing an exercise program that can improve or maintain their level of fitness throughout their lives. Information on fitness-related injuries and preventing these injuries is also provided in this chapter.

Learning Objectives 1. Describe physical activity for health, for fitness, and for performance.

2. Identify the motivating factors for getting physically fit, including benefits, fitness goals, and obstacles to overcome.

3. Design a program that works for you, incorporating the key components of a personal fitness program.

4. Understand and be able to use the FITT principle and to apply it to the different components of physical fitness.

5. Summarize ways to prevent and treat common injuries related to physical activity.

Lecture Outline I. Physical Activity for Health, Fitness, and Performance A. Most Americans are aware of the importance of physical activity for health and wellness, but recent research indicates that 25.4 percent of American adults do not engage in any leisure-time physical activity.

1. Physical activity refers to all body movements produced by the contraction of skeletal muscles, which substantially increases energy expenditure.

2. Exercise refers to planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness.

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B. Physical Activity for Health 1. Adding more physical activity to your day can benefit your health. a. If all Americans followed the 2008 guidelines, it is estimated that there would be a significant reduction in deaths and morbidity from chronic conditions.

C. Physical Activity for Physical Fitness 1. Physical fitness refers to a set of attributes that is either health or performance related. a. Cardiorespiratory fitness refers to the ability of the heart, lungs, and blood vessels to function efficiently. i. The primary category known to improve cardiorespiratory fitness is aerobic exercise. ii. The fitness of one’s cardiorespiratory system is assessed by measuring aerobic capacity (or power). b. Muscular strength refers to the amount of force a muscle or group of muscles is capable of exerting in one contraction. c. Muscular endurance is the ability of a muscle or group of muscles to exert force repeatedly without fatigue or the ability to sustain a muscular contraction. d. Flexibility refers to the range of motion, or the amount of movement possible, at a particular joint or series of joints. e. Body composition describes the relative proportions and distribution of fat and lean tissues in the body.

D. Physical Activity for Performance 1. Performance training is intended for individuals who already have a high physical fitness level and wish to train to enhance some aspect of their ability. a. For information about women and physical fitness, please see page 303, Gender & Health box.

Key Terms: physical activity, exercise, physical fitness, cardiorespiratory fitness, aerobic exercise, aerobic capacity (or power), muscular strength, muscular endurance, flexibility, body composition Figures and Tables:

Table 9.1 2008 Physical Activity Guidelines for Americans

Figure 9.1 Components of Physical Fitness

Additional Instructor Resources: PPT slides: 1–9; Digital Transparency Masters: Table 9.1, Figure 9.1

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II. Getting Motivated and Committing to Your Physical Fitness A. What are the Health Benefits of Regular Physical Activity?

1. Reduced risk of cardiovascular disease is a benefit of regular physical activity.

Aerobic exercise is good for the heart and lungs and reduces the risk for heart-related disease. a. Regular physical activity can reduce hypertension, the medical term for abnormally high blood pressure and a significant risk factor for cardiovascular disease and stroke.

2. Being regularly physically active reduces the risk of metabolic syndrome, a combination of heart disease and diabetes risk factors that produce a synergistic increase in risk. a. For more on diabetes prevention and management, please see the Focus On Minimizing Your Risk for Diabetes chapter. To learn more about exercise for people with diabetes and other special populations, please see page 308, Health in a Diverse World box.

3. Reduced cancer risk has been found as another benefit to regular physical activity. a. Strong evidence has been shown linking reduced risk of breast, colon, and rectal cancers to regular physical activity.

4. Improvements in bone mass and reduced osteoporosis have been shown to be a benefit of exercise. a. The full bone-related benefits of physical activity can only be achieved with sufficient hormone levels and adequate calcium, vitamin D, and total caloric intake.

5. Weight control can be maintained with exercise. a. Regular endurance-type exercise, combined with a moderate decrease in food intake, can be an effective method for weight loss and also improves chances of keeping weight off.

6. Improved immunity is a benefit of regular, consistent exercise. a. Moderate exercise has been shown to temporarily increase the number of white blood cells and boost immunity, but extreme exercise can be detrimental (such as increasing the risk of colds and flu).

7. Exercise can improve mental health and stress management. a. Exercise increases endorphins, giving your mood a natural boost. b. Exercise can improve confidence, which can improve self-esteem.

8. A longer life span has been supported by several large studies that found individuals who were physically active at a more intense level outlived sedentary subjects.

B. Identifying Your Physical Fitness Goals.

1. By taking time to reflect on your personal circumstances, goals, and desires regarding physical fitness, you will probably find it easier to come up with a plan you can stick to.

C. Overcoming Common Obstacles to Physical Activity 1. There are many excuses people give to explain why they do not exercise; it is important to honestly evaluate why you are not as physically active as you want to be.

D. Incorporating Fitness into Your Life 1. When designing a personal exercise program, choose activities that you genuinely like doing, that are convenient, and activities that are suitable to your current fitness level.

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2. Try to make exercise a part of your routine by incorporating it into something you already have to do. For more information about green transportation alternatives, please see page 305, Be Healthy, Be Green box.

Figures and Tables:

Figure 9.2 Some Health Benefits of Regular Exercise

Figure 9.3 Calories Burned by Different Activities

Table 9.2 Overcoming Obstacles to Physical Activity

Lecture Launcher Video: Personal Fitness and Exercise Additional Instructor Resources: PPT slides: 10–18; Digital Transparency Masters: Figure 9.2, Figure 9.3, Table 9.2

III. Fitness Program Components A. Warm-Up 1. Generally, a warm-up involves large body movements, followed by light stretching, and usually last 5 to 15 minutes. a. A warm-up provides a transition from rest to physical activity by slowly increasing heart rate, blood pressure, breathing rate, and body temperature.

B. Cardiorespiratory and/or Resistance Training 1. Immediately following your warm-up, move into cardiorespiratory training, resistance training, or a little of both. This should make up the bulk of your workout, lasting 20 or 30 minutes or more.

C. Cool-Down 1. Make sure that cooling down and stretching amount to at least 5 minutes of workout time. a. The purpose of the cool-down is to gradually reduce your heart rate, blood pressure, and body temperature to pre-exercising levels.

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Figures and Tables:

Table 9.3 Some Popular Fitness Gadgets and Equipment

Additional Instructor Resources: PPT slides: 19–20; Digital Transparency Masters: Table 9.3

IV. Creating Your Own Fitness Program: The FITT Principle A. Design a program based on several components referred to as FITT. 1. Frequency of exercise refers to the number of times per week you need to engage in a particular exercise to achieve the desired level of physical fitness.

2. Intensity refers to how hard your workout must be to achieve the desired level of physical fitness.

3. Time, or duration, refers to how many minutes or repetitions of an exercise are needed at a specified intensity during any one session to attain desired level of fitness.

4. Type refers to what kind of exercise should be performed to improve the various components of physical fitness.

B. The FITT principle for Cardiorespiratory Fitness 1. The most effective aerobic exercises for building cardiorespiratory fitness are total body activities involving large muscle groups of the body. a. To improve your cardiorespiratory fitness, you must vigorously exercise at least three times a week. b. The exercise intensity required to improve cardiorespiratory endurance is a heart rate between 70 and 90 percent of your maximum heart rate. i. This heart rate range is known as one’s target heart rate. c. For time, the ACSM recommends that vigorous activities be performed for at least 20 minutes at a time and moderate activities for at least 30 minutes. d. Any sort of rhythmic, continuous, and vigorous physical activity that can be done for more 20 minutes or more will improve cardiorespiratory fitness.

C. The FITT principle for Muscular Strength and Endurance 1. The FITT prescription for muscular strength and endurance includes 2 to 4 days per week of exercises that train the major muscle groups. a. For frequency, performing eight to ten exercises that train the major muscle groups 2 to 4 days a week is recommended. b. The one repetition maximum (1 RM) is used as the basis for intensity recommendations for improving muscular strength and endurance. Muscular strength is improved when resistance loads are greater than 60 percent of your 1 RM. Copyright © 2012 Pearson Education, Inc.

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c. Time recommended for muscular strength and endurance exercises is measured not in minutes of exercise but rather in repetitions and sets. i. To increase muscular strength you need higher intensity and fewer repetitions and sets. ii. The amount of rest between exercises is key to an effective strength-training workout. d. To improve muscular strength or endurance, resistance training is most often recommended either using your own body weight or devices that provide a fixed, variable, or accommodating load or resistance.

D. The FITT Principle for Flexibility 1. Improving flexibility not only enhances the efficiency of your movements, it can also enhance your sense of well-being, manage stress effectively, and prevent or reduce pain in your joints.

2. Flexibility training is effective in reducing the incidence and severity of lower back problems, and muscle or tendon injuries that can occur during sports and everyday physical activities. a. The FITT principle calls for a minimum of 2 to 3 days per week for flexibility training; even better is daily training. b. Recommendations are that you perform or hold static (still) stretching positions at the “point of tension.” c. Once you are in a static stretching position, you should hold the “point of tension” for 10 to 30 seconds for each stretch and repeat two or three times in close succession. d. The most effective exercises for building flexibility fitness involve stretching the major muscle groups of your body when the body is already warm and practicing static stretching.

E. What If I Have Been Inactive for a While?

1. If you have been physically inactive for the past few months or longer, the frequency, intensity, and time of your exercise sessions should begin at the lower end of recommendations.

F. Developing a Progressive Plan Using the FITT Principle 1. As physical fitness improves, you will need to adjust the frequency, intensity, time, and type of exercise that you do to continue to improve and/or maintain the level of physical fitness attained.

2. It is also important to reevaluate your overall physical fitness goals and action plan monthly to ensure that you are still motivated and that the plan is working for you.

Key Terms: FITT, frequency, intensity, time, type, target heart rate, one repetition maximum (1 RM), static stretching

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Figures and Tables:

Figure 9.4 The FITT Principle Applied to Cardiorespiratory Fitness, Muscular Strength and Endurance, and Flexibility

Figure 9.5 Target Heart Rate Ranges

Table 9.4 Methods of Providing Exercise Resistance

Figure 9.7 Stretching Exercises to Improve Flexibility and Prevent Injury

Figure 9.6 Taking a Pulse

Additional Instructor Resources: PPT slides: 21–30; Digital Transparency Masters: Figure 9.4, Figure 9.5, Figure 9.6, Figure 9.7, Table 9.4, Figure 9.7

V. Pulling It All Together: Activities that Develop Core Strength and Multiple Components of Fitness A. Some forms of physical activity—including three styles of exercise that have become increasingly popular in the United States in recent years, yoga, tai chi and Pilates—have the potential to improve several components of physical fitness.

1. Some people see these activities as strongly connected to the development of their spiritual health. For more on enhancing your spiritual health through movement, see the Focus On Cultivating Your Spiritual Health chapter.

B. Core Strength Training 1. The body’s core muscles are the foundation for all movement. The contraction of these muscles provides the basis of support for movements of the upper and lower body and powerful movement of the extremities.

C. Yoga 1. Yoga blends the mental and physical aspects of exercise, a union of mind and body that participants often find relaxing and satisfying.

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2. There are several types of yoga including, but not limited to: a. Ashtanga Yoga: an energetic form of yoga that focuses on a series of poses done in a continuous, repeated flow. b. Bikram Yoga: a unique form held in rooms heated to 105 degrees F. The theory behind this practice is that performing yoga in a hot environment allows the muscles to easily stretch to the point of tension, thus improving flexibility.

D. Tai Chi 1. Tai chi is an ancient Chinese form of exercise that combines stretching, balance, muscular endurance, coordination, and meditation.

E. Pilates 1. Pilates is an exercise style that combines stretching with movement against resistance, frequently aided by devices such as tension springs or heavy rubber bands. a. Pilates differs from yoga and tai chi in that it includes a component specifically designed to increase strength.

Lecture Launcher Video: Twist to Get Fit! Additional Instructor Resources: PPT slides: 31–37

VI. Nutrition and Exercise A. Getting the right fuel for workouts is important for good health and effective exercise.

1. Staying well hydrated is also crucial for active individuals to maintain a healthy, fully functional body. a. Hyponatremia or water intoxication is the effect of over-consumption of plain water which dilutes the sodium concentration in the blood. This occurs in athletes engaging in endurance events lasting over 4 hours. i. To learn more about what you should drink when you work out, please see page 317, Student Health Today box.

Key Terms: hyponatremia or water intoxication Figures and Tables:

Table 9.5 Performance-Enhancing Dietary Supplements and Drugs—Their Uses and Effects

Additional Instructor Resources: PPT slides: 38–40; Digital Transparency Masters: Table 9.5

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VII. Fitness-Related Injuries A. There are two basic types of injuries stemming from fitness-related activities.

1. Traumatic injuries occur suddenly and violently, typically by accident.

2. Overuse injuries occur because of cumulative, day-after-day stresses placed on body parts during exercise.

B. Common Overuse Injuries 1. Plantar fasciitis is an inflammation of the tissue on the bottom of the foot. Repetitive weight-bearing movements can aggravate the condition.

2. Shin splints is a general term used to describe pain occurring in the leg between the knee and the ankle. Sedentary people who begin a new weight-bearing exercise program are at greatest risk, but well-conditioned exercisers can experience shin splints as well.

3. Runner’s knee describes a series of problems involving the muscles, tendons, and ligaments of the knee. The most common cause is abnormal movements of the patella or kneecap.

C. Treatment of Fitness-Training Related Injuries 1. RICE (rest, ice, compression, and elevation) is an acronym for the standard first aid treatment of virtually all fitness-training injuries.

D. Preventing Injuries 1. Appropriate footwear is essential. a. Consider how well shoes fit and the activity for which they are needed. b. Running shoes should have the ability to absorb shock.

2. It is essential to use well-fitted, appropriate protective equipment for your physical activities. a. Wearing appropriate eye protection can prevent against eye injury. b. People who bike, skateboard, use kick-scooters, or snowboard should wear helmets that meet standards established by the American National Standards Institute and the Snell Memorial Foundation. c. For suggestions on evaluating and choosing a fitness center, equipment, and fitness clothing, please see page 319, Consumer Health box.

E. Exercising in hot or humid weather increases your risk of a heat-related injury. Drinking fluids after exercise is important.

1. Heat cramps are muscle cramps due to heat or dehydration.

2. Heat exhaustion is caused by excessive water loss resulting from intense exercise in hot or humid weather.

3. Heatstroke occurs when body core temperature rises and the cooling mechanism shuts down. This is a life-threatening emergency condition.

F. When exercising in cool weather, your body’s rate of heat loss is frequently greater than its rate of heat production.

1. Hypothermia is a potentially fatal condition cause by abnormally low body core temperature

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2. To prevent hypothermia, analyze weather conditions before outdoor activity; use the buddy system; have a friend join you for cold weather outdoor activities; wear layers of appropriate clothing to prevent excessive heat loss; keep head, hands, and feet warm; and do not allow yourself to become dehydrated.

Key Terms: traumatic injuries, overuse injuries, RICE, heat cramps, heat exhaustion, heatstroke, hypothermia Figures and Tables:

Figure 9.8 Anatomy of a Running Shoe

Additional Instructor Resources: PPT slides: 41–46; Digital Transparency Masters: Figure 9.8

Additional Chapter Activities Discussion Questions 1. What motivates people to exercise? How can we use these motivational factors on people who do not exercise?

2. Which of the components of fitness do you feel is most important for daily life? Why? 3. How can focusing on just one aspect of physical fitness (e.g., muscle strength) cause health problems?

4. Do you believe that exercise can help enhance your immune system? Why do you think excess exercise can decrease the immune system?

5. Explain how lack of proper attire and equipment in fitness activities can result in injuries.

Provide three examples.

Critical Thinking Questions 1. Do you believe that exercise is important to add into your daily schedule at this time in your life? If not, why not? If so, why? What are the biggest reasons you keep exercise in your busy schedule?

2. Do you own any of the popular fitness gadgets and equipment shown in Table 9.3? What do you like about that piece of equipment and what do you dislike? Is the device easy to use? Do you use it regularly?

3. 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 being physically active?

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4. Jessica is a 20-year-old female who never has exercised before in her life. She is interested in beginning an exercise program. What would you suggest to her?

5. What is your target heart rate? What heart rate do you try to maintain while doing physical activity?

Student Activities Individual 1. There are four phases of a workout (warming up and stretching, resistance training, cardiorespiratory training, and cooling down and stretching). Choose any activity, and set up a routine based on these four phases. Give examples of what you are doing during each phase of the workout.

2. Record you physical activities each day for one week. Do you meet the ACSM guidelines for exercise frequency, intensity, and duration?

3. List five ways you can embed your regular daily activities with physical activity.

Community 1. Explore mentored physical activity programs in your community, or work with a campus health educator to start up a mentored physical activity program between college students and middle school students.

2. Explore the types of subsidies and programs offered by your campus to promote physical activity as an alternative to driving and/or parking close to campus buildings.

Diverse Population/Nontraditional 1. What exercises are popular in other cultures? Do people participate in formal exercise programs or do their daily activities involve more physical movement 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 the Special Olympics, done to foster physical activity in individuals with both physical and mental disabilities?

Lecture Launcher Video Questions Twist to Get Fit! 1. Do you consider yoga a sport?

2. What overall effects does yoga have on the body? Does it affect other aspects of health?

3. What may hold a person back from beginning yoga?

4. Have you tried yoga? What did you think of it?

Personal Fitness and Exercise 1. What are the advantages of entire families committing to losing weight together through exercise and dietary changes?

2. What kinds of support can family members offer each other in making lifestyle changes?

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Additional References American College Health Association. Healthy campus 2010: Making it happen. (2009).

Retrieved September 2, 2010, from www.acha.org/info_resources/hc2010.cfm.

S. R. Bray and M. Y. Kwan, “Physical Activity is Associated with Better Health and Psychological Well-being during Transition to University Life,” Journal of American College Health, 55, (2006): 77–82.

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. Herbet, 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.

S. B. Racette, S. S. Deusinger, M. J. Strube, G. R. Highstein, and P. T. Deusinger, “Weight Changes, Exercises, and Dietary Patterns during Freshmen and Sophomore Years of College,” Journal of American College Health, 53, (2005): 245–251.

P. B. Sparling, “College Physical Education: An Unrecognized Agent of Change in Combating Inactivity-related Diseases,” Perspectives in Biology and Medicine, 46, (2003): 579–587.

For Further Information Centers for Disease Control and Prevention BAM! Body and Mind www.bam.gov/index.html Exercise is Medicine www.exerciseismedicine.org WebMD How to Start an Exercise Program www.webmd.com/fitness-exercise/features/how-start-exercise-program American Heart Association MyStart! Online www.americanheart.org/presenter.jhtml?identifier=3053103

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eHow Muscular Strength & Endurance Exercises www.ehow.com/way_5407559_muscular-strength-endurance-exercises.html President’s Council on Fitness, Sports, & Nutrition www.fitness.gov United We Serve www.serve.gov/lrlm.asp

Additional Media Beginner’s Guide to Exercise. 3 minutes, 30 seconds.

In this Illumistream production, Certified Fitness Coach, 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, 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 Fitness and Exercise. Multiple Videos.

The following link sends viewers to the Health and Fitness section of Health Guru. Examples of videos for viewing include, Your Ticket to Weight Loss: Yoga, Beginner’s Guide to Exercise, Exercise in No Time, and Home Gym. www.healthguru.com/content/browse/cid/135/sid/155/Weight_Loss/Fitness_Exercise 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_r22r-12-HM Sports & Fitness. Multiple Videos.

The following link sends viewers to the Sports & Fitness section of College Health Guru.

Examples of videos for viewing include, Your Ticket to Weight Loss: Exercise for Weight Loss, Exercise for Strength, and Students and Steroids. http://college.healthguru.com/content/browse/cid/104/Sports_Fitness The Official Global Launch of Exercise is MedicineTM – June 3, 2010. 2 minutes, 16 seconds.

In this clip of the American College of Sports Medicine, several clips are brought together to show the importance of exercise in overall health. www.youtube.com/watch?v=KuN50zr-0WE Copyright © 2012 Pearson Education, Inc.

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CHAPTER

10

Recognizing and Avoiding Addiction

Overview Addictive processes occur not just with chemical substances such as alcohol and illicit drugs, but also with shopping, sex, relationships, gambling, work, and exercise. Chapter 10 introduces students to the physiology of addiction and the multiple factors influencing the likelihood of developing addictions. The chapter also explains the negative consequences of addictions both for the person addicted and for those close to them, including families and friends. Terms like codependency and enabling are discussed. The chapter briefly describes the most common types of addiction and discusses treatment, recovery, and relapse processes.

Students will have a general understanding that will allow greater exploration of issues concerning alcohol, tobacco, and pharmaceutical and illicit drugs presented in later chapters.

Learning Objectives 1. Define and discuss addiction.

2. Distinguish addictions from habits, and identify the signs of addiction.

3. Discuss the addictive process, the physiology of addiction, and the biopsychosocial model of addiction, as well as codependence.

4. Describe types of addictions, including disordered gambling, compulsive buying, compulsive Internet or technology use, work addiction, compulsive exercise, and sexual addiction.

5. Evaluate treatment and recovery options for addicts, including intervention, individual therapy, group therapy, family therapy, and 12-step programs.

Lecture Outline I. What is Addiction?

A. Addiction is a persistent, compulsive dependence on a behavior or substance, including mood-altering behaviors or activities, despite ongoing negative consequences.

1. Physiological dependence is the adaptive state that occurs with regular addictive behavior and results in withdrawal syndrome; the term is used interchangeably with addiction in this chapter.

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2. There are several universal signs of addiction, whether chemical or behavioral, including: a. Compulsion, which is characterized by obsession or excessive preoccupation with the behavior. b. Loss of control, which is the inability to predict reliably whether an isolated occurrence of the behavior will be healthy or damaging. c. Negative consequences which include physical damage, legal trouble, financial problems, family dissolution, etc. d. Denial, which is the inability to perceive the behavior is self-destructive.

B. Habit versus Addiction 1. Habits are repetitious, and sometimes unconscious, behaviors. a. A habit can usually be broken without too much discomfort by becoming aware of its presence.

Key Terms: addiction, physiological dependence, compulsion, obsession, loss of control, negative consequences, denial, habit Additional Instructor Resources: PPT slides: 1–6

II. Addiction Affects Family and Friends A. The family and friends of an addicted person can suffer many negative consequences.

1. Codependence refers to a self-defeating relationship pattern in which a person is “addicted to the addict.” a. The codependent assumes responsibility for meeting others’ needs to the point that they subordinate or even ceases being aware of their own needs.

2. Enablers are people who knowingly or unknowingly protect addicts from the natural consequences of their behavior. a. Keeping the addict from realizing the consequences of his or her destructive behavior actually has the effect of allowing the addict to continue his or her addiction.

Key Terms: codependence, enablers Additional Instructor Resources: PPT slides: 7–8

III. How Addiction Develops A. Nurturing through avoidance is a developed, maladaptive way of taking care of emotional needs.

B. The Physiology of Addiction 1. Virtually all intellectual, emotional, and behavioral functions occur as a result of biochemical interactions between nerve cells in the body.

2. Neurotransmitters are biochemical messengers, and are involved in the physiology of addiction. a. Drug use can affect how the neurotransmitter is affecting the nerves and can trick the brain into thinking it has too much of some neurotransmitters so the brain will produce less. As the drug wears off, the receptor sites become emptied and the person is uncomfortable until the body gets back to normal.

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3. Mood-altering substances and experiences produce tolerance. a. This is a phenomenon in which progressively larger doses of a drug or more intense involvement in a behavior are needed to produce the desired effect.

4. Withdrawal is another physiological symptom of addiction. a. Withdrawal symptoms for chemical dependencies are usually the opposite of the effects of the drug being withdrawn. b. The most severe form of withdrawal is delirium tremens (DTs), which occurs in approximately 5 to 10 percent of dependent individuals withdrawing from alcohol.

C. The Biopsychosocial Model of Addiction 1. The biopsychosocial model of addiction is the most effective treatment of addiction today; it explains addiction as being caused by a variety of factors operating together. a. Psychological factors can affect the potential for addiction. i. People with low self-esteem or poor coping skills are more likely to develop addictive behaviors. b. For many people, addiction is thought to be based in biological or disease influences involving the brain, memory, motivation, and emotional states. c. Environmental influences, including cultural expectations, help determine whether people engage in certain behaviors. i. Cultural expectations and societal influences have an effect on addiction. ii The social learning theory states that we learn behaviors by watching role models. iii. Major and stressful life events can influence addiction as well.

Key Terms: neurotransmitters, tolerance, withdrawal, biopsychosocial model of addiction, social learning theory Figures and Tables:

Figure 10.1 Cycle of Psychological Addiction

Figure 10.2 Risk Factors for Addiction

Additional Instructor Resources: PPT slides: 9–14; Digital Transparency Masters: Figure 10.1, Figure 10.2

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IV. Addictive Behaviors A. Process addictions are behaviors known to be addictive because they are mood altering.

B. Disordered or Pathological Gambling 1. Disordered gambling is a compulsion to gamble even when facing devastating consequences and affects more than 2 million Americans. a. A recent study has shown that disordered gambling is like a drug addiction as gamblers and drug addicts describe many similar cravings and highs.

2. Gambling is more common in males, people with lower incomes, and those who are divorced.

3. College campuses are experiencing a rise in gambling due to online gambling, new casinos, scratch tickets, lotteries, sports-betting networks, and the increasing popularity of poker. a. To learn more about gambling and college students, please see page 336, Student Health Today box.

C. Compulsive Buying Disorder 1. Compulsive shoppers are preoccupied with shopping and spending and have little control over impulses to buy; compulsive shopping affects an estimated 16 percent of the U.S. population.

2. Compulsive buying can be seasonal and/or related to feelings of depression, loneliness, and anger.

3. Compulsive gambling and buying can often lead to compulsive borrowing of money to help support the addiction.

D. Technology Addictions 1. Some people become addicted to new technologies, such as smart phones, video games, personal digital assistants (PDAs), networking sites, and the Internet in general. a. Approximately 5 to 10 percent of Internet users will likely experience Internet addition, and about 11 percent of college students report that Internet use and computer games have interfered with their academic performance.

E. Work Addiction 1. Work addiction is defined as the compulsive use of work and the work persona to fulfill needs of intimacy, power, and success. a. Work addiction spans all groups, but it is most common in males in their forties and fifties. b. Work addicts usually set an intense work schedule, are unable to set boundaries regarding work, and feel driven to work even when they are away from work.

F. Exercise Addiction 1. Exercise addicts are people who exercise compulsively to try to meet needs of nurturance, intimacy, self-esteem, and self-competency. a. Traditionally, women have been perceived as being more at risk for exercise addiction, however, more men are beginning to develop unhealthy exercise patterns, often due to society’s view of the masculine ideal. i. To learn more about women and addiction, please see page 342, Gender & Health box.

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b. Muscle dysmorphia, or bigarexia, is a pathological preoccupation with being larger and more muscular.

G. Sexual Addiction 1. Sexual addiction is compulsive involvement in sexual activity. a. The addict confuses the intensity of sexual arousal with intimacy. b. Sexual addiction does not always manifest as a need for a sexual partner and may be satisfied by masturbation. c. Sex addicts often have a history of abuse, however there is no common type of person who is a sex addict.

H. Multiple Addictions 1. Health professionals at addiction treatment centers often find that addicts depend on more than one chemical or behavior.

2. Although multiple addictions certainly complicate recovery, they do not make it impossible.

Key Terms: process addictions, disordered gambling, compulsive shoppers, Internet addiction, work addiction, exercise addicts, sexual addiction Figures and Tables:

Figure 10.3 Signs of Work Addiction

Lecture Launcher Video: Money Rehab, Hidden Addictions Additional Instructor Resources: PPT slides: 15–23; Digital Transparency Masters: Figure 10.3

V. Recovering from Addiction A. Recognizing an addiction is a key step in the recovery process, though denial—the inability to see the truth—can make it difficult to do so.

B. Intervention 1. An intervention is the planned process of confronting an addict; carried out by close family, friends, and significant others.

2. Components of an effective intervention include: a. Emphasizing care and concern for the addicted person b. Describing the behavior that is of concern c. Expressing how the behavior affects the addict d. Outlining the desired outcome 3. Intervention is a serious step toward assisting someone who probably does not want help, therefore it should be well planned and rehearsed.

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C. Treatment for Addiction 1. Treatment and recovery often begin with abstinence—refraining from addictive behavior.

2. Detoxification refers to the early abstinence period during which the addict adjusts physically and cognitively to being free from the addicting substance or behavior.

3. Abstinence does little to address the dynamics that underlie an addictive behavior, so without recovery an addict is apt to relapse or change addictions. a. For a large number of addicts, recovery begins with a period of formal treatment. b. Most programs apply a combination of family, individual, and group counseling, supplemented with attendance at a 12-step support group.

D. Relapse 1. Relapse is an isolated occurrence of or full return to addictive behavior.

2. Without a relapse prevention plan, recovering addicts will relapse more often.

3. Relapse is not failure, and the addict is reminded of the addiction and redirected toward recovery efforts.

Key Terms: intervention, abstinence, detoxification, relapse Additional Instructor Resources: PPT slides: 24–26

Additional Chapter Activities Discussion Questions 1. Discuss the four common symptoms of addiction. Do certain symptoms develop before others?

2. Discuss the potential genetic, environmental, and psychological risk factors for addiction.

3. Which of the factors of the biopsychosocial model do you think has the greatest impact on the development of addiction? Why? 4. How are compulsive eating, compulsive gambling, compulsive spending, and compulsive working similar and how are they different? How would interventions for each be similar or different?

5. Discuss the concept of codependency. Do you think those close to an addict also need treatment? Why or why not? What would the benefits of treatment be to those close to an addict? What would the benefits be to the addict?

6. What is the difference between support of an addict and becoming an enabler to the addict? Have you experienced this in your own life or seen it in others?

7. What are the key components of an effective treatment program? How do these components vary for men and women?

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Critical Thinking Questions 1. Describe the difference between a habit and an addiction. Do you think one leads to the other? Provide two examples to support your response.

2. If you believe habits lead to addictions or vice versa, what types of habits do college students tend to engage in that might lead to an addiction? What prevention strategies could universities and colleges use to reduce the likelihood of addiction development?

3. How might addictions among male and female college students differ? What environmental factors influence these differences? What changes could be made on your campus to reduce risks?

4. 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?

5. Do you know anyone who has an addiction to technology? What advice would you offer this person to help them overcome their addiction?

Student Activities Individual 1. Make a list of addictions that are common to college students. Identify the possible phases of one addiction.

2. Keep a record for one week of all the time you spend using technology, such as cell phones, computers, iPods, and other similar devices. Based on this information, do you think you have a technology addiction?

Community 1. Find out what resources are available on campus for “addicted” college students at your school.

2. Work with your resident assistant to develop and promote an awareness building campaign to prevent technology addiction.

3. Contact your student health center or center of psychological services and inquire about treatment options for addiction among college students.

Diverse Population/Nontraditional 1. Compare and contrast how different cultures contribute different influences to addictions.

Lecture Launcher Video Questions New! Money Rehab 1. In what ways do you think Nikki’s compulsive spending disorder causes stress and problems in her marriage?

2. What do you think the clinical psychologist means when he states, “Money is the symptom but not the disease.”

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3. What connections did Nikki make between her shopping compulsion and childhood memories and trauma? What does this suggest about the effects that psychological factors can have on an addiction?

New! Hidden Addictions 1. After watching the video, how would you define a hidden addiction?

2. What are some common warning signs that are characteristic of someone who is hiding an addiction?

3. If you suspect someone you know has a secret addiction, why is it important to speak up and tell someone else?

Additional Resources G. M. Barnes, J. W. Welte, J. H. 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.

J. Hoffman and S. Froemke, (eds.). Addiction: Why Can’t They Just Stop? (New York: Rodale Books, 2007).

L. D. Johnston, P. M. O'Malley, J. G. Bachman, and J. E. Schulenberg, “Monitoring the Future: National Survey Results on Drug Use, 1975–2008,” Volume II: College Students and Adults Ages 19–50 (NIH Publication No. 09-7403, Bethesda, MD: National Institute on Drug Abuse, 306 pp., 2009) (Available at: www.monitoringthefuture.org/pubs/monographs/vol2_2008.pdf) S. E. McCabe, B. T. West, and H. 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.

J. L. Thome and D. L. Espelage, “Obligatory Exercise and Eating Pathology in College Females: Replication and Development of a Structural Model,” Eating Behaviors, 8, (2007): 334–349.

E. M. Wickwire, J. P. Whelan, R. West, A. Meyers, C. McCausland, and J. Leullen, “Perceived Availability, Risks, and Benefits of Gambling among College Students,” Journal of Gambling Studies, 23, (2007): 395–408.

J. Yen, C. Ko, C. Yen, C-S. Chen, and C-C. Chen, “The Association between Harmful Alcohol Use and Internet Addiction among College Students: Comparison of Personality,” Psychiatry and Clinical Neurosciences, 63, 218–224.

For Further Information Al-Anon/Alateen www.al-anon.alateen.org American Academy of Addiction Psychiatry www.aaap.org Community Anti-Drug Coalitions of America www.cadca.org Copyright © 2012 Pearson Education, Inc.

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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 Addiction. Nine Segments.

The following link sends viewers to HBO’s website for the ADDICTION documentary.

There, the viewer will find nine different segments on addiction. Examples of segments include, “Saturday Night in a Dallas ER,” “The Science of Relapse,” “A Mother’s Desperation,” and “The Adolescent Addict.” www.hbo.com/addiction/thefilm 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 NIDA Painkillers: Get Back in the Game – Use Painkillers Safely. 3 minutes.

In this production of the National Institute of Drug Abuse, NIDA scientists Cindy Miner and Joni Rutter discuss the prevalence of illicit use of painkillers amongst adolescents and the health effects of illicit use of prescription painkillers. www.youtube.com/user/NIDANIH#p/a/u/1/w2M3CxmJggs NIDA scientists Ruben Baler talks about the dangers and consequences of steroid abuse.

1 minute, 49 seconds.

In this production of the National Institute of Drug Abuse, NIDA scientist Ruben Baler discusses the negative health effects of steroid abuse. www.youtube.com/user/NIDANIH#p/u/25/z9Ynf2kPNIc NIH, on the Inside: Gambling Addiction. 7 minutes, 26 seconds.

In this production of the National Institute of Health, persons addicted to gambling share their personal struggles. Later in the segment, Dr. Jim Bjork of NIH discusses what the brain of someone with an addiction resembles. www.youtube.com/watch?v=8-IrXyNZbww

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CHAPTER

11

Drinking Alcohol Responsibly

Overview Alcohol consumption can be risky business, and college students must understand the risks associated with its use. This chapter discusses the current and future negative influences of binge drinking while in college, including how binge drinking affects students’ ability to learn. This chapter also highlights research indicating that even “moderate” drinking carries health risks. It is vital that students understand how much alcohol causes the relaxation effect and how it harms their bodies. Chapter 11 introduces students to the advantages and disadvantages of alcohol use and includes an exploration of treatment and recovery options.

