INSTRUCTOR MANUAL FOR An Invitation to Health (Brief Edition) 10th Edition. Dianne Hales by welldoneassistant

An Invitation to Health (Brief Edition) 10e Dianne Hales (Instructor Manual (Lecture Notes Only) All Chapters, 100% Original Verified, A+ Grade)

1 The Power of Now Learning Objectives After studying this chapter in the text, the student should be able to: 1.1

Define health and wellness.

1.2

Outline the dimensions of health.

1.3

Assess the current health status of Americans.

1.4

Discuss health disparities based on gender and race.

1.5

Evaluate the health behaviors of undergraduates.

1.6

Describe the impact of habits formed in college on future health.

1.7

Explain the influences on behavior that support or impede healthy change.

1.8

Identify the stages of change.

Chapter Summary This chapter shows you how to make healthy choices and thus how to live more fully, more happily, and more healthfully. This is an offer that you literally cannot afford to refuse. Your life may depend on it, starting now.

Lecture Outline I.

Health and Wellness A. What It Means 1. Health means being sound in body, mind, and spirit. 2. The World Health Organization defines health as “not merely the absence of disease or infirmity,” but “a state of complete physical, mental, and social well-being.” 3. Health has many dimensions: physical, psychological, spiritual, social, intellectual, and environmental.

© 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

4. Wellness can be defined as purposeful, enjoyable living or, more specifically, a deliberate lifestyle choice characterized by personal responsibility and optimal enhancement of physical, mental, and spiritual health. B. The Dimensions of Health 1. Physical Health a. According to a contemporary medical dictionary, health is “an optimal state of physical, mental, and social well-being, not merely the absence of disease or infirmity.” b. Health is not a static state, but a process that depends on the decisions we make and the behaviors we practice every day. c. We must feed our bodies nutritiously, exercise them regularly, avoid harmful behaviors and substances, watch out for early signs of sickness, and protect ourselves from accidents. 2. Psychological Health a. Psychological health refers to both our emotional and mental states. b. It involves awareness and acceptance of a wide range of feelings in oneself and others, as well as the ability to express emotions, to function independently, and to cope with the challenges of daily stressors. 3. Spiritual Health a. Spiritually healthy individuals identify their own basic purpose in life; learn how to experience love, joy, peace, and fulfillment; and help themselves and others achieve their full potential. 4. Social Health a. Social health refers to the ability to interact effectively with other people and the social environment, to develop satisfying interpersonal relationships, and to fulfill social roles. b. Health educators are placing greater emphasis on social health in its broadest sense as they expand the traditional individualistic concept of health to include the complex interrelationships between one person’s health and the health of the community and environment. c. This change in perspective has given rise to a new emphasis on health promotion, which educators define as “any planned combination of educational, political, regulatory, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities.”

5. Intellectual Health a. Intellectual health refers to your ability to think and learn from life experience, your openness to new ideas, and your capacity to question and evaluate information. 6. Occupational and Financial Health a. College provides the opportunity for you to choose and prepare for a career that is consistent with your personal values and beliefs and to learn how to manage your money and safeguard your financial wellbeing. b. Health educators have expanded the traditional individualistic concept of health to include the complex interrelationships between one person’s health and the health of the community and environment. i. This change in perspective has given rise to a new emphasis on health promotion, which educators define as “any planned combination of educational, political, regulatory, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities.” II.

Health in America A. Overview 1. According to a recent national survey of more than 4,700 people, 97.3 percent get a failing grade in healthy lifestyle habits. 2. For the minority who do adapt these health guidelines, the payoff includes a lower risk of many health problems, including type 2 diabetes, heart disease, and cancer. B. Healthy People 2020 1. Eliminate preventable disease, disability, injury, and premature death. 2. Achieve health equity, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health for all. 4. Promote healthy development and healthy behaviors across every stage of life. C. Health Disparities 1. Despite great improvements in the overall health of the nation, Americans who are members of racial and ethnic groups are more likely than whites to suffer poor health and die prematurely. a. Genetic variations, environmental influences, and specific health behaviors contribute to health disparities, but poverty may be a more significant factor.

2. Why Race Matters i. Black Americans lose substantially more years of potential life to homicide and diabetes ii. About one in three Hispanics has prediabetes iii. Caucasians are prone to osteoporosis (progressive weakening of bone tissue); cystic fibrosis; skin cancer; and phenylketonuria (PKU), a metabolic disorder that can lead to cognitive impairment iv. Native Americans, including those indigenous to Alaska, are more likely to die young than the population as a whole, primarily as a result of accidental injuries, cirrhosis of the liver, homicide, pneumonia, and complications of diabetes. v. The suicide rate among American Indians and Alaska Natives is 50 percent higher than the national rate. The rates of co-occurring mental illness and substance abuse (especially alcohol abuse) are also higher among Native American youth and adults. b. Cancer i. Overall, black Americans are more likely to develop cancer than persons of other racial or ethnic groups. ii. Although blacks continue to have higher cancer death rates than whites, the disparity has narrowed for all cancers combined in men and women and for lung and prostate cancers in men. iii. However, the racial gap in death rates has widened for breast cancer in women and remained level for colorectal cancer in men. c. Cardiovascular Disease i. Heart disease and stroke are the leading causes of death for all racial and ethnic groups in the United States, but rates of death from these diseases are higher among African American adults than among white adults. ii. African Americans also have higher rates of high blood pressure (hypertension), develop this problem earlier in life, suffer more severe hypertension, and have higher rates of stroke. d. Diabetes i. American Indians and Alaska Natives, African Americans, and Hispanics are twice as likely to be diagnosed with diabetes compared with non-Hispanic whites. e. Infant Mortality i. African American, American Indian, and Puerto Rican infants have higher death rates than white infants.

f. Mental Health i. American Indians and Alaska Natives suffer disproportionately from depression and substance abuse. ii. The prevalence of dementia varies significantly among Americans of different racial and ethnic groups, with the highest rates among blacks and American Indians/Alaskan Natives. g. Infectious Disease i. Asian Americans and Pacific Islanders have much higher rates of hepatitis B. ii. Black teenagers and young adults become infected with hepatitis B three to four times more often than those who are white. h. HIV and Sexually Transmitted Infections i. African Americans and Hispanics account for about two-thirds of adult AIDS cases and more than 80 percent of pediatric AIDS cases. 3. Sex, Gender, and Health a. Medical scientists define sex as a classification, generally as male or female, according to the reproductive organs and functions that derive from the chromosomal complement. b. Gender refers to a person’s self-representation as a male or female or how that person is responded to by social institutions on the basis of the individual’s gender presentation. c. Sex and gender may have a greater impact than any other variable on how our bodies function, on how long we live, and the symptoms, course, and treatment of the diseases that strike us. d. Among the reasons that may contribute to the health and longevity gap between the sexes are: i. Biological factors ii. Social factors iii. Behavioral factors iv. Health habits e. Sexual orientation can also affect health. III. Health on Campus A. Overview 1. As one of an estimated 21 million college students in the United States, you are part of a remarkably diverse group. 2. Although most undergraduates are “traditional” age (between 18 and 24 years old), more than ever before are over the age of 25. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

3. Today’s college students are both similar to and different from previous generations in many ways. B. College and Health 1. Although the words “college health” often appear together, they are, in fact, two different things that profoundly influence each other. Healthier students get better grades and are more likely to graduate. a. A college education boosts health status, income, and community engagement later in life. b. Yet the transition from high school to college is considered an at-risk period for health and healthy behaviors. 2. Although healthier than their peers who are not attending college, undergraduates have significant health issues that can affect their overall well-being and ability to perform well in an academic environment. C. How Healthy Are Today’s Students? 1. In the American College Health Association’s National College Health Assessment (ACHA-NCHA) survey, more than 8 in 10 undergraduates (fewer than in previous years) rated their health as good, very good, or excellent. 2. Yet the habits of young Americans often aren’t healthy. 3. Colleges and universities have tried various interventions to improve students’ health choices and habits. a. In a meta-analysis of 41 studies, most conducted in the United States, 34 yielded significant improvements in one of several key outcomes. D. Why “Now” Matters 1. The choices you make today have an immediate impact on how you feel as well as long-term consequences. E. Student Health Norms 1. Psychologists use the term norm, or social norm, to refer to a behavior or an attitude that a particular group expects, values, and enforces. a. Norms influence a wide variety of human activities, including health habits. b. However, perceptions of social norms are often inaccurate. c. Undergraduates are particularly likely to misjudge what their peers are and aren’t doing, especially regarding smoking, drinking, and other drug use. F. The Promise of Prevention 1. Many chronic problems begin early in life. 2. Two out of every three deaths and one in three hospitalizations in the United States could be prevented by changes in six main risk factors: © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

tobacco use, alcohol abuse, accidents, high blood pressure, obesity, and gaps in screening and primary health care. G. Protecting Yourself 1. Immunizations 2. Prevent STIs and unwanted pregnancies H. Understanding Risky Behavior 1. Today’s students face different and potentially deadlier risks than undergraduates did a generation or two ago. 2. The problem is not that students who engage in risky behavior feel invulnerable or do not know the danger. a. Young people, according to recent research, actually overestimate the risk of some outcomes. b. However, they also overestimate the benefit of immediate pleasure when, for instance, engaging in unsafe sex, and they underestimate the negative consequences, such as an STI. IV. Making Healthy Changes A. Understanding Health Behavior 1. Predisposing Factors a. Predisposing factors include knowledge, attitudes, beliefs, values, and perceptions. b. Researchers report that people are most likely to change health behavior if they hold three beliefs: i. Susceptibility ii. Severity iii. Benefits 2. Enabling Factors a. Enabling factors include skills, resources, accessible facilities, and physical and mental capacities. 3. Reinforcing Factors a. Reinforcing factors may be praise from family and friends, rewards from teachers and parents, or encouragement and recognition for meeting a goal. V. How and Why People Change A. Overview 1. Change can simply happen, but can also be intentional. a. In intentional change, a person consciously, deliberately sets out either to change a negative behavior, such as chronic procrastination, or to initiate a healthy behavior, such as daily exercise. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. For decades psychologists have studied how people intentionally change and have developed various models that reveal the anatomy of change. a. In the moral model, you take responsibility for a problem (such as smoking) and its solution; success depends on adequate motivation. b. In the enlightenment model, you submit to strict discipline to correct a problem; this is the approach used in Alcoholics Anonymous. c. The behavioral model involves rewarding yourself when you make positive changes. d. The medical model sees the behavior as caused by forces beyond your control (a genetic predisposition to being overweight, for example) and employs an expert to provide advice or treatment. B. The Health Belief Model 1. According to this model, people will take a health-related action if they: a. Feel susceptible to a possible negative consequence b. Perceive the consequence as serious or dangerous c. Think that a particular action will reduce or eliminate the threat d. Feel that they can take the necessary action without difficulty or negative consequences e. Believe that they can successfully do what’s necessary C. Self-Determination Theory 1. This approach focuses on whether an individual lacks motivation, is externally motivated, or is intrinsically motivated. D. Motivational Interviewing 1. Health professionals, counselors, and coaches use motivational interviewing to inspire individuals, regardless of their enthusiasm for change, to move toward improvements that could make their lives better. E. Self-Affirmation Theory 1. According to self-affirmation theory, thinking about core personal values, important personal strengths, or valued relationships can provide reassurance and reinforce self-worth. a. Repeating an affirmation is one of the fastest ways to restructure thought patterns, develop new pathways in the brain, and make individuals less defensive about changing health behaviors. F. Transtheoretical Model 1. Their transtheoretical model focuses on universal aspects of an individual’s decision-making process rather than on social or biological influences on behavior. 2. The key components of the transtheoretical model of change include stages of change, processes of change, and self-efficacy. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

a. Stages of Change i. Precontemplation ii. Contemplation iii. Preparation iv. Action v. Maintenance vi. Termination b. Processes of Change i. Consciousness-Raising ii. Social Liberation iii. Emotional Arousal iv. Self-Reevaluation v. Commitment vi. Rewards vii. Countering viii. Environmental Control ix. Helping Relationships 3. Self-Efficacy and Locus of Control a. Self-efficacy is the belief in your ability to change and to reach a goal. b. Locus of control is the sense of being in control of your life.

Discussion Questions •

Discuss with students which dimension of health is most prominent in their lives. Why? Which are they least concerned with? Ask students what they could do in order to incorporate all components into their lives? What are some of the obvious differences between those who do incorporate all of these aspects into their lives and those who only concentrate on one or two components?

•

Ask students to take a quick inventory of their own and their immediate family’s health status. Using the statistics found in the text, compare their inventory to the different health risks for their racial and ethnic group. Ask students what factors they believe contribute to the differences in health status that various racial and ethnic groups face. How might religion affect the health of a culture? Ask students which family health problems may “run in the family” and if they have concerns about eventually getting these illnesses?

•

What challenges do ethnicity, race, religion, gender, and sexual orientation bring to the health-care system? What actions can government, universities, hospitals, and other health-care facilities and individuals take to address these differences? What factors in the health-care system might keep various individuals from keeping up with their health?

•

Ask students how they have handled their newfound freedom since attending college or leaving home for the first time. How have their parents handled and reacted to it? How does the sense of independence affect their health? Are there any additional health challenges that they face?

•

Ask students to identify their most common health problems. Do students have similar health problems? Why or why not? Ask students to generate a list of ways to prevent these health problems?

Answers to Global Health Watch 1. b 2. c 3. surgery rates

Classroom Activities Activity #1: Meet Your Classmates Purpose: 1.

To meet your classmates and learn to appreciate the differences we all share.

To learn how to appreciate nonverbal communication.

Time: Ten to fifteen minutes of class.

Introduction: Introduce the disparities in health and how often we overlook our differences. Elaborate on the following communication facts: 1. Seven percent of communication is the result of the verbal message: words. 2. Thirty-five percent of communication is the result of verbal cues: volume, pitch, etc. 3. Fifty-eight percent of communication is the result of nonverbal cues.

Method: 1.

Go to an area in which students can easily move around.

Divide the class into two or three teams.

Have students stand in a straight line.

Give students a topic (most siblings, most pets, most operations, height, weight, age, foot size).

Have students line up accordingly (most to least, least to most).

Keep track of time to see which group lines up first (and then compare times after they are not allowed to speak).

To add a twist, don’t let students talk while trying to line up.

Repeat many times, so the students get a chance to be in a different location each time.

Discussion: 1.

Discuss with the students how they felt when they could not talk. What did they rely on to communicate? a. How did some communicate? Were there different styles? b. Is nonverbal communication as effective as verbal communication? Explain.

Discuss whether anyone was always in the same place in line. Discuss these differences.

How might these differences reflect how we treat ourselves? Our lifestyle behaviors?

Activity #2: The Dimensions of Health Purpose: 1.

To introduce and investigate the dimensions of health and how various individuals perceive these dimensions.

To analyze human behavior in the context of physical, psychological, social, intellectual, environmental, and spiritual health.

To enable students to meet their classmates.

Time: One class period.

Method: 1.

Form a circle in the room.

Instruct each student to introduce himself or herself and identify a dimension of health that represents their lifestyle by acting it out.

Discussion: 1.

Discuss the various ways that people perceived the dimensions not only from the person acting out the dimension but also from the audience.

Activity #3: Family Health History Purpose: 1.

To investigate your family health history.

To analyze how current health practices along with family health history can determine future health.

Time: One class period.

Method: 1.

Have students first create a family tree that includes parents, siblings, grandparents, aunts, and uncles. Students should also list close relatives who may be deceased.

After creating the family tree, students should list the health concerns or illnesses that any family member has experienced.

Discussion: 1.

How many relatives in their family tree have health concerns?

Discuss how those health conditions may play a role in the student’s life in terms of their own health.

Discuss strategies for behavior change or preventive measures each student can take to possibly avoid the same health concerns.

Activity #4: Goal Setting for a Healthy Change Purpose: To establish one or more goals that you would like to strive toward throughout the semester.

Time: Half of a class period.

Method: 1.

Have each student choose one lifestyle change that they would like to work on or improve during the semester.

Have the student determine what stage of change they feel they are currently in: precontemplation, contemplation, preparation, or action. (They will not be in the maintenance or the termination stage if they are working to improve a health behavior.)

Based on their stage of change, have the students refer to the chart on page 17 in the text and identify which of the nine processes in the transtheoretical model they can use to help them move to the next stage of change.

Have the student come up with one idea that they will use for each of the processes they identified.

Discussion: 1. Discuss the likelihood that the student will implement the ideas they thought of for the processes of change. If the likelihood is not good, ask why. Have the students reassess their goal, the stage of change they are in and the ideas for each process of change. If the likelihood is good, create an assignment or discussion to follow up on their progress.

References, Readings, and Resources American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Centers for Disease Control and Prevention. National Vital Statistics Report 64, no. 2 (February 16, 2016). United States Life Tables, 2009. Falk, Emily B., et al. “Self-Affirmation Alters the Brain’s Response to Health Messages and Subsequent Behavior Change.” Proceedings of the National Academy of Sciences 112, no. 7 (2015): 1977–82. doi: 10.1073/pnas.1500247112. McNamara, Robert S., et al. “Motivational Interviewing Intervention with College Student Tobacco Users: Providers’ Beliefs and Behaviors.” Journal of American College Health 63, no. 4 (2015): 286–90. doi: 10.1080/07448481.2014.1003376. Montanaro, E. A., & Bryan, A. D. “Comparing Theory- Based Condom Interventions: Health Belief Model versus Theory of Planned Behavior.” Health Psychology 33, no. 10 (2014): 1251–60. doi: http://dx.doi. org/10.1037/a0033969. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities (Hyattsville, MD: Author, 2016). Racial and Ethnic Health Disparities.

Films and Videos A Simple Way to Break a Bad Habit (Psychiatrist Judson Brewer studies the relationship between mindfulness and habits. Learn more about the mechanism of habit development and discover a simple but profound tactic that might help you beat your next urge to smoke, snack, or check a text while driving.) Judson Brewer: A Simple Way to Break a Bad Habit Achieve a Healthy Lifestyle (“What we do, and what we put into our bodies, has a direct impact on the way we feel.” To prove the point, Rick, a health enthusiast, is contrasted with his friend Tina, a nightclubbing, smoking, convenience-food junkie.) Films Media Group 132 West 31st Street, 16th Floor © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Homeostasis (This program introduces students to the phenomenon of homeostasis, illustrating its crucial importance and how it works inside the body.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Nutrition Starts Here (Join Chef Marshall O’Brien as he shares nutritious food choices and healthy eating strategies in Nutrition Starts Here: Smart Eating on a Budget.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Our Cultures Are Our Source of Health (Renowned Hollywood actor and Cherokee tribal member, Wes Studi, explains how American Indians and Alaska Natives are twice as likely to have diagnosed diabetes as non-Hispanic whites.) Centers for Disease Control and Prevention Our Cultures Are Our Source of Health Outbreak (This film tells the vivid, inside story of how and why the Ebola outbreak in West Africa wasn’t stopped before it was too late, drawing on revelatory and candid admissions of failure from key government and public health officials.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources Centers for Disease Control and Prevention Provides a wide variety of information and is a gateway to specific CDC agencies. Centers for Disease Control and Prevention Go Ask Alice Sponsored by Columbia University, this site offers questions and answers as well as an interactive service on a wide variety of health-related topics. Go Ask Alice Healthways “World Faces Shortage in Purpose Well-Being” Healthy People 2020 “Healthy People 2020” Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. health.gov – Healthy People Centers for Disease Control and Prevention – Healthy People National Institutes of Health A governmental organization that supplies data and resources on a wide variety of health issues. National Institutes of Health National Patient Safety Foundation and Partnership for Clear Health Communication The Partnership for Clear Health Communication is a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomes. Ask Me 3: Good Questions for Your Good Health Office of Minority Health The Office of Minority Health was created in 1986 as one of the most significant outcomes of the Heckler Report and was reauthorized by the Affordable Care Act (ACA) in 2010. The mission of the Office of Minority Health is to improve the health of © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

racial and ethnic minority populations through the development of health policies and programs that will eliminate health disparities. Office of Minority Health Home Page Office on Women’s Health The Office on Women’s Health provides national leadership and coordination to improve the health of women and girls through policy, education, and model programs. Womenshealth.gov U.S. National Library of Medicine This excellent governmental website features information on a variety of medical conditions; current health topics; research projects; directories of doctors, hospitals, and other health-care providers; as well as access to other online medical resources such as Medline. U.S. National Library of Medicine

Key Terms enabling factors

protection

health

reinforcing factors

health belief model (HBM)

self-efficacy

health promotion

social norm

locus of control

transtheoretical model

predisposing factors

wellness

prevention

2 Your Psychological and Spiritual WellBeing Learning Objectives After studying this chapter in the text, the student should be able to: 2.1

Identify the components of psychological health.

2.2

Discuss the ways in which positive psychology enhances quality of life.

2.3

Review the relationship of sleep and health.

2.4

Describe the key factors related to depressive disorders, their symptoms, and treatments.

2.5

Summarize four categories of anxiety disorders.

2.6

Outline the patterns of attempting or committing suicide among Americans.

2.7

List treatment options available for mental disorders.

Chapter Summary Psychological health can make the difference between facing a challenge with optimism and confidence or feeling overwhelmed by expectations and responsibilities.

Lecture Outline I.

Emotional and Mental Health A. Psychological health encompasses both our emotional and our mental states—that is, our feelings and our thoughts. B. Emotional health generally refers to feelings and moods. C. Characteristics of emotionally healthy persons, identified in an analysis of major studies of emotional wellness, include the following: 1. Determination and effort to be healthy

2. 3. 4. 5. 6. 7. 8.

Flexibility and adaptability to a variety of circumstances Development of a sense of meaning and affirmation of life An understanding that the self is not the center of the universe Compassion for others The ability to be unselfish in serving or relating to others Increased depth and satisfaction in intimate relationships A sense of control over the mind and body that enables the person to make health-enhancing choices and decisions D. Mental health describes our ability to perceive reality as it is, to respond to its challenges, and to develop rational strategies for living. E. The characteristics of mental health include: 1. The ability to function and carry out responsibilities 2. The ability to form relationships 3. Realistic perceptions of the motivations of others 4. Rational, logical thought processes 5. The ability to adapt to change and to cope with adversity F. Culture helps to define psychological health. In our diverse society, many cultural influences affect Americans’ sense of who they are, where they came from, and what they believe. II.

The Lessons of Positive Psychology A. Overview 1. Positive psychology is defined as “the scientific study of ordinary human strengths and virtues.” 2. The three major areas of positive psychology are the study of positive emotions, such as hope and trust; positive traits, such as wisdom and courage; and positive institutions, such as strong families and democracy. B. Develop Self-Compassion: a healthy form of self-acceptance and a way of conceptualizing our favorable and unfavorable attitudes about ourselves and others. Three components of self-compassion are: 1. Treating oneself kindly in the face of perceived inadequacy by engaging in self-soothing and positive self-talk 2. Recognizing that such discomfort is an unavoidable part of the human experience—this recognition of “common humanity” promotes a sense of connection to others even in the face of isolation and disappointment 3. Facing painful thoughts without avoiding or exaggerating them and managing disappointment and frustration by quelling self-pity and melodrama

C. Boost Emotional Intelligence: “EQ” (for emotional quotient) is the ability to monitor and use emotions to guide thinking and actions. D. Meet Your Needs. According to Maslow, human needs are the motivating factors in personality development. 1. First, we must satisfy our basic physiological needs, such as those for food, shelter, and sleep. 2. Only then can we pursue fulfillment of our higher needs—for safety and security, love and affection, and self-esteem. 3. Few reach the state of self-actualization, in which one functions at the highest possible level and derives the greatest possible satisfaction from life. E. Boost Self-Esteem 1. Self-esteem is belief or pride in ourselves; it gives us confidence to dare to attempt to achieve at school or work, and to reach out to others to form friendships and close relationships. 2. Self-esteem is based on what you believe about yourself. It is not something you are born with; it develops over time. 3. One of the most useful techniques for bolstering self-esteem and achieving your goals is developing the habit of positive thinking and talking. F. Pursue Happiness 1. Psychological research has identified three major factors that contribute to a sense of well-being: your happiness set-point, life circumstances such as income or marital status, and thoughts, behaviors, beliefs, and goal-based activities. 2. Education, intelligence, gender, and race do not matter much for happiness. 3. Recent research suggests that happiness comes from: a. Focusing on time rather than focusing on money b. Spending time and money on others rather than oneself c. Spending time and money to acquire experiences rather than possessions G. Become Optimistic 1. Mental health professionals define optimism as the “extent to which individuals expect favorable outcomes to occur.” 2. Studies have established “significant relationships” between optimism and cardiovascular health, stroke risk, immune function, cancer prognoses, physical symptoms, pain, and mortality rates. 3. In terms of health, optimists not only expect good outcomes—but take steps to increase this likelihood. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

H. Manage Your Moods 1. A mood is a more sustained emotional state that colors our view of the world for hours or days. 2. The most effective way to banish a sad or bad mood is by changing what caused it in the first place. III. Spiritual Health A. Overview 1. Spiritual health refers to a breath of life and involves our ability to identify our purpose in life and to experience the fulfillment of achieving our full potential. 2. Spirituality is a belief in what some call a higher power, in someone or something that transcends the boundaries of self. 3. Religiosity refers to various spiritual practices. B. Spirituality and Physical Health 1. A growing body of scientific evidence indicates that faith and spirituality can enhance health—and perhaps even extend life. 2. Church attendance may account for an additional two to three years of life (by comparison, exercise may add 3–5 extra years). 3. Prayer and other religious experiences, including meditation, may actually change the brain for the better. C. Deepen Your Spiritual Intelligence 1. Spiritual intelligence is the capacity to sense, understand, and tap into the highest parts of ourselves, others, and the world around us. 2. Spiritual intelligence, unlike spirituality, does not center on the worship of an external God, but the discovery of wisdom within. D. Clarify Your Values 1. Values are the criteria by which you evaluate things, people, events, and yourself; they represent what’s most important to you. 2. When you confront a situation in which you must choose different paths or behaviors, follow these steps: a. Carefully consider the consequences of each choice. b. Choose freely from among all of the options. c. Publicly affirm your values by sharing them with others. d. Act out your values. E. Enrich Your Spiritual Life 1. Whatever role religion plays in your life, you have the capacity for deep, meaningful spiritual experiences that can add great meaning to everyday existence. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

a. Sit quietly. b. Start small. c. Step outside. d. Use activity to tune into your spirit. e. Ask questions of yourself. f. Trust your spirit. g. Develop a spiritual practice. F. Consider the Power of Prayer 1. Prayer is the most commonly used form of complementary and alternative medicine. G. Cultivate Gratitude 1. A grateful spirit brightens mood, boosts energy, and infuses daily living with a sense of glad abundance. 2. Feelings of gratitude are associated with better mood, improved sleep, less fatigue, less inflammation, and lower risk of heart failure. H. Forgive 1. When you forgive, you let go of all the anger and pain that have been demanding your time and wasting your energy. 2. When you forgive, you reclaim your power to choose. 3. Forgiveness based interventions have resulted in greater self-esteem and hopefulness, positive emotions toward others, less depression and anxiety, and improved resistance to drug use. IV. Sleep and Health A. Overview 1. About 35 percent of U.S. adults sleep less than 7 hours a night, which puts them at risk of obesity, type 2 diabetes, high blood pressure, heart disease, stroke, mental distress, and death. B. Student Night Life 1. In recent research, about two-thirds of students reported poor sleep quality; the average number of hours slept reported by participants was 6.68, with a range of 1–11 hours. 2. In the American College Health Association–National College Health Assessment (ACHA-NCHA) survey, about one in five college students said that sleep difficulties have affected their academic performance, ranking behind stress and anxiety. 3. Alcohol compounds many sleep problems. 4. Female students generally have poorer sleep patterns than males and suffer more consequences as a result. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

5. On average college students go to bed 1–2 hours later and sleep 1–1.6 hours less than students of a generation ago. C. Sleep’s Impact on Health 1. Nighttime sleep affects your daytime well-being in the following areas: a. Learning and memory b. Metabolism and weight c. Safety d. Mood/quality of life e. Immunity f. Mental disorders g. Major diseases and death D. How Much Sleep Do You Need? 1. To figure out your sleep needs, keep your wake-up time the same every morning and vary your bedtime. See how you feel throughout the day. E. Treating Sleep Disorders 1. About 6–10 percent of adults suffer from insomnia, difficulty initiating or maintaining sleep, or early-morning waking with inability to return to sleep that leads to fatigue, poor cognitive function, mood disturbance, distress, or impaired personal functioning. 2. In its recent guidelines, the American College of Physicians recommends cognitive-behavioral therapy (CBT) as first-line therapy for chronic insomnia. 3. If CBT fails, medications may be considered, including a. Over-the-counter medications b. Dietary supplements c. Prescription medications V.

Understanding Mental Health A. Overview 1. Mentally healthy individuals value themselves, perceive reality as it is, accept their limitations and possibilities, carry out their responsibilities, establish and maintain close relationships, pursue work that suits their talent and training, and feel a sense of fulfillment that makes the efforts of daily living worthwhile. B. What Is a Mental Disorder? 1. Psychiatrists define a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

C. Mental Health on Campus 1. There have been increases in the numbers of students seeking psychological services and in the severity of problems they report, such as drug use, alcohol abuse, sexual assaults, self-injury, and suicide. 2. According to the ACHA-NCHA survey, about one in four undergraduates has been diagnosed or treated for a mental disorder. 3. Risk factors for significant mental health impairment include a. History of a mental disorder b. Ongoing psychiatric issues c. Breakup d. Financial pressures e. Discrimination f. Increased risk of other disorders g. Minority status 4. Psychological and emotional problems can affect every aspect of a student’s life, including physical health, overall satisfaction, and relationships. a. In the ACHA-NCHA’s national survey, 24 percent of students reported that anxiety had impaired their ability to learn and earn higher grades; 15 percent said that depression had affected their academic performance. b. The impact of mental health problems extends beyond an individual student to roommates, friends, classmates, family, and instructors. VI. Depressive Disorders A. Overview 1. Depression, the world’s most common mental ailment, affects more than 13 million adults in the United States every year and costs billions of dollars for treatment and lost productivity and lives. B. Depression in Students 1. An estimated 15–40 percent of college-age men and women may develop depression, but the number may be rising. 2. Three key contributors to depression in college students are stress, too little sleep, and academic and athletic pressures. C. Gender and Depression 1. Female Depression a. Depression is twice as common in women as men. i. However, this gender gap decreases or disappears in studies of men and women in similar socioeconomic situations. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. Brain chemistry and sex hormones may play a role. c. The DSM-5 classifies premenstrual dysphoric disorder (PDD), which is not the same as pre-menstrual syndrome (PMS), as a depressive disorder. i. In the final week before onset of menstruation, an estimated 1.8–5.8 percent of women experience the characteristic symptoms of PDD: 2. Male Depression a. More than 6 million men in the United States—1 in every 14—suffer from this insidious disorder, many without recognizing what’s wrong. b. Experts describe male depression as an “under” disease: underdiscussed, underrecognized, underdiagnosed, and undertreated. c. Genes may make some men more vulnerable to depression, but chronic stress of any sort plays a major role. D. Major Depressive Disorder 1. An estimated 20–30 percent of college students may develop a major depressive disorder, which can simply be defined as sadness that does not end. 2. The characteristics of depression include: a. Feeling depressed b. Loss of interest c. Eating more or less d. Having trouble sleeping e. Feeling slowed down or feeling restless f. Lacking energy g. Feeling helpless, hopeless, and worthless h. Having difficulty thinking or concentrating i. Having persistent thoughts of death or suicide E. Treating Depression 1. The most recent guidelines for treating depression call for an individualized approach tailored to each patient’s symptoms. 2. Medication has become the most common approach, while fewer patients receive psychotherapy, possibly because of limited insurance coverage. 3. A combination of psychotherapy and medication is considered the most effective approach for most patients. F. Bipolar Disorder 1. Known as manic depression in the past, bipolar disorder consists of mood swings, changes in thinking, changes in behavior, and changes in physical condition.

2. Bipolar and related disorders affect approximately 4 percent of the population. 3. Professional therapy is essential in treating bipolar disorders. VII. Anxiety Disorders A. Overview 1. Anxiety disorders, which affect an estimated 10–15 percent of psychiatric patients, are more common than depression (diagnosed in 7–10 percent of patients). B. Specific Phobia 1. Phobias—the most prevalent type of anxiety disorder—are out-of-theordinary, irrational, intense, persistent fears of certain objects or situations. 2. Although various medications have been tried, the best approach is behavioral therapy, which consists of gradual, systematic exposure to the feared object (a process called systematic desensitization). C. Panic Attacks and Panic Disorder 1. Panic attacks often involve one or more of the following: a racing heart, light-headedness or dizziness, rapid breathing, hyperventilation, tingling and numbness in parts of the body, and the sense that something horrible is about to happen. 2. Panic disorder develops when attacks recur or apprehension about them becomes so intense that individuals cannot function normally. 3. The two primary treatments for panic disorder are cognitive-behavioral therapy (CBT), which teaches specific strategies for coping with symptoms such as rapid breathing, and medication. D. Generalized Anxiety Disorder 1. About 10 million adults in the United States suffer from a generalized anxiety disorder (GAD), excessive or unrealistic apprehension that causes physical symptoms, such as restlessness, fatigue, and muscle tension that lasts for 6 months or longer. E. Obsessive–Compulsive Disorder 1. An estimated 1.9–3.3 percent of Americans have an obsessive–compulsive disorder (OCD). Some of these individuals suffer only from an obsession, a recurring idea, thought, or image that they realize, at least initially, is senseless. 2. The most common obsession are: a. Repetitive thoughts that usually involve harm and danger b. Contamination (e.g., becoming infected by shaking hands) © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

c. Doubt (e.g., wondering whether one has performed some act, such as having hurt someone in a traffic accident) 3. Compulsion: a repetitive behavior performed according to certain rules or in a stereotyped fashion. The most common compulsions are: a. Handwashing b. Cleaning c. Repeating words silently d. Counting e. Checking (e.g., making sure dozens of times that a door is locked) VIII. Other Common Disorders A. Attention-Deficit/Hyperactivity Disorder 1. Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common mental disorder in childhood. 2. An estimated 5.9–7.1 percent of children and adolescents suffer from ADHD. 3. About 5 percent of adults have ADHD. 4. The characteristic symptoms of ADHD are: a. Inattention b. Hyperactivity c. Impulsivity 5. ADHD on Campus 6. An estimated 2–8 percent of young adult college students report clinically significant ADHD symptoms. 7. The normal challenges of college—navigating the complexities of scheduling, planning courses, and honing study skills—may be especially daunting for these students, who may find it hard to concentrate, read, make decisions, complete complex projects, and meet deadlines. 8. The medications used for this disorder include stimulants (such as Ritalin), which improve behavior and cognition for about 70 percent of adolescents with ADHD. 9. Undergraduates with ADHD are at higher risk of becoming smokers, abusing alcohol and drugs, and having automobile accidents. B. Autism Spectrum Disorder 1. Autism, a complex neurodevelopmental disability that causes social and communication impairments, is a “spectrum” disorder that includes several disorders with similar features. 2. According to recent estimates from the CDC, about 1 in 68 children has autism spectrum disorder (ASD). © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

3. There is no scientific evidence that any part of a vaccine or combination of vaccines causes autism, nor is there proof that any material used to produce the vaccine, such as thimerosal, a mercury-containing preservative, plays a role in causing autism. 4. Symptoms, which include repetitive patterns of thoughts and behavior and inability to communicate verbally, usually start before age 3 and can create delays or problems in many different skills that develop from infancy to adulthood. 5. Autism Spectrum Disorder on Campus: a. Increasing numbers of adolescents and young adults diagnosed with ASD—an estimated 2 percent of all undergraduates with disabilities— are entering colleges and universities. b. Although many have the cognitive ability to succeed academically, a high percentage of ASD-diagnosed undergraduates do not complete their postsecondary programs. C. Schizophrenia 1. Schizophrenia is one of the most debilitating mental disorders, which profoundly impairs in individual’s sense of reality. 2. Symptoms: a. Hallucinations b. Delusions c. Disorganized thinking d. Talking in rambling or incoherent ways e. Making odd or purposeless movements or not moving at all f. Repeating others’ words or mimicking their gestures g. Showing few, if any, feelings; responding with inappropriate emotions h. Lacking will or motivation to complete a task or accomplish something i. Functioning at a much lower level than in the past at work, in interpersonal relations, or in taking care of themselves 3. Schizophrenia, which affects 0.3–0.7 percent of the world’s population, is one of the leading causes of disability among young adults. 4. For the vast majority of individuals with schizophrenia, antipsychotic drugs are the foundation of treatment. D. Nonsuicidal Self-Injury 1. Deliberately harming oneself may take any form of damage to the body: cutting, burning, stabbing, hitting, and excessive rubbing. 2. The intent is not to take one’s life but to obtain relief from painful feelings or thoughts.

IX. Suicide Suicide is not in itself a psychiatric disorder, but it is often the tragic consequence of emotional and psychological problems. At all ages, men commit suicide three to four times more frequently than women, but women attempt suicide much more often than men. A. Overview 1. Suicide is the third leading cause of death among 10- to 24-year-olds in the United States. 2. Long considered a threat to younger and older Americans, suicide has increased significantly among middle-aged men and women. B. Suicide on Campus 1. More than 1,100 college students take their own lives every year; many more—an estimated 1.2 percent of undergraduates—attempt to do so. C. Factors That Lead to Suicide 1. Suicidal behavior disorders 2. Mental disorders 3. Substance abuse 4. Hopelessness 5. Combat stress 6. Family history 7. Physical illness 8. Brain chemistry 9. Access to guns 10. Other factors a. Individuals who kill themselves often have gone through more major life crises—job changes, births, financial reversals, divorce, retirement—in the previous six months, compared with others. X.

Overcoming Problems of the Mind A. Overview 1. At any given time, about 25 percent of men, women, and children meet the criteria for a mental disorder, yet 70 percent of those in need of psychological help never receive it. B. Where to Turn for Help 1. About 10 percent of students seek care from a mental health counseling center on campus. 2. Your health education instructor can tell you about general and mental health counseling available on campus.

3. Within the community, you may be able to get help through the city or county health department and neighborhood health centers as well as local hospitals. C. Types of Therapy 1. Psychotherapy refers to any type of counseling based on the exchange of words in the context of the unique relationship that develops between a mental health professional and a person seeking help. 2. Brief Psychotherapies a. Short-term treatments typically focus on a central issue and typically conclude in less than 6 months or 24 sessions. 3. Psychodynamic Psychotherapy a. This therapy takes into account the role of early experiences and unconscious influences in actively shaping behavior. 4. Cognitive-Behavioral Therapy (CBT) a. CBT focuses on inappropriate and inaccurate thoughts or beliefs to help individuals break out of a distorted way of thinking. 5. Behavioral Therapy a. The goal is to substitute healthier ways of behaving for maladaptive patterns used in the past. 6. Interpersonal Therapy (IPT) a. IPT focuses on relationships in order to help individuals deal with unrecognized feelings and needs and improve their communication skills. D. Other Treatment Options 1. Psychiatric Drugs 2. Thanks to the development of more precise and effective psychiatric drugs (medications that regulate a person’s mental, emotional, and physical functions to facilitate normal functioning), success rates for treating many common and disabling disorders—depression, panic disorder, schizophrenia, and others—have soared. 3. Alternative Mind-Mood Products a. Some “natural” products, such as herbs and enzymes, claim to have psychological effects. i. However, they have not undergone rigorous scientific testing. b. Daily meditation might help relieve anxiety and depression.

Discussion Questions •

Discuss the concept of psychological health as it relates to the other five dimensions of health. Can psychological health be separate and distinct from the other components without affecting them? How so? How do the other dimensions affect one’s psychological health?

•

Ask students what it means to love and accept themselves. Can one accept and love another without first loving oneself? How? Why? How does this relate to Maslow’s hierarchy of thinking?

•

Ask students what emotional intelligence means to them. Discuss the benefits of possessing emotional intelligence. What role does an individual’s EQ play in their everyday life or career? Ask them which they would rather have, a high IQ or a high EQ? Why or why not?

•

Ask students what factors contribute to happiness. Compare these characteristics to those cited for contributing to good psychological health. Ask students to make a list of the things that make them happy. Do they think of the things on the list when they make choices or decisions that may or may not affect their happiness? Why? How come?

•

Discuss the concept of sleep deprivation as discussed in the text. Ask for volunteers who have experienced it to share their symptoms or experiences. Ask others to share the strategies and rituals they use in order to reduce sleep deprivation and maximize restful sleep. How might they improve their sleep rituals? Why is it important at this point in their lives to get enough sleep?

•

Provide a definition for mental well-being and for mental illness. Have students brainstorm characteristics and symptoms for each. Also work through the stereotypes of mental illness and attempt to explain how “normal” people can become so overwhelmed by “life” that depression or other illnesses occur.

•

Compare and contrast the everyday blues to depressive disorder. What characteristics differentiate the two? When might one seek professional counseling? How and where can they get it? What is available on campus? How might one afford such counseling? Describe the free services available and who to contact.

•

After reviewing the statistics related to suicide among the young, ask students why they believe this occurs. Note their responses on the chalkboard. Ask them to examine what society, families, and individuals can do to help prevent suicide.

•

Ask students how they might go about finding a mental health therapist. What questions might they ask in order to ascertain qualifications and experiences? (Have

them note that a similar list can be used to select any type of health practitioner). Formulate and share with them a list of low or no-cost counseling services available on your campus and within the community. Discuss the differences in psychiatrists, psychologists, and social workers. Also explain how some psychologists are trained in special areas. •

Discuss the number of psychiatric drugs that are out there and the differences between them. How do students view these types of drugs? How many students support Tom Cruise’s belief that they are not needed to treat depression? Why or why not?

•

Discuss suicide, including the major causes of suicide. Discuss the differences between males and females in terms of suicide risk.

Classroom Activities Activity #1: Abraham Maslow’s Hierarchy of Needs Purpose: To assist students in identifying their own potential.

Time: This activity will take 10–15 minutes.

Introduction: Introduce to students how not reaching our fullest potential can impact our health.

Method: 1.

Introduce to students Maslow’s Hierarchy of Needs and review the various levels within this model.

Have students make their own pyramid and have them write a brief statement about how they have reached each level or not reached a particular level.

Discussion: 1.

Ask students to identify areas that they are meeting.

Ask students to identify areas that they are not meeting.

How do they feel meeting or not meeting a particular area that has influenced their life?

Are there areas in life for which students believe that meeting each “step” isn’t necessary to achieve the next level? Why or why not?

Ask students to identify someone they believe has reached the self-actualization level. Why?

Activity #2: Enhancing Self-Esteem Purpose: To improve self-esteem.

Time: This activity will take 10–15 minutes.

Introduction: Enhancing self-esteem and personal well-being is a lifelong process.

Method: 1.

Have students ask themselves the following questions: a. How do I feel about my life in general—positively or negatively? b. Do I constantly send myself negative messages? c. What is one area of my life that I would like to improve upon?

Write two positive affirmations that you will repeat to yourself whenever you feel those negative or self-defeating thoughts begin to enter your mind.

Discussion: 1.

What factors have contributed to your feelings about your life in general, whether they are positive or negative?

Will your positive affirmations help derail any negative observations you have of yourself?

What role does self-esteem play in the ability to set and establish goals?

Activity #3: Self-Analysis: Depression Purpose: To increase awareness of signs of depression.

Time: This activity will take one-half to a whole class period with possible out of class research.

Introduction: Improving the ability to recognize the signs and symptoms of depression and to develop healthy strategies for coping with depression.

Method: 1.

Have students ask themselves the following questions: a. Do I have low self-esteem or feelings of inadequacy? b. Do I feel hopeless? c. Do I feel guilty? d. Do I have low energy and have feelings of fatigue? e. Am I having difficulty making decisions? f. Am I having difficulty enjoying pleasurable activities?

If students answered yes to any of those questions, then they should recognize that they could be suffering from depression.

Discussion: 1.

Ask students to reflect on how they feel about this experience? Were they surprised by the results?

Does this experience open their eyes to taking more time to work on their mental health and well-being?

If they are dealing with depression, what resources will they seek for help?

What resources are available on campus for students dealing with depression?

Activity #4: Self-Analysis: Sleep Purpose: To assess your daily sleep habits and to determine if you are getting an adequate amount of rest for optimal health.

Time: One week.

Method: 1.

Students should keep a sleep journal for 1 week. Students should keep track of the amount of time they sleep each day, the time at which they are sleeping, and how they felt upon waking each day.

At the end of 1 week, students should ask themselves the following questions: a. Do I wake up each day feeling well rested? b. Do I go to sleep at a different time each day? c. Am I taking a nap every day? d. Do I have to take medications or drink alcohol to go to sleep?

Discussion: 1.

Discuss the behavioral patterns that impact the amount of sleep students get on a daily basis.

Ask students if they have a clearer picture of their sleep habits and how they might be influencing their physical health.

Discuss the steps that students can take to improve their sleep habits.

References, Readings, and Resources Abbeduto, L., et al. “Neurodevelopmental Disorders.” In Textbook of Psychiatry, 6th ed., edited by Hales, R. E., et al. (Washington, DC: American Psychiatric Publishing, 2014). American College Health Association. American College Health Association-National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). American Psychiatric Association. Understanding Mental Disorders (Washington, DC: American Psychiatric Association, 2015). Baio, J. “Prevalence of Autism Spectrum Disorder among Children Aged 8 Years. Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010.” MMWR Surveillance Summaries 2, no. 63 (2014): 1–21. Dougherty, D. D., et al. “Obsessive Compulsive and Related Disorders.” In Textbook of Psychiatry, 6th ed., edited by Hales, R. E., et al. (Washington, DC: American Psychiatric Publishing, 2014). Ketter, T. A., and K. D. Chang. “Bipolar and Related Disorders.” In Textbook of Psychiatry, 6th ed., edited by Hales, R. E., et al. (Washington, DC: American Psychiatric Publishing, 2014). Liu, Y., et al. “Prevalence of Healthy Sleep Duration among Adults—United States, 2014.” Morbidity and Mortality Weekly Report 65, no. 6 (2016): 137–41. doi: 10.15585/mmwr.mm6506a1. Lucette, Aurelie, et al. “Spirituality and Religiousness Are Associated with Fewer Depressive Symptoms in Individuals with Medical Conditions.” Psychosomatics (2016). doi: 10.1016/j.psym.2016.03.005. Lyubominsky, S. The Myths of Happiness (New York: Penguin, 2013). Peach, Hannah, Jane F. Gaultney, and David D. Gray. “Sleep Hygiene and Sleep Quality as Predictors of Positive and Negative Dimensions of Mental Health in College Students.” Cogent Psychology 3, no. 1 (2016): 1168768. doi: 10.1080/23311908.2016.1168768.

Phillips, L., et al. “Eating Disorders and Spirituality in College Students.” Journal of Psychosocial Nursing and Mental Health Services 53, no. 1 (2015), 30–7. doi: 10.3928/02793695-20141201-01. Roberto, P. M., et al. “How Your Bank Balance Buys Happiness: The Importance of ‘Cash on Hand’ to Life Satisfaction.” Emotion (2016). doi: http://dx.doi.org/10.1037/emo0000184. Shatkin, J. P., and U. Diamond. “Psychiatry’s Next Generation: Teaching College Students about Mental Health.” Academic Psychiatry (2015). doi: 10.1007/s40596-0150305-1. Stein, M. B., et al. “Anxiety Disorders.” In Textbook of Psychiatry, 6th ed., edited by Hales, R. E., et al. (Washington, DC: American Psychiatric Publishing, 2014). Stroup, T. S., et al. “Schizophrenia Spectrum and Other Psychotic Disorders.” In Textbook of Psychiatry, 6th ed., edited by R. E. Hales, et al. (Washington, DC: American Psychiatric Publishing, 2014). Sontag-Padilla, Lisa, et al. “Factors Affecting Mental Health Service Utilization among California Public College and University Students.” Psychiatric Services (2016). doi: 10.1176/appi.ps.201500307.

Films and Videos A Beautiful Mind (The story of John Nash, Nobel Prize Winner who suffered from schizophrenia.) Available at most video stores. ADHD Rush Hour (This program speaks with students diagnosed with ADHD and to nearly a dozen medical and academic experts about its identification and treatment.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Anxiety Disorders (Humans, like many animals, possess a fine-tuned sense of danger. In truly hazardous situations, our awareness of threats is highly beneficial—but in 21st-century society it can become a constant state of mind, severely limiting a person’s ability to function.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Autism Spectrum Disorders (This three-part series presents the diagnosis evolution of autism, describes diagnostic mechanisms, and discusses specific treatment modalities.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group BLOW-UPS AND RAGES: Learning to Manage Your Anger

(Anger is a natural response to many of life’s most troubling situations, but all too often explosions of teen anger can be harmful and hurtful. Hostility and anger can devastate a teen’s life, destroy relationships, cloud effective thinking, impact school performance, affect physical health, and ruin future career plans.) Human Relations Media 800-431-2050 41 Kensico Drive Mt. Kisco, NY 10549 E: Human Relations Media Cut-Up Kids: The Epidemic of Self-Harm (For reasons still being explored, a growing number of children, teenagers, and young adults regularly and willfully cut, burn, and otherwise harm their own bodies. This film follows three young people as they confront the violence they have inflicted upon themselves.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Dark Days: Shedding Light on Depression (Even as ignorance about depression leads to social stigmas and alienation, many people with depression do not realize what ails them and therefore do not seek treatment in the first place. This program examines in detail what depression is, its various symptoms, and the options available for coping with or even curing it.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Girl Interrupted (Excellent movie about a young woman who is in a mental institution and the friendship and relationships endured.) Check your local video store.

Myths about Madness: Challenging Stigma and Changing Attitudes (Exposes myths surrounding afflictions of the mind and challenges discrimination against the mentally ill.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Schizophrenia (This three-part series takes a thorough look at schizophrenia, with discussions of the disorder’s etiology, its effects on the daily life of patients and their families, and the various impacts of deinstitutionalization.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group There’s No 3G in Heaven: Addressing Teen Suicide (This important program tells the story of an Australian community that, after a string of teen suicides, held a public meeting to allow the victims’ loved ones to share their experiences and discuss ways to prevent such tragedies in the future.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources American Association of Suicidology The American Association of Suicidology is an education and resource organization. American Association of Suicidology

Anxiety and Depression Association of American (ADAA) Gives information, resources, and referrals related to anxiety disorders. Anxiety and Depression Association of American American Foundation for Suicide Prevention Research, facts, survivor support, and more. Suicide Awareness Voices of Education American Psychiatric Association Provides information about a wide variety of mental health problems as well as psychiatric medications. American Psychiatric Association American Psychological Association Provides information on a wide variety of mental health topics. American Psychological Association Authentic Happiness The Authentic Happiness website is a University of Pennsylvania website developed by the Positive Psychology Center, which is directed by Martin Seligman. Authentic Happiness Website Brain & Behavior Research Foundation This association is dedicated to funding scientific research on brain and behavior disorders. Brain & Behavior Research Foundation Depression and Bipolar Support Alliance The mission of this website is to improve the lives of people living with mood disorders. Depression and Bipolar Support Alliance Depression Screen.org The mission of this website is to educate people about clinical depression, offer a confidential way for people to get screened for symptoms of the illness, and guide people toward appropriate professional help if necessary. DepressionScreen.org

Mental Health America Mental Health America (MHA)—founded in 1909—is the nation’s leading communitybased nonprofit dedicated to helping Americans achieve wellness by living mentally healthier lives. Mental Health America National Association for Self-Esteem The purpose of this organization is to fully integrate self-esteem into the fabric of American society so that every individual, no matter what their age or background, experiences personal worth and happiness. National Association for Self-Esteem National Center for PTSD To advance the clinical care and social welfare of America’s veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stressrelated disorders. This website is provided as an educational resource concerning PTSD and other enduring consequences of traumatic stress. PTSD: National Center for PTSD National Institute of Mental Health Working to improve mental health through biomedical research on mind, brain, and behavior. National Institute of Mental Health National Sleep Foundation This site features information on sleep disorders; healthy sleep, support, and advocacy; and online resources on sleep. National Sleep Foundation International OCD Foundation Organization of researchers and clinicians pioneering the world’s foremost innovative and aggressive efforts to find a cure for OCD. International OCD Foundation happier Learn about the evidence-based pursuit and practice of happiness. happier Home Page

Schizophrenia and Related Disorders Alliance of America Schizophrenia and Related Disorders Alliance of America promotes improvement in the lives of people with schizophrenia-related illnesses and their families by providing support, hope, and awareness so that early diagnosis, treatment, and community services increase recovery. Schizophrenia and Related Disorders Alliance of America Suicide: Read this First A collection of suicide resources. Metanoia – Suicide... Read This First World Federation for Mental Health An international, non-profit organization established in 1948 to advance, among all peoples and nations, the prevention of mental and emotional disorders, the proper treatment and care of those with such disorders, and the promotion of mental health. World Federation for Mental Health World Health Organization Part of the WHO’s website on mental health. World Health Organization – Mental Health

Key Terms antidepressant

interpersonal therapy (IPT)

anxiety disorders

major depressive disorder

attention deficit/hyperactivity disorder (ADHD)

mental disorder

autism spectrum disorder

mood

behavioral therapy

obsessive-compulsive disorder (OCD)

bipolar disorder

mental health

optimism

cognitive therapy

panic attacks

culture

panic disorder

emotional health

phobias

emotional intelligence

psychiatric drugs

generalized anxiety disorder (GAD)

psychodynamic

psychotherapy

spiritual health

schizophrenia

spiritual intelligence

self-actualization

spirituality

self-compassion

values

self-esteem

Answers to Global Health Watch 1. a 2. b 3. inflammatory

3 Stress Management Learning Objectives After studying this chapter in the text, the student should be able to: 3.1

Outline the types of stress and the effects of stress on people.

3.2

Identify stressors commonly reported by different groups across the United States.

3.3

Summarize the incidence, symptoms, and treatment of the stress disorders associated with traumatic life events.

3.4

Outline the ways in which the body responds to stress.

3.5

Describe how stress can affect a person’s heart, immune system, gastrointestinal system, and susceptibility to cancer.

3.6

Explain psychological responses to stress.

3.7

Discuss practical techniques of stress management.

3.8

Summarize how time management can help prevent stress.

Chapter Summary This chapter helps students learn to anticipate stressful events, manage day-to-day hassles, prevent stress overload, and find alternatives to running endlessly on a treadmill of alarm, panic, and exhaustion.

Lecture Outline I.

What Is Stress? A. Overview 1. Hans Selye, a pioneer in studying physiological responses to challenge, defined stress as “the non-specific response of the body to any demand made upon it.”

B. Eustress, Distress, and Neustress 1. Eustress refers to the positive stress in our lives. a. Eustress challenges us to grow, adapt, and find creative solutions in our lives. 2. Distress refers to the negative effects of stress that can deplete or even destroy life energy. 3. Some experts have introduced another category: “neustress” for neutral stressors that do not affect us immediately or directly but that may trigger anxiety, sadness, fear, and other stressful feelings. C. Stress and the Dimensions of Health 1. From a holistic perspective, stress can have an impact on every dimension of well-being. a. Physical—Stress triggers molecular changes within your body that affect your heart, muscles, immune system, bones, blood vessels, skin, lungs, gastrointestinal tract, and reproductive organs. b. Psychological—Chronic stress affects thoughts and feelings; however, positive emotions and attitudes can buffer the ill effects of stress and enhance satisfaction and genuine happiness. c. Spiritual—Stress can sidetrack us from achieving our full potential; but our spirit, when nurtured, can help resist and recover from stress. d. Social—Your relationships with your family, friends, coworkers, and loved ones affect and are affected by the stress in your life. e. Intellectual—Even mild stressors can interfere with your brain’s functioning. f. Occupational—Most undergraduates (about 70 percent) are employed, with 20 percent working full time year-round. They are more likely to feel overwhelmed and report greater anxiety and stress than students without jobs. g. Environmental—External forces such as pollution, noise, natural disasters, exposure to toxic chemicals, and threats to your safety can cause or intensify the stress in your life. 2. Types of Stressors a. Acute time-limited stressors: situations that cause feelings of anxiety, such as having to speak in public or work out a math problem while under pressure. b. Brief naturalistic stressors: more serious challenges (e.g., taking the SAT or meeting a deadline for a project). c. Life change events: include planned and predictable occurrences, such as graduation or marriage, as well as unexpected ones, such as the loss © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

of a home in a fire or flood. The death of a partner or parent ranks high on the list. d. Chronic stressors: ongoing demands caused by life changing circumstances, such as permanent disability from an accident or caring for a parent with dementia. e. Distant stressors: traumatic experiences that occurred long ago, such as child abuse or combat, which have an emotional and psychological impact. II.

Stress in America A. Overview 1. Every year the American Psychological Association (APA) asks men and women across the country to rank their stress level on a scale of 1 (little or no stress) to 10 (a great deal of stress). a. In its most recent Stress in America survey, the average stress level was 5.1, significantly higher than the 3.8 Americans see as a healthy stress rating. B. Stress on Campus 1. In the American College Health Association National College Health Assessment survey, about 85 percent—75 percent of men and 90 percent of women—reported feeling overwhelmed by all they had to do at some point in the past 12 months. C. Stress and Student Health 1. Students say they react to stress in various ways: a. Physiologically b. Emotionally c. Behaviorally d. Cognitively 2. Stress on students include the following documented effects: a. Difficulty paying attention and concentrating. b. Poor or inadequate sleep c. Lack of exercise d. Increased consumption of junk food e. Greater risk of anxiety and depression f. Lessened life satisfaction 3. Gender Differences a. More female than male students reported feeling hopeless, overwhelmed, or exhausted (but not from physical activity). b. Neither gender necessarily handles stress better.

4. Students under Age 25 a. The stage of life between the ages of 18 and 25 is termed “emerging adulthood.” b. During this potentially risky transition period, young men and women of every racial and ethnic group are more likely to engage in behaviors that can increase stress and imperil health. 5. Students over Age 25 a. The number of older undergraduates is skyrocketing, with an estimated increase of 21 percent from 2005 to 2016. b. Many of these students, often parents with full- or part-time jobs, find themselves playing multiple roles and facing multiple stressors. c. Veterans may be processing their experiences in distant and dangerous lands. d. Family typically emerges as the greatest source of both stress and support for women returning to school. D. Minority Students 1. Minority stress refers to negative experiences in the campus environment that students perceive to be linked to the social, physical, or cultural attributes characteristic of their racial or ethnic group. 2. Among the forms of minority stress are: a. University social climate stress b. Intergroup stress c. Discrimination stress d. Within-group stress e. Achievement stress f. Acculturative stress 3. While many minority students say that overt racism is rare and relatively easy to deal with, subtle racial expressions—sometimes termed microaggressions—may undermine their academic confidence and their ability to bond with the university. 4. Researchers have identified three common types of microaggressions: a. Microassaults—conscious and intentional actions or slurs b. Microinsults—verbal and nonverbal communications that subtly convey rudeness and insensitivity and demean a person’s racial heritage or identity c. Microinvalidation—communications that subtly exclude, negate, or nullify the thoughts, feelings, or experiential reality of a person of color

5. Entering Freshmen a. The first year of college is the most stressful for all undergraduates, even when they begin with positive expectations and attitudes. b. First-generation college students encounter more difficulties with social adjustment and lack of social support that adds to their stress levels. 6. Test Stress a. For some students, test anxiety provokes a marked elevation in blood pressure. b. The students most susceptible to exam stress are those who believe they’ll do poorly and who see tests as extremely threatening. c. Negative thoughts often become a self-fulfilling prophecy. d. You can overcome test stress by knowing—even mastering—the subject and by controlling the way you think about and talk to yourself about tests. III. Other Stressors A. Financial Stress 1. Money ranks second only to academics as a source of stress for college students. 2. Although money cannot buy happiness, it does buffer the ill effects of stress. B. Occupational Stress 1. About half of undergraduates have jobs, which helps make ends meet but can create other difficulties. 2. High job strain is defined as high psychological demands combined with low control or decision-making ability over one’s job. C. Burnout 1. Burnout is a state of physical, emotional, and mental exhaustion brought on by constant or repeated emotional pressure. D. Illness and Disability 1. A common source of stress for college students is learning disabilities, which may affect 1 out of every 10 Americans. IV. Traumatic Life Events A. Overview 1. According to epidemiological studies, about 60 percent of men and 50 percent of women experience at least one potentially traumatic event—natural or human caused, large scale or small—during the course of their lives. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

B. Acute Stress Disorder 1. In acute stress disorder, disabling symptoms occur within 3 days to a month after exposure to a traumatic event. 2. Symptoms of acute stress disorder may include: a. Recurrent, involuntary, and intrusive distressing memories of the trauma b. Recurrent distressing dreams related to the trauma c. Dissociative reactions, such as flashbacks, in which an individual feels that the traumatic event is recurring d. Persistent inability to experience happiness, satisfaction, or other positive emotions e. Altered sense of the reality of one’s surroundings or oneself, such as time slowing down f. Inability to remember an important aspect of the traumatic event g. Efforts to avoid distressing memories, thoughts, or feelings related to the trauma h. Efforts to avoid reminders, such as certain people, places, activities, objects, or situations, which arouse distressing feelings or thoughts i. Sleep disturbances, including difficulty falling or staying asleep and restless sleep j. Irritable behavior and angry outbursts k. Hypervigilance l. Problems with concentration m. Intensified startle response 3. Acute distress disorder causes significant distress and interferes with a person’s ability to work, study, relate to others, and maintain usual routine and social activities. C. Posttraumatic Stress Disorder 1. In the past, posttraumatic stress disorder (PTSD) was viewed as a psychological response to out-of-the-ordinary stressors, such as captivity or combat. a. However, other experiences can also forever change the way people view themselves and their world. 2. An estimated 9 percent of all college students suffer from PTSD. 3. Symptoms of PTSD, which usually begin within the first 3 months after a trauma, include: a. Recurrent, involuntary, and intrusive distressing memories of the traumatic event b. Recurrent distressing dreams related to the trauma © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

5. 6. 7.

c. Persistent avoidance of external reminders and distressing memories of the trauma d. Persistent feelings of guilt, shame, anger, horror, fear, or other negative emotions e. Hypervigilance and other changes in arousal and alertness Individuals with PTSD may require different types of help at different stages. a. Behavioral, cognitive, and psychodynamic therapy, sometimes along with psychiatric medication, can help individuals suffering with PTSD. b. Mind–body practices, such as exercise, mindfulness, meditation, and deep breathing, also have proven effective. Without recognition and treatment, PTSD can last for decades, with symptoms intensifying during periods of stress. When identified and treated, more than half of affected persons achieve complete recovery. Mental health professionals have found that no single approach to treatment works for all trauma victims.