Learning Objectives 1. Discuss the alcohol use patterns of college students and overall trends in consumption.

2. Explain the physiological and behavioral effects of alcohol, including blood alcohol concentration, absorption, metabolism, and the immediate and long-term effects of excess alcohol consumption on your overall health.

3. Learn practical strategies for drinking responsibly and coping effectively with campus and societal pressures to drink.

4. Explain the symptoms and causes of alcoholism, its cost to society, and its effects on you, your friends, your family, and the community.

5. Discuss the treatment of alcoholism, including the family’s role, varied treatment methods, and whether alcoholics can be cured.

Lecture Outline I. Alcohol Use on College Campuses A. Alcohol consumption levels among Americans have declined steadily since the late 1970s which is linked to a growing attention to weight, personal health, and physical activity.

1. The alcohol industry responded by introducing lower-calorie and lower-carbohydrate beers and wines.

B. Alcohol is the most popular drug used on college campuses.

1. It is estimated that 70 percent of college students have consumed an alcoholic beverage in the past 30 days.

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2. Almost half of college students engage in heavy episodic (binge) drinking. a. Binge drinking is defined as a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram-percent or above. i. For men this corresponds to consuming five or more drinks in two hours and for women this corresponds to consuming 4 or more drinks in two hours.

3. Binge drinking is dangerous because it can lead to extreme intoxication, unconsciousness, alcohol poisoning, and even death.

4. The independence of being away from home can be symbolized by alcohol use as well as boredom and the desire to have “fun.”

5. Students often experience negative consequences associated with alcohol consumption, including doing something they regret after drinking, losing track of where they are, injuring themselves, and having unprotected sex.

6. Protective behaviors, such as eating before or during drinking and having a designated driver, are also common.

C. High-Risk Drinking and College Students 1. A recent study showed that 1,825 college students die each year due to alcohol-related, unintentional injuries. Unintentional injuries are the leading cause of death in the 18– 24-year-old age group, and alcohol is the leading contributing factor in those deaths. a. Students who enter college will often drink at some point, but some are more likely to drink than others. i. Students who drank heavily in high school, as well as those who have parents that approve of their drinking, are at risk for heavy drinking in college. b. There are several reasons why college students are at particularly high risk for alcohol-related problems. i. College customs, norms, and traditions; advertising and promotions; peer influence; being a woman; aiming to feel better and less self-conscious; celebrating twenty-first birthdays; hazing; low price; and easy access are all factors that encourage students to drink in college. c. It is more common for college students than their noncollegiate peers to drink recklessly and to engage in drinking games and other dangerous practices. i. Pre-gaming is a strategy of drinking heavily at home before going out to an event or other location. ii. To learn more about alcohol and energy drinks, please see page 356, Health Headlines box. d. Drinkers and binge drinkers cause problems not only for themselves, but also for those around them. i. There is significant evidence that campus rape is linked to binge drinking. ii. Other students report sleep and study disruptions, and vandalism of personal property.

D. Colleges’ Efforts to Reduce Student Drinking 1. Some colleges are taking action to curb binge drinking and alcohol abuse by instituting strong policies. a. Many fraternities have elected to have “dry” houses.

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b. BACCHUS (Boost Alcohol Consciousness Concerning the Health of University Students) is a student organization aimed at promoting responsible drinking and party hosting. c. Effective programs shown to deal with alcohol problems on campus include: i. Motivational interviewing ii. E-Interventions (including podcasts, email, and text messages) iii. Social norms approaches are also gaining in popularity and involves sending consistent messages to students about actual drinking behavior on campus to resolve misperceptions about student drinking.

Key Terms: heavy episodic (binge) drinking, pre-gaming Figures and Tables:

Figure 11.1 College Students’ Patterns of Alcohol Use in the Past 30 Days

Figure 11.2 Prevalence of Negative Consequences of Drinking among College Students, Past Year

Additional Instructor Resources: PPT slides: 1–13; Digital Transparency Masters: Figure 11.1, Figure 11.2

II. Alcohol in the Body A. The Chemistry and Potency of Alcohol 1. The intoxicating substance found in beer, wine, and liquor is ethyl alcohol or ethanol.

It is produced in a process called fermentation. a. Hard liquors go through another process called distillation. b. The proof of an alcoholic beverage is the measure of the percentage of alcohol in that beverage.

2. “Standard drink” is a term used to refer the amount of any beverage that contains about 14 grams of pure alcohol (about 0.6 fluid ounce or 1.2 tablespoons).

B. Absorption and Metabolism 1. About 20 percent of alcohol is absorbed through the lining of the stomach. Nearly 80 percent is absorbed through the small intestine.

2. Several factors influence the speed of absorption. a. The alcohol concentration of the drink. b. The amount of food in your stomach. c. Your metabolism, weight, and body mass index. d. The amount of carbonation in the beverage.

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e. Your mood. i. Powerful moods like stress and tension cause the stomach to dump its contents more rapidly.

3. Alcohol is metabolized in the liver where it is converted by alcohol dehydrogenase to acetaldehyde, which is a toxic chemical that can cause nausea and vomiting as well as liver damage.

4. Alcohol contains 7 calories (kcal) per gram.

5. The breakdown of alcohol occurs at a fairly constant rate. Unmetabolized alcohol circulates in the bloodstream until enough time passes for the body to break it down.

C. Blood Alcohol Concentration 1. A drinker’s blood alcohol concentration (BAC) is the ratio of alcohol to blood volume and is the primary method used to measure the physiological and behavioral effects of alcohol.

2. BAC depends on weight and 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. Women are more likely than men to become more intoxicated after drinking the same amount of alcohol due to a higher percentage of body fat and less water in the body tissues. b. For more on differences of alcohol’s effects on women and men, please see page 359, Gender & Health box.

3. Both breath analysis and urinalysis help to determine legal intoxication, but blood tests are more accurate.

4. The ability to modify behavior so as to appear to be sober is called learned behavioral tolerance.

Key Terms: ethyl alcohol (ethanol), fermentation, distillation, proof, standard drink, blood alcohol concentration (BAC), learned behavioral tolerance Figures and Tables:

Figure 11.3 What Is a Standard Drink?

Figure 11.4 The Psychological and Physical Effects of Alcohol

Figure 11.5 Approximate Blood Alcohol Concentration (BAC) Based on Body Weight and Number of Drinks

Lecture Launcher Video: Teen Drinking Test Additional Instructor Resources: PPT slides: 14–26; Digital Transparency Masters: Figure 11.3, Figure 11.4, Figure 11.5 162

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III. Alcohol and Your Health A. Immediate and Short-Term Effects of Alcohol 1. The most immediate and dramatic effects of alcohol consumption occur within the central nervous system (CNS).

2. CNS depression can cause vital function depression and even death.

3. Alcohol is a diuretic. a. Dehydration can occur due to loss of water from cerebrospinal fluid. b. Dehydration occurs at the cellular level, so that the cells cannot function normally.

This causes several symptoms such as morning-after headaches. c. Indigestion and heartburn can occur if alcohol is consumed on an empty stomach.

4. Hangover a. A hangover can occur for many reasons. Symptoms include headache, upset stomach, anxiety, depression, and thirst. b. Congeners are forms of alcohol that are metabolized more slowly than ethanol and are more toxic. c. It usually takes 12 hours to recover from a hangover.

5. Alcohol and Injuries a. The use of alcohol plays a significant role in the various types of injuries people experience. b. Annually, nearly 524,000 emergency room visits in the U.S. result from alcohol use alone. c. Most people admitted to emergency rooms are men 21 years or older, mostly as the result of accidents or fights in which alcohol was involved.

6. Alcohol and Sexual Decision Making a. Alcohol use lowers one’s ability to make good decisions regarding sexual activities and also might lead one to engage in high-risk sexual behaviors.

7. Alcohol Poisoning a. Alcohol poisoning (also known as acute alcohol intoxication) occurs when one drinks large amounts of alcohol in a short amount of time. b. Death from alcohol poisoning can be caused by either CNS or respiratory depression, or by the inhalation of vomit or fluid into the lungs.

B. Long-Term Effects 1. Habitual use of alcohol is associated with serious health problems.

2. Effects on the Nervous System a. Long-term alcohol effects include shrinkage in brain size and weight and loss of some degree of intellectual ability. b. An adolescent’s developing brain is prone to damage due to alcohol consumption.

3. Effects on the Cardiovascular System a. Moderate alcohol use (no more than two drinks a day) is associated with a reduced risk of coronary artery disease. b. With moderate alcohol use, there is an increase in HDL.

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c. Alcohol has an antithrombotic effect, decreasing the clotting factors associated with atherosclerosis. d. Alcohol also contributes to high blood pressure and slightly increased heart rate and cardiac output.

4. Liver Disease a. One of the most common liver diseases related to alcohol abuse is cirrhosis of the liver, which is among the top ten leading causes of death in the United States. b. Fatty liver is the first stage of liver damage from heavy drinking. c. Fibrosis, when liver cells are replaced by scar tissue, is a further stage of deterioration. d. Alcoholic hepatitis is a serious condition from prolonged alcohol use. This can be fatal in itself or can lead to cirrhosis.

5. Cancer a. Many different cancers are associated with heavy alcohol use, particularly cancers of the esophagus, stomach, mouth, tongue, and liver. b. One compelling report demonstrated that women who drink three or more drinks per day were at greater risk for breast cancer.

6. Other Effects a. Alcohol abuse can cause inflammation of the pancreas, cause decreased enzyme production, and block the absorption of nutrients (calcium, in particular). b. Evidence also shows that alcohol can decrease the effectiveness of the immune system.

C. Alcohol and Pregnancy 1. Children exposed to high levels of alcohol in utero will experience varying degrees of effects—from mild learning disabilities to major impairment.

2. Fetal alcohol syndrome (FAS) is the third most common birth defect and one of the leading causes of mental retardation in the United States. It is the most common preventable cause of mental impairments in the Western world. a. Symptoms include mental retardation, small head size, tremors, and abnormalities of the face, limbs, heart, and brain. b. An estimated 40,000 infants in the United States are affected by fetal alcohol spectrum disorders (FASD) each year—more than those affected by spina bifida, Down syndrome, and muscular dystrophy combined. c. Any women of childbearing age who is or may become pregnant should not consume alcohol.

Key Terms: dehydration, cerebrospinal fluid, hangover, congeners, alcohol poisoning, cirrhosis, alcoholic hepatitis, fetal alcohol syndrome

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Figures and Tables:

Figure 11.6 Effects of Alcohol on the Body and Health

Figure 11.7 Comparison of a Healthy Liver with a Cirrhotic Liver

Lecture Launcher Video: Alcohol and Cancer Additional Instructor Resources: PPT slides: 27–36; Digital Transparency Masters: Figure 11.6, Figure 11.7

IV. Drinking and Driving A. The leading cause of accidental death for all persons aged 5 to 65 is traffic accidents, about 32 percent of which are alcohol related.

1. Over the past twenty years, alcohol-related traffic fatalities decreased due to zerotolerance laws, raising the drinking age to 21, stricter enforcement of laws, and educational and other prevention programs.

2. The risk of being involved in an alcohol-related automobile crash remains substantial, however.

3. There is a direct relationship between blood alcohol content (BAC) and likelihood of a car crash. As BAC increases, accident rates increase.

4. The riskiest time to be involved in an alcohol-related accident is between midnight and 3 AM. Figures and Tables:

Figure 11.8 Percentage of Fatally Injured Drivers with BACs > 0.08 Percent, by Driver Age, 1982–2008

Additional Instructor Resources: PPT slides: 37–38; Digital Transparency Masters: Figure 11.8

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V. Alcohol Abuse and Alcoholism A. Alcohol use becomes alcohol abuse when it interferes with work, school, or personal relationships or when it entails a violation of the law.

1. Alcoholism, or alcohol dependency, is a condition in which personal and health problems related to alcohol use are severe and stopping alcohol use results in withdrawal symptoms.

B. Identifying a Problem Drinker 1. Irresponsible and problem drinkers are not necessarily alcoholics; withdrawal symptoms must be present.

2. Alcoholism affects all socioeconomic status levels, professions, geographic locations, religions, and races. a. About 15 percent of people in the United States are problem drinkers. b. Alcoholism often includes a craving, loss of control, physical dependence, and tolerance. c. The heaviest college drinkers are the least likely to seek treatment, yet they experience and are responsible for most alcohol-related problems on campus.

C. Alcohol and Prescription Drug Abuse 1. Recent studies have shown that people with alcohol use disorders are 18 times more likely to report nonmedical use of prescription drugs than those who do not drink.

2. Mixing alcohol and prescription drugs can cause severe medical problems.

D. The Causes of Alcohol Abuse and Alcoholism 1. Alcoholism is a disease with biological, social, and environmental components, but it is unknown what role each component plays in the disease.

2. Biological and Family Factors a. The development of alcoholism among individuals with a family history of alcoholism is about four to eight times more common than it is among individuals with no such family history.

3. Social and Cultural Factors a. Some people begin drinking as a way to dull the pain of an acute loss or an emotional social problem. b. Family attitudes toward alcohol also seem to influence whether a person will develop a drinking problem. c. The amount of alcohol a person consumes seems to be directly related to the drinking habits of that individual’s social group. d. To learn more about patterns of alcohol use and abuse among different racial and ethnic groups in the United States, please see page 366, Health in a Diverse World box.

E. Effects of Alcoholism on Family and Friends 1. There are an estimated 27.8 million children in the United States affected or exposed to a family alcohol problem. a. The code in dysfunctional families is “don’t talk, don’t trust, and don’t feel,” allowing a family to avoid dealing with problems and issues as a family.

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b. Children in dysfunctional families generally assume one of these roles: i. The family hero ii. The scapegoat iii. The lost child iv. The mascot c. Children in alcoholic homes are more likely to experience abuse and are more prone to alcoholic behaviors when they grow up.

F. Costs to Society 1. Crimes, medical expenses, accidents, and alcoholic treatment all contribute to alcoholrelated costs to society.

2. Workplace Prevalence of Alcohol Dependence and Abuse a. Employed adults have a 27 percent greater risk of having an alcohol problem compared to those not in the workforce. b. Alcohol problems are estimated to contribute to 500 million lost workdays annually.

3. The Cost of Underage Drinking a. It is estimated that underage drinking costs society $61.9 billion annually.

G. Women and Alcoholism a. Studies show that there may now be as many female alcoholics as male alcoholics. b. Women alcoholics have death rates of 50 to 100 percent higher than male alcoholics and it is estimated that only 14 percent of women who need treatment for alcohol dependency get it.

Key Terms: alcohol abuse, alcoholism (alcohol dependency) Figures and Tables:

Table 11.1 Prevalence of Alcohol Problems by Industry Sector (%)

Additional Instructor Resources: PPT slides: 39–47; Digital Transparency Masters: Table 11.1

VI. Treatment and Recovery A. The Family’s Role in Recovery a. Family members of an alcoholic usually take action before the alcoholic does. b. Interventions are planned confrontations with the alcoholic involving family, friends, and professional counselors.

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B. Treatment Programs 1. Private treatment facilities provide medical assistance for withdrawal symptoms. a. Delirium tremens (DTs), which is characterized by confusion, delusions, agitated behavior, and hallucinations, occur in a small percentage of alcoholics. b. Detoxification refers to the process by which addicts end their dependence on the drug.

2. Family therapy, individual therapy, and group therapy are all used for alcoholic treatment.

3. Pharmacological treatment is also commonly used for alcoholism. a. The drugs Disulfiram (Antabuse) and Naltrexone are commonly used to treat alcoholism along with other drug therapies.

4. Group support has helped many people with alcohol problems. a. Alcoholics Anonymous (AA) teaches people that recovery is a lifelong process. b. Other groups such as Al-Anon, Alateen, and Women for Sobriety and Secular Organizations for Sobriety (SOS) are other self-help groups that aim to help recovering alcoholics.

C. Relapse 1. Over half of alcoholics relapse within the first 3 months of treatment.

2. A comprehensive approach that includes drug therapy, group support, family therapy, and personal counseling designed to improve living and coping skills is usually the most effective course of treatment.

3. To prevent returning to alcohol, abstinence is the safest and most effective path to take for recovery.

Key Terms: intervention, delirium tremens (DTs), Alcoholics Anonymous (AA) Additional Instructor Resources: PPT slides: 48–51

Additional Chapter Activities Points of View The Drinking Age: Is There A Right One? on page 352 of your textbook.

In Class Activity: Find and bring into class several old issues of fashion and other popular culture magazines in which alcohol is heavily advertised (enough for groups of four to each review a magazine; or ask students to bring them in for participation points. They can be shuffled around the room so that groups don’t review their own magazines). Break students into groups of four to review their magazine for their impression of the alcohol advertisements. Then have students answer these questions: At what age groups do they seem to be aimed?

Do the target groups seem to vary based on the particular liquor?

How many involve students?

How many occur at school?

How do the ads support or undermine underage drinking laws?

Based on the ads, what would you guess is the minimum drinking age?

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Synthesis: Reconvene as a class to discuss student findings. What are the primary themes uncovered by their reading of the ads? What messages are being sent with the alcohol advertising? What ages do the magazine ads appear to be targeting? Does this support or undermine legal-age drinking laws? How do these findings influence student’s advocacy or disagreement with drinking laws?

Discussion Questions 1. Discuss several reasons for the popularity of alcohol on college campuses. What can be done to decrease alcohol use in college students?

2. What are the rules regarding drinking alcohol on your campus? Do you think the rules regarding drinking alcohol that are in place on your campus are appropriate? Why or why not?

3. Explain the physiology of a hangover. How can this be used as a deterrent for future drinking episodes?

4. Explain how alcohol use is related to motor vehicle accidents. Do you think stricter penalties or random checkpoints will decrease the number of people who drive after drinking? What ideas do you have to curb drinking and driving?

5. How can family members, spouses, friends, or coworkers help an alcoholic they know confront his or her problem?

6. What conditions should be present to give the recovering alcoholic the best chance for complete recovery?

Critical Thinking Questions 1. How would you approach a friend who has a drinking problem? What types of interventions would be most appropriate for a college student and why? How could alcohol interventions be tailored to better meet the needs of college students?

2. What can you do to prepare yourself to be a responsible drinker at a college party? What things can you do during a party to be responsible with your drinking?

3. 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?

4. When it comes to drinking alcohol, how much is too much? How can you avoid drinking amounts of alcohol that will affect your judgment?

5. Why do you think the incidence of alcohol use and abuse in women has risen to the same level as men?

Student Activities Individual 1. How do you think alcohol advertisements promote the product? Make a list of several categories of promotional efforts.

2. Visit the Center for Alcohol and Addiction Studies website at www.caas.brown.edu to learn more about the prevention and effective treatment of alcohol and other drug use.

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3. 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. Find out what is being done on your campus or in your community to support the idea of having designated drivers (DD) to avoid alcohol-related automobile accidents. Have you ever been a DD? Have you ever asked a friend to be a DD? 3. Work with a campus health educator to develop a responsible drinking program to change drinking norms on your campus or in your dorm.

Diverse Population/Nontraditional 1. How is alcohol used in other cultures? Compare and contrast usage rates and rates of alcoholism.

2. Make a list of how society’s attitude toward drinking has changed in the last 25 years.

Lecture Launcher Video Questions New! Alcohol and Cancer 1. In what ways can even moderate drinking significantly raise a women’s risk of cancer?

2. What role does a person’s family history play in risks associated with drinking?

Teen Drinking Test 1. What are the ethical considerations involved with the ethyl glucuronide (EtG) test?

2. What are the pitfalls of the EtG test as it works now?

3. Is the EtG test really a deterrent? (Remember, it is effective up to 80 hours after drinking.)

4. Should there be consequences from a school for a positive test? Is notifying parents enough?

Additional References 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): 259–79.

National Advisory Council on Alcohol Abuse and Alcoholism (National Institute on Alcohol Abuse and Alcoholism). A Call to Action: Changing the Culture of Drinking at U.S. 170

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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 (National Institute 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.

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/Alateen www.al-anon.alateen.org National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov Substance Abuse and Mental Health Services Administration www.samhsa.gov The BACCHUS and GAMMA Peer Education Network http://bacchusgamma.org

Additional Media Alcohol: A Women’s Health Issue. 13 minutes.

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.

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

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End Result of Alcoholism (College Health Guru). 2 minutes.

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.

Dr. Adam J. Flisser of College Health Guru discusses alcoholism, alcohol abuse, and alcohol dependence. Dr. Flisser also discusses factors that increase 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). 2 minutes.

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

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CHAPTER

12

Ending Tobacco Use

Overview Tobacco use is widespread in the United States and involves many interrelated social and political issues. Currently, tobacco use is the single most preventable cause of death in the United States. Most people who smoke become addicted before they are 18 years old. Specific groups of people, including college aged people, are heavily targeted for advertising and promotional campaigns by the tobacco industry. Chapter 12 introduces students to the facts with regard to tobacco use and to its consequences in terms of both personal health and economic costs to society. Environmental tobacco smoke is described and the consequences are discussed. A primary message to college students is that they must be aware that the longer he or she uses tobacco, the harder it is to quit and the greater the cost is to his or her health.

Learning Objectives 1. Discuss tobacco use in the United States and on college campuses, and the social and political issues involved in tobacco use.

2. Describe how the chemicals in tobacco products affect the body.

3. Discuss the health risks of smoking and using smokeless tobacco, and the dangers of environmental tobacco smoke.

4. Describe quitting strategies, including strategies aimed at breaking the nicotine addiction and smoking habit.

Lecture Outline I. Tobacco Use in the United States A. Tobacco use is the single most preventable cause of death in the United States.

1. About 20 percent of Americans smoke and 1 in 5 American deaths are due to tobaccorelated diseases each year.

2. For every person who dies from tobacco use, another 20 suffer from at least one serious tobacco-related illness.

3. An estimated 71 million Americans report using tobacco products at least once in the past month. a. Men aged 25 to 44 are the most likely to smoke cigarettes, and among women aged 18 to 64, 21 percent are current smokers.

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4. Education is closely linked with cigarette use: Adults with a bachelor of arts degree or higher are three times less likely to smoke than those with less than a high school education.

5. Smoking also varies by ethnicity and gender with the highest rates of smoking among non-Hispanic black men, American Indian men, and Alaska Native men.

B. Why Do People Smoke?

1. Between 60 and 80 percent of people have tried a cigarette, but only some people get hooked.

2. Some people walk away from cigarettes while others get hooked for several reasons. a. Nicotine is a very addictive drug. b. People can become hooked on the habit of picking up a cigarette. c. Weight control can motivate smokers to continue smoking. d. People in the United States are bombarded with powerful cigarette advertising messages every day.

3. The effects of nicotine poisoning can usually be felt by beginning smokers with their first puff. a. Symptoms include dizziness, lightheadedness, rapid and erratic pulse, clammy skin, nausea, vomiting, and diarrhea. b. Tolerance to nicotine occurs almost immediately after two or three cigarettes.

4. People who smoke are not just physically dependent on nicotine; they are also psychologically dependent. a. Nicotine “tricks” the brain into creating pleasurable memory associations between sensory stimuli or environmental cues that may also trigger the urge for a cigarette.

5. Nicotine is an appetite suppressant and slightly increases the smoker’s basal metabolic rate.

C. Advertising 1. The tobacco industry spends an estimated $36 million per day on advertising and promotional materials.

2. Campaigns are directed at all age, social, and ethnic groups, but much of the advertising has been directed toward teenagers, who constitute 90 percent of all new smokers.

3. Advertising has recently been directed even more specifically to women.

D. Financial Costs to Society 1. The financial costs of tobacco to society are high. Health care costs related to tobacco use are estimated at $193 billion annually.

Key Terms: nicotine poisoning

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Figures and Tables:

Table 12.1 Percentage of Population That Smokes (Aged 18 and Older) among Select Groups in the United States

Additional Instructor Resources: PPT slides: 1–10; Digital Transparency Masters: Table 12.1

II. College Students and Tobacco Use A. College students are the targets of heavy tobacco marketing and advertising campaigns.

To learn more about tobacco products on college campuses, please see page 382, Student Health Today box.

B. Gender and Tobacco Use on Campus 1. The most significant increase in smoking among women is seen in the transition from high school to college.

2. On college campuses, female students who smoke are viewed in a more negative light than male students who smoke. a. To learn more about smoking and smoking trends among women in the United States, please see page 380, Gender & Health box.

C. Why Do College Students Smoke?

1. College students report that they smoke to relax and reduce stress, fit in, and because of addiction.

2. Other key reasons provided by students are to control weight and smoking because they are depressed.

D. Occasional or Social Smoking 1. Social smoking, which is smoking with people rather than alone, can still increase the risk of heart disease, cancer, and other tobacco-related health dangers.

E. Most Student Smokers Want to Quit 1. Most students who smoke regularly are nicotine dependent but often want to stop smoking.

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Figures and Tables:

Figure 12.1 Trends in Prevalence of Cigarette Smoking in the Past Month among College Students

Figure 12.2 Reasons for Tobacco Use among College Student Smokers

Additional Instructor Resources: PPT slides: 11–15; Digital Transparency Masters: Figure 12.1, Figure 12.2

III. Tobacco: Its Components and Effects A. There are many health effects of tobacco. Smoking in particular delivers 4,000 chemical substances to the lungs, including 250 that are harmful or toxic and 50 known carcinogens (cancer-cause agents).

B. Nicotine 1. Nicotine is the major primary stimulant chemical in tobacco products and is highly addictive. a. It is a powerful central nervous system (CNS) stimulant, which produces a variety of negative physiological effects.

C. Tar and Carbon Monoxide 1. Tar is the thick, brownish sludge condensed from particulate matter in smoked tobacco. It contains cancer-causing agents such as benzopyrene and carcinogens such as phenol.

2. Carbon monoxide is a gas found in cigarette smoke that binds at oxygen receptor sites in the blood. It reduces the oxygen-carrying capacity of red blood cells, which causes oxygen deprivation in many body tissues.

D. Tobacco Products 1. Cigarettes are the most common form of tobacco available today. a. Filtered cigarettes are designed to reduce levels of gases consumed, but they may deliver more hazardous gases than nonfiltered brands. b. Clove cigarettes are about 60 percent tobacco and are higher in tar, nicotine, and carbon monoxide than regular cigarettes. They also contain eugenol, which allows deeper inhalation and thereby increasing risk. The same effect is true of menthol cigarettes.

2. Cigar sales have increased dramatically in the last few years. a. Cigar smoke contains 23 poisons and 43 carcinogens, and most cigars contain as much nicotine as several cigarettes. Nicotine also can be absorbed through the mucous membranes in the mouth.

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3. Pipes and hookahs have a long history throughout the world, and while many think that they are safer than cigarettes, they are not risk-free options. a. Pipe smoking carries with it similar risks to cigar smoking. b. Hookahs are gaining in popularity but also pose harmful risks when used for smoking, as well as hygiene and sanitation concerns.

4. Bidis are small, hand-rolled, flavored cigarettes that look similar to a marijuana joint or clove cigarette, have no filter, and produce more carbon monoxide, nicotine, and tar than cigarettes. They also lack any sort of filter to lessen the levels.

5. Smokeless tobacco is used by an estimated 3 percent of adults in the United States. It is just as addictive as cigarettes and usually contains more nicotine. a. Chewing tobacco contains tobacco leaves treated with molasses and other flavorings and comes in forms of loose leaf, plug, or in a pouch. b. Dipping is a similar method where the tobacco is placed between the lower lip and teeth to stimulate the flow of saliva and release the nicotine. c. Snuff, a finely ground form of tobacco, can be inhaled, chewed, or placed inside the gums.

Key Terms: nicotine, tar, carbon monoxide, bidis, chewing tobacco, dipping, snuff Figures and Tables:

Table 12.2 What Exactly Are You Inhaling?

Figure 12.3 Lung Damage from Chemicals in Tobacco Smoke

Additional Instructor Resources: PPT slides: 16–25; Digital Transparency Masters: Table 12.2, Figure 12.3

IV. Health Hazards of Tobacco Products A. Each day cigarettes contribute to over 1,200 deaths from cancer, heart disease, and respiratory disorders.

B. Cancer 1. The American Cancer Society estimates that smoking causes 85 to 90 percent of lung cancers and 87 percent of lung cancer deaths. a. Lung cancer takes from 10 to 30 years to develop, has a 5-year survival rate of 16 percent, and risk depends on the following: i. Number of cigarettes smoked per day ii. When you started smoking iii. How deeply you inhale 2. Leukoplakia, a white leathery patch inside the mouth, is a precursor to oral cancer.

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3. It is estimated that 75 percent of oral cancer cases resulted from tobacco use in 2010.

4. Other cancers associated with tobacco use include pancreatic cancer; cancers of the lip, tongue, salivary glands, and esophagus; and cancer of the kidney, bladder, and larynx.

C. Cardiovascular Disease 1. Over a third of tobacco-related deaths occur from some form of heart disease. Smokers have a 70 percent higher death rate from heart disease than do nonsmokers. a. Smoking ages the arteries by about 10 years, increases the development of atherosclerosis, and decreases HDL levels. b. Smoking also contributes to platelet adhesiveness, the stickiness of red blood cells, which increases the risk of blood clots. c. Smokers are twice as likely as nonsmokers to suffer a stroke.

D. Respiratory Disorders 1. Chronic bronchitis develops when smoking causes inflammation in the lungs producing excess mucous, which causes a chronic, hacking cough.

2. Emphysema is a chronic condition where alveoli are destroyed, impairing the lungs’ ability to take in and distribute oxygen. a. Because of the difficulty in obtaining oxygen, a person with emphysema will expend 80 percent of their energy just breathing. i. Approximately 80 percent of all cases of emphysema are related to cigarette smoking. There is no cure, and the damage is irreversible.

E. Sexual Dysfunction and Fertility Problems 1. Research shows that tobacco use causes impotence in men. Male smokers are two times more likely than nonsmokers to suffer from impotence. This could indicate oncoming cardiovascular disease.

2. Infertility and problems with pregnancy may be a result of smoking for women.

Smoking during pregnancy contributes to low-birth-weight babies, preterm deliveries, and infant deaths, among other serious problems.

F. Other Health Effects 1. Dental problems are common among smokers, and gum disease is three times more common.

2. Medications are less effective for smokers.

3. It is possible that smokers are accelerating damage to the brain, possibly leading to Alzheimer’s disease.

Key Terms: leukoplakia, platelet adhesiveness, emphysema

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Figures and Tables:

Figure 12.4 Effects of Smoking on the Body and Health

Figure 12.5 Tobacco Use in the United States, 1990–2006

Lecture Launcher Video: Smash the Ash! Additional Instructor Resources: PPT slides: 26–34; Digital Transparency Masters: Figure 12.4, Figure 12.5

V. Environmental Tobacco Smoke A. Environmental tobacco smoke (ETS) also known as secondhand smoke is divided into two categories.

1. Mainstream smoke refers to the smoke drawn through tobacco while inhaling.

2. Sidestream smoke refers to smoke inhaled from a burning cigarette. a. Involuntary smokers, also called passive smokers, breathe less smoke than smokers but are still exposed to dangerous chemicals. b. Children are more heavily exposed to ETS than adults.

B. Risks from Environmental Tobacco Smoke 1. Although involuntary smokers breathe less tobacco than active smokers do, they still face major risks from exposure. a. Lung cancer, other cancers, and heart disease risks increase with exposure to ETS. b. Secondhand smoke has been designated as a known carcinogen (group A carcinogen) by the Environmental Protection Agency (EPA). To learn more about the measures being taken to address the problem of ETS, please see page 392, Be Healthy, Be Green box.

2. Children exposed to sidestream smoke have a greater risk of lower respiratory tract infections and other illnesses, such as asthma, chest colds, and decrease in pulmonary performance. Children under the age of 5 are at greatest health risks from sidestream smoke.

3. ETS also causes additional health problems including allergic reactions such as itchy eyes, difficulty breathing, painful headaches, nausea, and dizziness, and it may increase breast cancer in women.

Key Terms: environmental tobacco smoke (ETS), mainstream smoke, sidestream smoke Lecture Launcher Video: Secondhand smoke Additional Instructor Resources: PPT slides: 35–37

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VI. Tobacco Use Prevention Policies A. Forty-six states have sued the tobacco industry to recover health care costs related to treating smokers.

1. In 1998, the tobacco industry reached a master’s settlement agreement with 40 states, which required tobacco companies to pay approximately $206 billion over 25 years nationwide, in addition to a variety of measures to support antismoking education and advertising.

2. However, due to budgetary issues, many states have been required to cut funding to antismoking programs.

Additional Instructor Resources: PPT slide: 38

VII. Quitting A. Quitting 1. Approximately 70 percent of adult smokers in the United States want to quit smoking, and up to 44 percent make a serious attempt to quit each year. However, only somewhere between 4 and 7 percent succeed. a. See the Assess Yourself box to determine whether you are dependent on tobacco, page 400.

B. Benefits of Quitting 1. The body begins to repair itself as soon as a smoker stops smoking. a. Within 8 hours, carbon monoxide and oxygen levels return to normal, and “smoker’s breath” disappears. b. Within days, mucous that is clogging airways is broken up and eliminated. c. Within weeks, circulation and senses of taste and smell improve. d. After ten smoke-free years, an ex-smoker can expect to live out his or her normal life span.

2. Risks for several cancers and several types of heart disease drop considerably as well.

3. Money saved is a significant benefit of quitting—$1,921.92 is spent, on average, annually by a pack-a-day smoker.

C. How Can You Quit?

1. Options for quitting include quitting “cold turkey” (deciding not to smoke again), short-term programs, treatment centers, and personal health programs with help of a health care provider. a. The type of cessation method is up to the addict, but a combination of approaches seems to be most effective.

D. Breaking the Nicotine Addiction 1. Nicotine addiction is one of the toughest addictions to overcome due to nicotine withdrawal.

2. Nicotine replacement products are one way to help smokers break the addiction. a. Nicotine replacement gum, nicotine containing lozenges, the nicotine patch, the nicotine nasal spray, and a nicotine inhaler are all nontobacco products that replace depleted levels of nicotine in the bloodstream that have helped some people to stop using tobacco.

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3. Smoking-cessation medications are also available which aim to reduce withdrawal symptoms and decrease craving for nicotine. a. Zyban and Chantix, are two smoking-cessation prescription drugs approved by the FDA. NicVAX, an antismoking vaccine, is due on the market soon and is a radical new way to help smokers quit by preventing nicotine from reaching the brain, making smoking less pleasurable and therefore easier to give up. b. For more information about alternative tobacco-use cessation methods, please see page 398, Consumer Health box.

E. Breaking the Smoking Habit 1. There are other therapy methods used to help smokers quit the habit. a. Operant strategies involve pairing the act of smoking with an external stimulus such as a sounding buzzer to help condition the smoker into quitting when the stimulus is removed. b. Self-control strategies view smoking as a learned habit associated with specific situations. The therapy is aimed at identifying these situations and teaching smokers the skills necessary to resist smoking.