Inside Stress A. The stress response refers to a cascade of internal changes that mobilize the body’s resources for action. B. General Adaptation Syndrome (GAS) 1. In his GAS model of the stress response, Hans Selye postulated that our bodies continually strive to maintain a stable and consistent physiological state, called homeostasis. 2. When a stressor disrupts this state, it triggers a nonspecific physiological response, consisting of three distinct stages: a. Alarm—As it becomes aware of a stressor, the body mobilizes various systems for action. b. Resistance—If the stress continues, the body draws on its internal resources to try to sustain homeostasis, but this requires greater and greater effort. c. Exhaustion—If stress continues long enough, normal functioning becomes impossible. Even a small amount of additional stress at this point can lead to a breakdown.

VI.

Coping with Stress A. Fight or Flight 1. Physiologist Walter Cannon, another pioneer in stress research, dubbed the complex, near-instantaneous sequence of internal changes that kicks in when you confront any potential danger the “fight-or-flight” response. 2. In interpersonal situations, individuals “fight” by arguing, opposing, demanding, criticizing, accusing, insisting, or refusing. a. Alternatively, they may take flight—literally by physically removing themselves or by withdrawing, not talking, dissociating, changing the topic, or otherwise “checking out.” B. Freezing 1. More recently, scientists have identified an acute stress response that may precede fight or flight: freezing, a survival mechanism that stems from some of the oldest circuits within the brain. C. Submission 1. If unable to flee from or fight off a predator, animals may become immobile in the hope that their attacker will lose interest. 2. Submission occurs when no other option seems possible. D. Challenge Response Model 1. Unlike a threat response, which rewires the brain to heighten a sense of danger, a challenge response strengthens connections between the parts of the brain that suppress fear and enhance learning and positive motivation. 2. In various studies of people in high-stakes situations, the challenge response consistently predicted better performance under pressure than fight or flight or than the absence of any stress response. E. Tend-and-Befriend Model 1. The classic threat response that prepares us for fight or flight can make people angry, defensive, aggressive, or withdrawn. a. But some individuals respond differently under pressure and become more caring, compassionate, and cooperative. b. The reason, according to the tend-and-befriend model, is that an urge to forge social connections under stress may be, like fight or flight, an essential survival instinct, especially for the females of a species. 2. The very acts of connecting and caring for others enable individuals to overcome feelings of powerlessness and hopelessness by inducing increases in several key brain chemicals, including oxytocin, serotonin, and dopamine.

F. Transactional or Cognitive-Relational Model 1. The transactional or cognitive-relational model, developed by psychologist Richard Lazarus, is a framework for evaluating the processes of coping with stressful events. 2. According to this model, stress stems from an interaction or “transaction” between a person and a stress-inducing trigger. 3. Lazarus identified four stages in this process: a. Primary appraisal—individual judges the severity of a threat; if not perceived as dangerous, no stress develops b. Secondary appraisal—if the situation is perceived as threatening, individual assesses whether they have the power and resources to act c. Coping stage—individual does whatever they can to deal with the challenge d. Reappraisal—individual evaluates whether the original stressor has been eliminated or whether they need to try again or use a different approach G. Yerkes-Dodson Law 1. Increasing stress can boost performance—but only up to a certain point. VII. The Impact of Stress A. Overview 1. While stress alone doesn’t cause disease, it triggers molecular changes throughout the body that make us more susceptible to many illnesses. B. Stress and the Heart 1. The links between stress, behavior, and the heart are complex. a. One way in which stress increases the risk of heart attack and other cardiovascular problems is by pushing people toward bad habits. C. Stress and Immunity 1. Acute time-limited stressors, the type that produce a fight-or-flight response, prompt the immune system to ready itself for the possibility of infections resulting from bites, punctures, or other wounds. 2. Long-term or chronic stress creates excessive wear and tear, and the system breaks down. 3. The longer the stress, the more the immune system shifts from potentially adaptive changes to potentially harmful ones. 4. Traumatic stress can impair immunity for as long as a year. D. Stress and the Gastrointestinal System 1. The “brain–gut axis” links the brain with the organs involved in digesting food. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Stress can: a. Decrease saliva so your mouth becomes dry (a frequent occurrence when under the stress of speaking in public) b. Cause contractions in the esophagus that interfere with swallowing c. Increase the amount of hydrochloric acid in the stomach d. Constrict blood vessels in the digestive tract e. Alter the rhythmic movements of the small and large intestines necessary for the transport of food (leading to diarrhea if too fast or constipation if too slow) f. Contribute to or exacerbate GERD (gastroesophageal reflux disease) g. Lead to blockage of the bile and pancreatic ducts h. Increase the risk of pancreatitis (inflammation of the pancreas), ulcerative colitis, and irritable bowel syndrome 3. For many years stress alone was blamed for causing stomach ulcers, but scientists have discovered that a bacterium, Helicobacter pylori, infects the digestive system and sets the stage for ulcers. 4. Stress may increase susceptibility by reducing the protective gastric mucus that lines the stomach so ulcers develop more readily. 5. Stress directly affects what researchers call our “drive to eat.” 6. Even if they don’t consume more calories, some people, perhaps especially sensitive to cortisol, put on “belly,” or visceral, fat when stressed. E. Stress and Cancer 1. Among the latest findings from psycho-oncology, the field that combines medical and psychological approaches to cancer, are: a. Stress-related abnormalities in cortisol, inflammation, and the sympathetic nervous system can affect cancer growth. b. Stressful life experiences and depression are associated with poorer survival and greater mortality from various types of cancer, including breast, lung, and head and neck tumors. c. Psychosocial support and improved coping skills help even terminally ill patients to live better at the end of life—and in some cases to live longer as well. F. Other Stress Symptoms 1. The first signs of stress include muscle tightness, tension headaches, backaches, upset stomach, and sleep disruptions (caused by stress-altered brain-wave activity). 2. Stress is also closely linked to skin conditions.

VIII. Managing Stress A. Overview 1. Various approaches, including online stress management interventions, have proven effective in reducing perceived stress and symptoms of anxiety, depression, and stress. B. Journaling 1. College students that wrote in their journals about traumatic events felt much better afterward than those who wrote about superficial topics. C. Exercise 1. Regular physical activity can relieve stress, boost energy, lift mood, and keep stress under control. D. Routes to Relaxation 1. Relaxation is the physical and mental state opposite that of stress. 2. Relaxation techniques may alter brain chemistry such as increasing the levels of pleasure-inducing chemicals in the brain. a. Progressive relaxation works by intentionally increasing and then decreasing tension in the muscles. b. Visualization or guided imagery involves creating mental pictures that calm you down and focus your mind. c. Biofeedback is a method of obtaining information about some physiological activity occurring in the body. E. Meditation and Mindfulness 1. Meditation activates the sections of the brain in charge of the autonomic nervous system. 2. Meditation may be particularly helpful for people dealing with stressrelated medical conditions. 3. There is no right way to meditate. 4. Mindfulness is “an awareness that emerges by paying attention deliberately in the present to an experience as it happens moment by moment.” 5. Psychological benefits of mindfulness include greater self-compassion and decreased absent-mindedness, difficulty regulating emotions, fear of emotion, worry, and anger. 6. Mindfulness benefits individuals suffering from chronic pain, fibromyalgia, cancer, anxiety disorders, depression, and the stresses of everything from prison life to medical school. F. Yoga 1. Yoga is defined as a union of mind, body, and spirit.

2. Yoga eases conditions such as lower-back pain, migraine, asthma, and hypertension and has been proven to reduce anxiety and cortisol levels in those with moderate levels of stress. 3. Yoga may lower harmful compounds associated with stress that increase inflammation. G. Resilience 1. Adversity—whether in the form of a traumatic event or chronic stress— has different effects on individuals. 2. Various factors that enable individuals to thrive in the face of adversity include: a. An optimistic attitude b. Self-efficacy c. Stress inoculation d. Secure personal relationships e. Spirituality or religiosity IX. Stress Prevention: Taking Control of Your Time Symptoms of poor time management include rushing, chronic inability to make choices or decisions, fatigue or listlessness, constantly missed deadlines, not enough time for rest or personal relationships, and a sense of being overwhelmed by demands and details. A. Overview 1. Although you may struggle to cram all that you need and want to do into your allotted 24 hours each day, you can take control of how you use the time you have. 2. One of the hard lessons of being on your own is that your choices and your actions have consequences. B. Time Management 1. Schedule your time. 2. Develop a game plan. 3. Identify time robbers. 4. Make the most of classes. 5. Develop an efficient study style. 6. Focus on the task at hand. 7. Turn elephants into hors d’oeuvres. 8. Keep your workspace in order. C. Overcoming Procrastination 1. In various studies, 30–60 percent of undergraduates have reported postponing academic tasks, such as studying for exams, writing papers, © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

and reading weekly assignments, so often that their performance and grades have suffered. 2. The three most common types of procrastination are putting off unpleasant things, putting off difficult tasks, and putting off tough decisions. 3. To overcome procrastination: do what you like least first; build time into your schedule for interruptions, unforeseen problems, and unexpected events; establish ground rules for meeting your own needs; and learn to “Just do it.”

Discussion Questions •

A somewhat surprising observation for some students is that positive lifestyle changes can contribute to stress. Give examples of positive stressors (e.g., marriage, moving, acquisition of an automobile). Ask the class to name other positive changes and events that can contribute to stress. What are some negative stressors that affect them? How do our bodies react to the differences between these two stressors? Is there a difference?

•

Ask students why they, as a group, are prone to stress. Have them list ways in which their campus helps to alleviate stress. As a result of the students’ brainstorming, you may wish to compose a list of campus-based programs and services available to students and distribute it to the class.

•

Though many people seem to be working more and enjoying it less, the text states that “work is not hazardous to health.” Discuss why this might be true in light of the students’ work-related experiences. What steps can they take to reduce these hazards? What steps can they take to prevent such hazards?

•

Discuss strategies for coping with stress. Ask students to share their means of coping. Are there any ways by which coping with stress can indeed contribute to additional stress?

Classroom Activities Activity #1: Journal Writing Purpose: To teach students the benefits of writing in journals to alleviate stress.

Time: The initial session may take the entire period, but future sessions may only need to be 15–20 minutes.

Introduction: Journal writing is an excellent resource for stress management. Through the use of journals, one can release emotions onto paper and then review it at a later time to better understand oneself and how to handle future stressful situations better.

Method: 1.

Tell students to bring a new notebook or a journal that they are currently using to the next class meeting.

Explain the advantages of keeping a journal and the ability to release stress through journal writing.

Ask students to spread out across the room (or go outside if the weather is nice); make sure they are comfortable with their surroundings.

Then select a topic for them to write about, such as: who am I, how is my day going, favorite places in the world, how I feel today, what makes me angry, people I admire, what makes me happy, and what makes me sad.

Explain to the students that you will never see their work, that it is only for them, and that they should not show it to anyone.

Spend some time describing how you personally like to write in your journal and offer suggestions to them (e.g., I like to write in my journal at the end of the day, out on my porch, with a little soft or classical music in the background). Explain to them that you will assign them a topic to write on and that they should discover what is comfortable for them.

Though your students will not be turning in their work, have them write a paper about their journal writing experiences at the end of the semester.

Tell the students that for the remainder of the class they may write in their journals. For the initial session, it is a good idea to have them write about who they are. They can address their journal as if writing a letter or as in a class assignment (whatever they are comfortable doing). Remind them that they should just write whatever is on their mind and not pay attention to grammar or spelling. Just write, write, and write!

At the conclusion of class, ask students how they felt about writing in a journal and then discuss the benefits of writing in it as a stress reliever and as a record of their life.

10. Assign the next topic to be written. Topic ideas: • Who is my best friend? How would I describe him or her? • What do I like about the place I live? Dislike? • What music do I like to listen to? Why? • Draw my favorite place. • Who are my parents? What do I admire most about them? • What was my scariest moment? • What do I like about school? Why am I here? What do I dislike about school? • Who are my favorite teachers? Why? • Where would I go in the world if I could? • What do I think about dying? • What was the saddest day of my life? • What was the happiest day of my life?

Discussion: 1.

After the first few times writing, ask students for feedback on how they felt about writing about their thoughts.

After several weeks of assigning the journaling activity, ask students how many are continuing to use the journaling activity as a stress reliever.

Activity #2: Identifying Stress Purpose: To identify the stressors in our lives.

Time: A week outside of class, and half a class period for discussion.

Introduction: Discuss with students the various forms of stress and how it affects all of our lives.

Method: 1.

Inform students to bring a new notebook or a journal that they are currently using to the next class meeting.

Ask students to keep a stress management journal, so they can record their everyday stressors as well as the actions they take to relieve such stress.

Students will record their stressors for a week and then meet as a class to discuss their stressors.

Discussion: 1.

When did your stressors occur? Were they always at the same time of day? a. How might you modify these factors or eliminate some of your stress?

Did you notice during the week whether you started preparing to avoid these stressors?

How might you adjust your schedule, so these stressors are lessened in your everyday life?

To become better acquainted with your stress and how you handle it, you may want to try the following: a. Identify several of your personal health concerns (e.g., a concern that you drink or smoke too much). Share one of these concerns with a classmate. Ask for suggestions on making a lasting behavior change. Now reverse roles and offer suggestions to help your classmate with their personal health concern. b. Visit the university counseling center to discuss test anxiety and the measures

that can be taken to help students defuse exam stress. Prepare a handout for the class that summarizes suggestions for reducing test anxiety. c. Interview an older relative, friend, or neighbor and find out from this person the types of stressors they experienced when they were your age. Write about these stressful experiences and compare ways they are similar to and different from your experiences.

Activity #3: Time Management Purpose: To teach students the importance of managing time and prioritizing.

Time: One-half hour to an hour.

Introduction: Introduce students to time management and the benefits of improving an individual’s organizational skills.

Method: 1.

Have students use a daily schedule with one-half hour or 15-minute intervals to plan a normal day.

Have students make a “to-do list” for one “normal” day. You can have them do a whole week after they get the hang of it, if you wish.

Ask students to look at their list and then list the top 5–10 items they need to do (e.g., #1 take exam, #2 mail bills, #3 put air in tires, and so forth).

Next, have them look at their list and identify whether there are similar items (e.g., pick up stamps, mail bills, go grocery shopping, go workout). Similar items could be near each other in location, or they may need to be completed in the same time block (e.g., take exam at 8:00 am and drop off paper by 10:00 am). Once students have “blocked” their items, have them assess whether there are any that should change in priority as to when to be completed?

Now looking at their daily schedule, can they reorganize it, so they manage their time more efficiently?

Discussion: 1.

Did you find that you spent more time than you expected? Why? Can you use it to your advantage? How? Will you? Why or why not? What typically keeps us from using such an easy method of stress management?

What things do you think really eat up your time? Can these be corrected? Do they need to be?

How do you feel about scheduling “you time” or time for yourself? Is this important? Why or why not? Have any of you done this and had a positive experience? Would you share?

Activity #4: Stress and College Life Purpose: To identify the stress specifically experienced by college students.

Time: One-half hour to an hour.

Introduction: Discuss with students the various stressors specifically linked to being a college student.

Method: 1.

Students should write down their top three college-related stressors.

For each stressor listed, students should then list two specific healthy strategies for managing the stressor.

Discussion: 1.

Were these strategies new to you, or were they ideas from the past that you had just never put into place?

Will these three stressors remain constant during your college career or are they likely to change over time? If so, will you be able to develop healthy strategies for dealing with future stressors?

Activity #5: Time Management Purpose: To help students understand where their time is spent and how to be more efficient in using it.

Time: One to two days outside of class.

Method: 1.

Assign students to keep a time log for 1–2 days.

In their time log they will account for each hour of the day and what they did that hour.

At the end of each day, review the time log. Identify productive time, transition time, and wasted time. Add up the total amount of time in each area.

Identify strategies to reduce wasted time.

Discussion: 1.

2. 3.

Have students review their time logs. Discuss the amount of wasted time. When did this time occur? Why does wasted time occur? Were students surprised that so much time was spent in between productive activities? To what extent do things like procrastination, distraction, and not planning the day contribute to the loss of productive time? Discuss ways to improve time management and reducing wasted time. Include strategies and processes previously discussed in the Transtheoretical Model. Include a follow-up assignment to see if using these strategies has improved their time management.

Films and Videos Anger Management (Comedy about managing anger, with Adam Sandler.) Available at most video stores. Planes, Trains, and Automobiles (Video about two gentlemen trying to make it home for the holidays.) Available at most video stores.

Seriously Stressed (In this program, an immunologist, a psychiatrist, and a mental skills coach lay bare the symptoms of chronic stress, the negative impact on the body of continual exposure to adrenalin and cortisol, and biological and psychological factors that influence vulnerability to overstressing.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Stress (Stress and techniques to handle it are the focus of this video.) Growth Associates 190l East First Street, P.O. Box 467 Newton, KS 67114 Stress Management: How To Cope (Explores the stress management methods used by various professionals.) NIMCO, Inc. P.O. Box 9 102 Highway 81 North Calhoun, KY 42327-0009 P: 270-273-5000 • 800-962-6662 E: NIMCO Stress Test: Brain Games (Through a series of interactive games and experiments, you'll discover how stress works and how to handle it better.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Stress: The Good, the Bad, and the Healthy (One-third of all teens feel some negative stress on a daily basis. But not all stress is bad. Real teens talk about the types of situations that cause them to become too stressed.) Human Relations Media 800-431-2050 41 Kensico Drive Mt. Kisco, NY 10549 E: Human Relations Media Stressed Out: Stress Management 101 (This program describes different forms of stress (acute, episodic, and chronic) and explains how important it is for young people to learn effective techniques for coping with stressful situations.) Human Relations Media 800-431-2050 41 Kensico Drive Mt. Kisco, NY 10549 E: Human Relations Media Struggling with Stress (Struggling with Stress uses a documentary format to follow a group of ethnically and socioeconomically diverse teenagers through their normal everyday lives and exposes the challenges they face in managing stress.) Human Relations Media 800-431-2050 41 Kensico Drive Mt. Kisco, NY 10549 E: Human Relations Media Taking Control: Strategies for Coping with Stress (A student’s first step to dealing constructively with stress is understanding it: what it is, how it works, and why it’s such a powerful force in a teenager’s life.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Time Management (Compared to high school, where the day is structured down to the minute, college is a blank do-it-yourself calendar. Over the course of this program, viewers will learn to sidestep common time-management errors and plan out their semesters so they can take control of their time and enjoy a healthy work/life balance.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Unresolved Anger (Sparks fly when we look at the hurt and rage that has victimized us in the past. Working with this program will ultimately bring release from the bondage that creates the want to abuse one's self in the first place.) NIMCO, Inc. P.O. Box 9 102 Highway 81 North Calhoun, KY 42327-0009 P: 270-273-5000 • 800-962-6662 E: NIMCO

Internet Resources American College Health Association American College Health Association–National College Health Assessment web summary. National College Health Assessment American Psychological Association Information available on stress management and psychological disorders. American Psychological Association International Society for Traumatic Stress Studies Scientific research information on traumatic stress. International Society for Traumatic Stress Studies

American Academy of Experts in Traumatic Stress The American Academy of Experts in Traumatic Stress is a multidisciplinary network of professionals who are committed to the advancement of intervention for survivors of trauma. American Academy of Experts in Traumatic Stress The American Institute of Stress Website dedicated to improving the understanding of the role stress plays in health and illness. The American Institute of Stress

Key Terms biofeedback

microinvalidations

burnout

mindfulness

defense mechanisms

neustress

distress

posttraumatic stress disorder (PTSD)

eustress

progressive relaxation

holistic

stress

homeostasis

stress response

meditation

stressor

microaggression

tend and befriend

microassaults

visualization, or guided imagery

microinsults

Answers to Global Health Watch 1. a 2. b 3. structure

4 Social Health Learning Objectives After studying this chapter in the text, the student should be able to: 4.1

Explain the meaning of the term social health, using examples.

4.2

Outline various ways of communicating.

4.3

Examine how relationships contribute to the social health of individuals.

4.4

Evaluate the impact of modern technology on communicating.

4.5

Identify current trends in dating among young people.

4.6

Explain the significance of love to an individual’s well-being.

4.7

Summarize the impact of dysfunctional relationships.

4.8

Describe the trends, factors, and forms of long-term partnering in America.

4.9

Summarize the changes that have taken place in the American household over time.

Chapter Summary This chapter discusses the social needs we all share, the ways some of us respond to those needs, healthy and unhealthy relationships, and the possibilities that exist for coming together from our solitude to warm ourselves in each other’s glow.

Lecture Outline I.

The Social Dimension of Health A. Social health refers to the ability to interact effectively with other people and with the social environment, to develop satisfying interpersonal relationships, and to fulfill social roles. B. Supportive relationships buffer us from stress, distress, and disease. C. Social support refers to the ways in which we provide information or assistance, show affection, comfort, and confide in others.

1. A sense of belonging may have the greatest impact on a college students’ health. 2. According to the concept of social contagion, friends, friends of friends, acquaintances, and others in our social circle influence our behavior and our health—both positively and negatively. II.

Communicating A. Overview 1. Healthy, mutually beneficial relationships add joy to our years and maybe even years to our life. a. By mastering skills to communicate more clearly and by being responsible and responsive in your interactions with others, you can create relationships worth cherishing. B. Learning to Listen 1. Communication stems from a desire to know and a decision to tell. The first step is learning how to listen. 2. Information is easy to convey and comprehend, emotions are not. C. Being Agreeable but Assertive 1. “Agreeableness” includes being helpful, unselfish, generally trusting, considerate, cooperative, sympathetic, warm, and concerned for others. a. The benefits that agreeable people enjoy are strong relationships, less conflict, happy marriages, better job performance, healthier eating habits and behaviors, less stress, and fewer medical complaints. b. Agreeable people aren’t so “nice” that other people easily influence or take advantage of them. 2. Assertiveness involves respecting your rights and the rights of other people even when you disagree. D. How Men and Women Communicate 1. Gender differences start early and are apparent by age 1. 2. Although men and women are more similar than different, scientific evidence continues to confirm that gender differences in communication do exist. 3. Men a. Speak more often and for longer periods. b. Interrupt more, breaking in on another’s monologue if they aren’t getting the information they need. c. Look into a woman’s eyes more often when talking than they would if talking with another man.

d. When writing, use more numbers, more prepositions, and articles such as an and the. e. Write briefer, more utilitarian e-mails. f. In blogs or chat rooms, are more likely to make strong assertions, disagree with others, and use profanity and sarcasm. 4. Women a. Speak more in private, usually to build better connections with others. b. Are generally better listeners. c. Are more likely to wait for a speaker to finish rather than interrupting. d. Look into another woman’s eyes more often than if talking with a man. e. When writing use more words overall; more words related to emotion; more idea words; more hearing, feeling, and sensing words; more causal words; and more modal words. f. Write e-mails in much the same way they talk. g. In blogs or chat rooms, are more prone to posing questions, making suggestions, and including polite expressions. E. Nonverbal Communication 1. More than 90 percent of communication may be nonverbal. 2. Culture has a great deal of influence over body language. III. Forming Relationships A. Overview 1. We first learn how to relate as children. 2. Our relationships change over time, but throughout life, close relationships, tested and strengthened by time, allow us to explore the depths of our souls and the heights of our emotions. 3. Even a relationship with a pet can be beneficial. B. Friendship 1. Friendship has been described as “the most holy bond of society.” 2. Friends can be a basic source of happiness, a connection to a larger world, a source of solace in times of trouble. 3. On average we devote 40 percent of our limited social time to the five most important people we know, who represent just 3 percent of our social world. C. Loneliness 1. More so than many other countries, ours is a nation of loners. 2. Longer work hours, busy family schedules, frequent moves, and high divorce rates have created even more lonely people.

3. Loneliness, defined as “feelings of distress and dysphoria resulting from a discrepancy between a person’s desired and achieved social relations,” has been identified as a risk factor for depression and poor psychological health. 4. Loneliest of all are adolescents and older adults; those who are divorced, separated, or widowed; and adults who live alone or solely with children. 5. The true keys to overcoming loneliness are developing resources to fulfill our own potential and learning to reach out to others. D. Shyness and Social Anxiety Disorder 1. As many as 40 percent of people describe themselves as shy or socially anxious. a. An estimated 10–15 percent of children are born with a predisposition to shyness. b. Others become shy because they don’t learn proper social responses or because they experience rejection or shame. c. People are “fearfully shy” when they withdraw and avoid contact with others and experience a high degree of anxiety and fear in social situations. d. Others are “self-consciously” shy; they enjoy the company of others but become highly self-aware and anxious in social situations. e. About 7 percent of the population could be diagnosed with a social anxiety disorder in which individuals typically fear and avoid various social situations. 2. People can overcome much of shyness. E. Building a Healthy Community 1. Altruism is helping or giving to others without thought of self-benefit. a. Altruism enhances self-esteem, relieves physical and mental stress, and protects psychological well-being. F. Doing Good 1. Helping or giving to others enhances self-esteem, relieves physical and mental stress, and protects psychological well-being. 2. Volunteerism helps those who give as well as those who receive. IV. Living in a Wired World A. Overview 1. Modern technology is changing our social DNA. 2. The amygdala, a brain region involved in processing emotional reactions, is bigger in individuals with large, complex, social networks and these

networks are getting bigger than ever thanks to “computer-mediated communication.” B. Social Networking on Campus 1. More than 9 in 10 college students maintain a social networking profile, with Facebook the most popular choice. a. The most common motivations undergraduates give for their Facebook use are: i. Nurturing or maintaining existing relationships ii. Seeking new relationships iii. Enhancing their reputation iv. Avoiding loneliness v. Keeping tabs on other people vi. Feeling better about themselves 2. Women are more likely to use networking sites to compare themselves with others and search for information. 3. Men are more likely to look at other people’s profiles to find friends. 4. Freshmen who had a stronger emotional connection to, and spent more time on, Facebook reported having fewer friends on campus and experiencing more emotional and academic difficulties in adjusting to college life. C. Self-Disclosure and Privacy in a Digital Age 1. Self-disclosure is how much we reveal about ourselves to another person. 2. Social networking has transformed issues of privacy and disclosure. a. Previously personal moments now play out in public, sometimes by choice, sometimes by chance. 3. “Sexting”—sending sexually explicit text messages or digital photos—is fairly common among teens and young adults. b. Sexual disclosure can have unanticipated consequences. c. Sexual references generate powerful “subconscious impressions” that could put female students at risk for unwanted sexual advances. D. Problematic Cell Phone and Internet Use 1. Researchers have classified those who are on their phones 10 or more hours a day as “high users,” while those who spend 3 hours or less on their cell phones qualify as low users. a. In terms of personality characteristics, the low users showed a higher preference for challenge and were least susceptible to boredom. b. The high users reported greater distress and more susceptibility to boredom.

1. Estimates of problematic Internet use among college students range from 1 to 6 percent. 2. For some, the Internet has become an outlet for anger. a. Cyberbullying consists of deliberate, repeated, and hostile actions that use information and communication technologies, including online web pages and SMS text messages, with the intent of harming others by means of intimidation, control, manipulation, false accusations, or humiliation. b. Cyberstalking is a form of cyberbullying that uses online sites, forums, and social media to harass victims and try to damage their reputation or turn others against them. V.

Dating on Campus A. Overview 1. Dating isn’t what it used to be. a. Rather than the conventional dinner and a movie, college students may just get together to hang out. 2. Sexual relations have also changed. B. Hooking Up 1. An estimated 56–86 percent of college students report engaging in some form of casual sex. 2. A hookup might involve a range of physically intimate behaviors, from kissing to intercourse, characterized by a lack of any expectation of emotional intimacy or a romantic relationship. 3. Why Students Hook Up a. Students may engage in or endorse casual, commitment-free sexual encounters for various reasons, including a belief that hooking up is harmless because it requires no emotional commitment, that hooking up is fun, that hooking up will enhance their status in a peer group, that hooking up allows them to assert control over their sexuality, and that hooking up is a reflection of sexual freedom. b. Factors that plat a role in hooking up include alcohol use; attractiveness of a potential hookup partner; past hookup experience; an outgoing personality; and membership in certain social networks/clubs. 4. Consequences of Hooking Up a. Although hookups imply no conditions and no expectations, they can and do have unanticipated consequences, including unwanted pregnancy, sexually transmitted infections, and sexual violence.

C. Friends with Benefits 1. About 45–50 percent of college students report having engaged in a friends-with benefits relationship in the preceding 12 months. VI. Loving and Being Loved A. Overview 1. Love is essential for both physical and psychological well-being. a. People who lack love and commitment are at high risk for a host of illnesses, including infections, heart disease, and cancer. B. Intimate Relationships 1. Intimacy is the open, trusting sharing of close, confidential thoughts and feelings. 2. In intimate relationships, empathy becomes even more important. 3. Committed intimate relationships may be beneficial for college students’ physical and mental health, just as marriage is for spouses. C. What Attracts Two People to Each Other? 1. Four predictors rank as the most important reasons for attraction: warmth and kindness, desirable personality, something specific about the person, and reciprocal liking. D. Infatuation 1. At the time you are experiencing it, there is no difference between infatuation and lasting love. 2. However, if it is infatuation, it won’t last. a. Infatuation refers only to falling in love. b. People genuinely in love build a relationship together. c. Infatuation can be a disguise for a strong sex drive, a fear of loneliness, loneliness itself, or a hunger for approval. E. The Science of Romance Love 1. A Psychological View a. Robert Sternberg theorizes that love can be viewed as a triangle with three faces: passion, intimacy, and commitment. b. Sternberg identified six types of love: i. Liking ii. Infatuation iii. Romantic love iv. Companionate love v. Fatuous love vi. Consummate love

2. An Anthropological View a. Anthropologists have found evidence of romantic love between individuals in most of the cultures they have studied. 3. A Biochemical View a. According to research on neurotransmitters (the messenger chemicals within the brain), love sets off a chemical chain reaction that causes our skin to flush, our palms to sweat, and our lungs to breathe more deeply and rapidly. b. Neuroimaging studies reveal that viewing images of a romantic partner activates the areas of the brain that produce the so-called “love chemicals”—dopamine, norepinephrine, and phenylethylamine (PEA)—involved in various rewarding experiences, including beauty and love. F. Mature Love 1. Passionate love is characterized by intense feelings of elations, sexual desire, and ecstasy. 2. Companionate love is characterized by friendly affection and deep attachment. 3. Mature love is a complex combination of sexual excitement, tenderness, commitment, and most of all—an overriding passion that sets it apart from all other love relationships in one’s life. VII. Dysfunctional Relationships A. Overview 1. Mental health professionals define a dysfunctional relationship as one that doesn’t promote healthy communication, honesty, and intimacy and either person is made to feel worthless or incompetent. B. Intimate Partner Violence 1. Nearly half of all couples experience some form of physical aggression. 2. In the most recent ACHA survey, about 2 percent of students had been in a physically abusive relationship in the preceding 12 months and about 9 percent reported being in an emotionally abusive intimate relationship. C. Emotional Abuse 1. Abuse consists of any behavior that uses fear, humiliation, or verbal or physical assaults to control and subjugate another human being. 2. Emotional abuse includes name calling, blaming, threatening, accusing, demeaning, judging, and trivializing, minimizing, or denying what a person says or feels.

3. Often people who were emotionally abused in childhood find themselves in similar circumstances as adults. 4. Abusers also may have grown up with emotional abuse and view it as a way of coping with feelings of fear, hurt, powerlessness, or anger. 5. Among the signs of emotional abuse are: a. Attempting to control various aspects of your life b. Frequently humiliating you c. Making you feel as if you are to blame d. Wanting to know where you are e. Becoming jealous or angry f. Threatening to harm you g. Trying to coerce you D. Codependency 1. Codependency has expanded to include any maladaptive behaviors learned by family members in order to survive great emotional pain and stress, such as an addiction, chronic mental or physical illness, and abuse. 2. Some therapists refer to codependency as a “relationship addiction.” 3. Among the characteristics of codependency are: a. An exaggerated sense of responsibility for the actions of others b. An attraction to people who need rescuing c. Always trying to do more than one’s share d. Doing anything to cling to a relationship and avoid feeling abandoned e. An extreme need for approval and recognition f. A sense of guilt about asserting needs and desires g. A compelling need to control others h. Lack of trust in self and/or others i. Fear of being alone j. Difficulty identifying feelings k. Rigidity/difficulty adjusting to change l. Chronic anger m. Lying/dishonesty n. Poor communications o. Difficulty making decisions 4. Enabling a. Enabling is unwittingly contributing to a person’s addictive or abusive behavior.

E. When Love Ends 1. Sometimes two people grow apart gradually, and both of them realize that they must go their separate ways. More often, one person falls out of love first. 2. In surveys, college students say it’s more difficult to initiate a breakup than to be rejected. 3. It can help if both parties end the relationship in a way that shows kindness and respect. VIII. Partnering across the Lifespan A. Overview 1. Even though men and women today may have more sexual partners than in the past, most still yearn for an intense, supportive, exclusive relationship, based on mutual commitment and enduring over time. B. The New Transition to Adulthood 1. Emerging adulthood is a unique developmental period that spans the late teens and the 20s, marked by volatility and identity formation. a. More than 95 percent of Americans consider the most important markers of adulthood to be completing school, establishing an independent household, and being employed full time. b. Only about half consider it necessary to marry or have children to be regarded as an adult. c. Although just as eager for intimacy—emotional and sexual—younger adults are following a different pattern than past generations. C. Cohabitation 1. Although couples have always shared homes in informal relationships without any official ties, “living together,” or cohabitation, has become more common. 2. The number of couples living together has spiked in recent years. a. One reason may be economic. 3. Cohabitation can be a prelude to marriage, an alternative to living alone, or an alternative to marriage. 4. Couples who cohabit before getting engaged later report less marital satisfaction, dedication, and confidence as well as more negative communication and greater potential for divorce than those who lived together after engagement or after getting married. 5. In some areas, committed couples may register as domestic partners, which would qualify them for benefits such as health insurance.

D. Long-Term Same-Sex Relationships 1. Like heterosexual couples, same-sex relationships progress through various stages. 2. Because there are no social norms for same-sex unions, researchers describe these relationships as more egalitarian. 3. Same-sex couples have to deal with everyday ups-and-downs in a social context of isolation from family, workplace prejudice, and other social barriers. 4. They display less belligerence, domineering, and fear with each other than straight couples do. E. Marriage 1. The proportion of married people, especially in younger age groups, has been declining for decades. 2. Most young adults view marriage positively and 95 percent expect to marry in the future. 3. Preparing for Marriage a. Predictors of marital discord, unhappiness, and separation include: i. A high level of arousal during a discussion ii. Defensive behaviors iii. A wife’s expressions of contempt iv. A husband’s stonewalling b. By looking for such behaviors, researchers have been able to predict with better than 90 percent accuracy whether a couple will separate within the first few years of marriage. 4. The Benefits of Marriage a. Married people are healthier than those who are divorced, widowed, never married, or live with a partner. b. Married people live longer; have lower rates of coronary disease and cancer; are less likely to suffer back pain, headaches, and other common illnesses; and recover faster with a better chance of surviving a serious illness. c. Married people have lower rates of most mental disorders than single or divorced individuals. d. Married men have lower rates of alcohol and drug abuse, depression, and risk-taking behavior than divorced men. e. Happy marriage boosts mental health and well-being in both spouses. f. Theories as to why marriage benefits health include: i. Selection

ii. Social support iii. Behavioral regulation 5. Same-Sex Marriage a. Sometimes called gay, single-sex, or gender-neutral marriage, refers to a governmentally, socially, or religiously recognized marriage in which two people of the same sex live together as a family. b. Same-sex marriages account for about 2–7 percent of all marriages contracted in a single year. c. Same-sex couples live together and marry for similar reasons as heterosexual couples. 6. Issues Couples Confront a. Money: Even though most couples quarrel about money, they rarely fight over how much they have. What matters more is what money means to both partners. i. To avoid fighting: (a) Recognize the value of unpaid work. (b) Talk about financial goals you hope to attain 5 years from now. (c) Go over your finances together so that you have a firm basis in reality for what you can and can’t afford. (d) Set aside money for each person to spend without asking or answering to the other. b. Sex: Like every other aspect of a relationship, sex evolves and changes over the course of marriage. i. What matters most isn’t the quantity alone, but the quality of sexual activity and intimacy. c. Extramarital Affairs: University of Chicago researchers found that 25 percent of men and 15 percent of women had had affairs and that 94 percent of the married subjects had been monogamous in the past year. i. A husband or wife who learns about a spouse’s affair typically feels a devastating sense of betrayal as well as deep feelings of shame, fear of abandonment, depression, and anger. d. Two-Career Couples: More than 75 percent of women with children work which can bring pressure to a relationship. i. Two-career couples must be able to discuss their problems openly to resolve these pressures.

7. Conflict in Marriage a. In a 5-year study of newly married couples, 36 percent sought some form of help for their relationship, most often from books on relationships and marital therapy. b. Happier couples interject positive interactions, like a joke or a smile, into their arguments. c. As long as the ratio of positive to negative interactions remains at least five to one, the relationship remains intact. 8. Saving Marriages a. Fewer than two-thirds of couples—64 percent of husbands and 60 percent of wives—say their marriages are very happy (down from 70 percent of men and 66 percent of women a generation ago). b. Happy marriages allow both partners to self-actualize and develop to their fullest potential. c. Suggestions offered are: i. Focus on friendship. ii. Remember what you loved and admired in your partner in the first place. iii. Show respect. iv. Compliment what your partner does. v. Forgive one another. d. Couples therapy uses a variety of psychological techniques which include: i. Counseling ii. Marriage education workshops F. Divorce 1. According to the most recent estimates, 40–50 percent of first marriages end in divorce, affecting about 2.5 million adults a year. 2. The leveling of divorce among persons born since 1980, especially collegeeducated women, may reflect a delay in getting married, increasing selectivity when choosing partners, or a preference for cohabitation rather than marriage. 3. In addition to age, other factors lower the risk of divorce, including: a. Some college education b. Income higher than $50,000 c. Marrying at age 25 or older d. Not having a baby during the first 7 months after the wedding e. Some religious affiliation f. Coming from an intact family © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

g. Race also influences marriage and divorce rates h. Children whose parents divorced are less likely to marry and to stay married IX. Family Ties A. Overview 1. Only one-third of households now include children. 2. Today’s woman has an average of about two children, which is lower than the “replacement level” of 2.1 children per woman—that is, the level at which the population would be replaced by births alone. B. Diversity within Families 1. Families have become as diverse as the American population and reflect different traditions, beliefs, and values. 2. American families are diverse in other ways. a. Multigenerational families, with children, parents, and grandparents, make up 3.7 percent of households. b. Three of every 10 households consist of blended families, formed when one or both of the partners bring children from a previous union. C. Unmarried Parents 1. The proportion of babies born to unmarried parents has grown from about 4 percent in 1940 to about 40 percent today. 2. One-third of fathers virtually disappear from their children’s lives within 5 years. 3. The percentage of undergraduates who are unmarried parents has nearly doubled over the past 20 years, from 7 percent to just over 13 percent.

Discussion Questions •

Ask students if they agree or disagree with the statement, “You must learn how to communicate.” How and from whom do we learn communication skills? Can established patterns in communication be changed? How? What are the different methods by which we do communicate?

•

Have students think about verbal and nonverbal messages when they brainstorm the differences in communication that exist between men and women. Discuss how an awareness of these differences can help men and women to better understand one another. How do genders differ in the understanding of some sexual dialogue?

•

Ask students how they feel about the statement, “If we’re personally lacking in selfesteem, our relationships may suffer.” Is this true? Why or why not? How does selfesteem affect our relationships?

•

How has Facebook and other social media affected the way we communicate with each other? How has it affected socializing and dating? What are the pros and cons of using Facebook to keep in touch with others?

•

What are the characteristics of a good relationship? Ask students what role equality or differences in power play make in a relationship.

•

Ask students how they feel about unmarried couples (heterosexual or same-sex) receiving health and other types of benefits currently reserved for married couples. What are additional benefits that married couples get that singles don’t get? Is this fair? Why or why not?

•

Ask students how they feel about legislation that would mandate premarital counseling prior to getting married.

•

Brainstorm qualities in a relationship that contribute to a good marriage. Compare these to those cited in the text. Does everyone agree with this list? Why or why not? Discuss how communication interactions differ between beginning and established relationships. (You may wish to choose as examples money, sex, and time.)

•

List the variations of family (e.g., single mother or father, lesbian mother(s) or gay father(s), interracial couple, extended family, blended family, bicultural). Ask the class what constitutes a family and how diversity unifies or erodes family. What makes a family stronger? How do students feel about interracial marriages? Homosexual unions?

•

Discuss the concept of codependence as it relates to enabling. How does one enable another? What are some signs of codependency?

Classroom Activities Activity #1: Internet Dating Purpose: 1. To identify the dangers of Internet dating. 2. To demonstrate how individuals often feel more comfortable communicating with the opposite sex via the Internet.

Time: One class period.

Introduction: Sex crimes involving adults who are meeting on the Internet are increasing rapidly. Why are individuals who are using this method of “dating” not taking more precautions? There is also an increase in sexual crimes between adults and minors.

Method: 1. Provide examples of Internet dating websites. 2. Have students brainstorm the pros and cons of Internet dating and list these on the board.

Discussion: 1. Do students believe it is possible to develop intimacy with someone you’ve never met in person? Why or why not? 2. What types of people might benefit from Internet dating and why? 3. Do you believe we need any government control over Internet communication, for safety purposes? Why or why not?

Activity #2: Qualities in Your Future Spouse Purpose: 1. The purpose of this activity is to review our personal values and what we are looking for in a future spouse.

Time: One class period.

Introduction: Introduce the importance of identifying the characteristics we use to select our mates and the decisions we make to prioritize these characteristics.

Method: 1. Have students write down the qualities that they are looking for in a dating partner. 2. Have students rank their lists as far as which characteristics they must have, which they prefer but are okay if their partner doesn’t have, and which they are hopeful their partner will have but are okay with them not having. 3. Have students share some of these qualities with the class and make a list on the board of these characteristics, but separate the list by gender.

Discussion: 1. How are the lists different between genders? 2. Which characteristics are similar between genders? 3. Why do students often change their “lists” to meet those characteristics of the person they are dating? Is this healthy for that individual? Why or why not? 4. Why is it important to consider these characteristics before dating someone? How can these characteristics influence your decision as to whom you will date? Or marry? 5. How many of these qualities do you have? Is it fair to expect these qualities in your partner if you have not developed them yourself?

Activity #3: Gender Differences in Communication Purpose: 1.

To discuss gender conflicts and explore various cognitive interpretations of dating behaviors and sexuality.

Time: One class period.

Introduction: Introduce the importance of understanding gender differences in communication in all aspects of life.

Method: 1.

Divide the class into two sections—males will sit on one side of the classroom, facing the females, who will sit on the other side of the classroom.

Hand out two colored sheets of paper to the class: pink sheets for the males and blue sheets for the females.

Ask each person to write one anonymous question to the opposite sex. The student may ask anything they like! Their question will be collected and randomly distributed to a person of the other sex. No one will know who wrote each question, as they will omit their names from the papers. Have students write their question and fold the paper in half.

Collect the papers from each group (pink sheets from the males and blue sheets from the females) and carefully shuffle each stack separately. Randomly redistribute the questions to each group (blue sheets to the males and pink sheets to the females).

Inform both groups that whoever reads the question will answer the question based on their own opinion, after which members of the same group may add their comments regarding the specific question.

Have a male student read one question and ask one female student to initially respond. Go down the rows, so each person in each group responds to a question (this will facilitate total group discussion and prevent one or two individuals from dominating the conversation for one side). Repeat having one woman read a question, etc.

Discussion: 1.

What did students learn as a result of the questions and responses in this activity?

Did they experience any surprises?

Did any of the questions or responses affect your concept of gender role expectations or stereotypes?

Activity #4: Relationship Enhancement Purpose: 1.

To identify a relationship that needs improvement.

To develop strategies for improving that relationship.

Time: One class period.

Introduction: Introduce the importance of having healthy relationships in our lives and identify how healthy relationships can make our life more meaningful.

Method: 1.

Identify one current relationship that needs improvement.

Determine what aspects of this relationship need working on.

List specific strategies that can be used to enhance this relationship.

Discussion: 1.

Why is this relationship of importance to you?

How will improving this relationship enhance your well-being?

References, Readings, and Resources American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). 4. Boston Women’s Health Book Collective. (2005) Our Bodies, Ourselves: A New Edition for a New Era. New York: Simon and Schuster. DeGenova, M. K. (Ed.) (1997) Families in Cultural Context. Mountain View, CA: Mayfield. Gahagan, Kassandra, J. Mitchell Vaterlaus, and Libby R. Frost. “College Student Cyberbullying on Social Networking Sites: Conceptualization, Prevalence, and Perceived Bystander Responsibility.” Computers in Human Behavior 55 (2016): 1097–1105. doi: 10.1016/j.chb.2015.11.01. Gottman, J. (1994) Why Marriages Succeed or Fail. New York: Simon and Schuster. Gutierrez, Kevin M., and Theodore V. Cooper. “The Use of Social Networking Sites: A Risk Factor for Using Alcohol, Marijuana, and Synthetic Cannabinoids?” Drug and Alcohol Dependence (2016). doi: 10.1016/j.drugalcdep.2016.03.021 12. Janus, S. and Janus, C. (1995) The Janus Report on Sexual Behavior. New York: Wiley. Kitsantas, Anastasia, et al. “College Students’ Perceptions of Positive and Negative Effects of Social Networking.” in Social Networking and Education (New York: Springer International Publishing, 2016): 225–38. Kuss, Daria J., and Olatz Lopez-Fernandez. “Internet Addiction and Problematic Internet Use: A Systematic Review of Clinical Research.” World Journal of Psychiatry 6, no. 1 (2016): 143–76. doi: 10.5498/wjp.v6.i1.143. Laumann, E. et al. (l994) The Social Organization of Sexuality. Chicago: University of Chicago. Likosky, S. (Ed.) (l992) Coming Out. New York: Pantheon. Lips, H. (2001) Sex and Gender, Fifth Edition. Mountain View, CA: Mayfield. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Maes, Marlies, et al. “Gender Differences in Loneliness across the Lifespan: A Metaanalysis.” (2016, July). Biennial meeting of the International Society for the Study of Behavioral Development, Vilnius, Lithuania. McCarthy, Odhran, and Tony Bates. “Social Anxiety Disorder.” in The Handbook of Adult Clinical Psychology: An Evidence-Based Practice Approach (2016): 407. The National Gay Task Force, 2320 17th Street, NW, Washington, DC 20009, (202) 3326483. Nixon, Elizabeth, and Kristin Hadfield. “Blended Families.” in The Wiley Blackwell Encyclopedia of Family Studies (Hoboken, NJ: Wiley, 2016). Parents and Friends of Lesbians and Gays, 1101 14th Street NW, Suite 1030, Washington, DC 20005, (202) 638-4200. Robertson, P. N., et al. “Hooking Up during the College Years: Is There a Pattern?” Culture, Health and Sexuality 17, no. 5 (2015): 576–91. doi: 10.1080/13691058.2014.972458 Sheehey, G. (l998) Menopause, The Silent Passage. New York: Pocketbook. Sternberg, R. J. (1988) The Triangle of Love: Intimacy, Passion, Commitment. New York: Basic Books. Tsui, E. K., and E. K. Santamaria. “Intimate Partner Violence Risk among Undergraduate Women from an Urban Commuter College: the Role of Navigating Offand On-Campus Social Environments.” Journal of Urban Health 92, no. 3 (2015): 513–26. doi: 10.1007/ s11524-014-9933-0. Umberson, Debra, and Rhiannon A. Kroeger. “Gender, Marriage, and Health for SameSex and Different-Sex Couples: The Future Keeps Arriving.” in Gender and Couple Relationships (New York: Springer International Publishing, 2016): 189–213. Weinberg, M., Williams, C., and Pryor, D. (1994) Dual Attraction: Understanding Bisexuality. New York: Oxford University Press.

Wood, L., et al. “The Pet Factor–Companion Animals as a Conduit for Getting to Know People, Friendship Formation and Social Support.” PLoS One 10, no. 4 (2015): e0122085. doi: http://dx.doi.org/10.1371/ journal.pone.0122085 3.

Films and Videos Bridging the Couple Chasm (Filmed at a Gottman therapy workshop, this set shows John Gottman’s research with couples and presents video clips of actual clinical interactions with couples. It offers proven strategies and tools to help couples resolve conflict; outlines skills that allow partners to communicate about sensitive topics; and highlights approaches for such multiple presenting issues as the effects of poverty, PTSD, and infidelity.) Insight Media, Inc. 350 7th Ave, Suite 1100 New York, NY 10001 P: 800-233-9910 F: 212-799-5309 E: Insight Media, Inc. Coming Out in Adulthood (In this program, Ritch C. Savin-Williams discusses his approach to determining the impact of sexuality on a client’s self-perception, identity, relationships, career options, and life choices.) Insight Media, Inc. 350 7th Ave, Suite 1100 New York, NY 10001 P: 800-233-9910 F: 212-799-5309 E: Insight Media, Inc. Before Stonewall (Before Stonewall pries open the closet door—setting free the dramatic story of the sometimes horrifying public and private existences experienced by gay and lesbian Americans since the 1920s. Revealing and often humorous, this widely acclaimed film relives the emotionally charged sparking of today’s gay rights movement, from the events that led to the fevered 1969 riots to many other milestones in the brave fight for acceptance.) Available for purchase and streaming via online stores and services.

Two Dads, Two Moms: Gay Couples and Their Families (Profiling families in the United States, France, and Spain, this program focuses on the children of gay couples and how their experiences resemble or differ from more conventional upbringings.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group What Is a Marriage? (The institution of marriage is facing strong challenges in the 21st century, as diversity and inclusivity continue to reshape its underlying principles. Supported by some and opposed by others, issues such as same-sex marriages and the raising of families outside of marriage are ongoing sources of debate.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Changing Men: Unlearning the Behaviors of Domestic Violence (David Nugent, once a violent and abusive person himself, today runs a communitybased behavior change group in Australia called Heavy M.E.T.A.L.: Men’s Education Toward Anger & Life. Helen Wirtz is a facilitator at MonashLink’s Men’s Responsibility Group. This program tracks the progress of group members Andrew, Adam, and Alex—three husbands and fathers with dangerous antisocial behavioral issues—as they struggle to stop committing emotional and physical violence against those who love them the most.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Portraits in Human Sexuality (Parents, friends, sex education classes, and the media—all of them shape our perceptions of reproduction and physical intimacy. Starting at the beginning, then, this program focuses on developmental issues in human sexuality.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Real People, Real Sex—Clinical Conversations for the Human Sexuality Classroom (A follow-up to the popular series “Portraits in Human Sexuality,” this eight-part series of brief clinical interviews covers the major topics in the college human sexuality classroom.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Recognizing Abusive Relationships (Viewers are provided with straightforward information to help them understand and identify what abuse looks like in family and dating relationships. Forms of abuse (physical, psychological, sexual, and neglect) and warning signs are clearly outlined and supported through the dramatized voices of victims sharing their feelings on, and experiences of abuse.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Date Rape: A Violation of Trust (To the average student, the definitions of date rape and sexual assault are notoriously unclear. Use this program to eliminate the confusion so young adults understand

exactly what these things are—and the attitudes and biases that typically accompany them—before anyone gets hurt.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Gender and Communication (Based on the premise that males and females learn different ways to relate, this program investigates how communication styles fall onto a continuum of what society deems as masculine and feminine and what it means to deviate from the norm.) Learning Seed P.O. Box 617880 Chicago IL 60661 P: 800.634.4941 F: 800.998.0854 E: Learning Seed Embracing Our Sexuality (Embracing Our Sexuality is a fascinating look into the conversations of nine women who gather together for a weekend to talk about sex. The women range in age from 21 to 71 and come from diverse racial backgrounds and sexual orientations.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: orders@newday.com Finding Our Way (What do men really want sexually? How did they learn about sex? How does sexual expression change with age? Finding Our Way explores these questions and offers a rare glimpse into men’s experience of their sexuality as it follows the discussions of ten men who meet at a weekend retreat.) New Day Films PO Box 165 Blooming Grove, NY 10914 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

P: 888.367.9154 E: orders@newday.com F: 845.774.2945 Before You Know It (The subjects of Before You Know It are no ordinary senior citizens. They are go-go booted bar-hoppers, love struck activists, troublemaking baton twirlers, late night Internet cruisers, seasoned renegades, and bold adventurers. They are also among the estimated 2.4 million lesbian, gay, and bisexual Americans over the age of 55 in the United States, many of whom face heightened levels of discrimination, neglect, and exclusion.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Power and Control: Domestic Violence in America (A comprehensive and timely exploration of the shocking persistence of domestic violence in our society. The complex issues around domestic abuse are refracted through the story of Kim, a mother of three in Duluth, MN. Kim’s journey takes her from a domestic violence shelter, to a promising fresh start, and then through a disturbing final twist.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Refusal Skills: Yes, You Can Say No (National award winning video series of well-documented dramas showing teens faced with temptations to skip school, take drugs, and have premarital sex.) Learning Seed P.O. Box 617880 Chicago IL 60661 P: 800.634.4941

F: 800.998.0854 E: Learning Seed Sexuality Part I and II (Dr. Lee Salk interviews children to recall what they know about sexuality and how their image of sex has been shaped by television.) PBS Video 1320 Braddock Pl. Alexandria, VA 22314-1698 The Art of Listening (Teaches listening skills.) Learning Seed P.O. Box 617880 Chicago IL 60661 P: 800.634.4941 F: 800.998.0854 E: Learning Seed The Brandon Teena Story (Documentary film about Brandon Teena, who struggled with sexual identity before being brutally raped and beaten to death.) Available through online stores and video streaming.

Internet Resources American Association of Sexuality Educators, Counselors, and Therapists Website promoting the understanding of human sexuality and healthy sexual behavior. American Association of Sexuality Educators, Counselors, and Therapists First Wives World Provides divorce support for women. First Wives World Healthy Sex HealthySex.com is an educational site developed by Wendy Maltz, M.S.W. to promote healthy sexuality—sex based on caring, respect, and safety. HealthySex.com

Relationships Information on a variety of topics such as sexual health and healthy relationships. TODAY – Relationships American Medical Association Information on a wide variety of health-related issues is available throughout this site. American Medical Association HIV/AIDS This site, sponsored by the Centers for Disease Control and Prevention (CDC), features current information, fact sheets, conferences, media campaigns, publications, the 20year history of HIV/AIDS, information on prevention and treatment, an FAQ section, as well as the most current HIV/AIDS statistics. Centers for Disease Control and Prevention – HIV/AIDS SexualHealth.com The Sexual Health Network is dedicated to providing easy access to sexuality information, education, support, and other resources. Analyte Physicians Group – Sexual Health Sexual Orientation: Science, Education, and Policy Research that focuses on sexual orientation, antigay violence, homophobia, and other concerns of gay men and lesbians. Sexual Orientation: Science, Education, and Policy Anxiety Disorders Provides information about social anxiety disorder and other anxiety disorders. National Institutes of Health - Anxiety Disorders The Institute for the Advanced Study of Human Sexuality Has available a large collection of information and frequently asked questions about sexuality. The Institute for the Advanced Study of Human Sexuality The Kinsey Institute Research, updates, and links on issues related to sexuality. Kinsey Institute – Indiana University

John Gray Author of Men Are from Mars, Women Are from Venus. Mars Venus Women’s Sexual Health This is an informational site designed for women and their partners who have questions and concerns about women’s sexual health. Women’s Sexual Health

Key Terms altruism

families

blended families

hookup

codependency

intimacy

cohabitation

same-sex marriage

cyberbullying

self-disclosure

cyberstalking

social anxiety disorder

dysfunctional

social contagion

enabling

Answers to Global Health Watch 1. b 2. a 3. safety plans

5 Personal Nutrition Learning Objectives After studying this chapter in the text, the student should be able to: 5.1

Analyze the recommendations of the 2015–2020 Dietary Guidelines for Americans.

5.2

Identify the six categories of essential nutrients.

5.3

Differentiate between single and complex carbohydrates.

5.4

Describe the forms of fat and their effects on health.

5.5

Review the components of various healthy eating patterns.

5.6

Assess the importance and accuracy of food labels.

5.7

Discuss the causes, effects, and prevention of foodborne infections.

5.8

Outline ways to identify nutrition quackery.

Chapter Summary This chapter can help you create a healthy eating pattern, regardless of your financial or time constraints. It translates the latest scientific research and government dietary guidelines into specific advice designed to promote and preserve good health. By learning more about nutrients, food groups, eating patterns, nutrition labels, and safety practices, you can nourish your body with foods that not only taste good but are also good for you.

Lecture Outline I.

The 2015–2020 Dietary Guidelines for Americans A. Overview 1. The Dietary Guidelines for Americans, revised every 5 years by a team of experts assembled by the Departments of Agriculture and Health and Human Services, provide “science-based advice for healthy people ages 2

II.

years and older to assist them in their efforts to make food and physical activity choices that promote health and prevent the risk of disease.” 2. The five official Dietary Guidelines are as follows: a. Follow a healthy eating pattern across the lifespan. b. Focus on variety, nutrient density, and amount. c. Limit calories from added sugars and saturated fats and reduce sodium intake. d. Shift to healthier food and beverage choices. e. Support healthy eating patterns for all. The Building Blocks of Good Nutrition A. Introduction 1. The digestive system breaks down food into macronutrients, the nutrients required by the human body in the greatest amounts. 2. We also need vitamins and minerals, the so-called micronutrients, but in only very small amounts. B. Calories 1. Calories are the amount of energy that can be derived from macronutrients. The number of calories you need depends on the following: a. Gender, age, body-frame size, weight, percentage of body fat, and basal metabolic rate (BMR). b. BMR is the number of calories needed to sustain your body at rest. C. Essential Nutrients 1. Every day your body needs certain essential nutrients that provide energy, build and repair body tissues, and regulate body functions. 2. The six classes of essential nutrients are water, protein, carbohydrates, fats, vitamins, and minerals. 3. Water a. Water, which makes up 85 percent of blood, 70 percent of muscles, and about 75 percent of the brain, performs many essential functions including carrying nutrients, maintaining temperature, lubricating joints, helping with digestion, ridding the body of water through urine, and contributing to the production of sweat, which evaporates from the skin to cool the body. b. To ensure adequate water intake, nutritionists advise drinking enough so that your urine is not dark in color. 4. Protein a. Critical for growth and repair, proteins form the basic framework for our muscles, bones, blood, hair, and fingernails.

b. Proteins are made of combinations of 20 amino acids, nine of which we must get from our diet because the human body cannot produce them. These are called essential amino acids. c. A complete protein, or high-quality protein, source provides all of the essential amino acids. Animal-based foods are considered sources. d. Incomplete proteins are low in one or more of the essential amino acids. e. Complementary proteins are two or more incomplete protein sources that together provide adequate amounts of all the essential amino acids. f. The average person needs 50–65 grams of protein daily. 5. Protein sources a. Protein is found in the following foods: i. Meats, poultry, and fish ii. Legumes (dry beans and peas) iii. Tofu iv. Eggs v. Nuts and seeds vi. Milk and milk products vii. Grains, some vegetables, and some fruits b. Animal proteins are also sources of saturated fat, which has been linked to elevated low-density lipoprotein (LDL) cholesterol, a risk factor for cardiovascular disease. c. Because it is rich in omega-3 fatty acids, seafood, another good protein source, has been linked with fewer cardiac deaths among individuals with or without cardiovascular disease. d. Vegetarians who avoid eating all (or most) animal foods must rely on plant-based sources to meet their protein needs. 6. Carbohydrates a. Carbohydrates are organic compounds that provide our brains and bodies with glucose, their basic fuel. b. The major sources of carbohydrates are plants—including grains, vegetables, fruits, and beans—and milk. c. All provide 4 calories per gram and adults and children should consume at least 130 grams each day. d. Simple carbohydrates i. These include natural sugars, such as the lactose in milk and the fructose in fruit, and added sugars that are found in candy, soft drinks, fruit drinks, and other sweets. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

ii.