Key Terms: nicotine withdrawal Figures and Tables:

Figure 12.6 When Smokers Quit

Table 12.3 What to Expect When You Quit

Table 12.4 Recommended Therapies for Smoking Cessation

Additional Instructor Resources: PPT slides: 39–48; Digital Transparency Masters: Figure 12.6, Table 12.3, Table 12.4

Additional Chapter Activities Points of View Smoking on College & University Campuses: Should It Be Banned? on page 384 of your textbook.

In Class Activity: As students come into class, assign them to a secret symbol (+ for smokers, - for nonsmokers). Be sure that approximately 1 in 5 of the students is a smoker. Have students read the Points of View section regarding smoking bans on campuses. Next, have students get into groups of five (where at least one person is a smoker). Tell them that if they were assigned a + that they must debate the issue of a campus smoking ban from the perspective of a smoker, and if they were assigned a – they must argue the ban taking into consideration the perspective of a nonsmoker.

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Synthesis: After students have debated for 5 to 8 minutes, bring the class back together and have groups report back the lessons learned. Discuss and document the most interesting and powerful lessons on the board, and discuss the pros and cons of enacting a smoking ban.

Discussion Questions 1. Discuss the varied ways in which tobacco is used. Is any method less addictive or hazardous to one’s health than another? Why or why not?

2. Discuss short- and long-term health hazards associated with tobacco. How would increased tobacco use among adolescents and college students affect the future medical system? Who should be responsible for the medical expenses of smokers?

3. How does the media portray smoking? How have these portrayals changed in the last 30 years?

4. Explain the effects of nicotine, and describe why it is so difficult to break the addiction.

5. Explain the differences between mainstream and sidestream smoke. What are three ways that the amount of these types of smoke could be reduced?

6. Why are companies promoting smoke-free workplaces? How do these restrictions save the company money?

7. How is cigarette smoking related to lung cancer? How is smokeless tobacco related to oral cancer?

Critical Thinking Questions 1. Using facts from the text, pretend that you are explaining quitting options to a family member or other loved one. What recommendations would you make, and how would you assist them in getting the materials and resources needed for a successful quit attempt?

2. Do you find yourself in situations where secondhand smoke is affecting you? How have you dealt with it? How did your experience differ from that of a child exposed to secondhand smoke? What role does society have in protecting children from secondhand smoke?

3. Discuss the ways that tobacco use is costly to society. How could some of these costs be reduced or eliminated with reduced tobacco use?

4. Do you think people who smoke should pay higher rates for health insurance? Why or why not?

5. 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, and break down the tally by gender and age. How do your findings compare with the national average?

2. Your best friend is trying to quit smoking. Visit the tobacco website at www.tobacco.org and write down several suggestions on how to quit.

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3. Work with your dorm’s RA or a health promotion staff member at your student health services to promote a smoking reduction and education campaign.

Community 1. What kinds of laws are enforced on your campus or in your community to provide smoke-free environments in work, study, and meeting places; restaurants and bars; motels and hotels; and other public places? What are the penalties for breaking these laws?

2. Make a list of resources in the community and on campus for students who want to quit smoking. Are nicotine replacement products available at the health center?

3. Make a list of resources available in your community for low-cost or sliding scale alternatives to nicotine replacement products and services.

Diverse Population/Nontraditional 1. What is the percentage of cigarette smoking and other forms of tobacco use in other countries? How do these figures compare to similar figures in the United States?

2. Look in magazines from the 1950s and 1960s and find three tobacco ads. Compare and contrast them with three current tobacco ads.

Lecture Launcher Video Questions Smash the Ash! 1. What are the biggest deterrents to smoking?

2. Do antismoking ads reinforce smoking habits?

3. Is seeing the different lungs (a healthy lung, a smoker’s lung, a lung with cancer) effective?

4. Why do people quit smoking? Is there any way you can help a friend or family member quit?

Secondhand Smoke 1. According to a 2006 Surgeon General’s report, there are no acceptable exposure levels of secondhand smoke. Do you agree with this statement?

2. Does your state have antismoking laws in place? Do you think there should be such laws, or are they unfair to people who wish to smoke?

3. Are you exposed to secondhand smoke in your daily life? What can you do to limit your exposure?

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) www.cdc.gov/pcd/issues/2008/july/07_0116.htm.

V. Cokkindes, P. Brandi, C. McMahan, A. Jemal, T. Glynn, and E. Ward, “Tobacco Control in the United States—Recent Progress and Opportunities,” CA, 59, (2009): 352–365.

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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.

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, doi:10.1136/tc.2009.032888 (2010).

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.

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.

For Further Information 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 Free Help to Quit Smoking www.cancer.gov/cancertopics/smoking National Cancer Institute Tobacco Control Research http://dccps.nci.nih.gov/tcrb Smokefree.Gov www.smokefree.gov State Tobacco Activities Tracking and Evaluation (STATE) System http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx

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Additional Media Alternative Therapies to Help You Quit (Smoking Cessation 4). 3 minutes.

In this illumistream production, Dr. Joshua Fink discusses various non-nicotine 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.

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 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 amongst college students. www.youtube.com/watch?v=oB8AvqeOcZM The Real Cost of Smoking (Smoking Cessation #1). 3 minutes.

In this illustream 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

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CHAPTER

13

Avoiding Drug Misuse and Abuse

Overview Drug problems affect everyone from personal battles, to crime, to elevated health care costs.

In the spirit of prevention, this chapter provides information concerning drug addiction and drug categories. Having an understanding of the different categories of drugs and their effects is important for the student who is trying to decide whether to take drugs or not. Illicit drug use is rising on college campuses, so it is very important that students understand the negative health and other consequences of using illegal substances. This chapter helps the student become informed about the advantages and disadvantages of drug use, misuse, and abuse. It describes the major drugs categorized as stimulants, cannabinoids, depressants, opioids, hallucinogens, club drugs, and steroids. Students should be made aware of the short-term and long-term consequences to their health and their futures from using these drugs.

Learning Objectives 1. Discuss the six categories of drugs and their routes of administration.

2. Discuss the use of illicit drugs among college students.

3. Review problems relating to the misuse and abuse of prescription drugs.

4. Discuss the use and abuse of controlled substances, including cocaine, amphetamines, marijuana, opioids, hallucinogens, club drugs, inhalants, and steroids.

5. Profile illicit drug use in the United States, including who uses illicit drugs, financial impact, and impact on college campuses and the workplace.

Lecture Outline I. Drug Dynamics A. In 2008, an estimated 20 million Americans aged 12 or older were current users of illicit drugs: This represents 8 percent of the population.

B. Drugs work because they physically resemble chemicals produced naturally in the body and attach to the receptor sites for natural chemicals.

1. 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.

2. Psychoactive drugs bind to receptor sites in the brain and can alter a person’s mood or behavior.

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C. Types of Drugs 1. Prescription drugs are those drugs that can be obtained only with the written prescription of a licensed physician.

2. Over-the-counter (OTC) drugs can be purchased without a prescription.

3. Recreational drugs are a vague category depending on the definition of “recreation,” but this category generally includes alcohol, tobacco, and caffeine products.

4. Herbal preparations include teas and preparations of botanical origin believed to have medicinal properties.

5. Illicit or illegal drugs are generally recognized as harmful, are all psychoactive, and have laws governing them.

6. Commercial preparations are perfumes, cosmetics, household cleaners, paints, glues, and so forth, and they are the least commonly recognized chemical substances.

D. Routes of Drug Administration 1. There are several ways drugs can be taken into the body, also known as routes of administration. Route largely determines the rapidity of the drugs effect on the body.

2. Oral ingestion is the most common route. Effects may not be felt until 30 minutes after ingestion. This route is the slowest route of absorption.

3. Inhalation refers to administration of drugs through the respiratory tract. This route, via sniffing, smoking, or inhaling, is the fastest.

4. Injection involves use of a hypodermic needle to introduce a drug into the muscles, bloodstream, or under the skin.

5. Transdermal introduces a chemical into the body through the skin (e.g., nicotine patches).

6. Suppositories are introduced into the body through the anus or vagina.

E. Drug Interactions 1. Polydrug use, taking several medications, vitamins, recreational drugs, or illegal drugs simultaneously can lead to dangerous health problems.

2. Synergism 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 is when drugs work at the same receptor site so that one drug blocks the action of the other.

4. Inhibition is when the effects of one drug are eliminated or reduced by the presence of another drug.

5. Intolerance occurs when drugs combine in the body to produce extremely uncomfortable reactions.

6. Cross-tolerance is when a person develops physiological tolerance to one drug and shows a similar tolerance to certain other drugs as a result.

Key Terms: neurotransmitter, psychoactive drugs, oral ingestion, inhalation, injection, transdermal, suppositories, receptor sites, polydrug use, synergism, antagonism, inhibition, intolerance, cross-tolerance

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Figures and Tables:

Figure 13.1 The Action of Cocaine at Dopamine Receptors in the Brain, an Example of Psychoactive Drug Action

Figure 13.2 Routes of Drug Administration

Additional Instructor Resources: PPT slides: 1–10; Digital Transparency Masters: Figure 13.1, Figure 13.2

II. Using, Misusing, and Abusing Drugs A. Drug misuse is the use of a drug for a purpose for which it was not intended. Drug abuse is the excessive use of any drug and can lead to addiction.

B. Abuse of Over-the-Counter (OTC) Drugs 1. OTC medications can be abused, with resultant health complications and potential addiction. Some OTC medications are more often subject to misuse and abuse: a. Sleep aids b. Cold medicines (cough syrups and tablets) c. Diet pills C. Nonmedical Use or Abuse of Prescription Drugs 1. The latest data available indicate that over 48 million Americans aged 12 and older have used prescription drugs for nonmedical reasons in their lifetimes.

2. Prescription drug use is particularly common among teenagers and young adults.

3. Prescription drugs that are most commonly abused in the United States fall under three major categories: opioids/narcotics, depressants, and stimulants.

D. College student prescription drug abuse has increased dramatically over the past decade.

1. To learn more about the abuse of painkillers among college students, please see page 411, Student Health Today box.

2. Of particular concern on college campuses is the increased abuse of stimulant drugs, including Adderall and Ritalin.

E. Illicit Drugs 1. Illicit drugs are those drugs that are illegal to possess, produce, or sell.

2. In 2007, an estimated 20.4 million Americans were current illicit drug users. a. Illicit drug users span all age groups, ethnicities, occupations, and socioeconomic groups. To learn more about trends in drug use among racial and ethnic minorities, please see page 412, Health in a Diverse World box.

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F. Illicit drug use among college students has been increasing in recent years.

1. In 2008, the number of college students nationwide who had tried any drug stood at almost 50 percent; over a third had smoked marijuana in the past year, and 20 percent had done so in the past month.

2. College students use drugs for various reasons, although there are some factors that increase the risk of substance abuse. a. Positive expectations b. Genetics and family history c. Substance use in high school d. Mental health problems e. Sorority and fraternity membership f. Stress 3. Avoidance of illicit drugs on campus is commonly based on parental influence, religion or spirituality, student involvement in learning or extracurricular activities, participation in college athletics, and participation in health social networks.

Key Terms: drug misuse, drug abuse Figures and Tables:

Figure 13.3 College Students’ Stated Reasons for Nonmedical Use of ADHD Drugs

Table 13.1 30-Day Drug Use Prevalence, Full-Time College Students vs.

Respondents 1–4 Years beyond High School

Figure 13.4 Reasons College Students Use Illicit Drugs or Controlled Prescription Drugs

Additional Instructor Resources: PPT slides: 11–21; Digital Transparency Masters: Figure 13.3, Table 13.1, Figure 13.4

III. Common Drugs of Abuse A. For general purposes, drugs are divided into the following categories: stimulants, marijuana and other cannabinoids, depressants, hallucinogens, inhalants, and steriods.

B. Stimulants 1. Stimulants increase the activity of the central nervous system (CNS), so the effects generally include increased activity, anxiety, and agitation.

2. Cocaine is described as one of the most powerful naturally occurring stimulants. It binds with receptor sites in the CNS and produces intense pleasure that abates quickly, and the user experiences intense cravings and a strong desire to use it again. a. Cocaine can be snorted, smoked (freebased), or injected. b. The powdered form of cocaine is snorted through the nose, potentially ruining the user’s sense of smell and creating a hole in the septum.

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c. Freebase (cocaine alkaloid) is a form of cocaine for which the hydrochloride salt has been removed from the cocaine powder. d. Crack is a form of cocaine that has been processed using baking soda and water. e. There are many symptoms depending on dosage, some of which include irritability, paranoia, dramatic weight loss, convulsions, irregular heartbeat, and eventual death from overdose.

3. Amphetamines are a large and varied group of synthetic agents that stimulate the CNS. a. Small doses can cause increased alertness, lessen fatigue, and elevate mood, but there are many negative side effects associated with prolonged use and high doses. i. Certain types of amphetamines are used for medicinal purposes.

4. There are several new-generation stimulants, known as methamphetamines. a. Immediate effects of small doses can increase physical activity and alertness, and decrease appetite. b. Large doses of methamphetamine can lead to irritability and anxiety; increased body temperature, heart rate, and blood pressure; and possible death. c. Prolonged use of these drugs can cause psychosis, paranoia, aggression, weight loss, and stroke, as well as fatal lung and kidney damage. d. Methamphetamines can be snorted, smoked, injected, or orally ingested. i. Users of methamphetamines often experience tolerance immediately, making it a highly addictive drug from the first time it is used. ii. Abuse of methamphetamine is becoming an increasingly serious problem, exacerbated by how easy it is to make.

5. Caffeine is the most popular and widely consumed drug in the United States. a. Almost half of Americans drink coffee everyday, mainly for its well-known “wake up” effect. b. Caffeine is derived from the chemical family called xanthines. c. Symptoms of excessive caffeine consumption include chronic insomnia, jitters, irritability, nervousness, anxiety, and involuntary muscles twitches. d. Long-term caffeine use has been suspected of being linked to serious health problems. However, no strong evidence exists to suggest that moderate caffeine use produces harmful effects in nonpregnant people.

C. Marijuana and Other Cannabinoids 1. Marijuana is an illicit drug of choice among Americans. a. The psychoactive substance in marijuana is tetrahydrocannabinol (THC) which determines how powerful a high it will produce. b. Marijuana is generally smoked, either as cigarettes or from a pipe or water pipe. c. The most noticeable effect of use is dilation of the eye’s blood vessels. Users also often experience coughing, dry mouth and throat, increased thirst and appetite, lowered blood pressure, and muscular weakness. d. More intense effects include panic, paranoia, psychosis, and visual hallucinations. i. Marijuana use reduces a driver’s ability to react and make quick decisions, contributing to motor vehicle accidents. The perceptual and other performance impairments can persist for some time after the high subsides. ii Long-term effects of marijuana have been investigated in other countries and show damage similar to cigarette smoking.

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iii. Marijuana does have several potential medical uses, including relief of some effects produced by chemotherapy, and alleviation of some symptoms of multiple sclerosis, glaucoma, and AIDS-wasting syndrome.

D. Depressants 1. Drugs classified as depressants slow neuromuscular activity and cause sleepiness or calmness.

2. Opioids, also called narcotics, are all derived from the parent drug opium, which comes from the poppy plant. a. Opioids are powerful CNS depressants. In addition to relieving pain, they lower heart rate, respiration, and blood pressure; cause weakness, dizziness, nausea, vomiting, euphoria; decrease sex drive; cause visual disturbances; and cause lack of coordination.

3. Heroin and black tar heroin are illegal opioids. a. Heroin is a depressant that produces drowsiness and a dreamy, mentally slow feeling. It can cause drastic mood swings, slow respiration and urinary output, and constricted pupils. b. The most common route of administration is “mainlining,” or intravenous injection of powdered heroin mixed in a solution. c. Withdrawal symptoms include an intense desire to use, yawning, a runny nose, sweating, crying, sleep disturbance, loss of appetite, irritability, muscle tremors, nausea, abdominal cramps, vomiting, diarrhea, extreme anxiety, elevated blood pressure, and rapid heartbeat and respiration. d. Methadone maintenance is one treatment available for people addicted to heroin, though it is controversial due to the drug’s own potential for addiction.

4. Benzodiazepines and barbiturates are the most common sedative-hypnotic drugs. a. Sedative hypnotics have a synergistic effect when combined with alcohol, another central nervous system depressant. Used together, they can result in respiratory failure and death. b. Rohypnol is a benzodiaepine of concern and is commonly referred to as the “date rape” drug. i. The drug has been added to drinks and given to women in hopes of lowering their inhibitions and facilitating potential sexual conquests. c. Gamma-hydroxybutyrate (GHB) is a central nervous system depressant known to have euphoric, sedative, and anabolic effects. i. GHB has been slipped into drinks without being detected, resulting in loss of memory, unconsciousness, amnesia, and even death. Other side effects include nausea, vomiting, seizures, hallucinations, coma, and respiratory distress.

E. Hallucinogens 1. Hallucinogens are substances capable of creating auditory or visual distortions and heightened states. a. The mixing of sensory messages, such as hearing tastes, is called synesthesia. b. The most widely used hallucinogens are LSD, Ecstacy, mescaline, psilocybin, PCP, and ketamine.

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2. Lysergic acid diethylamide (LSD) is a psychedelic drug, also known as “acid.” The drug is becoming more popular, especially attracting younger users. a. Even in small doses, LSD can produce psychological and physical effects. b. LSD stimulates uterine contractions and can cause premature labor; increased heart rate; elevated blood pressure and temperature; and causes muscle tremors and twitches, sweating, chills, headaches, and nausea. c. Euphoria is common; however, sometimes dysphoria, a sense of evil and foreboding, occurs in many LSD users. d. Although there is no evidence that LSD creates physical dependency, it may cause psychological dependence.

3. Ecstasy is the common street name for the drug methylene-dioxymethamphetamine (MDMA), a synthetic compound with both stimulant and mildly hallucinogenic effects. a. It is one of the most well-known club drugs or “designer drugs.” b. Ecstasy 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. c. Risks associated with ecstasy include inappropriate and/or unintended emotional bonding and a person having a tendency to say things they might feel uncomfortable about later. d. Physical consequences of ecstasy may include extreme jaw clenching, tongue and cheek chewing, short-term memory loss or confusion, increased body temperature as a result of dehydration, heat stroke, and increased heart rate and blood pressure.

4. Mescaline is derived from the peyote cactus and is used legally. a. Mescaline is a powerful hallucinogen and a CNS stimulant.

5. Psilocybin is an active chemical found in a group of mushrooms that when ingested are similar to LSD in physical effects. a. Many mushrooms resemble the psilocybin variety, so those uncertain about what they are doing should refrain from ingesting unknown wild mushrooms.

6. Phencyclidine (PCP) was developed as an anesthetic but was too unpredictable for medical use. a. PCP is a white, crystalline powder often sprinkled onto marijuana cigarettes. b. In small doses, it produces feelings similar to strong CNS depressants. c. Serious side effects may occur with larger doses. These include drastic drops in blood pressure, coma, muscular rigidity, violent outbursts, and possible convulsions and death. Long-term effects of PCP use are unknown.

7. Ketamine, or Special K, in liquid form is used as an anesthetic in some hospitals and veterinary clinics. a. Ketamine is usually dried and ground into a powder for distribution. b. Ketamine’s effects are similar to those of PCP: confusion, agitation, aggression, and a lack of coordination.

F. Inhalants 1. Inhalants are products that are sniffed or inhaled in order to produce highs. a. Inhalants are legal to purchase but dangerous when used incorrectly. They are generally used by young people who cannot afford illicit drugs.

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b. Commonly used products are rubber cement, model glue, paint thinner, lighter fluid, varnish, wax, spot removers, and gasoline, which are usually sniffed (or “huffed”) by users. c. Users experience dizziness, disorientation, impaired coordination, reduced judgment, and slowed reaction times. Overdose can cause unconsciousness and even death within 5 minutes.

2. Amyl nitrite, or sometimes called “poppers” or “rush” is often prescribed to relieve chest pain in heart patients but is misused as an inhalant.

3. Nitrous oxide, or “laughing gas,” is a common dental anesthesia and is used as a propellant chemical in aerosol products, such as whipped topping. a. Effects include euphoria, illusions, and pain relief, but overuse can lead to unconsciousness, coma, and death.

G. Anabolic Steroids 1. Anabolic steroids are artificial forms of male hormone testosterone that promote muscle growth and strength. a. Anabolic steroids produce a state of euphoria, diminished fatigue, and increased bulk and power. b. There are many adverse side effects, including depression, aggressive and violent behavior or “roid rage,” acne, liver tumors, elevated cholesterol levels, hypertension, kidney disease, and immune system disorders.

2. To combat the growing problem of steroid use, Congress passed the Anabolic Steroids Control Act (ASCA) in 1990. a. Penalties for illegal steroid use includes up to five years of imprisonment and a $250,000 fine for the first offense and up to 10 years of imprisonment and a $500,000 fine for subsequent offenses.

Key Terms: stimulants, amphetamines, marijuana, tetrahydrocannabinol (THC), depressants, opioids, opium, endorphins, benzodiazepines, barbiturates, hallucinogens, club drugs, inhalants, anabolic steroids, ergogenic drug Figures and Tables:

Table 13.2 Drugs of Abuse: Uses and Effects

Figure 13.5 Caffeine Content Comparison

Lecture Launcher Videos: Eliminating Meth, Heroin in Suburbia Additional Instructor Resources: PPT slides: 22–47; Digital Transparency Masters: Table 13.2, Figure 13.5

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IV. Treatment and Recovery A. An estimated 23.1 million Americans aged 12 or older needed treatment for an illicit drug or alcohol problem in 2008. Of these, only 2.3 million, or about 10 percent, received treatment.

1. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. a. Detoxification refers to the early abstinence period during which an addict adjusts physically and cognitively to being free from the substance’s influence.

B. 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 effective, especially for those with more severe problems.

3. 12-Step programs are nonjudgmental and based on the idea that a program’s only purpose is to work on personal recovery.

C. For college students who have developed substance or behavioral addictions, early intervention increases the likelihood of successful treatment, successful sobriety, and completion of a college education.

1. College students’ rehabilitation needs are not that different from other adult recovering addicts, but for best results, the community of addicts should include others of a similar age and educational background.

2. A growing number of colleges and universities offer special services for students who are recovering from alcohol and drug addiction and who want to stay in school without being exposed to excessive drinking or drug use.

Key Terms: detoxification Additional Instructor Resources: PPT slides: 48–49

V. Addressing Drug Misuse and Abuse in the United States A. The economic cost of illegal drug use in the United States is estimated to be about $215 billion per year.

1. This includes the costs of prevention, treatment, health care, lost productivity, crime, and social welfare. In addition, about half of all money used to combat crime is related to illegal drugs.

B. According to the National Survey on Drug Abuse and Health, 73 percent of all U.S. workers who use illicit drugs are employed full- or part-time. Drug abuse is reflected in reduced work performance, efficiency, lost productivity, and absenteeism, costing American businesses roughly $128.6 billion in lost productivity alone per year.

1. Many employers have instituted drug testing to counteract the drug epidemic. a. While critics say drug testing violates the rights of employees, many employees are beginning to see drug testing in the workplace as a positive step toward improved safety and productivity.

C. There are several strategies proposed to decrease the drug problem on college campuses.

1. Some strategies include changing student expectations that college is a time to party and experiment with drugs; engaging parents about substance use on campus and encouraging them to continue open communication with their children; identifying 194

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high-risk students through early detection; and providing services, such as treatment programs tailored for students needing recovery and treatment services.

D. There are many possible solutions to the drug problem in the United States, and it is unlikely that any single change is going to end drug use and abuse.

1. Many researchers in the field of drug education agree that a multimodal approach to drug education for young people is best.

2. Harm reduction approaches reduce negative consequences of drug use and incorporate a spectrum of strategies from safer use to managed use to abstinence.

Additional Instructor Resources: PPT slides: 50–52

Additional Chapter Activities Points of View Medical Marijuana: Too Legal or Not Legal Enough? on page 420 of your textbook.

Currently 31 states and the District of Columbia have laws that recognize marijuana’s medical value.

Eight states have symbolic laws that recognize marijuana’s medical value but fail to protect patients from arrest for possession of an illegal drug.

Voters in 14 states have chosen to legalize marijuana for medicinal use. These new state laws conflict with federal laws against the possession of marijuana and have led to new, yet unresolved, battles in court.

In Class Activity: Have students read this Points of View box in class. Then have them write a short essay about their perspective on the legalization of marijuana. Next, have students exchange their essay with another student. In this exchange, have students take on the opposing view of whatever was written in the essay (even if this is not actually their own view), and write a respectful, educated counter argument to the essay. Have students retrieve their papers and blend the two essays to find an argument or position that is a moderate combination of both perspectives.

Synthesis: Have a classroom discussion with students about the exercise. What did they learn? How did they come to a moderate position? What was it like to be required to consider a moderate position? How has their view changed, or has it changed at all? Why or why not?

Close the synthesis discussion by having students discuss the “Where Do You Stand” questions provided in the Points of View box.

Discussion Questions 1. What are some examples in each of the six categories of drugs?

2. Consider the history of cocaine. 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?

3. Provide some examples of synergistic effects of drugs. What physiological dangers might be involved with synergistic drug reactions?

4. Describe reasons why treatment for heroin addiction has not been very successful.

5. What population group do you think is most at risk for abusing OTC drugs? Justify your answer.

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6. What is behind the popularity of club drugs? Why do you think college students are more likely to mix alcohol and club drugs?

7. What are the most popular drugs on college campuses and why?

8. Critics say that drug testing in the workplace is a violation of individual rights. Do you agree with this statement? Justify your answer.

Critical Thinking Questions 1. Do you think marijuana should be legalized? If so, do you think that all illicit drugs should be legalized? Why or why not? Why do you think some people consider marijuana different from other drugs?

2. Do you think legalization of illicit drugs would decrease the drug problem in the United States? Why or why not? Provide two clear examples to support your answer.

3. From your perspective, what are the most popular drugs abused on your college campus?

How might your college address drug abuse? How could individual students get involved? What would motivate students to get involved in addressing drug abuse? Why is this important?

4. Is drug use prevalent on your campus? How do you know? How are student perceptions of drug use influenced by rumor, media, gossip, and truth?

5. What policies should an administration have in place to prevent/control drug use on campus? How should the administration involve students in prevention and control of drug abuse on campus?

6. At what age should drug education begin? What harms could be involved in telling kids about drugs? How could drug education counter this harm if there is any harm?

Student Activities Individual 1. Write ten things you would tell an incoming freshman about avoiding drug use in college.

2. Make a list of all of the over-the-counter 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 they are not available to children or other possible users?

Community 1. Is medical marijuana available in your community? What criteria must a person meet to be able to receive medical marijuana?

2. Talk with one of the health educators on your campus about services offered for students in need of support services for drug addiction. Where are they located and what services are offered?

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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. Compare and contrast illegal drug use in other cultures. Identify countries that have used alternatives to illegalization in order to curb drug use.

Lecture Launcher Video Questions New! Heroin in Suburbia 1. Are you surprised that a drug like heroin is widely available in many American suburbs?

Why or why not? Why do you think many people do not associate a drug like heroin with middle-class America?

2. Why do you think rehab is not always successful for an addict? What do you think is necessary for a person to beat an addiction?

3. What are some possible signs that someone you know might be experimenting with drugs? Name some steps you might take to help someone you know get help with his or her addiction.

Eliminating Meth 1. Do you find the anti-meth ads effective?

2. Are there better ideas to curb meth use than with shock ads?

3. Could this type of ad be effective against other drugs? What might be the drawbacks to using the same format?

Additional References A. M. Arria, K. M. Caldeira, K. E. O’Grady, K. B. Vincent, D. B. 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. A. Herman-Stahl, C. P. Krebs, L. A. Kroutil, and D. C. 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.

L. D. Johnston, P. M. O'Malley, J. G. Bachman, and J. E. Schulenberg, “Monitoring the Future National Survey Results on Drug Use, 1975–2008,” Volume II: College Students and Adults Ages 19–50 (NIH Publication No. 09-7403). Bethesda, MD: National Institute on Drug Abuse. (2009). (Available at: www.monitoringthefuture.org/pubs/monographs/vol2_2008.pdf) S. E. McCabe, B. T. West, and H. 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.

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K. B. Vincent, K. M. Caldeira, K. E. O’Grady, E. D. Wish, and A. 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.

D. A. Yusko, J. F. Buckman, H. 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/Alateen www.al-anon.alateen.org American Academy of Addiction Psychiatry www.aaap.org Center for Substance Abuse Prevention www.prevention.samhsa.gov Center for Substance Abuse Treatment www.csat.samhsa.gov

Additional Media Addiction. Nine Segments.

The link below sends viewers to HBO’s website for the ADDICTION documentary. There, the viewer will find nine different segments on addiction. Examples of segments include, “Saturday Night in a Dallas ER,” “The Science of Relapse,” “A Mother’s Desperation,” and “The Adolescent Addict.” www.hbo.com/addiction/thefilm Marijuana addiction facts for teens video NIDA. 1 minute, 21 seconds.

In this production of the National Institute on Drug Abuse, NIDA scientist Joe Frascella discusses what we know about marijuana. www.youtube.com/watch?v=Bb2_JjdAZ3M&feature=channel NIDA Painkillers: Get Back in the Game – Use Painkillers Safely. 3 minutes.

In this production of the National Institute of Drug Abuse, NIDA scientists Cindy Miner and Joni Rutter discuss the prevalence of illicit use of painkillers amongst adolescents and the health effects of illicit use of prescription painkillers. www.youtube.com/user/NIDANIH#p/a/u/1/w2M3CxmJggs NIDA scientists Ruben Baler talks about the dangers and consequences of steroid abuse. 1 minute, 49 seconds.

In this production of the National Institute of Drug Abuse, NIDA scientist Ruben Baler discusses the negative health effects of steroid abuse. www.youtube.com/user/NIDANIH#p/u/25/z9Ynf2kPNIc 198

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Overview Cancer continues to be the second leading cause of death for all age groups. There are many different types of cancers, each with their own risk factors. It is important that students understand the nomenclature and treatments for cancer so they can make sound decisions for themselves and their loved ones. The primary focus of this chapter, for the student, needs to be related directly to controllable risk factors, such as smoking, fat in the diet, sun exposure, stress, and lack of physical activity. The student also needs to understand the early warning signs for these deadly disease processes in order to prevent disability and death whenever possible.

Learning Objectives 1. Understand what cancer is, how it develops, and its causes.

2. Discuss ways to prevent cancer and the implications of behavioral risks.

3. Describe the different types of cancer and the risks they pose to people at different ages and stages of life.

4. Explain the importance of early detection, self-exams, and medical exams, and understand the symptoms related to different types of cancer.

5. Discuss cancer diagnosis and treatment, including radiotherapy and chemotherapy, and other common methods of detection and treatment.

Lecture Outline I. An Overview of Cancer A. Cancer continues to be the second leading cause of death in the United States, under heart disease.

1. The 5-year survival rates have increased greatly from 50 percent survival rates.

2. Nearly 68 percent of people diagnosed with cancer each year will be alive 5 years after diagnosis.

3. The majority of cancer deaths are from preventable causes (poor nutrition, physical inactivity, and obesity), while other cancers can be prevented through behavioral changes, vaccines, or antibiotics.

Key Terms: 5-year survival rates

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Figures and Tables:

Table 16.1 Trends in 5-Year Relative Survival Rates (%) by Year of Diagnosis, United States, 1975–2005

Additional Instructor Resources: PPT Slides: 1–5; Transparency Masters: Table 16.1

II. What Is Cancer?

A. Cancer is the name given to a large group of diseases characterized by the uncontrolled growth and spread of abnormal cells.

1. This new growth of tissue, serving no physiological function, is called neoplasm. a. This neoplastic mass often forms a clumping of cells known as a tumor. To tell if a tumor is cancerous or not, a biopsy is done to remove some cells and inspect them under a microscope. b. Benign tumors are noncancerous, normal looking cells that are enclosed in a fibrous shell and do not spread. c. Malignant tumors are cancerous, with abnormal looking cells that are not enclosed in a protective capsule and can spread to other organs. i. Metastasis is the spreading of cancer cells to other organs. ii. Cancer cells disturb the DNA and RNA within normal cells, causing mutant cells.

Key Terms: cancer, neoplasm, tumor, malignant, benign, biopsy, metastasis, mutant cells Figures and Tables:

Figure 16.1 Metastasis

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Additional Instructor Resources: PPT slides: 6–8; Digital Transparency Masters: Figure 16.1

III. What Causes Cancer?

A. Many factors are believed to contribute to cancer development.

1. Most research supports the idea that cancer is caused by both hereditary risk and acquired (environmental) risk. a. Heredity risk cannot be modified. Environmental factors are potentially modifiable.

B. Lifetime risk refers to the probability that an individual, over the course of a lifetime will develop cancer or die from it.

1. Relative risk is a measure of the strength of the relationship between risk factors and a particular cancer.

2. Sedentary lifestyle, consumption of alcohol and cigarettes, stress, and consuming a diet high in fat are factors that have been found to play a role in the incidence of cancer.

3. Smoking holds the highest risk for developing cancer. Tobacco is responsible for 1 in 5 deaths annually. a. At least fifteen different cancers, including cancers of the lung, pancreas, bladder, and kidney, and (when combined with alcohol) the larynx, mouth, pharynx, and esophagus are associated with smoking.

4. The evidence linking alcohol to cancer varies by sex, consumption pattern, and other variables. a. Moderate alcohol intake in women appears to increase the risk of several cancers and overall cancer risk. b. Heavy alcohol consumption in men appears to significantly increase risk of pancreatic cancer. c. Regular heavy consumption of alcohol increased the risk of esophageal and liver cancers among men more than sevenfold.

5. Obesity, physical inactivity, and nutrition hold possible links to cancer as well. a. Having a high BMI yields several cancerous conditions among men and women. b. The relative risk of breast cancer in postmenopausal women is 50 percent higher for obese women than for nonobese women, whereas the relative risk of colon cancer in men is 40 percent higher for obese men than for nonobese men.

6. There are several psychological and social factors that contribute to cancer development. a. Stress has been implicated in increased susceptibility to several types of cancers. b. People who suffer chronic severe stress, are lonely, are depressed, and lack social support have been shown to be more susceptible to cancer. i. For more information about the relationship between poverty and health disparities, please see page 532, Health in a Diverse World box.

C. Biological factors of cancer include genetics and gender. Scientists believe that about 5 percent of all cancers are strongly hereditary.

1. Oncogenes are the genes suspected of being cancer causing.

2. Although oncogenes are typically dormant, certain conditions such as age, stress, and exposure to carcinogens, viruses, and radiation may activate them.

3. Certain cancers seem to run in families.

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D. Effects of reproductive factors on breast and cervical cancer have been well documented.

1. Late menarche, early menopause, and not having children later in life have been shown to reduce a women’s risk of breast cancer.

2. Some hormonal therapy has been shown to increase the risk of some cancers.

3. Dietary factors along with others may increase the likelihood of breast cancer.

E. Occupational and environmental hazards are known to cause cancer when exposure levels are high or prolonged.

1. Asbestos is the most widely known occupational carcinogen.

2. There are many other known occupational carcinogens, such as benzene, arsenic, and coal. To explore ways that you can avoid carcinogens in the products you buy and use daily, please see page 533, Be Healthy, Be Green box.