High-fructose corn syrup might stimulate the pancreas to produce more insulin. It also makes beverages very sweet, which may increase consumption and contribute to obesity and other health problems. e. Complex carbohydrates i. Examples are grains, cereals, vegetables, beans, and nuts. ii. Whole grains are made up of all the components of the grain, including the bran (fiber-rich outer layer), the endosperm (middle layer), and the germ (nutrient-packed inner layer). f. Fiber i. Dietary fiber is the nondigestible form of complex carbohydrates occurring naturally in plant foods, such as leaves, stems, skins, seeds, and hulls. ii. Functional fiber consists of isolated, nondigestible carbohydrates that may be added to foods that provide beneficial effects in humans. iii. Total fiber is the sum of dietary fiber and functional fiber. iv. Benefits of fiber: creates a feeling of fullness and aids in weight control, interferes with the absorption of dietary fat and cholesterol, and helps prevent constipation and diabetes. Fiber may also contribute to a longer lifespan. v. The Institute of Medicine recommends 38 grams of daily total fiber for men and 25 grams for women. vi. Good sources of fiber include wheat and corn bran; leafy greens; the skins of fruits and root vegetables; oats, beans, and barley; and the pulp, skin, and seeds of many vegetables and fruits, such as apples and strawberries. g. Glycemic Index and Glycemic Load i. Glycemic index is a ranking of carbohydrates, gram for gram, based on their immediate effect on blood glucose levels. ii. Glycemic load is a measure of how much a typical serving size of a particular food raises blood glucose. h. Low-Carb Foods i. Although many people may buy low-carb foods because they believe that they’re healthier, that isn’t necessarily the case. ii. Some people do lose weight when they switch to low-carb foods, but the reasons are probably that they consume fewer calories, lose water weight, and have decreased appetite because of a buildup of ketones (a by-product of fat metabolism) in the blood. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

i. Refined Grains i. Refining of whole grains removes vitamins, minerals, and fiber. ii. Many refined grain products, such as cookies and cake, are also high in solid fats and added sugars. j. Fats i. Fats carry the fat-soluble vitamins A, D, E, and K; aid in their absorption in the intestine; protect organs from injury; regulate body temperature; and play an important role in growth and development. ii. Fats provide 9 calories per gram. iii. Saturated fats are normally solid at room temperature. iv. Unsaturated fats can be divided into monounsaturated and polyunsaturated fats and are found in olive, soybean, canola, cottonseed, corn, and other vegetable oils. v. Omega-3 and omega-6 are polyunsaturated fatty acids with slightly different chemical compositions. (a) Omega-3 fatty acids are found in salmon, sardines, flaxseed, and walnuts. (b) Omega-3 fatty acids help to prevent blood clots, protect against irregular heartbeats, and lower blood pressure. (c) Omega-6 fats are found in vegetable oils, nuts, seeds, meat, poultry, and eggs. k. Cholesterol i. The body makes more cholesterol than it uses, and people do not need additional amounts. ii. The main sources of cholesterol, which is found only in animal foods, include eggs, chicken, and beef. l. Trans-Fatty Acids i. These substances, found naturally in some foods and formed during food processing, are not essential in the diet. ii. An increased intake of trans-fatty acids has been linked with higher levels of LDL and heart-harming cholesterol and greater danger of cardiovascular disease. m. Oils i. Fats with a high percentage of monounsaturated and polyunsaturated fatty acids are usually liquid at room temperature and so are referred to as oils. ii. The Dietary Guideliines recommend replacing some solid fats with oils. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

D. Vitamins 1. Vitamins help put proteins, fats, and carbohydrates to use and are essential to regulating growth, maintaining tissue, and releasing energy from foods. a. The fat soluble vitamins are A, D, E, and K. b. The B vitamins and vitamin C are water soluble. c. Antioxidants are substances that prevent the harmful effects caused by oxidation within the body. i. These include vitamin C and E and beta-carotene as well as compounds like carotenoids and flavonoids. d. Folic Acid i. Folic acid, or folate, a B vitamin, reduces the risk of neural tube defects in children. e. Vitamin D i. Vitamin D is essential for bone health, cognitive function, pain control, and many other processes. ii. Vitamin D3 is formed in the skin after exposure to the sun’s ultraviolet rays and ingested from animal sources, including some fish. iii. Vitamin D can also be found in fortified foods such as milk, cheese, bread, and juice. iv. The benefits of vitamin D include: (a) Lower risk of heart disease (b) Decreased blood pressure (c) Protection against infection (d) Formation and maintenance of strong bones (e) Better absorption of calcium v. Low levels of vitamin D can contribute to heart disease, falls and broken bones, breast cancer, prostate cancer, depression, memory loss, Parkinson’s disease, and stroke. E. Minerals 1. Minerals help build bones and teeth, aid in muscle function, and help our nervous systems transmit messages. 2. Calcium a. Calcium, the most abundant mineral in the body, builds strong bone tissue throughout life and plays a vital role in blood clotting and muscle and nerve functioning.

III.

b. Adequate vitamin D and calcium intake during childhood, adolescence, and young adulthood is crucial for preventing osteoporosis. 3. Sodium a. Sodium helps maintain proper fluid balance, regulates blood pressure, transmits muscle impulses, and relaxes muscles. b. The National Heart, Lung, and Blood Institute recommends less than one tablespoon of table salt a day. F. Other dietary components 1. Vegetables and Fruits a. Nutritionists and health officials consistently recommend eating more vegetables and fruits. b. Fruits and vegetables provide many nutrients that many Americans lack; lower the risk of many chronic illnesses, including type 2 diabetes, cardiovascular disease (including heart attack and stroke), and certain cancers; help individuals reach and maintain a healthy weight; and lessen the risk of dying. c. Fewer than one-third of American adults eat the recommended amounts of fruits and vegetables. 2. Milk and Milk Products a. Dairy products provide many nutrients, including calcium, vitamin D, and potassium, and may improve bone health, lower blood pressure, and reduce the risk of cardiovascular disease and type 2 diabetes. b. Health officials recommend 3 cups a day or the equivalent for adults. 3. Alcohol a. Depending on the amount consumed, age, and other factors, alcohol can have harmful or beneficial effects. b. However, there is no nutritional need for alcohol. 4. Phytochemicals a. Compounds that exist naturally in plants b. Serve many functions including helping a plant protect itself from bacteria and disease. c. In the body, act as antioxidants, mimic hormones, and reduce the risk of various illnesses, including cancer and heart disease Healthy Eating Patterns A. A healthy eating pattern is not a rigid prescription but an array of options that can accommodate cultural, ethnic, traditional, and personal preferences as well as food costs and availability.

B. My Plate 1. The United States Department of Agriculture’s (USDA’s) MyPlate icon serves as a visual reminder for healthy eating. C. The USDA Food Patterns 1. These approaches identify daily amounts of foods to eat from five major food groups and subgroups. 2. They include a vegan pattern and a lacto-ovo-vegetarian pattern. D. The DASH Eating Plan 1. It emphasizes vegetables, fruits, low-fat milk and milk products; includes whole grains, poultry, seafood, and nuts; and is lower in sodium, red and processed meats, sweets, and sugar-containing beverages. E. The Mediterranean Diet 1. Emphasizes vegetables, fruits and nuts, olive oil, and grains with only a small amount of meats and full-fat milk and milk products. F. Vegetarian Diets 1. Lacto-ovo-pesco-vegetarians eat dairy products, eggs, and fish but not red meat. 2. Lacto-vegetarians eat dairy products as well as grains, fruits, and vegetables. 3. Ovo-lacto-vegetarians also eat eggs. 4. Vegans or pure vegetarians eat only plant foods. 5. Vegetarians need to understand the concept of complementary proteins to get sufficient protein in their diet. 6. Vegetarian diets have proven health benefits including lower cholesterol levels, healthier weight, decreased risk of heart disease, and lower incidences of breast, colon, and prostate cancer; high blood pressure; and osteoporosis. G. Ethnic Cuisines 1. Each type of ethnic cooking has its own nutritional benefits and potential drawbacks. a. The cuisine served in Mexico features rice, corn, and beans, which are low in fat and high in nutrients. b. African American cuisine traces some of its roots to food preferences from western Africa (e.g., peanuts, okra, and black-eyed peas), as well as to traditional American foods, such as fish, game, greens, and sweet potatoes. c. The mainland Chinese diet, which is plant-based, high in carbohydrates, and low in fats and animal protein, is considered one of the most healthful in the world. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

However, Chinese restaurants in the United States serve more meat and sauces than are generally eaten in China. d. Traditional French cuisine, which includes rich, high-fat sauces and dishes, has never been considered healthful. e. Many Indian dishes highlight healthful ingredients such as vegetables and legumes (beans and peas). i. However, many also use ghee (a form of butter), which is rich in harmful saturated fats. f. The traditional Japanese diet is very low in fat, which may account for the low incidence of heart disease in Japan. IV.

The Way We Eat A. Campus Cuisine: How College Students Eat 1. Often on their own for the first time, college students typically change their usual eating patterns. 2. Students make meal choices based first on price, convenience, and then nutrition. B. Money and Time Issues 1. A growing problem on many campuses is “food insecurity,” defined as limited or uncertain availability of healthful foods and limited or uncertain ability to acquire healthful foods. 2. Many factors may be contributing to the increase in food insecurity, including rising costs for tuition, room, and board; parents’ more limited resources; greater competition for work–study jobs; and lack of food stamps or other safety-net services. 3. Even when cost is not an issue, college students don’t necessarily get all the nutrients they need. a. The proportion of 18–24-year-olds that eats the recommended amounts of fruits and vegetables is generally lower than in the population as a whole. 4. Time pressures often affect students’ food choices. C. Nutrition Knowledge 1. Undergraduates vary greatly in their awareness and understanding of basic nutrition. D. Fast Food: Eating on the Run 1. Young adults consume approximately 40 percent of their daily calories away from home and eat at fast-food restaurants on an average of two to three times a week.

2. Many fast foods are high in calories, sugar, salt, and fat and low in beneficial nutrients. E. His Plate, Her Plate: Gender and Nutrition 1. Men and women do not need to eat different foods, but their nutritional needs are different. a. Men: i. Consume more calories ii. Should cut back on fat and meat in their diets b. Women: i. Should increase their iron intake by eating meat ii. Should consume more calcium-rich foods, including low-fat and nonfat dairy products, leafy greens, and tofu iii. Who become pregnant should take a multivitamin with 400 micrograms of folic acid F. You Are What You Drink 1. “Enriched” or “fortified” water is not necessarily better. 2. Soft Drinks a. Soda consumption has decreased among young adults, although one in five still qualify as heavy users. b. The health dangers associated with sweetened drinks include increased calorie intake, higher body weight, lower consumption of calcium and other nutrients, and greater risk of medical problems, such as diabetes. 3. Energy Drinks a. Energy drinks have become the fastest-growing part of the beverage market in the United States. b. Some energy drinks contain 15 times the amount of caffeine in a 12 ounce of cola. c. Energy drink formulations vary widely. d. Doctors recommend that all adults limit their caffeine intake to 500 milligrams a day. G. Choosing Healthful Snacks 1. College students snack primarily “to satisfy hunger”; the second most common reason is “no time for meals.” 2. In response to consumer demands for smart snack choices, food manufacturers are offering “better-for-you” options that are lower in salt and sugar or free of trans fat and artificial colors. 3. A best-for-you option is fruits such as bananas, apples, or berries—rich in vitamins, low in calories, and packed with fiber. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Dietary Supplements A. About half of adults in the United States use dietary supplements, most often multivitamins to improve or maintain overall health. B. Years of research have found no clear evidence of a beneficial effect of supplements on all-cause mortality, cardiovascular disease, or cancer.

VI. Taking Charge of What You Eat A. Introduction 1. The Nutrition Labeling and Education Act requires food manufacturers to provide information about fat, calories, and ingredients in large type on packaged food labels, and they must show how a food item fits into a daily diet of 2,000 calories. 2. The law also restricts nutritional claims for terms such as healthy, low-fat, and high-fiber. B. Portions and Servings 1. A food-label serving is a specific amount of food that contains the quantity of nutrients described on the Nutrition Facts label. 2. A portion is the amount of a specific food that an individual eats at one time. 3. According to nutritionists, “marketplace portions” or the actual amounts served to customers are two to eight times larger than the standard serving sizes defined by the USDA. C. Nutrition Labels 4. The Nutrition Facts label, required on food packages for 20 years, focuses on those nutrients most clearly associated with disease risk and health. 5. The most recent changes proposed by the Food and Drug Administration include the following: a. Information about the amount of “added sugars” or empty calories in a food product. b. Updated serving size requirements to reflect the amounts people actually eat, not what they “should” be eating. c. Calorie and nutrition information for both “per serving” and “per package” calorie for larger packages that could be consumed in one sitting or multiple sittings. d. Inclusion of potassium and vitamin D, nutrients that some in the U.S. population need more of. Vitamins A and C are no longer required on the label.

e. Revised Daily Values (the total amount of a nutrient that the average adult should aim to get or not exceed on a daily basis) for a variety of nutrients such as sodium, dietary fiber, and vitamin D to help consumers understand the nutrition information in the context of a total daily diet. D. What is an “Organic” Food? 1. Foods certified as organic by the USDA must meet strict criteria, including the following: a. Processing or preservation only with substances approved by the USDA for organic foods. b. Processing without genetic modification or ionizing radiation. c. No use of most synthetic chemicals, such as pesticides, herbicides, or fertilizers. d. Fertilization without sewage sludge. e. Food-producing animals grown without medication such as antibiotics or hormones, provided with living conditions similar to their natural habitat, and fed with organic food. 2. There has been little research as to whether organic foods are nutritionally superior to conventional foods. E. Genetically Engineered Foods 1. Using recombinant DNA technology, scientists directly manipulate the genes of living things—removing some, adding others, changing gene positions—in order to influence how an organism grows and develops. 2. Although you may not realize it, you’ve probably eaten genetically modified organisms (GMOs) produced by recombinant DNA engineering. 3. The Food and Drug Administration, which evaluates the safety of genetically engineered foods, views them as safe unless they differ significantly from similar foods. VII. Food Safety A. Overview 1. Foodborne infections cause an estimated 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States every year. 2. Salmonella, Listeria, and Toxoplasma are responsible for more than 75 percent of these deaths. B. Fight BAC! 1. BAC stands for food bacteria, an invisible threat to your health. 2. Four key culprits in foodborne illness include the following: a. Improper cooling © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. Improper hand washing c. Inadequate cooking d. Failure to avoid cross-contamination C. Avoiding E. coli Infection 1. Eating unwashed produce, such as spinach or lettuce, or undercooked beef, especially hamburger, can increase your risk of infection with Escherichia coli (E. coli) bacteria. D. Food Poisoning 1. Salmonella a. A bacterium that contaminates many foods, particularly undercooked chicken, eggs, and sometimes processed meats 2. Campylobacter jejuni a. A bacterium found in water, milk, and some foods b. Campylobacter poisoning can lead to severe diarrhea and has been implicated in the growth of stomach ulcers. 3. Staphylococcus aureus a. When cooked foods are cross-contaminated with the bacteria from raw foods and not stored properly, staph infections can result, causing nausea and abdominal pain. 4. Clostridium botulinum a. Improper home canning can cause botulism, an uncommon but sometimes fatal form of food poisoning. 5. Listeria a. Bacteria commonly found in deli meats, hot dogs, soft cheeses, raw meat, and unpasteurized milk E. Pesticides 1. Commercial pesticides save billions of dollars of valuable crops from pests, but they also may endanger human health and life. 2. Fearful of potential risks in pesticides, many consumers are purchasing organic foods. F. Food Allergies 1. The National Institute of Allergy and Infectious Diseases define a food allergy as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.” 2. As many as 50–90 percent of presumed food allergies are not allergic reactions. 3. Cow’s milk, eggs, seafood, wheat, soybeans, nuts, seeds, and chocolate have all been identified as common triggers of food allergies.

VIII. Nutritional Quackery A. The Academy of Nutrition and Dietetics describes nutritional quackery as a growing problem for unsuspecting consumers. B. If the promises of a nutritional claim sound too good to be true, they probably are. C. Before you try any new nutritional approach, check with your doctor or a registered dietitian.

Discussion Questions •

How can you develop a well-balanced diet? What types of foods should you include daily? What are some of the barriers to achieving a well-balanced diet? How can you overcome those barriers?

•

What are the benefits of a vegetarian diet? How does a vegetarian diet promote optimal health and encourage environmental stability? Are there societal–economic benefits? What are they? Are there disadvantages?

•

What are the advantages and the disadvantages of multivitamin and mineral supplements? Which ones are most commonly used? Why are these chosen? What are the myths about multivitamin and mineral supplements that students have heard?

•

How can you become a wise consumer of good nutrition? Have students give examples from television and various forms of media. What is the general message behind each ad?

•

Students should select three food labels from foods that they regularly consume. They should analyze each label and report on serving size, calories, fat, carbohydrate, and protein content. They should also report on the fiber and vitamin and mineral content. Have each student determine if each food is a sound nutritional choice.

•

Have students sign up to research food items from a culture different than their own. Have a day set aside for all students to create a dish from the culture they are studying. Students can bring in their food items and share them with the class. Have students discuss the cultural differences as well as the health benefits and possible risks of consuming the different types of foods.

Classroom Activities Activity #1: Dietary Analysis Purpose: 1.

To have students identify their personal nutritional needs.

To have students review their personal diets and verify strengths and weaknesses in their diet.

Time: One class period.

Introduction: Introduce the new food guidelines for MyPlate and discuss what is considered a healthy diet.

Method: 1.

After reading Chapter 5 and discussing the importance of a healthy diet, have students keep track of what they eat for three days.

During the next class period or 3 days from giving out the assignment, use a nutritional analysis software program (e.g., ESHA) and have students analyze their diets for the last three days and create a nutritional profile.

Discussion: 1.

Have students discuss their nutritional profile. Were there any surprises? Is it what they expected?

How did their individual diets break down? Were they close to their recommended diets?

What improvements should they make? Where were they meeting their specific guidelines?

How close were they to getting all of the vitamins and minerals they needed? If they were short, would they consider taking supplements? Why or why not? Are there specific foods they could eat to help them meet their dietary needs?

How might the diets of those on high-protein or high-carbohydrate diets compare to those who have well-balanced diets? What are the concerns surrounding those types of diets?

Activity #2: Dinner Party Purpose: 1.

To assist students in applying dietary information to their own diet.

To assist students in applying dietary information to various restricted diets.

Time: One class period.

Introduction: After introducing the dietary guidelines for a healthy diet, begin to describe possible dietary changes that may be needed when an individual has restrictions to their diet.

Method: 1.

Have students plan a healthy dinner for five of their friends.

Students should consider caloric intake and amount of protein, carbohydrates, fat, and other nutrients that may be considered appropriate for a healthy dinner.

Have students calculate the amount of each nutrient as well the total calories for their dinner. If you gave them a restriction, have them compare their results. You may also want to have them use the remaining calories and nutrients that they still need in their daily diet to plan their lunch and breakfast.

To add a level of difficulty to this activity, pretend that one of their dinner guests has called to remind them that they are now a vegetarian and cannot eat meat. What changes do they need to make to their dinner to assure that this person meets the recommended nutrients in their day?

You may want to continue the activity with additional “calls” from friends who are diabetic, gluten sensitive, or who follow a Kosher diet.

Discussion: 1.

Ask students how difficult it was to plan a dinner for a “normally” healthy diet.

What difficulties did they have when they started receiving calls?

Is there a perfect diet that can be used for a variety of individuals? What would it include?

Why is it necessary to consider the dietary habits of others when preparing such a party? What are the risks (if any) to their guests, if the student neglects to take the specific diets into consideration?

Activity #3: Healthy Snacking Purpose: To have students review their personal diets and identify their snacking habits.

Time: One-half of a class period.

Introduction: Review the new food guidelines for MyPlate and discuss healthy food options.

Method: 1.

List all the snack foods that you currently have in your kitchen or that you have consumed in the last three days.

Determine whether each food is a healthy choice or not a healthy option.

Discussion: 1.

Have students discuss their snack choices. Were there any surprises?

Were their options more healthy or unhealthy?

What improvements should they make?

List specific alternatives to food options to ensure healthier choices.

Activity #4: Food Labels Purpose: To help students navigate through the complex and often perplexing art of reading food labels.

Time: Two and a half class periods with one full class period reserved for meeting at a local grocery store.

Methods: 1.

During the class period prior to your field trip, have the students write down what they would normally eat during a whole day: breakfast, lunch, dinner, and snacks.

Arrange for all students to meet at a local grocery store.

With their daily meal plans in hand, have the students search the grocery store aisles for the best buys on items on their meal plan and have them read the Nutritional Facts food panels on the items that make up their meal plan.

Discussion: 1.

During the next class period, have the students discuss how they were affected by reading the food labels? Would they change their meal plan based on the information they read on the food labels? Why or why not?

Activity #5: Fast Food Analysis Purpose: 1.

To have students recognize the impact of a fast food diet on health.

To increase awareness of the nutritional value in fast foods.

Time: One to two hours.

Method: 1.

Students should visit a fast food restaurant (or the corresponding website) where they are most likely to eat.

Students should review the menu, including the nutritional analysis of every food item offered.

Each student should write down their typical meal at that establishment and list the calories, total fat, saturated fat, sodium, and fiber content and percent of daily value for each item.

Next, students should look at the menu items and choose a meal that would be a healthy option.

Discussion: 1.

Were students surprised at the nutritional value of their meal? Do they feel compelled to change their eating habits?

Do students think that their health will be impacted if they change their fast food eating patterns?

References, Readings, and Resources American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Callejas, J. “Food Insecurity on College Campuses.” The Chronicle (April 28, 2015). http://www.duke-chronicle.com. Patrick, Megan E., Carlos Macuada, and Jennifer L. Maggs. ”Who Uses Alcohol Mixed with Energy Drinks?: Characteristics of College Student Users.” Journal of American College Health 64, no. 1 (2016): 74–9. doi: 10.1080/07448481.2015.1042877. Schlosser, E. (2001) Fast Food Nation. New York: Simon and Schuster. Schwingshackl, L., et al. “Dietary Supplements and Risk of Cause-Specific Death, Cardiovascular Disease, and Cancer: A Protocol for a Systematic Review and Network Meta-Analysis of Primary Prevention Trials.” Systemic Review 4, no. 1 (2015): 34. doi: 10.1186/ s13643-015-0029-z. Sizer, F. S., and E. N. Whiney. Nutrition: Concepts and Controversies, 14th ed. (Boston: Cengage Learning, 2017). U.S. Department of Health and Human Services and U.S Department of Agriculture. 2015–2020 Dietary Guidelines for Americans, 8th ed. 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/ executive-summary/. Vartanian, L. R. et al. “Effects of Soft Drink Consumption on Nutrition and Health: A Systematic Review and Meta-analysis.” American Journal of Public Health, Vol. 97, No. 4, Apr. 2007, pp. 667–675.

Films and Videos Healthy Eating: A Guide to Nutrition (A five-part series that covers basic nutrition, weight management, eating disorders, nutrition for athletes, and food safety and disease prevention.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001

P: 800.322.8755 F: 800.678.3633 E: Films Media Group Diets and Nutrition (Introduce your students to MyPyramid—and healthy habits that can last a lifetime— with this video. It explains how to read the steps and bands of the MyPyramid food guide; which diets are healthy (and which are not!); why physical activity is so important, and how much exercise is enough; and how to make sense of nutritional labeling on food packaging.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group A Scientific Look at Nutrition (What happens to the food we eat, and how does it benefit the body? This video illustrates how the six essential nutrient classes—carbohydrates, proteins, amino acids, vitamins, minerals, and water—function. It also explains mechanical and chemical digestion, the expenditure of energy, and the process of metabolism, a collection of chemical reactions that convert the fuel in food into the energy needed to power everything we do.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group 10 Things You Need to Know about Losing Weight (Each year, millions of people attempt to slim down—and fail. If super-diets and weight-loss fads don’t work, what does? This program presents 10 science-based approaches to losing weight without starving as volunteers put the theories to the test.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

F: 800.678.3633 E: Films Media Group Obesity in a Bottle 2: How to Pick Healthy Beverages (There’s a good reason that canned and bottled beverages are called liquid candy—and that term is not reserved for soda pop alone. Vitamin-enhanced waters, teas, and juices are loaded with empty calories from sugar, adding inches to Americans’ waistlines and possibly contributing to rising rates of chronic disease. In this program, registered dietician Susan Moores presents five segments that offer suggestions for beverage selections, including picking healthy drinks, choosing drinks for kids, selecting drinks for sports and athletic performance, low-calorie drinks, and the pros and cons of caffeine.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Food Labels: Misleading due to Misreading (John Strossel blasts counterintuitive food labels that calculate fat, carbs, sodium, and other essential nutritional information based on a serving size that is unrealistically smaller than the unit size.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Introduction to Food-Borne Illness (Learn to minimize the risk of contracting and spreading of food-borne illnesses.) NIMCO, Inc. P.O. Box 9 102 Highway 81 North Calhoun, KY 42327-0009 P: 270-273-5000 • 800-962-6662 E: NIMCO

The Food Label and You (What does "Reduced Fat" and "Low Fat" on a food product really mean? Which products contain more calcium and sodium? Can you believe a company's claims about their food products? Answers these questions and many more.) NIMCO, Inc. P.O. Box 9 102 Highway 81 North Calhoun, KY 42327-0009 P: 270-273-5000 • 800-962-6662 E: NIMCO

Internet Resources Academy of Nutrition and Dietetics Provides a wide variety of nutrition education information. eatright.org Amazing Collection of Nutrition Amazing Collection of Nutrition is a resource for everyone from newbies to experts. Amazing Collection of Nutrition American Diabetes Association Provides literature, a free newsletter, and referrals to local support groups. American Diabetes Association American Heart Association Information to help people build healthier lives, free of cardiovascular diseases and stroke. American Heart Association American Society for Nutrition Homepage for the American Society for Nutrition. American Society for Nutrition Ask the Dietitian Joanne Larsen is a licensed, registered dietitian with extensive clinical experience in nutrition therapy in hospitals, clinics, mental health, and long-term care. Ask the Dietitian

ChooseMyPlate.gov Provides practical information to individuals, health professionals, nutrition educators, and the food industry to help consumers build healthier diets with resources and tools for dietary assessment, nutrition education, and other user-friendly nutrition information. ChooseMyPlate.gov Food and Nutrition Information Center The USDA’s Food and Nutrition Information Center. USDA—Food and Nutrition Information Center Foodsafety.gov Information on food safety and consumer advice from the U.S. Department of Health & Human Services. Foodsafety.gov Harvard School of Public Health: The Nutrition Source A nutrition source maintained by the Department of Nutrition at the Harvard School of Public Health. Harvard School of Public Health—The Nutrition Source Nutrition.gov Provides easy access to vetted food and nutrition information from across the federal government. Nutrition.gov NIH Office of Dietary Supplements Information on dietary supplements. NIH Office of Dietary Supplements National Agricultural Library Collection of resources on a variety of topics such as meal planning and obesity prevention. USDA National Agricultural Library U.S. Food and Drug Administration (FDA) Provides information for consumers and professionals in the areas of food safety, supplements, and medical devices and links to other sources of nutrition and food information. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

U.S. Food and Drug Administration

Key Terms amino acids

incomplete protein

antioxidants

macronutrients

basal metabolic rate (BMR)

micronutrients

calorie

minerals

calorie balance

nutrition

carbohydrates

omega-3 and omega-6

certified organic

organic

complementary proteins

phytochemicals

complete protein

protein

complex carbohydrates

saturated fats

dietary fiber

simple carbohydrates

essential nutrients

trans fats

folic acid

unsaturated fats

functional fiber

vitamins

Answers to Global Health Watch 1. a 2. d 3. thermometer

6 Weight Management Learning Objectives After studying this chapter in the text, the student should be able to: 6.1

Summarize differences in weight among different populations in America.

6.2

Identify ways to assess body composition.

6.3

Explain the factors that have contributed to the obesity epidemic.

6.4

Discuss the impact of excess weight on health.

6.5

Review healthy approaches to gaining weight.

6.6

Assess ways of attaining and maintaining a healthy weight.

6.7

List the treatment options for extreme obesity.

6.8

Discuss the factors that lead to unhealthy eating on campus.

6.9

Recognize common forms of disordered eating and of eating disorders.

Chapter Summary This chapter explains what obesity is and why excess pounds are dangerous, describes current approaches to weight loss, discusses diets that work (and some that don’t), offers practical guidelines for exercise and behavioral approaches to losing weight, and examines unhealthy eating patterns and eating disorders. If you’re already at a healthy weight, this chapter can ensure that you remain so in the future. If, like two-thirds of Americans, you are overweight, you will find help in these pages. Remember: You can choose to lose. And you can start now.

Lecture Outline I.

Weighing In A. Introduction 1. For the first time in history, more people worldwide—some 2.1 billion— are overweight or obese rather than underweight.

2. In the United States, nearly 35 percent of adults are classified as obese. 3. The prevalence of obesity among women has remained relatively stable, at about 35 percent, since 2000, but the prevalence among men has increased from 27.5–35.5 percent. II.

Weight on Campus A. Whether or not they are enrolled in college, young adults gain an average of 30 pounds between ages 18 and 35. B. Only about 5 percent of students gain the legendary “freshman 15.” According to a recent estimate, the average is about 11 pounds.

III.

What Is a Healthy Weight? A. Body Mass Index (BMI) 1. BMI, a ratio between weight and height, is a mathematical formula that correlates with body fat. 2. A healthy BMI ranges from 18.5 to 24.9. 3. BMI of 25 or greater defines overweight and marks the point at which excess weight increases the risk of disease. 4. A BMI of 30 or greater defines obesity and marks the point at which excess weight increases the risk of death. 5. A BMI between 35 and 39.9 means increased risk of premature death. 6. A BMI of 40 or higher indicates class 3 or severe obesity, a truly lifethreatening condition. B. Waist Circumference 1. The general guideline is that a waist measuring more than 35 inches in a woman or more than 40 inches in a man signals greater health risks. C. Waist-to-Hip Ratio (WHR) 1. The proportion of one’s waist circumference to one’s hip circumference. 2. For women a ratio of 0.8 or less and for men a ratio of 0.9 or less is considered safe. D. Body Fat 1. Ideal body fat percentages for men range from 7 to 25 percent and for women from 16 to 35 percent. 2. Methods of assessing body composition include the following: a. Skinfold measurement b. Home body fat analyzers c. Laboratory methods such as hydrostatic weighing and bioelectrical impedance analysis

IV.

Understanding Weight Problems A. Overview 1. Ultimately, all weight problems result from a prolonged energy imbalance caused by consuming too many calories and burning too few in daily activities. 2. How many calories you need depends on your gender, age, body-frame size, weight, percentage of body fat, and basal metabolic rate (BMR)—the number of calories needed to sustain your body at rest. B. How Did So Many Get So Fat? 1. Bigger portions 2. Consuming more calories than we burn 3. Fast food 4. Physical inactivity 5. Passive entertainment 6. Emotional eating 7. Genetics 8. Social networks 9. Marriage

Health Dangers of Excess Weight A. The younger individuals are when they gain weight, the more health risks they may face over their lifetimes. B. The Impact on the Body 1. Major diseases linked to obesity include: a. Type 2 diabetes b. Cardiovascular disease and heart attacks c. Strokes d. Cancer e. Other health problems including musculoskeletal problems f. Premature death C. The Emotional and Social Toll 1. Overweight men and women often blame themselves for becoming heavy and feel guilty and depressed as a result. 2. Obesity also has social consequences. D. If You’re Too Thin: How To Gain Weight 1. Being underweight is not an uncommon problem, particularly among adolescent and young adult men as well as among those who diet excessively or suffer from an eating disorder. 2. Suggestions for gaining weight in healthy ways include the following:

a. Eat more of a variety of foods. b. If your appetite is small, eat more frequently. c. Choose some calorie-rich foods. d. Drink juice rather than regular or diet soda. e. Try adding a commercial liquid meal replacement as a snack. f. Exercise regularly. VI.

A Practical Guide to a Healthy Weight A. Overview 1. There are only two effective strategies for losing weight: eating less and exercising more. B. Preventing Weight Gain 1. As with other medical problems, the best approach to excess weight and obesity is prevention. C. Weight Loss Diets 1. High-Protein Diets a. The Institute of Medicine considers a range of 10–35 percent of calories from protein as acceptable for adults, and some diets advise even higher levels. b. Severe restriction of carbohydrates can induce ketosis, which is caused by an incomplete breakdown of fats that can lead to nausea, fatigue, and light-headedness and can worsen kidney disease and other medical problems. 2. Low-Carbohydrate, Low-Fat Diets a. Some popular diets are based on the premise that the correct proportions of various nutrients, particularly carbohydrates, fats, and proteins, lead to hormonal balance, weight loss, and greater vitality. b. Many people cannot stay on these diets for a sustained period. 3. The Bottom Line a. In a recent review of weight-loss interventions, researchers identified the key components of a successful diet. i. Daily caloric intake of about 500 calories less than usual ii. Relatively high in protein iii. Moderately low in calories iv. Low glycemic index v. A minimum of 30 minutes of daily, moderate-intensity physical exercise

4. Although people lose weight on any diet that helps them eat less, most dieters lose only about 5 percent of their initial weight and gain some of that back. D. Physical Activity and Exercise VII.

Do Weight Loss Programs Work? A. Weight Loss Programs 1. Counseling plus calorie control: These are the only programs backed by scientific evidence. 2. Very-low-calorie and low-calorie meal replacement programs: Consumers using these products initially reported greater weight loss than those given counseling alone, but attrition was high and the difference was not statistically significant by 9 months. 3. Self-directed: Results vary by program. 4. Internet-based programs: Results vary by program. B. Physical Activity and Exercise 1. Scientists use the acronym NEAT for nonexercise activity thermogenesis to describe “nonvolitional” movement, which may be an effective way of burning calories. 2. Although physical activity and exercise can prevent weight gain and improve health, usually it does not lead to significant weight loss. a. However, when combined with diet, exercise ensures that you lose fat rather than muscle and helps keep off excess pounds. 3. Moderate exercise, such as 30–60 minutes of daily physical activity, reduces the risk of heart disease and other health threats. 4. Exercising a minimum of 200–300 minutes weekly of moderately intense activity is necessary to maintain weight loss. 5. Physical activity increases energy expenditure, builds up muscle tissue, burns off fat stores, stimulates the immune system, and possibly reprograms metabolism. C. Complementary and Alternative Medicine (CAM) for Obesity 1. CAM is defined as “varied medical and health-care systems, practices, and products that are not considered to be part of any Western healthcare system” and include the following: a. Herbal supplements: Research suggests these are not effective. b. Acupuncture: Although research has suggested a beneficial effect, the design and validity of the studies have been criticized. c. Mindfulness: The impact of mindfulness alone is not clear. 2. Common Diet Traps

a. Over-the-counter diet pills b. Diet foods c. Artificial sweeteners and fake fats D. Maintaining Weight Loss 1. Surveys of people who lost significant amounts of weight and kept it off for several years show that most did so on their own—without medication, meal substitutes, or membership in an organized weight-loss group. 2. Their customized approaches share certain characteristics. a. Personal responsibility for change b. Exercise c. Monitoring d. Vigilance e. Frequent eating VIII.

Treating Severe Obesity A. The number of extremely obese adults—those at least 100 pounds overweight with BMIs over 40—has quadrupled in the last two decades from 1 in 200 to about 1 in every 50 men and women. B. Obesity Medications 1. Obesity medications are meant for individuals with BMIs equal to or greater than 30 or for those with a BMI equal to or greater than 27 with at least one weight-related health problem, such as hypertension or diabetes. C. Obesity Surgery 1. Obesity, or bariatric, surgery is becoming the most popular weight loss approach for the estimated 15 million men and women who qualify as “morbidly obese” (100 or more pounds overweight) because of their increased health risks. 2. The most common types of procedures are as follows: a. Gastric bypass b. Banding c. Endoscopic sleeve gastroplasty d. Duodenal switch 3. Long-term dangers—both physical and psychological—are unknown, particularly for adolescents.

IX.

Unhealthy Eating on Campus A. Introduction 1. Unhealthy eating behavior takes many forms, ranging from not eating enough to eating too much too quickly. 2. Researchers have linked specific genes to some cases of anorexia nervosa and binge eating, but most believe that a variety of factors, including stress and culture, combine to cause disordered eating. B. Body Image 1. As the gap between reality and ideal grows, both genders struggle with issues related to body image, although men and women report different concerns. 2. Women compare their appearance to that of celebrities and models as well as peers more frequently than men and worry more that others will think negatively about their looks. 3. College students of different ethnic and racial backgrounds express as much—and sometimes more—concern about their body shape and weight as whites.

Disordered Eating A. In a survey at a large, public, rural university in the mid-Atlantic states, 17 percent of the women were struggling with disordered eating. Younger women (ages 18–21) were more likely than older students to have an eating disorder. In this study, eating disorders did not discriminate, equally affecting women of different races, religions, athletic involvement, and living arrangements. B. Extreme Dieting 1. Extreme dieters go beyond cutting back on calories or increasing physical activity. They become preoccupied with what they eat and weigh. 2. Weight loss is severe enough to cause uncomfortable physical consequences, such as weakness and sensitivity to cold. 3. Extreme dieters may think they know a great deal about nutrition, yet many of their beliefs about food and weight are misconceptions or myths. C. Compulsive Overeating 1. People who eat compulsively cannot stop putting food in their mouths. They eat fast and eat a lot. They eat even when they are full. 2. The following behaviors may signal a potential problem with compulsive overeating. a. Turning to food when depressed or lonely, when feeling rejected, or as a reward

b. A history of failed diets and anxiety when dieting c. Thinking about food throughout the day d. Eating quickly and without pleasure e. Continuing to eat even when you are no longer hungry f. Frequently talking about food, or refusing to talk about food g. Fear of not being able to stop eating once you start D. Binge Eating 1. Binge eating is the rapid consumption of an abnormally large amount of food in a relatively short time. 2. Binge eaters experience at least three of the following: a. Eating much more rapidly than usual b. Eating until they feel uncomfortably full c. Eating large amounts of food when not feeling physically hungry d. Eating large amounts of food throughout the day with no planned mealtimes e. Eating alone because they are embarrassed by how much they eat and by their eating habits 3. Binge eaters may spend up to several hours eating, and consume 2,000 or more calories worth of food in a single binge. 4. If you binge once a week or more for at least a 3-month period, you may have binge-eating disorder, a recently recognized psychiatric disorder that can require professional help. E. Eating Disorders 1. Eating disorders affect an estimated 5–10 million women and 1 million men. a. Female college students who spend a lot of time on Facebook tend to be more likely to be concerned about their body image and could be at increased risk for eating disorders. b. Athletes in sports involving pressure either to maintain ideal body weight or to achieve a weight that might enhance their performance are more likely to develop eating disorders. 2. Anorexia Nervosa a. Although anorexia means “loss of appetite,” most individuals with anorexia nervosa are, in fact, hungry all of the time. b. For them, food is an enemy—a threat to their sense of self, identity, and autonomy. c. They see themselves as fat or flabby even at a normal or below-normal body weight. d. The key characteristics of anorexia nervosa include the following: © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Restriction of food intake, leading to a significantly low body weight for their age, health, and gender. ii. An intense fear of gaining weight or becoming fat, even though underweight. iii. Disturbance in the way individuals experience their body weight or shape. e. In the restrictive type of anorexia, individuals lose weight by avoiding any fatty foods, and by dieting, fasting, and exercising. f. In the binge-eating/purging type, individuals engage in binge eating, purging, or both. 3. Bulimia Nervosa a. Individuals with bulimia nervosa go on repeated eating binges and rapidly consume large amounts of food, usually sweets, stopping only because of severe abdominal pain or sleep, or because they are interrupted. b. The characteristics include the following: i. Repeated binge eating ii. Repeated attempts to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise iii. Binges and compensatory behaviors occur at least once a week for three months iv. Self-evaluation based on body shape and weight c. An estimated 1–2 percent of American women develop bulimia in adolescence or young adulthood.

Discussion Questions •

Ask students to describe the average woman and man. What are the factors that contribute to an unrealistic body image for either? What can we do to change those thoughts? How can an individual overcome these perceptions? What are some of the dangers associated with a poor body image?

•

Solicit from the class volunteers to discuss their culture’s view toward body image. How do these views compare with and influence women’s self-esteem and satisfaction with their bodies? What are some of the cultures that support opposite viewpoints from our typical “media-type” body image? What do you think the difference is between their mental health and those who struggle in our society?

•

Share with the class the variety of weight tables available (traditional, ideal, and average). Discuss the advantages and disadvantages of relying on these in order to evaluate body weight. Despite the disadvantages, why do we still count on them so much? What might be a better method?

•

What are the health risks associated with being overweight? How might one overcome this condition?

•

Ask students how they know when they are hungry or when they are full. Why do people keep eating despite being full? How can they overcome this?

•

Discuss the prevalence, causes, symptoms, and treatment for anorexia nervosa and bulimia nervosa. Examine the health problems that are associated with each of these disorders. As a friend or loved one, what can you do to help these individuals? Why do students think people suffer from these disorders?

•

Discuss diet foods, high-protein diets, very low-calorie diets, diet aids, and liquid diets. Note the effectiveness of these compared to exercise and reduced intake of calories. Focus on the medical and financial costs of these programs. Why do people buy into these diets so easily? What are the risks associated with each? Why are they so popular?

Classroom Activities Activity #1: Killing Us Softly Purpose: To review with students the image of women portrayed by the media.

Time: One class period.

Introduction: Prior to showing the video, discuss with the class what factors contribute to an individual’s self-image.

Method: 1.

Show the video Killing Us Softly by Jean Kilbourne who discusses the representation of women by the media and the social effects of this form of communication. This video may be purchased as a DVD or viewed on Youtube.com.

Discussion: 1.

How does Ms. Kilbourne feel women are represented through the media? Give examples.

What effect does this portrayal have on women?

What might be some of the consequences of these portrayals?

Do you feel this was an accurate portrayal of how the media does portray women?

What do you suggest we do to change this use of women by the media?

What can we do to eliminate some of these consequences?

Activity #2: Diet Analysis Purpose: 1.

To have students identify their personal nutritional needs.

To have students review their personal diets and to verify strengths and weaknesses in their diet.

Time: Maintenance of a 3-day food and activity record into USDA's SuperTracker and 20 minutes for class discussion.

Methods: 1.

After reading Chapters 4 and 5 and discussing the importance of regular physical activity and a healthy diet for maintenance of a healthy lifestyle, have students keep track of everything they eat and their activity for 3 days (24 hours per day).

Have the students use SuperTracker, a free online dietary and physical activity assessment tool, to obtain information on their diet quality as it relates to the Dietary Guidelines and their physical activity status.

You may have students choose to complete the 3-day diet log, or activate My Coach Center to set up personal goals.

Discussion: 1.

The best idea is for you, as the instructor to use the tool for several days. Then you can decide what options you would like your class to use.

Have the students discuss the findings of their 3-day dietary and activity analysis. Were there any surprises? Were the results what they expected? What improvements can they make?

Next, have the students compare their 3-day dietary and activity analysis generated by SuperTracker to their My Plan, which was generated from entering their age, sex, and activity level at SuperTracker—My Plan. How close or far was their actual diet from the plan recommendations?

Have the students make two to three dietary and/or physical activity goals that they would like to work on during the semester. At the end of the semester, have the students determine whether they have reached their goals and have them

discuss the challenges and barriers they faced in trying to achieve their dietary and physical activity goals.

Activity #3: The Dieting Dilemma Purpose: 1.

To promote the ideals of health and well-being, rather than diet/weight conflicts and eating disorders.

To examine media influences and personal beliefs regarding weight management.

Time: Approximately 30 minutes.

Introduction: Introduce the class to the effect of our own personal comments and how each of us might contribute to having a poor body image.

Method: 1.

Read recent research studies on how often adolescents and young adults are dieting to the class.

Divide the class into small discussion groups and assign the following discussion questions.

Discussion: 1.

Given the issue of weight management and extreme dieting in our society, what explanations do you have for this trend in dieting among young females?

What model or message is suggested by media? Parents? Peers? School?

What factors contribute to the large percentage of women with eating disorders?

Have you ever encouraged a loved one to feel that she/he should be thin? (Be honest in your response!) What message and behavior change can this type of inducement promote?

Make a list of “do’s” that promote sensible eating and dieting.

Activity #4: Weight Management Purpose: 1.

To provide an opportunity for the students to develop a plan for sensible weight management.

Time: One class period.

Method: a. After students have completed the dietary analysis, they should have an idea of how healthy or deficient their diet is. b. Students should then create a healthy proportioned meal plan. Food groups, portion sizes, and caloric intake should all be included.

Discussion: 1.

Ask students if they feel it will be difficult to make dietary changes. If so, why?

How can they plan ahead to deal with situations that may sidetrack their new plan?

What are the health benefits to following their new plan?

Activity #5: Weight Analysis Purpose: 1.

To have students determine their BMI and waist-to-hip ratio.

Time: One class period. Instructor should provide scales and tape measures.

Method: 1.

Students should use the scales provided by the instructor to determine their weight. Students can use the tape measure to determine height, waist circumference, and hip circumference.

Using Figure 6.1, determine BMI. Next, determine if your waist-to-hip ratio is considered safe or “at risk.” Refer to Figure 6.3 to determine if you are an “Apple” or “Pear” shape.

Discussion: 1.

Based on these simple calculations, students should determine if they are at an increased risk of health problems.

Students should list at least two strategies for improving their BMI or waist-to-hip ratio if they were not in the acceptable ranges.

References, Readings, and Resources American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Bakalar, J. L., et al. “Recent Advances in Developmental and Risk Factor Research on Eating Disorders.” Current Psychiatry Reports 17, no. 6 (2015): 585. doi: 10.1007/s11920015-0585-x. Harrington, M. Rachel, and Melinda J. Ickes. “Differences in Health Behaviors of Overweight or Obese College Students Compared to Healthy Weight Students.” American Journal of Health Education 47, no. 1 (2016): 32–41. doi: 10.1080/19325037.2015.1111179. Ickes, Melinda J., et al. “Impact of a University-Based Program on Obese College Students' Physical Activity Behaviors, Attitudes, and Self-efficacy.” American Journal of Health Education 47, no. 1 (2016): 47–55. doi: 10.1080/19325037.2015.1111178. Mabe, A. G., Forney, K. J., and Keel, P. K. “Do you ‘like’ my photo? Facebook use maintains eating disorder risk,” International Journal of Eating Disorders vol. 47, issue 5 (July 2014): pp. 516–523. doi: 10.1002/eat.22254. Mitchell, J. F., and S. A. Wonderlich. “Feeding and Eating Disorders.” In Textbook of Psychiatry, 6th ed., edited by R. E. Hales, et al. (Washington DC: American Psychiatric Publishing, 2014). Olson, K. L., and C. F. Emery. “Mindfulness and Weight Loss: A Systematic Review.” Psychosomatic Medicine 77, no. 1 (2015): 59–67. doi: 10.1097/ PSY.0000000000000127. Schroeder, R., et al. “Treatment of Adult Obesity with Bariatric Surgery.” American Family Physician 93, no. 1 (2016). Smith, K. B., and M. S. Smith. “Obesity Statistics.” Primary Care 43, no. 1 (2016): 121–35. doi: 10.1016/j. pop.2015.10.001. Wing, R. R., et al. “Innovative Self-Regulation Strategies to Reduce Weight Gain in Young Adults: The Study of Novel Approaches to Weight Gain Prevention (SNAP)

Randomized Clinical Trial.” JAMA Internal Medicine (2016). doi: 10.1001/ jamainternmed.2016.1236.

Films and Videos 10 Things You Need to Know about Losing Weight (Each year, millions of people attempt to slim down—and fail. If super-diets and weight-loss fads don’t work, what does? This program presents 10 science-based approaches to losing weight without starving as volunteers put the theories to the test.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group The Men Who Made Us Thin (Investigative journalist Jacques Peretti turns his attention to the diet industry where business is booming as obesity escalates. In this thought-provoking series, Peretti examines the connections between obesity and weight loss, and confronts some of those who are making a fortune from people’s desire to become thinner.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Recovering: Anorexia Nervosa and Bulimia Nervosa (Eating disorders such as anorexia nervosa and bulimia nervosa are serious medical conditions that can be deadly if left untreated, and they afflict people of all ages and races, especially young women. This video follows Peabody- and Emmy-winning documentary filmmaker Larkin McPhee (Dying to Be Thin) as she uncovers facts about eating disorders and the many challenges of coping with them.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755

F: 800.678.3633 E: Films Media Group Nutrition and Eating Disorders (Whether they’re viewed from a behavioral standpoint or from a profound psychological perspective, one thing is clear—eating disorders stress the body’s systems and put individuals at increased risk for disease, infertility, organ failure, and death. This video pinpoints the dangers of anorexia, bulimia, binge eating, and other eating disorders, exploring their possible causes as well as ways to overcome them.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Surgical Weight Loss (After repeated failed attempts at weight reduction through diet and exercise, surgery may be the most effective treatment for obese and morbidly obese individuals. By following the course of several men and women who undergo gastric reduction procedures, this program presents the complete process of surgical weight loss, from clinical assessment to postoperative follow-ups.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Losing It (This PBS Scientific America Frontiers episode tackles a common problem that confronts those who are struggling to lose weight—finding the healthiest and most successful way to shed those pounds and keep it off over the long term.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Dying to be Thin (Anorexia, bulimia, and other eating disorders are on the rise. What can be done to help those who are suffering?) NOVA—Dying to Be Thin Obesity (As Americans grapple with ever-increasing waistlines, science is looking at the biology behind the compulsion to eat. What exactly makes some people weigh 350 pounds and others 150?) NOVA—Obesity Stress, Weight Control and Emotional Eating (Follow four people as they learn practical strategies to overcome emotional eating, making it a natural centerpiece for your training program on stress, weight control, and food addiction.) Health EdCo P: 1-855-510-6720 E: Health EdCo Recovering Bodies (Through the first-hand stories and testimonies of seven college students—five women, two men, and the commentary of professionals—this video reveals the wide range of social pressure that can lead to disordered eating and its psychological and physical symptoms.) Media Education Foundation 60 Masonic St. #A Northampton, MA 01060 P: 1-800-897-0089

Internet Resources Academy for Eating Disorders The Academy for Eating Disorders is an international trans-disciplinary professional organization that promotes excellence in research, treatment, and prevention of eating disorders. Academy for Eating Disorders

Academy of Nutrition and Dietetics Nutrition information, educational materials, and safe strategies for weight loss and maintenance are made available. Academy of Nutrition and Dietetics American Society for Nutrition National organization related to nutrition research. American Society for Nutrition Eating Disorder Referral and Information Center Dedicated to the prevention and treatment of eating disorders. EDReferral.com Food and Nutrition Information Center Outstanding resource for all things related to weight control and obesity. USDA—Food and Nutrition Information Center Mirror Mirror Eating Disorders This site features information on all types of disordered eating, including compulsive eating and binge eating, and how eating disorders affect society, college students, children, teenagers, athletes, women, and men. Mirror Mirror Eating Disorders National Institute of Diabetes and Digestive and Kidney Diseases Provides health information on diabetes and weight control. National Institute of Diabetes and Digestive and Kidney Diseases NHLBI Obesity Education Initiative The Obesity Education Initiative is sponsored by the National, Heart, Lung, and Blood Institute of the National Institutes of Health. NHLBI Obesity Education Initiative Something Fishy: Website on Eating Disorders This very comprehensive and popular site features the latest news on eating disorders as well as links regarding signs to watch for, “Recovery: Reach Out,” treatment finders, doctors and patients, cultural issues, and a support chat. Something Fishy: Website on Eating Disorders

Obesity Society The Obesity Society website features statistics on overweight and obesity in the United States, research articles, consumer protection links, prevention topics, library resources, fact sheets on a variety of weight management topics, and more. Obesity Society Wake Forest Baptist Health Diet and nutrition information from Wake Forest Baptist Health Wake Forest Baptist Health WebMD—Weight Loss and Obesity Center Information on weight loss and obesity WebMD—Weight Loss and Obesity Center

Key Terms anorexia nervosa binge eating

NEAT (nonexercise activity thermogenesis)

binge-eating disorder

obesity

body mass index (BMI)

overweight

bulimia nervosa

waist-to-hip ratio (WHR)

eating disorders

Answers to Global Health Watch 1. a 2. b 3. physical activity

7 The Joy of Fitness Learning Objectives After studying this chapter in the text, the student should be able to: 7.1

Explain the relationship between the dimensions of health and physical fitness.

7.2

Summarize the health risks of inactivity and the need for physical exercise.

7.3

Outline current physical activity recommendations.

7.4

Discuss the overload, FITT, and reversibility principles of exercise.

7.5

Specify methods to improve cardiovascular fitness.

7.6

Explain the significance of muscular fitness.

7.7

Compare static and dynamic flexibility.

7.8

Summarize the benefits of mind–body approaches to physical fitness and wellness.

7.9

Identify the causes and treatment of low back pain.

7.10 Discuss the nutritional requirements of athletes. 7.11 Specify precautions for preventing exercise-related problems.

Chapter Summary Physical activity boosts energy, improves mood, soothes stress, improves sleep, and makes you look and feel better. In the long term, physical activity slows many of the changes associated with chronological aging, lowers the risk of serious chronic illnesses, and extends the lifespan. This chapter can help you reap these rewards. It presents the latest activity recommendations, documents the benefits of exercise, describes types of exercise, and provides guidelines for getting into shape and exercising safely.

Lecture Outline I.

Physical Activity and Fitness A. Introduction 1. Physical activity refers to any movement produced by the muscles that results in expenditure of energy (measured in calories). 2. Fitness is the ability to respond to routine physical demands, with enough reserve energy to cope with a sudden challenge. 3. The six health-related components of physical fitness are as follows: a. Cardiorespiratory fitness is the ability of the heart to pump blood through the body efficiently. b. Metabolic fitness is the optimal functioning of bodily systems, which reduces the risk for diabetes and cardiovascular disease. c. Muscular strength is the force within muscles, measured by the absolute maximum weight that you can lift, push, or press in one effort. d. Muscular endurance is the ability to perform repeated muscular effort; it is measured by counting how many times you can lift, push, or press a given weight. e. Flexibility is the range of motion around specific joints. f. Body composition is the relative amounts of fat and lean tissue (bone, muscle, organs, and water) in the body. g. Functional fitness refers to the performance of activities of daily living. B. Fitness and the Dimensions of Health 1. Instructors, coaches, and consumers are pursuing a broader vision of total fitness that encompasses every dimension of health. a. Physical b. Emotional c. Social d. Intellectual e. Occupational f. Spiritual g. Environmental C. Working Out on Campus 1. Only 45 percent of undergraduates meet the current recommendations for moderate or vigorous exercise. 2. College men are generally more active than women. 3. As students progress from their first to fourth year of studies, they exercise less.

4. In research on influences on students’ health behaviors, peer pressure to exercise (for men more than women), and having an exercise partner, a flexible class schedule, access to fitness facilities, and a sense of being stressed increase physical activity. II.

Physical Activity and Exercise A. Introduction 1. Exercise is a physical activity that requires planned, structured, and repetitive bodily movement with the intent of improving one or more components of physical fitness. B. Exercise Is Medicine 1. Declaring physical inactivity “the greatest public health problem of the 21st century,” the American College of Sports Medicine (ACSM) has launched a “global initiative involving health and fitness professionals, businesses, universities, government leaders, organizations of every kind, and anyone who gets it” to start or renew an exercise program as “an investment in lifelong health”. C. The Benefits of Exercise 1. Longer Life a. In various studies, physical activity increased life expectancy by 1.3 to 5.5 years. 2. Healthier Heart and Blood Vessels a. Sedentary people are about twice as likely to die of a heart attack as compared to people who are physically active. b. Exercise lowers levels of the indicators of increased risk of heart disease, such as high cholesterol. 3. Healthier Lungs a. Exercise makes the lungs more efficient. b. Cardiorespiratory fitness declines more rapidly after age 45, but exercising regularly, maintaining a healthy weight, and not smoking can help maintain cardiorespiratory health throughout life. 4. Protection against Cancer a. Physical activity may reduce the risk of several cancers, including breast, colon, endometrial, prostate, and possibly pancreatic. b. It may also help to prevent cancer by regulating sex hormones, insulin, and prostaglandins and by enhancing the immune system. c. The combination of excess weight and physical inactivity may account for a quarter to a third of all breast cancer cases.

5. Better Bones a. Osteoporosis is a condition in which bones become increasingly soft and porous, making them susceptible to injury; 2 percent of collegeage women have osteoporosis; another 15 percent have already sustained significant losses in bone density and are at high risk of osteoporosis. b. The ACSM recommends moderate- to high-intensity weight-bearing activities to maintain bone mass in adults. 6. Lower Weight a. Exercise may help to control weight by suppressing appetite. 7. Better Mental Health and Functioning a. Exercise is an effective—but underused—treatment for mild to moderate depression and may help in treating other mental disorders. b. Lifelong fitness may protect the brain as we age. 8. Benefits for Students a. Unlike middle-aged and older individuals, traditional-age college students cite improved fitness as the number one advantage that exercise offers, followed by improved appearance and muscle tone. b. Your brain may also benefit. 9. Brighter Mood and Less Stress a. Exercise boosts mood, elevates self-esteem, increases energy, reduces tension, improves concentration and alertness, and relieves stress. 10. A More Active and Healthy Old Age a. Exercise slows the changes that are associated with advancing age, such as loss of lean muscle, increase in body fat, and decrease in work capacity. 11. Enhanced Sexuality a. By improving physical endurance, muscle tone, blood flow, and body composition, exercise improves sexual functioning. D. Exercise Risks 1. Hypertrophic cardiomyopathy (HCM) is a genetic disease that results in thickening or enlargement of the heart that affects up to 1 in 500 people. a. HCM accounts for 40 percent of all deaths on athletic fields in the United States. 2. College students who play contact sports, such as football, may be at risk of a condition called chronic traumatic encephalopathy (CTE), the result of multiple mild head injuries.

III. Physical Activity Guidelines for Americans A. Overview 1. The following are the recommendations from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans: a. All adults should avoid inactivity. b. For substantial benefits, adults should do at least 150 minutes a week of moderate-intensity aerobic activity or 75 minutes a week of vigorous-intensity aerobic activity. c. For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes a week of moderate-intensity aerobic activity or 150 minutes a week of vigorousintensity aerobic activity. d. Adults should also do muscle-strengthening activities on two or more days a week. 2. The ACSM and the American Heart Association (AHA) guidelines recommend the following: a. Moderately intense cardiorespiratory exercise for 30 minutes a day, 5 days a week, or b. Vigorously intense cardiorespiratory exercise for 20 minutes a day, 3 days a week, and c. 8–10 strength-training exercises, with 8–12 repetitions of each exercise, twice a week. B. How Much Exercise Is Enough? 1. The minimum amount of exercise required for a significant lowering of the risk of premature dying is 500 MET (metabolic equivalent task) minutes of exercise a week. 2. A single MET is the amount of energy a person uses at rest. C. Your Exercise Prescription 1. Even a little exercise can help those who were previously sedentary. 2. Get at least 150 minutes of physical activity per week, including 20–30 minutes of vigorous exertion. IV. The Principles of Exercise A. Overload Principle 1. It requires a person exercising to provide a greater stress or demand on the body than it’s usually accustomed to handling. 2. Progressive overloading—gradually increasing physical challenges— provides the benefits of exercise without the risk of injuries.

B. FITT 1. The acronym FITT sums up the four dimensions of progressive overload: frequency, intensity, time, and type. a. Frequency i. Health officials urge Americans to engage in moderate-intensity aerobic activity most days and resistance and flexibility training for two or three days a week. b. Intensity i. Exercise intensity varies with the type of exercise and with personal goals. c. Time (Duration) i. The ACSM recommends 30–45 minutes of aerobic exercise, proceeded by 5–10 minutes of warm-up, and followed by 5–10 minutes of stretching. d. Type (Specificity) i. The specificity principle refers to the body’s adaptation to a particular type of activity or amount of stress placed upon it. C. Reversibility Principle 1. The reversibility principle is the opposite of the overload principle. If you stop exercising, you can lose as much as 50 percent of your fitness improvements within two months. V.

Improving Cardiorespiratory Fitness 1. Aerobic exercise, which improves cardiorespiratory endurance, can take many forms, but all involve working strenuously without pushing to the point of breathlessness. 2. Anaerobic exercise involves activities in which the amount of oxygen taken in the body cannot meet the demands of the activity. 3. In nonaerobic activity, which often involves frequent breaks in activity, the body can take in all the oxygen it needs so the heart and lungs don’t get much of a workout.

VI.

Monitoring Intensity A. High-Tech Gadgets 1. Despite the popularity of these devices, scientists have questioned their accuracy and usefulness. 2. Wearable activity monitors include the following: a. Pedometers b. Activity trackers

c. Running watches d. Heart rate monitors B. Nontech Methods 1. For a no-tech approach, you can use your pulse, or heart rate, as a guide. a. Slightly tilt your head back and to one side. b. Use your middle finger or forefinger, or both, to feel for your pulse in the carotid artery in your neck. (Do not use your thumb; it has a beat of its own.) c. To determine your heart rate, count the number of pulses you feel for 10 seconds and multiply that number by six, or count for 30 seconds and multiply that number by two. d. Learn to recognize the pulsing of your heart when you’re sitting or lying down. This is your resting heart rate. 2. Target Heart Rate a. 220 − Age = Maximum heart rate (MHR) b. The ACSM recommends that for endurance training and general aerobic conditioning, you calculate 50–65 percent of your maximum heart rate if you’re a beginner, 60–75 percent for intermediate-level exercisers, and 70–85 percent for established aerobic exercisers. 3. The Karvonen Formula a. The Karvonen formula is another mathematical formula for determining your target heart rate (HR) training zone. i. Target heart rate = ((Max HR − Resting HR) × Intensity) + Resting HR 4. Rating Perceived Exertion (RPE) a. A self-assessment scale that rates symptoms of breathlessness and fatigue. b. RPE is considered fairly reliable, but about 10 percent of the population tends to over- or underestimate their exertion. C. Designing an Aerobic Workout 1. An aerobic workout should include the following: a. Warm-up i. The ACSM concluded that preparing for sports or exercise should involve a variety of activities and not be limited to stretching alone. b. Aerobic activity i. The current recommendation is to keep moving for 30–60 minutes, either in one session or several briefer sessions, each lasting at least 10 minutes. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

c. Cool-down i. Ideally, you should walk for 5–10 minutes at a comfortable pace before you end your workout session. D. Your Long-Term Fitness Plan 1. One of the most common mistakes people make is to push too hard too fast. 2. If you are just starting an aerobic program, think of it as a series of phases: beginning, progression, and maintenance. E. Aerobic Options 1. Stepping Out: Walk the Walk a. Walking may reduce the risk factors for cardiorespiratory disease, such as insulin resistance, as much as vigorous activity does. 2. America on the Move a. The national “America on the Move” program recommends 10,000 steps each day. b. You take about 5,000 steps just to accomplish your daily tasks. Adding about 2,000 steps brings you to a level that can improve your health and wellness. Another 3,000 steps can help you lose excess pounds and prevent weight gain. 3. Jogging and Running a. To enhance aerobic fitness, long, slow, distance running is best. b. To improve speed, try interval training, which is repeated hard runs over a certain distance with intervals of relaxed jogging in between. 4. High-Intensity Interval Training a. High-intensity interval training (HIIT) refers to an exercise session that includes short periods of strenuous aerobic exercise, usually alternating with moderate exercise. b. Although HIIT has been shown to improve fitness, glucose metabolism, blood pressure, and blood vessel health, it is not yet clear whether it is effective in lowering weight, altering blood fats, or strengthening muscles and bones. 5. Other Aerobic Activities a. Swimming b. Cycling c. Spinning d. Cardio kickboxing e. Rowing f. Skipping rope g. Stair climbing © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

h. Inline skating i. Tennis j. Zumba VII. Building Muscular Fitness A. Overview 1. Strength workouts are important because they enable muscles to work more efficiently and reliably. 2. Muscular strength is the maximal force that a muscle or group of muscles can generate for one movement. 3. Muscular endurance is the capacity to sustain repeated muscle actions. 4. The best way to reduce your body fat is to add muscle-strengthening exercise to your workouts. B. Muscles at Work 1. Overloading is demanding more of muscles than you usually do. a. To develop strength, do a few repetitions with heavy loads. b. To increase endurance, do many more repetitions with lighter loads. 2. In an isometric contraction, the muscle applies force while maintaining an equal length. 3. An isotonic contraction involves movement, but the muscle tension remains the same. 4. Isokinetic contraction is a constant speed contraction. C. Designing a Muscle Workout 1. A workout with weights should exercise your body’s primary muscle groups. a. Deltoids (shoulders); pectorals (chest); triceps and biceps (back and front of upper arms); quadriceps and hamstrings (front and back of thighs); gluteus maximus (buttocks); trapezius and rhomboids (back); abdomen. 2. A weight-training program is made up of reps (the single performance, or repetition, of an exercise, such as lifting 50 pounds one time) and sets (a set number of repetitions of the same movement). 3. Free Weights versus Machines a. Free weights offer great versatility for strength training and can be used for a variety of exercises to work-specific muscle groups. b. Strength-training machines i. Can ensure correct movement that helps to protect against injury.

ii.

Can isolate specific muscles, which is good for rehabilitating an injury or strengthening a specific body part. iii. Can tax muscles in ways that a traditional barbell cannot. D. Recovery 1. The ACSM recommends a minimum of 8–10 exercises involving the major muscle groups for two to three days a week. 2. Never work a sore muscle. 3. Allow no less than 48 hours, but no more than 96 hours, between training sessions. E. Core Strength Conditioning 1. Core strength refers to the ability of the muscles to support your spine and to keep your body stable and balanced. 2. The major muscles of your core include the transverse abdominis, external and internal obliques, and rectus abdominis. F. Muscle Dysmorphia 1. Also referred to as “bigorexia” or “reverse anorexia” is a condition that primarily affects male body builders. 2. Its primary characteristics include giving up important activities to work out, avoiding situations that include body exposure, preoccupation with body size, and continued use of exercise, diet, or performance-enhancing substances despite physical or psychological harm. G. Drugs Used to Boost Athletic Performance 1. The number of college athletes using or at least checking into performance-enhancing drugs is believed to be growing. a. The risks include cancer, liver disease, blood diseases, severe arthritis, and sexual dysfunction. 2. Anabolic steroids are synthetic derivatives of the male hormone testosterone that promote growth of skeletal muscle and increase lean body mass. a. Taking them to improve athletic performance is illegal. b. Use may lead to liver tumors, jaundice, fluid retention, high blood pressure, decreased immune function, and severe acne. c. In men they may cause shrinking of the testicles, reduced sperm count, infertility, baldness, and development of breasts. d. Women may experience growth of facial hair, changes or cessation in menstrual cycle, enlargement of the clitoris, and a deepened voice. 3. Androstenedione—this testosterone precursor is normally produced by the adrenal glands and gonads. a. It is a controlled substance, and its use is illegal. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

4. Creatine is an amino acid made by and stored by the body and stored predominantly in skeletal muscle. a. It may increase strength and endurance. 5. Gamma-Butyrolactone (GBL) is marketed as a performance enhancer and muscle builder. 6. Ergogenic aids are substances, such as caffeine, baking soda, and glycerol, used to enhance energy and provide athletes with a competitive edge. 7. Human growth hormone increases lean body mass but does not affect exercise capacity or aerobic endurance. 8. Erythroprotein (EPO) is a hormone that increases red blood cell production and improves endurance. VIII. Becoming More Flexible A. Overview 1. Flexibility is the characteristic of body tissues that determines the range of motion achievable without injury at a joint or group of joints. 2. Two Types of Flexibility: a. Static flexibility refers to the ability to assume and maintain an extended position at one end point in a joint’s range of motion. b. Dynamic flexibility is the ability to move a joint quickly and fluidly through its entire range of motion with little resistance. B. The Benefits of Flexibility 1. Prevention of injuries 2. Relief of muscle strain 3. Relaxation 4. Relief of soreness after exercise 5. Improved posture C. Stretching 1. Static stretching involves a gradual stretch held for a short time. 2. Passive stretching uses your own body, a partner, gravity or weight as an external force or resistance to help your joints move through their range of motion. 3. Active stretching involves stretching a muscle by contracting an opposing muscle. 4. Dynamic stretching increases the range of motion around a joint or group of joints by using active muscular effort, momentum, and speed. 5. Ballistic stretching is characterized by rapid bouncing movements.

D. Stretching and Warming Up 1. While stretching does not necessarily prevent injuries from jogging, cycling, or swimming, it may benefit sports like soccer and football, which involve bouncing and jumping. 2. A better choice is to warm up dynamically by moving the muscles that will be used in your workout. IX. Mind–Body Approaches A. Yoga 1. Yoga comes from the Sanskrit word meaning “union,” and consists of various breathing and stretching exercises that unite all aspects of a person. 2. Benefits include the following: a. Improved flexibility b. Protection of joints c. Stronger, denser bones d. Enhanced circulation e. Lower blood pressure f. Relief of stress-related symptoms and anxiety g. Lower blood sugar h. Reduced pain in people with back problems, arthritis, carpal tunnel syndrome, fibromyalgia, and other chronic problems i. Improved lung function in people with asthma j. Less inflammation, fatigue, and depression in breast cancer survivors k. Eased depression in pregnant women B. Pilates 1. Pilates enhances flexibility and muscular endurance, particularly for intermediate and advanced practitioners, but its potential to increase cardiorespiratory fitness and reduce body weight is limited. C. T’ai Chi 1. Ancient Chinese practice, designed to exercise body, mind, and spirit. 2. It gently works on muscles, focuses concentration, and improves the flow of “qi” (often spelled “chi”), the vital life energy that sustains health. 3. According to a recent review of 35 studies involving more than 2,200 people in 10 countries, t’ai chi and other traditional Chinese exercises help in lowering the blood pressure and levels of low-density lipoprotein (LDL or "bad") cholesterol and other unhealthy blood fats as well as improve mood and quality of life.

Keeping Your Back Healthy A. Low back pain causes more disability than nearly 300 other conditions worldwide, according to new research, and nearly 1 in 10 people around the globe suffers from an aching low back. B. Psychological approaches, including mindfulness-based stress reduction and cognitive-behavioral therapy have proven effective in relieving low back pain. C. Acetaminophen is the first-line medication for pain relief. If it is not effective, doctors recommend nonsteroidal anti-inflammatory drugs, such as ibuprofen. D. The sooner that back patients return to normal activity, the less pain medication they require and the less long-term disability they suffer.

XI. Sports Nutrition A. Introduction 1. Athletes in competitive sports may have increased energy requirements. a. Athletes generally do not need more protein. b. Complex carbohydrates are essential in an athlete’s diet. c. Including the right types of fats in the daily diet can actually improve athletic performance. B. Water 1. We need more than any other nutrient. 2. The ACSM recommends fluid intake before, during, and after exercise to regulate body temperature, and replace body fluids lost through sweating. 3. Hyponatremia or water intoxication is too much water during long prolonged bouts of exercise. C. Sports Drinks 1. Consuming a high-carbohydrate, high-caffeine sports drink 10–60 minutes before exercise may improve mental focus, alertness, anaerobic performance, and endurance, but athletes should also consider the effects on their metabolic health. 2. Nonfat milk may be more effective than soy or sports drinks like Gatorade at burning fat and building lean muscles mass. D. Dietary Supplements 1. Vitamin and mineral supplements do not provide benefits to healthy, well-nourished individuals. 2. Vitamin supplements marketed for athletes are poorly regulated, and some may be adulterated with banned substances, such as ephedrine.

E. Energy Bars 1. Little scientific research has studied the benefits of the various types of energy bars, including their effects on blood glucose levels and athletic performance. XII. Safe and Healthy Workouts A. To prevent exercise-related problems before they happen, use common sense and take appropriate precautions, including the following: 1. Get proper instruction. 2. Make sure you have good equipment and keep it in good condition. 3. Always warm up before and cool down after a workout. 4. Stay active throughout the week and do not overdo on weekends. 5. Use reasonable protective measures. 6. Go with a buddy. 7. Take each outing seriously. 8. Never combine alcohol or drugs with any sport. B. Temperature 1. Heat Cramps a. Heat cramps are caused by profuse sweating and the consequent loss of electrolytes. 2. Heat Syndromes a. Heat syndromes are more serious temperature-related conditions that include heat exhaustion and heat stroke. 3. Heat Exhaustion a. Heat exhaustion is a mild form of heat-related illness that can be caused by exercise or hot weather. 4. Heat Stroke a. A heat stroke can occur when the body temperature rises to 106°F or higher within 10–15 minutes. 5. Protecting Yourself from the Cold a. Because frostnip is painless, you may not even be aware that it is occurring. b. Frostbite is more severe. i. There are two types of frostbite, superficial (freezing of skin and tissue just below it) and deep frostbite (freezing of skin, muscle, and even bone). c. Hypothermia occurs when the body temperature falls below 95°F and requires emergency medical attention.

C. Exercise Injuries 1. Types of injuries include the following: a. Acute injuries—sprains, bruises, and pulled muscles—result from sudden trauma, such as a fall or collision. b. Overuse injuries result from overdoing a repetitive activity, such as running. 2. If you are injured, use PRICE. a. Protect the area with an elastic wrap, sling, splint, cane, crutches, or air cast. b. Rest to promote tissue healing. c. Ice the area immediately. d. Compress the area with an elastic bandage until swelling stops. e. Elevate the area above your heart. 3. Overtraining a. Signs of overdoing it include persistent muscle soreness, frequent injuries, unintended weight loss, nervousness, and an inability to relax. 4. Exercise Addiction a. Excessive exercise can become a form of addiction, and “exercise dependence” is not uncommon among young men and women.

Discussion Questions •

Ask students to brainstorm the benefits of exercise. Now ask each person to prioritize this list, from the benefit that is most important to the least important. Discuss how these priorities might change over time. What are some of the differences within the class? What might you expect if you were living in a different part of the world?

•

How much exercise? Describe the recommendations for physical activity made by the ACSM. Ask students what strategies they might use to realistically achieve this. What might be some of the barriers to achieving this? How might one overcome these possible barriers?

•

Discuss women and exercise, highlighting some of the misconceptions that are associated with this. Ask the class if they can add any myths or misconceptions. Now ask the class what women can do to overcome some of the barriers to achieving regular exercise.

•

Discuss the value of stretching and flexibility as it relates to health and injury prevention. When is stretching beneficial? Discuss the benefits of yoga, pilates, and t’ai chi.

•

Discuss the value of muscle strength and aerobic exercise. Define and differentiate between isometric, isotonic, and isokinetic exercises. What are the myths associated with strength training? What are the benefits of strength training?

•

Discuss exercise safety in light of environmental temperature, proper use of equipment (including shoes), air quality, and use of gym equipment.

Classroom Activities Activity #1: Self-Survey: Are You Ready to Become More Active? Purpose: 1.

To determine your stage of motivational readiness to become more active.

Based on your fitness stage of change, develop strategies to move to the next level with the goal of reaching the action and maintenance stage.

Time: 30 minutes (15 minutes to complete the Self-Survey and 15 minutes for class discussion).

Method: 1.

Review the transtheoretical model found in Chapter 1 of the text.

Determine the stage of motivational readiness.

Discussion: 1.

After the students have determined the stage of change they are in, have them identify the processes of change that will help them move to the next level of change.

Direct them to come up with several ideas for each process of change that will help them in their progression.

Have them follow through with these ideas for several weeks and then come back and report their progress with other students.

You may require students to keep a log of their progress, or write a paper on how their behavior change went. Have them discuss the things that most helped them, as well as the things that hindered their progress.

Activity #2: Fitness Testing Purpose: To identify our fitness levels.

Time: One class period.

Introduction: Introduce the importance of understanding our own fitness levels.

Method: 1.

Organize for a personal trainer or wellness coordinator to perform fitness assessments on your students.

Perform height and weight measurements.

Perform body composition assessments.

Have students warm up and stretch.

Perform a 30-second push-up test.

Perform a 12-minute run or walk test.

Perform a flexibility test, such as the sit-and-reach test.

Discussion: 1.

Discuss the results with students.

Ask your students how they feel about their results. Was it an accurate assessment?

Discuss reasonable goals and how to properly achieve those goals.

Discuss how they might encourage one another to reach their goals.

Note: Additional testing can be done using similar methods. Examples can be found at ExRx.net Fitness Testing

Activity #3: Designing a Program © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Purpose: To design a personal cardiovascular training program.

Time: One class period.

Introduction: Introduce the steps necessary to begin an aerobic workout program.

Method: 1.

Determine what type of aerobic activity you will engage in.

Determine the frequency and duration of your activity.

List any special equipment needed for this activity.

Be sure to include warm-up and stretching activities.

Discussion: 1.

Discuss reasonable fitness goals and how to properly achieve those goals.

Discuss strategies for dealing with issues that may conflict with your exercise plan.

Activity #4: Heart Monitor Workout Purpose: 1.

To learn the effectiveness of a heart monitor.

To become aware of various exercise equipment.

To become knowledgeable about combining a cardiovascular workout with a resistance workout.

Time: One to one and one-half hours. You could introduce equipment and heart monitors at the end of the previous class meeting, and then have the next whole class period for the workout.

Method: 1.

Review equipment (e.g., resistance equipment, cardio equipment, and the heart monitors).

Remind the students to bring workout clothes for the next session.

Explain the importance of a combined cardiovascular workout with a resistance workout and the use of the heart monitor.

Have the students put on the heart monitor and make sure they are working correctly.

Show the students the order in which to rotate amongst the equipment. Putting up signs will help as well. Be sure to have the name of the equipment on the machines.

Explain the sequence of events—each will be on a resistance exercise; after 12 to 20 reps (or 30 seconds), you will blow your whistle; and they will then rotate to an aerobic machine or jog for 1–2 minutes (depending on time available and the current condition of the class). An example workout might look like this: Leg press Bench press Leg extension Bicep curls Leg curls Tricep extension Calf raises Lat pulldown Bent rows Abs or crunches 5-minute jog or walk 5–10 minutes stretch

Jog 2 minutes Stair master 2 minutes Rowing machine 2 minutes Treadmill 2 minutes Bike 2 minutes Jog 2 minutes Stair master 2 minutes Rowing machine 2 minutes Bike 2 minutes Jog 2 minutes Cool down at the end of the workout

Be sure to warn the students that if they are not feeling well at any time to stop the activity and to get in touch with you.

Discussion: 1.

While stretching, discuss how the students feel and what type of soreness they might experience over the next few days.

If you have access, have them retrieve a computerized graph of their workout, and then discuss target heart rates with them and analyze their personal results.

Ask students if they think using a heart rate monitor is valuable. Why or why not?

Activity #5: Exercise and Aging Purpose: To gain first-hand knowledge of how exercise (or the lack thereof) can impact aging.

Time: 1 hour.

Method: 1.

Students should interview an individual over the age of 65.

Students should ask the following questions: a. What is your age? b. What is your current level of physical fitness? c. How often do you exercise? What types of activities do you engage in? d. Is exercise a social activity for you, or do you exercise for the health benefits? e. If you do not exercise, did you ever participate in physical activity? If yes, why did you stop? f. Do you believe that exercise plays a role in your health? g. What advice would you give me in terms of physical fitness?

Discussion: 1.

Have students discuss their findings with the class. Were there commonalities throughout the group?

Will these observations impact their level of physical activity? Do they feel more inclined to exercise now?

References, Readings, and Resources American College Health Association. American College Health Association—National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). American College of Sports Medicine. Exercise Is Medicine Toolkit. Exercise is Medicine. Griffin, Katherine. “Yoga for Every Body: Experts Say Yoga Can Ease Pain and Improve Mobility for People with Neurologic Conditions. And a Disability is No Reason Not to Try It.” Neurology Now 12, no. 2 (2016): 53–7. doi: 10.1097/01. NNN.0000482683.19268.a1. Mozaffarian, Dariush, et al. “Executive Summary: Heart Disease and Stroke Statistics— 2016 Update: A Report from the American Heart Association.” Circulation 133, no. 4 (2016): 447–54. doi: 10.1161/ CIR.0000000000000366. Quartiroli, Ale, and Hotaka Maeda. “The Effects of a Lifetime Physical Activity and Fitness Course on College Students’ Health Behaviors,” International Journal of Exercise Science 9, no. 2 (2016), Article 3. http://digitalcommons.wku.edu/ijes/vol9/iss2/3. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. http://health. gov/paguidelines/guidelines/.

Films and Videos Cancer Prevention: Is Exercise or Healthy Body Weight More Important? (Featuring three renowned health/wellness professionals, Cancer Prevention: Is Exercise or Healthy Body Weight More Important? presents an overview of the impact of a physically active lifestyle, an appropriate body weight, and/or the interaction between the two factors on the prevention of cancer.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817

Exercise and Cancer—Catalyst (By the time you hit midlife, odds are you or someone close to you will be touched by cancer. Cancer remains a potentially lethal lottery and everyone’s experience is different. But appropriate exercise under professional supervision—before, during, or after treatment—seems to substantially improve your odds.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Exercise and Cognitive Function in Older Adults (Exercise and Cognitive Function in Older Adults discusses the fact that the aging population is increasing dramatically, as is the number of aging-related diseases, such as Alzheimer’s. The DVD looks at physical inactivity as a significant risk factor for dementia.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Exercise and Obesity: Practical Aspects (Exercise and Obesity: Practical Aspects reviews the increased prevalence of obesity in the United States and presents results of numerous research studies examining the contribution of genetics and lifestyle to obesity and the effect of exercise on this major public health problem.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Exercise is Medicine™—Expanding Personal Training to Subclinical Populations (Exercise is Medicine™—Expanding Personal Training to Subclinical Populations provides an overview of programs, past and present, within the military community that have effectively helped to bridge the gap between fitness and medical professionals. American College of Sports Medicine © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Exercise is MedicineTM on Campus: Celebrate and Participate (Exercise is MedicineTM on Campus: Celebrate and Participate discusses the results of several surveys that looked at how well the Exercise on Campus Initiative was doing at those institutions that have signed up to participate. Not only does the DVD outline the goals of the Initiative, it also details the obstacles and barriers to success that these schools have encountered.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Exercise is Medicine™ on Campus: Thoughts from the Advocates (Exercise is Medicine (EIM) on Campus is a natural extension of the overall effort to advance ACSM’s renowned EIM initiative. Given that college campuses can be excellent environments in which to effect positive change on the overall physical activity culture of students, faculty, and staff. Exercise is Medicine™ on Campus: Thoughts from the Advocates presents an overview of key issues involved with developing and/or improving an EIM on Campus project.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Exercising with Type 1 Diabetes: Physiological Concerns and a Clinical Perspective (Exercising with Type 1 Diabetes: Physiological Concerns and a Clinical Perspective addresses the key aspects of exercising with Type 1 Diabetes (T1D). The DVD details the physiological concerns of athletes with T1D, as well as looks at exercising with T1D from a clinical perspective.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233

P: (317) 637-9200 F: (317) 634-7817 Health, Fitness, and Lifestyle Medicine: The Future is Now! (Health, Fitness, and Lifestyle Medicine: The Future is Now! explores the impact of exercise, as well as adhering to positive habits on a daily basis, in both short- and long-term health and quality of life.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Injury Prevention (Injury Prevention features over 2 hours of information, ideas, and insights on preventing sports-related injuries in five key areas from five renowned and respected medical and health/wellness professionals.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817 Nutrition and Exercise (When diabetes forced Yvonne to take her health seriously, she enlisted the help of a registered dietician and started exercising. By looking at Yvonne and others, this program details how the right foods combined with an adequate amount of exercise can help you avoid certain diseases and cope with existing medical conditions.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Recent Advances in Preventive Cardiology and Lifestyle Medicine (Recent Advances in Preventive Cardiology and Lifestyle Medicine provides an overview of a number of underlying factors attendant to preventive cardiology and lifestyle medicine.

The DVD discusses cardioprotective mediations, as well as looks at dietary strategies that can help enhance heart health.) American College of Sports Medicine 401 West Michigan Street, Indianapolis, IN 46202-3233 P: (317) 637-9200 F: (317) 634-7817

Internet Resources American College of Sports Medicine (ACSM) The American College of Sports Medicine advances and integrates scientific research to provide educational and practical applications of exercise science and sports medicine. American College of Sports Medicine American Council on Exercise (ACE) ACE is a nonprofit organization committed to enriching quality of life through safe and effective physical activity. American Council on Exercise Division of Nutrition, Physical Activity, and Obesity The Centers for Disease Control and Prevention’s website that provides guidelines for physical activity. CDC – Division of Nutrition, Physical Activity, and Obesity Exercise Prescription ExRx.net is a free resource for the exercise professional, coach, or fitness enthusiast. ExRx.net Mayo Clinic Provides information on osteoporosis including causes, prevention, and risk factors. Mayo Clinic – Osteoporosis National Strength and Conditioning Association The National Strength and Conditioning Association (NSCA) is the world’s leading authority on strength and conditioning. They provide reliable, research-based strength and conditioning information to members and the general public. National Strength and Conditioning Association

SHAPE America The Society of Health and Physical Educators. SHAPE America The President’s Challenge The President’s Challenge is a program that encourages all Americans to make being active part of their everyday lives. The President’s Challenge Program President's Council on Fitness, Sports & Nutrition The President’s Council engages, educates, and empowers all Americans to adopt a healthy lifestyle that includes regular physical activity and good nutrition. The President’s Council is made up of athletes, chefs, physicians, fitness professionals, and educators who are appointed by the President and serve in an advisory capacity through the Secretary of Health and Human Services. President's Council on Fitness, Sports & Nutrition

Key Terms active stretching

hypothermia

acute injuries

isokinetic

aerobic exercise

isometric

anabolic steroids

isotonic

anaerobic exercise

MET (metabolic equivalent of task)

ballistic stretching

metabolic fitness

body composition

muscle dysmorphia

cardiorespiratory fitness

muscular endurance

dynamic flexibility

muscular strength

dynamic stretching

overload principle

exercise

overloading

fitness

overtrain

FITT

overuse injuries

flexibility

passive stretching

functional fitness

physical activity

physical fitness

set

progressive overloading

specificity principle

range of motion

static flexibility

Rating of Perceived Exertion (RPE)

static stretching

reps (or repetitions)

target heart rate

resting heart rate reversibility principle

Answers to Global Health Watch 1. b 2. a 3. increase

8 Sexual Health Learning Objectives After studying this chapter in the text, the student should be able to: 8.1

Describe women’s and men’s sexual health, their sexual anatomy, and the role of sex hormones in the development of gender identities.

8.2

Specify the aspects of healthy sexual relationships that lead toward responsible sexuality.

8.3

Summarize the sexual practices of college students.

8.4

Discuss sexual diversity in human beings.

8.5

Outline the major types of sexual activity.

8.6

Describe the stages of sexual response in men and women.

8.7

Identify the risk factors and characteristics of sexually transmitted infections and diseases.

8.8

Review the signs, symptoms, and treatment of common sexually transmitted diseases.

Chapter Summary Sexual responsibility means learning about your body, your partner’s body, your sexual development and preferences, and the health risks associated with sexual activity. This chapter is an introduction to your sexual self, and an exploration of sexual issues in today’s world. It provides the information and insight you can use in making decisions and choosing behaviors that are responsible for all concerned.

Lecture Outline I.

Sexual Health A. Overview 1. Sexuality is the quality of being sexual. Our sex is our biological maleness or femaleness. Sexual intimacy is physical closeness. Sexual health refers, by simplest definition, to a state of optimal well-being related to sexuality throughout the lifespan. B. Sexuality and the Dimensions of Health 1. Our sexuality affects and is affected by the various dimensions of health. 2. Aspects of health enhance our sexuality. Some examples are as follows: a. Physical—safer sex practices reduce the risk of sexually transmitted infections (STIs). Also, when our bodies are healthy and well, we feel better about ourselves, which enhances both self-esteem and healthy sexuality. b. Emotional—when our emotional health is high, we can better understand and cope with the complex feelings related to being sexual. c. Social—from dating to mating, we express and fulfill our sexual identities in the context of families, friends, and society as a whole. d. Intellectual—our most fulfilling relationships involve a meeting of minds as well as bodies. e. Spiritual—at its deepest, most fulfilling level, sexuality uplifts the soul by allowing us to connect to something greater than ourselves. f. Environmental—responsible sexuality makes people more aware of the impact of their decisions on others.

II.

Women’s Sexual Health A. All women of childbearing age should undergo regular “health maintenance” exams to monitor their sexual and reproductive well-being, detect infections and other medical problems, and prevent unwanted pregnancy. B. Female Sexual Anatomy 1. The mons pubis is the rounded, fleshy area over the junction of the pubic bones. 2. The folds of skin that form the outer lips of a woman’s genital area are called the labia majora. 3. The labia majora cover soft flaps of skin (inner lips) called the labia minora.

4. The inner lips join at the top to form a hood over the clitoris, a small, elongated erectile organ and the most sensitive spot in the entire female genital area. 5. Below the clitoris is the urethral opening, the outer opening of the thin tube that carries urine from the bladder. 6. Below that is a larger opening, the mouth of the vagina, the canal that leads to the primary internal organs of reproduction. 7. The perineum is the area between the vagina and anus (the opening to the rectum and large intestine). 8. At the back of the vagina is the cervix, the opening to the womb, or uterus. 9. The uterine walls are lined by a layer of tissue called the endometrium. 10. The ovaries, about the size and shape of almonds, are located on either side of the uterus and contain egg cells called ova. 11. Extending outward and back from the upper uterus are the fallopian tubes, the canals that transport ova from the ovaries to the uterus. C. The Menstrual Cycle 1. The menstrual cycle begins in the brain with the production of gonadotropin-releasing hormone (GnHR). a. Ovulation is the release of the egg cell from the follicle at midcycle. b. Estrogen levels drop and the remaining cells of the follicle then enlarge, change character, and form the corpus luteum, or yellow body. c. In the second half of the menstrual cycle, the corpus luteum secretes estrogen and larger amounts of progesterone. d. The endometrium (uterine lining) is stimulated by progesterone to thicken and become more engorged with blood in preparation for nourishing an implanted, fertilized ovum. e. If the ovum is not fertilized, the corpus luteum disintegrates. f. As the level of progesterone drops, menstruation occurs: the uterine lining is shed during the course of a menstrual period. g. If the egg is fertilized and pregnancy occurs, the cells that eventually develop into the placenta secrete human chorionic gonadotropin, a messenger hormone that signals the pituitary not to start a new cycle. 2. Premenstrual Syndrome a. Women with premenstrual syndrome (PMS) experience bodily discomfort and emotional distress for up to 2 weeks, from ovulation until the onset of menstruation.

b. Once dismissed as a psychological problem, PMS has been recognized as a very real physical disorder that may be caused by various factors, including the following: i. A hormonal deficiency ii. Abnormal imbalance of estrogen and progesterone iii. An imbalance of estrogen and progesterone iv. Social and environmental factors, particularly stress v. The most common symptoms of PMS are as follows: • Mood changes • Anxiety • Irritability • Difficulty concentrating • Forgetfulness • Impaired judgment • Tearfulness • Digestive symptoms (diarrhea, bloating, constipation) • Hot flashes • Palpitations • Dizziness • Headache • Fatigue • Changes in appetite • Cravings (usually for sweet or salt) • Water retention • Breast tenderness • Insomnia c. Treatments for PMS depend on specific symptoms: i. Diuretics for water retention ii. Cognitive behavioral therapy iii. Relaxation or stress-management techniques iv. Sleep deprivation and bright lights to adjust circadian or daily rhythm v. Charting of cycles to identify vulnerable periods vi. Low doses of selective serotonin reuptake inhibitor medications for symptoms, such as tension, depression, irritability, and mood swings

3. Premenstrual Dysphoric Disorder a. Premenstrual dysphoric disorder (PMDD), which is not related to PMS, occurs in an estimated 3–5 percent of all menstruating women. b. It is characterized by regular symptoms of depression (depressed mood, anxiety, mood swings, diminished interest or pleasure) during the last week of the menstrual cycle. 4. Menstrual Cramps a. Dysmenorrhea is the medical name for the discomforts—abdominal cramps and pain, back and leg pain, diarrhea, tension, water retention, fatigue, and depression—that can occur during menstruation. 5. Amenorrhea a. Women may stop menstruating—a condition called amenorrhea—for a variety of reasons, including a hormonal disorder, drastic weight loss, strenuous exercise, or change in the environment. 6. Toxic Shock Syndrome a. This rare, potentially deadly bacterial infection primarily strikes menstruating women under the age of 30 who use tampons. b. Both Staphylococcus aureus and group A Streptococcus pyogenes can produce toxic shock syndrome. c. Symptoms include the following: i. A high fever; a rash that leads to peeling of the skin on the fingers, toes, palms, and soles; dizziness; dangerously low blood pressure; and abnormalities in several organ systems, and in the muscles and blood. III. Men’s Sexual Health A. Men should make regular self-exams (including checking the penis and testes) part of their routine. B. Men’s Sexual Anatomy 1. The visible parts of the male sexual anatomy are the penis and the scrotum, the pouch that contains the testes. 2. The testes manufacture testosterone, the hormone that stimulates the development of a male’s secondary sex characteristics, and sperm, the male reproductive cells. 3. Immature sperm are stored in the epididymis, a collection of coiled tubes adjacent to each testis.

4. The penis contains three hollow cylinders loosely covered with skin. a. The two major cylinders, the corpora cavernosa, extend side by side through the length of the penis. The third cylinder, the corpus spongiosum, surrounds the urethra. 5. Men of all ages may have concerns about the size of their penises. a. The mean length of a flaccid penis was 3.6 inches; the mean length of an erect penis is about 5.2 inches. 6. The urethra is the channel for seminal fluid and urine. 7. Semen is the liquid in which the sperm cells are carried out of the body during ejaculation. 8. The vas deferens is comprised of two tubes that carry the sperm from the epididymis into the urethra. 9. The seminal vesicles, which make some of the seminal fluid, join with the vas deferens to form the ejaculatory ducts. 10. The prostate gland produces some of the seminal fluid, which it secretes into the urethra during ejaculation. 11. The Cowper’s glands are two pea-sized structures on either side of the urethra and are connected to it via tiny ducts. C. Circumcision 1. Circumcision is the surgical removal of the foreskin. 2. Some of the health benefits of circumcision are as follows: a. Reduces the risk of infection with human immunodeficiency virus (HIV), herpes simplex virus type 2, and human papillomavirus (HPV) b. Lowers the risk of cancer of the penis c. May lower a man’s risk of prostate cancer d. Helps female partners who are less likely to develop bacterial vaginosis and Trichomonas vaginalis e. Lessons the risk of urinary tract infections during the first year of life f. Helps prevent foreskin infections and retraction g. Makes hygiene easier 3. Complications of circumcision include the following: a. Bleeding b. Infection c. Improper healing d. Cutting the foreskin too long or too short e. Discomfort 4. There is little consensus on what impact the presence or absence of a foreskin has on sexual functioning or satisfaction.

IV. Responsible Sexuality A. Most people grow up with a lot of myths and misconceptions about sex. Rather than relying on what peers say or what you’ve always thought was true, find out the facts. B. Creating a Sexually Healthy Relationship. 1. A sexually healthy relationship is based on shared values and has five characteristics as follows: a. Consensual, nonexploitive, honest, mutually pleasurable, and protected against unintended pregnancy and sexuality transmitted infections. b. All individuals also have sexual rights, which include the right to the information, education, skills, support, and services they need to make responsible decisions. c. Communication is vital. C. Making Sexual Decisions 1. Making responsible sexual decisions means considering all the possible consequences—including emotional consequences—of sexual behavior for you and your partner. 2. Prior to any sexual activity that involves the risk of STI or pregnancy, both partners should talk about their prior sexual histories and other high-risk behavior, such as the use of injection drugs. 3. Partners should also discuss the issue of birth control and which methods might be best for them to use. 4. Both partners should ask each other questions. D. Saying No to Sex 1. The following strategies can help you assert yourself when saying no to sex: a. Recognize your own values and feelings. b. Be direct. c. Just say no. d. If you’re still at a loss for words, try responses such as: “I like you a lot, but I’m not ready to have sex.” e. If you are feeling pressured, let your date know that you are uncomfortable. f. If you are a woman, monitor your sexual signals. g. Communicate your feelings to your date sooner rather than later. h. Remember that if saying no to sex puts an end to a relationship, it was not much of a relationship in the first place.

Sexual Behavior A. Overview 1. Our sexual identities emerge in adolescence and become clearer as we enter adulthood, but continue to change and evolve throughout our lives. 2. Sexuality may be timeless, but sexual behaviors change over time. B. Sexual Initiation: “Having Sex” for the First Time 1. According to longitudinal studies, most people engage in vaginal intercourse for the first time between the ages of 15 and 17, with 70–90 percent engaging in sexual behavior by age 18. C. Sex on Campus 1. College students see sexual activity as normal behavior for their peer group, but they tend to overestimate how much sex their peers are having. 2. Today’s undergraduates are more likely to question potential partners about their past, use condoms with a new partner, and maintain fairly long-term monogamous relationships. 3. “Casual” sex, defined as any sexual experience outside a committed relationship, is common among “emerging adults,” with estimates ranging from 14–64 percent. D. Hooking Up 1. Hooking up is characterized by a lack of any expectation of emotional intimacy or a romantic relationship. 2. In studies of U.S. undergraduates, more than half—a range of 56–86 percent—have reported some form of hooking up. 3. Although some report positive reactions and view hooking up as an opportunity for sexual exploration, it also involves potential risks, such as unprotected sex, unwanted sex, and emotional distress, including sexual regret, loss of self-respect, and embarrassment. 4. College students hook up for a wide range of reasons: looking for sexual gratification and excitement, feeling happier and less lonely, conforming to what their peers seem to be doing, connecting with another person without making any commitment—and, conversely, increasing the likelihood of forming a committed relationship. E. Friends with Benefits 1. Relationships between “friends with benefits” occur between two individuals who have a friendship extending beyond a one-time sexual encounter. 2. An estimated 45–50 percent of college students report engaging in a friends-with-benefits relationship in the preceding 12 months.

3. Men were more likely to desire no change in such a relationship, while women preferred either going back to being “just friends” or moving into a committed romantic relationship. F. Choosing Sexual Partners 1. Physical attraction may matter most. a. Men, according to numerous studies, are more likely to judge an attractive woman as less risky because she looks healthy. b. Women also see physically attractive men as more desirable short-term sexual partners than those who look less appealing. G. Romantic Relationships 1. Most college students still engage in sex in the context of a romantic relationship. 2. The context of sexual activity can affect sexual enjoyment in both sexes. H. Ethnic Variations 1. As with other aspects of health, cultural, religious, and personal values affect students’ sexual behaviors. 2. Acculturation—the process of adaptation that occurs when immigrants enter a new country—also affects sexual behavior. VI. Sex in America A. Overview 1. The average American adult reports having sex about once a week. 2. One in five has been celibate for at least a year. 3. One in twenty engage in sex at least every other day. B. Sexual Diversity 1. Human beings are diverse in all ways—including sexual preferences and practices. 2. Physiological, psychological, and social factors determine whether we are attracted to members of the same sex or the other sex. This attraction is our sexual orientation. A. Heterosexuality 1. Heterosexuality or “straight,” the most common sexual orientation, is the term used for individuals whose primary orientation is toward members of the other sex. C. Bisexuality 1. Bisexuality is the term for individuals who are attracted to both sexes. 2. Serial bisexuals are sexually involved with the same-sex partner for a while and then with partners of the other sex, or vice versa. 3. Fear of HIV infection has sparked great concern about bisexuality. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

D. Homosexuality 1. Homosexuality—social, emotional, and sexual attraction to members of the same sex—exists in almost all cultures. Homophobia has led to gay bashing in many communities, including college campuses. 2. Roots of Homosexuality a. Sexual orientation probably emerges from a complex interaction that includes biological and environmental factors. 3. Coming Out a. Relatively few gay adolescents declare their homosexuality, or come out, while in a state of identity confusion. b. Most homosexual men and women progress through several stages: Stage 1: “I feel different from other kids …” Stage 2: “I think I might be gay, but I’m not sure, and if I am, I’m not sure that I want to be …” Stage 3: “I accept the fact that I’m gay, but what’s my family going to say?” Stage 4: “I finally told my parents I’m gay.” 4. Homosexuality on Campus a. Students most likely to be accepting of homosexuality were those who were women, had less traditional sex-role attitudes, were less religious, attended colleges that did not have Greek social clubs, and had gay, lesbian, and/or bisexual friends. E. The Gender Spectrum 1. Experts in human sexuality have created a multidimensional gender spectrum that includes biology, gender identity, and gender expression. 2. Transgender includes individuals whose behaviors do not conform to commonly understood gender norms. b. Transyouth—young people experiencing issues related to gender identity or expression. c. Transsexuals—those who identify with a gender other than the one they were given at birth. d. Transwomen—male to female transsexuals. e. Transmen—female to male transsexuals. 3. Queer and gender queer—refer to a range of sexual orientations, gender behaviors, or ideologies. 4. LGBTQQI—acronym for lesbian, gay, bisexual, transgendered, queer or questioning, and intersex individuals. 5. Transgender individuals may be happy with the biological sex they were born with but enjoy dressing up and behaving like the other sex. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

6. Gender Dysphoria—transsexuals who feel trapped in the body of the wrong gender. VII. Sexual Activity A. Celibacy 1. Celibacy means that a person doesn’t engage in sexual activity. 2. Complete celibacy means that the person doesn’t masturbate or engage in sexual activity with a partner. 3. Partial celibacy means that a person masturbates but doesn’t have sexual activity with a partner. B. Abstinence 1. The Centers for Disease Control and Prevention (CDC) defines abstinence as “refraining from sexual activities which involve vaginal, anal, and oral intercourse.” 2. Increasing numbers of adolescents and young adults are choosing to remain virgins and abstain from sexual intercourse until they enter a permanent, committed, monogamous relationship. 3. Among the reasons for abstinence undergraduates have reported are as follows: a. Wanting to remain a virgin until they meet someone they love and see as a life partner b. Being true to their religious and moral values c. Getting to know a partner better d. If they are heterosexual, avoiding the risk of pregnancy e. To be sure of safety from STIs C. Fantasy 1. The mind is the most powerful sex organ in the body, and erotic mental images can be sexually stimulating. 2. Fantasies generally enhance sexual arousal, reduce anxiety, and boost sexual drive. 3. Men and women have different types of sexy thoughts. D. Pornography 1. The explosive growth of the Internet has made pornography more available, affordable, and accessible almost anywhere on computers and mobile devices. 2. Although, as researchers put it, “the effects of pornography are probably not uniformly negative,” a considerable amount of research suggests potentially negative impacts.

E. Masturbation 1. Not everybody masturbates, but most people do. 2. Masturbation is often the primary sexual activity of individuals not involved in a sexual relationship. F. Nonpenetrative Sexual Activity (Outercourse) 1. Outercourse includes kissing and hugging but does not involve genital-togenital, mouth-to-genital, or insertive anal sexual contact. 2. Usually kissing is the first sexual activity that couples engage in. 3. Stimulating erogenous regions can lead to orgasm in both men and women—more couples are gaining an appreciation of these activities as primary sources of sexual fulfillment and as safer alternatives to intercourse. G. Intercourse 1. Vaginal intercourse, or coitus, refers to the penetration of the vagina by the penis. 2. Sexual activity, including intercourse, is possible throughout a woman’s menstrual cycle. 3. Vaginal intercourse, like other forms of sexual activity involving an exchange of bodily fluids, carries a risk of STIs, including HIV infection. H. Oral Sex 1. The formal terms for oral sex are cunnilingus, which refers to oral stimulation of the woman’s genitals, and fellatio, oral stimulation of the man’s genitals. 2. Oral sex with a partner infected with herpes, HIV, or other pathogens can transmit an STI, so a condom should be used I. Anal Stimulation and Intercourse 1. Because the anus has many nerve endings, it can produce intense erotic responses. 2. Anal sex involves important health risks, such as damage to sensitive tissue, and the transmission of various intestinal infections, hepatitis, and STIs, including HIV. VIII. Sexual Response A. Excitement 1. In men, sexual stimuli set off a rush of blood to the genitals, filling the blood vessels in the penis, which becomes erect. 2. Women respond to stimulation with vaginal lubrication. B. Plateau 1. The penis further increases in both length and diameter. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. The outer one-third of the vagina swells. 3. During intercourse, the vaginal muscles grasp the penis to increase stimulation for both partners. 4. The upper two-thirds of the vagina become wider as the uterus moves up; eventually its diameter is 2½–3 inches. C. Orgasm 1. Both men and women experience orgasm. 2. During the process of ejaculation, the vas deferens, the seminal vesicles, the prostate, and upper portion of the urethra contract. Seconds later muscle contractions force semen out of the penis via the urethra. 3. Female orgasms are primarily triggered by stimulating the clitoris until the vagina responds by contracting. D. Resolution 1. The sexual organs return to their normal, nonexcited state. 2. After orgasm, men typically enter a refractory period, during which they are incapable of another orgasm. The duration of this period varies from minutes to days. E. Other Models of Sexual Response 1. Some researchers have argued that the Masters and Johnson’s model neglects the importance of desire and that the plateau stage is virtually indistinguishable from excitement. 2. Others note that arousal may come before desire, particularly for women who may not have spontaneous feelings of sexual desire. IX. Sexually Transmitted Infections and Diseases A. Overview 1. STI refers to the presence of an infectious agent that can be passed from one sexual partner to another. 2. STI replaces the term sexually transmitted disease (STD) because sexual infections can be often transmitted by people who do not have symptoms. 3. STIs can: a. Last a lifetime b. Put stress on relationships c. Cause serious medical complications d. Impair fertility e. Cause birth defects f. Lead to major illness and death

4. STIs are transmitted mainly through the following: a. Direct sexual contact with someone’s symptoms or sexual contact with someone’s infected semen, vaginal fluid, blood, and other body fluid b. Sharing contaminated needles through injectable drug use c. Maternal transfer 5. STI pathogens like dark, warm, moist body surfaces, particularly the mucous membranes that line the reproductive organs. 6. Many STIs, including early HIV infection and gonorrhea in women, may not cause any symptoms. 7. More Americans are infected with STIs now than at any other time in history. 8. The odds of acquiring an STI during a lifetime are one in four. 9. The three most common STIs are chlamydia, gonorrhea, and trichomoniasis. B. Zika Virus 1. Zika virus, which is mosquito-borne, can be transmitted sexually and is of particular concern during pregnancy. 2. Health officials advise pregnant women and partners who may have been exposed to Zika virus to abstain from sex or to use condoms conscientiously. C. Risk Factors for STIs 1. Various factors put young people at risk of STIs, including the following: a. A sexual partner who has an STI b. A history of STIs c. Feelings of invulnerability d. Multiple partners or a partner who has had more than one sexual partner e. Meeting sex partners through the Internet f. Failure to use condoms g. Alcohol and drug h. Failure of a partner to be notified and treated i. Use of injection drugs or sexual partner who uses them X.

The ABCs of Safer Sex A. A Is for Abstain 1. Abstinence from vaginal, anal, and oral sex, is: a. Free b. Available to everyone c. Extremely effective at preventing pregnancy and STIs

2. Ways to avoid STIs during oral sex: a. Use barrier methods b. Be aware of sores, discharge and/or unpleasant odors c. Don’t floss or brush teeth before oral sex d. Avoid aggressive and deep thrusting in oral sex e. Remember that oral sex can transmit STIs B. B Is for Be Faithful 1. Women and men in a committed relationship don’t need to worry about getting STIs if: a. Neither partner ever had sex with anyone else b. Neither partner ever shared needles c. Neither partner currently has or ever had an STI 2. A committed relationship remains safe only as long as both partners remain committed. C. C Is for Condoms 1. Condoms are the only contraceptive that helps prevent both pregnancy and STIs when used properly and consistently. 2. Here are some essential guidelines to keep in mind: a. Most physicians recommend American-made latex condoms. Check the packages for FDA approval. b. Check the expiration date. c. Make sure the package is in good condition. Also, make sure the package says the condom is meant to prevent disease. d. Make sure they are the right size. e. Condoms can deteriorate if not stored properly. D. STIs and Gender 1. Both men and women can develop STIs, but their risks are not the same. 2. If You Are a Woman a. Your risk of getting an infection is greater than a man’s. b. Symptoms of STIs tend to be more “silent” in women. c. Talk to your doctor about whether you should be tested for STIs. 3. If You Are a Man a. Involve your partner. b. After potential exposure to an STI, urinate and wash your genitals with antibacterial soap. c. Ask your doctor whether you should be tested for STIs. 4. Although it can be awkward to bring up the subject of condoms, don’t let your embarrassment put your health at risk.

5. Additional guidelines: a. Use a new condom each time. b. Do not open the wrapper of a condom with your teeth. c. Squeeze the air out of a condom before putting it on. d. Do not use spermicide containing nonxynol-9 (N-9). e. If a condom fails, remove it carefully and replace with a new condom. XI. STIs on Campus A. What College Students Don’t Know about STIs 1. Many undergraduates think that they know more than they actually do. 2. Many do not realize that STIs can exist without symptoms so they don’t take steps to protect themselves or to avoid risky sexual behaviors. XII.

Common STIs and STDs A. Human Papilloma Virus 1. Human Papilloma Virus (HPV) is the most common sexually transmitted infection in the United States. 2. There are 100 or more different strains, approximately 40 are sexually transmitted. 3. There are higher infection rates in women as well as higher risk of oral cancer. 4. “High-risk” strains higher the risk of cervical, vulva, vagina, anus, or penis cancer. 5. “Lower-risk” may cause Pap test abnormalities and genital warts. 6. Genital warts are single or multiple growths or bumps that appear in the genital area. 7. Primary risk factors for oral HPV infection include the following: a. Number of sex partners. b. Smoking. c. Heavy drinking. d. Marijuana use. 8. Incidence a. Approximately 20 million people in the United States are currently infected. b. 6.2 million get a new HPV infection each year. c. College-age women are at greatest risk of infection. 9. HPV Vaccination a. There are two FDA-approved vaccines for HPV. b. These vaccines are different in the types of HPV strains they prevent.

c. Federal authorities and the American Academy of Pediatrics recommends HPV vaccination for the following: i. All girls and boys ages 11 or 12, with catch-up vaccinations for those ages 13–21. ii. Women ages 13 through 26 who were not previously vaccinated. iii. Men ages 13 through 21 who were not previously vaccinated; men ages 22 through 26 may also receive the vaccine. 10. HPV Vaccination on Campus a. Sexually active young adults are at the highest risk of HPV infection. 11. Signs and Symptoms a. HPV lives in the skin or mucous membranes and usually causes no symptoms. b. Some people get visible genital warts or have precancerous changes in the cervix, vulva, anus, or penis. c. After contact with an infected individual, genital warts may appear within 3 weeks to 18 months, with an average period of about 3 months. 12. Diagnosis and Treatment a. Most women are diagnosed with HPV after an abnormal Pap test or HPV DNA test. b. No form of therapy has been shown to completely eradicate HPV, nor has any single treatment been uniformly effective in removing warts or preventing their reoccurrence. B. Genital Herpes 1. Herpes describes some of the most common viral infections in humans. 2. Herpes simplex causes blisters on the skin or mucous membranes. a. Herpes simplex virus (HSV-1) can be transmitted by kissing and generally causes cold sores and fever blisters around the mouth. b. Herpes simplex virus 2 (HSV-2) is sexually transmitted. 3. HSV transmission occurs through close contact with mucous membranes or abraded skin. 4. Past views saw herpes as an episodic disease with the greatest of risk during flare-ups, however “classis herpes” for most people, is a chronic nearly continuously active infection that may produce subtle, varied, and often overlooked symptoms. 5. Herpes can be spread even between flare-ups. 6. Incidence a. At least 50 million people in the United States have genital herpes. b. Only a minority know they are affected. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

7. Signs and Symptoms a. Most people with genital herpes have no symptoms or very mild symptoms that go unnoticed. b. The most common symptom is a cluster of blistery sores. c. Other symptoms include: blisters, burning feelings if urine flows over sores, inability to urinate if severe swelling of sores block the urethra and itching and pain in the infected area. d. Herpes never entirely goes away. 8. Diagnosis and Treatment a. There are several antiviral therapies that not only reduce symptoms and heal herpes lesions but also, if taken continuously, significantly reduce the risk of transmission of the virus to sexual partners. C. Chlamydia 1. Chlamydia trachomatis is the most widespread sexually transmitted bacterium in the United States. 2. Incidence a. One in 25 Americans is infected with chlamydia. b. Women are at greater risk. 3. Signs and Symptoms a. As many as 75 percent of women and 50 percent of men have no symptoms or those that are so mild they don’t seek medical attention. b. Without treatment, up to 40 percent of cases of chlamydia can lead to pelvic inflammatory disease. c. Untreated women have three to five times the risk of getting infected with HIV if exposed. d. In women, symptoms include abdominal pain, abnormal vaginal discharge, bleeding between menstrual periods, cervical or rectal inflammation, low-grade fever, yellowish discharge from the cervix, vaginal bleeding after intercourse, painful intercourse, painful urination, and the urge to urinate more than usual. e. In men, symptoms include pain or burning while urinating, pus, watery, or milky discharge from the penis, swollen or tender testicles, and rectal inflammation. f. Epididymitis can also occur in men, which can cause sterility. 4. Diagnosis and Treatment a. Antibiotics are used to treat chlamydia. D. Pelvic Inflammatory Disease 1. Pelvic inflammatory disease (PID) is the infection of a woman’s fallopian tubes or uterus. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Not actually an STI, but a complication of STIs. 3. Initial episodes of PID lead to scarring and obstruction of the fallopian tubes severe enough to cause infertility. 4. Potential complications of PID infertility, ectopic pregnancy, and chronic pelvic pain. 5. Smoking may increase the likelihood of PID. 6. Incidence a. About one in seven women of reproductive age has PID: half of all women may have had it. 7. Signs and Symptoms a. Half of all cases produce no symptoms. b. Early symptoms include the following: i. Abdominal pain or tenderness ii. Fever iii. Vaginal discharge that may have a foul odor iv. Painful intercourse or urination v. Irregular menstrual bleeding vi. Rarely, pain in the right upper abdomen 8. Diagnosis and Treatment a. Detecting gonorrhea and chlamydia as well as pelvic ultrasound or magnetic resonance imaging (MRI) can prevent or diagnose PID. E. Gonorrhea 1. Sometimes called “the clap,” gonorrhea is one of the most common STIs in the United States. 2. Incidence b. Some 350,000 new cases are reported annually. c. Rates are higher in women. 3. Signs and Symptoms a. Men i. Thick pus oozes from the penis and urination is painful. ii. If untreated, it can spread to the prostate gland, testicles, bladder, and kidneys. iii. Complications include urinary obstruction and sterility. b. Women i. May have a discharge and burning or no symptoms at all ii. Inflammation travels from the vagina and cervix, through the uterus, to the fallopian tubes and ovaries and causes pain and fever. iii. Gonorrhea is the leading cause of sterility in women and can cause PID. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

c. In both sexes, gonorrhea can develop into a serious, even fatal, bloodborne infection that can cause arthritis in joints, attack the heart muscle and lining, cause meningitis, and attack the skin and other organs. 4. Diagnosis and Treatment a. The tried-and-true method of diagnosis is still a microscopic analysis of cultures from the male’s urethra, the female’s cervix, and the throat and anus of both sexes. b. Cephalosporin antibiotic plus azithromycin or doxycyline is now the recommended treatment. F. Nongonococcal Urethritis (NGU) 1. NGU refers to any inflammation of the urethra that is not caused by gonorrhea. 2. NGU is the most common STI in men. Symptoms in men are similar to those of gonorrhea. 3. Women frequently develop no symptoms or very mild itching, burning during urination, or discharge. 4. Treatment consists of doxycycline or azithromycin given to both partners. G. Syphilis 1. A corkscrew-shaped, spiral bacterium called Treponema pallidum causes syphilis. 2. Sexual contact, including oral sex or intercourse, is the primary means of transmission. 3. Genital ulcers increase the risk of HIV, while those with HIV may be more likely to develop syphilis. 4. Incidence a. An estimated 300,000 cases are reported each year. 5. Signs and Symptoms a. Primary syphilis i. The first sign of syphilis is a lesion, or chancre, which appears exactly where the bacteria entered the body. b. Secondary syphilis i. Anywhere from 1–12 months after the chancres appear, secondary-stage symptoms may appear. ii. Some people have no symptoms. iii. Others develop a skin rash or small, flat rash in moist regions on the skin; whitish patches on the mucous membranes of the mouth or throat, temporary baldness, low-grade fever, headache, swollen glands, or large moist sores around the mouth and genitals. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iv. Sores are loaded with bacteria and can transmit the infection. v. Symptoms may last for several days or several months. c. Late and latent syphilis i. Involves no signs and symptoms and no sores or rashes. ii. At this stage, the bacteria are invading various organs inside the body, including the heart and the brain. iii. For 2–4 years, there may be recurring infectious and highly contagious lesions of the skin or mucous membranes. iv. Syphilis loses its infectiousness as it progresses: After the first 2 years, a person rarely transmits syphilis through intercourse. d. Tertiary syphilis i. Ten to twenty years after the beginning of the latent stage, the most serious symptoms of syphilis emerge. ii. Victims rarely live this long, but if they do, they may die of a ruptured aorta or other heart damage or may have progressive brain damage. 6. Diagnosis and Treatment a. Penicillin is the drug of choice for treating primary, secondary, and latent syphilis. H. Chancroid 1. Soft, painful sore or localized infection caused by the bacterium Haemophilus ducrevi and usually acquired through sexual contact. 2. Half of all cases heal by themselves. 3. Treated with antibiotics. I. Pubic Lice and Scabies 1. These infections are sometimes, but not always transmitted sexually. 2. Pubic lice or “crabs” a. Pubic lice are usually found in the pubic hair, although they can migrate to other hairy parts of the body. b. Irritation from the lice may lead to intense itching, and scratching can lead to sores. a. Scabies is caused by a mite that burrows under the skin, where it lays eggs. 3. Lice and scabies are treated with applications of permethrin cream and lindane shampoo. J. Trichomoniasis 1. An estimated 7.4 million new cases of this curable STI appear each year. 2. It is caused by a single-celled protozoan parasite Trichomonus vaginalis. 3. Most men have no signs or symptoms.

4. Some may have irritation inside the penis, mild discharge, or slight burning or irritation during urination. 5. Some women develop a frothy, yellow-green vaginal discharge. a. They may experience discomfort during intercourse or urination, and genital itching and irritation. This may increase susceptibility to HIV if exposed to the virus. K. Bacterial Vaginosis 1. Bacterial vaginosis (BV), the most common vaginal infection in women ages 15–44, is caused by an imbalance of normal bacteria in the vagina. 2. Many women with BV do not have symptoms. a. Others may notice a thin white or gray vaginal discharge and odor, pain, itching, or burning in the vagina. 3. Laboratory tests of vaginal fluid can determine if BV is present. 4. Antibiotics can treat BV, although the infection may recur. a. Male sex partners of women diagnosed with BV generally do not need to be treated. L. HIV and AIDS 1. HIV stands for human immunodeficiency virus. 2. AIDS stands for acquired immune deficiency syndrome. 3. Incidence a. According to statistics, 34 million people are living with HIV or AIDS worldwide. b. Nearly 30 million people have died. c. An estimated 2.5 million become infected with HIV every year. d. About 1.2 million people in the United States are living with HIV or AIDS. e. Those at highest risk are as follows: i. Gay and bisexual men ii. Black Americans iii. Women iv. Young adults 4. Testing a. An estimated 50 percent of young Americans infected with the virus that causes AIDS don't know they have it. b. However, the HIV testing rate is lower among those ages 18–24 than for older people in the United States. 5. Reducing the Risk of HIV Transmission a. The risk of HIV transmission depends on sexual behavior, not sexual orientation. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

6. Sexual Transmission a. Casual contact does not spread HIV infection. b. Compared to other viruses, HIV is extremely difficult to get. c. HIV can live in blood, semen, vaginal fluids, and breast milk. d. Many chemicals, including household bleach, alcohol, and hydrogen peroxide, can inactivate HIV. e. In studies of family members sharing dishes, food, clothing, and frequent hugs with people with HIV infection or AIDS, those who have contracted the virus have shared razor blades, toothbrushes, or had other means of blood contact. f. You cannot tell visually whether a potential sexual partner has HIV. g. HIV can be spread in semen and vaginal fluids during a single instance of anal, vaginal, or oral sexual contact between heterosexuals, bisexuals, or homosexuals. h. Teenage girls may be particularly vulnerable to HIV infection. i. Anal intercourse is an extremely high-risk behavior. j. Other behaviors that increase the risk of HIV infection include having multiple sexual partners, engaging in sex without condoms or viruskilling spermicides, sexual contact with persons known to be at high risk, and sharing injection equipment for drugs. k. Condom use significantly reduces the risk of HIV transmission. l. Individuals are at greater risk if they have an active sexual infection. m. No cases of HIV transmission by deep (French) kissing have been reported, but it could happen. n. Oral sex can lead to HIV transmission. o. HIV infection is not widespread among lesbians, although there have been documented cases of possible female-to-female HIV transmission. 7. Nonsexual Transmission a. Efforts to prevent nonsexual forms of HIV transmission have been very effective. These include: b. Screening the blood supply has reduced the rate of transfusionassociated HIV transmission by 99.9 percent. c. Treatment with antiretroviral drugs during pregnancy and birth reduced transmission to newborns by about 90 percent in optimal conditions. d. HIV infections among injection drug users have fallen by half in the past decade.

8. Preventing HIV Infection a. Behavioral methods, such as safer sex practices, remain the primary means of preventing transmission. b. Biological approaches may provide additional protection. 9. Recognizing and Treating HIV or AIDS a. HIV infection refers to a wide spectrum of health problems that result from immunologic abnormities caused by the virus when it enters the bloodstream. b. HIV destroys the cell-mediated immune system, particularly the CD4+ T-lymphocytes. c. Shortly after becoming infected with HIV, individuals may experience a few days of flu-like symptoms, which most ignore or attribute to other viruses. d. Symptoms: swollen lymph nodes, fever chills, night sweats, diarrhea, weight loss, coughing and shortness of breath, persistent tiredness, skin sores, blurred vision and headaches, and development of other infections, such as certain kinds of pneumonia. e. HIV infection is associated with a variety of HIV-related diseases, including different cancers and dangerous infections like tuberculosis. f. Diminished mental function may appear before other symptoms. 10. HIV Testing a. All HIV tests measure antibodies, cells produced by the body to fight HIV infection. b. It can take 3–6 months for the body to produce the telltale antibodies, so a negative result may not be accurate, depending on the timing of the test. c. Testing can be confidential or anonymous. d. Home Access is approved by the FDA and is available in drug stores or online for $40–$50. e. New blood tests can determine how recently a person was infected with HIV. 11. Diagnosing AIDS a. A diagnosis of AIDS applies to anyone with HIV whose immune system is severely impaired, as indicated by a CD4+ count of less than 200 cells per cubic millimeter of blood. b. AIDS is diagnosed in persons with HIV infection who experience recurrent pneumonia, invasive cervical cancer, or pulmonary tuberculosis.

c. People with AIDS may experience persistent fever, diarrhea that persists for more than a month, or involuntary weight gain or loss of more than 10 percent of body weight. 12. Treatments a. New forms of therapy have been remarkably effective in boosting levels of protective T cells and reducing viral load—the amount of HIV in the bloodstream. b. Starting treatments early can dramatically improve survival.

Discussion Questions •

Ask students why it is so difficult to talk about sex. Factors that might be discussed include society’s ambivalence about sexuality, feeling awkward, or ignorance. Is it easier for men to talk about sex or for women?

•

Ask students how they feel about legislation that would mandate premarital counseling prior to getting married. What about testing for STIs?

•

Ask students to recount what they learned about being a boy or a girl. Ask students to include examples of how they developed their own gender roles. Consider parents, peers, religion, teachers, and media, and ask students who and what influenced their gender role development. Encourage them to think about both the positive and negative influences and how they contributed to shaping who they are as a sexual being.