3. Radiation can be a carcinogen. a. Ionizing radiation from X rays, radon, cosmic rays, and ultraviolet radiation is proven to cause human cancer. b. Nonionizing radiation (radiation produced from cell phones, TVs, computer screens) is under debate.

4. Chemicals in food have been implicated as a cause of cancer a. Pesticide and herbicide residue left on plants is an area of concern.

F. Certain infectious diseases have been associated with cancer.

1. Infections are thought to influence cancer development in several ways but most commonly through chronic inflammation, suppression of the immune system, and chronic stimulation.

2. Hepatitis B and C are believed to stimulate cancer cells in the liver due to the inflammation of the liver as a result of HBV and HCV. 3. Cervical cancer has been associated with the human papillomavirus (HPV).

4. Heliocobacter pylori is a potent bacterium that can be found embedded in the stomach lining for approximately 30 to 40 percent of Americans. a. It causes irritation, scarring, and ulcers for 20 percent of those infected and another 5 percent develop stomach cancer.

G. Certain medical factors may contribute to cancer development.

1. Estrogen replacement therapy has been linked to multiple cancer risks.

2. Chemotherapy drugs used to treat one form of cancer can increase the risk of other forms of cancer.

Key Terms: carcinogens, oncogenes

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Table:

Table 16.2 Probability of Developing Invasive Cancers during Selected Age Intervals by Sex, United States, 2004–2006

Additional Instructor Resources: PPT Slides: 9–18;

IV. Types of Cancers A. There are several broad classifications of cancer according to the type of tissue from which the cancer arises.

1. Carcinomas affect the epithelial tissue and metastasize through the circulatory or lymph system. These are the most common and include breast, lung, intestinal, and skin and mouth carcinomas.

2. Sarcomas occur in the mesodermal layer of tissues and metastasize via the blood.

Although less common, these are more virulent. Examples include bone, muscle, and general connective tissue cancers.

3. Lymphomas develop in the lymphatic system and metastasize through the lymphatic system. Hodgkin’s disease is one type of lymphoma.

4. Leukemias occur in the blood-forming parts of the body, such as the bone marrow and spleen. They are nonsolid tumors, and leukemia is characterized by an abnormal increase in white blood cells.

B. Lung cancer is the leading cause of cancer deaths for men and women in the United States and killed an estimated 157,300 people in 2010.

1. Rates have declined slightly in recent decades due to a decrease in smoking and laws against smoking in public places.

2. 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 options.

4. Prevention of lung cancer includes refraining from cigarette smoking or being exposed to environmental tobacco smoke, and decreasing one’s amount of exposure to occupational carcinogens, such as asbestos and arsenic.

C. Breast cancer is the second leading cause of cancer death for women.

1. The earliest signs of breast cancer are generally seen on mammograms, but they are not foolproof. Regular self-examination is important for early detection. a. To learn more about the importance of regular breast self-examination, please see page 538, Gender & Health box.

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2. Warning signals include breast changes such as a lump, thickening or swelling, dimpling, skin irritation, distortion, and nipple pain or discharge.

3. The incidence of breast cancer increases with age, but other risk factors vary.

D. Colon and rectal cancers are the third most commonly diagnosed cancer in men and women, with over 142,570 cases diagnosed in 2010.

1. Being over age 50, being obese, having a family history of colon and rectal cancer, as well as having inflammatory bowel problems, may increase risk. High-fat, low-fiber diets, smoking, sedentary lifestyle, high alcohol consumption, and low intake of fruits and vegetables are associated with increased risk.

2. Early colorectal cancer has no symptoms, but later symptoms include bleeding from the rectum, blood in the stool, and changes in bowel habits.

3. Prevention includes regular exercise, a diet with plenty of fruits and vegetables, a healthy body weight, and alcohol in moderation.

E. Skin cancer is the most common form of cancer in the United States.

1. Long-term effects of sun exposure include the following: a. Skin cancer: It is estimated that 11,790 died of skin cancer in 2010. b. Malignant melanoma: This is a highly virulent cancer that is the most dangerous cancer for American women aged 25 to 29. c. Basal and squamous cell carcinomas, the two most common and curable skin cancers, show up most commonly on the face, ears, neck, arms, hands, and legs as warty bumps, colored spots, or scaly patches.

2. Symptoms include any unusual change in skin condition. Remember the ABCD rule when looking for symptoms of malignant melanoma. They are asymmetry, border irregularity, color, and diameter greater than 6 millimeters.

3. Skin cancer prevention is a matter of limiting exposure to ultraviolet (UV) rays.

4. Those who have fair skin, burn before tanning, experienced severe sunburns during childhood, do not tan easily but spend lots of time outdoors, use no or low-SPF sunscreens, or have previously been treated for skin cancer are at highest risk.

5. Those who tan in the sun or by artificial means may experience a short “high” due to the associations between UV light and endorphins. To learn more about the risks associated with using tanning booths and salons, please see page 542, Student Health Today box.

F. Prostate cancer is the second leading cause of cancer death for men, after lung cancer. In 2010, about 217,230 new cases were diagnosed in the United States.

1. Symptoms include weak or interrupted urine flow or difficulty starting and stopping urine flow; feeling the need to urinate frequently; pain or difficulty urinating; blood in the urine; and pain in the lower back, pelvis, or thighs.

2. Every man over age 50 should have an annual digital rectal prostate examination. a. A prostate-specific antigen (PSA) test can screen for prostate cancer, detecting it earlier. b. The 5-year survival rate is almost 99 percent, and the 15-year survival rate is over 76 percent.

3. Age, race, and diet all influence a man’s risk of prostate cancer. a. Increasing one’s intake of fruits and vegetables (particularly those high in lycopene) may lower the risk.

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G. Ovarian cancer, the fifth leading cause of cancer death for women, usually shows nonspecific symptoms until late stages.

1. Symptoms include an enlargement of the abdomen or feeling of bloating in women over age 40, digestive irregularities, unusual amounts of gas or stomachaches, fatigue, pain during intercourse, unexplained weight loss, and unexplained changes in bowel or bladder habits.

2. Ovarian cancer treatment can include surgery (with possible removal of ovaries, fallopian tubes, and uterus), chemotherapy, and radiation therapy.

3. Risk factors include primary relatives with ovarian cancer, family history of breast or colon cancer, absence of childbearing state, and use of fertility drugs.

4. Reducing saturated fat, having children, breast-feeding, and using birth control pills are proposed preventive factors. a. Prevention includes regular annual pelvic exams.

H. Most uterine cancers develop in the endometrium (lining) of the uterus.

1. Cervical cancers occur at the base of the uterus.

2. Pap tests screen for cervical (early-stage) cancer, but not uterine lining cancer.

3. Risk factors for cervical cancer include early age of first intercourse, multiple sex partners, cigarette smoking, and some sexually transmitted infections such as herpes and the human papillomavirus.

4. Warning signs include bleeding outside the normal menstrual period or after menopause or persistent vaginal discharge.

5. Risk factors for endometrial cancer include age, estrogen, never having children, overweight/obesity, a history of other cancers, race (white women are at higher risk), and treatment with tamoxifen for breast cancer.

I. Testicular cancer is one of the most common types of solid tumors found in young males, affecting 8,400 young men in 2010. Males between the ages of 15 and 35 are at greatest risk.

1. The cause is unknown, but risk factors include undescended testicles and genetic influences.

2. Symptoms include a painless enlargement of the testis or an apparent thickening in the testicular tissue.

3. Testicular self-examination is key to early diagnosis. For more information on testicular self-exams, please see page 544, Gender & Health box.

J. Leukemia is a cancer of the blood-forming tissues, which leads to the proliferation of millions of immature white blood cells.

1. Symptoms include fatigue, paleness, weight loss, easy bruising, nosebleeds, hemorrhaging, and repeated infections.

2. Although thought to be a childhood disease, leukemia affects both sexes and all age groups.

3. Leukemia is generally treated with radiation and chemotherapy, but treatments can include bone marrow and stem cell transplants.

K. Lymphomas are a group of cancers of the lymphatic system (Hodgkin’s, non-Hodgkin’s lymphoma).

1. They are among the fastest growing cancers, with 74,030 new cases in 2010.

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2. The cause is unknown, but a weakened immune system is suspected. a. Exposure to HIV, hepatitis C, and Epstein-Barr virus (EBV) increase risk.

3. Treatments for lymphomas vary but generally include chemotherapy and radiotherapy.

Key Terms: malignant melanoma, prostate-specific antigen (PSA), Pap test Figures:

Figure 16.2 Leading Sites of New Cancer Cases and Deaths, 2010 Estimates

Figure 16.3 Types of Skin Cancers

Lecture Launcher Videos: Mammogram Controversy, Tanning Beds Additional Instructor Resources: PPT Slides: 19–40; Digital Transparency Masters: Figure 16.2, Figure 16.3

V. Facing Cancer A. Detecting cancer in early stages can enhance prognosis.

1. Regular checkups and self-exams play an important role in early detection.

2. High-tech medical diagnoses can also help. a. Magnetic resonance imaging (MRI) has replaced exploratory surgery for some cancer patients. b. Computerized axial tomography (CAT) scan uses X rays to examine parts of the body and shows a tumor’s shape and location. c. Prostatic ultrasound uses a rectal probe to look at the prostate.

B. There have been several new advances in cancer treatment.

1. Surgery is still a common treatment.

2. Radiotherapy and chemotherapy are often used in combination with surgery. a. Radiotherapy is the use of radiation to destroy malignant cells and is most effective in treating localized cancer masses. b. Chemotherapy is the use of anticancer drugs to kill cancer cells and is necessary when cancer has spread throughout the body. c. To learn more about other techniques being used in clinical trials or have become available in selected cancer centers throughout the country, please see page 546, Health Headlines box.

3. Before beginning any form of cancer treatment, it is imperative to be a vigilant and vocal consumer. a. For more information on being your own health advocate or an advocate for someone you love, please see page 548, Consumer Health box.

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Key Terms: magnetic resonance imaging (MRI), computerized axial tomography (CAT) scan, radiotherapy, chemotherapy Table:

Table 16.3 Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People

Additional Instructor Resources: PPT slides: 41–45; Digital Transparency Masters: Table 16.3

VI. Cancer Survivors A. Life after cancer is less threatening and isolating than it once was.

1. Cancer support groups, cancer information workshops, and low-cost medical consultation also help the cancer patient to survive better.

2. Survivorship is now viewed much more broadly and is concerned with both years and quality of life that a person experiences post-diagnosis. a. Some suggest that the psychosocial factors, such as quality of life, including spiritual, social, and emotional well-being, are among the most significant and the most in need of study for understanding their influence in cancer survivorship.

Key Terms: survivorship Additional Instructor Resources: PPT slides: 46–47

Additional Chapter Activities Points of View Mammography for Women under Age 50: To Screen or Not to Screen? on page 537 of your textbook.

In Class Activity: Have students read the POV for mammography in class and develop a thoughtful argument in favor of the new mammography standard or opposing this standard.

Arguments should be supported with rational, clear arguments (and may include points from the POV). Break students into groups of 4 or 5, and have them discuss the health benefits and health problems associated with the new standard. Which groups of women are put at risk and which groups of women are protected by this new standard?

Synthesis: Bring the class together and discuss their findings from the small group discussion and writing exercise. Have students discuss how they think this policy would be the same or different if it were a prostate test policy change.

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Discussion Questions 1. What is cancer? How does it spread? What is the difference between malignant and benign tumors?

2. Compare and contrast how occupational factors and social and psychological factors contribute to the cause of cancer. Who bears the greatest burden of psychosocial factors?

What are some things that could be done to reduce cancer risk among those most at risk?

3. Do you think that exposure to passive smoke increases cancer risk? Why or why not?

4. How does the government regulate occupational carcinogens? Do these regulations reach far enough or too far? Support your answer by connecting health and policy examples.

5. How does the media portray tanning? Why are we more willing to take a risk and injure the skin with tanning? What are some alternatives to tanning?

6. If you were diagnosed with a form of cancer, what questions would you ask your health care provider before and during treatment?

Critical Thinking Questions 1. What types of cancers have members of your family experienced? Which are you at risk for?

2. What can you do to reduce your risk of developing cancer? Make a plan and list three behavioral changes you can make this week and sustain long term to reduce your risk for cancer.

3. If you or someone you loved was diagnosed with cancer, how would you go about seeking treatment? Where would you go for information?

4. Do you think that all forms of cancer-causing products, such as cigarettes, should be made illegal in our country? Why or why not?

5. What types of cancer prevention practices do you regularly perform? Do you do selfexams? 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. Make a list of your cancer risks and discuss them with your parents. What is your family history of cancer on your maternal and paternal sides of the family? What behaviors could you modify to reduce your cancer risk?

2. 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.

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Community 1. 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?

2. Do a fundraiser to help raise the money for cancer research or participate in a local or regional cancer fundraising event.

Diverse Population/Nontraditional 1. Compare and contrast social factors as contributors to cancer in the United States and other cultures. Create a list of the main differences.

Lecture Launcher Video Questions New! Mammogram Controversy 1. What is the controversy over when women should start getting mammograms? What dangers are posed for women on both sides of the debate?

2. What stances do breast cancer experts Susan Love and Marisa Weiss take in regard to new mammogram regulations? What pros and cons can you find on either side of the debate?

New! Tanning Beds 1. Why do you think some people become fixated on having a tan? In what ways do you think the media influence our society in terms of why many people feel the need to be tanned?

2. Were you surprised by the answers the tanning salon clerks gave when asked about the risk of tanning beds and cancer? Why or why not? In what ways do tanning beds increase your risk of skin cancer?

3. What do you know about vitamin D? Discuss the myth of getting vitamin D from tanning beds and what Dr. Oz suggests are the best ways to get it.

4. What alternatives can you think of to tanning in a tanning bed? What kinds of products are available today that offer safer ways to get a tan?

Additional References J. D. Burke, I. E. Lofgren, J. S. Morrell, and R. A. Reilly, “College Students Dietary and Lifestyle Practices Compared to Recommendations of the American Institute for Cancer Research and World Cancer Research Fund,” The FASEB Journal, 22, (2008): 886.6.

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 17Year 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.

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.

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A. Jemal, R. Siegel, J. Xu, and E. Ward, “Cancer Statistics, 2010,” CA: A Cancer Journal for Clinicians, 60, (2010): 277–300.

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 Institute for Cancer Research www.aicr.org Centers for Disease Control and Prevention Cancer Statistics www.cdc.gov/nchs/fastats/cancer.htm International Agency for Research on Cancer www.iarc.fr World Cancer Research Fund www.dietandcancerreport.org World Health Organization Cancer www.who.int/cancer/en

Additional Media Effects of Cancer (Cancer #3). 4 minutes.

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

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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 following when applying sunscreen. www.youtube.com/watch?v=Hp_jvEAQGLk Treating Cancer (Cancer #4). 4 minutes.

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

19

Preventing Violence and Abuse

Overview Each of us is faced with working to overcome the preventable causes of injury and death in the United States. Violence accounts for a great deal of our health problems. Whether it is collective violence in the form of bombing of our federal buildings, or individual violence in the forms of shootings in our schools, or abuse of our husbands, wives, and children, violence is a significant problem that has come to national attention. This chapter focuses on the problems of violence in our culture. It gives us data that are important to helping us understand the scope of the problem, as well as clues as to the antecedents of violence, which may help us to prevent it. Chapter 19 also helps us to understand why people stay in situations in which their health and lives may be put at risk. As we move toward a greater understanding of the impact of violence on our culture, we may be able to change our children’s futures in terms of violence in the next century.

Learning Objectives 1. Discuss the various types of intentional injuries and societal and individual factors that contribute to violence in American society.

2. Discuss factors that contribute to homicide, domestic violence, sexual victimization, child and elder abuse, gang violence, and terrorism.

3. Discuss strategies to prevent intentional injuries and reduce their risk of occurrence.

4. Explain potential risks of violence to students on campus and potential strategies that campus leaders, law enforcement officials, and individuals can develop to protect themselves and prevent others from becoming victims.

Lecture Outline I. Preventing Violence and Abuse A. Today violence is pervasive and takes all forms.

1. The WHO defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”

2. Emotional and psychological forms of violence can be as devastating as physical blows to the body.

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B. Intentional injuries are those committed with intent to harm including assaults, homicides, and self-directed injuries.

C. Unintended injuries are those committed without intent to harm.

1. To learn more about unintended injuries, please see the Focus On Your Risk for Unintentional Injuries chapter in your textbook.

Key Terms: violence, intentional injuries, unintentional injuries Additional Instructor Resources: PPT slides: 1–4

II. Violence in the United States A. In the 1980s, the U.S. Public Health Service identified violence as a leading public health problem contributing to significant death and disability.

B. Violent crimes involve force or threat of force and include four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault.

1. According to the FBI, violent crime in the United States decreased 4.4 percent in 2009.

C. Violence on U.S. Campuses 1. College campuses are potential crime areas given the high-stress environment.

2. Relationship violence is one of the most prevalent problems on college campuses. a. About 11 percent of women and 7 percent of men report being emotionally abused in the past 12 months by a significant other. b. Two percent of men and 2 percent of women reported being involved in a physically abusive relationship. c. As many as 20 to 25 percent of college women will be raped or sexually assaulted before they graduate, and 95 percent of these women will never report these crimes. i. For more information about why women are not reporting these crimes, please see page 613, Student Health Today box.

Figure:

Figure 19.1 Declining Crime Rates

Additional Instructor Resources: PPT slides: 5–7; Digital Transparency Masters: Figure 19.1

III. Factors Contributing to Violence A. Causes of violent acts include several social, cultural, and individual factors.

1. Poverty contributes to hopelessness and the use of violence to meet needs.

2. Unemployment is linked to increases in violent crime, suicide, and assault.

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3. Parental influence has an impact on violence. If a child is raised around violence, they are more apt to act out behaviors as adults.

4. Cultural beliefs that objectify women and empower men to be tough and aggressive can lead to violent acts.

5. Discrimination and oppression can make the incidence of hate crimes rise.

6. Religious beliefs and differences can lead people to think violence is justified.

7. Political differences can become triggers for violent acts.

8. Breakdowns in the criminal justice system leading to early release or lenient sentences may encourage violence.

9. People in crisis or under stress are more likely to strike out at others or act irrationally.

10. Heavy use of alcohol and other substances are often catalysts for violence.

B. What Makes Some People Prone to Violence?

1. People who anger easily may become verbally or physically aggressive. a. Primary aggression is goal-directed, hostile self-assertion that is destructive. b. Reactive aggression is a reaction brought about by frustrating life experiences. c. Intermittent explosive disorder (IED) is characterized by repeated episodes of aggressive, violent behavior that are grossly out of proportion to the situation. i. To learn more about (IED) and road rage, please see page 615, Health Headlines box.

2. Substance abuse and violence have been linked. a. Alcohol consumption immediately precedes at least half of all violent crimes. b. Users of illegal drugs commit robberies and assaults more frequently than nonusers. c. In domestic assault, 86 percent of assailants and 42 percent of victims were using alcohol at the time of the attack. d. Alcohol abuse, particularly binge drinking, is associated with physical victimization among males and sexual victimization among females on college and university campuses. i. To learn more about dangers of hazing on college campuses, please see page 614, Student Health Today box.

C. How Much Impact Do the Media Have?

1. The association between violence in the media and the escalation of violence in culture is unclear.

2. A recent study of 1,600 young people aged 10 to 15 indicated that there was a perception of significantly higher levels of shootings, stabbings, assault, robbery, and sexual assault among those who had watched higher amounts of violence in the media.

3. However, according to the National Crime Victimization Survey the violent crime rate declined by 41 percent and the property crime fell by 32 percent over the 10-year period between 1999 to 2008.

4. There has been concern raised that children who spend too much time watching TV or being online may miss the important communication lessons that come from talking with people in person and learning to get along with others.

Key Terms: primary aggression, reactive aggression, intermittent explosive disorder (IED) Additional Instructor Resources: PPT slides: 8–11

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IV. Interpersonal Violence A. Intentional injury can be categorized into three major types: interpersonal violence, collective violence, and self-directed violence.

1. Interpersonal violence includes violence inflicted against one individual by another or a small group of others; homicide, domestic violence, child abuse, elder abuse, and sexual victimization all fit into this category.

B. Homicide is death that results from intent to injure or kill.

1. It is the fifteenth leading cause of death for all age groups but is the second leading cause of death for persons aged 15 to 24.

2. Homicide rates reveal clear differences across races and ages.

3. Rates of homicide in the U.S. are higher than in many other developed nations.

C. Bias-motivated crimes and hate crimes are on the rise due to increased lack of tolerance for diversity.

1. Ethnoviolence is based on prejudice and discrimination and is randomly directed at people with a particular group affiliation, such as religious or ethnic groups.

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

3. Discrimination is the behavioral component, involving actions that deny equal treatment or opportunities to a group of people based on prejudice and bias.

4. Common reasons given to explain bias-related and hate crime include: a. Thrill seeking by multiple offenders through a group attack. b. Feeling threatened that others will take their jobs or property or best them in some way. c. Retaliating for some real or perceived insult or slight. d. Fearing the unknown differences.

5. Nearly 12 percent of all bias-related and hate crimes occur on college campuses.

D. Domestic violence refers to the use of force to control and maintain power over another person in the home environment. It includes both actual harm and the threat of harm.

1. Women are much more likely to become victims of violent acts by spouses, lovers, and exes. This form of domestic violence is known as intimate partner violence (IPV).

2. Women are not the only victims of intimate partner violence. To learn more about issues surrounding male victimization, please see page 620, Gender & Health box.

E. The cycle of violence theory was proposed to explain how women get caught in the downward spiral without knowing what is happening to them. There are three phases of this cycle: 1. Phase one is the tension building phase where minor battering occurs and the woman becomes more nurturing in order to prevent further battering. She assumes guilt for doing something to provoke the abuse.

2. Phase two is the acute battering phase where the abuse is unpredictable and the man beats the woman in order to “teach her a lesson.”

3. Phase three is the remorse/reconciliation phase where the batterer apologizes and the woman downplays the seriousness of the attack while tension builds and the whole cycle starts again.

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F. Domestic violence is associated with alcohol abuse, marital dissatisfaction, differences in communication patterns, and male personality disorders.

G. Child Abuse and Neglect 1. Child abuse refers to the systematic harm of a child by a caregiver, generally a parent.

The effects of child abuse are powerful and long lasting. a. The abuse may be sexual, psychological, physical, or any combination of these.

2. Neglect includes the failure to provide for a child’s basic needs. a. An estimated 1.25 million children (1 out of every 58) experienced maltreatment in one form or another between 2005 and 2006.

3. Not all violence against children is physical. Health can be severely affected by psychological violence as well.

H. Elders Abuse 1. Elder abuse statistics indicate that between 700,000 and 3.5 million older Americans are abused, neglected, or exploited each year.

2. Many victims fail to report because they are embarrassed that a family member is an abuser; they don’t want the abuser to get in trouble or retaliate.

I. Sexual Victimization 1. Sexual victimization includes any situation in which an individual is coerced or forced to comply with another’s sexual acts or overtures.

2. Both men and women are susceptible to sexual victimization, and young people are especially vulnerable.

J. Sexual assault is any act in which one person is sexually intimate with another without that person’s consent.

1. Rape is the most extreme form and is defined as “penetration without the victim’s consent.”

2. Aggravated rape involves more than one attacker, strangers, weapons, or physical beatings.

3. Simple rape is perpetrated by one person, whom the victim knows and does not involve a physical beating or the use of a weapon. a. The National Center for Injury Prevention and Control indicates that 1 in 6 women and 1 in 33 men reported experiencing an attempted or completed rape at some point in their lives. b. Reported cases of rape have declined, perhaps as a result of public awareness, but it may also be due to fear of retaliation if a rape is reported, perception of insufficient evidence, or uncertainty about how to report or if a crime was committed.

4. Acquaintance rape or date rape is not miscommunication; it is an act of violence. a. Most acquaintance rapes happen to women aged 15 to 24 years, and the most likely victim is the 18-year-old new college student.

5. About 12 percent of women currently attending college in the United States have been raped. Over 80 percent of these rapes were committed by an acquaintance, most happened on campus, and alcohol or drugs were commonly involved. a. Congress passed the Campus Sexual Assault Victim’s Bill of Rights (Ramstad Act) in 1992, which, among other rights, gives victims the right to call in off-campus authorities to investigate serious campus crimes.

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6. Marital rape can be defined as any unwanted intercourse of penetration obtained by force, threat of force, or when the spouse is unable to consent. a. Many states still treat marital rape as a lesser crime. b. Women under the age of 25 and those from lower socioeconomic groups are at highest risk.

K. 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.

1. The most frequent abusers are a child’s parent or a parent’s companion or spouse.

2. People who were abused as children bear spiritual, psychological, or physical scars, and studies have shown that child sexual abuse has a negative impact on later life.

L. Sexual harassment is defined as any form of unwanted sexual conduct that is related to any condition of employment or evaluation of performance.

1. Sexual harassment can include unwanted touching, unwarranted sex-related comments, deliberate or repeated humiliation or intimidation based on sex, sexually explicit comments, or spreading rumors about a person’s sexuality.

2. Harassment can happen between peers, with persons in power, and between men and women or members of the same gender.

3. Many schools and companies enforce strict sexual harassment policies.

4. If you feel you are being harassed, the most important thing you can do is to be assertive to ensure that it will not be repeated. a. Tell the harasser to stop. b. Document the harassment. c. Try to make sure you aren’t alone in the harasser’s presence. d. Complain to a higher authority. e. Remember that you have not done anything wrong.

M. Stalking is conduct directed at a specific person that involves repeated visual or physical proximity, features nonconsensual written or verbal communication, and may imply threats.

1. The most common form of stalking occurs following the termination of a romantic relationship.

2. Cyberstalkers use modern technology to stalk a person with cell phones and circumvent computer security measures. a. For information on how to remain safe when using social networking sites, please see page 624, Consumer Health box.

3. Researchers suggest several reasons for stalking: a. Stalkers may have deficits in social skills. b. They are young and have not yet learned how to deal with complex social relationships and situations. c. They may not realize that their behavior is stalking. d. They have a flexible schedule and free time. e. They are not accountable to authority figures for their daily activities.

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N. Emotional and psychological abuse is a common form of violence between intimate partners.

1. This abuse often takes the form of constant criticisms, personal verbal attacks, displays of explosive anger meant to intimidate, and controlling behavior.

2. Emotional abuse often accompanies physical or sexual coercion.

O. Social Contributors to Sexual Violence 1. Common assumptions in our society prevent the recognition by both perpetrator and the wider public about the true nature of assault. a. Sexual assault crimes are often minimized, even though research indicates that 1 in 6 women have been victims of sexual assault in the United States. b. Sexual assault on women is still trivialized with jokes and banter. c. Many people still “blame the victim” by assuming that he or she did something to provoke the attack. d. People assume that “boys will be boys”—men cannot control themselves and once men “start” they cannot “stop.” e. Media implications that when a woman says “no” she wants to be seduced has men believing that women don’t mean no when they say no. f. Dates in which the male makes all the decisions, pays for everything, and generally controls the entire situation are more likely to end in an aggressive sexual scenario.

Key Terms: interpersonal violence, homicide, hate crime, ethnoviolence, prejudice, discrimination, domestic violence, intimate partner violence (IPV), child abuse, neglect, sexual assault, rape, aggravated rape, simple rape, sexual abuse of children, sexual harassment, stalking Figures and Tables:

Table 19.1 Per Capita Homicide Rates in Selected Nations

Figure 19.2 Homicide in the United States

by Weapon Type, 1976–2005

Figure 19.3 Bias-Motivated Crimes, 2008, Breakdown by Bias

Figure 19.4 Child Maltreatment Rates by Age, 2007 286

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Lecture Launcher Video: Date Rape Drug Additional Instructor Resources: PPT slides: 12–37; Digital Transparency Masters: Table 19.1, Figure 19.2, Figure 19.3, Figure 19.4

VI. Collective Violence A. Collective violence is violence perpetrated by groups and includes political parties, militia, and governmental violence; religious or cultural clashes; national or international violence; mobs; riots; and other group against group violence.

1. Gang violence and terrorists threats are two forms of collective violence that have surfaced as major threats in recent years.

B. Gang violence is pervading all cities across the United States. What causes people to join gangs?

1. Gangs provide a sense of belonging to a “family.”

2. Gangs provide a means of attaining economic security through criminal activity and other actions.

3. Gang members are usually 12 to 22 years old, and risk factors include low self-esteem, academic problems, low socioeconomic status, alienation from family and society, a history of family violence, and living in a gang-controlled area.

C. Terrorism is the use of unlawful 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.

1. Domestic terrorism is directed against a person’s or group’s own government or population without foreign intervention.

2. International terrorism involves those acting against the government whose terrorist activities are foreign-based, cross national boundaries, or are directed by foreign countries or groups.

3. The CDC and the Department of Homeland Security have programs and services in place to ensure domestic safety.

Key Terms: collective violence, terrorism Additional Instructor Resources: PPT slide: 38

VII. How to Avoid Becoming a Victim of Violence A. Self-Defense against Rape and Personal Assault 1. Assault can occur no matter what preventive actions you take, but commonsense self-defense tactics can lower the risk.

2. Because rape on campus often occurs in social or dating settings, it is important to know ways to avoid and extract yourself from potentially dangerous situations.

3. Be assertive and direct to someone who is getting out of line. Several steps can be taken to show that you are in control: a. Speak in a strong voice, avoiding apologies and excuses. b. Maintain eye contact. c. Stand up straight, act confident, and remain alert. d. If you are attacked, scream “Fire!” rather than just scream.

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B. What to Do If a Rape Occurs 1. Call 9-1-1 if available.

2. Do not bathe, change clothes, douche, clean up, or touch anything the attacker touched in order to preserve evidence.

3. Bring a clean change of clothes to the clinic or hospital.

4. Call a rape assistance hotline for counseling help. a. If a friend is raped, believe him or her and do not ask implicating questions, encourage him or her to see a doctor, report the crime, be there for your friend, and encourage him or her to seek counseling.

Additional Instructor Resources: PPT slides: 39–41

VIII. Campuswide Responses to Violence A. Prevention and Early Response Efforts 1. Newer violence prevention programs include emergency response drills that enable campus police, campus administration, community law enforcement, and emergency medical teams to practice how they would respond in the event of a major threat.

2. Campuses are reviewing the effectiveness of messaging systems including email alerts and text messaging.

3. The REVERSE 9-1-1 system uses database and geographic information system mapping technologies to notify campus policy and community members in the event of problems.

B. Changes in Campus Environment 1. Changes and programs include the installation of call boxes, removal of overgrown shrubbery, stepped up security, and buildings designed with better lighting and security provisions.

C. Campus Law Enforcement 1. Campus law enforcement has changed over the years by increasing numbers of its members and its authority to prosecute student offenders.

2. Campus policy is responsible for emergency responses, general campus environment, traffic and bicycle riders, and other dangers.

Lecture Launcher Video: Hazing Additional Instructor Resources: PPT slides: 42–43

IX. Community Strategies for Preventing Violence A. There are many steps you can take to ensure your personal safety, but it necessary to develop programs to prevent violence and promote safety at the community level.

1. Develop and implement education programs to teach people communication, conflict resolution, and coping skills.

2. Work with individuals to help them develop self-esteem and respect for others.

3. Begin early to provide experiences that help young people to develop self-esteem and self-efficacy.

4. Establish and enforce policies that forbid discrimination on the basis of gender, religious affiliation, race, sexual orientation, marital status, or age.

5. Increase and enrich educational programs for family planning.

6. Improve the built environment to reduce threats to users.

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7. Improve treatment and support for victims.

Additional Instructor Resources: PPT slides: 44–45

Additional Chapter Activities Discussion Questions 1. Discuss what you believe to be the top five societal factors that increase the likelihood of violent acts in the United States.

2. Out of all the factors you listed as societal causes of violence, which seem most prevalent to you? Why? Provide one solution to prevent societal causes of violence at the individual level of prevention and one solution at the community level of prevention.

3. What puts a child at risk for abuse? Is there anything that can be done to prevent or to decrease the amount of child abuse?

4. Why do you think intolerance of differences continues to be a societal problem? What can individuals do to combat intolerance and promote difference?

5. How do advertisements, television shows, and movies portray sexual assault? Cite examples. What are the consequences of this portrayal?

6. How can the use of drugs or alcohol increase the likelihood of date rape?

Critical Thinking Questions 1. While it may be difficult to consider, in what ways do you find yourself being violent or sexually aggressive? How can you reduce the risk of targeting someone with these feelings?

2. What are the common behaviors among college students that could be perceived as offensive to some people? How might you avoid engaging in these behaviors?

3. 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?

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

5. 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 would you do in this situation and what advice might you give?

Student Activities Individual 1. Identify your most vulnerable times for an assault to occur at school, work, and at your residence. Make an action plan to protect yourself.

2. Research self-defense programs available on campus or in your local community. How do these classes help a person to defend him or herself in a potentially violent situation?

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

Share this information with friends and classmates.

2. Contact campus law enforcement and make a list of the violence prevention programs and emergency alert systems in place on your campus.

3. Research the procedures your campus has in place to prevent a tragedy such as 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 Populations/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 those in the United States? What are the major causes of violent crime in these other countries? What are some of the consequences of committing a violent crime in these countries?

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. Explore hate crimes perpetrated against LGBT in your community and the nation. What can you do to help prevent bias-related and hate-motivated crimes?

Lecture Launcher Video Questions New! Date Rape Drug 1. Why do you think a person might hesitate to get involved if they witnessed someone putting a suspicious substance into an unknowing person’s drink? Why is it crucial to speak up?

2. When you are drinking with others, what can you do personally to ensure your safety and the safety of those around you to avoid the date rape drug?

New! Hazing 1. In what ways can hazing be detrimental to one’s health, both physically and mentally?

2. Why do you think some people stood up to the hidden-camera hazers while others did not? What would you do if you witnessed a hazing situation?

3. What can you do in your community to discourage hazing? Can you think of any alternatives to hazing that might be more healthy and constructive ways to join a fraternity or sorority?

Additional References K. L. Chan, M. A. Straus, D. A. Brownridge, A. Tiwari, and W. C. 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.

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

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

G. 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.

E. O. Laumann, S. A. Leitsch, and L. J. 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, G. Guilera, M. Forns, and J. Gomez-Benito, “The Prevalence of Child Sexual Abuse in Community and Student Samples: A Meta-analysis,” Clinical Psychology Review, 29, (2009). 328–338.

I. 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 National Committee for the Prevention of Elder Abuse http://preventelderabuse.org National Sexual Violence Resource Center www.nsvrc.org Prevent Child Abuse America www.preventchildabuse.org Center for Preventing Hate www.preventinghate.org Rape, Abuse, and Incest National Network (RAINN) www.rainn.org Stop the Hate http://stophate.org

Additional Media Cyber Bullying Prevention. 4 minutes.

In this video, cyber bullying is defined, the prevalence of cyber bullying amongst children and adults is examined, and tips on how to break the cyber bullying cycle are provided. http://www.youtube.com/user/KamaronInstitute?feature=pyv&ad=3973362293&kw= cyber%20bullying%20prevention#p/u/0/ck-OIP6nwLo Copyright © 2012 Pearson Education, Inc.

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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 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

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CHAPTER

19A

Focus On Reducing Your Risk of Unintentional Injury

Overview Unintended injuries are a leading cause of death in young adults; however, with a focus on prevention and a few behavior modifications, these injuries can be prevented. Chapter 19A discusses the most common unintended injuries and specific strategies for their prevention.

These commonsense strategies are included as targets for behavior change that can reduce risk in college years and beyond. After reading this chapter, students will have a clear sense of how to prevent unintentional injuries common among leisure activities, such as snowboarding and bicycling, and injuries caused by repetitive motion from employment and sports. Chapter 19A also raises awareness about the risks for hearing loss among young adults and provides tips for reducing these risks today.

Lecture Outline I. Reducing Your Risk of Unintentional Injury A. Although the term unintentional injury might sound academic, most health professionals shy away from the term “accidental injury” because it implies that these injuries occur without individuals having any control over a situation.

B. For adults aged 18 to 44, unintentional injuries are a leading cause of death, killing approximately 45,000 young adults in the prime of life, or 1 in 4 deaths in this age group.

1. Car accidents are responsible for the greatest percentage of unintended injuries and deaths in this age group.

II. Are You at Risk on the Road?

A. According to the National Highway Traffic Safety Administration, nearly 100 Americans die every day from motor vehicle accidents. Five factors contribute to the majority of motor vehicle accidents—distracted driving, impaired driving, speeding, vehicle safety issues, and driver age.

B. Nearly 8 out of 10 crashes occur within just 3 seconds of a driver becoming distracted.

1. In 2008, 1.4 million crashes were attributed to cell phone use, and texting was responsible for an estimated 200,000 to 1 million crashes.

C. Every day, 32 people in the United States die in a motor vehicle accident that involves an alcohol-impaired driver; this accounts for 1 death every 45 minutes.

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b. Strict law enforcement of existing laws regarding impaired driving and legal drinking age c. Implementation of measures to prevent repeat offenses d. Stricter testing and punishment of those who abuse prescription medication and/or drive when sleep impaired D. Speeding is a factor in 1 out of 3 fatal crashes and leads to more than 13,000 deaths each year.

E. Failure to wear a safety belt increases your risk of a motor vehicle injury and death.

1. Cars today are equipped with several advanced safety features. Look for the following features when purchasing your next car: a. Front and side airbags b. Antilock breaks, traction, and stability control c. Impact absorbing crumple zones d. Strengthened passenger compartment side walls e. Strong roof support F. Car crashes most often involve teen drivers; the first year of driving is the most risky for accidents.

G. Although you cannot control what other drivers do, you can reduce your risk for injury by practicing the following techniques: a. Don’t manipulate electronic devices while driving, including cell phones. b. Don’t drink and drive and always select a sober designated driver. c. Don’t drive when tired or when in a highly emotional or stressed state. d. Surround your car with a safety bubble and keep the bumper of the car ahead of you at least 3 seconds away. e. Scan the road ahead of you and to both sides. f. Drive with your low beam headlights on day and night. g. Anticipate the actions of other drivers as much as possible. h. Obey traffic laws. i. Always wear a seat belt, as a driver and as a passenger.

Key Terms: unintentional injury Additional Instructor Resources: PPT slides: 1–7

III. Can You Play It Safe and Still Have Fun? A. Following bike safety rules is important as 63 million Americans of all ages ride bicycles for transportation, recreation, and fitness, and about 700 to 750 of deaths per year are cycling related.

1. All cyclists should wear a properly fitted bicycle helmet every time they ride; however, fewer than half of all college students report wearing a helmet while riding.

2. Cyclists should consider the following suggestions: a. Wear an approved helmet. b. Watch the road and listen to traffic. c. Don’t drink and ride. d. Follow all traffic laws, signs, and signals. e. Ride with the flow of traffic.

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f. Wear light or brightly colored clothing. g. Avoid riding after dark, and if you must ride after dark, wear highly reflective clothing. h. Know and use proper hand signals. i. Keep your bicycle in good working condition. j. Use bike paths whenever possible. k. Stop at stop lights and traffic lights.

B. According to the U.S. Consumer Product Safety Commission (CPSC), approximately 26,000 people are treated in hospital emergency rooms each year with skateboard-related injuries.

1. Three factors commonly contribute to skateboard injuries: a. Lack of protective equipment b. Poor board maintenance c. Irregular riding surfaces 2. Consider the following skateboard safety tips: a. Wear an approved helmet, padded clothes, and other skateboard safety gear. b. Maintain your board and check regularly for loose, broken, or sharp parts. c. Examine the surface where you’ll be riding for holes, bumps, and debris. d. Never skateboard in the street. e. Never hitch a ride from a car, bicycle, or other motor vehicle. f. Practice complicated stunts in specially designed areas and wear protective padding. g. Practice safe falling—try to relax and roll. h. Don’t drink and ride.

C. Skiing and snowboarding fatality occurs at 3.9 per 1 million participants each year, and this is on the decline.

1. Wearing an approved helmet reduces the risk of any head injury by 30 to 50 percent.

D. Drowning is the fourth most common cause of accidental death among Americans of all ages, with 1 in 5 of those deaths occurring in children aged 14 and younger.

1. Males are nearly four times more likely than females to die of unintentional drowning.

2. Alcohol plays a significant role in many fatal drownings, as about half involve alcohol.

3. All swimmers should take the following precautions: a. Don’t drink alcohol before or while swimming. b. Don’t enter water without a lifejacket unless you can swim at least 50 feet unassisted. c. Know your limitations. d. Never swim alone. e. Never leave a child unattended. f. Before entering water, check its depth and never dive into shallow water. g. Never swim in a river with a current too swift for relaxed, easy swimming. h. Never swim in muddy, dirty water that obstructs your view of the bottom. i. If caught in a current, swim parallel to the shore.

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j. Learn CPR. E. In 2006, the U.S. Coast Guard received reports of 3,474 injured boaters and 710 deaths; 9 out of 10 of those who drown are not wearing a personal flotation device.

1. The following boating safety tips are recommended by the American Boating Association: a. Share your plans for your outing. b. Check the weather and listen to boating advisories. c. Make sure your boat is sea worthy. d. Make sure you have enough life jackets for all who are on board and that they are easily accessible. e. Carry an emergency radio and cell phone. f. Don’t drink alcohol before you leave and don’t bring alcohol on board.

F. Each year, fireworks cause an estimated 7,000 injuries and often the loss of fingers or hands.

1. The National Council on Fireworks Safety recommends: a. Only use fireworks outdoors in an open area. b. Have plenty of water on hand—either in a hose or bucket. c. When lighting fireworks, light the fuse and step away. d. Never bend over them or throw them. e. Use only commercial fireworks and never homemade fireworks. f. Never tamper with fireworks. g. Never try to relight a “dud” firework. h. Don’t drink and use fireworks.

Key Terms: personal flotation device Figure:

Figure 1 Fitting a Bicycle Helmet

Lecture Launcher Videos: Driven Mad? Additional Instructor Resources: PPT slides: 8–21; Digital Transparency Masters: Figure 1

IV. How Can You Avoid Injuries at Home?

A. Every day in the United States, about 75 people die as a result of unintentional poisoning and another 2,000 are treated in emergency departments.

1. Tips to prevent poisoning include: a. Read and follow all usage and warning labels before taking medication.

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b. Never share or sell prescription drugs. c. Never mix household products together. d. When working with chemicals, wear a protective mask and work in a wellventilated environment. e. Be especially careful with medications, supplements, and alcohol around children.

All such items should be out of sight and locked up. f. Program the national poison control number into your phone: 1.800.222.1222.

2. If you suspect that you have ingested or inhaled a poison or you are with someone who has, dial 9-1-1.

B. About 20 to 30 percent of people who fall suffer moderate to severe injury, such as bruises, fractures, dislocation, or a head injury.

1. The following measures are meant to reduce your risk for falls: a. Leave nothing lying around on the floor and stairs. b. Avoid using small scatter rugs. c. Train your pets to say away from your feet. d. Install slip proof mats, treads, or decals in the shower. e. Use an appropriate step stool or small ladder when reaching for something on a high shelf, cupboard, or closet. f. When using a ladder, make sure it’s stable before climbing and wear protective shoes.

C. In the United States, a residential fire claims a life every 3 hours. On an average day, nine college campuses in the United States will experience fire in a residential structure.

1. Five factors typically contribute to injuries from dormitory fires: a. In more than 50 percent of fire fatalities, victims are intoxicated at the time of the fire. b. Many students do not believe that fire is a risk to them, and they ignore both fire drills and actual fire alarms. c. Building evacuations are delayed because of inadequate fire drills, inability to recall exits routes, etc. d. Smoke alarms and fire alarm systems have not been maintained in working order or have been vandalized. e. Students fail to properly notify the fire department using the 9-1-1 system.

2. To prevent fires, do the following: a. Never smoke in bed and extinguish cigarettes in ashtrays. b. Set lamps away from drapes, linens, and paper. c. Keep hot pads and kitchen cloths away from stove burners. d. Keep candles under control and away from combustibles. e. Avoid overloading electrical circuits. f. Have the proper fire extinguishers ready in case of fire.

3. If a fire breaks out, leave the building immediately. a. First, check the door handle to see if it’s hot. If it is hot, do not open the door. Go out a window or call for help from a window. b. If the door is not hot, open it cautiously.

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D. It is important to learn first aid and CPR. If you witness someone who has collapsed and you cannot detect a pulse, the American Heart Association advises that you call 9-1-1 and then begin chest compressions.

E. About 26 million Americans between the ages of 20 and 69 have hearing loss due to exposure to loud sounds either at work or in leisure activities.

1. In general, noise above 85 dB increases a person’s risk for hearing loss.

2. One of the highest rates of sudden noise-induced hearing loss is among adults aged 20 to 29. a. For more information about protecting your hearing while enjoying your tunes, please see page 645, Student Health Today box.

Key Terms: poison, cardiopulmonary resuscitation (CPR) Figure:

Figure 2 Noise Levels of Various Sounds (dB)

Additional Instructor Resources: PPT slides: 22–25; Digital Transparency Masters: Figure 2

V. How Can You Avoid Injury While Working?

A. Common work injuries include cuts and lacerations, chemical burns, fractures, sprains, strains, and repetitive motion disorders.

1. Low back pain (LBP) is a major cause of pain and disability for people aged 20 to 45 in the United States.

2. Avoid the typical risks for low back pain by following these suggestions: a. Invest in a high-quality, supportive mattress. b. Avoid high-heeled shoes. c. Control your weight. d. Warm up and stretch before exercising or lifting heavy objects. e. When lifting something heavy, use proper form. f. Buy a desk chair with good lumbar support. g. Move your car seat forward so your knees are elevated slightly. h. Exercise regularly and participate in exercises that strengthen the abdominal muscles and stretch the back. i. Downsize your backpack.

B. Maintaining healthy back alignment while sitting is important for preventing aching and stiffness.

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a. Sit comfortably with feet flat on the floor or on a footrest. Knees should be level with your hips. b. Your middle back should be firmly against the back of your chair and the small of your back should also be supported. c. Keep your shoulders relaxed and straight, not rolled or hunched. d. The angle of your elbows should be 90 degrees. e. Ideally you should be looking straight ahead.

C. Repetitive motion disorders (RMDs) refers to a family of painful soft tissue injuries that begin with inflammation and gradually become more disabling.

1. These disorders include carpel tunnel syndrome, bursitis, tendonitis, and ganglion cysts, among others.

2. Carpal tunnel syndrome (CTS) is one of the most common RMDs. a. Symptoms include numbness, tingling, and pain in fingers and hands. b. Physical and occupational therapy is an important part of treatment and recovery.

Key Terms: repetitive motion disorder (RMD), carpal tunnel syndrome Figures:

Figure 3 Lifting a Heavy Object

Figure 4 Carpal Tunnel Syndrome

Additional Instructor Resources: PPT slides: 26–28; Digital Transparency Masters: Figure 3, Figure 4

VI. Are You Prepared for Environmental Events?

A. A natural disaster is any extreme environmental event that causes widespread destruction of land and/or property, injuries, and sometimes deaths.

B. It is important to take the time to learn about the different types of natural disasters and prepare for them.

Key Terms: natural disaster Additional Instructor Resources: PPT slides: 29–30

Additional Chapter Activities Discussion Questions 1. What are three ways to avoid unintended car accidents? What behaviors might you need to modify personally in order to reduce your risk for car accidents?

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2. Why is helmet use so important when bicycling, skateboarding, skiing, and snowboarding? In which of these sports are individuals least likely to use a helmet? Why? What should be done to promote helmet use in these cases?

3. What are the factors that typically contribute to injuries from dormitory fires? What can you do to prevent each of these factors in your living situation?

4. Imagine that you are at a party and a man has collapsed and you cannot detect his pulse.

What do you do?

5. Why are young adults experiencing higher rates of hearing loss? What can you do to protect your hearing?

Critical Thinking Questions 1. What behaviors are putting college students at risk for low back pain? What are four things you can do today to protect yourself from low back pain in the future?

2. What are repetitive motion disorders? Describe the causes of these disorders and provide three strategies for avoiding them.

3. Which levels of noise, listed in Figure 2, are you most likely to be exposed to? What can you do to reduce your exposure to these noise levels? Are there specific populations who might be more likely to be exposed to some levels of noise compared to others? Who and why?

4. Why do you think the elderly are most likely to be stigmatized for hearing loss when so many young adults are reporting significant hearing loss?

5. What are the five strategies for maintaining your alignment while sitting?

Student Activities Individual 1. Do an Internet search for attractive, approved helmets available for bicycling, snowboarding, skateboarding, and skiing.

2. Do an internet search to determine where and when a CPR course is offered near your campus and enroll.

3. Load your backpack or messenger bag for the day and then place the bag on a scale. How much does your bag weigh? If it is over 15 pounds, what can you remove to protect yourself from damage to your back?

Community 1. Work with your campus peer health education organization to develop a pro-helmet campaign on campus.

2. Develop and implement a hearing awareness campaign on campus or in your campus residence to raise awareness of the risks posed by MP3 players.

Diverse Populations/Nontraditional 1. Search online for the CDC Workers Health Chartbook to investigate how individuals of varying racial and ethnic backgrounds experience unintended injuries.

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Lecture Launcher Video Questions New! Driven Mad? 1. What discovery did neuropathologist Dr. Bennet Omalu find in Mike Webster’s brain?

What do his findings suggest about the brains of other deceased football players?

2. The NFL and several manufactures have focused on improving helmet safety and implementing other safety regulations for their players. Can you think of any other precautions the NFL and its players can take, other than those mentioned in the video, that might decrease the prevalence of head injuries in the sport?

3. Would you want to play pro-football now, knowing the long-term consequences of concussions? Support your answer with points from the video.

Additional References J. K. Caird, C. R. Willness, P. Steel, and C. Scialfa, “A Meta-analysis of the Effects of Cell Phones on Driver Performance,” Accident Analysis & Prevention, 40, (2008): 1282–1293.

S. Cramer, J. 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.

S. A. Gyekye and S. Salminen, “Workplace Safety Perceptions and Perceived Organizational Support: Do Supportive Perceptions Influence Safety Perceptions?” International Journal of Occupational Safety and Ergonomics, 13, (2007): 189–200.

D. M. Rempel, P. J. Keir, and J. M. Bach, “Effect of Wrist Posture on Carpal Tunnel Pressure While Typing,” Journal of Orthopedic Research, 26, (2008): 1269–1273.

For Further Information American Red Cross www.redcross.org International Ergonomics Association www.iea.cc National Center for Injury Prevention and Control www.cdc.gov/ncipc National Highway Traffic Safety Administration www.nhtsa.gov National Rifle Association NRA Gun Safety Rules www.nrahq.org/education/guide.asp National Safety Council www.nsc.org United States Department of Labor Occupational Safety & Health Administration http://osha.gov Copyright © 2012 Pearson Education, Inc.

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Additional Media Bike Helmet Safety. 2 minutes.

In this Consumer Reports video, the viewer is taught what to consider when selecting a bicycle helmet for themselves or their child. 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 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. www.youtube.com/user/AmRedCross#p/u/237/exhsd2YhO58 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. www.youtube.com/user/AmRedCross#p/u/240/qCfXyhbbl9c

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CHAPTER

17

Reducing Risks and Coping with Chronic Conditions

Overview Chronic diseases cause a great deal of suffering and contribute to morbidity and mortality annually. Chapter 17 provides students with an overview of the more common chronic diseases that are associated with the higher rates of morbidity in the United States today. A theme that is central to the discussion of the prevention and coping with chronic conditions is the importance of proper nutrition, exercise, rest, and reducing environmental exposures that can work together to reduce students’ risks for developing long-term chronic conditions.

Many of these diseases develop slowly, and some are the result of lifestyle choices.

Learning Objectives 1. Discuss key chronic respiratory diseases, including bronchitis, emphysema, and asthma.

2. Describe the allergic response and complications associated with allergies.

3. Explain common neurological illnesses, including headaches and seizure disorders.

4. Understand the major digestive disorders affecting adults in the United States today.

5. Discuss the effects of various musculoskeletal diseases, including arthritis and low back pain.

Lecture Outline I. Reducing Risks and Coping with Chronic Conditions A. Chronic diseases and conditions often develop over a long period of time and cause progressive damage to human tissues.

1. Often these conditions result in illness and suffering and are not easily cured.

2. A number of these chronic maladies have no known underlying cause, and they are referred to as idiopathic. a. Many college students are facing or dealing with chronic conditions. To learn more about the global threat of chronic disease, please see page 557, Health in a Diverse World box.

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II. Coping with Respiratory Problems A. Lung diseases have become the fourth leading cause of death in the United States.

1. Lung diseases are any disease or disorder in which lung function is impaired, such as dyspnea, either by a single dose or long-term exposure.

2. Major disability can result, and many underlying conditions can lead to hospitalization or death.

B. Chronic obstructive pulmonary diseases (COPDs) include bronchitis and emphysema.

1. About 12 million people in the United States are believed to have COPD. COPDs are mostly preventable, and smokers make up 80 to 90 percent of cases.

2. Occupational exposure to fumes or gases can increase risks. a. For more information about ways in which exposure to household chemicals can be minimized to lessen their effect on COPD, see page 558, Be Healthy, Be Green box.

C. Bronchitis involves inflammation on the bronchial tubes to the point of impaired breathing. It comes in two forms, acute and chronic.

1. Bronchitis sufferers typically have numerous coughing spasms, frequent clearing of the throat, tightness in the chest, and shortness of breath.

2. Inhaling certain chemicals, cigarette smoke, and fumes from hairsprays and many other substances can trigger bronchitis.

3. Most cases of acute bronchitis clear up in a week or two once the source is removed and symptoms are treated.

4. Chronic bronchitis sufferers experience symptoms for at least 3 months of a year for two successive years. This is often undiagnosed and medical care is often sought after lung damage is already severe. a. Nearly 10 million Americans suffer from chronic bronchitis; 33 percent under the age of 45. b. To prevent bronchitis, stop smoking, avoid particulates that trigger bronchitis attacks, and see a doctor early if you have recurrent, regular symptoms.

D. Over 3.8 million Americans suffer from emphysema, with nearly 70 percent of cases occurring in men.

1. Emphysema involves the gradual destruction of the alveoli of the lungs, so affected persons find it difficult to exhale.

2. The exact cause is uncertain, but there is an association with long-term cigarette smoking and environmental air pollution.

3. Those with emphysema can experience intense anxiety and fear. Emphysema is a life-threatening condition. a. Healthy meals, exercise, stress management, adequate rest, and prescribed medications are all a part of coping and fighting emphysema.

E. Asthma is a long-term, chronic inflammatory disorder that blocks airflow in and out of the lungs. It is characterized by attacks of wheezing, difficulty breathing, shortness of breath, and coughing spasms.

1. There are two types: extrinsic (allergic) and intrinsic (non-allergic).

2. Extrinsic is the most common type and is associated with allergic triggers. It tends to run in families and develops in childhood.

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3. Intrinsic asthma may be triggered by anything except an allergy (smoke inhalation, chest infection, stress, laughter, exercise, or cold air). a. It affects an estimated 22 million people in the United States and has become the most common chronic disease of childhood. b. Relaxation techniques seem to help some asthma sufferers. Using medicines and reducing exposure to allergens can also reduce symptoms.

Key Terms: idiopathic, dyspnea, chronic obstructive pulmonary diseases (COPDs), bronchitis, emphysema, alveoli, asthma Figures:

Figure 17.1 Proportion of College Students Diagnosed with or Treated for Chronic Conditions in the Past 12 Months

Figure 17.2 Asthma Is an Inflammation of the Airways within the Lungs

Additional Instructor Resources: PPT slides: 1–12; Digital Transparency Masters: Figure 17.1, Figure 17.2

III. Coping with Allergies A. Allergies are diseases of the immune system that cause an overreaction to substances called allergens or antigens.

1. In some people, the body’s defense system overreacts and develops an overly elaborate protective mechanism against relatively harmless allergens or antigens (hypersensitivity).

2. Once hypersensitivity occurs, the antigens trigger the release of histamines, causing dilation of blood vessels, increased mucous secretions, swelling of tissues, as well as other allergy symptoms. a. Many people have found that immunotherapy treatment (allergy shots) is helpful. b. More than half of all Americans test positive for one or more allergens and at least 50 percent of homes have at least six allergens present.

B. Hay fever, or pollen allergy, is usually considered to be a seasonally-related disease and is common throughout the world.

1. Symptoms include sneezing and itchy, watery eyes and nose. a. Hay fever affects between 10 and 30 percent of all adults and up to 40 percent of children in the United States. b. Avoiding environmental triggers is the best prevention, and shots or antihistamines may provide relief.

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C. Food Allergies 1. A food allergy is an immune response to food and should not be confused with food intolerance, which is an inability to digest a particular food due to problems with physical, hormonal, or biochemical systems in your digestive tract.

2. True allergies are most often triggered by milk, eggs, peanuts, other nuts, soybeans, wheat, fish, and shellfish.

3. Symptoms of food allergies are similar to other forms of allergies and may include swelling of the mouth or esophagus, difficulty breathing, itching, stomach pain, diarrhea, dizziness, and nausea; the reaction can be so severe that the victim goes into shock, with a rapid heart rate and changes in blood pressure. a. Over 200 Americans die each year from food allergies, and another 30,000 or more end up in the emergency room because of their symptoms. b. If you have a food allergy, you can avoid reactions by reading labels, asking questions in restaurants, and knowing exactly what you’re eating.

Key Terms: allergy, histamine, immunotherapy, hay fever Figure:

Figure 17.3 Steps of an Allergic Response

Additional Instructor Resources: PPT slides: 13–15; Digital Transparency Masters: Figure 17.3

IV. Coping with Neurological Disorders A. There are more than 600 disorders that affect the nervous system, and an estimated 50 million Americans are afflicted with them each year. For more information about chronic pain as a unique neurological disorder, see page 563, Health Headlines box.

B. Millions of people see their doctors for headaches each year, and millions more silently put up with the pain or take pain relievers to blunt their symptoms.

1. Tension-type headaches are caused by chemical and neuronal imbalances in the brain and/or tensions in the neck or head. a. Symptoms include mild to moderate pain in the head. These headaches are often episodic and readily treatable. b. Chronic tension headaches are more frequent and are difficult to treat with OTC medications and are the result of physical or psychological problems or depression.

A visit to a health care provider can help determine the underlying cause.

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2. Migraine headaches are believed to be triggered within the brain itself as a result of a complex biochemical and inflammatory process. a. Migraines usually occur on one or both sides of the head and are combined with dizziness, nausea, and a severe intolerance for light and noise. Other symptoms include the sensation of an “aura,” numbness or weakness on one side of the body, or slurred speech. They also appear to run in families. b. Relaxation is only minimally adequate for pain relief of true migraines. Often strong pain relieving prescription drugs are necessary. c. A migraine is also an example of a condition that is more common among members of one gender than another; three times as many women as men suffer from migraines. For more discussion about two other conditions that are unique to women, please see page 565, Gender & Health box.

C. Seizure disorders, including epilepsy, are generally caused by abnormal electrical activity in the brain and are characterized by loss of control of muscular activity and unconsciousness.

1. About half of all seizure cases are of unknown origin. Other causes may include stroke and head injury, illness, poisoning, and heredity.

2. In most cases, people afflicted with seizure disorders can lead normal, seizure-free lives when under medical supervision.

Key Terms: migraine, epilepsy Table:

Table 17.1 Types of Headaches

Lecture Launcher Videos: Med-Free Migraine Relief, Understanding Over-theCounter Painkillers Additional Instructor Resources: PPT slides: 16–24; Digital Transparency Masters: Table 17.1

V. Coping with Digestion-Related Disorders A. More than 95 million people in the United States are suffering from one or more digestive-related disorders.

1. Symptoms can be subtle and there is great variability in the type of treatment and effectiveness of treatment.

B. Two of the most common disorders are lactose intolerance and celiac disease (gluten intolerance).

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C. Inflammatory bowel disease (IBD) is an umbrella term for a group of disorders in which the intestines become inflamed.

1. Adults between the ages of 15 to 35 are the most common victims of this disease.

2. The most common types of IBD are ulcerative colitis (UC) and Crohn’s disease. a. Symptoms of ulcerative colitis include bloody diarrhea, cramps, nausea, sweating, and fever. The cause of colitis remains unknown. Treatment includes increasing fiber intake and taking anti-inflammatory drugs. b. Crohn’s disease is usually diagnosed in men and women in their twenties and thirties and is characterized by intense stomach pain, often in the lower right area, and diarrhea. It is generally managed with carefully monitored diet and medication.

D. Irritable bowel syndrome (IBS) is a condition where nausea, pain, gas, diarrhea attacks, or cramps occur after eating or when there is unusual stress. The cause of IBS is unknown. Stress management, regular activity, and diet can bring IBS under control.

E. Gastroesophageal reflux disease (GERD) is commonly referred to as heartburn or acid reflux.

1. Risk factors include age, diet, alcohol use, obesity, pregnancy, and smoking.

2. Symptoms of GERD include coughing, choking, heartburn, and vomiting; it can lead to bleeding of the stomach or esophagus, ulcers, and cancer.

3. Prevention of GERD is often focused on determining which foods or beverages trigger symptoms and avoiding spicy or fried foods.

Key Terms: inflammatory bowel disease (IBD), ulcerative colitis (UC), Crohn’s disease, irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD) Table:

Table 17.2 Other Modern Maladies

Additional Instructor Resources: PPT slides: 25–30; Digital Transparency Masters: Table 17.2

VI. Coping with Musculoskeletal Diseases A. Over 108 million adults, or 1 in every 2 aged 18 or over, suffered from a musculoskeletal condition lasting longer than 3 months in the past year.

1. More than half of all days of work missed due to a major medical condition are a result of musculoskeletal disease.

2. Sedentary lifestyle and obesity are listed as major contributors to this growing epidemic.

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B. Arthritis is a painful inflammatory disease of the joints and is credited with affecting over 47 million people.

1. With more than 100 different types of arthritis, it accounts for over 30 million lost workdays a year. The cost to the economy was over $282 billion in treatment alone in 2005.

C. Osteoarthritis (OA), also called degenerative joint disease, is a progressive deterioration of the weight-bearing joints and the related bones.

1. Heredity, abnormal use of the joints, diet, age, obesity, and injury are factors in osteoarthritis development.

2. Joint replacement and bone fusion are common surgical repair techniques, though for most people, anti-inflammatory drugs and pain relievers help ease discomfort.

D. Rheumatoid arthritis is an autoimmune disease involving chronic inflammation of the synovial membrane.

1. It is more common among young adults and affects more than 2.1 million Americans.

2. The joints swell and deform, often leaving the victim without the use of their hands and feet.

3. Treatment emphasizes symptom and pain relief and improved functional mobility.

E. Approximately 85 percent of the population will at some point in life injure their back.

1. To learn more about low back pain (LBP) among young adults, please see page 572, Student Health Today box.

2. In the United States, direct and indirect costs (such as lost wages) relating to spinal injuries cost over $200 billion annually.

3. Health experts believe the following factors contribute to low back pain: a. Age: People between the ages of 20 to 45 run the greatest risk of LBP. b. Body Type: People who are very tall, have a high BMI, or have a lanky body type run an increased risk of LBP. c. Posture: Poor posture is one of the greatest contributors to LBP. d. Strength and Fitness: People with LBP tend to have less overall trunk strength than other people. e. Psychological Factors: Depression, apathy, inattentiveness, boredom, emotional upsets, drug abuse, and family and financial problems all heighten risk of LBP. f. Occupational Risk: The type of work you do and the condition you do it in greatly affect risk for LBP. Key Terms: arthritis, osteoarthritis (OA), rheumatoid arthritis, low back pain (LBP)

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Figure:

Figure 17.4 Proportion of Lost Work Days for Persons Aged 18 and Older by Major Medical Condition

Additional Instructor Resources: PPT slides: 31–33; Digital Transparency Masters: Figure 17.4

Additional Chapter Activities Discussion Questions 1. What are some of the major noninfectious chronic conditions affecting Americans today?

What patterns exist in the types of conditions being reported?

2. How would you distinguish between a tension headache and a migraine headache? How would you approach prevention and treatment of each?

3. List common respiratory conditions affecting Americans. Which of these conditions has genetic basis, individual basis, and environmental basis? How many of them are influenced by all three?

4. What is the difference between a food allergy and food intolerance? Why is this distinction important?

5. What are the major disorders of the musculoskeletal system? Describe the difference between osteoarthritis and rheumatoid arthritis.

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?

2. What are the causes of asthma, and how has it affected the quality of life for sufferers?

What are two prevention techniques for an individual diagnosed with asthma?

3. What are the direct and indirect financial impacts on society from low back pain? Brainstorm three ways that you can prevent the development of low back pain.

4. In what ways do people change their lifestyles to prevent chronic conditions? How would you support a friend trying to prevent GERD for example?

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Student Activities Individual 1. Write out your medical family tree. Identify any disorders of family members that might put you at a greater risk for chronic conditions due to genetic links.

Community 1. Visit an Arthritis Foundation exercise class available in your area. Learn ways that arthritis victims can seek relief from their symptoms.

2. Use the Internet to research a disease that runs in your family, such as diabetes or asthma.

List the symptoms, treatment, and prevalence.

Diverse Population/Nontraditional 1. Compare and contrast two ailments listed under Table 17.2, Modern Maladies, in American cultures versus other cultures. What are the main differences?

Lecture Launcher Video Questions New! Understanding Over-the-Counter Painkillers 1. Why is it important to know how painkillers work in the body?

2. When you take a painkiller, do you read the fine print on the bottle? Why is this important? What long-term consequences might follow if you do not?

3. What downsides are linked to the two main categories of painkillers? Do you believe that the potential risks of taking painkillers outweigh the potential benefits? Why or why not?

Med-Free Migraine Relief 1. Can this technique really work? Would you try something like this?

2. The test subjects were not allowed to keep the device, even if it was working for them.

Why? Do you think this is right?

3. In what ways do migraines differ from headaches? How do you know if you have a migraine?

Additional References G. Alves, E. B. Forsaa, K. F. Pedersen, M. D. Gjerstad, and J. P. Larsen, “Epidemiology of Parkinson’s disease,” Journal of Neurobiology, 255, (2008): 18–32.

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.

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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.

R. C. Lawrence et al. “Estimates of the Prevalence of Arthritis and other Rheumatic Conditions in the United States: Part II,” Arthritis & Rheumatism, 58, (2007): 26–35.

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.

For Further Information American Headache Society www.americanheadachesociety.org American Pain Society www.ampainsoc.org Institute of Health and Society Advancing Research in Chronic Disease Epidemiology www.ncl.ac.uk/ihs/research/archepi The Michael J. Fox Foundation for Parkinson’s Research www.michaeljfox.org

Additional Media Is it a Migraine? (Migraine #1). 3 minutes.

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.

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). 4 minutes.

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.

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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Understanding Epilepsy (Epilepsy #1). 3 minutes.

In this illumstream production, Dr. Robert Fisher sheds light on the biological process of seizures and distinguishes epilepsy from seizures. www.youtube.com/watch?v=MNQlq004FkE Understanding Parkinson’s Disease. 3 minutes.

In this illumistream video, Dr. Stephen Silberstein discusses the history of Parkinson’s disease and the current understanding of Parkinson’s disease. www.youtube.com/watch?v=q458IgW-lLk

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CHAPTER

18

Choosing Conventional and Complementary Health Care

Overview Part of our overall health includes becoming educated consumers of the health care system and the products that it dispenses, such as therapies and medications. Chapter 18 defines self care and discusses its importance, as well as when to look for outside help. After reading this chapter, students will understand the importance of knowing what credentials the provider holds, how the provider is funded, and what patients’ rights and responsibilities are when selecting a health care provider. Knowledge about the factors that motivate hospitals and insurance companies will be useful to students when they are faced with making health care choices. This chapter includes a section on managed care, a direction that many insurance companies, health care providers, and employers are taking. This chapter heavily focuses on the importance of students becoming educated consumers and understanding the effects of medications, whether prescribed by their physician or bought in the grocery store. Drug interactions can be dangerous, and so it might be important to understand that certain antibiotics can impair the effectiveness of birth control pills, or an antihistamine can greatly enhance the effects of alcohol through synergism. It is vital for students to know that just because one can buy a drug over the counter does not mean that it is harmless.

Learning Objectives 1. Explain why it is important to be a responsible health care consumer and how to encourage health care consumers to take action.

2. Understand what factors to consider when making health care decisions.

3. Describe and discuss conventional and complementary and alternative health care.

4. Discuss types of health care products and treatments available in conventional and complementary care and their potential benefits and risks.

5. Describe the U.S. health care system in terms of types of insurance; the changing structure of the system; and issues concerning cost, quality, and access to services.

6. Discuss issues facing our health care system today.

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Lecture Outline I. Taking Responsibility for Your Health Care A. Self-Help or Self-Care 1. Self-care consists of knowing your own body and its signals and taking appropriate action to stop the progression of illness and injury or to improve your overall health.

2. Common forms of self-care are as follows: a. Self-diagnosing symptoms or conditions that occur frequently but may not necessitate a physician visit b. Treating symptoms with over-the-counter (OTC) medications c. Conducting breast and testicular self-exams d. Administering first aid for common, uncomplicated injuries e. Checking blood pressure, pulse, and temperature f. Using home pregnancy and ovulation kits g. Using home HIV test kits h. Having periodic cholesterol checks i. Learning from reliable self-help books, tapes, software, websites, and DVDs j. Incorporating relaxation techniques, including meditation, nutrition, rest, and exercise, into daily life B. When to Seek Help 1. A physician should be consulted if you experience any of the following: a. A serious accident or injury b. Sudden or severe chest pains, particularly with difficulty breathing 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 and/or sweats (over 102°F for children and 103°F for adults) e. Tingling sensation in the arm accompanied by slurred speech or impaired thought processes f. Adverse reactions to drugs or insect bites (shortness of breath, severe swelling, and dizziness) g. Unexplained bleeding or loss of body fluid from any body opening h. Unexplained sudden weight loss i. Persistent or recurrent diarrhea or vomiting j. Blue-colored lips, eyelids, or nail beds k. Any lump, swelling, thickness, or sore that does not subside or that grows for over a month l. Any marked change or pain in bowel or bladder habits m. Yellowing of the skin or the whites of the eyes n. Any symptom that is unusual and recurs over time o. Pregnancy

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C. Assessing the qualifications of a physician is an important part of responsible consumerism.