•

As boys and girls begin to physically mature, there is often discomfort and confusion between how they feel and how they are perceived by others as sexual beings. Discuss these discrepancies and the impact they had on sexual development and self-acceptance. How might one overcome these stereotypes as well as gain selfacceptance?

•

Ask students how referring to the other gender as “the opposite sex” effects our perception of gender differences. How might it polarize our relationships?

•

Briefly discuss the interaction of hormones and their effect on the menstrual cycle. Discuss why some men and women attribute certain behaviors, e.g., moodiness and irritability, to menstruation. Is this possible? Why or why not? How do men and women’s attitudes about menstruation differ?

•

Ask the class to cite reasons why a person who is at risk for HIV would not get tested. Which of these reasons does the class feel are justifiable? Discuss and differentiate between anonymous and confidential test sites and point out where the local anonymous test site is where students can get free or low-cost tests. Ask

students why it is so hard to talk about STIs and their prevention with a perspective partner. How can we overcome these barriers? •

Ask students what the term “outercourse” refers to. Discuss forms of outercourse and how it can (or cannot) be used in the following: to prevent pregnancy, STIs, and/or for moral or religious dilemmas. Is it safe against STIs?

•

Ask students at what point, if ever, they might consider becoming sterilized. Should there be laws about age, consent, the number of children already in the family, etc. to dictate or prohibit sterilization?

•

Ask students whether they believe additional money should be directed toward research in developing new methods of contraception or in the prevention of STIs? What would they be willing to pay in order to assure this would happen (e.g., pay additional taxes, increase cost of device)?

Classroom Activities Activity #1: Understanding Our Bodies Purpose: To get students to identify with the purposes of the female and male anatomy.

Time: One class period.

Introduction: Introduce students to the male and female reproductive systems and discuss the importance of understanding the functions of each of their activities.

Method: 1.

Provide students with paper, clay, cotton balls, balloons, paper clips, and pipe filters and have them form the male and female reproductive systems with the items you have provided.

They may work in groups and use their book. You may want to have them try this without using their book at first.

Discussion: 1.

Why is it important to know the different parts of the reproductive systems and the functions of each?

How might this knowledge influence one’s sexual experiences? What about not knowing this information?

Activity #2: Sexual Health Assessment Purpose: To inventory your own sexual practices.

Time: One-half to one whole class period.

Method: 1.

Take an inventory of your sexual history, including each partner and type of sexual activity engaged in.

Discussion: 1.

Were any of your sexual encounters unprotected or were any behaviors considered risky in terms of your health?

What are you going to do in the future to make better choices and to protect your health?

Activity #3: “And the Band Played On” Purpose: To understand the history of HIV or AIDS and the application of epidemiology.

Time: Two and a half class periods.

Introduction: Introduction to the concepts and content of the activity.

Method: 1.

View the movie “And the Band Played On.”

Discussion: 1.

How are infections such as HIV or AIDS studied?

What role has the government played in the study of HIV or AIDS? Did they do “everything” they could have done? Why or why not?

What role did the media play in treating HIV in the early stages? Was it positive or negative?

Why do you think our society is currently experiencing an increase in HIV infection?

Who do you think is most at risk of contracting HIV or AIDS?

Activity #4: STI Transmissions Purpose: To increase awareness of how STIs might be spread and the encompassing possibilities of whom an individual might be exposed to.

Time: Twenty to thirty minutes.

Introduction: Demonstrate how easy it is to transmit an STI to another person when one individual is not having protected sex.

Method: 1.

Hand out envelopes to every person in class. a.

Include condoms in three of the envelopes, mark three with a big X, and place a blank piece of paper inside three of the envelopes. Do not open the envelopes until the exercise is complete.

After everyone has an envelope, ask students to mingle for two or three minutes, and to shake hands with anyone they greet. After the meet and greet, inform them that for the purposes of this exercise, the handshake will represent sexual contact with another person.

Have students open their envelope to determine who used a condom and who did not during their “contact.”

Next identify the carriers of HIV. Those students with an X are carriers; those with the blank pieces of paper represent contact with no contraction of disease; and those with condoms represent those who protected themselves.

Discussion: 1.

Identify those who had been infected with HIV, and then using a mapping technique, see if you can put everyone “in contact” with the individual with HIV.

How can we be sure we are safe from contracting an STI? What precautions do we need to take? Does a condom assure an individual of not contracting an STI and/or HIV?

Activity #5: STI Risk Purpose: To increase awareness of your own potential exposure to STIs.

Time: Thirty minutes.

Method: 1.

Students should list every person that they have ever had intimate physical contact with.

Next to each name, they should list the type of contact and whether or not they used protection to prevent the spread of infection.

Discussion: 1.

After creating the list, were students surprised by the number of people they had intimate contact with?

Were they surprised by their actual use or lack of use of protection?

Do they feel they are exposing themselves to the risk of contracting an STI?

Are they going to change their behaviors as a result of this exercise?

Activity #6: How Does Your School Inform You? Purpose: The purpose of this activity is to have students research the educational opportunities available to them concerning their sexual health.

Time: Two class periods.

Method: 1.

Students should visit various departments on campus in search of educational programs related to sexual health and wellness.

Offices may include the Student Health Center, Student Life Department, Student Affairs Office, Recreation Center, etc.

Students should create a list of all programs with topics related to sexual health, including physical and reproductive health, communication, dating and relationships, birth control, sexual orientation, date rape, etc.

Discussion: 1.

As a class, discuss the programs that are available on your college campus. Do you feel like these programs really address the needs of your student population? Are there enough educational opportunities for the size of your campus? What other topics would you like to see available to students?

References, Readings, and Resources American Academy of Pediatrics. “Coming Out: Information for Parents of LGBT Teens” Coming Out: Information for Parents of LGBT Teens. American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Aubrey, Jennifer Stevens, and Siobhan E. Smith. “The Impact of Exposure to Sexually Oriented Media on the Endorsement of Hookup Culture: A Panel Study of First-Year College Students.” Mass Communication and Society 19, no. 1 (2016): 74–101. doi: 10.1080/15205436.2015.1070875. Becasen, Jeffrey, et al. “Sexual and Healthcare Seeking Behaviors of Young Adults by College Enrollment.” Journal of Adolescent Health 56, no. 2 (2015): S72. doi: Sexual and Healthcare Seeking Behaviors of Young Adults by College Enrollment. Bersamin, M. M. et al. “Risky Business: Is There an Association between Casual Sex and Mental Health in Emerging Adults?” Journal of Sex Research 51, no. 1 (2014): 43–51. doi: 10.1080/00224499.2013.772088. Boston Women’s Health Book Collective. (2005) Our Bodies, Ourselves: A New Edition for a New Era. New York: Simon and Schuster. Copen, C. E., A. Chandra, and I. Febo-Vazquez. “Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults Aged 18–44 in the United States: Data From the 2011–2013 National Survey of Family Growth.” National Health Statistics Reports 88 (2016): 1–14. Habel, Melissa A., Jeffrey S. Becasen, and Patricia J. Dittus. “The State of Sexual Health Services at US Colleges & Universities.” Journal of Adolescent Health 56, no. 2 (2015): S74– S75. doi: http://dx.doi. org/10.1016/j.jadohealth.2014.10.149. Hills, S. L., et al. “Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission—Continental United States, 2016.” Morbidity and Mortality Weekly Report 65 (2016): 215–6. doi.

Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission — Continental United States, 2016 Lechner, K. F., et al. “College Students’ Sexual Health: Personal Responsibility or the Responsibility of the College?” Journal of College Health 61, no. 1 (2013): 28–35. doi: 10.1080/07448481.2012.750608. The National Gay Task Force, 2320 17th Street, NW, Washington, DC 20009, (202) 3326483. Pearlstein, Teri. “Treatment of Premenstrual Dysphoric Disorder: Therapeutic Challenges, Expert Review of Clinical Pharmacology.” Expert Review of Clinical Pharmacology 9, no. 4 (2016): 493–6. doi: 10.1586/17512433.2016.1142371. Smith, Haley. “Sexually Transmitted Infections.” Professional Nursing Today 18, no. 1 (2015): 29–32. http://pntonline.co.za/index.php/PNT/article/ view/748/1132. Sternberg, R. J. (1988) The Triangle of Love: Intimacy, Passion, Commitment. New York: Basic Books.

Films and Videos Coming Out in Adulthood (In this program, Ritch C. Savin-Williams discusses his approach to determining the impact of sexuality on a client’s self-perception, identity, relationships, career options, and life choices.) Insight Media, Inc. 350 7th Ave, Suite 1100 New York, NY 10001 P: 800-233-9910 F: 212-799-5309 E: Insight Media, Inc. Before Stonewall (Before Stonewall pries open the closet door—setting free the dramatic story of the sometimes horrifying public and private existences experienced by gay and lesbian Americans since the 1920s.

Revealing and often humorous, this widely acclaimed film relives the emotionally charged sparking of today's gay rights movement, from the events that led to the fevered 1969 riots to many other milestones in the brave fight for acceptance.) Available for purchase and streaming via online stores and services. Two Dads, Two Moms: Gay Couples and Their Families (Profiling families in the United States, France, and Spain, this program focuses on the children of gay couples and how their experiences resemble or differ from more conventional upbringings.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group What Is a Marriage? (The institution of marriage is facing strong challenges in the 21st century, as diversity and inclusivity continue to reshape its underlying principles. Supported by some and opposed by others, issues such as same-sex marriages and the raising of families outside of marriage are ongoing sources of debate.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Changing Men: Unlearning the Behaviors of Domestic Violence (David Nugent, once a violent and abusive person himself, today runs a communitybased behavior change group in Australia called Heavy M.E.T.A.L.: Men’s Education Toward Anger & Life. Helen Wirtz is a facilitator at MonashLink’s Men’s Responsibility Group. This program tracks the progress of group members Andrew, Adam, and Alex—three husbands and fathers with dangerous antisocial behavioral issues—as they struggle to stop committing emotional and physical violence against those who love them the most.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

P: 800.322.8755 F: 800.678.3633 E: Films Media Group Portraits in Human Sexuality (Parents, friends, sex education classes, and the media—all of them shape our perceptions of reproduction and physical intimacy. Starting at the beginning, then, this program focuses on developmental issues in human sexuality.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Real People, Real Sex—Clinical Conversations for the Human Sexuality Classroom (A follow-up to the popular series "Portraits in Human Sexuality," this eight-part series of brief clinical interviews covers the major topics in the college human sexuality classroom.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Recognizing Abusive Relationships (Viewers are provided with straightforward information to help them understand and identify what abuse looks like in family and dating relationships. Forms of abuse (physical, psychological, sexual, and neglect) and warning signs are clearly outlined and supported through the dramatized voices of victims sharing their feelings on, and experiences of abuse.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Date Rape: A Violation of Trust (To the average student, the definitions of date rape and sexual assault are notoriously unclear. Use this program to eliminate the confusion, so young adults understand exactly what these things are—and the attitudes and biases that typically accompany them—before anyone gets hurt.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Gender and Communication (Based on the premise that males and females learn different ways to relate, this program investigates how communication styles fall onto a continuum of what society deems as masculine and feminine and what it means to deviate from the norm.) Learning Seed P.O. Box 617880 Chicago IL 60661 P: 800.634.4941 F: 800.998.0854 E: Films Media Group Embracing Our Sexuality (Embracing Our Sexuality is a fascinating look into the conversations of nine women who gather together for a weekend to talk about sex. The women range in age from 21– 71 and come from diverse racial backgrounds and sexual orientations.) New Day Films PO Box 165 Blooming Grove, NY 10914 Email: orders@newday.com P: 888.367.9154 F: 845.774.2945 Finding Our Way (What do men really want sexually? How did they learn about sex? How does sexual expression change with age? Finding Our Way explores these questions and offers a rare glimpse into men's experience of their sexuality as it follows the discussions of 10 men who meet at a weekend retreat.) © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Before You Know It (The subjects of Before You Know It are no ordinary senior citizens. They are go-go booted bar-hoppers, love struck activists, troublemaking baton twirlers, late night Internet cruisers, seasoned renegades, and bold adventurers. They are also among the estimated 2.4 million lesbian, gay, and bisexual Americans over the age of 55 in the United States, many of whom face heightened levels of discrimination, neglect, and exclusion.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Power and Control: Domestic Violence in America (A comprehensive and timely exploration of the shocking persistence of domestic violence in our society. The complex issues around domestic abuse are refracted through the story of Kim, a mother of three in Duluth, MN. Kim's journey takes her from a domestic violence shelter, to a promising fresh start, and then through a disturbing final twist.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Refusal Skills: Yes, You Can Say No (National award winning video series of well-documented dramas showing teens faced with temptations to skip school, take drugs, and have premarital sex.) Learning Seed P.O. Box 617880 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Chicago IL 60661 P: 800.634.4941 F: 800.998.0854 E: Learning Seed The Brandon Teena Story (Documentary film about Brandon Teena, who struggled with sexual identity before being brutally raped and beaten to death.) Available through online stores and video streaming.

Internet Resources American Association of Sexuality Educators, Counselors and Therapists Website promoting the understanding of human sexuality and healthy sexual behavior. American Association of Sexuality Educators, Counselors and Therapists Go Ask Alice Sponsored by the health education and wellness program of the Columbia University Health Service, educators answer questions on a wide variety of topics, including those related to relationships and marriage and family. Go Ask Alice! – Sexual & Reproductive Health Healthy Sex HealthySex.com is an educational site developed by Wendy Maltz, M.S.W. to promote healthy sexuality—sex based on caring, respect, and safety. HealthySex.com Journal of the American Medical Association Information on a wide variety of sexual health-related issues is available throughout this site. American Medical Association Menstruation Information on the menstrual cycle. Museum of Menstruation HIV or AIDS This site, sponsored by the Centers for Disease Control and Prevention (CDC), features current information, fact sheets, conferences, media campaigns, publications, the 20© 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

year history of HIV or AIDS, information on prevention and treatment, a frequently asked question (FAQ) section, as well as the most current HIV or AIDS statistics. Centers for Disease Control and Prevention – HIV/AIDS Sex and Sexuality Resource Center This resource center focuses on human sexuality issues, including sexual health. Research indicates that sex and sexuality issues are very important to the well-being and health of individuals, yet many are unaware of the facts surrounding these issues. This resource center covers sexual identity and orientation, sexual behavior, sex therapies, sexual violence and harassment, and related issues. Association of Reproductive Health Professionals SexualHealth.com The Sexual Health Network is dedicated to providing easy access to sexuality information, education, support, and other resources. Analyte Physicians Group – Sexual Health Sexual Orientation: Science, Education, and Policy Research that focuses on sexual orientation, antigay violence, homophobia, and other concerns of gay men and lesbians. Sexual Orientation: Science, Education, and Policy The Institute for the Advanced Study of Human Sexuality Has available a large collection of information and FAQs about sexuality. The Institute for the Advanced Study of Human Sexuality The Kinsey Institute for Research in Sex, Gender, and Reproduction Research, updates, and links on issues related to sexuality. Kinsey Institute – Indiana University John Gray Author of Men Are from Mars, Women Are from Venus. Mars Venus Women’s Sexual Health This is an informational site designed for women and their partners who have questions and concerns about women’s sexual health. Women's Sexual Health

Key Terms abstinence

homosexual

acquired immune deficiency syndrome (AIDS)

hooking up

amenorrhea

human papillomavirus (HPV)

bacterial vaginosis

intercourse

bisexual

intimacy

celibacy

labia majora

cervix

labia minora

chancroid

masturbation

chlamydia

menstruation

circumcision

mons pubis

clitoris

nongonococcal urethritis (NGU)

corpus luteum

orgasm

Cowper’s glands

ovaries

cunnilingus

ovulation

dysmenorrhea

ovum (ova)

ejaculation

pelvic inflammatory disease (PID)

ejaculatory ducts

penis

endometrium

perineum

epididymis erogenous

premenstrual dysphoric disorder (PMDD)

estrogen

premenstrual syndrome (PMS)

fallopian tubes

prostate gland

fellatio

refractory period

gonorrhea

scrotum

herpes simplex

semen

heterosexual

seminal vesicles

human immunodeficiency virus (HIV)

sex

testes

sexual health

toxic shock syndrome (TSS)

sexual orientation

transgender

sexuality

urethra

sexually transmitted disease (STD)

urethral opening

sexually transmitted infection (STI)

uterus

sperm

vagina

syphilis

vas deferens

Answers to Global Health Watch 1. a 2. c 3. prevention

9 Reproductive Options Learning Objectives After studying this chapter in the text, the student should be able to: 9.1

Explore issues that should be considered when choosing to conceive or not conceive a child.

9.2

Describe the process of conception from spermatogenesis to implantation.

9.3

Explain abstinence and nonpenetrative sexual activity.

9.4

Describe the major types of contraceptives, their benefits, and their risks.

9.5

Review the options for dealing with an unwanted pregnancy.

9.6

Outline the stages of pregnancy and childbirth.

9.7

Give examples of alternatives available to childless couples.

Chapter Summary This chapter provides information on conception, birth control, abortion, infertility, adoption, and the processes by which a new human life develops and enters the world.

Lecture Outline I.

Reproductive Responsibility A. Anyone who engages in vaginal intercourse must be willing to accept the consequences of this activity, including the possibility of conceiving a child, or must take action to avoid an unintended pregnancy. 1. Since it takes two people to conceive a child, they should decide whether to conceive a baby.

II.

Conception A. Introduction 1. The processes that affect or permit conception are as follows:

a. The creation of sperm, or spermatogenesis, starts in the male at puberty, and the production of sperm is regulated by hormones. b. Sperm cells form in the seminiferous tubules of the testes and are passed into the epididymis, where they are stored until ejaculation. c. A single male ejaculation may contain 500 million sperm. d. To reach its goal, the sperm must move through the acidic secretions of the vagina, enter the uterus, travel up the fallopian tube containing the ovum, then fuse with the nucleus of the egg (fertilization). e. Each woman is born with her lifetime supply of ova; between 300 and 500 eggs eventually mature and leave a woman’s ovaries during ovulation. f. Every month, one or the other of the woman’s ovaries releases an ovum to the nearby fallopian tube. It travels through the fallopian tube until it reaches the uterus. g. An unfertilized egg lives for about 24 to 36 hours, disintegrates, and during menstruation is expelled along with the uterine lining. h. A mature ovum releases the chemical alluring, which attracts the sperm. A sperm is able to penetrate the ovum’s outer membrane because of a protein called fertilin. i. The fertilized egg, called a zygote, travels down the fallopian tube. When it reaches the uterus, about a week after fertilization, it burrows into the endometrium, a process called implantation. 2. Conception can be prevented by contraception. III. Abstinence or Nonpenetrative Sexual Activity A. Abstinence is to abstain from vaginal intercourse and forms of nonpenetrative sexual activity that could result in conception. B. People choose abstinence for various reasons, including: waiting until they are ready for a sexual relationship; waiting until they find the “right” partner; respecting religious or moral values; enjoying friendships without sexual involvement; recovering from a breakup; or preventing pregnancy and sexually transmitted infection. C. Abstinence is the only form of birth control that is 100 percent effective and risk-free. D. Individuals who choose abstinence from vaginal intercourse often engage in activities sometimes called outercourse, such as kissing, hugging, sensual touching, and mutual masturbation.

E. Outercourse has no medical or hormonal side effects; it may prolong sex play and enhance orgasm; it can be used when no other birth control methods are available. IV. Contraception A. Introduction 1. Some couples use withdrawal, or coitus interruptus (removal of the penis from the vagina before ejaculation), to prevent pregnancy, even though this is not a reliable form of birth control. 2. Good decisions are based on sound information. 3. You should consult a physician or family planning counselor if you have questions or want to know how certain methods might affects existing of familial medical conditions. 4. Failure rate refers to the number of pregnancies that occur per year for every 100 women using a particular method of birth control. B. The Benefits and Risks of Contraceptives 1. Using birth control is safer and healthier than not using it. 2. If you have any of the following, you should talk with your doctor about which types of contraceptives may increase your health risks that include the following: a. High blood pressure b. Episodes of depression c. Seizure disorder d. Ectopic pregnancy history e. Hepatitis 3. Various methods of birth control have side effects, although pregnancy and childbirth account for much higher rates of medical complications and deaths than any contraceptive. C. Birth Control on Campus 1. 54.4 percent of students–51.1 percent of men and 56.3 percent of women– reported using contraception the last time they had vaginal intercourse. 2. Even students who know and understand the risks associated with unprotected sex often do not take steps to prevent pregnancy or sexually transmitted disease. V.

Contraception Choices A. Introduction 1. In recent years, birth control methods made with synthetic hormones have become available in a variety of forms.

B. Oral Contraceptives 1. The pill—the popular term for oral contraceptives—is the method of birth control preferred by unmarried women and by those under age 30. a. Monophasic pills release a constant dose of estrogen and progestin throughout a woman’s menstrual cycle. b. Multiphasic pills mimic normal hormonal fluctuations of the natural menstrual cycle by providing different levels of estrogen and progesterone at different times of the month. c. The doses in today’s oral contraceptives are much lower—less than one-fourth the amount of estrogen and 1/20th the progestin—than in the original pill. i. However, they may still increase the risk of cardiovascular problems in some women, and the likelihood of recurrence or death remains elevated among pill users who suffer a heart attack or stroke. d. Combination Oral Contraceptives i. These pills consist of two hormones, synthetic estrogen and progestin, which play important roles in controlling ovulation and the menstrual cycle. e. Progestin-Only Pills i. Progestin-only “mini pills” contain only a small amount of progestin and no estrogen. ii. The pills prevent pregnancy by thickening cervical mucus, making it hard for sperm to penetrate, and by interfering with implantation of a fertilized egg. iii. The risk of heart disease and stroke is lower with progestin-only pills than with any combination pill. iv. Users of progestin-only pills have to be conscientious about taking these pills—not just every day, but at the same time every day. f. Before Using Oral Contraceptives i. Before starting the pill, a woman should undergo a physical examination that includes a blood pressure test, a breast exam, blood tests, and a urine sample. g. How they Work i. Oral contraceptives usually come in 28-day packets: 21 of the pills contain hormones, and 7 are “blanks,” included so the woman can take a pill every day, even during her menstrual period.

h. A Special Caution i. Common antibiotics, including many of the ones prescribed for dental procedures or skin conditions, may lower the effectiveness of oral contraceptives, particularly low-dose birth control pills. i. Advantages of oral contraceptives i. Extremely effective when taken consistently ii. Convenient iii. Moderately priced iv. Does not interrupt sexual activity v. Reversible within 3 months of stopping the pill vi. Reduces the risk of benign breast lumps, ovarian cysts, irondeficiency anemia, pelvic inflammatory disease, endometrial cancer, and ovarian cancer vii. May relieve painful menstruation j. Disadvantages of oral contraceptives i. In real life, rates of unintended pregnancies among pill users are as high as 2.8 percent in the first year of use and 5.7 percent after 3 years. ii. It requires a prescription. iii. It increases the risk of cardiovascular problems, primarily for women over age 35 who smoke and those with high blood pressure or other health problems. iv. Side effects vary with different brands but include spotting between periods, weight gain or loss, nausea and vomiting, breast tenderness, and decreased sex drive. v. It must be taken at the same time every day (especially critical with low-dose estrogen and progestin-only pills). vi. It provides no protection against STIs. vii. Women must use a secondary form of birth control for the initial 7 days of use k. Seasonale and Seasonique i. Seasonale and Seasonique are prescription forms of oral contraception that prevent pregnancy as effectively as other birth control pills but produce only four menstrual periods a year. ii. How They Work (a) Women take “active” pills continuously for 3 months. During this time, Seasonale prevents the uterine lining from thickening enough to produce a full menstrual period.

(b) Every 3 months, a woman takes 1 week of inactive pills to produce a “pill period,” which may be lighter than a regular period. iii. Advantages (a) Fewer periods (b) Tri-monthly periods are usually lighter, with less blood flow iv. Disadvantages (a) Similar to those of other oral contraceptives in terms of health risk, costs, and side effects (b) No protection from STIs (c) More spotting and breakthrough bleeding than with a 28-day pill (d) Determining pregnancy is difficult without a monthly period l. Lybrel, the “No-Period” Pill i. Lybrel works the same way as other combination hormonal birth control pills, but it is taken 365 days without interruption. ii. How It Works (a) Lybrel stops the body’s monthly preparation for pregnancy by lowering the production of hormones that make pregnancy possible. iii. Advantages (a) No menstrual periods, cramps, or other symptoms (b) No need to stop taking pills or switch to dummy pills for a week (c) Relief from menstruation-linked conditions, such as endometriosis and menstrual migraines iv. Disadvantages (a) Spotting (b) Health risks similar to those of other combination pills (c) Determining pregnancy is difficult without a monthly period (d) Some women feel that eliminating periods is unnatural C. Other Contraceptive Choices 1. The Ortho Evra birth control patch, the first transdermal (through the skin) contraceptive, works like a combination pill but looks like a BandAid. a. How it Works i. A woman applies the patch to her back, upper arm, lower abdomen, or buttocks and changes it every 7 days for 3 weeks. b. Advantages of the patch © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Good alternative for women who cannot remember, do not like, or have problems swallowing daily pills ii. Highly effective when used correctly iii. Does not interrupt sexual activity iv. Fewer side effects—such as nausea, breakthrough bleeding, and mood swings—than pills v. Fertility returns quickly after you stop using it c. Disadvantages of the patch i. Must apply a new patch every week ii. Requires a prescription iii. No protection against STIs iv. Increases risk of blood clots, heart attack, and stroke particularly for women who smoke or have certain health conditions v. Less effective in women who weigh more than 198 pounds vi. Some women report breast tenderness, headaches, upper respiratory infections, or self-consciousness wearing the patch vii. Contact lens wearers may experience vision changes viii. Five percent of women report that at least one patch slipped off; 2 percent report skin irritation ix. Must use another form of birth control for the initial 7 days of use 2. Contraceptive Vaginal Ring (CVR) a. The silver-dollar-sized NuvaRing, a 2-inch ring made of flexible, transparent plastic, slowly emits the same hormones as oral contraceptives through the vaginal tissues. b. How it Works i. The flexible, plastic 2-inch ring compresses so a woman can easily insert it. Each ring stays in place for 3 weeks, and then is removed for the fourth week of the menstrual cycle. c. Advantages of the NuvaRing i. Under medical supervision, may be safer than birth control pills for women with mild hypertension or diabetes ii. Less likelihood of pill-related side effects, such as nausea, mood swings, spotting, and cramping iii. No need to remember a daily pill or weekly patch iv. Fertility returns quickly when ring is removed v. Reduced pain during menstrual periods vi. May improve acne and reduce excess body hair vii. Can help prevent menstrual migraines d. Disadvantages of the NuvaRing © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Slight increased risk of blood clots, heart attack, and stroke in women older than 35 who smoke 15 or more cigarettes a day or who have other cardiovascular risk factors ii. Some women do not feel comfortable placing and removing something inside their vagina iii. Possible side effects include vaginal discharge, irritation, and infection iv. Cannot use oil-based vaginal medications for yeast infections while ring is in place v. No protection against STIs 3. Long-Acting Reversible Contraceptives a. Long-acting reversible contraceptives (LARCs), which provide protection from pregnancy for an extended period without any action by users, include intrauterine devices (IUDs), injections, and implants. b. The primary disadvantage of LARCS is that they do not protect against STIs. c. Their advantages include the following: i. No need to remember to take a pill every day or insert a cap or diaphragm prior to sex. ii. Long-lasting, quickly reversible, and 20 times more effective than oral contraceptive pills, patches, and rings. iii. Cost-effective; can save thousands of dollars for users over a 5year period compared to the cost of oral contraceptives and other birth control methods. iv. Better control of menstrual bleeding and spotting. v. Can be inserted immediately after delivery or abortion. vi. Rapid restoration of fertility following removal. 4. An IUD is a small piece of molded plastic, with a nylon string attached, which is inserted into the uterus through the cervix. a. The ParaGard IUD, which contains copper, protects against pregnancy for 12 years. b. The Mirena intrauterine system consists of a T-shaped device inserted in the uterus by a physician that releases a continuous low dose of progestin and provides 5 years of protection from pregnancy. c. How It Works i. A physician must insert the IUD into a woman’s uterus. d. Advantages of IUD i. Highly effective at preventing pregnancy ii. No need to think about contraception for 5 years © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. Allows sexual spontaneity; neither partner can feel it iv. Starts working immediately v. New mothers can breast-feed while using it vi. Periods become shorter and lighter or stop altogether vii. Low incidence of side effects viii. Can be removed at any time e. Disadvantages of IUD i. Spotting or breakthrough bleeding in first 3–6 months ii. No protection against STIs iii. Potential side effects include acne, headaches, nausea, breast tenderness, and mood changes iv. Increased risk of benign ovarian cysts v. May take up to a year for fertility to return after discontinuation 5. Contraception Injection a. A progestin-only contraceptive is available in the form of a birth control “shot” or injection. b. Depo-Provera or its newer form, Depo-subQ Provera, must be given every 12 weeks. c. Because of the risk of significant bone mineral loss, the FDA has recommended that women should not use Depo-Provera for longer than 2 years. d. How It Works i. The long-acting hormonal contraceptive raises levels of progesterone, thereby simulating pregnancy. The pituitary gland does not produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which normally cause egg ripening and release. The endometrial lining of the uterus thins, thus preventing the implantation of a fertilized egg. e. Advantages of contraceptive injections i. Because it contains only progestin, it is safe for women who cannot take combination birth control pills ii. No risk of user error iii. No worry about buying, storing, or using contraceptives iv. No need to think about contraception for 3 months at a time v. Possible protection against endometrial and ovarian cancer vi. Can be used by women who are breast-feeding vii. May decrease menstrual migraines f. Disadvantages of contraceptive injections i. Must visit a doctor or clinic every 3 months for injection © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

ii. Menstrual cycles become irregular or cease iii. Potential side effects include decreased sex drive, depression, headaches, dizziness, frequent urination, allergic reactions, and hair loss or increase in hair growth iv. Increased weight gain v. No protection against STIs vi. May increase the risk of acquiring chlamydia and gonorrhea as compared to women not using a hormonal contraceptive and scientists do not know the reason for this increased risk vii. Delayed return of fertility viii. Long-term use may significantly reduce bone density 6. Contraceptive Implants a. Thin, flexible, and plastic implant—about the size of a matchstick—is inserted under the skin of the upper arm to provide birth control that is 99 percent effective for up to 3 years. b. Implanon is now available throughout the United States. Nexplanon is a newer version designed for easier insertion and removal. c. How They Work i. Contraceptive implants work primarily by releasing progestin and suppressing ovulation. d. Advantages i. Can be used while breast-feeding ii. Can be used by women who cannot take estrogen iii. Provides continuous long-lasting birth control without sterilization iv. No medicine to take every day v. Does not interfere with sexual foreplay vi. Ability to become pregnant returns quickly once it is removed e. Disadvantages i. Irregular bleeding ii. Side effects such as dizziness, acne, hair loss, headache, nausea, nervousness, and pain at insertion site iii. No protection against STIs iv. Change in appetite v. Change in sex drive vi. Cysts on the ovaries vii. Depression, mood changes viii. Discoloring or scarring of the skin over the implant D. Barrier Contraceptives © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

1. As their name implies, barrier contraceptives block the meeting of egg and sperm by means of a physical barrier (condom, sponge, diaphragm, cervical cap, or FemCap) or a chemical one (vaginal spermicide in jellies, foams, creams, suppositories, or film). 2. Condoms a. Advantages of condoms i. Effective when used correctly ii. Lowers a woman’s risk of pelvic inflammatory disease (PID) and may protect against some urinary tract and genital infections iii. No side effects iv. No prescription required v. Can be carried in a pocket or purse vi. Inexpensive vii. The female condom gives women more control in reducing their risk of pregnancy and STIs and does not require a prescription or medical appointment viii. No effect on a woman’s natural hormones or fertility ix. Female condom can be inserted up to eight hours before sex b. Disadvantages of condoms i. Requires consistent and diligent use ii. Not 100 percent effective in preventing pregnancy or STIs iii. Risk of manufacturing defects, such as pin-size holes, and breaking or slipping off during intercourse iv. May inhibit sexual spontaneity v. Users or partners may complain about odor, lubrication (too much or too little), feel, taste, difficulty opening the packages, and disposal vi. Some men complain of reduced penile sensitivity or cannot sustain an erection while putting on a condom vii. Some women complain that the female condom is difficult to use, squeaks, and looks odd c. Male Condom i. Covers the erect penis and catches the ejaculate, thus preventing sperm from entering the woman’s reproductive tract ii. How It Works (a) The polyurethane condom has proven to be not as effective as the latex condom for pregnancy prevention. iii. Effectiveness

(a) The theoretical effectiveness rate for condoms is 97 percent; the actual rate is only 80–85 percent. The major reason that condoms have such a low actual effectiveness is that the couples do not use them each and every time they have sex. d. Female Condom i. The second-generation female condom, known as FC2, is a strong thin, flexible nitrite sheath or pouch about 6.5 inches long. It consists of flexible polyurethane ring at the closed ends of the pouch. ii. How It Works (a) When properly inserted, the outer ring should rest on the folds of the skin around the vaginal opening, and inner ring (the closed end) should fit against the cervix. iii. Effectiveness (a) Properly used, they are believed to be as good as or better than the male condom for preventing infections. e. Contraceptive Sponge i. How It Works (a) The contraceptive sponge acts as a barrier by blocking the entrance to the uterus and absorbing and deactivating sperm. ii. Advantages of the contraceptive sponge (a) Does not require a prescription (b) Easy to carry and use (c) Can be inserted up to 24 hours before intercourse (d) Effective immediately if used correctly (e) No effect on fertility (f) Generally cannot be felt by a woman or her partner (g) Can be used by women who are breast-feeding iii. Disadvantages of the contraceptive sponge (a) May be difficult to remove (b) May be less effective in women who have had children (c) No reliable protection against STIs (d) Requires advance planning to place the sponge (e) Side effects include vaginal irritation and allergic reactions (f) Should not be used during menstruation (g) Slightly increased risk of toxic shock syndrome f. Vaginal Spermicides and Film i. Include chemical foams, creams, jellies, vaginal suppositories, gels, and film. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

ii. Failure rates for vaginal suppositories are as high as 10–25 percent. iii. Vaginal contraceptive film, a thin two-inch-square film laced with spermicide, is folded and inserted into the vagina, where it dissolves into a stay-in-place gel. iv. How They Work (a) Spermicides consist of a chemical that kills sperm and potential pathogens and an inert base, such as jelly, cream, foam, or film that holds the spermicide close to the cervix. v. Advantages of Vaginal Spermicides (a) Easy to use (b) Effective if used with another form of contraception, such as condoms (c) Reduces the risk of some vaginal infections, PID, and STIs (d) No effect on fertility vi. Disadvantages of vaginal spermicides (a) When used alone, does not protect against STIs (b) Frequent use can increase risk of HIV from an infected partner (c) Insertion interrupts sexual spontaneity (d) May cause irritation (e) Some people cannot use them because of an allergic reaction (f) Some users complain that spermicides are messy or interfere with oral–genital contact (g) Spermicidal suppositories that do not dissolve completely can feel gritty g. Diaphragm i. The diaphragm is a bowl-like rubber cup with a flexible rim that is inserted into the vagina to cover the cervix and prevent the passage of sperm into the uterus during sexual intercourse. ii. How It Works (a) Diaphragms are fitted and prescribed by a qualified healthcare professional in a range of diameter sizes. (b) A diaphragm should remain in the vagina for at least six hours after intercourse to ensure that all sperm are killed. h. Cervical Cap i. Like the diaphragm, the cervical cap combined with spermicide serves as both a chemical and physical barrier to block the path of the sperm to the uterus. ii. How It Works

(a) The cervical cap is fitted by a qualified health-care professional. (b) The woman fills it one-third to two-thirds full with spermicide and inserts it by holding its edges together and sliding it into the vagina. The cup is then pressed into the cervix. i. FemCap i. The FemCap is a non-hormonal, latex-free barrier contraceptive that works with a spermicide. ii. How It Works (a) A prescription is required to purchase the FemCap. To use the FemCap, apply spermicide to the bowl of the FemCap (which goes over the cervix) to the outer brim, to the groove that will face into the vagina. Insert the squeezed, flattened cap into the vagina with the bowl facing upward. iii. Advantages of prescription barriers (a) Can be inserted up to six hours before sex (b) Doesn’t interrupt sexual activity; can be inserted hours ahead of time (c) Usually not felt by either partner (d) Can easily be carried in pocket or purse (e) No effect on a woman’s natural hormones or fertility (f) Cervical caps are an alternative for women who cannot use diaphragms or find them too messy iv. Disadvantages of prescription barriers (a) Less effective than hormonal contraceptives (b) Available by prescription only (c) Require advance planning or interruption of sexual activity to position the device before intercourse (d) May slip out of place during intercourse (e) May be uncomfortable for some women and their partners (f) Spermicidal foams, creams, and jellies may be messy, cause irritation, and detract from oral–genital sex (g) Some diaphragm users report bladder discomfort, urethral irritation, or recurrent cystitis (h) Some cap users find it more difficult to insert and remove, and uncomfortable to wear (i) Slightly increased risk of toxic shock syndrome

E. Fertility Awareness Methods (FAMs) 1. Overview a. The different methods of birth control based on a woman’s menstrual cycle are sometimes referred to as natural family planning or fertility awareness methods. b. How It Works i. The Calendar Method (a) Often called the rhythm method; based on counting the woman’s safe days based on her individual menstrual cycle ii. Basal-Body-Temperature Method (a) Determines the safe days based on the woman’s basal body temperature, which rises after ovulation iii. The Cervical Mucus Method (a) Also called the ovulation method; based on observation of changes in the consistency of the woman’s vaginal mucus throughout her menstrual cycle. The period of maximum fertility occurs when the mucus is smooth and slippery. c. Advantages i. No expense ii. No side effects iii. No need for a prescription, medical visit, or fittings iv. Nothing to insert, swallow, or check v. No effect on fertility vi. Complies with the teachings of the Roman Catholic Church d. Disadvantages i. Less reliable than other forms of birth control ii. Couples must abstain from vaginal intercourse 8–11 days a month or use some form of contraception iii. Conscientious planning and scheduling are essential iv. May not work for women with irregular menstrual cycles v. Some women find the mucus or temperature methods difficult to use F. Emergency Contraception 1. Introduction a. Emergency contraception (EC) is the use of a method of contraception to prevent unintended pregnancy after unprotected intercourse or the failure of another form of contraception, such as a condom breaking or slipping off.

b. The use of EC has more than doubled in recent years, particularly among women in their early 20s. c. EC provides a second chance to prevent pregnancy following unprotected sexual intercourse or contraceptive failure. d. How It Works i. EC methods stop pregnancy in the same way as other hormonal contraceptives. They delay or inhibit ovulation, inhibit fertilization, or block implantation of a fertilized egg, depending on a woman’s phase of the menstrual cycle. ii. They have no effect once a pregnancy has been established. iii. The morning-after pill also may be safe for use as a regular birth control method and may appeal to women who do not have sex regularly and who could use it before or after sex. However, it is not as effective as regular birth control pills, patches, or rings. G. Sterilization 1. Introduction a. This is the most popular method of birth control among married couples in the United States. b. Sterilization is surgery to end a person’s reproductive capability. 2. Male Sterilization a. The cutting of the vas deferens, the tube that carries sperm from one of the testes into the urethra for ejaculation, is called a vasectomy. b. During the 15- or 20-minute office procedure, done under a local anesthetic, the doctor makes small incisions in the scrotum, lifts up each vas deferens, cuts it, and ties off the ends to block the flow of sperm. 3. Female Sterilization a. The two terms used to describe female sterilization are tubal ligation (the cutting or tying of the fallopian tubes) and tubal occlusion (the blocking of the tubes). b. One of the common methods of tubal ligation or occlusion uses laparoscopy, commonly called belly-button or band-aid surgery. c. Essure i. This involves the placement of small, flexible microcoils into the fallopian tubes via the vagina by a physician. 4. Advantages of sterilization a. It offers permanent protection against unwanted pregnancy.

b. No effect on sex drive in men or women. Many couples report greater sexual activity and pleasure because they no longer have to worry about pregnancy or deal with contraceptives. c. Vasectomy and tubal ligation are performed as outpatient procedures, with a quick recovery time. d. Use of Essure requires no incision, so there is less discomfort and very rapid recovery. Essure may be an option for women with chronic health conditions, such as obesity, diabetes, or heart disease. 5. Disadvantages of sterilization a. All procedures should be considered permanent and used only if both partners are certain they want no more children b. No protection against STIs c. Must use another form of birth control for first 3 months 6. Many long-term risks remain unknown, but there is no evidence of any link between vasectomy and prostate cancer. H. Unwanted Pregnancy 1. A woman can find it extremely difficult to decide what to do. 2. Practical and emotional factors are involved. 3. Giving up a child for adoption is an option for women who do not feel abortion is right for them. I. Abortion 1. Overview a. An abortion is a procedure that uses medicine or surgery to end a pregnancy. b. Women in their 20s account for the majority of abortions. c. Research has found no correlation between the termination of a pregnancy, whether induced or spontaneous, and increased risk of breast cancer. d. The term medical abortion describes the use of drugs, also called abortifacients, to terminate a pregnancy. i. The abortion pill mifepristone (Mifeprex), formerly known as RU486, is 97 percent effective in inducing abortion. ii. Medical abortion does not require anesthesia and can be performed very early in pregnancy. e. About three-fourths of abortions performed in the United States today are surgical. i. Suction curettage, usually done from 7 to 13 weeks after the last menstrual period, involves the gradual dilation (opening) of the cervix. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. The Psychological Impact of Abortion 3. As decades of research have shown, the primary emotion of women who have just had an abortion is relief. a. Although many women also express feelings of guilt or sadness, usually their anxiety levels drop to lower levels than immediately before the abortion. 4. The Politics of Abortion a. Abortion is one of the most controversial political, religious, and ethical issues of our time. i. The issues of when life begins, a woman’s right to choose, and an unborn child’s right to survival are among the most divisive Americans face. b. Although the majority of Americans continue to support abortion, many feel that it should be more restricted and difficult to obtain. VI. Pregnancy A. Overview 1. Pregnancy and birthrates in the United States have declined to the lowest rate ever recorded. 2. Pregnancy rates have fallen for women in their teens and 20s, while they have increased for women in their late 30s and early 40s. B. Preconception Care 1. Preconception care—the enhancement of a woman’s health and wellbeing prior to conception in order to ensure a healthy pregnancy and baby—includes risk assessment, health promotion, and interventions to reduce risk. C. Home Pregnancy Tests 1. Home pregnancy tests detect the presence of human chorionic gonadotropin (hCG), which is secreted as the fertilized egg implants in the uterus. D. Prenatal Care 1. A Healthy Diet a. Doctors have long recommended a well-balanced diet that provides a complete variety of key nutrients. b. In addition, pregnant women should: i. Make sure they are getting an adequate level of folic acid in order to prevent neural tube defects. ii. Avoid soft unpasteurized cheeses to prevent Listeria infections, which can be harmful to a fetus. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. Eat a diet rich in fruit and vegetables, which provides an additional benefit: a lower risk of premature birth. iv. Increase their caloric intake to ensure adequate nutrition for the fetus but not put on so much weight that it increases the risks to their own health and their baby’s. v. Not avoid any specific foods unless they are allergic to them. Recent research suggests that eating nuts during pregnancy lowers a child’s risk of having a nut allergy—as long as the mother is not allergic herself. 2. Exercise a. The proven benefits of light to moderate exercise during pregnancy include a greater sense of well-being, enhanced mood, shorter labor, and fewer obstetric complications. 3. Avoid Smoking and Smoke a. Smoking and exposure to secondhand smoke during pregnancy puts a woman and her unborn child in jeopardy. 4. Don’t Use Alcohol or Drugs a. Alcohol and illegal drugs are clear threats to an unborn child. However, even some common prescription drugs, such as acetaminophen and antidepressants, can pose short- and long-term risks. E. How a Woman’s Body Changes During Pregnancy 1. The woman’s uterus becomes slightly larger, and the cervix becomes softer and bluish due to increased blood flow. 2. Progesterone and estrogen trigger changes in the milk glands and ducts in the breasts, increasing size and tenderness. 3. More frequent need to urinate. 4. As the pregnancy progresses, the woman’s skin stretches as her body shape changes, her center of gravity changes as her abdomen protrudes, and her internal organs shift as the baby grows. F. How a Baby Grows 1. When a zygote reaches the uterus, it is still smaller than the head of a pin. 2. Once nestled into the spongy uterine lining, it becomes an embryo. 3. The embryo takes on an elongated shape, rounded at one end. A sac called the amnion envelops it. 4. As water and other small molecules cross the amniotic membrane, the embryo floats freely in the absorbed fluid, cushioned from shocks and bumps. 5. At 9 weeks, the embryo is called a fetus. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

6. A special organ, the placenta, forms. Attached to the embryo by the umbilical cord, the placenta supplies the growing baby with fluid and nutrients from the maternal bloodstream and carries waste back to the mother’s body for disposal. G. Complications of Pregnancy 1. Perinatology, or maternal-fetal medicine, focuses on the special needs of high-risk mothers and their unborn babies. 2. Ectopic Pregnancy a. In this type of pregnancy, the fertilized egg remains in the fallopian tube instead of traveling to the uterus. 3. Miscarriage a. It is also called spontaneous abortion. b. About 10–20 percent of pregnancies end in miscarriage, or spontaneous abortion, before the 20th week of gestation. 4. Infections a. Rubella is the infectious disease most clearly linked to birth defects. b. Cytomegalovirus is the most common prenatal infection today. i. This infection produces mild flu-like symptoms in adults but can cause brain damage, retardation, liver disease, cerebral palsy, hearing problems, and other malformations in unborn babies. 5. Zika Virus a. Health officials are recommending at least 8 weeks of abstinence or contraception for women who or whose partners may have been exposed to the Zika virus due to the risk of serious birth defects, including microencephaly, a condition characterized by abnormally small head size caused by impaired brain development, prematurity, stillbirths, and blindness. 6. Genetic Disorders a. Every individual has an estimated four to six defective genes, but the chances of passing them on to a child are slim. b. The child of a parent with an abnormal dominant gene has a 50 percent likelihood of inheriting it. c. A mother’s age has long been associated with increased risk of chromosomal disorders such as Down syndrome. More recently, research has linked a father’s age of 45 or older to several neuropsychiatric disorders. 7. Premature Labor a. Approximately 8 percent of all babies are born too soon (before the 37th week of pregnancy). © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. The warning signs of premature labor include a dull, low backache; a feeling of tightness or pressure on the lower abdomen; and intestinal cramps, sometimes with diarrhea. H. Childbirth 1. Preparing for Childbirth a. Women who attend prenatal classes are less likely to undergo caesarean deliveries and more likely to breast-feed. b. An epidural block involves injecting an anesthetic into the membrane around the spinal cord, numbing the lower body. c. A spinal block involves the injection going directly into the spinal canal and numbs the lower body. 2. Labor and Delivery a. There are three stages of labor. i. The first stage (a) This stage (early or latent phase) starts with effacement (thinning) and dilation (opening up) of the cervix. (b) During this time the amniotic sac of fluids usually breaks a sign that the woman should call her doctor. (c) Contractions go from being not uncomfortable to the most difficult during this stage. (d) This stage ends when the cervix is dilated to about 8 centimeters. ii. The second stage (a) During this stage of labor, the cervix is completely dilated, during which the baby moves into the vagina, or birth canal, and out of the mother’s body. (b) This stage can take up to an hour or more. (c) Strong contractions may last 60–90 seconds and occur every 2– 3minutes. (d) An episiotomy—an incision from the lower end of the vagina toward the anus to enlarge the vaginal opening as the baby’s head appears, or crowns—may be performed by a doctor. (e) The baby can be in a more difficult position, facing up rather than down, or with the feet or buttocks first (a breech birth), and a cesarean birth may then be necessary. iii. The third stage (a) During this stage of labor, the uterus contracts firmly after the birth of the baby and, usually within five minutes, the placenta separates from the uterine wall. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. Caesarean Birth i. In a caesarean delivery (also referred to as a caesarean section, or C-section), the doctor lifts the baby out of the woman’s body through an incision made in the lower abdomen and uterus. ii. The most common reason for caesarean birth is failure to progress, a vague term indicating that labor has gone on too long and may put the baby or mother at risk. I. Infertility 1. Introduction a. The World Health Organization defines infertility as the failure to conceive after 1 year of unprotected intercourse. b. Affects one in six couples in the United States. c. In women, the most common causes of sub-fertility or infertility are age, abnormal menstrual patterns, suppression of ovulation, and blocked fallopian tubes. d. Male sub-fertility or infertility is usually linked to either the quantity or the quality of sperm, which may be inactive, misshapen, or insufficient. e. Infertility can have an enormous emotional impact. 2. Options for Infertile Couples a. The odds of successful pregnancy range from 30–70 percent, depending on the specific cause of infertility. b. One result of successful infertility treatments has been a boom in multiple births. c. Artificial Insemination i. The introduction of viable sperm into the vagina by artificial means d. Assisted Reproductive Technology (ART) i. The most common ART procedure is in vitro fertilization (IVF), which involves removing the ova from a woman’s ovary and placing the woman’s egg and her mate’s sperm in a laboratory dish for fertilization. After several days, if the egg shows signs of development, it is returned to the woman’s uterus. J. Adoption 1. Adoption matches would-be parents yearning for youngsters to love with infants or children who need loving. 2. Census records indicate that there are currently 1.6 million adopted children in the United States.

Discussion Questions •

What factors go into the decision to have a baby? What role does economics, family, society, education, status of relationship, and differences in ethnicity or religion play into this decision? How does one know when they are ready to have a child?

•

Should prenatal tests and counseling be mandatory? Why or why not?

•

Ask the class to develop a birth plan. Consider such issues as the presence of a coach, use of a birthing room, cameras, episiotomy, medication, etc. Are there any issues that are especially important?

•

Discuss the high rate of C-sections and ask students what questions they might ask to assess whether the procedure is medically necessary. Do students believe doctors order C-sections in order to better meet their own schedules?

•

Ask the students whose responsibility between partners it is to initiate a discussion about birth control. Who should pay for the device and medical care? What are some of the barriers to purchasing birth control?

•

Ask the students to list factors they would or have considered before choosing a method of birth control. Are the students willing to try new methods (e.g., the ring and the patch)? What precautions might they take first?

•

Ask the students at what point, if ever, they might consider becoming sterilized. Should there be laws about age, consent, number of children already in the family, and so on that dictate or prohibit sterilization?

•

Ask the students whether they believe additional money should be directed toward research in developing new methods of contraception. What would they be willing to pay in order to assure this would happen (e.g., pay additional taxes, increase cost of device, etc.)?

•

Ask the students why they think women might elect to have an abortion. What are the psychological and physical consequences of this decision? Should laws regulate this procedure?

Classroom Activities Activity #1: Exploring Reproductive Choices (Guest Speaker) Purpose: 1.

To explore current reproductive issues, choices, and technologies.

To provide an opportunity for students to address personal and community issues in human reproduction.

Time: One class period.

Introduction: Discuss the various reproductive choices a couple may want to consider when having a baby.

Method: 1.

Invite a guest speaker to address the topic of reproductive health. This may be a public health nurse who counsels community residents on reproductive choices, an obstetrician, or a child birth educator who discusses the process of childbirth.

Prior to the guest speaker’s appearance, ask the students to write one or two anonymous questions on reproductive technology, reproductive decision-making, or any other related issue.

Mention that the guest speaker will be given these questions to answer prior to his or her appearance in class and will subsequently provide answers to the questions.

Discussion: 1.

What factors will the students consider when the time comes for them to have a child?

How do students feel about using pain relief to ease the delivery process? What are their concerns of using such drugs?

Activity #2: Timing Pregnancy Purpose: 1. The intention of this activity is to assist students with identifying the appropriate time for them to plan for pregnancy and to clarify their priorities before they become pregnant.

Time: One class period.

Introduction: Introduce the benefits of planning for a pregnancy for the child and for the parents.

Method: 1.

Ask the students to consider the top five life conditions that they would want in order to become pregnant in an ideal fashion. They should be as specific as possible (e.g., exactly how much sacrifice, love, time, family support, and money would they need.)

Have students list these conditions on a piece of paper and have each student identify their gender on the back of each paper.

List all of the conditions that students identified and separate by gender.

Discussion: 1.

How might this list help the students to make informed reproductive choices? What are the benefits of planning pregnancy? The disadvantages?

Were their common conditions that came up often? Why are these conditions so important to so many? How would students feel if they did not meet one of these conditions prior to becoming pregnant? Why?

How important are these conditions to students?

Is it important to students that their partners have the same list or a similar list?

How might the genders differ?

Activity #3: Budgeting Time for a Child? Purpose: This activity is meant to demonstrate the responsibilities of being a parent and the time commitments of having a child.

Time: One class period or less depending on the amount of discussion.

Introduction: Introduce the responsibilities of being a parent and identify the necessary resources should an individual have a child.

Method: 1.

Have students list the responsibilities involved in having a dog or another pet. a.

Include everyday responsibilities: walking the dog, feeding the dog, etc. and the long-term responsibilities: vet care, dog sitters when on vacation, possible pregnancies, obedience school, etc.

Next, list the material goods necessary to be a proper dog owner.

List these items on the board.

Next, list the same categories for raising a child: responsibilities for every day, long term, material goods, financial costs, etc.

Discussion: 1.

Ask the students how many of them believe they could be a good dog owner. What would happen if students do not meet all of the responsibilities or have all of the resources? Would they still feel like they could or should be able to have a pet? Why or why not?

Next, ask them how many could be a good parent. What would happen if students do not meet all of the responsibilities or have all of the resources to raise a child? Would they still feel like they could or should be able to have a child? Why or why not?

Ask the students what they believe makes a good parent.

Ask the students to identify various parenting skills that they would like to have that they believe their parents did not have. Are there things that they would do differently than their parents? Why or why not?

Activity #4: Reproductive Choices Purpose: To explore personal reproductive choices.

Time: One class period.

Introduction: Discuss the various birth control options available.

Method: 1. Students should conduct a personal inventory, and research the different birth control options available to them. 2. Have students visit the campus health center to speak to a nurse or health educator to determine what birth control options are available to students. 3. Students should choose the most appropriate method of birth control for them. 4. If they are not sexually active, they can still complete the exercise by choosing which method they feel would be most appropriate for them.

Discussion: 1. What factors will students consider when choosing a method of birth control? 2. Would anyone consider using more than one method?

Activity #5: Adoption Purpose: 1.

The purpose of this activity is to have students research the adoption process.

Time: One class period.

Introduction: Adoption has become increasingly popular among celebrities and single men and women who want to have a child on their own.

Method: 1.

Students should research the adoption process and list the steps necessary for adopting a child in the United States versus a child from a foreign country.

Which of the following demographic groups has the highest rate of adoption: single men and women, celebrities, married couples, homosexual couples? Which group has the most difficulties in the adoption process? Are celebrities given special treatment?

Discussion: 1.

Discuss the process of adoption in the United States. Do students feel that the process is too difficult or too easy? Are certain groups treated differently throughout the adoption process because of their marital status, sexual orientation, or net worth?

References, Readings, and Resources American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Boston Women’s Health Book Collective. (2005) Our Bodies, Ourselves: A New Edition for a New Era. New York: Simon and Schuster. Eisenberg, A. et al. (2008) What to Expect While You’re Expecting, Fourth Edition. New York: Workman. Farrington, E. M. et al. “Reasons People Give for Using (or Not Using) Condoms.” AIDS Behavior (2016). doi: 10.1007/s10461-016-1352-7. Food and Drug Administration. Mifeprex (mifepristone) Information. Mifeprex (mifepristone) Information Guttmacher Institute. Unintended Pregnancy in the United States. March 2016 https://www.guttmacher. org/pubs/FB-Unintended-Pregnancy-US.html. National Abortion and Reproductive Rights Action League Foundation (20166) Who Decides? The Status of Women’s Reproductive Rights in the United States, Twenty-fifth Edition. Washington, DC: NARAL Foundation. Nykjaer, C., et al. “Maternal Alcohol Intake prior to and during Pregnancy and Risk of Adverse Birth Outcomes: Evidence from a British Cohort.” Journal of Epidemiology and Community Health 68, no. 6 (2014): 543–99. doi: 10.1136/jech-2013-202934. Oster, A. M., et al. Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016. Morbidity and Mortality Weekly Report 65, no. 5 (2016):120–1. doi: 10.15585/mmwr.mm6505e1. Sedgh, Gilda, et al. “Adolescent Pregnancy, Birth, and Abortion Rates Across Countries: Levels and Recent Trends.” Journal of Adolescent Health 56, no. 2 (2015): 223–33. doi: 10.1016/j.jadohealth.2014.09.007.

Films and Videos Abortion: Ancient and Modern (The video discusses the legal and ethical attitudes to abortion through the ages, highlighting key ideas, such as Animation, Ensoulment, Quickening, and The Born Alive rule. It explains that in ancient times, the dangers of abortion for women were compared with the dangers of war for men and little changed for thousands of years.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Abortion: The Choice (While abortion will no doubt polarize our society for the foreseeable future, students can learn a great deal from the circumstances, anxieties, and life goals that surround the decision to end a pregnancy. This program presents a poignant and profoundly honest look at that decision through intimate discussions with young British women.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Adopted (This two-part series includes the documentary Adopted and a companion film Adopted—We Can Do Better.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

The Last Abortion Clinic (From the PBS “Frontline” series, this video takes an in-depth view of abortion clinics and the battles that continue to be waged over laws.) http://www.pbs.org/wgbh/pages/frontline/clinic/ Goodbye Baby (Are rich foreigners buying babies or are poor children being offered the chance for a better life? As the number of adoptions from Guatemala to the United States continues to rise dramatically, so does the controversy.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Moyers & Company: The Crusade Against Reproductive Rights (Bill Moyers speaks with Planned Parenthood President Cecile Richards about new state abortion regulations, Supreme Court rulings in the Hobby Lobby case, and on abortion buffer zones.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Pregnancy, Labor, and Delivery (This nine-part series provides an excellent overview of pregnancy, labor, and both vaginal and caesarean delivery, and also includes information about pain management, pregnancy complications, and postpartum and neonatal assessments.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Real Life Teens: Teen Pregnancy (Pregnancy amongst teenagers is becoming a growing problem in today’s society. About 1 million teenagers become pregnant each year and more than 530,000 give birth.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Silent Choices (Silent Choices is about abortion and its impact on the lives of African American women. The film is a "hybrid" documentary: part historical piece, part social and religious analysis, and part first-person narrative.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 F: 845.774.2945 E: New Day Films Spinning a Pill (A provocative health documentary, this program investigation takes a closer look at Yasmin, a controversial oral contraceptive that has become a top-selling birth control pill. In the United States, more than 4,000 women have taken legal action against the manufacturer, Bayer, and more than 800 in Canada have joined a class-action lawsuit.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group They Think I’m Chinese (Thousands of girls who were in the first wave of Chinese children to be adopted in Québec in the 1990s have reached adolescence. The filmmaker focused her lens on five of them and accompanied them throughout their emotionally charged transition to adulthood.) © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources American Congress of Obstetricians and Gynecology This professional organization works to improve women’s health care through advocacy, continuing education of clinicians, patient education, and increasing public awareness of women’s health issues. American Congress of Obstetricians and Gynecology American College of Nurse-Midwives Provides information on childbirth and pregnancy. American College of Nurse-Midwives Association of Reproductive Health Professionals Educational materials about contraception, family planning, and an interactive questionnaire are available. Association of Reproductive Health Professionals Guttmacher Institute The Guttmacher Institute’s mission is to protect the reproductive choices of all women and men in the United States and throughout the world. Guttmacher Institute NARAL Pro-Choice America Provides information on the politics of the pro-choice movement. NARAL Pro-Choice America The National Parenting Center Invites parents to expand their parenting skills and strengths by sharing information. The National Parenting Center

National Right to Life Committee Provides information on the politics of the pro-life movement. National Right to Life Committee Planned Parenthood Planned Parenthood believes in the fundamental right of each individual, throughout the world, to manage his or her fertility, regardless of the individual’s income, marital status, race, ethnicity, sexual orientation, age, national origin, or residence. Planned Parenthood The Kinsey Institute for Research in Sex, Gender, and Reproduction The mission of the Kinsey Institute is to promote interdisciplinary research and scholarship in the fields of human sexuality, gender, and reproduction. Kinsey Institute – Indiana University Women’s Sexual Health This is an informational site designed for women and their partners who have questions and concerns about women’s sexual health. Women’s Sexual Health

Key Terms adoption

ectopic pregnancy

amnion

embryo

artificial insemination

emergency contraception (EC)

barrier contraceptives

failure rate

blastocyst

fertilization

caesarean delivery

fetus

cervical cap

implantation

coitus interruptus

infertility

combination oral contraceptives (COCs)

intrauterine device (IUD)

conception

labor

condom

laparoscopy

contraception

long-acting reversible contraceptives (LARCs)

diaphragm

medical abortion

spermatogenesis

progestin-only pills, minipills

sterilization

miscarriage

suction curettage

monophasic pills

tubal ligation

multiphasic pills

tubal occlusion

oral contraceptives

vaginal contraceptive film (VCF)

placenta

vaginal spermicide

preconception care

vasectomy

premature labor

zygote

rhythm method rubella

Answers to Global Health Watch 1. b 2. d 3. abortion

10 Major Diseases Learning Objectives After studying this chapter in the text, the student should be able to: 10.1 List the risk factors for cardiovascular diseases. 10.2 Summarize the risks and signs of metabolic syndrome and diabetes. 10.3 Discuss the risk factors and management of hypertension and high blood cholesterol. 10.4 Explain the patterns and consequences of cardiovascular diseases. 10.5 Identify the risk factors and common causes of strokes. 10.6 Outline the risk factors for cancer. 10.7 Review the signs, causes, and treatments of common types of cancer. 10.8 Describe the agents of infection and their effects on human health.