1. Several studies indicate that bedside manner and positive interactions with doctors are key to patient satisfaction.

2. When selecting from a network of providers, make sure you understand your coverage options and consider the following: a. Do they listen to you, respect you, and allow you time to ask questions? b. What professional training and education have they had? Are they board eligible or board certified? c. Affiliation with accredited institutions d. Are they open to complementary or alternative strategies? e. Treatment explanation f. Who will be responsible for your care when the doctor is on vacation or off call? g. Are there professional reviews and information on any lawsuits against them available online?

3. Practice defensive medicine and consider quality of care as well. a. Did your health care provider take a thorough health history and ask for recent updates to your health history? b. Did your health care provider listen to you? c. Did you feel comfortable asking questions? d. Would you feel comfortable seeing the health care provider again?

4. In addition to evaluating your provider, be aware of your rights as a patient. a. Be fully informed of what kind of care is being planned, the risks and benefits, and alternative forms of treatment. b. You should know if the treatment is standard or experimental, and if the treatment is experimental, know everything possible about the study. To learn more about the placebo effect, please see page 583, Student Health Today box. c. You have a right to privacy. d. You have the right to receive care. e. You are entitled to have access to all your medical records and have the right for your records to remain confidential. f. You have the right to seek the opinions of other health care professionals regarding your condition.

Key Terms: defensive medicine Additional Instructor Resources: PPT slides: 1–11

II. Conventional Health Care A. Allopathic medicine is traditional Western medical practice based on scientifically validated methods.

1. What is a currently believed standard may change in the future or may be refuted by alternate studies.

2. Health care providers strive to ensure the quality of care they provide to their patients and one of the ways that they do this is by using evidence-based medicine.

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B. Selecting a medical practitioner is not always easy.

1. A primary care practitioner (PCP) is a medical professional whom you can go to for routine ailments, preventive care, general medical advice, and appropriate referrals.

2. Many allopathic practitioners get additional training in specialties. For more information on specializations in elective surgeries, please see page 584, Consumer Health box.

3. Osteopaths are general practitioners who receive training similar to that of a medical doctor but with special emphasis on the skeletal and muscular systems. An osteopath receives a degree of doctor of osteopathy (DO).

4. An ophthalmologist holds a medical degree and can perform surgery, whereas an optometrist evaluates visual problems but is not a trained physician.

5. Dentists are specialists who diagnose and treat diseases of the teeth, gums, and oral cavity. a. Orthodontists are specialists in the alignment of teeth. b. Oral surgeons perform surgical procedures to correct problems of the mouth, face, and jaw.

6. Nurses are highly trained and strictly regulated health practitioners who administer medication, participate in patient education, and perform many other tasks. a. There are several levels of nurse training. b. Nurse practitioners (NPs) have advanced training through a Master’s program and can conduct diagnostic tests and prescribe medications in some states.

7. Physician assistants (PAs) are licensed to examine and diagnose patients, offer treatment, and write prescriptions. a. Unlike nurse practitioners, they must work under the supervision of a physician.

Key Terms: allopathic medicine, evidence-based practice, primary care practitioner (PCP), osteopath, ophthalmologist, optometrist, dentist, nurse, nurse practitioner (NP), physician assistant (PA) Lecture Launcher Video: Dr. Web’s Credentials Additional Instructor Resources: PPT slides: 12–15

III. Complementary and Alternative Medicine (CAM) A. Complementary and alternative medicine are terms that are often used interchangeably when referring to therapies, but there is an important distinction between them.

1. Complementary medicine is used together with conventional medicine as part of the modern integrative medicine approach.

2. Alternative medicine has traditionally been used in place of conventional medicine.

B. Complementary and alternative therapies incorporate a holistic approach to medicine that focuses on treating the mind and the whole body rather than just an isolated part of the body.

1. The following groups are likely to use or to have used CAM: a. More women than men b. People with higher education levels c. People who have been hospitalized in the past year d. Former smokers (compared with current smokers or those who have never smoked) 270

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e. People with back, neck, head, or joint aches or other painful conditions f. People with gastrointestinal disorders or sleeping problems 2. There is no national training or licensure standard for practitioners of complementary and alternative therapies. a. Each CAM domain has a different set of training standards, guidelines for practice, and licensure procedures.

C. Alternative (whole) medical systems are built on specific systems of theory and practice, and these vary by culture and have evolved from centuries of practice.

1. Traditional Chinese medicine (TCM) emphasizes the proper balance or distribution of qi, or vital energy in health and disease. a. Techniques include acupuncture, herbal medicine, massage and qigong.

2. Ayurveda (Ayurvedic medicine) seeks to integrate and balance the body, mind, and spirit and to restore harmony in the individual. a. The goals of Ayurvedic treatment are to eliminate impurities in the body and reduce symptoms. b. Common treatments include dietary modification and herbal remedies.

3. Homeopathic medicine is an unconventional Western system based on the principle that “like cures like.” a. Homeopathic physicians use herbal medicine, minerals, and chemicals in extremely diluted forms to kill infectious agents or to ward off illness that are caused by more potent forms or doses of the substances.

4. Naturopathic medicine views disease as a manifestation of an alteration in the processes by which the body naturally heals itself. a. Naturopathic physicians emphasize restoring health rather than curing disease and employ an array of healing practices. b. Practices include diet and clinical nutrition, homeopathy, herbal medicine, hydrotherapy, spinal and soft tissues manipulation, physical therapies, light therapy, therapeutic counseling, and pharmacology.

5. As the number of the alternative therapists grows and systems become entwined, so do the number of options available to consumers. Before considering treatments, consult reliable resources to evaluate risks and the scientific basis of claimed benefits.

D. The National Center for Complementary and Alternative Medicine (NCCAM) serves as a clearinghouse for CAM information and has grouped CAM into four domains of practice.

1. Manipulative and body-based practices include methods that are based on manipulation or movement of the body. a. Chiropractic medicine is based on the idea that a life-giving energy flows through the spine by way of the nervous system and that if the spine is partly misaligned or dislocated that force is disrupted. b. Massage therapy is defined as soft tissue manipulation and is used as a means of treating painful conditions. There are many different types of massage therapy. c. Bodywork consists of several forms of exercise including the Feldenkrais method, Rolfing, Shiatsu, and Trager bodywork.

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2. Energy medicine therapies manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. a. Acupuncture describes a family of procedures that involve stimulating anatomical points of the body with a series of precisely placed needles. b. Acupressure is similar to acupuncture, but does not use needles; instead a practitioner applies pressure to the points critical for balancing yin and yang.

3. Mind–body medicine employs a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms. a. Psychoneuroimmunology is defined as the interaction of consciousness, the brain, and the central nervous system and the body’s defense against external infection and internal aberrant cell division.

4. Biologically based practices are among the most controversial domain of CAM therapies and include natural treatments, interventions, and products which often overlap with conventional medicine’s use of dietary supplements. a. Functional foods, or nutraceuticals, are foods or supplements designed to improve some specific aspect of physical or mental functioning and are often included in CAM therapies. b. Common functional foods that have received attention include: antioxidants, plant stanols/sterols, oat fiber, sunflower seeds and oil, soy protein, garlic, ginger, and yogurt.

Key Terms: complementary medicine, alternative medicine, holistic, alternative (whole) medical systems, traditional Chinese medicine (TCM), qi, Ayurveda (Ayurvedic medicine), homeopathic medicine, naturopathic medicine, manipulative and body-based practices, chiropractic medicine, energy medicine, acupuncture, acupressure, mind–body medicine, biologically based practices, nutraceuticals Figures:

Figure 18.1 The 10 Most Common CAM Therapies Among U.S. Adults

Figure 18.2 Diseases and Conditions for Which CAM is Most Frequently Used Among Adults, 2007

Figure 18.3 The Domains of Complementary and Alternative Medicine (CAM)

Additional Instructor Resources: PPT slides: 16–22; Digital Transparency Masters: Figure 18.1, Figure 18.2, Figure 18.3

IV. Choosing Health Products A. There are potential risks associated with ordering prescription drugs from online sources.

To learn more about ordering prescriptions online, please see page 592, Consumer Health box.

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1. There are several common types of prescription drugs. Generic drugs are medications sold under their chemical name rather than under a brand name.

B. Over-the-counter (OTC) drugs are nonprescription substances we use in the course of self-diagnosis and self-medication. The U.S. Food and Drug Administration (FDA) regularly reviews prescription drugs for suitability as OTC drugs.

1. There are several types of OTC drugs. The FDA has developed a standard label that appears on most OTC products providing directions for use, warnings, and other information.

C. Herbal remedies and special supplements have been used for thousands of years and many have been original sources for compounds found in nearly 25 percent of the drugs we use today, including aspirin.

1. However, just because something is natural does not make it safe, and the FDA has warned that certain herbal products can cause specific damage.

D. Although many CAM procedures and products appear promising, be aware that most of them are not currently regulated in the United States as strictly as are food, drugs, and Western medical procedures.

1. While FDA regulations of supplements are being phased in and until other regulations of CAM are in place, it is important to have as much information as possible to make smart decisions when evaluating CAM options.

Key Terms: generic drugs, tinctures Figures and Tables:

Table 18.1 Common Over-the-Counter Drugs, Their Uses, and Potential Side Effects

Figure 18.4 The Over-the-Counter Medicine Label

Figure 18.5 Assessing the Risks and Benefits of CAM Treatments

Table 18.2 Common Herbs and Herbal Supplements: Benefits, Research, and Risks

Table 18.3 Common Nonherbal Supplements: Benefits, Research, and Risks

Figure 18.6 The U.S. Pharmocopela Verified Mark

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Digital Transparency Masters: Table 18.1, Figure 18.4, Figure 18.5, Table 18.2, Table 18.3, Figure 18.6

V. Health Insurance A. The fundamental principal of insurance underwriting is that the cost of health care can be predicted for large populations. This is the principle by which health care premiums are determined.

1. By paying affordable premiums, you may not have to pay catastrophic bills.

2. Many Americans are uninsured or underinsured. a. Over 46 million Americans are uninsured. b. Another 25 million Americans between the ages of 19 and 64 are underinsured. c. College students need to be aware of their insurance status. Approximately 20 percent of college students report not having health insurance.

B. Private Health Insurance 1. Today, private insurance companies employ several mechanisms to control consumers’ use of insurance and limit potential losses. a. Deductibles are front-end payments that you must make to your provider before your company will start to pay for your care. b. Co-payments are set amounts that you pay each time you receive services. c. Coinsurance is the percentage of the bill that you must pay throughout the course of treatment. d. Preexisting condition clauses limit the insurance company’s liability for medical conditions that a consumer had before obtaining insurance coverage. e. Group plans through employers vary.

C. Managed Care 1. Managed care depends on three elements including a network of physicians, hospitals, and other providers; a budget based on estimates of the annual cost of delivering health; and established rules requiring patients to follow the advice of their providers in order for their care to be paid for.

2. Health maintenance organizations (HMOs) are organized health care systems that provide financing and delivery of comprehensive services to an enrolled population for a fixed, prepaid fee.

3. Preferred provider organizations (PPOs) are networks of independent doctors and hospitals that contract to provide care at discounted rates.

4. Point of service (POS) plans provide a more acceptable form of managed care and are among the fastest growing of the managed care plans.

D. Medicare and Medicaid 1. Medicare is a federal social insurance program covering 99 percent of individuals over age 65 and those people who are permanently disabled or have end-stage kidney failure.

2. Medicaid is a federal-state matching funds welfare program for the categorically eligible poor. Each state determines income eligibility and physician payments.

Key Terms: managed care, capitation, diagnosis-related groups (DRGs) Additional Instructor Resources: PPT slides: 34–36

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VI. Issues Facing Today’s Health Care System A. In recent years the numbers of individuals who are underinsured has risen dramatically, and without reform, the rise will likely continue.

1. For an examination of the waste produced by the health care system, please see page 602, Be Healthy, Be Green box.

B. Nearly 18.3 percent of our gross domestic product (GDP) is spent on health care, or about $2 trillion annually.

1. Costs are increasing due to, among other things, excess administrative costs; duplication of services; growth, use, and demand for new diagnostic and treatment technologies; and inappropriate use of services by consumers.

2. Rising costs of health insurance have left many uninsured or underinsured, leaving these people to access care only in the event of a crisis. Emergency care is extraordinarily high.

C. Access to health care is determined by several factors including health insurance, supply of providers and facilities in your area, proximity to care, ability to work the system, and health status.

D. Quality of services is based on education, licensure, certification, accreditation, peer review, and a legal system of malpractice litigation.

1. A newer form of quality measurement uses “outcome” as the main indicator for measuring health care quality. Two measurements used are mortality rates and complication rates of individual practitioners and facilities. a. For more information on guidelines to ensure that you receive the best care possible, please see page 605, Consumer Health box.

Figures:

Figure 18.7 Health Care Spending Per Person, 2008 (in thousands of U.S. dollars)

Figure 18.8 Where Do We Spend Our Health Care Dollars?

Lecture Launcher Video: What Health Care’s Passage Means for You Additional Instructor Resources: PPT slides: 37–44; Digital Transparency Masters: Figure 18.7, Figure 18.8

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Additional Chapter Activities Points of View National Health Care: Is It a Government Responsibility? on page 604 of your textbook.

In Class Activity: Have students read the POV arguments for and against national health insurance. Next, divide the class evenly into two groups and assign one group to develop an argument in favor of national insurance and one group in opposition to national insurance.

Give the groups 8 to 10 minutes to craft thoughtful arguments to support their assigned position. Next, have students debate the pros and cons of national health insurance. You may act as the mediator and ask questions (possible questions are included in the POV, Where Do You Stand? section).

Synthesis: After a thorough debate and exploration of the issue, bring the class back together and debrief the experience. What did students learn? What was difficult? How have their personal positions changed or remained the same? What were their arguments based on?

How is this similar or different than their personal positions? Was it difficult to rein in their emotional reasoning and remain focused on the rationale reasoning?

Discussion Questions 1. Can you think of examples of a placebo effect? Has this happened to you? What are the benefits of the placebo effect? What are the disadvantages?

2. What is the difference between self-care and medical care? Provide three examples of each.

3. What types of things do you look for when you choose a physician? How comfortable are you asking your physician questions regarding your health? How do you prepare for visits with your physician?

4. Where do you stand on the issue of national health insurance? How much responsibility does the government have to provide universal health care? How does this relate to your philosophy on health and health care?

5. What challenges do different segments of the population face when it comes to health care obstacles and options? List three specific subpopulations and three specific challenges that each group may face.

Critical Thinking Questions 1. What type of health care coverage do you have as a college student? What are the benefits and disadvantages? How will you prepare for your insurance needs when you complete college?

2. What actions have you taken to become more responsible for your own health care?

What additional actions can you take?

3. Do you think that extending Medicare coverage to people under the age of 65 would be a good solution to providing health insurance to the uninsured in America? Why or why not?

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4. Have you ever consulted a medical website instead of visiting a health care professional?

If so, why? What was your experience?

5. Discuss the major issues related to health care reform today. Do you think the U.S. government and citizens will ever come to a consensus and improve our health care system? Why or why not?

Student Activities Individual 1. 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?

2. 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 plain, constipation, and stress.

Community 1. What services are offered by your student health center? Do they treat people only affiliated with the college?

2. Ask five of your friends and your parent(s) what they think should be done to improve the health care system in the United States. Compare and contrast their answers. How do your friends’ answers differ from your parents’? What surprised you about the responses?

Diverse Population/Nontraditional 1. What do you know about health care coverage in other cultures? Compare and contrast it to coverage in the United States.

ABC News Lecture Launcher Video Questions New! What Health Care’s Passage Means for You 1. What changes are expected to occur in the first year of President Obama’s health care reform? How do these significant changes affect children, adults, and seniors?

2. By 2014, what other significant changes should we expect to see in terms of health care?

3. What is the price tag attached to the health care reform plan? Do you agree with the way taxes will work to support the new plan? Why or why not?

Dr. Web’s Credentials 1. Would you ever get an online diagnosis of a medical problem?

2. Do you think Web doctors or websites should be held responsible for the outcomes from advice they give?

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3. Why might a person pursue an online consultation rather than make a live visit to a health care provider? Is an online doctor better than none at all?

4. Does your insurance cover this type of consultation? Do you think it should?

Additional Resources 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.

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): 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 International Association for Ayurvedic Healing http://ayurveda-association.com North American Society of Homeopaths www.homeopathy.org

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Additional Media Complementary and Alternative Medicine: Integrating Care for Your health and Wellness (Complmentary/Alternative Medicine: Traditional Chinese). 59 minutes.

In this UCtelevision production, Acupuncturist Beerly Burns of the Osher Center for Integrative Medicine at the University of California at San Francisco discusses traditional Chinese medicine. www.youtube.com/watch?v=9EkwukyMV9o&feature=related Naturopathy vs. Homeopathy. 3 minutes.

In this ihealthtube video, naturopathic doctor Todd Ferguson distinguishes naturopathy from homeopathy. www.youtube.com/watch?v=yMWhaLDR2hU The Basics of Acupuncture: Types of Acupuncture Treatments. 3 minutes.

In this expertvillage production, Certified Chiropractic Physician Dr. Filardo discusses the different forms of acupuncture. www.youtube.com/watch?v=C0eUxjO2VNU&p=47A168F0DB13E5F4&index=9 What Does a Chiropractor Do? What is Chiropractic Care & Treatment? 2 minutes.

In this expertvillage production, Chiropractic Doctor Sean Flaherty provides insight on the philosophy of chiropractic treatment and care. www.youtube.com/watch?v=OFSRD1TdHx8&feature=related

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CHAPTER

20

Preserving and Protecting Your Environment

Overview As our worldwide population grows, the demands placed on the environment are of increasing concern. The United States is among the greatest consumer of natural resources in the world and environmental health has come to the forefront as a major concern for each of us.

Even if we take care of our own health through many of the means we have discussed previously in this text, if we do not have clean water to drink, clean air to breathe, and uncontaminated land on which to grow our crops and animals, we cannot be healthy. Chapter 20 describes in detail many of the problems that our planet is facing. It is of vital importance that students leave this chapter with an increased sense of personal responsibility for behaviors that benefit, as well as behaviors that harm, the environment. It must be understood that individual as well as community behaviors do make a difference.

Learning Objectives 1. Explain the environmental impact associated with the current global population and its projected growth.

2. Discuss major causes of air pollution and the global consequences of the accumulation of greenhouse gases and ozone depletion.

3. Identify sources of water pollution and chemical contaminants often found in water.

4. Explain how municipal solid waste is different from hazardous waste, and list strategies for reducing land pollution.

5. Discuss the health concerns associated with ionizing and nonionizing radiation.

Lecture Outline I. Overpopulation A. Population growth increases the competition for Earth’s resources. At the current rate it is estimated that the world’s population will grow to 9.4 billion by 2050 and 11.5 billion by 2150.

1. The population of the world grows, but Earth’s resources do not. This causes heavy pressure on natural resources to support human life and world health.

2. Humans live far beyond their means and inflict damage on the environment which may already be irreparable.

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B. Bursting with People: Measuring the Impact 1. Changes in our ecosystem are resulting in the destruction of many species, including catastrophic influences on fish populations, and extinction of bird, mammal, and amphibian populations.

2. Chemical and human waste and use are affecting the available food supply.

3. Land degradation and contamination of drinking water may pose serious threats to our existence in the coming years.

4. Use of fossil fuels and excessive energy consumption is depleting nonrenewable resources.

C. Factors That Affect Population Growth 1. High fertility rates lead to rapid increases in overall population in poorer countries and create a significant impact on environmental resources.

2. Mortality rates from chronic and infectious diseases have declined, causing people to live longer and consume more resources over their lifetimes.

D. Different Nations, Different Growth Rates 1. Although the United States makes up only 5 percent of the world’s population, it is responsible for nearly 25 percent of total global resource consumption.

2. China, India, and other regions of the world are becoming major consumers of fossil fuels as they emulate Western lifestyles.

E. Zero Population Growth 1. Total zero population growth is a concept that each couple should only produce two offspring. a. Education can help limit population growth. b. Policies that encourage low birth rates can be effective.

Key Terms: ecosystem, fossil fuels, total fertility rate Figures and Tables:

Figure 20.1 World Population Growth, 1950–2050 (Projected)

Figure 20.2 World Liquid Fuels Consumption by Region and Country Group, 2007 and 2035 (Projected)

Table 20.1 Selected Total Fertility Rates Worldwide, 2010

Additional Instructor Resources: PPT slides: 1–11; Digital Transparency Masters Figure 20.1, Figure 20.2, Table 20.1

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II. Air Pollution A. The presence of substances not found in perfectly clean air is known as air pollution.

1. Air pollutants are either naturally occurring (such as dust from windstorms, smoke and ash from major forest fires, or salt spray from oceans) or anthropogenic (caused by humans, such as emissions from factories, refineries, cars, and airplanes).

B. Components of Air Pollution 1. The Clean Air Act of 1970 was amended in 1977 and 1990, developing standards for six of the most widespread air pollutants that seriously affect health.

C. Photochemical Smog 1. Photochemical smog is a brown, hazy mix of particulates and gases that forms when oxygen-containing compounds of nitrogen and hydrocarbons react in the presence of sunlight.

2. It is sometimes called ozone pollution.

3. Temperature inversion is when a cool layer of air is trapped under a warmer layer, preventing the air from circulating. a. Smog is more likely to be produced in valley regions blocked by hills or mountains—for example, Los Angeles, Denver, and Tokyo.

4. The most noticeable effects are respiratory problems, burning eyes, nausea, and headaches.

5. Air quality can change hourly. The Air Quality Index (AQI), the measure of daily air quality, can keep people aware of associated health concerns. a. The higher the AQI value (from 0 to 500), the greater the level of air pollution and associated health risks will be.

D. Acid Deposition and Acid Rain 1. Acid rain is a term being replaced by a new term, acid deposition, and refers to precipitation that has fallen through acidic air pollutants, particularly those containing sulfur dioxides and nitrogen dioxides.

2. There are several sources of acid rain. a. The single greatest sources of acid rain in the United States are coal-fired power plants, ore smelters, oil refineries, and steel mills.

3. Acidic pollutants are deposited in two ways: a. Wet deposition: Mostly found in the Northern Hemisphere, this type of pollutant is deposited into rain and snow. b. Dry deposition: A common form of pollutant, this type is found in much of Europe and North America and is deposited in gases and particles.

4. There are several detrimental effects of acid rain. a. Millions of trees each year are destroyed by acid rain. b. Acid rain can aggravate and may even cause bronchitis, asthma, and other respiratory problems, as well as is hazardous to unborn children. c. Acidic precipitation can cause metals such as aluminum, cadmium, lead, and mercury to leach out of soil into water and food supplies, potentially causing cancer in the humans who consume them.

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E. Indoor Air Pollution 1. Indoor air pollution can be more hazardous than outdoor air, with potentially 20 to 100 dangerous chemical compounds in the average American home.

2. Factors such as age, medical conditions, sensitivity, room temperature and humidity, and the functioning of certain body systems can affect the risk for being affected by indoor air pollution. a. Health effects may develop over years of exposure. b. The use of green building products and furnishings can help to reduce exposure to indoor air pollution.

3. It is possible that environmental tobacco smoke is the greatest source of indoor air pollution.

4. Home heating can create environmental hazards. a. Wood stoves emit significant levels of particulates and other pollutants.

5. Asbestos is a mineral that was commonly used in insulating materials in buildings constructed before 1970. a. When fibers are inhaled, they embed themselves into the lungs and cannot be expelled, increasing cancer risk and risk of the fatal lung diseases.

6. Formaldehyde is a colorless, strong-smelling gas present in some carpets, draperies, furniture, particle board, plywood, paneling, countertops, and adhesives. a. It is released into the air by a process called offgassing. b. To reduce exposure to formaldehyde, avoid products with it and buy houseplants, such as philodendrons and spider plants, which absorb it.

7. Radon is a gas that is the natural by-product of the decay of uranium and radium in the soil, which can cause cancer. a. Radon is the second leading cause of lung cancer (after smoking). b. The Environmental Protection Agency (EPA) estimates that 8.1 million homes in the United States have elevated radon levels. c. Home testing kits are available through mail order.

8. Lead is a metal pollutant that is found in paint, batteries, drinking water, pipes, dishes with lead-glazed glosses, dirt, soldered cans, and some candies made in Mexico. a. As many as 25 percent of homes in the United States have lead-based paint hazards, and an estimated 250,000 American children aged 1 to 5 have unsafe blood lead levels.

9. Molds are fungi that produce tiny reproductive spores that circulate throughout the air.

Many people are sensitive to or have allergies to molds. a. Cleaning, controlling moisture, and providing proper ventilation can address the problem.

10. Sick building syndrome (SBS) exists when 80 percent of the building’s occupants report health problems. a. Poor ventilation is the primary cause of SBS. b. Symptoms include eye irritation, sore throat, queasiness, and worsened asthma. c. SBS is of concern in schools and workplaces. A significant number of schools in the United States have unsatisfactory air quality.

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F. Ozone Layer Depletion 1. The ozone layer forms a protective stratum in Earth’s stratosphere.

2. The ozone layer protects our planet from UVB radiation, a primary cause of skin cancer.

3. Chlorofluorocarbons (CFCs) are chemicals that deplete the ozone layer. a. They were used in products such as refrigerants, aerosol propellants, cleaning solvents, medical sterilizers, and foam insulation. b. Since 1987, many countries have worked to reduce use of CFCs, which are banned in the United States.

G. Global Warming 1. The greenhouse effect is a natural phenomenon in which greenhouse gases allow solar heat to pass through and then trap that heat close to Earth’s surface.

2. Carbon dioxide (CO2) emissions from activities such as burning fossil fuels create a buildup of greenhouse gases, resulting in the enhanced greenhouse effect in which excess solar heat is trapped, raising the planet’s temperature. a. The surface temperature of the planet has risen by about 1.4 degrees Fahrenheit since 1900, and it is likely that the temperature will continue to rise unless immediate steps are taken. b. A temperature increase may result in rising sea levels, glacier retreat, drought, extreme weather events, loss of biological species, among other catastrophic outcomes. c. Rapid deforestation of the tropical rain forests also contributes to global warming, robbing the world of the capacity to dissipate carbon dioxide.

3. The Kyoto Protocol, which took effect in 2005, requires participating countries to decrease their emissions between 2008 and 2012 by at least 5 percent below 1990 levels. a. The United States, which would be required to reduce emissions by 33 percent, has refused to ratify the treaty due to concerns that large developing nations such as India and China are not required to reduce emissions under the treaty.

H. Reducing Air Pollution and the Threat of Global Warming 1. Reducing air pollution means changing energy, transportation, and industrial practices, and supporting policies that encourage the use of renewable resources like the sun, wind, and water for energy.

2. Many experts believe shifting away from automobiles as the primary source of transportation is the only way to reduce air pollution significantly. a. Increased fees relating to car use and encouragement of alternative commuting methods are being enacted in numerous communities. b. For more information on ways to reduce your own carbon footprint, please see page 662, Be Healthy, Be Green box.

Key Terms: pollutant, photochemical smog, temperature inversion, acid deposition, leach, asbestos, formaldehyde, radon, lead, sick building syndrome (SBS), chlorofluorocarbons (CFCs), greenhouse gases, carbon dioxide (CO2), enhanced greenhouse effect, carbon footprint

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Figures and Tables:

Table 20.2 Sources, Health Effects, and Welfare Effects for Criteria Pollutants

Figure 20.3 Air Quality Index (AQI)

Table 20.3 Health Effects of Indoor Air Pollution

Figure 20.4 The Enhanced Greenhouse Effect

Additional Instructor Resources: PPT slides: 12–24; Digital Transparency Masters: Table 20.2, Figure 20.3, Table 20.3, Figure 20.4

III. Water Pollution and Shortages A. Our drinking water comes from underground water sources or surface freshwater.

1. Only 1 percent of the world’s water supply is available for human use and more than half the global population faces a shortage of potable water.

2. Each U.S. resident uses an average of 1,500 gallons of water daily for all purposes.

B. Water Contamination 1. Any substance that gets into soil can potentially enter the water supply.

2. Contamination can enter waterways by a number of different routes. a. Point source pollutants enter a waterway at a specific point through a pipe, ditch, culvert, or other such conduit. b. Nonpoint source pollutants (runoff and sedimentation) run off or seep into waterways from broad areas of land rather than through a discrete pipe or conduit.

3. Gasoline and petroleum products from leaking underground tanks can be a source of water pollution.

4. Organic solvents designed to dissolve grease and oil can be very toxic.

5. Polychlorinated biphenyls (PCBs) were used for the insulation of high-voltage electrical equipment and also pose potential harm.

6. Dioxins are chlorinated hydrocarbons that are contained in herbicides and produced in some industrial processes. Dioxins are much more toxic than PCBs. 308

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7. Pesticides are chemicals designed to kill insects, rodents, plants, and fungi.

8. Lead in water increases due to acidity that increases water’s ability to leach lead from pipes.

Key Terms: point source pollutants, nonpoint source pollutants, polychlorinated biphenyls (PCBs), dioxins, pesticides Figure:

Figure 20.5 Potential Sources of Groundwater Contamination

Lecture Launcher Video: Which Fish Is Safest to Eat? Additional Instructor Resources: PPT slides: 25–28; Digital Transparency Masters: Figure 20.5

IV. Land Pollution A. Solid Waste 1. Each day, every person in the United States generates about 4.5 pounds of municipal solid waste (MSW).

2. Experts believe that up to 90 percent of trash is recyclable, though we still fall far short of this goal in the United States.

3. Currently 54 percent of solid waste is buried in landfills, which are filling up quickly.

4. Communities, businesses, and individuals can adopt several strategies to control waste, such as source reduction, recycling, composting, and implementing combustion with energy recovery.

B. Hazardous Waste 1. The 1980 Superfund was enacted to provide funds for cleaning up chemical dumpsites that endanger public health and land due to hazardous waste.

2. To date, there are 32,500 potentially hazardous waste sites across the nation.

3. The EPA has taken action to decrease the risks from toxic waste sites, including the development of protective requirements, detection systems, and economic incentives.

Key Terms: municipal solid waste (MSW), hazardous waste, Superfund

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Figures:

Figure 20.6 What’s in Our Trash?

Figure 20.7 How Much Do We Recycle?

Lecture Launcher Video: Crack Those Recycling Codes Additional Instructor Resources: PPT slides: 29–34; Digital Transparency Masters: Figure 20.6, Figure 20.7

V. Radiation A. Nonionizing Radiation 1. Nonionizing radiation, such as radio waves, TV signals, and microwaves, is at the lower end of the electromagnetic spectrum.

2. The effects of nonionizing radiation (electromagnetic fields, or EMFs) are not known. a. To learn more about the findings regarding the radio frequency waves generated by cell phones, please see page 668, Consumer Health box.

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.

2. The three types of radiation are alpha particles (not capable of penetrating human skin, but can pose hazards when inhaled or ingested), beta particles (can penetrate the skin slightly, harmful if ingested or inhaled), and gamma rays (can pass through the skin, may lead to mutations, cancer, miscarriages, etc.).

3. Reactions to radiation absorbed doses (rads) differ from person to person. a. Radiation as low as 100 to 200 rads can produce signs of radiation sickness, whereas doses of 600 to 700 rads cause death.

4. Approximately 50 percent of radiation we are exposed to comes from natural sources, another 48 percent comes from medical and dental X rays, and the remaining 2 percent comes from computer display screens, microwaves, televisions, and so forth.

5. Effects of long-term exposure to relatively low levels of radiation are unknown.

C. Nuclear Power Plants 1. Proponents say that it is a safe and efficient way to produce electricity and that use could help slow global warming.

2. Disadvantages include those listed below. a. Disposing of nuclear waste is problematic. b. There is a chance that a reactor core meltdown (occurs when the temperature in the core of a reactor increases enough to melt both the nuclear fuel and the containment vessel) could occur, known as a nuclear meltdown.

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c. Nuclear accidents continue to pose risks to human health, even in well-controlled settings.

Key Terms: nonionizing radiation, ionizing radiation, radiation absorbed doses (rads), nuclear meltdown Additional Instructor Resources: PPT slides: 35–36

Additional Chapter Activities Points of View Nuclear Power: Is It Worth the Risks? on page 670 of your textbook.

In Class Activity: Have students write for 5 minutes about their position on the use of nuclear power. Then, have them read the POV and related arguments. Now have student re-read their short position statement and make changes (additions or subtractions) based on the information provided in the POV. Break students into groups of 2 and ask them to discuss their statements and positions.

Synthesis: Have a classroom discussion about the pros and cons of nuclear energy use in the United States.

Discussion Questions 1. What are the physical effects of indoor air pollution? What things can be done to reduce these effects? What can you do to contribute to indoor air pollution solutions?

2. Do you believe zero population growth is an answer to the growing population problem?

What strategies would you suggest to address the preference for large families in developing countries?

3. Discuss ways communities are beginning to increase bicycle use instead of automobile transportation. What are your reactions to these policy changes? How have they influenced your transportation choices?

4. Describe four strategies you can personally engage in to reduce environmental pollution and protect your own health. What are some of the challenges you may face when implementing these behavior changes? How can you be prepared for these challenges in order to reach your overall goal of reducing environmental pollution?

5. Discuss the consequences of global warming. How can we emphasize the severity of this problem to the American public? Why does the American public seemingly doubt the effects of global warming and resist the call for change? How can we support positive awareness and change?

Critical Thinking Questions 1. Do you make conscious choices to protect your environment? If not, what can you and your friends do today to change that?

2. How would you and your future be affected if the United States enacted stricter population control measures?

3. What materials do you recycle on a daily basis? What additional materials could you recycle easily? Do you and your family, friends, coworkers, etc. make recycling a part of your daily lives?

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4. 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. Do you believe this situation is possible in the future? If so, what can you, as an individual, do to prevent this hypothetical situation?

5. How can we promote recycling as a way to reduce the amount of waste in landfills?

What are three individual level solutions? What are three policy level solutions that communities or campuses could implement?

Student Activities Individual 1. Keep a diary for two weeks. List everything you have done in your home, your classes, and your place of work that reduced your carbon footprint. 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 wherever possible.

3. Use the website www.niehs.nih.gov 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 that the program is promoted, and find out what percentage of trash is recycled. Volunteer (if possible) to get a firsthand account of how waste is dealt with on your campus.

2. What is the average daily Air Quality Index for your community? What was the highest AQI reported, 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 certain times of the year? If so, when? Find out what the average daily water consumption is on your campus or in your community.

Diverse Population/Nontraditional 1. 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 the United States.

2. Describe how environmental awareness has changed in the past 25 years. Give examples of how consumer products have changed to become more “environmentally friendly.”

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Lecture Launcher Video Questions New! Which Fish Is Safest to Eat? 1. What types of fish have high levels of mercury and should be avoided by children and pregnant women?

2. What types of fish are lower in mercury and are safer to eat?

3. What is the greatest health danger of consuming too much mercury in your diet?

Crack Those Recycling Codes 1. Can you recycle on campus? Do you?

2. Were you aware of the Great Pacific Garbage Patch? In what way do you think it affects the environment? What should be done about it?

Additional Resources M. Bahar, H. Bag, and O. Bozkurt, “Pre-service Science Teachers’ Understanding of an Environmental Issue: Ozone Layer Depletion,” Ekoloji, 18, (2008): 51–58.

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 Inc. www.iaqa.org National Groundwater Association www.ngwa.org National Oceanic and Atmospheric Administration www.noaa.gov

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Resource Conservation and Recovery Act (RCRA) www.epa.gov/epawaste/inforesources/online/index.htm Superfund www.epa.gov/superfund

Additional Media A Breath of Air: What Is Pollution Doing to Our Children. 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 is 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 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 is 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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CHAPTER

21

Preparing for Aging, Death, and Dying

Overview Healthy aging, preventing disease in our later years, and dealing with end of life issues is the focus of this chapter. Chapter 21 outlines the theories on aging and discusses many of the changes that occur as we age. At first glance, this may be disheartening. However, an emphasis on health promotion through disease prevention, and a slowing of the aging process through positive and long-term lifestyle choices will prepare students for a rewarding and healthy life. Healthy aging should be a major focus for students now and in the future. To age healthfully, people need something to do, someone who cares about them, money to live on, and a place to live. Working now to ensure that these things are in place when we are older is of vital importance.

We all lose something or someone who is 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 may die soon. We all have the right to die in our own way. It is important to know about this process. Also, grieving is a normal process that we experience from loss. Many people do not understand the grieving process, and this chapter explains it in detail and provides opportunities to build skills in this area. It is important for students to know all of the legal consequences of living wills, regular wills, and not having a will. Dealing with the legal and emotional details of losing someone important to us will go smoother if we understand what is happening.

Learning Objectives 1. Define aging, and explain the related concepts of biological, psychological, social, legal, and functional age.

2. Explain how the growing population of older adults will impact society, including considerations of economics, health care, living arrangements, and ethical and moral issues.

3. Discuss the biological and psychosocial theories of aging, and summarize major physiological changes that occur as a result of the normal aging process.

4. Discuss unique health challenges faced by older adults, and describe strategies for successful and healthy aging that can begin during young adulthood.

5. Discuss death, the stages of the grieving process, and strategies for coping with death.

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6. Explain the ethical concerns that arise from the concepts of the right to die and rational suicide.

7. 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. Preparing for Aging, Death, and Dying A. Aging has been described as the patterns of life changes that occur in members of all species as they grow older. Some say aging begins at the moment of conception, others say aging begins at the moment of birth, and still others say true aging does not begin until we reach our late forties.

B. Who you are as you age and the manner in which you view aging are important factors in how successfully you will adapt to life’s transitions.

II. Redefining Aging A. Attempts have been made to better understand and define aging.

1. Gerontology is the study of individual and collective aging processes. There are several age-related characteristics used to determine age development. a. Biological age refers to the relative age or condition of the person’s organs and body systems. b. Psychological age refers to a person’s adaptive capacities, such as coping abilities and intelligence, and the person’s awareness of his or her individual capabilities. c. Social age refers to a person’s habits and roles relative to society’s expectations. d. Legal age is based on chronological years and is used to determine such things as voting rights, driving privileges, drinking age, and eligibility for Social Security. e. Functional age refers to the ways in which people compare to others of a similar age.

B. What Is Successful Aging?

1. Avoiding serious, debilitating diseases and disability.

2. Maintaining a high level of physical functioning, living independently, and engaging in most normal activities of daily living.

3. Maintaining cognitive functioning and actively engaging in mentally challenging and stimulating activities.

4. Having sustained or developed an active engagement in social and productive activities.

5. Being resilient and able to cope reasonably well with physical, social, and emotional changes.

6. Having a sense of control over circumstances in life.

7. Aging gracefully takes into account chronological age as well as quality of life, which means the person leads a productive, full, and satisfying life.

Key Terms: aging, gerontology Additional Instructor Resources: PPT slides: 1–5

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III. Older Adults: A Growing Population A. Current life expectancy for a child born in 2007 is 77.9 years.

1. Currently, there are nearly 39 million people 65 or older in the United States, versus 3 million people aged 65 and older in 1900.

2. The WHO predicts that by 2050 the percentage of adults over 60 years old will double to 22 percent.

3. In order to address concerns about an aging population, more health plans are focusing on keeping younger people healthy to avoid later health-related complications.

B. Health Issues for an Aging Society 1. Meeting an older population’s financial and medical needs, providing health care and adequate housing, and addressing end-of-life ethical considerations are all of concern in an aging society.

2. Older Americans average $4,605 per year in out-of-pocket medical expenses, an increase of 57 percent since 1998. a. Living longer increases chances for chronic illnesses, but modern medicine means that some chronic illnesses that may previously have been fatal can now be treated successfully for years. b. Nearly 69 percent of those turning 65 today will need some form of long-term care.

3. Most older people, over 95 percent, never live in a true nursing home. a. Increasing numbers of older adults are remaining in their own homes or are living with relatives or friends. b. Many who can afford it are choosing community living, assisted living, and other living arrangements. c. Housing problems for low-income elderly remain a concern. Who will provide the needed social services and who will pay the bills?

4. There are several ethical and moral issues to consider. a. The shortage of donor organs begs the question of who should receive them. b. Is prolongation of life at all costs a moral imperative? Do we prolong the life of a terminally ill older person for a few weeks by hooking them up to machines, no matter the cost? c. Stem cell research asks us to balance scientific achievements with questions of morality. i. To learn more about the debate over stem cell research, please see page 680, Health Headlines box.

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Figures:

Figure 21.1 Number of Americans 65 and Older (in millions), Years 1900–2008, and Projected 2010–2050

Figure 21.2 Living Arrangements of Americans Aged 65 and Older

Additional Instructor Resources: PPT slides: 6–10; Digital Transparency Masters: Figure 21.1, Figure 21.2

IV. Theories of Aging A. There are common theories about the biological causes of aging.

1. The wear-and-tear theory states that the human body wears out. More abuse causes faster wear.

2. The cellular theory states that at birth we have only a certain number of usable cells, and these cells are programmed to reproduce only a limited number of times.

3. The genetic mutation theory proposes that the number of cells exhibiting unusual or different characteristics increases with age.

4. The autoimmune theory states that aging is due to our declining immunological system.

Additional Instructor Resources: PPT slide: 11

V. Physical and Mental Changes of Aging A. Physical changes of aging vary by person, but certain standard changes tend to occur.

B. The skin becomes thinner and loses elasticity, and fat deposits under the skin tend to diminish.

1. Lines on the face develop during a person’s thirties and forties.

2. Skin begins to lose color and sag during a person’s fifties and sixties, leading to pallor in the seventies.

3. Exposure to the sun tends to increase age spots.

C. By the third or fourth decade of life, bones are losing minerals at a rate greater than accumulation.

1. Loss of calcium in the bones contributes to osteoporosis, making bones susceptible to fracture and potentially causing malformation of the spine. a. Some risk factors for osteoporosis cannot be avoided (being female, older age, body size, and family history). b. Factors that can be controlled include adequate nutrition, particularly consuming enough calcium and vitamin D.

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i. For more information on preventing osteoporosis, please see page 683, Gender & Health box c. Osteoarthritis, a progressive breakdown of joint cartilage, is a leading cause of disability in the United States.

D. With age, the features of the head enlarge and become more noticeable.

1. Head circumference increases, the skull thickens, and the nose and earlobes grow.

E. At age 70, kidneys can filter waste from the blood only half as fast as at age 30.

1. Urinary incontinence can pose many social, physical, and emotional issues for the aging. Treatment includes drug therapy to slow bladder contractions, surgery, and artificial devices to slow urine flow.

F. Resting heart rate remains the same, but stroke volume and vital capacity decrease with age.

1. Exercise is beneficial in preserving heart and lung function.

G. Eyesight worsens and cataracts and glaucoma become more likely.

1. By age 30, the lens of the eye begins to harden, causing problems by the early forties.

2. Cataracts are a clouding of the lens of the eye.

3. Glaucoma is elevated pressure within the eye.

4. Macular degeneration is the breakdown of the light sensitive area of the retina responsible for the sharp, direct vision needed to read or drive.

5. The ability to hear extreme ranges of sound decreases.

6. Many studies have indicated that with age, there is a reduced or changed sensation of pain, vibration, cold, heat, pressure, and touch.

H. Many people continue sexual activity while aging, but some sexual changes do occur.

1. Sexual changes in men include the following: a. The ability to obtain an erection is slowed. b. The ability to maintain an erection is diminished. c. The length of the refractory period between orgasms increases. d. The angle of the erection declines with age. e. The orgasm becomes shorter in duration.

2. Sexual changes in women include the following. a. Hormonal changes occur with menopause. b. The walls of the vagina become less elastic and the epithelium thins, making painful intercourse more likely, however water-based lubricants can help with this. c. Vaginal secretions during sexual activity diminish. d. The breasts decrease in firmness and body contours change.

I. Because of many of the physical changes associated with aging, regulating body temperature is more difficult, making people more likely to develop hypothermia, heat stroke, and heat exhaustion.

J. Given the appropriate time, elderly people learn and develop skills in a similar manner to younger people. What they lack in speed of learning, they make up for in practical knowledge—“wisdom of age.”

1. Short-term memory may fluctuate on a daily basis, but long-term memory usually remains intact.

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2. Memory and mental function may be improved through regular physical activity throughout life, keeping the mind active and engaged, and being involved in social activities.

K. Research indicates that depression may be the most common psychological problem facing older adults. However, the rate of depression is actually lower in older adults than in younger adults.

1. Strong coping skills can help lessen the severity and duration of depression.

L. Correcting underlying issues can often mitigate the effects of memory loss and disorientation often attributed to aging.

1. The terms dementing diseases, or dementias, are used to describe reversible symptoms or progressive forms of brain malfunction.

2. Alzheimer’s disease (AD) is the most common form of dementia, interfering with memory and normal intellectual functioning. a. AD is characterized by memory loss, followed by complete loss of ability to function. The disease currently affects about 5.3 million Americans and is projected to increase to 11 to 16 million individuals by 2050. b. AD is a disease of the brain where the nerve cells stop communicating with each other. It is a slow, progressive disease that may affect a person for 20 years before symptoms are recognized. c. The three stages include memory loss, agitation and restlessness, and complete disorientation, respectively. d. Current research on the cause of AD includes genetic predisposition, malfunction of the immune system, a slow-acting virus, chromosomal or genetic defects, neurotransmitter imbalance, and other possibilities. e. Some researchers believe it is an inflammatory ailment and are looking at the use of anti-inflammatory drugs, and others focus on stimulating the brain to develop more connections among cells to replace those that are lost.

Key Terms: osteoporosis, urinary incontinence, cataracts, glaucoma, macular degeneration, dementias, Alzheimer’s disease (AD) Figure:

Figure 21.3 Normal Effects of Aging on the Body

Lecture Launcher Video: The Science of Growing Old Additional Instructor Resources: PPT slides: 12–18; Digital Transparency Masters: Figure 21.3

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VI. Alcohol and Drug Use and Abuse A. A person who is prone to alcoholism during younger and middle years is more likely to continue during later years.

1. Most older adults who consume alcohol are neither alcoholics nor using alcohol to cope with their losses, but rather are those who drink socially.

B. Older adults rarely use illicit drugs, but some overuse or misuse prescription medications.

1. Older people often take many prescription drugs without being aware of potential interactions. The use of multiple medications is called polypharmacy.

2. To avoid drug interactions and other problems, older adults should use the same pharmacy consistently, ask questions, and read directions carefully.

3. A substantial segment of the over-60 population avoids orthodox medical treatment and views it only as a last resort as Medicare coverage becomes less adequate.

Additional Instructor Resources: PPT slide: 19

VII. Strategies for Healthy Aging A. Factors that prolong life and improve quality of life need to become a part of one’s behavior in younger years, thereby providing for healthier older years.

B. Develop and Maintain Healthy Relationships 1. Developing and maintaining healthy relationships with others lends vigor and energy to life. a. Be willing to give to others and expect little in return. b. Seek variety and diversity in relationships. c. Interact with people with different points of view.

C. Enrich the Spiritual Side of Life 1. Enrich the spiritual side of life by having a relationship with nature, the environment, a higher being, and yourself. a. Take time for thought and for quiet contemplation. b. Enjoy the sunsets, sounds, and energy of life. c. Take time for yourself now, to cope better with life’s ups and downs. i. See the Focus On Cultivating Your Spiritual Health chapter of your textbook for more information.

D. Improve Fitness 1. Improve your fitness—get moving and keep moving. No matter how old you are, exercise can improve your longevity. The more muscle you have, the better. a. Sarcopenia is age-related loss of muscle mass. b. Both aerobic and muscle strengthening activities are critical for healthy aging. c. The American Heart Association also recommends that people who are at risk for falling should perform regular balance exercises.

E. Eat for Health 1. Calcium is important to reduce the risk of osteoporosis. Calcium is particularly recommended for postmenopausal women.

2. Vitamin D is necessary for adequate calcium absorption.

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3. Many older adults cut back on protein to a point that is below the recommended daily amount. Be sure to maintain protein levels to maintain muscle mass and immune function.

4. Vitamin E, folic acid (folate), iron, potassium, and vitamin B12 are also important to the aging process.

Table:

Table 21.1 Exercise Recommendations for Adults over Age 65

Lecture Launcher Video: Vitality Project: A Town’s Push for Longer Life Additional Instructor Resources: PPT slides: 20–22; Digital Transparency Masters: Table 21.1

VIII. Understanding the Final Transitions: Dying and Death A. Death eventually comes to everyone, but understanding the process can help in accepting the inevitable.

B. Defining Death 1. Death can be defined as the “final cessation of the vital functions which are incapable of being restored.”

2. The Uniform Determination of Death Act in 1981 defined death as an individual who has sustained either: a. Irreversible cessation of circulatory and respiratory functions, b. Or irreversible cessation of all functions of the entire brain, including the brain stem.

3. The concept of brain death is the irreversible cessation of all functions of the entire brainstem.

4. There are several criteria determined by the Ad Hoc Committee of the Harvard Medical School in determining brain death. a. Unreceptivity and unresponsiveness—no response even to painful stimuli b. No movement for a continuous hour after observation by a physician and no breathing after 3 minutes off a respirator c. No reflexes, including brain stem reflexes; fixed and dilated pupils d. A “flat” electroencephalogram (EEG) for at least 10 minutes e. All of these tests repeated at least 24 hours later with no change f. Certainty that loss of body heat and depression of the central nervous system caused by the use of drugs are not responsible for these conditions

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Key Terms: death, brain death Additional Instructor Resources: PPT slide: 23

IX. The Process of Dying A. Dying is the process of decline in body functions, resulting in the death of an organism.

1. The process of dying includes physical, intellectual, social, spiritual, and emotional dimensions.

B. Coping Emotionally with Death 1. Elisabeth Kübler-Ross, a pioneer in thanatology (the study of death and dying), identified five stages in coping emotionally with death. Even though many dying people’s experiences do not fit easily into these stages, they can be helpful. a. Denial is characterized by shock and disbelief. b. Anger is characterized by the dying person perceiving the situation as “unfair.” c. Bargaining is a phase where the dying person resolves to be a better person in exchange for a longer life or may pray for a short reprieve from death in order to experience a special event, such as a wedding or a birth. d. Depression occurs when the deteriorating condition becomes impossible to deny. e. Acceptance is the final stage where the person becomes tired and passive.

C. Theorist Charles Corr describes a task-based approach to coping with dying. The primary tasks are as follows: 1. Physical: satisfying bodily needs and minimizing stress.

2. Psychological: maximizing security, autonomy, and richness in living.

3. Social: sustaining relationships and addressing social implications of dying.

4. Spiritual: identifying, developing, or reaffirming sources of meaning and fostering hope.

D. Social Death 1. Social death refers to a situation where a person is not treated like an active member of society.

2. The following behaviors can promote social death: a. Excluding the dying person from conversations b. Moving patients to terminal wards to receive minimal care c. Avoiding bereaved family members d. Medical personnel may make degrading comments about patients in their presence. e. Pain control in the patient may be difficult, leading to hostile interactions with caregivers.

Key Terms: dying, thanatology, social death

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Figure:

Figure 21.4 Kübler-Ross’s Stages of Dying

Additional Instructor Resources: PPT slides: 24–27; Digital Transparency Masters: Figure 21.4

X. Coping with Loss A. Reaction to the death of a loved one can vary, and assumptions about the feelings of the bereaved should be avoided.

1. Bereavement is generally defined as the loss or deprivation experienced by a survivor when a loved one dies.

2. Grief is the process of coping with a significant loss. a. Disenfranchised grief is when a person suffers a loss that cannot be openly acknowledged, publicly mourned, or socially supportive. Examples include miscarriage and disability.

3. Mourning refers to culturally prescribed and accepted time periods and behavior patterns for expression of grief.

4. Religion often provides comfort to dying and grieving people.

B. What Is “Typical” Grief?

1. Grief responses vary from person to person.

2. Acute stages of normal grief often includes periodic waves of physical distress, a feeling of tightness in the throat, choking and shortness of breath, a frequent need to sigh, a feeling of emptiness in the abdomen, a sensation of muscular weakness, and intense anxiety that is described as actually painful.

3. Other common grief symptoms include insomnia, memory lapses, loss of appetite, difficulty concentrating, and other behaviors.

4. Grief work is the process of integrating the reality of the loss into everyday life and learning how to feel better.

C. Worden’s Model of Grieving Tasks 1. Researcher William Worden developed a more active grieving model, defining four tasks necessary for the individual to complete: a. Accept the reality of the loss. b. Work through the pain of grief. c. Adjust to an environment in which the deceased is missing. d. Emotionally relocate the deceased and move on with life.

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D. Children and Death 1. Grief experienced when a child dies may be overwhelming.

2. Children react to death differently than adults. a. They tend to have more prolonged grieving periods and worry about their role in the death. b. Surviving children after the death of a sibling may feel emotionally abandoned by their parents and may receive less social support than their parents.

Key Terms: bereavement, grief, mourning, grief work Additional Instructor Resources: PPT slides: 28–31

XI. Life-and-Death Decision Making A. The Right to Die 1. Many people believe that they should be allowed to die if their condition is inevitably terminal.

2. Artificial life-support techniques may be legally refused by competent and conscious patients.

3. When a person is in a coma or is incapable of speaking on his or her own behalf, medical personnel, family members, and administrative policy will dictate treatment.

4. Advance directives are indications of a person’s desires regarding artificial life support.

5. Even young people should have a living will—a type of advance directive. a. Be specific in filling out advanced directives. b. Get an agent or proxy. c. Discuss your wishes with your proxy and physician. d. Deliver the directive to your physician, family, and lawyer.

6. A document called Five Wishes can meet the legal requirements for advance directive status in most states. a. It differs from other living wills by addressing personal, emotional, spiritual, as well as medical needs.

B. Rational Suicide and Euthanasia 1. The alternative to an extended, painful dying process is known as rational suicide. a. About 70 percent of Americans believe that doctors should be allowed to help end an incurably ill patient’s life painlessly at the patient’s request. b. Currently more than 30 states have statutes explicitly prohibiting-assisted suicide and only three states have laws allowing for physician-assisted suicide.

2. Euthanasia is 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 a physician-prescribed lethal injection. b. Passive euthanasia refers to the intentional withholding of treatment that would prolong life. An example would be deciding not to put a person on life support.

Key Terms: advance directive, living will, rationale suicide, active euthanasia, passive euthanasia Additional Instructor Resources: PPT slides: 32–36

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XII. Making Final Arrangements A. Hospice Care: Positive Alternatives 1. Hospice programs are positive alternatives that allow patients to experience death at home or at a home-like facility.

2. The goals of hospice programs, or palliative care, are to relieve the person’s pain; offer emotional support to the dying person and loved ones; and restore a sense of control to the dying person, the family, and friends.

3. Hospice programs are usually characterized by the following: a. The patient and family constitute the unit of care. b. Emphasis is placed on symptom control, primarily alleviation of pain. c. Medical direction is provided by one qualified physician. d. Services are provided by an interdisciplinary team. e. Coverage is provided 24 hours a day, every day. f. Volunteers are an integral part of the health care team. g. Care of the family extends through the bereavement period. h. Patients are accepted on the basis of health needs, not their ability to pay.

4. Despite the growing number of people considering hospice, many people prefer to die in a hospital, while others choose to die at home.

B. Making Funeral Arrangements 1. Decisions concerning funeral arrangements can be difficult and costly for survivors.

2. Making your own funeral arrangements ahead of time can save time and remove the burden from loved ones. a. To learn more about how concern for environmental responsibility is influencing modern funeral, burial, and memorial practices, please see page 696, Be Healthy, Be Green box.

C. Wills 1. A legal will is relatively simple and inexpensive and can reduce both conflict and needless expense after the person dies.

2. A person who dies intestate dies without a will, and the court, directed by state laws, makes the person’s will in which legal issues rather than the wishes of the deceased will preside.

3. Holographic wills are written in the handwriting of the testator and are unwitnessed.

They may be contested in court.

D. Organ Donation.

1. The demand for organs and transplant tissues has become so great that people are encouraged to be organ donors upon death.

2. Uniform donor cards are available and donor information is printed on the backs of drivers’ licenses.

3. It is important to inform your loved ones of your feelings about organ donation.

Key Terms: hospice, palliative care, intestate, holographic will, testator

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Figure:

Figure 21.5 Organ Donor Card

Additional Instructor Resources: PPT Slides: 37–39; Digital Transparency Masters: Figure 21.5

Additional Chapter Activities Points of View Physician-Assisted Suicide: Should It Be Legalized? on page 694 of your textbook.

Physician-assisted suicide refers to a practice in which the physician provides, after a terminally ill patient’s request, a lethal dose of medication that the patient intends to use to end his or her own life.

The arguments for and against the legalization of physician-assisted suicide within individual states continues.

In Class Activity: Read the POV in class. Next, have students count off, 1 through 5. Next, reveal to them that their number corresponds to the following identities: 1. Gerontologist 2. Medical doctor 3. Older adult 4. Terminally ill person 5. Daughter of a terminally ill father Have students get into groups of 5 to discuss physician-assisted suicide from the perspective of these alternative identities (not their own identity, but from the perspective of the person they have been assigned).

Synthesis: Next bring the class back together and debrief the experience and their thoughts about physician-assisted suicide.

Discussion Questions 1. How are the elderly portrayed in movies and on television? List some positive portrayals of elderly people. Why don’t we see more of these positive portrayals? Is there a difference when considering older adults of varying races and ethnicities?

2. Describe the relationship between physical and mental health. How does this relationship affect the way a person ages? Consider examples you have observed in your own life and relationships with older adults. What can you do to help promote healthy mental aging?

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3. Do you think the working class should pays for the increased share of health care costs for people on fixed incomes who cannot pay for themselves? Why or why not? How does this link with your personal philosophy on health and health care?

4. Describe the range of states a dying person may experience. How can family and friends assist the dying person in his or her passage through these stages?

5. How does grieving affect daily living, and what things can be done to cope? How does the media portray bereavement and grief? Are these portrayals consistent with the descriptions in the text?

6. Discuss the ethical concerns of the individual’s right to die with dignity. What factors have influenced the prolonging of the dying process?

Critical Thinking Questions 1. Why should you be concerned now about your life as an older adult?

2. What types of things could you be doing now to age in a healthful manner? List and describe three changes you’re willing to make in the next month to help you age in a healthful manner.

3. Have you considered a directive that states your wishes if you were placed on life support for a long period of time? Why or why not?

4. Have you ever 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 you experience? Did you experience the stages in the order in which they are presented in the text?

5. 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?

6. 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 think you will be like when you are age 60. Reflect on past accomplishments, describe yourself physically, and compose a 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?

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Community 1. Visit a local senior center and interview several elderly people. Find out their views on aging.

2. Find out what laws your state has regarding rational suicide and euthanasia. Do you agree with these laws? How do you think these laws should be changed?

3. Look into whether there are any resources in the community to help people fill out living wills or advanced directives. What type of services do they offer?

Diverse Population/Nontraditional 1. Describe how aging is viewed in other cultures. Compare and contrast societal views on aging in the United States and other countries.

2. Collect several brochures from Medicare supplement plans. Compare and contrast the benefits and choose a plan as if you were to join. Justify your decision.

3. Compare and contrast funeral rites in the United States and other countries. Compare and contrast different cultures with the United States with regard to funerals.

Lecture Launcher Video Questions New! The Science of Growing Old 1. Were you surprised by the emotional reactions of those who participated in the Alzheimer’s experiment? What does this tell us about our society’s awareness of Alzheimer’s disease?

2. After watching the video, why do you think it is important to understand what is going on in the mind of someone with Alzheimer’s?

New! Vitality Project: A Town’s Push for Longer Life 1. What lessons did explorer and author Dan Buettner want to bring to Albert Lea, Minnesota? What was his goal?

2. What do places like Sardinia, Italy; Icaria, Greece; Okinawa, Japan; and Loma Linda, California all have in common and what are these places called?

3. What are some of the steps mentioned in the video that can increase the chances of a long and healthy life? For example, the simple act of removing a television from a child’s bedroom can cause what specific health and academic benefits?

4. What does “de-convenience” your life mean? List five ways you can de-convenience your life, starting today.

Additional References K. Christensen, G. Doblhammer, R. Rau, and J. W. Vaupel, “Aging Populations: The Challenges Ahead,” The Lancet, 374, 9696, (2009): 1196–1208.

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.

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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 Center for Healthy Aging www.healthyagingprograms.org Death with Dignity National Center www.deathwithdignity.org eHow Funeral Arrangements www.ehow.com/funeral-arrangements Mental Health America Factsheet: Coping With Bereavement www.nmha.org/index.cfm?objectid=C7DF9618-1372-4D20-C807F41CB3E97654 National Association of State Long-Term Care Ombudsman www.nasop.org National Committee for the Prevention of Elder Abuse http://preventelderabuse.org Put It in Writing http://putitinwriting.org The Elder Justice Coalition www.elderjusticecoalition.com

Additional Media Healthy Brain Aging. 60 minutes.

In this UCtelevision production, healthy brain aging is discussed by UC Davis Alzheimer’s Disease Research Center Associate Professor, Dan Mungas. www.youtube.com/watch?v=D6d2S62tWLg&feature=related

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Research on Aging: The Inconstant Brain. 58 minutes.

In this lecture provided in conjunction with the Sam and Rose Stein Institute for Research on Aging, Dr. Terry Jernigan discusses new research on the changes that occur in brain tissue and the implications of these finding. www.youtube.com/watch?v=1mzacZPlZ9E&feature=related SIRA: Grief and Bereavement. 59 minutes.

In this UCtelevision production, Dr. Sidney Zisook provides a lecture for UCSD’s Sam and Rose Stein Institute for Research on Aging. Specifically, Dr. Zisook discusses the process of grief and loss. www.youtube.com/watch?v=Qyt56m_3tNM The Aging Brain. 3 minutes.

In this U.S. News and World Report, 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.

In this presentation of the UCSF Osher Center for Integrative Medicine, Dr. Ellen Hughes discusses healthy living and aging. www.youtube.com/watch?v=jQrkioHOJLs

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INSTRUCTOR RESOURCE AND SUPPORT MANUAL

Access to Health TWELFTH EDITION

Rebecca J. Donatelle

Jennifer M. Jabson, PhD BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

Benjamin Cummings Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo

Executive Editor: Sandra Lindelof Director of Development: Barbara Yien Assistant Editor: Brianna Paulson Senior Managing Editor: Deborah Cogan Production Project Manager: Megan Power Executive Marketing Manager: Neena Bali Manufacturing Buyer: Jeffrey Sargent Main Text Cover Design: Hespenheide Design Cover Photo: Lawrence Monneret/Getty Images Supplement Cover Design: Seventeenth Street Studios

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning.

Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

ISBN 10: 0321723058 ISBN 13: 9780321723055 Copyright © 2012 Pearson Education, Inc., publishing as Pearson Benjamin Cummings, 1301 Sansome St., San Francisco, CA 94111. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. To obtain permission(s) to use material from this work, please submit a written request to Pearson Education, Inc., Permissions Department, 1900 E. Lake Ave., Glenview, IL 60025. For information regarding permissions, call (847) 486-2635.

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1 2 3 4 5 6 7 8 9 10—EB—15 14 13 12 11

Table of Contents

PART 1

Chapter Overview and Visual Lecture Outline

CHAPTER 1

Accessing Your Health

1

CHAPTER 2

Promoting and Preserving Your Psychological Health

14

CHAPTER 2A

Focus On Cultivating Your Spiritual Health

28

CHAPTER 3

Managing Stress and Coping with Life’s Challenges

36

CHAPTER 3A

Focus On Improving Your Sleep

50

CHAPTER 4

Building Healthy Relationships and Communicating Effectively

58

CHAPTER 5

Understanding Your Sexuality

71

CHAPTER 6

Considering Your Reproductive Choices

84

CHAPTER 7

Eating for a Healthier You

105

CHAPTER 8

Reaching and Maintaining a Healthy Weight

118

CHAPTER 8A

Focus On Enhancing Your Body Image

129

CHAPTER 9

Improving Your Physical Fitness

137

CHAPTER 10

Recognizing and Avoiding Addiction

150

CHAPTER 11

Drinking Alcohol Responsibly

159

CHAPTER 12

Ending Tobacco Use

173

CHAPTER 13

Avoiding Drug Misuse and Abuse

186

CHAPTER 14

Protecting against Infectious Diseases and Sexually Transmitted Infections

199

CHAPTER 14A Focus On Understanding Your Health Inheritance

216

Preventing Cardiovascular Disease

223

CHAPTER 15

CHAPTER 15A Focus On Minimizing Your Risk for Diabetes

235

CHAPTER 16

Reducing Your Cancer Risk

243

CHAPTER 17

Reducing Risks and Coping with Chronic Conditions

256

iii

CHAPTER 18

CHAPTER 19

Choosing Conventional and Complementary Health Care

267

Preventing Violence and Abuse

280

CHAPTER 19A Focus On Reducing Your Risk of Unintentional Injury

293

CHAPTER 20

Preserving and Protecting Your Environment

303

CHAPTER 21

Preparing for Aging, Death, and Dying

315

Teaching Tips for First-Time Instructors and Adjunct Professors

333

PART 3

Sample Syllabi for Personal Health

341

PART 4

Using MyHealthLab

347

PART 5

Health & Wellness Teaching Community

355

PART 6

Great Ideas in Teaching Health & Wellness

357

PART 2

iv

TABLE OF CONTENTS

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 twelfth edition of Access to Health 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 of 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 Objectives The learning objectives list the key concepts students should understand as they reach the conclusion of each chapter. These objectives 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.

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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.

Lecture Launcher Video Discussion Questions A list of critical thinking questions is provided for the ABC News Lecture Launcher video clips available to instructors on the Instructor Resource DVD.

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 Using MyHealthLab are a valuable resource for any instructors with online components to their course, and can be found in Part 4. An overview of our Health and Wellness Teaching Community Website for instructors has been provided in Part 5.

We’ve also included the full set of our popular Great Ideas in Teaching Health and Wellness newsletters in Part 6, which have helped many professors add fun interactive activities to their classrooms.

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PART

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Teaching Tips for First-Time Instructors and Adjunct Professors

How to Be an Effective Teacher (From David Royse, Teaching Tips for College and University Instructors: A Practical Guide, published by Allyn & Bacon, Boston, MA. © 2001 by Pearson Education, Inc. Adapted by permission of the publisher.)

A look at fifty years of research “on the way teachers teach and learners learn” reveals five broad principles of good teaching practice (Chickering and Gamson, 1987).

Five Principles of Good Teaching Practice 1. Frequent student-faculty contact: Faculty who are concerned about their students and their progress and who are perceived to be easy to talk to, serve to motivate and keep students involved.

Things you can do to apply this principle: • Attend events sponsored by students.

• Serve as a mentor or advisor to students.

• Keep “open” or “drop-in” office hours.

2. The encouragement of cooperation among students: There is a wealth of research indicating that students benefit from the use of small-group and peerlearning instructional approaches.

Things you can do to apply this principle: • Have students share in class their interests and backgrounds.

• Create small groups to work on projects together.

• Encourage students to study together.

3. Prompt feedback: Learning theory research has consistently shown that the quicker the feedback, the greater the learning.

Things you can do to apply this principle: • Return quizzes and exams by the next class meeting.

• Return homework within one week.

• Provide students with detailed comments on their written papers.

4. Emphasize time on task: This principle refers to the amount of actual involvement with the material being studied and applies, obviously, to the way the instructor uses classroom instructional time. Faculty need good timemanagement skills.

Things you can do to apply this principle: • Require students who miss classes to make up lost work.

• Require students to rehearse before making oral presentations.

• Don’t let class breaks stretch out too long.

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5. Communicating high expectations: The key here is not to make the course impossibly difficult but to have goals that can be attained as long as individual learners stretch and work hard, going beyond what they already know.

Things you can do to apply this principle: • Communicate your expectations orally and in writing at the beginning of the course.

• Explain the penalties for students who turn work in late.

• Identify excellent work by students; display exemplars if possible.

Tips for Thriving: CREATING AN INCLUSIVE CLASSROOM How do you model an open, accepting attitude within your classroom where students will feel it is safe to engage in give-and-take discussions? First, view students as individuals instead of representatives of separate and distinct groups. Cultivate a climate that is respectful of diverse viewpoints, and don’t allow ridicule, or defamatory or hurtful remarks. Try to encourage everyone in the class to participate, and be alert to showing favoritism.

Planning Your Course (From David Royse, Teaching Tips for College and University Instructors: A Practical Guide, published by Allyn & Bacon, Boston, MA. © 2001 by Pearson Education, Inc. Adapted by permission of the publisher.)

Constructing the syllabus: The syllabus should clearly communicate course objectives, assignments, required readings, and grading policies. Think of the syllabus as a stand-alone document. Those students who miss the first or second meeting of a class should be able to learn most of what they need to know about the requirements of the course from reading the syllabus. Start by collecting syllabi from colleagues who have recently taught the course you will be teaching and look for common threads and themes.

Problems to avoid: One mistake commonly made by educators teaching a course for the first time is that they may have rich and intricate visions of how they want students to demonstrate comprehension and synthesis of the material, but they somehow fail to convey this information to those enrolled. Check your syllabus to make sure your expectations have been fully articulated. Be very specific. Avoid vaguely worded instructions that can be misinterpreted.