Chapter Summary Regardless of whether you’re a teen, a 20-something, or 30-plus, the choices you make and the habits you develop now can put you at risk for a major disease that could sabotage your health and even shorten your life. The earlier in life that body fat, blood pressure, blood sugar, and cholesterol rise above optimal levels, the greater the threat to well-being and longevity. This chapter shows you steps you can take to protect your health and prevent disease—and the sooner you start, the better.

Lecture Outline I.

Your Cardiometabolic Health A. Introduction 1. “Cardio” refers to the heart and blood vessels of the cardiovascular system.

2. “Metabolic” refers to the biochemical processes involved in the body’s functioning. 3. Cardiovascular diseases account for one of every three deaths, including an increasing number among younger adults ages 35–54. B. Cardiometabolic Risk Factors 1. Specific risk factors determine your cardiometabolic health. 2. Risk Factors You Can Control a. Overweight/Obesity i. Excess weight, an increasingly common and dangerous cardiometabolic risk factor in both men and women, undermines good health. b. Body Fat i. Apple-shaped people who carry most of their excess weight around their waists are at greater risk of cardiometabolic conditions than are pear-shaped individuals who carry most of their excess weight below their waist. ii. Fat, regardless of where it is stored, boosts the likelihood of heart attack or stroke. c. Waist Circumference i. A waist measurement of more than 40 inches in men and more than 35 inches in women indicates increased health risks. d. Physical Inactivity i. The risk for cardiometabolic conditions is higher for people who are inactive than for those who engage in regular physical activity. e. Prolonged Sitting i. Defined as being seated from 8 to 12 hours a day, prolonged sitting significantly increases the odds of heart disease, diabetes, cancer, and death. f. Healthy Diet i. A recent 10-year study has confirmed that closely following the Mediterranean diet—high in fresh fruits and vegetables, whole grains, beans, nuts, fish, and olive oil—can reduce the risk of heart disease by almost half. g. Tobacco Use i. Smoking may be the single most significant risk factor for cardiometabolic conditions. h. High Blood Glucose i. “Insulin-resistant” cells no longer respond well to insulin, and so glucose, unable to enter the cells, builds up in the bloodstream. (a) Healthy blood glucose—under 100 (b) Prediabetes—100–125 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

(c) Diabetes—more than 125 i. High Blood Pressure (Hypertension) i. Systolic—blood pressure when the heart contracts. ii. Diastolic—blood pressure when the heart is at rest. iii. A blood pressure reading consists of the systolic measurement “over” the diastolic measurement. iv. The higher the blood pressure reading the higher the risk of stroke. j. Lipoprotein Levels i. Cholesterol is a fatty substance found in certain foods and also manufactured by the body. ii. Lipoproteins are compounds in the blood that are made up of proteins and fat. iii. HDL—high-density lipoproteins are the “good guys.” iv. LDL—low-density lipoproteins are the “bad guys.” v. Triglycerides are fats that flow through the blood after meals and have been linked to increased risk of coronary artery disease, especially in women. 3. Risk Factors You Can’t Control a. Family history i. Certain cardiometabolic risk factors can be passed down from generation to generation. b. Race and Ethnicity i. Risk factors are at higher rates among ethnic minority populations. c. Age i. Risk factors increase as people get older, especially past the age of 45. d. Height i. Tall men are less likely to develop heart failure than shorter ones. However, it is not clear whether the extra inches protect the heart or whether shorter men differ in other ways. II.

Metabolic Syndrome A. Overview 1. Once called Syndrome X or insulin-resistant syndrome. 2. It is not a disease but a cluster of disorders of the body’s metabolism— including high blood pressure, high insulin levels, abdominal obesity, and abnormal cholesterol levels—that make a person more likely to develop diabetes, heart disease, or stroke.

B. Who Is at Risk? 1. The national prevalence of metabolic syndrome has fallen, particularly among teenagers who have lower levels of triglycerides and higher levels of “good” HDL cholesterol. C. What Are the Signs? 1. Three or more of the following characteristics indicate metabolic syndrome: a. A larger-than-normal waist measurement b. A higher-than-normal triglyceride level c. A lower-than-normal HDL level d. A higher-than-normal blood pressure e. A higher-than-normal fasting blood sugar 2. People with three factors of metabolic syndrome are nearly twice as likely to have a heart attack or stroke and more than three times more likely to develop heart disease than those with none. 3. College-age men and women who maintain their weight as they get older are much less likely to develop metabolic syndrome. III. Diabetes A. Overview 1. Glucose is the primary form of sugar that body cells use for energy. 2. When a person without diabetes eats a meal, the level of glucose in the blood rises, triggering the production and release of insulin by special cell clusters in the pancreas. 3. In those who have diabetes, however, insulin secretion is either nonexistent or deficient. 4. The levels of glucose in the blood rise higher and unused glucose passes through the kidneys, which are unable to process it. 5. Deprived of the fuel it needs, the body begins to break down stored fat as a source of energy bringing an upheaval in the body’s chemical balance that can cause many problems and even eventual death. 6. An estimated 29 million Americans—almost 1 in 10—have diabetes. B. Insulin Resistance 1. A condition in which the body produces insulin but does not use it properly. 2. Excess weight and lack of physical activity, along with genetic factors, contribute to insulin resistance. C. Prediabetes

1. It is sometimes called impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). 2. A condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. D. Diabetes Mellitus 1. When the pancreas either stops producing insulin or does not produce sufficient insulin to meet the body’s needs, almost every body system can be damaged. 2. Diabetes mellitus, the seventh leading cause of death in the United States, shortens life expectancy by an average of eight years. E. Who Is at Risk? 1. Several factors—some of which you can control—increase your risk for prediabetes and diabetes. a. Overweight or obese b. Age 60 or older c. Physically inactive d. Parent or sibling with diabetes e. Family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander. Asian Americans start developing diabetes at lower weights. f. Sitting—the more time that individuals spend on a chair or sofa, the greater their odds of developing high blood sugar. g. Exercising fewer than three times a week h. Giving birth to a baby weighing more than 9 pounds or being diagnosed with diabetes during pregnancy i. High blood pressure—140/90 mm Hg or above—or being treated for high blood pressure j. HDL, or “good,” cholesterol level below 35 mg/dL or a triglyceride level above 250 mg/dL k. IFG or IGT on previous testing l. Other conditions associated with insulin resistance, such as severe obesity m. History of cardiovascular disease n. Sugary drinks—even a single can of sugary soda a day can increase the risk of prediabetes and diabetes. o. Certain common medications, including antibiotics such as penicillin and cholesterol-lowering statin drugs, may increase the risk of type 2 diabetes.

F. Types of Diabetes 1. Diabetes includes several conditions in which the body has difficulty controlling levels of glucose in the bloodstream. a. Type 1 Diabetes i. In this form of diabetes, the body’s immune system attacks the insulin-producing beta cells in the pancreas and destroys them. b. Type 2 Diabetes i. In type 2, either the pancreas does not make enough insulin (insufficient insulin) or the body is unable to use insulin correctly (insulin resistance). c. Gestational Diabetes i. Women who get diabetes while pregnant are more likely to have a family history of diabetes and to develop diabetes later in life. 2. Although type 1 and type 2 diabetes have different causes, two factors are important in both: an inherited predisposition to the disease and something in the environment that triggers diabetes. a. In most cases of type 1 diabetes, people need to inherit risk factors from both parents and to experience some environmental trigger, which might involve prenatal nutrition, a virus, or an unknown agent. b. In type 2 diabetes, family history is one of the strongest risk factors for getting the disease, but only in Westernized countries. i. Excess weight, especially around the waistline, is the major and most controllable risk factor for type 2 diabetes. G. Diabetes Signs and Symptoms 1. Increased thirst and frequent urination 2. Flulike symptoms 3. Weight loss or gain 4. Blurred vision 5. Slow-healing sores or frequent infections 6. Nerve damage (neuropathy) 7. Red, swollen, tender gums H. Diabetes Management 1. Before the development of insulin injections, diabetes was a fatal illness. Today diabetics can have normal lifespans. 2. Diabetes educators teach patients a new set of ABCs: a. A is for the A1c test. This test measures the amount of glucose attached to hemoglobin molecules, the iron-rich molecules in red blood cells that deliver oxygen to the body.

b. B is for blood pressure. c. C is for cholesterol. I. Treatment 1. The goal for diabetics is to keep blood sugar levels as stable as possible to prevent complications, such as kidney damage. 2. Home glucose monitoring allows diabetics to check their blood sugar levels as many times a day as necessary and to adjust their diet or insulin doses as appropriate. 3. Those with type 1 diabetes require daily doses of insulin via injections, an insulin infusion pump, or oral medication. 4. Those with type 2 diabetes often can control their disease through a wellbalanced diet, exercise, and weight management. However, insulin therapy may be needed to keep blood glucose levels normal or near normal. IV. Hypertension A. Introduction 1. Blood pressure refers to the force of blood against the walls of arteries. 2. Hypertension is a condition when blood pressure remains elevated over time and the heart pumps harder than is healthy. 3. This can lead to organs such as the heart, brain, and kidneys to start to deteriorate. 4. Especially when combined with obesity, smoking, high cholesterol levels, or diabetes, hypertension greatly increases the risks of cardiovascular problems. B. Hypertension in the Young 1. In a young person, even mild hypertension can cause organs such as the heart, brain, and kidneys to start to deteriorate. 2. High blood pressure can damage the structure of the brain in people as young as age 40. 3. In individuals at genetic risk, high blood pressure may spur development of the brain plaques characteristic of Alzheimer’s disease. C. Who Is at Risk? 1. About 3 in 10 adults age 18 and older in the United States—some 65 million men and women—have high blood pressure. 2. Blood pressure has increased among children and adolescents as well as adults, primarily because of obesity. 3. Binge drinking can raise systolic blood pressure among young adults and increase their risk of hypertension later in life. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

4. Different races suffer different consequences of high blood pressure. 5. Family history increases the risk. 6. Men and women are equally likely to develop hypertension, but in women, blood pressure tends to rise around the time of menopause. 7. People with chronic insomnia who take longer than 14 minutes to fall asleep may have a 300 percent higher risk of high blood pressure. D. What Is a Healthy Blood Pressure? 1. Current guidelines categorize a reading of 120–139/80–89 as prehypertension, a condition that is likely to worsen in time. 2. A healthy reading is 115/75. 3. Once blood pressure rises above this threshold, the risk of cardiovascular disease may increase. 4. The current guidelines classify hypertension into two categories: a. Stage 1: This consists of a systolic pressure ranging from 140 to 159 or a diastolic pressure ranging from 90 to 99. b. Stage 2: The most severe form of hypertension occurs with a systolic pressure of 160 or higher, or a diastolic reading of 100 or higher. E. Lowering High Blood Pressure 1. Lifestyle changes are the first line of weapon in the fight against high blood pressure: 2. Reducing Sodium: Too much sodium and too little potassium boost blood pressure in people who are sensitive to salt. 3. The DASH Eating Pattern: The National Heart, Lung, and Blood Institute (NHLBI) has developed the DASH eating pattern (for Dietary Approaches to Stop Hypertension), which has proved as effective as drug therapy in lowering blood pressure. 4. Exercise: Regular exercise, both aerobic workouts and resistance training, can lower blood pressure. 5. Medications—drugs for lowering blood pressure come in a range of regiments with a range of effects on other conditions, interactions with other drugs, and potential side effects. V.

Your Lipoprotein Profile A. Overview 1. This blood test, which should be performed after a 9–12-hour fast and repeated at least once every five years, provides readings of the following: a. Total cholesterol b. LDL (bad) cholesterol, the main culprit in the buildup of plaque within the arteries

c. HDL (good or healthy) cholesterol, which helps prevent cholesterol buildup d. Triglycerides, the blood fats released into the bloodstream after a meal B. What Is a Healthy Cholesterol Reading? 1. Less than 200 mg/dL is the ideal level that puts you at lower risk for heart disease. 2. 200–239 mg/dL is the borderline-high level. 3. 240 mg/dL and above is the high level of blood cholesterol. A person with this level has more than twice the risk of heart disease compared to someone whose cholesterol is below 200 mg/dL. C. Lowering Cholesterol 1. Lifestyle Changes a. Dietary Changes b. Weight Management c. Physical Activity 2. Medications a. Statins can cut the risk of dying of a heart attack by as much as 40 percent. b. Statins work in the liver to block production of cholesterol. When the liver cannot make cholesterol, it draws LDL cholesterol from the blood to use as a raw material. c. Statins also appear to stabilize cholesterol-filled deposits in artery walls and to cool down inflammation. VI. Cardiovascular (Heart) Disease A. Introduction 1. Heart disease, stroke, and other cardiovascular diseases cause about one of every three deaths in the United States, killing about 787,000 Americans annually. B. How the Heart Works 1. The heart is a hollow, muscular organ with four chambers that serve as two pumps. 2. A human heart is about the size of a clenched fist. 3. Each pump consists of a pair of chambers formed as muscles. a. The upper two—each called an atrium—receive blood, which flows through valves into the lower two chambers—the ventricles—which contract to pump blood out into arteries through a second set of valves.

b. The two sides of the heart are separated by a thick wall; they contract at about the same time. Contraction of the ventricles is called systole; the period of relaxation between the contractions is called diastole. 4. The heart valves, located at the entrance and exit of the ventricular chambers, have flaps that open and close to allow blood to flow through the chambers of the heart. 5. The myocardium (heart muscle) consists of branching fibers that enable the heart to contract or beat between 60 and 80 times per minute. 6. The heart is surrounded by the pericardium, which consists of two layers of tough membrane. 7. The endocardium is a smooth membrane lining the inside of the heart and its valves. Blood circulates through the body by means of the pumping action of the heart. 8. The right ventricle pumps blood to the lungs, where it picks up oxygen and gives off carbon dioxide. a. The blood returns from the lungs to the left side of the heart, which pumps blood, via the aorta, to the arteries and the rest of the body. 9. The arteries divide into smaller and smaller branches and finally into capillaries, the smallest blood vessels of all. 10. The blood within the capillaries supplies oxygen and nutrients to the cells and tissues. Blood returns to the heart via the veins. C. Heart Risks on Campus 1. Heart disease is the third-leading cause of death among adults aged 25–44. 2. High aerobic fitness in the college-age years has been linked with a lower risk of heart attacks later in life. 3. Certain behaviors put students’ hearts at risk. Binge drinking may hinder the function of blood vessels and increase the risk of stroke, sudden cardiac death, and heart attack. 4. Young athletes face special risks. D. Hearts and Minds: Psychosocial Risk Factors 1. Our psychological and social health affects not just our minds but our bodies. a. Chronic factors, such as job strain or lack of social support, play an important role in the buildup of artery-clogging plaque and may increase blood pressure. b. Episodic factors, such as depression, can last from several weeks to 2 years and may lead to the creation of “unstable” plaque, which is more likely to break off and block a blood vessel within the heart.

c. Short-term, or acute, factors, such as an angry outburst, can directly trigger a heart attack in people with underlying heart disease. 2. How you respond to stress can affect your heart as well as your overall health. 3. Depression and heart disease often occur together. 4. Anger and hostility have both short- and long-term consequences for the heart, particularly for men. 5. Dutch scientists have identified a “Type D” (for distressed) personality type. Type D people tend to be anxious, self-conscious, irritable, insecure, and negative, and they go to great lengths not to say or do anything that others might not like. In the Dutch study, almost four times as many Type D individuals as others in cardiac rehabilitation programs died within an 8-year period. E. The Heart of a Woman 1. Many people still think of heart disease as a “guy problem.” Men do have a higher incidence of cardiovascular problems than women before age 45, but women’s hearts are also vulnerable. 2. Women need to know the early signs and symptoms of female heart disease: a. Tiredness, even after getting adequate sleep b. Trouble breathing c. Trouble sleeping d. Feeling sick to the stomach e. Feeling scared or nervous f. New or worse headaches g. An ache in the chest h. Feeling “heavy” or “tight” in the chest i. A burning feeling in the chest j. Pain in the back, between the shoulders k. Pain or tightness in the chest that spreads to the jaw, neck, shoulders, ear, or the inside of the arms l. Pain in the belly, above the belly button VII. Crises of the Heart A. Coronary Artery Disease 1. The general term for any impairment of blood flow through the blood vessels, often referred to as “hardening of the arteries,” is arteriosclerosis. a. The most common form is atherosclerosis, a disease of the lining of the arteries in which plaque—deposits of fat, fibrin (a clotting material), © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

cholesterol, other cell parts, and calcium—narrows the artery channels. Inflammation also plays a crucial role. B. Atherosclerosis 1. This process begins when LDL cholesterol penetrates the wall of an artery. 2. The body’s own immune cells ingest the LDL then enlarge and rupture releasing the cholesterol into the artery wall. 3. The smooth muscles cells in the artery wall create a fibrous cap over the inflamed area. C. Heart Attack (Myocardial Infarction) 1. The medical name for a heart attack, or coronary, is myocardial infarction (MI). 2. If an artery is blocked by a clot or plaque, or by a spasm, the myocardial cells do not get sufficient oxygen, and the portion of the myocardium deprived of its blood supply begins to die. 3. Although such an attack may seem sudden, usually it has been building up for years. D. Is It a Heart Attack? 1. If they experience the following symptoms, individuals should seek immediate medical care and take an aspirin (325 milligrams) to keep the blood clot in a coronary artery from getting any bigger: a. A tight ache, heavy, squeezing pain, or discomfort in the center of the chest, which may last for 30 minutes or more and is not relieved by rest b. Chest pain that radiates to the shoulder, arm, neck, back, or jaw c. Anxiety d. Sweating or cold, clammy skin e. Nausea and vomiting f. Shortness of breath g. Dizziness, fainting, or loss of consciousness 2. If you’re with someone who’s exhibiting the classic signs of heart attack, and if those signs last for two minutes or more, act at once. 3. State-of-the-art treatments for heart attacks include clot-dissolving drugs, early administration of medications to thin the blood, intravenous nitroglycerin, and, in some cases, beta-blockers. VIII. Stroke A. Introduction 1. A stoke occurs when the blood supply to a portion of the brain is blocked.

2. The proportion of strokes among young adults between ages 20 and 45 has been rising, probably as a consequence of the higher incidence of obesity, hypertension, and diabetes. 3. Although the number and mortality rate have declined, strokes rank third, after heart disease and cancer, as a cause of death in this country. 4. As many as 80 percent of strokes are preventable, primarily through lifestyle modification. The most important steps are: a. Treating hypertension b. Not smoking c. Managing diabetes d. Lowering cholesterol e. If you’re a woman, taking aspirin (which reduces stroke risk in women but not in men) B. Risk Factors 1. Gender a. Up to age 85, men have a greater risk of stroke than women. However, women are at increased risk at times of marked hormonal changes, particularly pregnancy and childbirth. 2. Race a. Two to three times greater for blacks than whites. Hispanics also are more likely to develop hemorrhagic strokes than whites. 3. Age a. Risk of stroke more than doubles every decade after age 55. 4. Obesity a. The more overweight individuals are, the more likely they are to have a stroke. 5. Hypertension a. Detection and treatment of high blood pressure are the best means of stroke prevention. 6. High Red Blood Cell Count a. Moderate to marked increase in the number of a person’s red blood cells increases the risk of stroke. 7. Heart Disease a. Heart problems can interfere with the flow of blood to the brain and form clots. 8. Blood Fats a. It may be more important to raise HDL than to lower LDL levels. 9. Diabetes Mellitus a. Diabetics have a higher incidence of strokes than nondiabetics. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

10. Estrogen Therapy a. Women on estrogen-only therapy significantly increase the risk of stroke. 11. A Diet High in Fat and Sodium a. Individuals consuming the largest amounts of fatty foods and sodium are at much greater risk than those eating low-fat, low-salt diets. 12. Marijuana Use a. Smoking marijuana may double the risk of stroke in young adults. C. Causes of Stroke 1. There are two types of stroke. a. Ischemic stroke, which is the result of a blockage that disrupts blood flow to the brain. i. One of the most common causes of ischemic stroke is the blockage of a brain artery by a thrombus, or blood clot—a cerebral thrombosis. b. Hemorrhagic stroke, which occurs when blood vessels rupture. i. In hemorrhagic stroke, a diseased artery in the brain floods the surrounding tissue with blood. The cells nourished by that artery are deprived of blood and cannot function and blood from the artery forms a clot that may interfere with brain function. Brain tissue, like heart muscle, begins to die if deprived of oxygen, which may then cause difficulty speaking and walking, and loss of memory. D. Why Quick Treatment Matters 1. Brain tissue, like heart muscle, begins to die if deprived of oxygen, which may then cause difficulty speaking and walking, as well as loss of memory. 2. For patients who suffer a thrombotic stroke, thrombolytic drugs such as tissue-type plasminogen activator (tPA) can restore brain blood flow and save blood cells. IX. Cancer A. Overview 1. Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. 2. Second only to heart disease as a cause of death in the United States, cancer accounts for nearly one of every four deaths.

3. The gap in cancer deaths among blacks and whites has narrowed for most cancers, but disparities remain for two common cancers: breast cancer in women and colon cancer in men. 4. Many cancers are preventable, including those caused by the following: a. Tobacco smoking b. Heavy alcohol consumption c. Overweight and obesity d. Physical inactivity e. Poor nutrition f. Excessive sun exposure and indoor tanning g. Infections that could be avoided by behavioral changes on vaccination B. Understanding Cancer 1. Normal cells follow the code of instructions embedded in DNA (the body’s genetic material); cancer cells do not. 2. The abnormal cell divides to create other abnormal cells, which again divide, eventually forming neoplasms (new formations), or tumors. 3. Tumors can be either benign (slightly abnormal, not considered lifethreatening) or malignant (cancerous). 4. Without treatment, cancer cells continue to grow, crowding out and replacing healthy cells. a. This process is called infiltration, or invasion. b. Cancer cells may also metastasize, or spread to other parts of the body via the bloodstream or lymphatic system. C. Who Is at Risk? 1. Cancer strikes individuals at all social, economic, and educational levels. 2. Heredity a. In some cancers, a specific cancer-causing gene is passed down from generation to generation. b. Other people are born with genes that make them susceptible to having certain cells grow and divide uncontrollably, which may contribute to cancer development. c. Genetic tests can identify some individuals who are born with an increased susceptibility to cancer. 3. Racial and Ethnic Groups a. African Americans have the highest rates of fatal cancers. b. Hispanics have a six times lower risk of developing melanoma than Caucasians yet tend to have a worse prognosis than Caucasians when they do develop this skin cancer.

c. The incidence of female breast cancer is highest among white women and lowest among Native American women. d. Cervical cancer is most common in Hispanic women. e. Vietnamese men have much higher rates of liver cancer than whites, while Korean men and women are much more likely to develop stomach cancer. f. Compared with other Asian Americans, Chinese and Vietnamese women have higher rates of lung cancer. g. Asian Americans who have lived in the United States the longest are likely to develop the cancers that are most common here, such as breast and colon cancer, although at lower rates than whites. 4. Obesity a. Obesity plays a significant role in cancer deaths each year. b. The higher an individual’s BMI, the greater the likelihood of dying of cancer. c. An unhealthy body weight increases the risk of many types of cancer. d. The degree to which extra pounds affect cancer risk varies by the site of the cancer. 5. Infectious Agents a. Worldwide, an estimated 17 percent of cancers can be attributed to infection. b. Among the cancers that have been linked with infectious agents are as follows: i. Human papillomavirus (HPV) with cancer of the cervix, mouth, and throat, vulva, and anus ii. Helicobacter pylori with stomach cancer iii. Viruses with certain leukemias (cancers of the blood system) and lymphomas (cancers of the lymphatic system), cancers of the nose and pharynx, and liver cancer iv. Human immunodeficiency virus (HIV) with certain lymphomas and leukemias and a type of cancer called Kaposi’s sarcoma D. Common Types of Cancer 1. Cancers are classified according to the type of cell and the organ in which they originate, such as the following: a. Carcinoma i. The most common cancer, which starts in the epithelium b. Sarcoma i. Forms in the supporting or connective tissues in the body c. Leukemia © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

i. Begins in the blood forming tissues d. Lymphoma i. Arises in the cells of the lymph system 2. Skin Cancer a. One in every five Americans can expect to develop skin cancer in his or her lifetime. b. Using tanning beds at a young age significantly raises a woman's risk of developing melanoma before the age of 50. c. The most common types of skin cancers are basal cell and squamous cell. d. Malignant melanoma, the deadliest type of skin cancer, causes 1–2 percent of all cancer deaths. i. Individuals with the following characteristics are at an increased risk for melanoma: (a) Fair skin, light eyes, or fair hair (b) A tendency to develop freckles and to burn instead of tan (c) A history of childhood sunburn or intermittent intense sun exposure (d) A personal or family history of melanoma (e) A large number of nevi, or moles, or dysplastic moles e. Detection i. The most important early indicators of malignant melanoma are change in color, an increase in diameter, and changes in the borders of a mole. f. Treatment. i. When caught early, it is highly curable. Treatment may include surgery alone or may include chemotherapy to shrink it. 3. Breast Cancer a. Common risk factors include the following: i. Age ii. Family history iii. Long menstrual history iv. Age at birth of first child v. Breast biopsies vi. Race and ethnicity vii. Occupation viii. Alcohol ix. Smoking x. Hormone therapy xi. Obesity xii. Sedentary lifestyle © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. Screening for Breast Cancer i. Women ages 40–44 at average risk who do not have a personal or family history of breast cancer, a genetic mutation known to increase risk of breast cancer (such as BRCA), or radiation therapy to the chest before the age of 30, should have the choice to start annual breast cancer screening with mammograms if they wish to do so. ii. Women ages 45–54 should get mammograms every year. iii. Women ages 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening. c. Treatment i. Treatment options for a woman diagnosed with breast cancer depend on the size of the tumor and the extent of spread, but may involve the following: (a) Breast-conserving surgery (surgical removal of the tumor and surrounding tissue) (b) Mastectomy (surgical removal of the breast) (c) Radiation (d) Chemotherapy before or after surgery (e) Hormone therapy d. About 6 in 10 diagnosed breast cancers are localized and have not spread to lymph nodes or other locations outside the breast. i. The 5-year survival rate for women with these cancers is 99 percent. 4. Cervical Cancer a. This is the second most common cancer in women worldwide. b. HPV infection is the primary risk factor for cervical cancer. c. Other risk factors include sexual activity before the age of 16, having had multiple sex partners, genital herpes, and smoking or significant exposure to secondhand smoke. d. Doctors no longer recommend annual Pap test because it generally takes 10–20 years for cervical cancer to develop and overly frequent screening could lead to unneeded medical and surgical problems. 5. Ovarian Cancer a. Ovarian cancer is the leading cause of death from gynecological cancers. b. Risk factors for ovarian cancer include family history of ovarian cancer, smoking, and testing positive for inherited mutations in BRCA1 and BRCA2 genes.

c. Ovarian cancer may be diagnosed by pelvic examination, ultrasound, MRI (magnetic resonance imaging), computed tomography, or PET (positron emission tomography) scan. d. Symptoms that are often overlooked are abdominal pain, feeling full quickly after eating, and urinary urgency. e. Treatment involves surgery and usually chemotherapy. 6. Testicular Cancer a. In the past 20 years, the incidence of testicular cancer has risen by about 50 percent in the United States, to 5.44 per 100,000. b. Testicular cancer occurs mostly among young men between the ages of 18 and 35, who are not normally at risk of cancer. c. Risk factors include the following: i. Chronic use of marijuana ii. An undescended testicle iii. Family history of testicular cancer iv. HIV infection v. Cancer in the other testicle vi. Caucasian race d. To detect possibly cancerous growths, men should perform monthly testicular self-exams. e. Symptoms my include a slight enlargement of one testicle, different sensation to touch, lumps on the testicle, a dull ache in the lower abdomen or groin, along with a sense of heaviness or sluggishness. f. Treatment generally involves surgery, radiation therapy, chemotherapy, and the removal of nearby lymph nodes. 7. Colon and Rectal Cancer a. This is the third most common cancer and accounts for 10 percent of cancer deaths. b. Risk factors include being over 50 years of age, personal or family history of colon and rectal cancer, polyps in the colon or rectum, ulcerative colitis, smoking, alcohol consumption, prolonged high consumption of red and processed meat, high-fat or low-fiber diets, and inadequate intake of fruits and vegetables. c. Early symptoms include bleeding from the rectum, blood in the stool, or a change in bowel habits. d. A colonoscopy is recommended beginning at age 50, earlier for those at higher risk based on personal, family, or medical history. e. Treatment may include surgery, radiation therapy, and/or chemotherapy. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

8. Prostate Cancer a. After skin cancer, prostate cancer is the most common form of cancer in American men. b. The risk of prostate cancer increases with age, family history, exposure to the heavy metal cadmium, a high number of sexual partners, or a history of frequent sexually transmitted infections (STIs). Diet high in saturated fat may play a role and there is a possible inherited predisposition. c. An annual PSA test is no longer recommended. X.

Infectious Diseases A. Overview 1. Infection is a complex process. a. Pathogens, (disease causing organisms), trigger infections that are countered by the body’s own defenders. b. Host—either a person or a population that contacts one or more agents in an environment c. Vector—a biological or physical vehicle that carries the agent to the host and provides the means of transmission B. Agents of Infection 1. Viruses are the tiniest pathogens but the toughest, consisting of a nucleic acid with a protein coat. a. The most common viruses include the following: i. Rhinoviruses and adenoviruses ii. Influenza viruses iii. Herpes viruses iv. Papillomaviruses v. Hepatitis viruses vi. Slow viruses vii. Retroviruses viii. Filoviruses 2. Antibiotics—drugs that inhibit or kill bacteria—have no effect on viruses. 3. Antiviral drugs do not completely eradicate a viral infection, although they can decrease its severity and duration. 4. Bacteria are simple one-celled organisms, but are the most plentiful microorganisms as well as the most pathogenic. a. Most bacteria do not cause disease, but play an important role in our bodies. However, some bacteria can get out of control, causing urinary tract infections and vaginal infections.

b. They can harm the body by releasing enzymes that digest body cells and cause illnesses. c. Most bacterial infections can be treated with an antibiotic. 5. Fungi are single-celled or multicelled organisms that consist of threadlike fibers and reproductive spores. a. Athlete’s foot is a type of fungi. b. Treatment consists of antifungal drugs. 6. Protozoa are single-celled, microscopic animals that release enzymes and toxins that destroy cells or interfere with their function. a. Not a major health problem in this country, primarily because of public health measures. 7. Helminths (parasitic worms) are small parasitic worms that attack specific tissues or organs and compete with the host for nutrients. C. How Infections Spread 1. Animals and insects can spread a variety of diseases. 2. People can transmit pathogens through the air, through touch, and through sexual contact. 3. Food that is undercooked or inadequately washed can have bacteria that cause disease. a. Escherichia coli (E coli) and Salmonella are bacteria that can cause serious infections. 4. Waterborne diseases are still widespread in underdeveloped parts of the world but uncommon in the United States. D. The Process of Infection 1. If someone infected with the flu sits next to you on a bus and coughs or sneezes, tiny viral particles may travel into your nose and mouth. 2. Immediately, the virus finds or creates an opening in the wall of a cell, and the process of infection begins. 3. Incubation period is the time between invasion and the first symptom. 4. Prodromal period is the early stage of the battle between your body and the invaders. 5. Recovery begins when the body’s forces gain the advantage. E. Who Develops Infections? 1. Among the most vulnerable populations are the following groups: a. Children and Families. Youngsters get up to a dozen colds annually; adults average two a year. Parents get up to six times as many colds as other adults.

b. The elderly. People 65 years or older who get the flu have a 1 in 10 chance of being hospitalized for pneumonia or other respiratory problems, and a 1 in 50 chance of dying from the disease. c. The chronically ill. Lifelong diseases decrease an individual’s ability to fend off infections. d. Smokers and those with respiratory problems are at high risk for respiratory problems. e. Those who live or work in close contact with someone sick face greater odds of catching cold and flu. f. Residents or workers in poorly ventilated buildings. Building technology has helped spread certain airborne illnesses via recirculated air. 2. Various parts of your body safeguard you against infectious diseases by providing immunity, or protection, from these health threats. 3. The immune system includes structures of the lymphatic system—the spleen, thymus gland, lymph nodes, and lymph vessels—that help filter impurities from the body. a. The lymph nodes, or glands, are small tissue masses in which some protective cells are stored. b. An antigen is any substance the white blood cells recognize as foreign. c. Active immunity—the body makes its own antibodies. d. Passive immunity—it is produced by the injection of gamma globulin, the antibody-containing part of the blood, from another person. F. Immune Response 1. When an antigen enters the body, the T cells aided by macrophages engage in combat with the invader. 2. Certain T cells (cytotoxic T cells) can destroy infected body cells or tumor cells by “touch-killing.” 3. Meanwhile, the B cells churn out antibodies, which rush to the scene and join in the fray. 4. Also busy at surveillance are natural killer cells that, like the elite forces of a SWAT team, seek out and destroy viruses and cancer cells. 5. Inflammation is redness, swelling, local warmth, and pain. 6. An abscess is a localized accumulation of pus and disintegrating tissue. 7. If the invaders aren’t killed or inactivated, the pathogens are able to spread into the bloodstream and cause systemic disease. . 8. Some people have an immune deficiency—either inborn or acquired. a. Immune deficiency is partial or complete inability of the immune system to response to pathogens. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

G. Immunity and Stress 1. Stress affects the body’s immune system in different ways, depending on two factors: the controllability or the uncontrollability of the stressor and the mental effort required to cope with the stress. H. Immunization for Adults 1. Although many people associate vaccination with children’s health, the vast majority of vaccine-preventable deaths occur among adults. 2. Only slightly more than one-third of adults get an annual flu shot; many seniors have not gotten a pneumonia vaccination, a one-time shot recommended for everyone over age 65. XI. Upper Respiratory Infections A. Common Cold 1. There are more than 200 distinct cold viruses. 2. Colds can strike in any season, but different cold viruses are more common at different times of the year. a. Rhinoviruses cause most spring, summer, and early fall colds and tend to cause more symptoms above the neck (stuffy nose, headache, runny eyes). b. Adenoviruses, para-influenza viruses, coronaviruses, influenza viruses, and others that strike in the winter are more likely to get into the bronchi and trachea (the breathing passages) and cause more fever and bronchitis. 3. Cold viruses spread by coughs, sneezes, and touch. 4. Antibiotics have no effect against viruses and may make your body more resistant to such medications when you develop a bacterial infection in the future. 5. Preventing Colds a. Taking vitamin C ever day does not ward off the common cold or shorten its length or severity. b. The findings on Echinacea are also mixed. c. Lozenges or syrup containing zinc, a mineral that inhibits rhinoviral replication, did help reduce the duration and severity of the common cold in healthy people when taken within 24 hours of onset of symptoms. d. Antibiotics are effective only against bacteria. Antibiotics can foster the growth of one or more strains of antibiotic-resistant bacteria.

B. Influenza 1. Similar to a cold, influenza—or the flu—causes more severe symptoms that last longer. 2. Flu viruses, transmitted by coughs, sneezes, laughs, and even normal conversation, are extraordinarily contagious, particularly in the first three days of the disease. 3. Two varieties of viruses—influenza A and influenza B—cause the most flus. 4. The Centers for Disease Control & Prevention (CDC) recommends an annual flu shot for everyone over the age of six months, except for those with certain medical conditions. 5. For those who don’t get vaccinated, antiviral drugs, which must be taken within 36–48 hours of the first flu symptom, have provided the next-best line of defense. C. Meningitis 1. An invasive meningococcal disease that attacks the membranes around the brain and spinal cord and can result in hearing loss, kidney failure, and permanent brain damage. 2. If not treated early, meningitis can lead to death or permanent disabilities. 3. Meningitis spreads through the exchange of respiratory droplets, which can come from sharing a drink, cigarette, or silverware; kissing; coughing; or sneezing. Even inhaling secondhand smoke can infect you with the disease. 4. Preventing Meningitis a. Vaccination is recommended for all American adolescents, with initial immunization at age 11 or 12 and a booster at age 16. b. Vaccination protects against four of the five most common types of meningococcal bacteria. 5. Recognizing Meningitis—The most common symptoms of meningitis are as follows: a. Sudden high fever b. Severe, persistent headache c. Neck stiffness and pain d. Nausea and vomiting e. Confusion and disorientation f. Drowsiness and sluggishness g. Eye pain or sensitivity to bright light h. Pain or weakness in muscles or joints i. Abnormal skin color © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

j. Stomach cramps k. Ice-cold hands and feet l. Dizziness m. Reddish or brownish skin rash n. Numbness and tingling o. Seizures 6. When to Seek Medical Care a. If two or more symptoms appear together or suddenly, seek treatment immediately. XII. Hepatitis A. Overview 1. An estimated 500,000 Americans contract hepatitis each year and the number of hepatitis-related deaths have been rising in the last decade. 2. There are at least five different viruses referred to as hepatitis. A, B, C, Delta, and E can cause this inflammation of the liver. B. Hepatitis A 1. It is a less serious form and is usually transmitted by poor sanitation. 1. It is less common in industrialized nations than in developing countries. 2. It is common among men who sleep with men and among people who use illegal drugs. C. Hepatitis B 1. It is a potentially fatal disease and is transmitted through the blood and other bodily fluids. 2. Once spread mainly by contaminated tattoo needles, needles shared by drug users, or transfusions of contaminated blood, hepatitis B is now transmitted mainly through sexual contact. 3. It can cause chronic liver infection, cirrhosis, and liver cancer. D. Who Develops Hepatitis B? 1. At highest risk are: a. Young people b. Athletes in contact sports c. Male homosexuals d. Heterosexuals with multiple sex partners e. Health-care workers in frequent contact with blood f. Injection drug users g. Infants born to infected mothers 2. Vaccination can prevent hepatitis B and is recommended for all newborns and, if not already vaccinated, for travelers to certain regions, health-care © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

workers, dialysis patients, and anyone engaging in unprotected sexual activity (homosexual or heterosexual). E. Hepatitis C 1. About 3.2 million people in the United States are infected with hepatitis C virus (HCV), but most do not realize it because the virus causes so few symptoms. 2. HCV is not spread by casual contact, such as hugging, kissing, or sharing food utensils. 3. The latest treatment is a once-daily pill called Harvoni, which combines two drugs—ledipasvir and sofosbuvir (Sovaldi)—and cures the disease in most people in 8–12 weeks. 4. About three-quarters of those infected with HCV develop chronic or longterm hepatitis. a. About one-quarter develop progressive, irreversible liver damage, with scar tissue (cirrhosis) gradually replacing healthy liver tissue. 5. Hepatitis C also increases the risk of a rare form of liver cancer. XIII. Insect- and Animal-Borne Infections A. Introduction 1. Common insects and animals, including ticks and mosquitoes, can transmit dangerous infections, among them Lyme disease and West Nile virus. 2. Of all emerging infections, 75 percent originate in animals; of these, 61 percent can be transmitted to humans. B. Lyme Disease 1. The most commonly reported vector-borne infectious disease in the United States, affecting 20,000–30,000 annually. 2. This bacterial infection is spread by ticks carrying a particular bacterium. 3. What you need to know: a. Symptoms include joint inflammation, heart arrhythmias, blinding headaches, and memory lapses. The disease can also cause miscarriages and birth defects. b. You are not likely to get Lyme disease if a tick is attached to your skin for less than 48 hours. c. About 70–80 percent of infected individuals develop a red rash at the site of the tick bite. d. Once diagnosed, Lyme disease is treated with antibiotics. C. West Nile Virus (WNV)

1. Transmitted by mosquitoes that feed on an infected bird and then bite a human. 2. Things to remember include the following: a. WNV interferes with the normal central nervous system functioning and causes inflammation of the brain tissue. b. The risk of catching it is low. c. Repellents that contain an EPA-registered insect repellent can protect against these mosquitoes. d. There is no specific treatment. D. Zika Virus 1. First discovered in 1947, the Zika virus often causes no symptoms or mild ones similar to those of other infections. 2. Infection prior to or during pregnancy is associated with serious threats, including prematurity, blindness, and congenital microcephaly (a birth defect characterized by small head size and abnormal brain development). 3. In adults, Zika can cause brain inflammation and Guillain-Barré syndrome, an autoimmune disorder characterized by weakness and abnormal sensation in the legs and arms. 4. Transmission a. Through a mosquito bite b. From mother to child c. Through sexual contact d. Through blood transfusion 5. Symptoms a. Most people infected with Zika virus don’t have symptoms. b. Others may develop fever, rash, joint pain, conjunctivitis (red eyes), muscle pain, and headache a few days to a week. 6. Diagnosis and Treatment a. There is a blood test to detect Zika and similar viruses. b. If you are infected, health officials recommend rest, fluids to prevent dehydration, and acetaminophen (Tylenol) or paracetamol to reduce fever and pain. 7. Prevention a. To find out where Zika has been identified, visit the CDC’s website. b. If you are a man or a sex partner of a man who lives in or has traveled to an area with Zika and your partner is pregnant, do not have sex during pregnancy or use condoms every time you have sex. c. To avoid mosquito bites, wear long-sleeved shirts and long pants and use insect repellents as directed. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

E. Avian Influenza 1. Commonly known as bird flu 2. Caused by viruses that occur naturally in birds and does not usually affect humans F. The “Superbug” Threat: MRSA 1. When the bacterium Staphylococcus aureus became resistant to penicillin, physicians switched to a newer antibiotic, methicillin. 2. Methicillin-resistant S. aureus (MRSA) enters the body through a scrape, burn, or surgical incision. 3. MRSA poses the greatest danger to athletes in contact sports, the elderly, babies, and individuals who have undergone surgery, taken antibiotics, or have a weakened immune system, preexisting infection, open wounds, cuts, burns, or other types of wounds, such as skin breaks from an intravenous drug line.

Discussion Questions •

Explain to the class why antibiotics have no effect on viruses. Ask why, when we go to the doctor, many of us insist on being treated for a virus. How are antibiotics being misused in our society? Explain the advantages, disadvantages, and dangers of overuse of antibiotics.

•

Brainstorm the pathogens that students may be potentially exposed to in their homes, workplace, school, etc. Discuss how these risks can be minimized.

•

Ask students to provide examples of how stress has affected their immune system. Discuss research findings on the link between stress and immunity. Brainstorm ways for students to reduce and cope with stress.

•

Given the prevalence of some communicable diseases, ask students why some parents might choose not to immunize their children. Are any of these reasons justified? Where do the rights of individuals stop and the rights of the public begin?

•

Review prevalent diseases and their primary outbreak sites throughout the world. Discuss how viruses spread and ways we can protect ourselves at home and abroad. What methods can we use to reduce our risks in traveling abroad? Discuss the CDC site for precautions when traveling abroad. What information is given and how can it be useful?

•

Acknowledging the costs verses the benefits of early intervention, ask the class whether all children should be routinely screened for heart disease. Discuss the implications for each option. Why might an individual not want to know?

•

Discuss why the incidence of type 2 diabetes is increasing in America. Describe what environmental changes need to occur in America to reduce the incidence of diabetes.

•

Describe the heart, including each part of the heart. Describe the path of blood flow through the heart.

•

Discuss factors that we can control to reduce our risk of coronary heart disease and then review those factors that cannot be controlled: heredity, age, and race and ethnicity. Discuss how “blaming the victim” can be counterproductive in preventing heart (or any other type) of disease.

•

Describe the many ways in which physical activity lowers your risk of heart disease. Discuss the forms of physical activity that you are engaging in to help lower your risk of heart disease. If you do not exercise, list the reason why you do not.

•

With strokes being one of the leading causes of death among Americans each year, it is important that students be able to recognize its causes, symptoms, prevention, and treatments. What can they do to take preventative measures now?

Classroom Activities Activity #1: Controlling the Spread of Disease Purpose: To increase awareness of individual risk of infectious diseases and ways to stop the spread of disease.

Time: Thirty minutes.

Introduction: Introduce vulnerability to the spread of infectious disease.

Method: 1.

Students should list every type of infectious disease that they might be exposed to as a college student.

Students should then list the preventive measures that they should or are taking to avoid that disease or infection.

Discussion: 1.

Students should share their responses because there may be many illnesses that some students are unaware of but could possibly be at risk for contracting.

What steps do they plan to take to avoid disease?

Does living in a dorm put students at an increased risk for contracting an infectious disease?

Activity #2: STIs on Campus Purpose: To increase awareness of the STIs present on your college campus.

Time: One class period.

Method: 1. Students should visit their student health center or school nurse to find out the top five most-treated STIs for their campus.

Discussion: 1. Discuss the most common STIs on campus. Are these infections curable? What overall health risks do they pose? 2. Were students surprised by the types of STIs found on their campus? Do they realize they could be putting themselves at risk if they have casual sex on campus? 3. What are students doing to protect themselves? What can be done to raise awareness of STI transmission and prevention?

Activity #3: What’s My Risk? Purpose: To learn the importance of understanding your risks for cardiovascular disease.

Time: This activity will take approximately 15 minutes to explain, and then students will need additional time outside of class to identify their family history for cardiovascular disease. You may wish to spend an additional 10–15 minutes after students have completed their family history to discuss what they found.

Introduction: Introduce the importance of understanding an individual’s family history of disease, so they can identify their personal risk for disease.

Method: 1.

Brainstorm with students the risk factors associated with heart disease and identify which factors are controllable and which ones are uncontrollable.

Demonstrate an example of how one’s family history might influence the risk of cardiovascular disease.

Ask students to research their own personal family history for diseases and then have them outline their family history as in a genealogy outline. You may want to find an alternative activity for students who were adopted.

Discussion: 1.

How does it make you feel to know the additional risks?

Were students able to identify possible factors related to their family members’ disease, such as smoking, lack of physical activity, and a poor diet?

If you had a choice to know more about individual lifespan—which diseases you would get or when you would die—would students want to know?

If someone is at a greater risk for cardiovascular disease, what might they do to overcome these odds?

Activity #4: Know Your Blood Pressure Purpose: The purpose of this activity is for students to measure their blood pressure and to determine if it is in a healthy range.

Time: One class period.

Method: 1.

Students should visit their personal physician or the student health center to have their blood pressure measured.

Students should then determine if their reading is within a healthy range. If not, do they have prehypertension, type 1 or type 2 hypertension, or hypotension?

Ask students to review their family health history to see if there is a history of blood pressure problems.

Students should develop a plan for monitoring and controlling their blood pressure.

Discussion: 1.

Discuss family health history as it relates to blood pressure.

Ask students if they were surprised by their individual blood pressure readings.

If their blood pressure readings were not in the normal range, how do they plan to address this issue?

References, Readings, and Resources Adriani, K. S., M. C. Brouwer, and D. van de Beek. “Risk Factors for CommunityAcquired Bacterial Meningitis in Adults.” Netherlands Journal of Medicine 2 (2015): 53–60. 75. American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). Biswas, A., et al. “Sedentary Time and Its Association with Risk for Disease Incidence, Mortality, and Hospitalization in Adults: A Systematic Review and Meta-analysis.” Annals of Internal Medicine 162, no. 12 (2015): 875–6. doi: 10.7326/L15-5060-2. Centers for Disease Control and Prevention. “2016 Vaccine Recommendations: What They Mean for You.” Centers for Disease Control and Prevention Centers for Disease Control and Prevention. “Tips for Minorities: Prevent High Blood Pressure.” Centers for Disease Control and Prevention DeSantis, Carol E., et al. "Cancer Statistics for African Americans, 2016: Progress and Opportunities in Reducing Racial Disparities." CA: A Cancer Journal for Clinicians (2016). doi: 10.3322/caac.21340. Kung, Hsiang-Ching, et al. Hypertension-Related Mortality in the United States (Washington DC: National Center for Health Statistics, 2015). Mozaffarian, Dariush, et al. “Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association.” Circulation 133, no. 4 (2016): 447–54. doi: 10.1161/CIR.0000000000000366. Ryerson, A. B., et al. "Annual Report to the Nation on the Status of Cancer, 1975–2012, Featuring the Increasing Incidence of Liver Cancer." Cancer 122, no. 9 (2016): 1312–37. doi: 10.1002/cncr.29936 45. Siegel, Rebecca L., Kimberly D. Miller, and Ahmedin Jemal. "Cancer Statistics, 2016." CA: A Cancer Journal for Clinicians 66, no. 1 (2016): 7–30. doi: 10.3322/ caac.21332 46. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Wellman, Robert J., et al. "Relationships between Current and Past Binge Drinking and Systolic Blood Pressure in Young Adults." Journal of Adolescent Health 58, no. 3 (2016): 352–7. doi: 10.1016/j. jadohealth.2015.10.251.

Films and Videos And the Band Played On (Excellent film covering much of the epidemiology of HIV/AIDS.) Available at most video stores. Angela’s Journey: Facing Terminal Cancer (“I didn’t know I wasn’t supposed to talk about it.” When Angela Vecchio-Ozmon was diagnosed with terminal breast cancer, she chose to be candid and open, sharing with the cameras all that she experienced in her battle with the disease.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Are Health Tests Really a Good Idea? (Despite living longer and healthier lives than ever before, we have never been more obsessed with our health. And in an effort to detect the signs of silent killers lurking inside, more and more of us are turning to health tests.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Asthma: Disease and Ease (With the help of this program, viewers travel to Quebec City, Canada, for the 21st World Congress of Asthma, organized by the Interasma Global Asthma Association.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

F: 800.678.3633 E: Films Media Group Breast Cancer: Disease and Ease (According to the World Health Organization, breast cancer is the most common cancer among women worldwide, and the American Cancer Society estimates that the lifetime risk of breast cancer will rise to one in seven women by the year 2024.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Cancer Story (This four-part series sets the medical and personal complexities of cancer into an easily understood framework. Designed to facilitate decisions involving the disease—whether those decisions are preventive in nature or are part of a treatment process—Cancer Story is an important resource for patients, healthcare providers, instructors, and support group participants alike.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Cancer: The New Trailblazer (Should cancer really be understood and treated as a genetic disease or could another avenue—which was once abandoned but has now been taken up again—enable us to combat it?) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Curing Allergies: Medical Revolution (A half century ago, the number of people with allergies suddenly began to rise. Currently, one out of three people in developed countries has an allergy. Researchers now know that increasing the number of regulatory T cells can possibly cure allergies.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Ebola Outbreak (FRONTLINE travels to the epicenter of the Ebola crisis to find out how and why the outbreak has spiraled out of control—and to track the fight to contain the virus’s deadly spread. With special access to teams fighting Ebola in Sierra Leone, FRONTLINE, in collaboration with the Channel 4 foreign affairs series Unreported World, brings you an up-close, on-the-ground look at how and why the outbreak is endangering civilians and health-care workers, overwhelming hospitals and getting worse.) Frontline—Ebola Outbreak Hepatitis B: After Diagnosis (Most patients with untreated hepatitis B, or HBV, show no symptoms until liver damage has already taken a toll. This program highlights the importance for those at risk to overcome the perceived stigma of the disease and be tested for or vaccinated against it.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Hepatitis C: A Silent Epidemic (Hepatitis C is a chronic viral infection of the liver that can lead to cancer, liver failure, and even death. Millions of Americans are believed to be infected by the virus, and the shocking fact is that many don’t even know it.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

P: 800.322.8755 F: 800.678.3633 E: Films Media Group The Hidden Epidemic: Heart Disease in America (Heart disease is the number one killer in America and one of the nation's greatest health challenges for both men and women. Hear dramatic personal stories that showcase the stunning scientific advances that are transforming the field of cardiology, and the effect these changes will have on people stricken with the disease.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group I Can't Believe I'm Telling You This: Prostate Cancer in the Age of the Internet (Although many men have prostate cancer—a disease that occurs in two-thirds of all men by the age of 80—there is a culture of silence among patients that stifles conversation about it. The complexities of the illness, the disease’s location, and potential post-treatment side effects such as incontinence and erectile dysfunction have left them at a loss for words.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Liberty: 3 Stories about Life & Death (This extraordinary work interweaves the stories of three close lesbian friends: Joyce Fulton (66), who died over the course of two years from a brain tumor; Mary Bell Wilson (79), who, with indefatigable courage, faces up to her own losing battle with lymphoma; and Nan Golub (58), a black-leather-jacketed, platinum-dyed New York City artist, very much alive.) New Day Films PO Box 165 Blooming Grove, NY 10914 P: 888.367.9154 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

F: 845.774.2945 E: orders@newday.com Outbreak (Why wasn't the Ebola outbreak stopped? When the largest Ebola outbreak on record began to devastate West Africa, why did it take so long for the world to respond?) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Real Life Teens: STDs (The CDC reported last year that one in four teenage girls had contracted a sexually transmitted disease (STD). STDs—or STIs—are infectious diseases that spread from person to person through intimate contact.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Stroke: Understanding the Disease (In some cases, stroke is a life-threatening medical emergency that leaves the victim with permanent disability. But for many stroke patients, much can be done through quick medical attention, good rehabilitation, and community support.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group TB Silent Killer (Tuberculosis was once thought to be a disease of the past. But with virulent new drugresistant strains emerging faster than ever, TB—passed simply by a cough or a sneeze— is the second leading cause of death from an infectious disease on the planet. In TB © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Silent Killer, FRONTLINE presents an unforgettable portrait of the lives at the pandemic’s epicenter.) FRONTLINE—TB Silent Killer The Trouble with Antibiotics (FRONTLINE investigates the widespread use of antibiotics in food animals and whether it is fueling the growing crisis of antibiotic resistance in people. Also this hour: An exclusive interview with the family of a young man who died in a nightmare bacteria outbreak that swept through a hospital at the National Institutes of Health.) FRONTLINE—The Trouble with Antibiotics Trust Me…I'm a Doctor, Series 3 (Michael Mosley and his team of doctors return to tackle more questions about our health, offering uncomplicated, trustworthy advice on important and topical medical issues.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Understanding Hepatitis (Sex, drugs, and food—only a few of the means by which hepatitis hijacks and quietly assaults the human body. This three-part series presents valuable facts about the causes of, and treatments for, the stealthy virus; it also features case studies that offer a realworld perspective on the globe-spanning disease.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group What Is Diabetes? (Diabetes Mellitus is a chronic disease characterized by hyperglycemia resulting from a defect in insulin secretion, insulin action, or both.

This program is designed to provide insight on what diabetes does to a person's body, the various types of diabetes, complications associated with this disease and important self-management steps to prevent or decrease the risk of complications, including nutrition and exercise.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Women and Heart Disease (Heart disease used to be thought of as a man’s disease, but the reality is that more women die from first heart attacks than men. In addition, heart disease can have different symptoms in women, symptoms other than the classic chest pain that has been so well publicized over the years.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources American Academy of Allergy, Asthma & Immunology Provides information and publications. American Academy of Allergy, Asthma & Immunology American College of Allergy, Asthma, and Immunology Information for patients and professionals, and links to other websites. American Academy of Allergy, Asthma & Immunology American Sexual Health Association Information and referrals for STIs; specializes in support for those with herpes and HPV. American Sexual Health Association

American Society of Hypertension Information about the organization, its news, publications, meetings, and links to related sites. American Society of Hypertension Centers for Disease Control and Prevention Provides a wealth of information and statistics about STIs, HIV and AIDS, and other diseases. Centers for Disease Control and Prevention HIV/AIDS Fact Sheet Information on HIV/AIDS. WHO—HIV/AIDS Fact Sheet HIV InSite: Gateway to AIDS Knowledge Provides statistics, education, prevention, and new developments related to AIDS. HIV InSite HIV/AIDS Information Immunization Action Coalition This site features comprehensive vaccination information for children, adolescents, and adults. Immunization Action Coalition National Prevention Information Network Information on HIV and AIDS. Formerly known as the National AIDS Clearinghouse. National Prevention Information Network National Institute of Allergy and Infectious Diseases Includes fact sheets about many topics related to allergies and infectious diseases, including tuberculosis and STIs. National Institute of Allergy and Infectious Diseases American Diabetes Association Latest information on both type 1 and type 2 diabetes mellitus, online bookstore, and access to community resources. American Diabetes Association

American Heart Association Provides information on a wide variety of topics related to heart health, prevention, and treatment. American Heart Association How Can Heart Disease Be Prevented? Excellent information from the National Heart, Lung, and Blood Institute. Links to many other resources on heart disease. How Can Heart Disease Be Prevented? Cancer Prevention and Control This site, sponsored by the Centers for Disease Control and Prevention (CDC), features current information on cancer of the breast, cervix, prostate, skin, and colon. Cancer Prevention and Control Congenital Heart Information Network Information and resources for families of children with congenital and acquired heart disease. Congenital Heart Information Network The Franklin Institute—The Heart: The Engine of Life An exploration of how the heart functions and links to other resources. The Franklin Institute—The Heart: The Engine of Life National Heart, Lung, and Blood Institute Information on a variety of topics and risk factors related to heart health. National Heart, Lung, and Blood Institute National Stroke Association Information, referrals, and support for stroke victims and their families. National Stroke Association

Key Terms angina

arteriosclerosis

antibiotics

atherosclerosis

antiviral drugs

atrium

aorta

bacteria

capillary

lumpectomy

cardiometabolic

Lyme disease

cardiopulmonary resuscitation (CPR)

lymph nodes

cholesterol

mastectomy

diabetes mellitus

meningitis

diastole

metabolic syndrome

diastolic blood pressure

metastasize

fungi

myocardial infarction (MI)

gamma globulin

pathogen

helminth

plaque

hepatitis

prediabetes

host

prehypertension

hypertension

protozoa

immune deficiency

stroke

immunity

systemic disease

incubation period

systole

infiltration

systolic blood pressure

inflammation

triglyceride

influenza

vector

insulin resistance

ventricle

lipoprotein

virus

Answers to Global Health Watch 1. b 2. c 3. snacking

11 Addictive Behaviors and Drugs Learning Objectives After studying this chapter in the text, the student should be able to: 11.1 Explain how substance abuse and other self-destructive behaviors can affect health. 11.2 Discuss the ill effects of problem gambling and gambling disorder. 11.3 Outline the key indicators and effects of substance abuse on college campuses. 11.4 Summarize the effects that drugs have on the brain, body, and behavior. 11.5 Identify the benefits and the adverse effects of caffeine. 11.6 Describe the harmful effects of inappropriate use of over-the-counter (OTC) drugs and prescription drugs. 11.7 Classify the characteristics and harmful effects of common drugs of abuse. 11.8 Explain how substance dependence and abuse can be treated.

Chapter Summary This chapter provides information and insights on how addictions start, why students use and abuse drugs, the nature and effect of drugs, and the most commonly used, misused, and abused drugs. It also offers practical strategies for preventing, recognizing the signs of, and seeking help for addiction.

Lecture Outline I.

Understanding Addiction A. Overview 1. Once people thought of addiction—a compulsive need for and reliance on a habit-forming substance or behavior—as a moral issue.

2. We now understand that addiction is a chronic illness that affects brain, body, and spirit. 3. According to the American Society of Addiction Medicine, its characteristics are as follows: a. Inability to abstain from use of a substance b. Craving or “hunger” for a substance or rewarding experience c. Diminished recognition of significant problems with one’s behavior and interpersonal relationships d. Dysfunctional or unhealthy emotional response B. Addiction and the Dimensions of Health 1. Young adults have the highest rates of illicit drug use. 2. Many do not realize that substance abuse and other self-destructive behaviors, such as gambling or compulsive eating, can affect every dimension of health. a. Physical health: Abuse of alcohol, tobacco, and drugs takes a toll on every organ system in the body, increasing the likelihood of disease, disability, and premature death. b. Psychological health: Sometimes people begin abusing substances or engaging in addictive behavior as a way of “self- medicating” symptoms of anxiety or depression. However, depression and anxiety are as likely to be consequences as causes of substance abuse. c. Spiritual health: Addictive behavior blocks the pursuit of meaning and inner fulfillment. d. Social health: Addictive behavior strains and, in time, severs ties to family, friends, colleagues, and classmates. e. Intellectual health: The brain is one of the targets of alcohol and drugs. Under their influence, logic and reasoning break down. f. Environmental health: The use of some substances, such as tobacco, directly harms the environment. Abusers of alcohol and drugs also pose indirect threats to others because their behavior can lead to injury and damage. C. Preventing Addiction 1. A majority of college students do not engage in addictive behaviors. a. One fundamental reason is that they have better things to do. 2. Without any passion to pursue, the students are more likely to use and abuse multiple drugs. a. The more that students use mind-altering substances, the less they engage in drug-free activities. b. Fortunately, this condition is reversible. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

II.

c. When college students increase physical or creative activities, they often simultaneously reduce their drug and alcohol use, even if not directed to do so. Gambling and Behavioral Addictions A. Introduction 1. Gambling disorder is the only “behavioral” addiction officially recognized as a psychiatric diagnosis. 2. However, Internet use, video game playing, shopping, eating, and other behaviors also bear a resemblance to alcohol and drug dependence. 3. Gambling is an act of risking a sum of money on the outcome of a game or an event that is determined by chance. B. Problem Gambling 1. The term problem gambling refers to all gambling-related problems, including mild or occasional ones. 2. Problem gambling has become more common among American adults than alcohol dependence. 3. Levels of gambling, frequent gambling, and problem gambling increase during the teen years (even though underage gambling is illegal in most states), peak in the 20s and 30s, and decline after age 70. 4. Whites are much more likely to report gambling in the past year than Blacks or Asians, but African Americans and Native Americans report higher levels of frequent gambling. 5. Men, who are twice as likely to be frequent gamblers as women, reach their highest gambling rates in their late teens. 6. Gamblers typically progress through various stages: a. Winning: In the winning phase, they feel empowered by their winning and success. b. Losing: Next comes the losing phase, during which gamblers try to win back their losses. c. Desperation: During the desperation phase, a gambler may resort to illegal activity, including stealing, to continue gambling. d. Giving up: In the giving-up phase, gamblers may try desperately try to stay afloat in a game even though they realize they can’t win. C. Gambling Disorder 1. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classifies persistent and recurrent problematic gambling that leads to significant impairment or distress as a gambling disorder, similar to other addictive disorders in its effects on brain and behavior.