Tips for Thriving: VISUAL QUALITY Students today are highly visual learners, so you should give special emphasis to the visual quality of the materials you provide to students. Incorporate graphics into your syllabus and other handouts. Color code your materials so materials for different sections of the course are on different-colored papers. Such visuals are likely to create a perception among students that you are contemporary.

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Your First Class (From Richard E. Lyons, Marcella L. Kysilka, & George E. Pawlas, The Adjunct Professor’s Guide to Success: Surviving and Thriving In The Classroom, published by Allyn & Bacon, Boston, MA. © 1999 by Pearson Education, Inc. Adapted by permission of the publisher.)

Success in achieving a great start is almost always directly attributable to the quality and quantity of planning that has been invested by the course professor. If the first meeting of your class is to be successful, you should strive to achieve seven distinct goals.

Seven Goals for a Successful First Meeting 1. Create a positive first impression: Renowned communications consultant Roger Ailes claims you have fewer than 10 seconds to create a positive image of yourself. Students are greatly influenced by the visual component; therefore, you must look the part of the professional professor. Dress as you would for a professional job interview. Greet each student entering the room. Be approachable and genuine.

2. Introduce yourself effectively: Communicate to students who you are and why you are credible as the teacher of the course. Seek to establish your approachability by “building common ground,” such as stating your understanding of students’ hectic lifestyles or their common preconceptions toward the subject matter.

3. Clarify the goals and expectations: Make a transparency of each page of the syllabus for display on an overhead projector and, using a cover sheet, expose each section as you explain it. Provide clarification and elicit questions.

4. Conduct an activity that introduces students to each other: Students’ chances of being able to complete a course effectively are enhanced if each comes to perceive the classmates as a “support network.” The small amount of time you invest in an icebreaker will help create a positive classroom atmosphere and pay additional dividends throughout the term.

5. Learn students’ names: A student who is regularly addressed by name feels more valued, is invested more effectively in classroom discussion, and will approach the professor with questions and concerns.

6. Whet students’ appetite for the course material: The textbook adopted for the course is critical to your success. Your first meeting should include a review of its approach, features, and sequencing. Explain to students what percentage of class tests will be derived from material from the textbook.

7. Reassure students of the value of the course: At the close of your first meeting reassure students that the course will be a valuable learning experience and a wise investment of their time. Review the reasons why the course is a good investment: important and relevant content, interesting classmates, and a dynamic classroom environment.

Strategies for Teaching and Learning (From David Royse, Teaching Tips for College and University Instructors: A Practical Guide, published by Allyn & Bacon, Boston, MA. © 2001 by Pearson Education, Inc. Adapted by permission of the publisher.)

Team learning: The essential features of this small-group learning approach, developed originally for use in large college classrooms, are (1) relatively permanent

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heterogeneous task groups; (2) grading based on a combination of individual performance, group performance, and peer evaluation; (3) organization of the course so that the majority of class time is spent on small-group activities; and (4) a six-step instructional process similar to the following model: 1. Individual study of material outside of the class is assigned.

2. Individual testing is used (multiple-choice questions over homework at the beginning of class).

3. Groups discuss their answers and then are given a group test of the same items.

They then get immediate feedback (answers).

4. Groups may prepare written appeals of items.

5. Feedback is given from instructor.

6. An application-oriented activity is assigned (e.g., a problem to be solved requiring input from all group members).

If you plan to use team learning in your class, inform students at the beginning of the course of your intentions to do so and explain the benefits of small-group learning. Foster group cohesion by sitting groups together and letting them choose “identities” such as a team name or slogan. You will need to structure and supervise the groups and ensure that the projects build on newly acquired learning.

Make the projects realistic and interesting and ensure that they are adequately structured so that each member’s contribution is 25 percent. Students should be given criteria by which they can assess and evaluate the contributions of their peers on a project-by-project basis (Michaelsen, 1994).

Tips for Thriving: ACTIVE LEARNING AND LECTURING Lecturing is one of the most time-honored teaching methods, but does it have a place in an active learning environment? There are times when lecturing can be effective. Think about the following when planning a lecture: Build interest: Capture your students’ attention by leading off with an anecdote or cartoon.

Maximize understanding and retention: Use brief handouts and demonstrations as a visual backup to enable your students to see as well as hear.

Involve students during the lecture: Interrupt the lecture occasionally to challenge students to answer spot quiz questions.

Reinforce the lecture: Give students a self-scoring review test at the end of the lecture.

Grading and Assessment Techniques (From Philip C. Wankat, The Effective, Efficient Professor: Teaching Scholarship and Service, published by Allyn & Bacon, Boston, MA. © 2002 by Pearson Education, Inc. Adapted by permission of the publisher.)

Philosophy of grading: Develop your own philosophy of grading by picturing in your mind the performance of typical A students, B students, and so on. Try different grading methods until you find one that fits your philosophy and is reasonably fair. Always look closely at students on grade borders—take into account personal factors if the group is small. Be consistent with or slightly more generous than the procedure outlined in your syllabus.

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Criterion grading: Professor Philip Wankat writes: “I currently use a form of criterion grading for my sophomore and junior courses. I list the scores in the syllabus that will guarantee the students A’s, B’s, and so forth. For example, a score of 85 to 100 guarantees an A; 75 to 85, a B; 65 to 75, a C; and 55 to 65, a D. If half the class gets above 85% they all get an A. This reduces competition and allows students to work together and help each other. The standard grade gives students something to aim for and tells them exactly what their grade is at any time. For students whose net scores are close to the borders at the end of the course, I look at other factors before deciding a final grade, such as attendance.”

Tips for Thriving: RESULT FEEDBACK As stated earlier, feedback on results is the most effective of motivating factors. Anxious students are especially hungry for positive feedback. You can quickly and easily provide it by simply writing “Great job!” on the answer sheets or tests. For students who didn’t perform well, a brief note such as “I’d love to talk with you at the end of class” can be especially reassuring. The key is to be proactive and maintain high standards, while requiring students to retain ownership of their success.

Managing Problem Situations (From Philip C. Wankat, The Effective, Efficient Professor: Teaching, Scholarship and Service, published by Allyn & Bacon, Boston, MA. © 2002 by Pearson Education, Inc. Adapted by permission of the publisher.)

Cheating: Cheating is one behavior that should not be tolerated. Tolerating cheating tends to make it worse. Prevention of cheating is much more effective than trying to cure it once it has occurred. A professor can prevent cheating by: • Creating rapport with students • Gaining a reputation for giving fair tests • Giving clear instructions and guidelines before, during, and after tests • Educating students on the ethics of plagiarism • Requiring periodic progress reports and outlines before a paper is due Try to develop exams that are perceived as fair and secure by students. Often, the accusation that certain questions were tricky is valid as it relates to ambiguous language and trivial material. Ask your mentor or an experienced instructor to closely review the final draft of your first few exams for these factors.

(From David Royse, Teaching Tips for College and University Instructors: A Practical Guide, published by Allyn & Bacon, Boston, MA. © 2001 by Pearson Education, Inc. Adapted by permission of the publisher.)

Unmotivated students: There are numerous reasons why students may not be motivated. The “required course” scenario is a likely explanation—although politics in colonial America is your life’s work, it is safe to assume that not everyone will share your enthusiasm. There are also personal reasons such as a death of a loved one or depression. Whenever you detect a pattern that you assume to be due to lack of motivation (e.g., missing classes, not handing assignments in on time, nonparticipation in class), arrange a time to have the student meet with you outside the classroom. Candidly express your concerns and then listen.

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Tips for Thriving: DISCIPLINE One effective method for dealing with some discipline problems is to ask the class for feedback (Angelo & Cross, 1993). In a one-minute quiz, ask the students, “What can I do to help you learn?”

Collate the responses and present them to the class. If behavior such as excessive talking appears in some responses (e.g., “Tell people to shut up”), this gives you the backing to ask students to be quiet. Use of properly channeled peer pressure is often effective in controlling undesired behavior.

Motivating students is part of the faculty members’ job. To increase motivation, professors should show enthusiasm for the topic, use various media and methods to present material, use humor in the classroom, employ activities that encourage active learning, and give frequent, positive feedback.

(From Sharon Baiocco, & Jamie N. De Waters, Successful College Teaching: Problem Solving Strategies of Distinguished Professors, published by Allyn & Bacon, Boston, MA. © 1998 by Pearson Education, Inc. Adapted by permission of the publisher.)

Credibility problems: If you are an inexperienced instructor, you may have problems with students not taking you seriously. At the first class meeting, articulate clear rules of classroom decorum and conduct yourself with dignity and respect for students. Try to exude that you are in charge and are the “authority” and avoid trying to pose as the students’ friend.

Improving Your Performance (From Richard E. Lyons, Marcella L. Kysilka, & George E. Pawlas, The Adjunct Professor’s Guide to Success: Surviving and Thriving In The Classroom, published by Allyn & Bacon, Boston, MA. © 1999 by Pearson Education, Inc. Adapted by permission of the publisher.)

Self-evaluation: The instructor who regularly engages in systematic self-evaluation will unquestionably derive greater reward from the formal methods of evaluation commonly employed by colleges and universities. One method for providing structure to an ongoing system of self-evaluation is to keep a journal of reflections on your teaching experiences. Regularly invest 15 or 20 introspective minutes following each class meeting to focus especially on the strategies and events in class that you feel could be improved. Committing your thoughts and emotions to writing enables you to develop more effective habits, build confidence in your teaching performance, and make more effective comparisons later. The following questions will help guide self-assessment: How do I typically begin a class?

Where/How do I position myself in the class?

How do I move in the classroom?

Where are my eyes usually focused?

Do I facilitate students’ visual processing of course material?

Do I change the speed, volume, energy, and tone of my voice?

How do I ask questions of students?

How often, and when, do I smile or laugh in class?

How do I react when students are inattentive?

How do I react when students disagree or challenge what I say?

How do I typically end a class?

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Tips for Thriving: VIDEO-RECORDING YOUR CLASS In recent years, a wide range of professionals has markedly improved their job performance by employing video recorders in their preparation efforts. As an instructor, an effective method might be to ask your mentor or another colleague to tape a 10- to 15-minute mini-lesson, then to debrief it using the assessment questions listed previously. Critiquing a videotaped session provides objectivity and is therefore more likely to effect change. Involving a colleague as an informal coach will enable you to gain from that person’s experience and perspective and will reduce the chances of your engaging in self-depreciation.

References R. Ailes, You Are the Message: Getting What You Want by Being Who You Are. (New York: Doubleday 1996). R. (1996).

A. W. Chickering and Z. F. Gamson, “Seven Principles for Good Practice in Undergraduate Education.” AAHE Bulletin, 39, (1987): 3–7.

L. K. Michaelson, "Team Learning: Making a Case for the Small-group Option," In K. W. Prichard and R. M. Sawyer (Eds.), Handbook of College Teaching. (Westport, CT: Greenwood Press 1994).

M. D. Sorcinelli, "Research Findings on the Seven Principles," In A. W. Chickering and Z. Gamson (Eds.), “Applying the Seven Principles of Good Practice in Undergraduate Education.” New Directions for Teaching and Learning 47. San Francisco: Jossey-Bass 1991).

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PART

3

Sample Syllabi for Personal Health

Course Syllabus for Personal Health 101 Spring 2011 Instructor: Office: e-mail: Phone: Office Hours: M 10:00–12:00 pm T 11:00–12:00 pm W 10:00–12:00 pm Required Materials:

Rebecca J. Donatelle, Access to Health (12th ed.), (San Francisco, CA: Pearson Benjamin Cummings 2012).

Goal: To promote students’ understanding of their physical, emotional, and social health needs and to develop strategies to meet these needs and improve overall health and well-being.

Objectives: At the conclusion of this course, students will be able to: 1. Assess their individual levels of wellness and understand enhancement strategies.

2. Describe current stressors in their lives and how to effectively cope with or eliminate the sources of stress.

3. Analyze their current fitness level; develop a realistic health modification plan for their current lifestyle.

4. Identify ways to manage weight and to improve communication and relationships with others.

5. Describe the health risks of addictive behaviors, including binge drinking, drug abuse, and tobacco use.

6. Identify a lifestyle change they intend to make to improve their overall wellness.

Course Requirements: Students are expected to attend class regularly and complete all course reading assignments. There will be two mid-term exams, a final examination, and a term paper. Students may also do optional extra credit assignments.

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Grades will be determined by the following point scores: A+ 500+ A 460–499 A– 450–459 B+ 435–449 B 410–434 B– 400–409 C+ 385–399 C 350–384 D 300–349 F Below 300 points Your grade is based on the following elements: Wellness self-assessment (20%); Examinations (60%); and Class Participation (20%).

A. Participation (100 points) Students wishing to earn an A for their participation may miss no more than two classes during the semester.

Class participation during both large- and small-group discussion will also affect this portion of students’ grades.

B. Three Examinations (300 points) Examinations will contain a combination of multiple-choice, true/false, sentence completion, and shortanswer questions, covering both text and lecture material. The exams are not cumulative and students will receive a review sheet during the preceding class.

If you must miss an examination, please contact me immediately. You will be allowed to make up the exam but must do so within one week of the missed exam.

C. Wellness Self-Assessment (100 points) Due: 3/1 Students will complete a wellness assessment that will serve as the basis for a 6- to 8-page paper in which students assess their current health status. These papers must be typed, double-spaced, in a font not to exceed 12 pt.

In this paper, you will describe:

1. Two “unhealthy” behaviors you currently engage in that you are not prepared to change, why you engage in them even though they are unhealthy, and what would encourage you to consider changing them.

2. Two unhealthy behaviors you are currently contemplating changing and why.

3. If applicable, two behaviors you have already changed, why you did, and how you accomplished your goal.

4. Your willingness and ability to act healthfully.

Your paper is due on 4/11. Please be advised that you will lose a letter grade each day your paper is late.

Extra Credit Possibilities: Due by 4/23 at the latest Any student can add a maximum of 30 points in extra credit by doing three 10-point assignments, or participating in a group project and one independent assignment. Please see me for information regarding the assignment choices.

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Springfield University Department of Health, Physical Education and Recreation HPER101 Personal Health Promotion M W 8:00 to 8:50 a.m.

Health Education Building Fall Semester 2011

Instructor: Office: Phone: FAX: E-Mail: Office Hours: Required Text:

Rebecca J. Donatelle, Access to Health (12th ed.), (San Francisco, CA: Pearson Benjamin Cummings 2012).

Course Description:

The goals of this course are: • To gain an understanding of personal wellness • To increase your knowledge of common health problems and gain understanding of the promotion of personal health and prevention of illness • To learn strategies to maintain or improve your well-being

Your Responsibilities:

Attend class and be prepared to participate.

Complete assigned readings prior to class.

Complete all class assignments.

Be flexible and have fun.

Lecture Attendance:

Attendance will be taken at the start of each class. Students may miss three classes without penalty. Subsequent absences (for all reasons) will result in a 5-point deduction from your attendance point total.

Evaluation:

Exams: 4 @ 100 points each = 400 points.

• The exams can cover any material from readings, lectures, handouts, presentations by guest speakers, and films.

• The exams include multiple-choice, true/false, fill-in-the-blank, matching, or short-answer questions.

• The exams are noncumulative (only material since the previous exam).

• Bring #2 pencils to each exam.

• Make-up exams will be given only to persons with a valid reason (documented emergency or illness) for missing the exam.

In-Class Activities: 10 at 5 points each = 50 points.

In-class assignments, quizzes, etc., will be given at random throughout the semester. There will not be any notice prior to an in-class assignment.

You must be in class on the day of the assignment to receive credit. If you do the assignment completely and properly, you will get the points.

There are no make-ups for missed in-class assignments.

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Projects: 2 @ 50 points each = 100 points.

You may choose two of three projects. Instructions for these projects will be passed out on the first day of class.

Lecture attendance = 50 points.

(See policy on previous page) Example: 5 absences = 50 – 10 = 40 attendance points 6 absences = 50 – 20 = 30 attendance points 7 absences = 50 – 30 = 20 attendance points 8 absences = 50 – 40 = 10 attendance points 9 or more absences = 0 attendance points

Total Possible Points = 600 Grading Scale: A = 540–600 pts. (90–100%) B = 480–539 pts. (80–89%) C = 420–479 pts. (70–79%) D = 360–419 pts. (60–69%) F = 359 and below (less than 60%) Academic Integrity:

Academic and personal misconduct by students in this class is defined and dealt with according to the procedures in the University-wide Student Rights and Responsibilities policy. Please refer to your course catalog or the University website for policy details.

Guest Speakers:

We may have several guest speakers during the course. These professionals are experts in their respective fields and they welcome your questions.

Please be courteous. Disruptive students will be asked to leave the classroom.

Missed Classes:

If you miss class, it is your responsibility to get notes from someone else in the class.

Please note: “In accordance with University policy and the Americans with Disabilities Act (ADA), academic accommodations may be made for any student who notifies the instructor of the need for an accommodation. It is imperative that you take the initiative to bring such needs to the instructor’s attention, as he/she is not legally permitted to inquire about such particular needs of students. Students who may require special assistance in emergency evacuations (i.e., fire, tornado, etc.) should contact the instructor as to the most appropriate procedures to follow in such an emergency.”

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Tentative Course Outline* Week Week 1 Week 2 Week 3 Week 4

Week 5 Week 6

Date 8/24/2011 8/26 8/31 9/02 9/07 9/09 9/14 9/16 9/21 9/23 9/28 9/30 10/05 10/07

Week 7 Week 8 Week 9 Week 10

10/12 10/14 10/19 10/21 10/26 10/28

Topic Introduction & Syllabus Overview Wellness & Taking Charge of Your Health Psychological Health Spiritual Health Stress Management Improving Your Sleep Building Relationships Communication Exam 1—Chapters 1, 2, 2A, 3, 3A, & 4 Sexuality Contraception and Pregnancy Nutrition Weight Management Enhancing Body Image Exercise for Health and Fitness Exam 1I—Chapters 5, 6, 7, 8, 8A, & 9 Addictions Alcohol Tobacco Use Drug Use and Abuse Infectious Diseases and STIs Health Inheritance Cardiovascular Disease Exam 1II—Chapters 10, 11, 12, 13, 14, & 14A Diabetes Cancer Chronic Conditions Health Care and Alternative Medicine Preventing Violence and Abuse Unintentional Injuries

Week 12

11/02 11/04 11/09 11/11

Week 13

11/16 11/18

Week 14

11/23 11/25 11/30 12/02

Thanksgiving Break – No Classes Preserving the Environment Life’s Transitions

Finals Week

12/09/2011 at 8AM

Final Exam —Chapters 15, 15A 16, 17, 18, 19, 19A, 20, & 21

Week 11

Reading Chapter 1 Chapter 2 Chapter 2A Chapter 3 Chapter 3A Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 8A Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 14A Chapter 15 Chapter 15A Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 19A

Chapter 20 Chapter 21

*Scheduled course outline is subject to change with notice from the instructor*

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PART

4

Using MyHealthLab

The MyHealthLab (also referred to as MHL) software series is a set of online course materials to use as an online class or as a complement to Donatelle’s Access to Health, twelfth edition. Materials can be customized to provide your students with preloaded course materials or with course content you load for them. After registering, faculty can begin to tailor the content to meet their needs and can then make the course available to students by clicking the Adopt button. MyHealthLab offers premium online content, including a Behavior Change Logbook, a Wellness Journal, textbook quizzes, ABC News video segments, selfassessment activities, and much more. Once students are logged into the MHL course site, they are also set up in your CourseCompass Gradebook, which records all scores and assignments they complete through MHL. This primer, prepared by Barbara Hewitt, M.S., from Diablo Valley College, gives a brief introduction to MyHealthLab, providing an overview of how to integrate MHL resources into your course (from navigating the actual program to providing assignments for classroom sessions), to use MHL to enhance lecture content, and to assign student homework. Sample assignments are also included to illustrate how MHL will enhance your course and increase student involvement.

The Practical Aspects MHL is hosted by CourseCompass. After creating your CourseCompass login name, you will need to log in to customize your course. When you log in, the “MyPearson” page will open.

CourseCompass is organized by four blocks that appear in the page. Your course will appear on the “MyCourseCompass Courses” block.

Most of the setup and customization is initiated from the control panel on the bottom left tabs. These control panel items are visible to you but not to your students.

Working with the Control Panel Content Areas The content area of the control panel includes the course information, tools for success, chapter content assignments, and external links.

Course Information Here you will find all software requirements to run MHL and downloads, if needed. This is an excellent place to load in your syllabus and a personal biography or curriculum vitae.

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Chapter Contents Instructors can choose to use all or some of these resources.

The items loaded into chapter contents include text-based resources, everything from the full chapter (Pearson eText), practice quizzes, chapter objectives, critical thinking activities, flashcards, case studies, and video segments. These items can be modified or removed for use in your class or assigned for homework. Chapter practice quizzes and case studies are particularly useful to use as homework assignments to reinforce chapter comprehension.

This edition makes it easier than ever to organize your personal health class by function: • New! On the Go: More and more, students are relying on mobile devices that let them study on the go. In this section of MyHealthLab, your students will find tools to help them take control of their health at any time. TweetYourHealth is a brand-new Twitter application that will remind students about their behavior change project, and allow them to track their progress throughout the semester using their mobile phone.

• Read It: The new Pearson eText, a full-featured electronic book, is laid out just like the textbook, so it is easy and engaging for your students to read. They can create notes, highlight text in different colors, create bookmarks, zoom, click hyperlinked words and phrases to view definitions, and view a video or visit a website as they read the text. Also available in this section of MyHealthLab are chapter objectives that direct student learning and chapter-specific RSS feeds.

• See It: Students can’t help but learn when they watch the more than 60 ABC News videos, each 5-10 minutes long, about important health topics. Each video is followed by assignable quiz questions.

• Hear It: MP3 tutor sessions with assignable quizzes explain the big picture concepts for each chapter and new audio case studies with accompanying essay questions encourage students to think about real life health choices.

• Do It: This is where students can put their newly learned chapter knowledge to work.

Critical thinking questions, news quizzes, and web links provide further opportunities for student learning.

• Review It: Online glossary, flashcards available for mobile phones, and practice quizzes for each chapter mean your students will always be ready at exam time.

• Live It: This electronic toolkit helps jumpstart your students’ behavior change project.

More than 30 assessments from the book, additional worksheets, and the new How Healthy Are You? module help your students target the health behaviors they wish to change. The site guides students through planning for change, creating a behavior change contract, journaling and logging their behaviors as they implement change, and preparing a reflection piece to aid in behavior change evaluation.

Assignments The remaining content areas such as assignments and external links are not preloaded and are places for instructors to load personal course assignment instructions or links. A nice use for this area is to load any assignment instruction sheets, review sheets, and/or your PowerPoint lectures for student viewing. An example of how to use both of these assignments and external links is to load your PowerPoint lecture from the external links section (or from the Instructor Resource DVD) and include an assignment to complete after viewing the PowerPoint lecture.

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the label (number of servings in a container, total calories per container, percentage of fat in the food, health value of food, etc.). This can be printed out and brought to class, sent directly to your email for grading, or put in the digital dropbox for your viewing later.

Course Tools This area of MHL is an area for personalizing your content and creating a course calendar.

Each section may or may not be made available to your students to use for e-mail, handing in assignments (digital dropbox) or obtaining staff information. If you use MHL as a standalone course, this area works well for classroom management. When MHL is purely a complement to your lecture classes, you may choose to remove many of these options. It has been my experience that the nononline students already feel bombarded with materials in class and providing too many outside materials may be overwhelming. Sometimes providing only the materials distributed in class as required materials works the best. Be careful not to overload your MHL with unnecessary items that may distract students from the required content and assignments for your course. The area I use most is sending e-mails to students to remind them of tests, assignments, or class cancellations.

The Announcement area is another area I use often and make as my opening page. I change it weekly and update all assignment information, class lecture content, and test information. This is where I describe the weekly assignments and readings due and any other announcements regarding class.

The discussion board is particularly useful for bringing students together to discuss among themselves (either anonymously or by name) controversial issues or topics. A forum can be posted for students to write about and reply to other students with comments. This is valuable to use when a class discussion isn’t finished or needs more exploration. The discussion responses can be organized alphabetically and printed out for grading at any time. They can also be stored as an archive, for viewing at a later date.

Course Options The “Manage Course Menu” and “Manage Tools” areas are found in this section. This is where to choose which icons (on the tool bar) you will make available to your students and how you will display them. Remember, try not to overload students and to only post the items you will be using in your course (i.e., don’t make the digital dropbox available if you want your students to hand in assignments in class). I use this area to add any other icon or materials to the course.

For example, this is where I load the PowerPoint lectures I use in class so students can refer to this to study for tests or obtain lecture notes if they missed class. I name this tool Lecture Notes, and it will be placed in the tool area of CourseCompass as a separate icon.

User Management This tool is helpful to enhance group project work and to provide necessary group project materials for all students to access and/or store their work for group members to view or to work on together.

Assessment This is an excellent tool for instructors to use for administering tests, surveying students, and storing grades. MHL automatically posts grades from quizzes and other assessments you’ve assigned, which saves instructors a lot of grading time. TestGen is the test-making program MHL uses. I use this to create practice tests or timed tests.

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Help This area is for instructors to access technical support and CourseCompass help.

MyHealthLab In The Classroom Using MHL to Enhance Classroom Learning After navigating the control panel, you can now plan some ways to use this in your class. As an instructor of health and wellness, and fitness and health, I use MHL both as a classroom supplement and as a stand-alone online class for students to use to access class materials and complete assignments.

Course companion website content is also available on MyHealthLab

One of the most useful tools on MHL is the ABC News video launchers. Gone are the days of VCR and VHS. Now, you can access these excellent videos from your laptop and then easily open your PowerPoint slides to start the lecture. The “case studies in health” are also nice lecture introductions to open a discussion of how this chapter relates to student’s lives. Some of these come with an audio tool so students can read them and hear them as a class opener.

For example, in MHL click on chapter contents, and then choose Chapter 1, in the “case studies section” there is a scenario for two individuals and their habits. This helps describe the relative nature of the definition of health. I use this to open a discussion about how health is relative to each individual’s “potential” and quality of life and includes different dimensions.

Another useful way to use MHL in class is to build flashcards for your lecture. Have students work in pairs to find the definition of the term and raise their hands if they know the answer. If they’re right, I give them one extra credit point. You can also show the definition and have them try to find the term instead. This section is found under Chapter Contents, in the flashcards area.

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MyHealthLab Online Course Only Setting up an online class takes time, particularly in the health sciences, as course materials need to be updated frequently and the assignments need to reflect the new content. The preloaded content of MHL makes this task somewhat easier. The challenge is to choose materials which equate to the required time per unit at your school and to offer an online class experience that provides some interaction and teacher involvement. For example, for a 3-semester unit class, the estimated hours of work for a student is 3 in-class hours per week and approximately 2–3 study hours outside of class. Therefore, when a student is taking your class online, they need to spend 5–6 hours per week working on the assignments and readings for this class.

For classroom management, I also make my online class correspond closely to my face-toface class so students can use them interchangeably; course planning is also easier when we are all doing the same assignments. Online teaching is a new pedagogy for many instructors.

In some ways, online teaching allows for more individual teaching (through e-mail) and thus allows for a more “intimate” or personalized experience; yet, students do not get to work closely with each other as they do in a classroom setting. There are pros and cons to online classes; as instructors, I believe we are still trying to determine the most effective ways to provide the best experience online. Here are some suggestions that have worked for my MHL class.

Orientation To best allow students to succeed in an online class, I require a two-hour, face-to-face orientation. Together, we enroll in CourseCompass; browse the site; and download the syllabus, assignments, and calendar. Students tend to have issues with access codes, plug-ins, or system requirements with their home computers, so doing this orientation is crucial. I suggest that students set up a “virtual” classroom at home with their computer and a bulletin board with the syllabus, the assignments, the discussion items, the calendar, and the quizzes for each chapter. This way, each week they can refer to a hard copy of the discussion, assignments, or quizzes. They can work on them at other times throughout the day and answer them first on paper before submitting them for grading. I do not require timed tests online because I still require they come on campus for three proctored tests with me.

During orientation, I do a class exercise for students to get to know each other and begin to relate as a class. For example, I have them respond to a discussion item about “What Is Health?” (you can use the scenarios in the chapter content, case study area) and reply to someone else’s definition; we then discuss these in class. Students can then see who everyone is and begin to feel more comfortable navigating the site and interacting with each other online.

Weekly Announcements I use this section for my opening page. Students see these when they log in to MHL. Each week, I post the required class assignments, readings, and due dates. For example: Second Week of August 1) Please read Chapter 1 and answer the two multiple-choice quizzes and case studies, due Friday at 2 p.m. Case studies need to be submitted to the dropbox. Quizzes are graded and recorded automatically when you hit “submit.”

2) Personal Health Assessment assignment is also due next week; remember to review the assignment instructions under the assignment section.

3) Discussion item is also posted and due on Friday by 2 p.m.

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Under “Options” in the announcement modification section, I choose to always show all announcements throughout the semester so students can see the previous week’s assignments as well.

The video lecture launchers are available for students to view, so they can be assigned for homework. For example, I require students to view the Chapter 15 (cardiovascular disease) video and in a separate word document outline the symptoms and risk factors for heart disease. These answers are then e-mailed directly to me (or can be placed in the dropbox for viewing).

Quizzes Each week, students will take multiple-choice tests for at least one chapter (sometimes two).

These tests are automatically graded and organized in your Gradebook section in MHL. I like to know that my students are reading the texts and understand the terms and concepts. Students can print these out and work on them in hard copy before submitting them online.

Therefore, they are open book tests. Once the test has been submitted, the correct answers can be viewed. In the control panel, in the course document quiz area, I set up the tests so that they can only take them once. The students can view the tests as often as they like, but once they take the test, they are done. I give 100 semester points for completing each chapter multiple-choice test (only one for each chapter). They must have at least 70 percent correct to get credit. The chapter multiple-choice tests are due weekly and are e-mailed directly to me. You can also load a TestGen test here that can be scored and submitted directly to the Gradebook.

Case Studies Depending on the topic, I will assign these case studies to be answered as well. These have a nice audio portion that breaks up the monotony of “screen” reading. I ask that the answers to case study questions be written as a separate text document, and either put in the dropbox or e-mailed directly to me. I give credit for completion, but do not assign grades to these.

Discussion Each week, students are required to respond to at least one other person on a discussion topic related to the weekly content. I post all discussion items at the beginning of the semester, so students can print these out and think about them from a hard copy before replying. Sometimes, these discussions require outside research. For example, I ask students to research their local Planned Parenthood and describe at least two of the services they offer. I also require a grocery store field trip with a label viewing assignment. Students can meet up to do this assignment together by discussing this in this area. There are some good questions for discussion and reflection found in the end of each chapter. Other sample discussion questions to use on the forums include: 1) How can you tell the difference between a love relationship and one that is purely physical attraction? Use Sternberg’s theory on love and discuss what characteristics love relationships share.

2) Discuss three ideas to curb the rising rates of childhood obesity.

3) Complementary and Alternative Medicines (CAM) are now used widely. Discuss two CAMs you would use and why.

Allowing anonymous posting on discussion items may encourage more sharing of information here. However, with this option, instructors do not know which students have 352

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participated. I have used this anonymous posting option for sensitive issues such as discussions on STIs, addictions, or abortion, and they have lead to some very intimate discussions.

Assignments I require seven assignments outside of the text (approximately one every other week). Some of these can be done by pairs of students, but most are done alone. For the disease research assignment, students can use the Research Navigator tool to find five sources to use to research information on the definition, risk factors, symptoms, treatments, and prevention strategies of a disease of their choice.

They can also use this for the drug research assignment where they must learn about a drug of their choice, including the history of a drug, the common uses, the effects on the body and mind, and the long-term risks of using the drug. This assignment can be done in groups by using the “manage group” section. I set up group discussion boards and group sharing through this section, and later I can see what work was done by whom.

Other assignments I include are: personal health review, assessing health information, a fitness plan, a diet analysis (using MyDietAnalysis), and research on a CAM of their choice.

Instructions for assignment formats, requirements, and submission are all loaded into the assignment section.

For the fitness assignment, I have students log in to the behavior change section and open the Fitness and Weight Training log book. They need to print out the fitness level section and test their fitness with a 1.5 mile run test, 60 second push up and sit-up test, and a flexibility test measure. We go to the track for a class period and take these measures together (for an online class, they must do this on their own). This is used as an indicator of their current fitness in each component of fitness. After finishing the tests, they can set some goals and write their plan. For example, some students find they score excellent on flexibility (the sit-andreach tests), while their strength is low; the fitness plan they design will then need to focus more on strength.

You can also print out the fitness logs for students to use to record their progress. Studies show that tracking behavior helps exercise adherence. I do not base my grading on behavior change, but will discuss how the tracking can be helpful to use for success.

Sample Assessing Health Information Assignment Using ABC News Health RSS Feed Accessing and assessing accurate health information is a course objective for all my students.

One assignment I use to explore health information resources is to read a highlight from the ABC News Health RSS Feed. I ask students to find other online sources related to the article.

I then ask them to distinguish between a primary, secondary, and tertiary source. I use a worksheet loaded in the assignment section with the assignment instructions and ask for the worksheet to be answered and e-mailed directly to me or placed in the dropbox. Some questions I have students answer are: 1) When would you choose an online source for accessing health information?

2) Describe what you found on the American College of Obstetrics and Gynecology website.

3) What is the difference between a primary, secondary, and tertiary source?

4) What is the Web good for?

5) What is the difference between an .org and a .com site?

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Proctored Tests I do not use the timed TestGen tests preloaded in MHL but prefer to require students take two midterms and a final with me. During the exams, students can also discuss problems, assignments, or health issues that the course brought up for them. Through the years I have been teaching online, I believe these students perform as well or better than my face-to-face students on tests. They are required to read the text and become more disciplined with their study habits. Some students do not succeed in an online class, but the ones who do have disciplined themselves to “show up” at their virtual classroom and do their work.

MHL is a good introduction to an online experience. The excellent content and overlap with the in-class resources allow students to use these materials as they may have used similar ones in class. The MHL materials are easy to use and creative.

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5

Health & Wellness Teaching Community

Connect with Your Health & Wellness Teaching Peers 24/7 Access to Great Ideas and Strategies The Health & Wellness Teaching Community offers you a resource for reaching out and connecting with fellow instructors. The community website, available at www.pearsonhighered.com/healthcommunity, is provided in partnership by the American Association for Health Education (AAHE) and Pearson and is moderated by a certified health educator specialist who is a coordinator of a personal health course.

Access teaching tips and activities by specific content information, general teaching tips, or professional resources, including: • Teaching in large lecture settings • Incorporating technology into the classroom • Guidance and strategies for new faculty or graduate teaching assistants • Share and post syllabi, mid-term and final exams, and more View updates on important health topics.

• Access daily health news feeds from ABC News, Yahoo!, CNN, and Health Behavior News Service.

Contribute to the site.

• Start discussions on topics with your peers.

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INSTRUCTOR RESOURCE AND SUPPORT MANUAL FOR ACCESS TO HEALTH

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