2. A diagnosis is made if individuals exhibit four or more of the following in a 12-month period: a. Need to gamble with increasing amounts of money to achieve excitement b. Becoming restless or irritable if they cut down or stop gambling c. Repeated unsuccessful attempts to control, reduce, or stop gambling d. Preoccupation with gambling e. Gambling when feeling guilty, anxious, or distressed f. After losing money, trying to recoup by “chasing” losses g. Lying to conceal the extent of gambling h. Putting a significant relationship, job, or opportunity in jeopardy because of gambling i. Reliance on others for money to relieve desperate financial situations caused by gambling D. Gambling on Campus 1. Researchers have identified the following key indicators associated with “pathological” gambling: a. Gambling more than once a month b. Gambling more than 2 hours at a time c. Wagering more than 10 percent of monthly income d. A combination of parental gambling problems, gambling frequency, and psychological distress 2. College students who gamble say they do so for fun or excitement, to socialize, to win money, or to “just have something to do”—reasons similar to those of other adults who gamble. 3. Researchers view problem or pathological gambling as an addiction that runs in families. E. Risk Factors for Problem Gambling 1. Being male 2. Gambling at an early age (as young as 8) 3. A big win earlier in one’s gambling career 4. Consistently chasing losses 5. Gambling alone 6. Feeling depressed before gambling 7. Feeling excited or aroused during gambling 8. Behaving irrationally during gambling 9. Poor grades at school 10. Engaging in other addictive behaviors 11. Lower socioeconomic class © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

12. Parents with a gambling or addiction problem 13. A history of delinquency or stealing money to fund gambling 14. Skipping class to go gambling III.

Drug Use on Campus A. Introduction 1. More than six in ten college students have never used marijuana or other illegal drugs. 2. Yet substance abuse remains a serious health risk for the minority of undergraduates who do use drugs. B. Why Students Don’t Use Drugs 1. A majority of undergraduates do not use illegal drugs or abuse prescription drugs. What keeps them drug-free? a. Lack of interest b. Students who enroll at an older age are less likely to use drugs c. Spirituality and religion d. Academic engagement e. Perceived harmfulness f. Athletics C. Why Students Use Drugs 1. Various factors that influence the students to use drugs are as follows: a. Genetics and family history b. Parental attitudes and behavior c. Substance use in high school d. Social norms e. Positive expectations f. Self-medication g. Risk perception h. Mental health problems i. Social influences j. Alcohol use k. Race or ethnicity l. Sexual identity

IV. Understanding Drugs and Their Effects A. Introduction 1. A drug is a chemical substance that affects the way you feel and function. 2. Drug abuse is a pattern of substance use resulting in negative consequences or impairment. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

3. Drug dependence is a pattern of continuing substance use despite cognitive, behavioral, and physical symptoms. 4. Drug misuse is taking a drug for a purpose or by a person other than that for which it was intended or not taking the recommended doses. 5. Drug diversion is the transfer of a medication from the individual to whom it was prescribed to another person. 6. Risks are involved with all forms of drug use. a. Medications, caffeine, alcohol, and tobacco have potentially lifethreatening problems. B. Routes of Administration 1. By Swallowing a. The most common way of taking a drug is by swallowing a tablet, capsule, or liquid. b. It may not have an effect for 30 minutes or more. 2. By Inhaling a. Drugs enter the body through the lungs by inhaling smoke, gasses, aerosol sprays, or fumes from solvents or other compounds, which evaporate quickly. b. Huffing is placing inhalants in a plastic bag, putting it over the mouth and nose, and taking deep breaths. i. Huffing can have fatal consequences. 3. By Injecting a. Drugs can be injected with a syringe subcutaneously (beneath the skin), intramuscularly (into muscle tissue, which is richly supplied with blood vessels), or intravenously (directly into a vein). i. Intravenous (IV) injection gets the drug into the bloodstream immediately (within seconds, in most cases), intramuscular injection, moderately fast (within a few minutes), and subcutaneous injection, more slowly (within 10 minutes). b. Injecting drugs is extremely dangerous because many diseases, including hepatitis and infection with human immunodeficiency virus (HIV), can be transmitted by sharing contaminated needles. C. Dosage and Toxicity 1. Increasing dose intensifies the effect produced by smaller doses. 2. Toxicity: dosage level at which a drug becomes poisonous to the body, causing either temporary or permanent damage. D. Individual Differences 1. Each person responds differently to different drugs, depending on circumstances or setting. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Often drugs intensify the emotional state a person is in. 3. Personality and psychological attitude also play a role in drug effects. a. User’s mindset—his or her expectations or preconceptions about using the drug—affects the experience. E. Gender and Drugs 1. Men encounter more opportunities to use drugs. 2. Both genders display equal opportunity to use drugs for the first time. 3. Men and women are equally likely to become addicted to cocaine, heroin, hallucinogens, tobacco, and inhalants. 4. Women are more likely to become addicted to sedatives and drugs to treat anxiety or insomnia. 5. Men are more likely to abuse alcohol and marijuana. 6. Female cocaine users are more vulnerable to poor nutrition, depression, and physical abuse. F. Setting 1. The setting for drug use also influences its effects. Passing around a marijuana joint at a friend’s place is not a healthy or safe behavior, but the experience of going to a crack house is very different. G. Types of Action 1. A drug can act locally, as novocaine does to deaden pain in a tooth; generally, throughout a body system, as barbiturates are used to depress the central nervous system; or selectively, as a drug does when it has a greater effect on one specific organ or system than on others, such as a spinal anesthetic. 2. A drug that accumulates in the body because it’s taken in faster than it can be metabolized and excreted is called cumulative; alcohol is such a drug. H. Interaction with Other Drugs or Alcohol 1. A drug can interact with other drugs in four different ways: 2. An additive interaction is one in which the resulting effect is equal to the sum of the effects of the different drugs used. 3. A synergistic interaction is one in which the total effect of the two drugs taken together is greater than the sum of the effects the two drugs would have had if taken by themselves on separate occasions. 4. A drug can be potentiating—that is, one drug can increase the effect of another. 5. Drugs can interact in an antagonistic fashion—that is, one drug can neutralize or block another drug with opposite effects. Caffeine and Its Effects A. Overview

1. More than 85 percent of Americans consume caffeine. 2. As a stimulant, caffeine relieves drowsiness, helps in the performance of repetitive tasks, and improves the capacity for work. 3. For most people, caffeine poses few serious health risks. a. Drinking up to six cups a day of caffeinated or decaffeinated coffee won’t shorten your lifespan and may convey some health benefits. 4. Despite these positive findings, doctors advise pregnant women, heart patients, and those at risk for osteoporosis to limit or avoid coffee. B. Caffeine Intoxication 1. Doctors recommend that all adults limit their caffeine intake to 500 milligrams a day, with lesser amounts for those who have heart problems, high blood pressure, or trouble sleeping, or who are taking medications. 2. You can overdose on caffeine and develop symptoms, such as restlessness, nervousness, excitement, insomnia, flushed face, increased urination, digestive complaints, and muscle twitching. 3. Withdrawal can cause headaches and other neurological symptoms. C. Caffeine-Containing Energy Drinks 1. Caffeine-containing energy drinks have become extremely popular, especially in Western and Asian countries. 2. These fortified beverages differ from soft or sports drinks and contain higher levels of caffeine—typically 500 milligrams or more— as well as sugars and dietary supplements. 3. Many of these drinks contain herbs that enhance the effects of caffeine and can interact with medication, causing harmful effects. 4. Alcohol mixed with energy drinks (AmED, in the medical literature) presents even greater dangers. a. Students mixing alcohol and caffeine engage in more high-risk drinking behaviors and are twice as likely to report being hurt or injured as those who don’t. VI. Medications A. Introduction 1. As many as half of all patients take the wrong medications, in the wrong doses, at the wrong times, or in the wrong ways. 2. Every year, these errors lead to an estimated 125,000 deaths and more than $8.5 billion in hospital costs. 3. Doctors occasionally make errors when it comes to prescription drugs. B. Over-the-Counter Drugs 1. Many widely used OTC drugs pose unsuspected hazards. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. OTC medications can be used improperly, often simply because of a lack of education. 3. The most often misused are as follows: a. Painkillers b. Nasal sprays c. Laxatives d. Eye drops e. Sleep aids f. Cough syrup C. Prescription Drugs 1. Like OTC drugs, many prescribed medications aren’t taken the way they should be; millions simply aren’t taken at all. a. As many as 70 percent of adults have trouble understanding dosage information, and 30 percent can’t read standard labels, according to the Food and Drug Administration (FDA). 2. The dangers of nonadherence (not properly taking prescription drugs) include the following: a. Recurrent infections b. Serious medical complications c. Emergency hospital treatment 3. The most widely used prescription drugs are pain medications, sedative or anxiety medications, sleeping medications, and stimulant medications. 4. The drugs most likely to be taken incorrectly are those that treat problems with no obvious symptoms (such as high blood pressure), require complex dosage schedules, treat psychiatric disorders, or have unpleasant side effects. 5. Physical Side Effects a. Serious complications include heart failure, heart attack seizures, kidney and liver failure, severe blood disorders, birth defects, blindness, memory problems, and allergic reactions. b. Overdoses of opioid painkillers now cause more deaths than heroin and cocaine combined. 6. Psychological Side Effects a. The drugs can cause change in the way people think, feel, and behave. b. Doctors may not even mention potential mental and emotional problems. 7. Drug Interactions a. Drugs can interact in a variety of ways.

b. What you eat or drink can impair or completely wipe out the effectiveness of drugs or lead to unexpected effects on the body. 8. Drugs and Alcohol a. About 4 in 10 current drinkers in the United States take prescription drugs that interact with alcohol. b. Depending on the medication, the combination could cause side effects that range from drowsiness to depressed breathing and lower heart rate. 9. Generic Drugs a. The generic name is the chemical name for a drug. b. It has the same active ingredient and costs 20–85 percent less than brand names. c. Fillers and binders that may affect the drugs absorption may be different. d. Ask the physician if generic versus brand name matters. 10. Buying Drugs Online a. Millions of people in the United States purchase prescription medications online. i. Although some websites fill only faxed prescriptions from medical doctors, others ignore or sidestep traditional regulations and safeguards. b. Many individuals turn to the Internet for “lifestyle” drugs, such as pills for erectile dysfunction, weight control, and smoking cessation. c. Consumers have to be wary. i. Patients need to be monitored when some medications are used. ii. Quality control is an issue. iii. Counterfeit drugs are increasingly sold online. VII. Substance Use Disorders A. The American Psychiatric Association defines a substance use disorder as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substancerelated problems.” 1. Symptoms include the following: a. Taking a substance in larger amounts or over a longer period than was originally intended b. A persistent desire to cut down or stop substance use c. Unsuccessful efforts to decrease or discontinue use

d. A great deal of time given to obtaining the substance, using the substance, or recovering from its effects e. Cravings, which may be so strong that a user cannot think of anything else f. Failure to fulfill major obligations at work, school, or home because of substance use g. Recurrent substance use in physically hazardous situations B. Dependence 1. Substance users may develop psychological dependence and feel a strong craving for a drug because it produces pleasurable feelings or relieves stress and anxiety. 2. Physical dependence occurs when a person develops tolerance to the effects of a drug and needs larger and larger doses to achieve intoxication or another desired effect. C. Abuse 1. Some drug users do not develop the symptoms of tolerance and withdrawal that characterize dependence, yet they use drugs in ways that clearly have a harmful effect on them. a. These individuals are diagnosed as having a psychoactive substance abuse disorder. D. Intoxication and Withdrawal 1. Intoxication refers to maladaptive behavioral, psychological, and physiologic changes that occur as a result of substance use. 2. Withdrawal is the development of symptoms that cause significant psychological and physical distress when an individual reduces or stops drug use. E. Polyabuse 1. Most users prefer a certain type of drug but also use several others; this behavior is called polyabuse. F. Coexisting Conditions 1. Many individuals with substance use disorders also have another psychiatric disorder, such as depression. a. Individuals with such dual diagnoses require careful evaluation and appropriate treatment for the complete range of complex and chronic difficulties they face.

G. Causes of Drug Dependence and Abuse 1. The Biology of Dependence a. Scientists now view drug dependence as a brain disease triggered by frequent use of drugs that change the biochemistry and anatomy of neurons and alter the way they work. b. A major breakthrough in understanding dependence has been the discovery that certain mood-altering substances and experiences—a puff of marijuana, a slug of whiskey, a snort of cocaine, a big win at blackjack—trigger a rise in a brain chemical called dopamine, which is associated with feelings of satisfaction and euphoria. c. The mechanism governing the rise in dopamine levels is not the same for all drugs. 2. The Psychology of Vulnerability a. Although scientists do not believe that there is an addictive personality, certain individuals are at increased risk of drug dependence because of psychological factors, including the following: i. Difficulty controlling impulses ii. A lack of values that might constrain drug use (whether based in religion, family, or society) iii. Low self-esteem iv. Feelings of powerlessness v. Depression H. Prescription Drug Abuse 1. According to the most recent federal data, the “epidemic” of prescription painkiller abuse and fatal overdoses may be starting to reverse course. a. After rising steadily until 2010, the rates of abuse have flattened or decreased nationwide. I. Prescription Drugs on Campus 1. About 11 percent of college students report using drugs that were not prescribed for them, including stimulants, painkillers, sedatives, and antidepressants. 2. Abuse of prescription medications on college campuses has increased in the last 15 years. J. Prescription Stimulants 1. Stimulants are among the most widely abused prescription drugs on campus, with about 6 percent of students reporting their misuse. 2. Users generally obtain these drugs from peers with prescriptions for the treatment of attention-deficit or hyperactivity disorder (ADHD), which affects an estimated 2–8 percent of undergraduates. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

3. Students who misuse stimulants typically perceive them as relatively safe, but they produce a range of effects. K. Prescription Painkillers 1. The most commonly abused prescription painkillers are codeine (sold under various brand names), Vicodin, Dilaudid, Demerol, OxyContin, Perdodan, and Percocet. 2. About 5 percent of college students report use of Vicodin or OxyContin, down from previous years. 3. Abuse of these medications can cause serious, potentially fatal side effects. VIII. Common Drugs of Abuse A. Cannabinoids 1. Marijuana and hashish are the most widely used illegal drugs. 2. According to government surveys, some 12 million Americans use cannabis and more than 1 million cannot control this use. a. An estimated 12.5 percent of adults were reported using marijuana in the previous year. 3. How Administered a. It is swallowed, smoked in a joint (hand-rolled cigarette), or pipe. b. It may also be drunk in tea or eaten as an ingredient in other foods (as when baked in brownies), though with a less predictable effect. 4. How Users Feel a. In low to moderate doses, marijuana typically creates a mild sense of euphoria, a sense of slowed time, a dreamy sort of self-absorption, and some impairment in thinking and communicating. b. The immediate physical effects of marijuana include increased pulse rate, bloodshot eyes, dry mouth and throat, slowed reaction times, impaired motor skills, increased appetites, and diminished short-term memory. 5. Risks a. Brain i. Long-term marijuana use causes significant brain abnormalities, including shrinkage of key structures involved in memory, learning, and emotion that can lead to memory loss, difficulty learning new information, and psychotic symptoms. ii. Short-term effects include problems with memory and learning, distorted perceptions, difficulty thinking and problem solving, loss of coordination, increased anxiety, and panic attacks.

b. Lungs i. Smoking cannabis may cause similar effects to smoking tobacco. c. Heart i. Increased risk of heart attack and sudden death d. Pregnancy i. Babies born to mothers who use marijuana during pregnancy are smaller and more likely to develop health problems than those born to mothers who did not use the drug. e. Cancer i. Marijuana smoke contains known cancer-causing chemicals. f. Motor vehicle accidents i. Fatal crashes have increased among drivers who tested positive for marijuana after the drug was legalized in their states. 6. Medical Marijuana a. A growing number of states have passed voter referenda or legislative actions making marijuana available for a variety of medical conditions upon a doctor’s recommendation. b. There is limited scientific evidence supporting the use of cannabis or cannabinoid drugs as a medical therapy. c. Medical scientists and policy experts are monitoring the effects of marijuana decriminalization on health, safety, crime, and other dimensions of daily life, but the impact is not yet clear. 7. Dependence a. Although marijuana is less addictive than heroin or tobacco, it can cause dependence. b. One in six of those who start smoking pot at younger ages may become addicted. 8. Withdrawal a. Compulsive, often uncontrollable craving for the drug. b. Stopping after long-term use can produce marijuana withdrawal syndrome. i. Insomnia, restlessness, loss of appetite, and irritability B. Herbal Drugs 1. Salvia a. Salvia (Salvia divinorum) is an herb grown in southern Mexico and Central and South America. b. Its main active ingredient, salvinorin A, activates kappa opioid receptors that differ from those activated by the more commonly known opioids, such as heroin and morphine. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Khat a. For centuries, people in East Africa and the Arabian Peninsula consumed the fresh young leaves of the Catha edulis shrub in ways similar to our drinking coffee. b. Its active ingredients are two controlled substances, cathinone and cathine. C. Synthetic Designer Drugs 1. Unregulated psychoactive substances, often referred to as designer drugs, include marijuana-like smoking blends frequently branded as “K2” or “Spice,” designer stimulant preparations of powders generally termed “bath salts,” and various tablets or capsules frequently described as “party pills” or “research chemicals.” 2. Synthetic Marijuana a. Synthetic versions of the active ingredient in marijuana, developed for medical use, act on the brain like the tetrahydrocannabinol (THC) in smoked marijuana but eliminate the need to inhale harmful chemicals. b. Various herbal mixtures, marketed as safe and legal alternatives to pot yet labeled “not for human consumption,” contain dried and shredded plant material and chemical additives. 3. Synthetic Cathinone a. “Bath salts” are a new family of drugs that contain one or more synthetic chemicals related to cathinone, an amphetamine-like stimulant found naturally in the khat plant. D. Club Drugs 1. A variety of drugs—MDMA, GHB, GBL, ketamine, fentanyl, Rohypnol, and nitrites—called “club drugs”—first became popular among teens and young adults at nightclubs, bars, and raves, nightlong dances often held in warehouses or other unusual settings. a. Their use by teenagers has been dropping in recent years. 2. How Users Feel a. Young people may take club drugs to relax, energize, and enhance their social interactions, but a large number also experience negative consequences. 3. Ecstasy a. Ecstasy (MDMA) is the most common street name for methylenedioxymethamphetamine, a synthetic compound with stimulant and mildly hallucinogenic properties that belongs to a family of drugs called enactogens, which literally means “touching within.” © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. MDMA increases the activity of three brain chemicals: dopamine, norepinephrine, and serotonin. c. Medical emergencies related to the drug have increased 75 percent in recent years. d. Ecstasy is more likely than other stimulants, such as methamphetamine, to kill young and healthy people between the ages of 16 and 24 who are not known to be regular drug users. e. Ecstasy poses risks similar to those of cocaine and amphetamines. 4. Herbal Ecstasy a. Herbal Ecstasy, also known as Cloud Nine, Herbal Bliss, and Herbal X, is a mixture of stimulants, such as ephedrine, pseudoephedrine, and caffeine. b. Sold in tablet or capsule form as a “natural” and safe alternative to Ecstasy, its ingredients vary greatly. c. Herbal Ecstasy can have dangerous and unpleasant side effects, including stroke, heart irregularities, and a disfiguring skin condition. 5. GHB and GBL a. Once sold in health-food stores for its muscle-building and alleged fatburning properties, gamma hydroxybutyrate (GHB)— also known as G, Georgia Home Boy, Grievous Bodily Harm, Liquid Ecstasy, Liquid X, Soap, and Scoop—was banned because of its effects on the brain and nervous system. i. The main ingredient is gamma butyrolactone (GBL), an industrial solvent often used to strip floors, which converts into GHB once ingested. ii. GHB acts as a sedative while producing feelings of euphoria and heightened sexuality as well as confusion and impaired memory. 6. Nitrites a. They are used recreationally for a high feeling, a slowed sense of time, a carefree sense of well-being, and intensified sexual experiences. E. Stimulants 1. Central nervous system stimulants are drugs that increase activity in some portion of the brain or spinal cord. 2. Amphetamine a. It triggers the release of epinephrine (adrenaline), which stimulates the central nervous system. i. How Users Feel (a) Amphetamine produces a state of hyperalertness and energy.

ii.

Risks (a) Amphetamine intoxication may cause feelings of grandiosity, increased heart rate, less frequent effects such as speeding up or slowing down of muscular movement, and in high doses, a rapid or irregular heartbeat. iii. Withdrawal (a) When the immediate effects of amphetamines wear off, users experience a crash and become shaky, irritable, anxious, and depressed. 3. Methamphetamine a. An addictive stimulant that is less expensive and possibly more addictive than cocaine or heroin, and has become American’s leading drug problem. i. How Users Feel (a) Methamphetamine (meth) causes the release of large amounts of dopamine, which causes a sensation of euphoria, increased self-esteem, and alertness. ii. Risks (a) Increased heart rate, blood pressure, wakefulness and physical activity, depressed appetite, and elevated body temperature. Other effects on the central nervous system include irritability, insomnia, confusion, tremors, convulsions, anxiety, paranoia, and aggressiveness. (b) Meth users engage in more sex, more carelessly. iii. The Toll on Society (a) Law enforcement officials consider meth their biggest drug problem. iv. Withdrawal (a) Meth addiction is difficult to treat. 4. Cocaine a. Cocaine (also called coke, snow, lady), is a white crystalline powder extracted from the leaves of the South American coca plant. i. Various forms (a) Freebase (b) Crack ii. How Users Feel (a) A powerful stimulant to the central nervous system, cocaine targets several chemical sites in the brain, producing feelings of soaring well-being and boundless energy. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. Risks (a) Cocaine dependence is an easy habit to acquire. (b) The physical effects of acute cocaine intoxication include dilated pupils, elevated or lowered blood pressure, perspiration or chills, nausea or vomiting, speeding up or slowing down of physical activity, muscular weakness, impaired breathing, chest pain, and impaired movements or muscle tone. (c) Cocaine use can cause blood vessels in the brain to clamp shut and can trigger a stroke, bleeding in the brain, and potentially fatal brain seizures. (d) Cocaine can damage the liver and cause lung damage in freebasers. (e) The combination of alcohol and cocaine is particularly lethal. iv. Withdrawal (a) When addicted individuals stop using cocaine, they often become depressed. (b) Other symptoms of cocaine withdrawal include fatigue, vivid and disturbing dreams, excessive or too little sleep, irritability, increased appetite, and physical slowing down or speeding up. F. Depressants 1. They depress the central nervous system, reduce activity, and induce relaxation, drowsiness, or sleep. 2. Benzodiazepines and Barbiturates a. These depressants are the sedative-hypnotics, also known as anxiolytic or antianxiety drugs. b. Rohypnol, also called Roofies, Rophie, Roche, or the Forget-Me Pill, is one of the benzodiazepines that has been of particular concern because of its abuse in date rape. i. How Users Feel (a) Low doses of these drugs may reduce or relieve tension, but increasing doses can cause a loosening of sexual or aggressive inhibitions. ii. Risks (a) All sedative-hypnotic drugs can produce physical and psychological dependence within 2–4 weeks. (b) Intoxication with these drugs can produce changes in mood and behavior. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

(c) Taken in combination with alcohol, these drugs have a synergistic effect that can be dangerous or even lethal. iii. Withdrawal (a) Withdrawal from sedative-hypnotic drugs may range from relatively mild discomfort to a severe syndrome with grand mal seizures, depending on the degree of dependence. 3. Opioids a. The opioids include opium and its derivatives (morphine, codeine, and heroin) and synthetic drugs that have similar sleep-inducing and painrelieving properties. b. Synthetic opioids include meperidine (Demerol), Methadone, and Propoxyphene (Darvon). c. How Users Feel i. All opioids relax the user. d. Risks i. Addiction is common. All regular users of opioids rapidly develop drug dependence, which can lead to lethargy, weight loss, loss of sex drive, and the continual efforts to avoid withdrawal symptoms through repeated drug administration. e. Withdrawal i. The intensity of opioid withdrawal depends on the degree of addiction. f. Fentanyl (the generic name for Sublimaze) i. This synthetic narcotic, which was developed as an anesthetic, may be 50–100 times more potent than morphine. ii. Injected when used in surgery, fentanyl (called Apache, Cash, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, Tango, TNT, and Tango) is usually snorted or smoked by abusers. G. Hallucinogens 1. Hallucinogens produce vivid and unusual changes in thought, feeling, and perception. 2. They do not produce dependence in the same way as cocaine or heroin. a. LSD (lysergic acid diethylamide) and peyote are common hallucinogens. H. Dissociative Drugs 1. Initially developed as general anesthetics for surgery, these drugs distort perceptions of sight and sound and produce feeling of dissociation or detachment from the environment or self. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Ketamine a. It is an anesthetic used by veterinarians. b. It has become common in club scenes and has been used as a date-rape drug. c. It can be addictive and cause long-term memory loss. 3. PCP a. It is an illicit drug manufactured as a tablet, capsule, liquid, spray, or crystal-like white powder than can be swallowed, smoked, sniffed, or injected. b. Its effects are utterly unpredictable. c. It may trigger violent behavior or irreversible psychosis the first time it is used, or the 20th time, or never. I. Inhalants 1. Inhalants or deleriants are chemicals that produce vapors with psychoactive effects. a. The most commonly abused inhalants are solvents, aerosols, modelairplane glue, cleaning fluids, and petroleum products like kerosene and butane. b. Only alcohol is a more widely used intoxicant among preteens and teens. c. At lower doses, users may feel slightly stimulated; at higher doses, they may feel less inhibited. d. Regular use of inhalants leads to tolerance, and the effects are unpredictable. IX. Treatment of Substance Dependence and Abuse A. Overview 1. An estimated 6.1 million Americans are in need of drug treatment, but most never get treatment. 2. The most difficult step is for users to admit that they are addicted. 3. Treatment can take place in an outpatient setting, a residential facility, or a hospital. 4. Personal treatment plans may consist of individual psychotherapy, marital and family therapy, medication, and behavior therapy. B. Principles of Drug Addiction Treatment 1. Principles that characterize effective drug abuse treatment include the following: a. Addiction is a complex but treatable disease that affects brain function and behavior. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

b. No single treatment is appropriate for everyone. c. Treatment needs to be readily available. d. Effective treatment attends to multiple needs of the individual. e. Remaining in treatment for an adequate time is critical. f. Counseling and other behavioral therapies are the most commonly used forms of drug abuse treatment. g. Medications are an important element of treatment. h. Many drug-addicted individuals also have other mental disorders. i. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change the long-term drug abuse. j. Treatment does not need to be voluntary to be effective. k. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. C. 12-Step Programs 1. As many as 200 different recovery programs are based on the spiritual 12step program. 2. The basic precept is that members have been powerless when it comes to controlling their addictive behavior on their own. 3. To get the most out of a 12-step program do the following: a. Try out different groups. b. Once you find a comfortable group, go back several times before making a final decision to continue. c. Keep an open mind. d. Accept whatever feels right to you and ignore the rest. D. Relapse Prevention 1. When relapses do occur, they should be viewed as neither a mark of defeat nor evidence or moral weakness. 2. The key is learning to avoid obvious cues and associations that can set off intense cravings. 3. Therapists emphasize that every lapse does not have to lead to a fullblown relapse.

Discussion Questions •

Ask the class to suggest examples of common OTC and prescription drugs and then discuss the advantages and disadvantages of these types of drugs.

•

Ask students to differentiate between drug use and drug misuse. What are the indicators that might signal a person has crossed the line between these two concepts? Ask the students for examples of appropriate drug use and of drug misuse.

•

Ask the class why some people become addicted to drugs, while others do not. Briefly explain the concepts of dosage, individual differences, setting, toxicity, and interaction with other drugs and alcohol. How do these factors affect drug use?

•

Discuss the ways in which drugs act to increase or negate the effect of other drugs. Ask the students how they might assess the effect of a drug when ingesting a certain food, taking another drug, or using alcohol. Is there any safe level of a drug?

•

Ask the students why they believe so many people allow themselves to enable others to continue using drugs? What are some examples of how individuals enable others to continue drug use?

•

Ask the students which drug they think is the most dangerous? Why? Are some drugs more dangerous for particular populations?

•

Familiarize students with generic versus brand-name drugs. What questions do they have regarding the differences and effectiveness of generic drugs versus brandname drugs? To whom should these questions or concerns be addressed? Discuss the value of seeking information from a pharmacist.

•

Ask the students to share information about their caffeine habits. What are some favorite sources? How do they feel when they haven’t had enough or need a boost? How many feel that they are physically and/or psychologically addicted to caffeine? How can you get over this addiction?

•

Ask students what factors contribute to the high levels of alcohol and drug use on campus. How do gender, race and ethnicity, early substance use, perception of risk, and environment influence drug use? What could be done to reduce the incidence?

•

Discuss quality control as it relates to illegal and street drug use. Who is responsible for ensuring safety, dosage amounts, and purity of these drugs? How can a person protect him or herself from accidental poisoning? What about with alcohol?

•

Just as any one drug is not used by all drug abusers, so must approaches to treatment be varied and personalized. Discuss the various approaches to drug treatment. Why is success in drug treatment so difficult to attain?

Classroom Activities Activity #1: Drug Effects on the Nervous System Purpose: To make students aware of the effects of drug use on the brain.

Time: One class period.

Introduction: Introduce the various drug categories to the class and the major functions of the different areas of the brain.

Method: 1.

Divide the class into the different drug categories (narcotics, stimulants, depressants, hallucinogens, marijuana, club drugs).

Once students have been assigned a category or a drug, have them outline the effects of their assigned drug.

After the effects of their drug have been identified, map out on the brain where these effects occur.

Discussion: 1.

How does it make you feel about drugs to see how they affect the various parts of the brain?

Knowing that drugs do affect our brain, why do you think people continue to use drugs?

How do drugs affect our brain chemistry?

Do you know people who have extensive damage to these areas as a result of drug use?

Activity #2: Identifying Your Resources Purpose: To make students aware of the resources available to them, for those who might be struggling with drugs or know someone close to them who is struggling with drugs.

Time: One class period, plus outside class time. Introduction: Introduce the various drug categories to the class and the major functions of the different areas of the brain.

Method: 1.

Have students locate and categorize the resources available on campus and in the community that provide information about drugs covered in this chapter and resources that aid in recovery from drug addiction.

You may want your students to report their findings within small groups, to combine into larger groups, or you may want to facilitate.

Discussion: 1.

You will want them to discuss how these services are available to the public, costs, if there are any restrictions, and so on.

Discuss why, if there are so many services available, people still neglect to use them.

What are some of the barriers for individuals seeking help?

Are there different resources for different ethnicities, religions, genders?

Are there resources for family members?

Knowing that drugs do affect our brain, why do you think people continue to use drugs?

How do drugs affect our brain chemistry?

Do you know people who have extensive damage to these areas as a result of drug use?

Activity #3: How Does Your Community Contribute to Drug Use? Purpose: To make students aware of how a community contributes to drug use.

Time: One class period, plus outside class time.

Method: 1.

Have students visit local businesses and organizations to determine how they are contributing to drug use. Examples of such might be: a. Grocery stores that do not restrict the sale of certain cold medications, whipping cream (inhalant use), cigarettes, and alcohol sales to minors. b. Department stores who sell clothes that promote various drugs. c. Stores that sell drug paraphernalia. d. Businesses that promote the sale of various drugs. e. Organizations that do nothing to discourage drug use. f. Community policies that promote or do nothing to prevent drug use.

You may want your students to report their findings within small groups or to the entire class.

Discussion: 1.

Were you surprised at your findings? Why or why not?

Do you think these businesses or organizations are aware of what they are doing?

Do you think these examples actually contribute to drug use, or do you think it has been blown out of proportion? Why or why not?

How might your community make stronger steps toward prevention? What can you personally do?

Activity #4: The Legalization of Marijuana Purpose: To help students understand that perspectives on what is legal and what is illegal may change over time.

Time: One class period, plus outside class time.

Method: 1.

Have students research the following questions: a. Which states have legalized recreational marijuana? b. Which states have legalized medical marijuana? c. Is growing marijuana also legal in those states which have legalized its use? d. What is the federal law with regard to marijuana growing and use?

Discussion: 1.

Do the state legalization events address whether or not marijuana is addictive, or otherwise unhealthy for a person?

Are there any cases in which medical marijuana is not acceptable?

In terms of marijuana use, can a person break a federal law even if they are not breaking a state law?

Activity #5: Are You Addicted to Caffeine? Purpose: To increase the awareness of caffeine intake and the possible health risks associated with it.

Time: One week.

Method: 1.

Students should keep a journal of their caffeine intake for one full week. Every drink, pill, or product that contains caffeine should be recorded.

Students should record the approximate caffeine content consumed. Students should refer to Table 11.1, food labels, or even the Internet to determine caffeine content.

Discussion: 1.

Discuss daily caffeine intake with students. Were they surprised by their results? Did they consume more or less caffeine than they anticipated?

Do students feel that they are addicted to caffeine? Do they experience withdrawal symptoms when they don’t have it?

Why do so many college students consume caffeine-containing products? Is there a healthier alternative?

References, Readings, and Resources Ahluwalia, N., and K. Herrick. “Caffeine Intake from Food and Beverage Sources and Trends among Children and Adolescents in the United States: Review of National Quantitative Studies from 1999 to 2011.” Advanced Nutrition 6, no. 1 (2015): 102–11. doi: 10.3945/ an.114.007401. American College Health Association. American College Health Association–National College Health Assessment II: Reference Group Executive Summary Fall 2015 (Hanover, MD: American College Health Association, 2016). American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Arlington, VA: American Psychiatric Association, 2013). American Society of Addiction Medicine. http://www. asam.org/advocacy/find-apolicy-statement/view-policy-statement/public-policy-statements/2011/12/15/ thedefinition-of-addiction. Johnston, L. D., et al. Monitoring the Future National Survey Results on Drug Use, 1975– 2015: Overview, Key Findings on Adolescent Drug Use (Ann Arbor: Institute for Social Research, University of Michigan, 2016). Kramer, J. L. “Medical Marijuana for Cancer.” CA: A Cancer Journal for Clinicians 65, no. 2 (2015): 109–22. doi: 10.3322/caac.21260. Reid, A. M., et al. “Frequent Nonprescription Stimulant Use and Risky Behaviors in College Stu- dents: The Role of Effortful Control.” Journal of American College Health 63, no. 1 (2015): 23–30. doi: 10.1080/07448481.2014.960422. Sahker, E.S, et al. “National Analysis of Differences among Substance Abuse Treatment Outcomes: College Student and Nonstudent Emerging Adults.” Journal of American College Health 63, no. 2 (2015): 118–24. doi: 10.1080/07448481.2014.990970. Scholes-Balog, K. E., et al. “A Prospective Study of Adolescent Risk and Protective Factors for Problem Gambling among Young Adults.” Journal of Adolescence 37, no. 2 (2014): 215–24. doi: 10.1016/j. adolescence.2013.12.006.

Films and Videos Addiction (Several of the nation's leading experts on drug and alcohol addiction, together with a group of accomplished filmmakers, have assembled to create Addiction, an unprecedented documentary aimed at helping Americans understand addiction as a treatable brain disease.) Hazelden Publishing P.O. Box 176 Center City, MN 55012-0176 P: 800-328-9000 F: 651-213-4793 E: Hazelden Publishing Addiction: A Comprehensive View (Made up of several concise segments, this program deals with a wide range of drugs, addiction issues, and case studies. Viewers will enter a chaotic Dallas ER, where the majority of injuries are drug and alcohol related, and meet a desperate middle-aged woman who finally turns in her heroin-addicted daughter to police.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Addictions: Chemical and Behavioral (Addiction is a way to escape from anxiety, anger, or pain—unfortunately, it also leads to them. This video shows how addictions develop and how they can involve both substances and behaviors.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group The Addictive Personality (Does addiction have a genetic factor? Can any type of addiction be treated medically? What steps can family members take to help a loved one struggling with addiction? © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

This program provides answers to several addiction-related questions, focusing on the complexities of the addictive personality.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Bill W. (A documentary about the co-founder of Alcoholics Anonymous. With Bill as its driving force, A.A. grew from a handful of men to a worldwide fellowship of over 2 million men and women, a success that made him an icon within A.A., but also an alcoholic unable to be a member of the very society he had created.) Hazelden Publishing P.O. Box 176 Center City, MN 55012-0176 P: 800-328-9000 F: 651-213-4793 E: Hazelden Publishing Breaking Point: Heroin in America (In this 20/20 special report, David Muir takes us to New Hampshire and inside the lives of recovering heroin addicts, their families, the health professionals working to help them, and those who do not survive.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Cracked, Not Broken: One Woman's Struggle with Addiction and Recovery (Nothing reveals the dangers of drug addiction more accurately than honesty. In this intense program, filmmaker Paul Perrier interviews a family friend, crack cocaine– addicted Lisa, in her dingy hotel room where she prostitutes herself to earn the money she needs to buy drugs.) Films Media Group 132 West 31st Street, 16th Floor © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Gambling Addiction—Adolescent Problems and Workable Solutions (In this video, experts discuss compulsive gambling behavior, possible symptoms, and how to get help. Gambling addicts share their stories.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Heroin: Cape Cod, USA (Twenty years after his groundbreaking Emmy®-nominated film Black Tar Heroin: The Dark End of the Street, which chronicled three years in the lives of five young heroin addicts in San Francisco’s Tenderloin, Academy Award®-winning filmmaker Steven Okazaki turns his focus to America’s current opiate-addiction crisis with Heroin: Cape Cod, USA.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group It's Not about Money (Winner of Time Inc.'s 2000 Freddie (Medical and Media) Award for Behavioral Disease, Gambling: It's Not about the Money, features first-hand testimonials from a diverse group of recovering compulsive gamblers who help viewers identify the symptoms of gambling addiction and offer help for long-term recovery.) Hazelden Publishing P.O. Box 176 Center City, MN 55012-0176 P: 800-328-9000 F: 651-213-4793 E: Hazelden Publishing © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Medical Aspects of Chemical Dependency: The Neurobiology of Addiction (This fascinating and authoritative video on how addiction affects brain function outlines the latest research on brain chemistry. Includes commentary by Dr. David E. Smith, founder of the Haight Ashbury Free Clinic. ) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Myths of Addiction (Not all opinions about alcohol and other drug addiction are based on fact. Produced by Hazelden and Twin Cities Public Television, this video debunks commonly held myths and misconceptions about the nature and treatment of addiction.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Oxyana (Once a thriving mining community, now a destitute hinterland ravaged by its addiction to a prescription painkiller, the West Virginian town of Oceana is a portentous glimpse of the American dream, collapsed.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Rehab (“A year from now, two of you will be dead.” So begins an orientation session at Camp Recovery, a Santa Cruz drug and alcohol treatment center. This documentary follows five young addicts through the camp’s 30-day rehab program and tracks their progress, or lack thereof, in the months that follow.) Films Media Group © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Treating Stimulant Addiction: The CBT Approach (A nonmedical approach, Cognitive Behavioral Therapy (CBT) is considered the most effective treatment for stimulant addiction. This program goes inside the MATRIX Institute on Addictions, where methamphetamine and cocaine addicts attend evidencebased behavioral therapy groups as well as individual and family counseling, drug testing, and 12-step programs.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group What Is Addiction? (To understand the nature of substance abuse and why an individual succumbs to addiction, a wide range of factors must be examined. This program follows Dr. Nora Volkow, Director of the National Institute on Drug Abuse, as she conducts informal group therapy with addicts and their family members.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources Al-Anon/Alateen A 12-step recovery program for teens who are affected or concerned about a relative or friend’s drinking. Al-Anon Family Groups

Association for Medical Education and Research in Substance Abuse (AMERSA) AMERSA members have developed, implemented, and evaluated state-of-the-art curricula, educational programs, and faculty development programs. Members have developed clinical and research measures for substance abuse services and professional education. They are actively engaged in research related to substance abuse education, clinical service, and prevention. AMERSA Substance Abuse and Mental Health Services Administration (SAMHSA) – Center for Substance Abuse Prevention (CSAP) CSAP works with states and communities to develop comprehensive prevention systems that create healthy communities in which people enjoy a quality life. This includes supportive work and school environments, drug- and crime-free neighborhoods, and positive connections with friends and family. Center for Substance Abuse Prevention SAMSA—Center for Substance Abuse Treatment (CSAT) The Treatment Improvement Exchange (TIE) is a resource sponsored by the Division of State and Community Assistance of the CSAT to provide information exchange between CSAT staff and state and local alcohol and substance abuse agencies. The TIE Contract is funded by the CSAT, Substance Abuse, and Mental Health Services Administration. Center for Substance Abuse Treatment Club Drugs Service of the National Institute of Drug Abuse, providing information on club drugs. Club Drugs Cocaine Anonymous World Services Information for addicts, professionals, and families. Cocaine Anonymous World Services U.S. Drug Enforcement Administration (DEA) Supplies information, statistics, and photos of psychoactive drugs; also provides information on U.S. drug enforcement activities. U.S. Drug Enforcement Administration

Drug Strategies A nonprofit research institute that promotes more effective approaches to the nation’s drug problems and supports private and public efforts to reduce the demand for drugs through prevention, education, treatment, law enforcement, and community initiatives. Drug Strategies Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention Provides support for campus alcohol and illegal drug prevention efforts. Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention Narcotics Anonymous World Services Similar to AA, this site sponsors 12-step meetings and provides other support services for abusers. Narcotics Anonymous World Services National Center on Addiction and Substance Abuse (CASA) at Columbia University Information about the costs of substance abuse to individuals and society. National Center on Addiction and Substance Abuse National Institute on Alcohol Abuse and Alcoholism (NIAAA) NIAAA supports and conducts research on the impact of alcohol use on human health and well-being. National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse Develops and supports research on drug abuse prevention programs. National Institute on Drug Abuse Office of National Drug Control Policy The principal purpose of ONDCP is to establish policies, priorities, and objectives for the nation’s drug control program. The goals of the program are to reduce illicit drug use, manufacturing, and trafficking, drug-related crime and violence, and drug-related health consequences. Office of National Drug Control Policy

The Partnership for Drug-Free Kids The Partnership for Drug-Free Kids is a nonprofit coalition of communication, health, medical, and educational professionals working to reduce illicit drug use and help people live healthy and drug-free lives. The Partnership for Drug-Free Kids National Council on Alcoholism and Drug Dependence (NCADD) NCADD fights the stigma and the disease of alcoholism and other drug addictions. National Council on Alcoholism and Drug Dependence

Keywords addiction

gamma butyrolactone (GBL)

addictive

generic

amphetamines

hallucinogen

antagonistic

hashish

barbiturates

inhalants

benzodiazepine

intoxication

cannabinoids

intramuscular

cathinone

intravenous

club drugs

LSD (lysergic acid diethylamide)

cocaine

marijuana

designer drugs

opioids

dopamine

over-the-counter (OTC)

drug

PCP (phencyclidine)

drug abuse

physical dependence

drug dependence

polyabuse

drug diversion

potentiating

drug misuse

psychoactive

ecstasy (MDMA)

psychological dependence

gambling disorder

salvia

gamma hydroxybutyrate (GHB)

stimulant

subcutaneous

12-Step program

synergistic

withdrawal

toxicity

Answers to Global Health Watch 1. a 2. d 3. novelty-seeking

12 Alcohol and Tobacco Learning Objectives After studying this chapter in the text, the student should be able to: 12.1 Outline the patterns of alcohol consumption among different populations in America. 12.2 Discuss the patterns, reasons, and perils of drinking on campus. 12.3 Describe the characteristics of alcohol and its effects on human health. 12.4 Explain how alcohol is associated with serious health risks and disorders. 12.5 Review racial, ethnic, and gender differences in alcohol-related risks. 12.6 Examine the health consequences of alcohol-related disorders. 12.7 Compare the patterns of tobacco consumption among the populations in America. 12.8 Outline the patterns of tobacco consumption among different groups of students. 12.9 Discuss gender, racial, and ethnic differences in tobacco consumption. 12.10 Identify immediate effects of tobacco consumption on body and brain functions. 12.11 Evaluate the serious health risks and dangers associated with cigarette smoking. 12.12 Review the health risks posed by different forms of tobacco. 12.13 Compare the different ways of quitting to show advantages and disadvantages of each. 12.14 Analyze the harmful effects of environmental tobacco smoke on health.

Chapter Summary Even if you never abuse alcohol or smoke, you live with the consequences of others’ drinking and smoking. That’s why it’s important for everyone to know about the health risks of alcohol and tobacco. This chapter provides information that can help you understand, avoid, and change behaviors that could undermine your health, happiness, and life. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Lecture Outline I.

Drinking in America A. Introduction 1. Although many Americans drink alcohol, most do not misuse or abuse it. 2. Alcohol is the third leading preventable cause of death in the United States. 3. No medical conditions other than heart disease cause more disability and premature death than alcohol-related problems. B. Why People Don’t Drink 1. More Americans are choosing not to drink and alcohol consumption is at its lowest level in decades. 2. Nonalcoholic beverages have grown in popularity. 3. Certain people should not drink at all. These include: a. Anyone younger than 21. b. Anyone who plans to drive, to operate motorized equipment, or to engage in other activities that require alertness and skill. c. Women who are pregnant or trying to become pregnant. d. Individuals taking certain over-the-counter or prescription medications. e. People with medical conditions that can be made worse by drinking. f. Recovering alcoholics. C. Why People Drink 1. The most common reason people drink is to relax. a. Confirmatory drinking—drinking to reinforce the image of masculinity associated with alcohol consumption. b. Compensatory drinking—consuming alcohol to heighten their sense of masculinity or femininity. 2. Other reasons men and women drink include: a. Social ease b. Role models c. Advertising d. Relationship issues e. Childhood traumas f. Unemployment g. Psychological factors h. Self-medication i. Depression

j. Inherited susceptibility k. Long work hours. II.

Drinking on Campus A. Overview 1. Young adults are the most frequent users of alcohol in the United States. 2. The highest proportion of heavy drinkers and individuals with diagnosable alcohol abuse disorders are 18 to 25 years old. 3. According to the NIAAA, four in five college students drink alcohol, and about half of them engage in binge drinking. 4. More students drink simply to get drunk and drink more per drinking episode. 5. About one-third of students increase alcohol use and encounter more related problems throughout the college years, one-third do not change previous patterns, and one-third decrease drinking. B. Why Students Don’t Drink 1. About 25.5 percent of students report never using alcohol. 2. Students who do not drink give various reasons for their choice, including being under 21, not having access to alcohol, parental or peer pressure, costs, not liking the taste, and spiritual or religious values. 3. Spiritual and religious values also influence drinking on campus. C. Why Students Drink 1. Undergraduates have always turned to alcohol for the same reasons. 2. The most common influences on student drinking include: a. Social norms b. Coping c. Party schools d. Living arrangements e. Weekends and Special Occasions f. Spring break g. Participation in sports h. Parental attitudes i. First-year transition j. Victimization k. Discrimination l. Sexual orientation m. Alcohol-related cues.

D. High-Risk Drinking on Campus 1. Overview a. The most common types of student high-risk drinking are binge drinking, predrinking, underage drinking, and binge drinking combined with disordered eating and consumption of caffeinated alcoholic beverages. 2. Binge Drinking a. According to the NIAAA, a binge is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram-percent or above. i. For a typical adult man, this pattern corresponds to consuming five or more drinks in about 2 hours; for a woman, four or more drinks. 3. Who Binge-Drinks in College? a. An estimated 4 in 10 college students drink at binge levels or greater. Here are some of their characteristics: i. Binge drinkers are more likely to be male than female, although one in three female students reports binge drinking. ii. They are more likely to be white than any other ethnic or racial group. iii. Most are under age 24. iv. More binge drinkers are enrolled in 4-year colleges than in 2-year ones. v. Binge drinkers tend to be residents of states with fewer alcohol control policies. vi. Binge drinkers tend to be involved in athletics and socialize frequently. vii. They tend to be in a fraternity or sorority. viii. They are dissatisfied with their bodies, not prone to exercise, eat poorly, and go on unhealthy diets. ix. Binge drinkers tend to be behind in schoolwork or miss class. x. They are often users of other substances, including nicotine, marijuana, cocaine, and LSD. xi. Binge drinkers are likely to be injured or hurt, to engage in unplanned or unprotected sexual activity, or to get in trouble with campus police. b. Why Students Binge-Drink i. Low price for alcohol ii. Easy access to alcohol iii. Proximity to other binge drinkers iv. Peer pressure © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

v. Family attitudes vi. Early access to alcohol vii. Campus environment viii. Drinking games c. Binge Drinking and Disordered Eating i. The combination of two risky behaviors—disordered eating and heavy drinking—poses special dangers to students. ii. In women, the combination of these behaviors increases the risk of many negative consequences, including blackouts, unintended sexual activity, and forced sexual intercourse. d. Predrinking/Pregaming i. Drinking before going out has become increasingly common on college campuses, where predrinking (also called prepartying, prefunking, pregaming, preloading, or front-loading) is announced and celebrated in text messages, e-mails, blogs, YouTube videos, and Facebook posts. e. Why Is Predrinking Popular? i. Economy ii. Intoxication iii. Socializing iv. Hooking up with a partner for the evening v. Anxiety reduction vi. Group bonding f. The Perils of Predrinking i. Various studies have shown that students drink more and have higher blood-alcohol concentrations on days when they predrink. ii. They are also at greater risk of blackouts, passing out, hangovers, and alcohol poisoning. iii. In addition to drinking more alcohol, predrinkers are more likely to use other drugs, such as marijuana and cocaine. g. Underage Drinking on Campus i. Students under age 21 drink less often than older students but tend to drink more heavily and to experience more negative alcohol-related consequences. h. Caffeinated Alcoholic Beverages i. Alcohol mixed with energy drinks (AmEDs) refers to any combination of alcohol with caffeine and other stimulants. ii. The caffeine in these drinks may mask the depressant effects of alcohol, but it has no effect on the liver’s metabolism of alcohol and thus does not reduce blood alcohol concentrations or reduce alcohol-related risks. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. College students who use AmEDs are more likely to belong to a fraternity or sorority; participate in athletics; live off campus; use alcohol to relax and have more fun; and binge-drink. E. Why Students Stop Drinking 1. Only 1 percent of students aged 18–24 receive treatment for alcohol or drug abuse. a. Nonetheless, as many as 22 percent of college students who abuse alcohol “spontaneously” reduce their drinking as they progress through college. 2. Unlike older adults, who often hit bottom before they change their drinking behaviors, many college students go through a gradual process of reduced drinking. 3. Psychologists have found that students “mature out” of heavy drinking as they become less impulsive and develop healthier coping behaviors. F. Alcohol-Related Problems on Campus 1. As many as 10–30 percent of college students experience some negative consequences of drinking. 2. Consequences of Drinking a. Atypical behavior b. Academic problems c. Risky sexual behavior d. Sexual assault e. Intimate partner violence f. Unintentional injury g. Consequences beyond college h. Illness and death 3. Drinking and Driving a. In the ACHA survey, 21.2 percent of students reported driving after having had any alcohol; 2.2 percent reported driving after five or more drinks. b. Alcohol impairs driving-related skills regardless of the age of the driver or the time of day it is consumed. i. However, younger students who drink and drive are at greatest risk. 4. Secondhand Drinking Problems a. Heavy alcohol use can endanger both drinkers and others. b. Secondhand problems caused by others’ alcohol use include: i. Loss of sleep ii. Interruption of studies © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. Assaults iv. Vandalism v. Unwanted sexual advances and sexual harassment III. Understanding Alcohol A. Overview 1. Alcohol is a colorless liquid obtained through the fermentation of a liquid containing sugar. 2. Ethyl alcohol, or ethanol, is the type of alcohol in alcoholic beverages. 3. Any liquid containing 0.05–80 percent ethyl alcohol by volume is an alcoholic beverage. 4. One drink can be any of the following: a. One bottle or can (12 ounces) beer, which is 5 percent alcohol. b. One glass (4 or 5 ounces) table wine, such as burgundy, which is 12 percent alcohol. c. One small glass (2 ½ ounces) fortified wine, which is 20 percent alcohol. d. One shot (1 ounce) distilled spirits (such as whiskey, vodka, and rum), which is 50 percent alcohol. 5. Drinks at college parties vary greatly in their alcoholic content. 6. It may be impossible for students to monitor their alcohol intake simply by counting the number of drinks they have. 7. The words bottle and glass can also be deceiving: a. Drinking a 16-ounce bottle of malt liquor, which is 6.4 percent alcohol, is not the same as drinking a 12-ounce glass of light beer (3.2 percent alcohol) b. Two bottles of high-alcohol wines packaged to resemble much less powerful wine coolers can lead to alcohol poisoning. 8. With distilled spirits, alcohol content is expressed in terms of proof. a. Proof is a number that is twice the percentage of alcohol: 100 proof is 50 percent alcohol. 9. In a recent study, 18 percent of college students overestimated and 10 percent underestimated their alcohol consumption. B. Blood Alcohol Concentration 1. BAC is expressed in the terms of percentage of alcohol in the blood and is often measured from breath or urine samples. a. Law enforcement officers use BAC to determine whether a driver is legally drunk. b. All the states have followed the recommendation of the federal Department of Transportation to set 0.08 percent. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

A 150-pound man would have had to consume three mixed drinks within an hour threshold to be cited for drunk driving. 2. Factors that influence BAC: a. How much and how quickly you drink b. What you are drinking i. Absorption is the rate of the passage of substances into or across membranes or tissues. c. Mixers d. Your size e. Your gender f. Your age g. Your race h. Other drugs i. Family history of alcoholism j. Eating k. Expectations l. Physical tolerance C. Moderate Alcohol Use 1. The federal government’s Dietary Guidelines for Americans recommended no more than one drink a day for women and no more than two drinks a day for men. 2. The American Heart Association advises that alcohol account for no more than 15 percent of the total calories consumed by an individual every day, up to an absolute maximum of 1.75 ounces of alcohol a day. 3. Moderate alcohol use has been linked with some positive health benefits, including lower risks of heart disease. a. However, even occasional binges of four to five drinks a day can undo alcohol’s positive effects. 4. The benefits of alcohol are also related to age. a. Below age 40, drinking at all levels is associated with an increased risk of death. b. Among people older than 50 or 60, moderate drinkers have the lowest risk of death. D. Alcohol Intoxication 1. Intoxication can range from mild inebriation to loss of consciousness. a. Characterized by at least one of the following symptoms: i. Slurred speech, poor coordination, unsteady gait, abnormal eye movements, impaired attention or memory, stupor, or coma.

2. Medical risks of intoxication include falls, hypothermia in cold climates, and increased risk of infections because of suppressed immune function. 3. Time and a protective environment are the recommended treatments for alcohol intoxication. E. Alcohol Poisoning 1. In large enough doses, alcohol can and does kill. a. According to the CDC, alcohol poisoning kills more than 2,200 Americans a year—an average of six people a day. b. About three in four are men, most often between the ages of 35 and 64. 2. Alcohol depresses nerves that control involuntary actions, such as breathing and the gag reflex (which prevents choking). a. A fatal dose of alcohol will eventually suppress these functions. 3. Signs of alcohol poisoning: a. Mental confusion, stupor, coma, or person cannot be roused b. Vomiting c. Seizures d. Slow breathing e. Irregular breathing f. Hypothermia IV. The Impact of Alcohol on the Body A. Overview 1. Unlike food or drugs in tablet form, alcohol is directly and quickly absorbed into the bloodstream through the stomach walls and upper intestine. 2. Most (about 95 percent) of the alcohol you drink can leave your body only after metabolism by the liver. 3. Alcohol is a diuretic, which is a drug that speeds up the elimination of fluid from the body. a. Drink water while drinking alcohol to maintain fluid balance. B. Digestive System 1. In the stomach, alcohol triggers the secretion of acids, which irritate the stomach lining. 2. In the liver excess alcohol is converted to fat. 3. More than 2 million Americans have alcohol-related liver diseases. C. Weight and Waists 1. Alcohol has 7 calories per gram. 2. In addition to being a calorie-dense food, alcohol stimulates the appetite, so you are likely to eat more. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

D. Cardiorespiratory System 1. Alcohol gets mixed reviews regarding its effects on the cardiorespiratory system. 2. Some cardiologists contend that the benefits of moderate drinking may be overstated, especially because of alcohol’s contribution to the epidemic of obesity. E. Cancer 1. Overall past and current drinking may contribute to about 10 percent of all cancer cases in men and 3 percent in women. 2. Alcohol consumption has been specifically implicated as a cause of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon– rectum, pancreas, and female breast. F. Brain and Behavior 1. Moderate amounts of alcohol can have disturbing effects on perception and judgment, including the following: a. Impaired perceptions b. Dulled sense of smell and taste c. Diminished sensation d. Alerted sense of space e. Impaired motor skills f. Sleep problems g. Impaired sexual performance h. Less impulse control G. Interactions with Other Drugs 1. Alcohol can interact with other drugs—prescription and nonprescription, legal and illegal. 2. Of the 100 most frequently prescribed drugs, more than half contain at least one ingredient that interacts adversely with alcohol. H. Immune System 1. Chronic alcohol use can inhibit the production of both white blood cells, which fight off infections, and red blood cells, which carry oxygen to all the organs and tissues of the body. I. Increased Risk of Dying 1. Alcohol is responsible for 100,000 deaths each year and is the third leading cause of death after tobacco and improper diet and lack of exercise. a. The leading alcohol-related cause of death is injury. b. The second leading cause of alcohol-related deaths is cirrhosis of the liver.

c. Young drinkers—teens and those in their early 20s—are at highest risk of dying from injuries, mostly car accidents. d. Drinkers over age 50 face the greatest danger of premature death from cirrhosis of the liver, hepatitis, and other alcohol-linked illnesses. V.

Alcohol, Gender, and Race Experts are increasingly recognizing racial and ethnic differences in risk factors for drinking problems, patterns of drinking, and most effective types of treatment. A. Gender 1. In general, men drink more frequently, consume larger quantities of alcohol per drinking occasion, and report more problems related to drinking. 2. More than half of women drink. They drink alone more often, binge less, have more regular drinking patterns, and drink smaller quantities than men. 3. The bodies of men and women respond to alcohol in different ways. 4. An estimated 15 percent of women drink alcohol while pregnant, most having one drink or less per day. a. Fetal alcohol effects (FAE) can occur from even light consumption of alcohol. These include: i. Low birth weight ii. Irritability as a newborn iii. Permanent mental impairment b. An estimated 2–5 percent of children may have a fetal alcohol spectrum disorder (FASD), a cluster of physical and mental defects that include: i. Small head ii. Abnormal facial features iii. Sluggish motor development iv. Failure to thrive v. Short stature vi. Delayed speech vii. Lower IQ viii. Hyperactivity 5. Alcohol interferes with male sexual function and fertility. B. Race 1. African Americans a. Overall, African Americans consume less alcohol per person than whites, yet twice as many blacks die of cirrhosis of the liver each year.

2. Hispanics a. The various Hispanic cultures tend to discourage any drinking by women but encourage heavy drinking by men as part of machismo, or feelings of manhood. 3. Native Americans a. European settlers introduced alcohol to Native Americans. b. Because of the societal and physical problems resulting from excessive drinking, at the request of tribal leaders, the U.S. Congress in 1832 prohibited the use of alcohol by Native Americans. i. Many reservations still ban alcohol use. c. Native Americans have three times the general population’s rate of alcohol-related injury and illness. 4. Asian Americans a. Asian Americans tend to drink very little or not at all, in part because of an inborn physiological reaction to alcohol that causes facial flushing, rapid heart rate, lowered blood pressure, nausea, vomiting, and other symptoms. VI. Alcohol-Related Disorders A. Introduction 1. As many as one in six adults in the United States may have a problem with drinking, which means, by the simplest definition, that they use alcohol in any way that creates difficulties, potential difficulties, or health risks. B. Alcohol Use Disorder 1. Approximately 17 million adults—an estimated 7.2 percent of Americans over age 18, 9.9 percent of men, and 4.6 percent of women—have an alcohol use disorder. a. The prevalence of this problem is greatest among individuals ages 18– 29 but declines over the lifetime. 2. In its most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association defines an alcohol use disorder as a problematic pattern of alcohol use leading to significant impairment or distress and characterized by at least two of the following: a. Drinking larger amounts of alcohol or drinking for a longer time than intended b. A strong urge or craving to use alcohol c. Persistent desire or unsuccessful efforts to cut down or control alcohol use © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

d. Spending a great deal of time obtaining or using alcohol or recovering from its effects e. Use of alcohol in physically hazardous situations f. Continued alcohol use despite social, interpersonal, or occupational problems caused by drinking g. Tolerance, as defined by a need for markedly increased amounts of alcohol to achieve the desired effect or a markedly diminished effect with continued use of the same amount of alcohol h. Withdrawal, including symptoms such as sweating, rapid pulse, increased hand tremors, insomnia, nausea or vomiting, temporary hallucinations or illusions, physical agitation or restlessness, anxiety, or seizures. 3. Alcoholism, as defined by the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine, is a primary, chronic disease whose development and manifestations are influenced by genetic, psychosocial, and environmental factors. a. The disease is often progressive and fatal and is characterized by: i. An inability to control drinking ii. A preoccupation with alcohol iii. Continued use of alcohol despite adverse consequences iv. Distorted thinking, most notably denial C. Causes of Alcohol Dependence and Abuse 1. Genetics 2. Parental alcoholism 3. Drug abuse 4. Stress and traumatic experiences D. Medical Complications of Alcohol Abuse and Dependence 1. Liver disease 2. Cardiorespiratory disease 3. Cancer 4. Brain damage 5. Vitamin deficiencies 6. Digestive problems VII. Treatment for Alcoholism A. Individuals whose drinking could be hazardous to their health may choose from a variety of approaches, including medication, inpatient or outpatient treatment, behavioral therapy, support groups, or a combination. 1. There is no one path to sobriety. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

VIII.

B. The most widely prescribed medications for alcoholism recovery include: 1. Disulfiram (Antabuse), in use for more than 50 years, causes unpleasant effects when even small amounts of alcohol are consumed. 2. Acamprosate (Campral), combined with counseling and social support, helps the brains of people who have drunk large amounts of alcohol work normally again. 3. Naltrexone (Revia, Decade, and Vivitrol) reduces cravings, perhaps by blocking the normal pleasurable reaction of the part of the brain that reacts to alcohol or opioids. C. Individuals with alcohol abuse problems may receive intensive inpatient treatment for 28 days or longer in a hospital or residential facility. D. Cognitive behavioral therapies reinforce motivation to abstain, enhance coping skills, facilitate self-change, and deal with adverse effects. E. AA offers support from others struggling with the same illness, from a sponsor available at any time of the day or night, and from fellowship meetings that are held every day of the year. Its 12 steps, which emphasize honesty, sobriety, and acknowledgment of a “higher power,” have become the model for self-help groups for other addictive behaviors, including drug abuse. F. Alternatives to AA include Secular Organizations for Sobriety (also known as Save Ourselves, or SOS), developed for people who do not accept the spirituality of AA, and Rational Recovery, which focuses on learning to control the impulse to drink by controlling the emotions that trigger a desire to drink. G. Harm reduction therapy is a controversial approach that aims to help substance abusers reduce the negative impact of alcohol or drugs on their lives. Recovery A. Recovery from alcoholism is a lifelong process of personal growth and healing. 1. The first 2–3 years are the most difficult, and relapses are extremely common. B. Relapse prevention includes the development of coping strategies, social skills training, and mindfulness training.

IX. Tobacco in America A. According to the Center for Disease Control and Prevention (CDC), some 42 million men and women smoke.

1. American Indians and Alaska Natives have the highest smoking rates, while Asians and Hispanics have the lowest. 2. Smoking rates vary in different regions. 3. Smoking rates are highest among those who are poor; who are mentally ill; who abuse drugs and alcohol; who have a disability; and who are lesbian, gay, bisexual, and transgendered. B. Why Do People Start Smoking? 1. Limited education 2. Underestimation of risks 3. Adolescent experimentation and rebellion 4. Stress 5. Parental role models 6. Addiction 7. Genetics 8. Weight control 9. Mental disorders C. Tobacco Use Disorder 1. In its DSM-5, the American Psychiatric Association defines a tobacco use disorder as “a problematic pattern of tobacco use leading to clinically significant impairment or distress,” characterized by at least two of the following signs and symptoms within a 12-month period: a. Use of tobacco in larger amounts or over a longer period than was intended b. Persistent desire or unsuccessful efforts to cut down or control tobacco use c. A great deal of time spent in activities necessary to obtain or use tobacco d. Craving, or a strong desire or urge to use tobacco e. Interference with obligations at work, school, or home because of continued tobacco use f. Persistent or recurrent social or interpersonal problems, such as arguments about smoking, caused or exacerbated by tobacco g. Giving up or cutting back on important social, occupational, or recreational activities h. Recurrent tobacco use in physically hazardous situations, such as smoking in bed i. Continued tobacco use despite a persistent or recurrent physical or psychological problem caused or exacerbated by tobacco

Tolerance, as indicated by a need for markedly increased amounts of tobacco to achieve the desired effect or a markedly diminished effect with continued use of the same amount of tobacco k. Withdrawal, as indicated by symptoms such as irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, and insomnia, or use of tobacco or closely related substances to avoid such symptoms. X.

Tobacco Use on Campus A. Introduction 1. About 12 percent of students report smoking in the previous 30 days. 2. More than 7 in 10 have never smoked. B. Social Smoking 1. “Social smokers” average less than one cigarette a day and smoke mainly in the company of others. 2. Even smokers who don’t inhale or nonsmokers who breathe in secondhand smoke are at increased risk for negative health effects. 3. Social smokers are less motivated to quit and make fewer attempts to do so. C. College Tobacco Control Policies 1. More than 1,300 schools have 100 percent smoke- or tobacco-free policies; others prohibit smoking everywhere but in designated areas. a. Enforcement of campus tobacco bans varies, and student smokers often ignore or disregard their schools’ policies. D. Smoking, Gender, and Race 1. Almost 1 billion men in the world smoke—about 35 percent of men in developed countries and 50 percent of men in developing countries. a. Male smoking rates are slowly declining, but tobacco still kills about 5 million men every year. b. Men also face specific risks because smoking: i. Increases the risk of aggressive prostate cancer ii. May affect male hormones, including testosterone iii. Can reduce blood flow to the penis, impairing a man’s sexual performance and increasing the likelihood of erectile dysfunction 2. About 20 million women and girls in the United States smoke. a. Women are as likely as men to die from smoking-related diseases. i. Their relative risk of dying from coronary heart disease is now higher than it is for men.

XI. Tobacco’s Immediate Effects A. Introduction 1. Tobacco is an herb that can be smoked or chewed, directly affects the brain. 2. While its primary active ingredient is nicotine, tobacco smoke contains almost 400 other compounds and chemicals. B. How Nicotine Works 1. A colorless, oily compound, nicotine is poisonous in concentrated amounts. 2. The FDA has concluded that nicotine is a dangerous, addictive drug that should be regulated. 3. Nicotine affects the brain in much the same way as cocaine, opiates, and amphetamines, triggering the release of dopamine, a neurotransmitter associated with pleasure and addiction. 4. Nicotine may enhance performance on some tasks but leaves other mental skills unchanged. 5. Nicotine stimulates the adrenal glands to produce adrenaline, a hormone that increases blood pressure, speeds the heart rate, and constricts blood vessels. C. Tar and Carbon Monoxide 1. As it burns, tobacco produces tar, a thick, sticky dark fluid made up of several hundred different chemicals—many of them poisonous, some of them carcinogenic. 2. Smoke from cigarettes, cigars, and pipes also contains carbon monoxide, the deadly gas that comes out of the exhaust pipes of cars. XII. Health Effects of Cigarette Smoking A. Overview 1. More than 10 times as many U.S. citizens have died prematurely from cigarette smoking than in all the wars fought in the history of the United States. B. Health Effects on Students 1. An estimated 6.4 million young people will eventually suffer premature death or diminished quality of life, or both, as a result of smoking-related diseases. 2. Young people who smoke are less physically fit and suffer diminished lung function and growth. 3. Long-term health consequences of smoking in young adulthood include dental problems, lung disorders, heart disease, and cancer. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

C. Premature Death 1. Smoking kills, robbing smokers of a decade of life. 2. Mortality among current smokers is two to three times as high as that of people who never smoked. 3. Research has tied the higher death rates to 21 diseases proven to be caused by smoking. a. However, a long-term analysis has found that smoking also may increase the risk of dying by contributing to other diseases. D. Heart Disease and Stroke 1. Heart attack is the leading cause of death for smokers. 2. The federal Office of the Surgeon General blames cigarettes for 1 in every 10 deaths attributable to heart disease. 3. Even people who have smoked for decades can reduce their risk of heart attack if they quit smoking. E. Cancer 1. Smoking is linked to at least ten different cancers and accounts for 30 percent of all deaths from cancer. F. Respiratory Diseases 1. Smoking quickly impairs the respiratory system, including the cough reflex, a vital protective response. 2. Smoking is a major cause of chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. G. Other Harmful Effects 1. Smoking: a. Can cause diabetes mellitus and rheumatoid arthritis b. Contributes to gum disease and the loss of teeth and teeth-supporting bone, even in individuals with good oral hygiene c. Worsens the symptoms or complications of allergies, hypertension, cirrhosis of the liver, peptic ulcers, and disorders of the lungs or blood vessels d. Is an independent risk factor for high-frequency hearing loss and adds to the danger of hearing loss for those exposed to noise XIII. Emerging Tobacco Products A. Overview 1. Cigarettes remain the most widely used form of tobacco, but more college students are trying new or “emerging” tobacco products.

B. Electronic Cigarettes 1. E-cigarettes are battery-powered devices that deliver aerosolized nicotine and additives flavored with chocolate, mint, candy, and other sweetness. 2. In the ACHA survey, 84.6 percent of students had never used e-cigarettes, while about 5 percent reported any use in the previous 30 days. 3. Cigarette smokers report being attracted to e-cigarettes for several reasons, including lower cost, perceived lesser danger, freedom to use them in some places where cigarettes are banned, and enjoyment of the “smoking experience.” 4. Researchers have found that puffing on e-cigarettes produces airway constriction and inflammation, which might lead to serious lung diseases such as emphysema. 5. Other potential risks include headache, cough, dizziness, sore throat, nosebleeds, chest pain or other cardiovascular problems, and allergic reactions such as itchiness and swelling of the lips. C. Water Pipes (Hookahs) 1. Also known as narghile, arghile, and hubble-bubble, water pipes involve the passage of smoke through water prior to inhalation. 2. Although also used to smoke other substances including marijuana and hashish, oater pipes are most often used with flavored tobacco, made by mixing shredded tobacco with honey or molasses and dried fruit. This mix is called shisha in the United States. 3. In the ACHA survey, 78.8 percent of students reported never having done so; 4.7 percent reported any use in the previous 30 days. 4. The risks are similar to those of smoking cigarettes. D. Other Forms of Tobacco 1. Two percent of Americans smoke cigars; 2 percent use smokeless tobacco. E. Cigars 1. Cigar use has declined in the past few years. a. However, after cigarettes, cigars are the tobacco product most widely used by college students. 2. The risk of death related to cigars approaches that of cigarettes, depending on the number of cigars smoked and the amount of cigar smoke inhaled. F. Pipes 1. Cigarette smokers may switch to pipes to reduce their risk of health problems, but former cigarette smokers may continue to inhale, even though pipe smoke is more irritating to the respiratory system than cigarette smoke.

2. People who have smoked only pipes and who do not inhale are less likely to develop lung and heart disease. 3. They are likely to suffer respiratory problems and to develop—and die from—cancer of the mouth, larynx, throat, and esophagus. G. Bidis 1. Bidis are skinny, sweet-flavored cigarettes. They are legal for adults and even minors in some states and are sold on the Internet as well as in stores. 2. Although bidis contain less tobacco than regular cigarettes, their unprocessed tobacco is more potent. H. Clove Cigarettes (Kreteks) 1. Clove cigarettes typically contain two-thirds tobacco and one-third cloves. 2. The CDC reports that people who smoke clove cigarettes may be at risk of serious lung injury. 3. Clove cigarettes deliver twice as much nicotine, tar, and carbon monoxide as moderate-tar American brands. I. Smokeless Tobacco 1. An estimated 3 percent of adults in the United States use smokeless tobacco products (sometimes called “spit”). a. About 9 percent of college men (and 0.4 percent of women) use smokeless tobacco. 2. Types of smokeless tobacco include snuff, finely ground tobacco that can be sniffed or placed inside the cheek and sucked, and chewing tobacco, tobacco leaves mixed with flavoring agents such as molasses. 3. Smokeless tobacco causes a user’s heart rate, blood pressure, and epinephrine levels to jump. 4. Powerful carcinogens (cancer-causing agents) in smokeless tobacco include nitrosamines, polycyclic aromatic hydrocarbons, and radiationemitting polonium. 5. In addition, smokeless tobacco can cause cancer and noncancerous oral conditions and lead to nicotine addiction and dependence. 6. Snus (rhymes with “loose”) is a smokeless tobacco product similar to snuff and chewing tobacco. a. Users, generally white males between the ages of 18 and 24, pack snus under their upper lip and then swallow the by-product rather than spit it out. b. Snus may pose less of a cancer risk than other forms of tobacco, but this does not mean that it is risk-free.

XIV. Quitting Tobacco Use A. Introduction 1. The U.S. Public Health Service’s new guidelines for treating tobacco use and dependence recognize tobacco dependence as “a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.” 2. Once a former smoker takes a single puff, the odds of a relapse are 80–85 percent. a. Smokers are most likely to quit in the third, fourth, or fifth attempt. B. Physical Benefits of Quitting 1. Young adults who quit smoking see improvements in coughing and other respiratory symptoms within a few weeks, according to a recent study of college students ages 18–24. C. Psychological Benefits of Quitting 1. Quitting may be as good for your mental health as it is for your physical health. D. Quitting 1. More than 90 percent of former smokers quit on their own—by throwing away all their cigarettes, by gradually cutting down, or by first switching to a less potent brand. 2. Successful quitters see themselves as active participants in health maintenance and take personal responsibility for their own health. 3. Physically active smokers have greater success quitting. 4. Virtual Support a. Electronic communications generally resulted in higher quit rates, but only if continued over time. 5. Stop-Smoking Groups a. Joining a support group doubles your chances of quitting for good. b. Aversion therapy, which provides a negative experience every time a smoker has a cigarette, is used in some smoking cessation programs. 6. Aversion therapy may involve taking drugs that make tobacco smoke taste unpleasant, undergoing electric shocks, having smoke blown at you, or rapid smoking (inhaling smoke every 6 seconds until you’re dizzy or nauseated). 7. Nicotine Anonymous acknowledges the power of nicotine and provides support to help smokers, chewers, and dippers live free of nicotine.

E. Nicotine Replacement Therapy (NRT) 1. This approach uses a variety of products that supply low doses of nicotine in a way that allows smoker to taper off gradually over a period of months. 2. Although NRT is touted as an aid to permanent cessation of smoking, recent studies have found equivalent rates of relapse among smokers, regardless of whether they used NRT, with or without professional counseling. 3. The most effective approaches combine medication with psychological intervention. 4. Nicotine gum maintains enough nicotine in the blood to diminish withdrawal symptoms. 5. Nicotine patches provide nicotine via a patch attached to the skin by an adhesive. Occasional side effects include redness, itching, or swelling at the site of the patch application, insomnia, dry mouth, and nervousness. 6. Nicotine inhalers are available only by prescription and total treatment should not exceed 6 months. 7. Medication: Bupropion, a drug initially developed to treat depression, is marketed in a slow-release form for nicotine addiction as Zyban. F. Electronic Cigarettes 1. E-cigarettes simulate the act of smoking and provide smokers with a “fix” of nicotine without exposure to tobacco smoke. 2. However, some argue that e-cigarettes may promote continued smoking by allowing smokers of conventional cigarettes to use these alternatives in no-smoking environments. XV. Environmental Tobacco Smoke A. Introduction 1. Environmental tobacco smoke, or secondhand smoke, the most hazardous form of indoor air pollution ranks behind cigarette smoke and alcohol as the third-leading preventable cause of death. 2. On average, a smoker inhales what is known as mainstream smoke eight or nine times with each cigarette, for a total of about 24 seconds. a. However, the cigarette burns for about 12 minutes, and everyone in the room (including the smoker) breathes in what is known as sidestream smoke. i. According to the American Lung Association, incomplete combustion from the lower temperatures of a smoldering cigarette

makes sidestream smoke dirtier and chemically different from main-stream smoke. ii. It has twice as much tar and nicotine, 5 times as much carbon monoxide, and 50 times as much ammonia. iii. Because the particles in sidestream smoke are small, this mixture of irritating gases and carcinogenic tar reaches deeper into the lungs and poses a greater threat, especially to infants and children. B. Health Effects of Secondhand Smoke 1. Environmental tobacco smoke is both dangerous and deadly. 2. It leads to an estimated 3,000 deaths of nonsmokers each year. C. Thirdhand Smoke 1. Thirdhand smoke is the residue that is left behind on furniture, walls, and carpeting after a cigarette has been smoked in a room. 2. The toxins it contains can enter the body by breathing, ingestion, or skin absorption. 3. Among the effects on nonsmokers is an increased risk of breathing problems and cancer. 4. The danger may be greatest to infants, children, pregnant women, and older adults.

Discussion Questions •

Ask students what it means to drink responsibly and drive responsibly. Ask them why they think it is so difficult for many people to understand the risks of driving while intoxicated.

•

Ask students whether they believe addiction is a disease or an emotional problem. Ask them if viewing alcoholism as a disease removes the responsibility from the drinker. Are there different classifications of alcoholics?

•

Discuss the dangers of alcoholism. Are these “dangers” any less than, or greater than, those for someone who is addicted to cocaine or another illegal drug? Why or why not?

•

Ask the students whether alcohol dependency is an individual problem or a societal issue. Why do they feel that way? What factors are related to each? Are these changeable? Next, ask the students to brainstorm and later discuss what the following can do to prevent alcoholism within: an individual, a family, an educational institution, the government, and society.

•

Brainstorm with students the effects of drinking on all of the dimensions of health. Be sure to clarify any myths.

•

Why do various ethnic groups suffer disproportionately high rates of alcohol dependence and abuse? Ask the class how these statistics might be used to target prevention efforts by government and educators. Can targeting particular groups be detrimental to such efforts? How? Can targeting particular groups be viewed as racial or ethnic profiling?

•

Have students debate whether they believe the drinking age should be maintained at 21 years or lowered. List the pros and cons and then discuss each.

•

What responsibility does the media have in promoting alcoholic beverages or preventing abuse of such beverages? Should alcohol advertisements be banned from television? What about from college sporting events?

•

Discuss the role alcohol plays in violence, especially date rape. Ask students who is responsible when rape occurs. Point out the fact that there is a large discrepancy between reported cases of rape and estimated occurrence. List factors that might account for this difference. Does alcohol play a role in whether or not a person will report the rape or not? Acknowledging that a large percentage of students are at risk for alcoholism, ask them how awareness of these factors affects their use of alcohol. What steps can they take to protect themselves? Their friends?

•

Ask students whether they believe a person who has successfully gone through treatment for alcoholism and has abstained for 1 year is now recovered. With an overwhelming number of statistics pointing to the hazards of smoking, it’s obvious that many people don’t take these threats seriously. It may be helpful to turn to the more immediate and short-term effects of smoking and evaluate them. Have the class cite these hazards. You may also wish to add these problems: chronic cough, excess phlegm production, gum disease, breathlessness, and noncancerous diseases of the lungs.

•

Ask students to brainstorm all of the reasons why individuals smoke. Do the same for why they don’t smoke. What are some of the barriers to quitting?

•

Have students discuss whether or not smoking should be banned from all public facilities. Why or why not? What about in an individual’s home, among children? Should companies be allowed to refuse to hire smokers? Or fire smokers? Do laws that ban smoking discriminate against smokers? How so? What about other hazardous habits?

•

It’s no mystery that tobacco advertisers and their manufacturers are reaping huge profits each year with the sale of their product. What about taxing cigarettes more? Lawsuits? When winning a lawsuit such as in the tobacco settlement, where should

the money be spent? Has the increased tax on cigarettes discouraged people from smoking? •

Acknowledging that more women than men are starting the habit and that lung cancer now claims more women’s lives than breast cancer, cite the risks that are unique to women who smoke. Ask why they think this is happening. Do prevention efforts that specifically target women also send a message about women and smoking?

•

Ask students what measures they can take to protect themselves from passive smoke both in their homes and in social situations.

•

Bring to class (or have students collect and share) cigarette advertisements in order to discuss the following: Who is the target population? What image is created? Is the warning label effective in deterring or educating people about the hazards of smoking?

Classroom Activities Activity #1: Alcohol on Trial Purpose: Opportunity for students to reflect on several issues surrounding alcohol.

Time: This activity will take 2–3 class periods.

Introduction: Introduce to the class the negative effects that drinking has on a community. You may want to share with your class the various laws in other countries regarding driving while under the influence.

Method: 1.

Divide students into two groups. One group will be for supporting stricter laws (allow them to set the standards and punishments); the other group will be against stricter laws.

Allow for time to gather data to support each side’s argument.

Set up an actual trial setting for these two sides to debate their issues.

An example trial might include the following: a.

Two minutes for opening arguments for each side.

Side 1 gets 2 minutes to present a position or a “witness—role player”/the opposing side gets 1 minute for rebuttal.

Side 2 now gets 2 minutes to present their first position/the opposing side gets 1 minute for rebuttal.

Side 1 gets 2 minutes to present a position or a “witness—role player.” / The opposing side gets one minute for rebuttal.

Side 2 now gets two minutes to present their second position. / The opposing side gets one minute for rebuttal.

Side 1 gets two minutes to present a position or a “witness—role player.” / The opposing side gets one minute for rebuttal.

Side 2 now gets two minutes to present their third position. / The opposing side gets one minute for rebuttal.

The side that presented their opening argument first goes second in the closing argument round. However, the other side gets an additional minute after closing arguments.

Discussion: 1.

At the conclusion of the debate or trial: How did students feel about representing their side? Did they change their opinions throughout the process?

What arguments did students find the most difficult to represent?

Activity #2: Facts about Alcohol Purpose: Introduce the class to the facts about alcohol use and clarify any myths about alcohol use or abuse.

Time: This activity will take 30 to 45 minutes, depending on how many questions you have or if you spend additional time clarifying each question and answer.

Introduction: Introduce the dangers of drinking and the effects of drinking on the individual and their family.

Method/Discussion: 1.

You can select a variety of “game shows” to test the knowledge of your students or to provide them with additional information about alcohol use. a. Examples of such games might be Jeopardy, Deal or No Deal, Family Feud, Who Wants to Be a Millionaire, etc.

Select your questions and assign them a difficulty rating, so they will fit appropriately into your game.

If you have selected Jeopardy, you can assign a point total to the questions, and students will be allowed to select a question under any of the categories regarding various alcohol issues. a. You may want to design several rounds, include a “double jeopardy” and a “final jeopardy” to provide additional opportunities for points.

Examples of such questions are included below: Category 1

Category 2

Category 3

Category 4

Category 5

200

400

600

800

1,000

Example Questions: 1.

The abbreviation for the central nervous system. What is the CNS?

A cluster of physical and mental defects caused by the mother’s alcohol consumption during pregnancy. What is fetal alcohol syndrome?

Three characteristics that define FAS. What are abnormal facial features and growth, and central nervous system problems?

Difficulties in school, trouble with the law, alcohol and drug problems. What are additional problems associated with FAS?

How to eliminate the chance of having a child with FAS. What is do not drink alcohol while pregnant?

The amount of alcohol that is safe to drink during pregnancy. What is no alcohol?

The time after which it is too late for a pregnant woman to stop drinking. What is never?

BAL (blood alcohol level). What is a way to measure the level of alcohol in a person’s body?

Cirrhosis. What is a condition in which the liver cells are replaced by useless scar tissue?

10. Hepatitis. What is inflammation of the liver? 11. FAS (fetal alcohol syndrome). What is a birth defect caused by the mother drinking during pregnancy? 12. A chronic, progressive, potentially fatal disease characterized by impaired control of drinking, a preoccupation with alcohol, continued use of alcohol despite adverse consequences; and distorted thinking, most notably denial. What is alcoholism? © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

13. Increased resistance to a drug’s effects accompanying continued use. What is tolerance? 14. Physical and psychological symptoms that occur when someone addicted to a drug stops taking it. What is withdrawal? 15. Overdoses (leading to respiratory failure), drowning, drunk driving crashes, homicides, suicides, fire deaths, firearms accidents, and unintentional falls. What are ways in which alcohol is involved in death? 16. Body weight, gender, genetics, amount of food in the stomach, rate of drinking, presence of other drugs. What are factors that affect alcohol metabolism? 17. Development of a strong craving for alcohol due to the pleasurable feelings or relief of stress or anxiety produced by drinking. What is alcohol dependence?

Activity #3: Short-Term Effects of Smoking Purpose: To have students experience the physical of having emphysema

Time: This activity will take 15 to 20 minutes.

Introduction: Introduce the dangers of smoking.

Method: 1.

Provide each class member with a 3- to 4-inch cocktail straw.

Have students close their lips around the straw and pinch their nostrils together.

Tell them to breathe only through the straw for one minute; have any student who is having difficulty breathe normally when needed.

Discussion: 1.

Discuss the physical and emotional feelings related to this one-minute breathing experience.

Discuss how difficult it would be to have an active lifestyle or meet any responsibilities with this type of physical limitation.

Activity #4: Long-Term Effects of Smoking Purpose: To have students experience and identify their long-term health risks of being exposed to tobacco smoke.

Time: This activity will take one-half to one class period.

Introduction: Introduce the dangers of smoking.

Method: 1.

Have students write down their daily exposure to tobacco smoke. It might be incidental exposure, secondhand, or they could be smokers themselves.

Students should record how that exposure impacts their health.

Discussion: 1.

Discuss the physical health consequences you have experienced due to your exposure to tobacco smoke.

If they themselves are not smokers, what changes can they make to reduce their exposure to tobacco smoke?

If they do smoke, do they plan to quit due to negative health consequences?

Do they know available resources to help them quit smoking?

Activity #5: Advertisements and Smoking Purpose: To learn how tobacco companies target various populations to use their product.

Time: This activity will take one class period.

Introduction: Introduce the marketing schemes of tobacco companies and how they attempt to influence people to use their product.

Method: 1.

Have students collect smoking advertisements from various magazines.

Divide the class into groups of five or six and spend time discussing the various appeals tobacco companies use to sell their product to women, children, and men.

Discussion: 1.

If you had a tobacco executive in front of you, what questions would you ask them about how they use their advertisements to target these populations?

What about the dangers of their product?

How does it make you feel to understand how these companies have been manipulating our society for so many years and with so much to lose?

Activity #6: The Price of Smoking Purpose: To understand the financial costs of smoking.

Time: This activity will take 10 to 20 minutes of class.

Introduction: Introduce the high costs of smoking and the use of tobacco products for the individual, community, health care, states, etc.

Method: 1.

Have students calculate the amount it costs a one-pack-a-day smoker to maintain his or her habit for 20 years (without considering inflation) with a cost of $3.50 per pack.

What about a person who smokes two packs a day?

What about for 30 years? 40 years? 50 years?

Discussion: 1.

Did the totals surprise students? You may want to add that this is only the cost of the cigarettes and doesn’t include health-care costs or higher insurance rates.

What additional expenses might a smoker have versus a nonsmoker?

What other things could this money be spent on instead of cigarettes? What are some examples of items that have a similar cost?

What are some of the economic costs of smoking for our society?

How do these costs compare with the advantages that some states realize from tobacco production?

What are the medical costs associated with smoking and secondhand smoke?

Activity #7: Tobacco Cessation Purpose: To learn about smoking cessation programs available to students.

Time: One class period.

Method: 1.

Students should research the community resources available for smoking cessation, including the on-campus resources for students.

List the available smoking cessation programs and their costs.

Discussion: 1.

Does your school have a tobacco policy? If so, what is the policy, and do you agree with it? If not, do you think your school should have any tobacco-related policies? Why or why not?

Do you feel that there are enough resources available to students who want to stop smoking? Are the costs affordable for college students?

If you do not smoke, do you have a friend or roommate who does smoke or use tobacco? Does their use impact your health? What can you do to support and encourage them to stop using tobacco?

Is smoking really a problem on college campuses, and is enough being done to address the issue?

References, Readings, and Resources American College Health Association. (2016). American College Health Association– National College Health Assessment II: Reference Group Executive Summary Fall 2015. Hanover, MD: American College Health Association. Armeli, S., et al. (2014). A longitudinal study of the effects of coping motives, negative affect and drinking level on drinking problems among college students. Anxiety, Stress, & Coping, 27(5), 527–541. doi: 10.1080/10615806.2014.895821. BeTobaccoFree.gov. Smoked Tobacco Products. http://betobaccofree.hhs.gov/abouttobacco/Smoked-Tobacco-Products/. Callahan-Lyon, P. (2014). Electronic cigarettes: human health effects. Tobacco Control, 23(Suppl. 2), ii36–ii40. doi: 10.1136/tobaccocontrol-2013-051470. Carter, B. D., et al. (2015). Smoking and mortality—beyond established causes. New England Journal of Medicine, 372(7), 631–640. doi: 10.1056/NEJMsa1407211. Hultgren, B. A., et al. (2014). How estimation of drinking influences alcohol-related consequences across the first year of college. Alcoholism: Clinical and Experimental Research, 38(7), 1160–1166. doi: 10.1111/acer.12351. National Institute on Alcohol Abuse and Alcoholism. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-factsand-statistics. National Institute on Alcohol Abuse and Alcoholism. http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurringdisorders/college-drinking. Patrick, M. E., Macuada, C., & Maggs, J. L. (2016). Who uses alcohol mixed with energy drinks?: Characteristics of college student users. Journal of American College Health, 64.1, 74–79. doi: 10.1080/07448481.2015.1042877. Pedersen, E. R., et al. (2014). Demographic and predeparture factors associated with drinking and alcohol-related consequences for college students completing study abroad experiences. Journal of American College Health, 62(4), 244–254. doi: 10.1080/07448481.2014.887573. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

US Department of Health and Human Services (2014). The Health Consequences of Smoking: 50 Years of Progress: a Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Turchik, J. A., & Hassija, C. M. (2014). Female sexual victimization among college students: assault severity, health risk behaviors, and sexual functioning. Journal of Interpersonal Violence, 29(13), 2439–2457. doi: 10.1177/0886260513520230. Verster, J. C., et al. (2016). Mixing alcohol with energy drink (AMED) and total alcohol consumption: A systematic review and meta-analysis. Human Psychopharmacology, 31.1, 2–10. doi: 10.1002/hup.2513.

Films and Videos Addiction (Several of the nation’s leading experts on drug and alcohol addiction, together with a group of accomplished filmmakers, have assembled to create Addiction, an unprecedented documentary aimed at helping Americans understand addiction as a treatable brain disease.) Hazelden Publishing P.O. Box 176 Center City, MN 55012-0176 P: 800-328-9000 F: 651-213-4793 E: Hazelden Publishing Addiction: A Comprehensive View (Made up of several concise segments, this program deals with a wide range of drugs, addiction issues, and case studies. Viewers will enter a chaotic Dallas ER, where the majority of injuries are drug- and alcohol-related, and meet a desperate middle-aged woman who finally turns in her heroin-addicted daughter to police.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: custserv@films.com © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Addictions: Chemical and Behavioral (Addiction is a way to escape from anxiety, anger, or pain—unfortunately, it also leads to them. This video shows how addictions develop and how they can involve both substances and behaviors.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group The Addictive Personality (Does addiction have a genetic factor? Can any type of addiction be treated medically? What steps can family members take to help a loved one struggling with addiction? This program provides answers to several addiction-related questions, focusing on the complexities of the addictive personality.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Bill W. (A documentary about the co-founder of Alcoholics Anonymous. With Bill as its driving force, A.A. grew from a handful of men to a worldwide fellowship of over 2 million men and women, a success that made him an icon within A.A., but also an alcoholic unable to be a member of the very society he had created.) Hazelden Publishing P.O. Box 176 Center City, MN 55012-0176 P: 800-328-9000 F: 651-213-4793 E: Hazelden Publishing

Clearing the Smoke (Kentucky has the second highest smoking rate in the entire country. This episode looks at the policies, programs, and community solutions needed to reduce dependence on tobacco and create a healthier Kentucky.) Clearing the Smoke Cozy Killer: The History of Cigarettes (The health hazards of cigarettes were scientifically established by the 1930s. What kept those findings under wraps for so long? This program explores the history of medical research into smoking and the sustained efforts of tobacco companies to block public scrutiny of their deadly product.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Introducing Tobacco: Risks, Laws, and Habits (It leads to bad breath, yellow teeth, and black lungs—so why is smoking such a popular pastime? What enables the tobacco companies to snare young consumers so effectively? How do advertising, Hollywood imagery, and peer pressure fit into the equation? This program explores the cold, hard facts about cigarette smoking, including legal issues surrounding it and the impact it can have on both users and nonusers.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Medical Aspects of Chemical Dependency: The Neurobiology of Addiction (This fascinating and authoritative video on how addiction affects brain function outlines the latest research on brain chemistry. Includes commentary by Dr. David E. Smith, founder of the Haight Ashbury Free Clinic.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

F: 800.678.3633 E: Films Media Group Myths of Addiction (Not all opinions about alcohol and other drug addiction are based on fact. Produced by Hazelden and Twin Cities Public Television, this video debunks commonly held myths and misconceptions about the nature and treatment of addiction.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Rehab (“A year from now, two of you will be dead.” So begins an orientation session at Camp Recovery, a Santa Cruz drug and alcohol treatment center. This documentary follows five young addicts through the camp’s 30-day rehab program and tracks their progress, or lack thereof, in the months that follow.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Treating Stimulant Addiction: The CBT Approach (A nonmedical approach, Cognitive Behavioral Therapy (CBT), is considered the most effective treatment for stimulant addiction. This program goes inside the MATRIX Institute on Addictions, where methamphetamine and cocaine addicts attend evidencebased behavioral therapy groups as well as individual and family counseling, drug testing, and 12-step programs.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Tobacco: Addicted to Pleasure (Growing up in the streets of Dundee, actor Brian Cox was surrounded by tobacco. His entire family either smoked it or chewed it and yet Brian reveals, he never took up the habit. To find out why not, Brian travels to Virginia in the United States to discover how the habit of smoking kick-started the British Empire and created a global market of addicts.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group What Is Addiction? (To understand the nature of substance abuse and why an individual succumbs to addiction, a wide range of factors must be examined. This program follows Dr. Nora Volkow, director of the National Institute on Drug Abuse, as she conducts informal group therapy with addicts and their family members.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group The World’s Second-Most Popular Drug (Kevin Strang, Faculty Associate in the Department of Neuroscience at the UWMadison School of Medicine and Public Health, joins UW Chemistry Professor Bassam Shakhashiri to discuss alcohol consumption. Strang focuses on why people drink, how neurological systems are effected by alcohol, and looks at historical and cultural aspects of drinking.) The World’s Second-Most Popular Drug

Internet Resources Action on Smoking and Health (ASH) Antismoking activist website that provides specific strategies for decreasing smoking in America and protecting the rights of nonsmokers. Action on Smoking and Health © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Al-Anon/Alateen Al-Anon (which includes Alateen for younger members) offers hope and help to families and friends of alcoholics. Al-Anon Family Groups Alcoholics Anonymous (AA) Website on AA program and resources for meeting sites. Alcoholics Anonymous American Cancer Society Provides information about cancer including information about tobacco and alcohol and their role in cancer. Expert Voices Blog American Lung Association Information on lung diseases, environmental health, and tobacco control. American Lung Association Campaign for Tobacco-Free Kids Working to expose Big Tobacco’s lies, the campaign reveals the truth about the deadly effects of smoking, and the advertising and marketing tactics. Campaign for Tobacco-Free Kids Centers for Disease Control: Tobacco Information and Prevention Sources (Tips) Tips on how to stop smoking and related educational materials. Tobacco Information and Prevention Sources (Tips) College Drinking – Changing the Culture One-stop resource for comprehensive research-based information on issues related to alcohol abuse and binge drinking among college students. College Drinking – Changing the Culture National Association for Children of Alcoholics Advocating for all children and families affected by alcoholism and other drug dependencies. National Association for Children of Alcoholics

National Institute on Alcohol Abuse and Alcoholism (NIAAA) NIAAA provides leadership in the national effort to reduce alcohol-related problems. National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse (NIDA) NIDA’s mission is to lead the nation in bringing the power of science to bear on drug abuse and addiction. National Institute on Drug Abuse National Organization on Fetal Alcohol Syndrome Helping children and families by fighting the leading known cause of mental retardation and birth defects. National Organization on Fetal Alcohol Syndrome Smoking and Drug Abuse Information and research on cigarettes and other nicotine products. Tobacco/Nicotine Smokefree – Find a Quit Method that Works for You This website was created by the Tobacco Control Research Branch of the National Cancer Institute, with important contributions from other nationally recognized agencies and organizations such as the Centers for Disease Control and Prevention and the American Cancer Society. smokefree.gov Substance Abuse and Mental Health Services Administration (SAMHSA) SAMHSA works to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services. Includes links to support groups, information resources, events, and articles. Substance Abuse and Mental Health Services Administration National Council on Alcoholism and Drug Dependence (NCADD) NCADD fights the stigma and the disease of alcoholism and other drug addictions. National Council on Alcoholism and Drug Dependence

Key Terms absorption

fetal alcohol effects (FAE)

alcohol use disorder

mainstream smoke

alcoholism

nicotine

AmED (alcohol mixed with energy drink)

predrinking

aversion therapy

sidestream smoke

bidis

snus

binge

proof

tar

blood alcohol concentration (BAC)

tobacco use disorder

carbon monoxide

tolerance

environmental tobacco smoke

withdrawal

ethyl alcohol

Answers to Global Health Watch 1. a 2. a 3. equal risk

13 Consumer Health Learning Objectives After studying this chapter in the text, the student should be able to: 13.1 Assess the impact of the Affordable Care Act (ACA) on access to health care. 13.2 Understand the benefits and terms of health insurance policies. 13.3 Explain the significance of personalized health care. 13.4 Describe what it means to be a savvy health-care consumer. 13.5 Outline your rights as a health-care consumer. 13.6 Discuss the pros and cons of elective treatments to enhance health or appearance. 13.7 Identify ways to recognize health hoaxes and medical quackery. 13.8 Weigh the benefits and potential risks of complementary and alternative medicine (CAM). 13.9 Review the components of the health-care system, including types of practitioners and health-care facilities.

Chapter Summary This chapter helps you take greater responsibility for your personal well-being. Whether you are monitoring your blood pressure, taking medication, or deciding whether to try an alternative therapy, you need to gather information, ask questions, weigh advantages and disadvantages, and take charge of your health. The reason: No one cares more about your health than you do, and no one will do more to protect your well-being.

Lecture Outline I.

The Affordable Care Act (ACA) A. Introduction 1. The Affordable Care Act (ACA), initially referred to as Obamacare and signed into law in 2010, ushered in a new era in consumer health and provided insurance to more than 20 million people. 2. The ACA continues to generate legal and political controversy. 3. Under the ACA, Americans have had significantly less trouble getting and paying for needed medical care.

II.

What You Need to Know A. Carefully read and research advertisements and promotional material for insurance policies. 1. Some cover only certain diseases or injuries and do not offer comprehensive insurance protection. 2. Different policies offer different benefits; some limit which doctors, hospitals, or other providers you can use: a. Prescriptions b. Doctor’s visits c. Emergency care d. Deductibles e. Copayment f. Penalty

III.

Consumer-Driven Health Care A. Overview 1. Increasingly Americans are approaching “purchases” of health care the same way as other major investments, like buying a car. B. Improving Your Health Literacy 1. About one-third of the population in the United States has limited ability to understand health information and to use that information to make good decisions about health and medical care. a. Health literacy is the ability to understand health information and use it to make good decisions about health and medical care. 2. Regardless of their literacy skills, college students do not seek out information on health concerns.

C. Finding Good Advice Online 1. More than one-third of Americans turn to the Internet to diagnose their health problems. 2. Guidelines for evaluating websites with medical information: a. Check the creator b. Look for the latest research c. Check the references d. Consider the author e. Look for possible bias. D. Getting Medical Facts Straight 1. Rather than putting your faith in the most recent report or the hottest trend, try to gather as much background information and as many opinions as you can. 2. Look for answers to the following questions: a. Who are the researchers? b. Where did the researchers report their findings? c. Is the information based on personal observances? d. Does the article, report, or advertisement include words like amazing, secret, or quick? e. Is someone trying to sell you something? f. Does the information defy all common sense? E. Evidence-Based Medicine 1. Evidence-based medicine is a way of improving and evaluating patient care by combining the best research evidence with the patient’s personal values. 2. Practice guidelines can be developed by doctors who use evidence-based medicine. F. Outcomes Research 1. Outcomes are the impact that a specific medication or treatment has on a patient’s condition, overall health, and quality of life. 2. Outcomes research can help determine which of several therapies or approaches provides the best results at the most reasonable costs. IV. Personalizing Your Health Care A. Overview 1. Personalized medicine can alert your doctor to potential threats that might be prevented, delayed, or detected at an earlier, more treatable stage and, if you do develop a disease, pinpoint the medications that will do the most good and cause the least harm. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

B. Your Family Health History 1. Mapping your family medical history can help identify health risks you may fact in the future. C. Gender Differences 1. The genders differ significantly in the way they use health-care services in the United States. 2. Many experts believe that the need for birth control and reproductive health services gets women into the habit of making regular visits to health-care professionals. There are no comparable specialists for men. 3. Men tend to be more positive about their experiences of being hospitalized. 4. The genders also differ in the symptoms and syndromes they develop. D. Mobile Health (mHealth) Apps and Monitors 1. Usually run on a smartphone or other handheld device, apps rely on an operating system and network connection to send and receive data. 2. Sensors or trackers consist of physical hardware with limited computing and communication capabilities that provide objective reporting of indicators such as blood glucose levels and heart rate. 3. Although they cannot replace a doctor, mobile apps and wearable monitors may offer significant benefits. 4. Skeptics argue that digital self-monitoring may create uncertainty and anxiety and cause healthy men and women needless worry. E. Self-Care 1. Self-care means head-to-toe maintenance, including good oral care, appropriate screening tests, knowing your medical rights, and understanding the health-care system. 2. Most people do treat themselves. a. At the very least, you should know what your vital signs are and how they compare against normal readings. F. Oral Health 1. Oral health refers to the entire mouth, including all the structures that allow us to talk, bite, chew, taste, swallow, smile, scream, or scowl. 2. Oral health is a critical part of overall health. 3. Poor oral health can lead to a variety of health problems. 4. Gum or periodontal disease is an inflammation that attacks the gum and bone that hold teeth in place. 5. Plaque is the sticky film of bacteria that forms on teeth. 6. Gingivitis is the early stage of gum disease.

7. Periodontitis is where plaque moves down the tooth to the roots, which then become infected. 8. Gingivitis and periodontitis trigger an inflammatory response that eventually leads to an increase in the incidence of cardiovascular disease. V.

Becoming a Savvy Health-Care Consumer A. Overview 1. Because physicians today have less time and less autonomy than they once had, patients today must do more. a. Your first step should be learning more about your body, any medical conditions or problems you develop, and your options for treatment. B. Making the Most of a Medical Visit 1. Scheduling the Appointment: When you schedule the appointment, you need to both get and give information. 2. Before Your Appointment: To get the most out of your appointment, you need to do some homework ahead of time, including writing down questions. 3. At Your Appointment: Provide a complete health history. C. The Physical Examination 1. Typically, your doctor will begin an exam by inspecting your body for any unusual marks or growths. 2. Next, he or she may palpate your abdomen and other parts of your body to assess the consistency, location, size, tenderness, and texture of individual organs. 3. Your doctor will use a stethoscope to listen to your heart and lungs as you take deep breaths. 4. By using a technique known as percussion—tapping around the body as if it were a drum—your doctor checks for fluid in areas where it should not be, as well as locates the borders, consistency, and size of organs. D. Talking with Your Health-Care Provider 1. With the clues obtained during the history and physical examination, a health-care provider can formulate a differential diagnosis—that is, a list of potential causes of the symptoms. 2. Specific diagnostic tests generally confirm the cause or reveal other, previously unsuspected causes. 3. When you are talking with your health-care provider, keep these points in mind: a. If you have questions, ask them.

b. Make sure you understand everything your health-care provider says. c. If you are given a diagnosis and need further care, ask about the different treatments that are available. d. If you need a test, procedure, or surgery, ask questions. e. If a medication is prescribed, make sure you find out the details. f. Ask about a “question hour” or corresponding via e-mail. g. Interrupt the interrupter. h. Ask for access to your medical record. E. After your Visit 1. After seeing your primary care physician evaluate the quality of care you are getting. F. Diagnostic Tests 1. If you are a woman, your physician will provide counseling on birth control and, if indicated, preconception care. Your doctor should also screen for intimate partner violence and, if you are at risk, for sexually transmitted infections. 2. Physicians may also order chest X-rays, urinalysis, and blood tests. G. Screening Tests 1. In recent years, the medical profession has changed its recommendations for many tests used to screen for or detect disease at early stages. 2. Specific tests and procedures that are often overused include those for low back pain, osteoporosis screening, cardiac screening, mammography, pap testing, and pelvic exams. 3. Pap smear is a test in which cells removed from the cervix are examined under a microscope for signs of cancer, also called a Pap test. H. Preventing Medical Errors 1. More people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. 2. The best defense against medical errors is information. I. Avoiding Medical Mistakes 1. Whenever you get a prescription, be sure to learn as much as possible about it. a. Know the name of the drug, what it is supposed to do, and how and when to take it and for how long. b. Are there foods, drinks, other medications, or activities you should avoid while taking the medication? c. Ask if the drug causes any side effects and what you should do if any occur.

d. Inform your doctor if you take popular herbal supplements or common over-the-counter drugs, which can interact with many prescription drugs to cause serious problems, such as excessive bleeding. e. If possible, always go to the same pharmacy, which can keep track of your prescriptions and identify any potentially harmful interactions. f. Don’t use a kitchen spoon to dispense liquid medications. g. Don’t crush or chew a medicine without checking with your doctor or pharmacist first. h. Keep a record of all your medications, listing both their brand and generic (chemical) names and the reason you are taking them. Update the list regularly. i. Always turn on the lights when you take your medication. Familiarize yourself with the size and shape of the imprint on each tablet or capsule so you can recognize each pill. If a refill looks different, check with your pharmacist or doctor before taking it. j. Never take someone else’s medications. k. Always check labels for warnings on interactions with alcohol and instructions on whether to take before, with, or after meals. l. Don’t take medicine with grapefruit juice, which can interact with more than 200 medications, including cholesterol-lowering statins, sleeping pills, and anti-anxiety agents. m. Don’t leave medicines in a car for prolonged periods. Temperature extremes, along with moisture, light, and oxygen, can affect the potency of many medications. VI. Your Medical Rights A. Overview 1. Consumers have basic rights that help ensure that you know about any potential dangers, receive competent diagnosis and treatment, and retain control and dignity in your interactions with health-care professionals. B. Your Right to Be Treated with Respect and Dignity 1. If you feel that health-care professionals are being condescending or inconsiderate, say so. 2. If you’re hospitalized, find out if there’s a patient advocate or representative at your hospital. C. Your Right to Information 1. By law, a patient must give consent for hospitalization, surgery, and other major treatments. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. Informed consent is a right, not a privilege. D. Your Right to Privacy and Access to Medical Records 1. Your medical records are your property. 2. Key provisions to the federal standards that protect the privacy of patients’ medical information include: a. Access to medical records b. Notice to privacy practices c. Prohibition on marketing d. Confidentiality E. Your Right to Quality Health Care 1. The essence of a malpractice suit is the claim that the physician failed to meet the standard of quality care required of a reasonably skilled and careful medical doctor. VII. Elective Treatments A. Introduction 1. Medical technology has developed new treatments. 2. Some treatments are new alternatives for correcting common problems; others offer the promise of looking younger or more attractive. B. Vision Surgery 1. LASIK (laser-assisted in situ keratomileusis) is the most common technique to correct vision. 2. A surgeon uses a razor-like instrument to life a flap of the cornea and then reshapes the exposed area. 3. Prices have fallen, but ophthalmologists have warned consumers that some laser surgery centers have cut corners to cut prices, such as hiring inexperienced surgeons or using optometrists or technicians rather than MDs. 4. Some individuals are not good candidates for LASIK. C. Cosmetic Surgery 1. The most common cosmetic operations are: a. Injections of synthetic soft tissue fillers and botulinum toxin (Botox®), chemical peels, and laser hair removal account for more than 90 percent of cosmetic procedures. b. Liposuction, the removal of fatty tissue by means of a vacuum device, c. Breast augmentation d. Buttocks augmentation

D. Body Art Perils 1. About one in five American adults has a tattoo; 14 percent say they regret having gotten tattoos. 2. “Body art” such as piercings and tattoos presents unique dangers, including adverse reactions to tattoo inks and bacterial and viral infections. VIII.

Health Hoaxes and Medical Quackery A. Every year, Americans spend more than $10 billion on medical quackery, unproven health products and services. 1. Be suspicious when you see: a. Claims that a product is a “scientific breakthrough,” “miraculous cure,” “secret ingredient,” or “ancient remedy” b. Claims that the product is an effective cure for a wide range of ailments c. Claims that use impressive-sounding medical terms d. Undocumented case histories of people who’ve had amazing results e. Claims that the product is available from only one source and payment is required in advance f. Claims of a “money-back” guarantee g. Websites that fail to list the company’s name, physical address, phone number, or other contact information 2. To keep from risking your life on false hopes, follow these guidelines: a. Arm yourself with up-to-date information b. Ask for a written explanation of what a treatment does and why it works. c. Don’t part with your money quickly d. Don’t discontinue your current treatment without your physician’s approval

IX. Nontraditional Health Care A. Overview 1. Complementary and alternative medicine (CAM) refers to various medical and health-care systems, practices, and products that are not considered part of conventional medicine because there is not yet sufficient proof of their safety and effectiveness. 2. Holistic methods focus on the whole person and the physical, mental, emotional, and spiritual aspects of well-being.

3. Integrative medicine, which combines selected elements of both conventional and alternative medicine in a comprehensive approach to diagnosis and treatment, has gained greater acceptance within the medical community, including insurance coverage for more CAM therapies. B. Who Uses CAM 1. An estimated 30–40 percent of Americans use a complementary health approach every year, usually along with rather than instead of conventional care. 2. Populations most likely to use CAM are: women, young adults ages 18– 44, whites, and adults with higher levels of education. C. Types of CAM 1. Alternative Medical Systems a. Acupuncture is an ancient Chinese form of medicine, based on the philosophy that a cycle of energy circulating through the body controls health, which corrects pain and disease by inserting needles into meridians throughout the body. i. Long thin needles are inserted at specific points along longitudinal lines, or meridians, throughout the body. ii. Research has found that acupuncture: (a) Helps alleviate nausea in cancer patients undergoing chemotherapy. (b) Relieves pain and improves function for some people with osteoarthritis of the knee. (c) Helps in treating chronic lower back pain. (d) May or may not be of value for many other conditions. b. Ayurveda is a traditional form of medical treatment in India. i. Ayurveda’s basic premise is that illness stems from incorrect mental attitudes, diet, and posture. c. Homeopathy is based on the idea that increasing dilution can increase efficacy. d. Naturopathy emphasizes natural remedies such as sun, water, heat, and air as the best treatments for disease. 2. Mind–Body Medicine a. Mind–body medicine uses techniques designed to enhance the mind’s capacity to affect bodily function and symptoms and can have a positive effect on psychological functioning and quality of life. b. Some of these therapies are now mainstream such as patient support groups and cognitive behavior therapy. Some are still considered CAM

such as prayer, yoga, t’ai chi, visual imager, mental healing, and creative outlets such as art, music, or dance. c. Other approaches that have won some acceptance include hypnosis and biofeedback. 3. Biologically-Based Therapies a. Biologically-based therapies use substances such as herbs, foods, and vitamins. b. In the last 10 years, sales of herbal supplements have skyrocketed by 100 percent. c. Most of the herbs tested have proven generally safe, although side effects such as headache and nausea can occur. 4. Manipulative and Body-Based Methods a. CAM therapies based on manipulation and/or movement of the body are divided into three subcategories: i. Chiropractic medicine is based on the theory that many diseases are caused by misalignment of the bones. ii. Massage therapy and bodywork includes osteopathic manipulation, Swedish massage, Alexander technique, reflexology, Pilates, acupressure, and Rolfing. iii. Unconventional physical therapies include colonics, hydrotherapy, and light and color therapy. iv. Energy Therapies (a) Energy therapies focus on energy fields believed to exist in and around the body, including the use of electromagnetic fields and even therapeutic touch. X.

The Health-Care System A. Health-Care Practitioners 1. Physicians—a medical doctor (M.D.) trained in American medical schools usually takes at least 3 years of premedical college courses and then completes 4 or 5 years at medical school. 2. The Healthcare Team—more than 60 types of health practitioners work with physicians and nurses providing medical services. a. Nurses—a registered nurse (RN) graduates from a school of nursing approved by a state board and passes a state board examination. They may have bachelor degrees and may specialize in certain areas. b. Physician assistants, also known as PAs, serve on a health-care team under the supervision of physicians and surgeons.

c. Licensed practical nurses (LPNs), also called licensed vocational nurses, are graduates of state-approved schools of practical nursing, who work under the supervision of RNs or physicians. d. Certified nursing assistants (CNAs), nursing aides, and orderlies assist in providing services directly related to the comfort and well-being of hospitalized patients. e. Allied health professionals may specialize in a variety of fields. i. Clinical psychologists have graduate degrees and provide a wide range of mental health services but don’t prescribe medications. ii. Optometrists, trained in special schools of optometry, diagnose visual abnormalities and prescribe lenses or visual aids. iii. Podiatrists are specially trained, licensed health-care professionals who specialize in problems of the feet. 3. Dentists—(Doctor of Dental Surgery, D.D.S. or Doctor of Medical Dentistry, D.M.D.) 4. Chiropractors (Doctor of Chiropractic, D.C.) B. Health-Care Facilities 1. Most primary care—also referred to as ambulatory or outpatient care—is provided by a physician in an office, an emergency room, or a clinic. a. Secondary care usually is provided by specialists or subspecialists in either an outpatient or inpatient (hospital) setting. b. Tertiary care, available at university-affiliated hospitals and regional referral centers, includes special procedures such as kidney dialysis, open-heart surgery, and organ transplants. 2. College Health Centers—institutions of higher learning provide direct health services. 3. Outpatient Treatment Centers handle many common surgical procedures. 4. Hospitals and Medical Centers offer different types of care. a. The most common hospital is a private, or community hospital, which may be run on a profit or nonprofit basis. b. Public hospitals include city, county, public health service, military, and Veterans Administration hospitals. c. Of the more than 6,500 hospitals nationwide, about 300 are major academic medical centers or teaching hospitals. d. Hospital emergency rooms should be used only in a true emergency. e. After checking with your health insurance, also, i. Talk to your physician about recommended hospitals. ii. Check with the local nursing association about the ratio of patients to nurses. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iii. Find out about room rates. iv. Ask how many times in the past year the hospital has performed the procedure recommended for you. v. If possible, tour the hospital. 5. Emergency Services should only be used in a true emergency. 6. Inpatient Care remains the most expensive form of health care. 7. Home Health Care is the provision of equipment and services to patients in the home to restore or maintain comfort, function, and health.

Discussion Questions •

From standing in front of the mirror while brushing our teeth to taking an aspirin when we have a temperature, we all practice self-care. Ask the class how they recognize when it’s time to cross the line and seek professional medical care. (You may wish to go issue-by-issue, focusing on the concepts of “prolonged and severe” as a guide for when medical care is necessary.) Be sure to discuss self-breast and testicular exams. Include what they are looking for and what they should do if they feel any abnormalities.

•

Discuss with students what your state’s laws are concerning patient access to medical records. Point out ways to protect their privacy and use their rights to the fullest.

•

Ask the class with whom they believe the responsibility for quality control of hospitals lies: the government or the consumer.

•

After explaining each of the different types of alternative therapies, have students discuss the appeal and attraction of each type. Which therapies are they most willing to try? Why or why not?

•

Share with the class advertisements for unproven health products and services. Discuss which groups of people seem to be the most vulnerable to using these products and services. What is quackery and how do economics, ethnicity, and educational background play into quackery?

•

What do insurance plans generally pay for? Should your insurance pay for infertility? Weight loss? Smoking cessation programs? Viagra but not birth control? Should insurance plans restrict mental health visits? Why or why not?

Classroom Activities Activity #1: Advertising Influences Purpose: To increase awareness of the tactics used in medical advertisements and of how easy it is to fall into those traps.

Time: At least one class period.

Introduction: Introduce the approaches used in advertisements and how they influence our selections.

Method: 1.

Place students into groups of three to five class members.

Have students develop a television, radio, and magazine advertisement for a health-care product. Rather than using an existing product, create a new one (dental health, cigarettes, birth control, prevention of STIs, medication to reduce PMS, cosmetic surgery, dating service, deodorant product, home health tests, or any other health-related products).

Have students show their final product and demonstrate their advertisement to the class.

Discussion: 1.

Did you find yourself using some of the techniques used by the media?

What stereotypes did you use? Were they fair assessments?

Were you concerned with portraying the truth about your product? Were there things about your product that you did not share because it would decrease its marketing appeal?

How easy it is to falsely market a product, or mislead the public about a product’s health benefits?

Activity #2: Complementary/Alternative Medicine Purpose: To examine the different types of complementary and alternative medicine.

Time: Ten to fifteen minutes to discuss the topic and assignment during one class. Then another class period for group discussion.

Method: 1.

Discuss the five different types of CAM listed in the text.

Have students select health concern, illness, or injury.

Have them research possible CAM treatments for the problem they selected.

In the next class, divide the students up into groups of five or six. Have each of them share the problem they selected and the possible CAM treatments they researched to help the problem.

Have them identify the pros and cons of each treatment.

Discussion: 1.

Have the students discuss in their groups, which of these CAM treatments they would try and which ones they would not.

Ask them to explain what influenced their decisions. Is there anything that would change their minds?

Activity #3: Guest Speaker Purpose: To examine the different types of complementary and alternative medicine.

Time: One class period and then 15 minutes of follow-up discussion in a following class period.

Method: 1.

Invite one or two guest speakers who practice CAM (a chiropractor, a yoga instructor, someone who teaches Ayurveda, or an acupuncturist). Be sure that the speakers have the appropriate credentials for their field.

Have them demonstrate or talk about what they do, what type of patients they usually see, and what kind of success they have.

Discussion: 1.

During the next class period, ask students what they thought about the guest speakers?

Would they try these alternative therapies if they had the same conditions as their patients?

What credentials should CAM practitioners have?

What things should you look for when choosing a qualified practitioner?

Activity #4: Family History Purpose: To identify health risks you may have in the future.

Time: Ten to fifteen minutes to discuss and give the assignment.

Method: 1.

Have students create a family tree with branches representing their siblings, parents, uncles and aunts, grandparents, etc.

Have them interview each person and ask them about health problems or concerns they have.

Have them list these concerns under their name on their family tree.

Discussion: 1.

Are there health issues that seem to run in your family?

Do you think you might be at risk for any of these problems?

Are there tests or procedures that you might need to have done to see if you are at risk?

What can you do to possibly help, cure, or avoid these health concerns?

References, Readings, and Resources Chan, J. K. Y., et al. (2016). University students’ views on the perceived benefits and drawbacks of seeking help for mental health problems on the Internet: A qualitative study. JMIR Human Factors, 3.1, e3. doi: 10.2196/humanfactors.4765. Chen, J., et al. (2016). Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical Care, 54(2), 140–146 doi: 10.1097/MLR.0000000000000467. Pechmann, C., & Catlin, J. R. (2016). The effects of advertising and other marketing communications on health-related consumer behaviors. Current Opinion in Psychology, 10, 44–49.

Films and Videos A Different Way to Heal (Acupuncture. Herbal remedies. Magnet therapy. Consumers and patients have made alternative and “complementary” medicine a billion-dollar industry. But do these and other alternatives to traditional Western medicine really work?) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Bill Moyers Journal: Diagnosing Health Care Reform (After months of lobbying, grandstanding, and political theater, is there any real reform left in President Obama’s health care reform bill? In this edition of the Journal, Bill Moyers sits down with Wendell Potter, a former insurance executive turned public health advocate, who argues that all is not lost in the health-care bill and details what he likes about the legislation.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Doctor Hotspot (New Yorker writer and FRONTLINE correspondent Atul Gawande reports on a doctor in Camden, NJ, who actually seeks out the community’s sickest—and most expensive— patients. Dr. Jeffrey Brenner and his team are pioneering a practice called “hotspotting,” in which medical care is focused on the hardest-to-treat to improve their health and dramatically reduce costs.) FRONTLINE – Doctor Hotspot Dollars and Dentists (Dental care can be a matter of life and death. Yet millions of Americans can’t afford a visit to the dentist. An investigation by FRONTLINE and the Center for Public Integrity reveals the shocking consequences of a broken safety net. Poor children, entitled by law to dental care, often cannot find a dentist willing to see them. Others kids receive excessive care billed to Medicaid, or major surgery for preventable tooth infections. For adults with dental disease, the situation can be as dire—and bankrupting. While millions of Americans use emergency rooms for dental care, at a cost of more than half a billion dollars, corporate dental chains are filling the gaps in care, in some cases allegedly overcharging patients or loading them with high priced credit card debt.) FRONTLINE – Dollars and Dentists Make Me Well: Inside Harley Street—What Price Health? (What happens when a patient becomes the customer and health is a consumer product, where money gives you access to the best available care? This observational documentary series looks inside the world of private medicine in Harley Street, the iconic British institution.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Supplements and Safety (FRONTLINE, The New York Times and the Canadian Broadcasting Corporation examine the hidden dangers of vitamins and supplements, a multibillion-dollar industry with limited FDA oversight.) FRONTLINE – Supplements and Safety

Internet Resources National Center for Complementary and Integrative Health The lead agency for scientific research on the diverse medical and health-care systems, practices, and products that are not generally considered part of conventional medicine. National Center for Complementary and Integrative Health American Medical Association Provides a credible and comprehensive source of information on a variety of specific medical conditions. American Medical Association American Council on Science and Health Provides consumer education materials relating to food, chemicals, lifestyle, environment, and health. American Council on Science and Health American Massage Therapy Association Homepage for the AMTA. American Massage Therapy Association Facts about Sexual Harassment Provides practical information for those dealing with sexual harassment issues. Feminist Majority Foundation Federal Bureau of Investigation Provides crime statistics. Federal Bureau of Investigation U.S. Food and Drug Administration (FDA) Homepage for the FDA. Provides information on strategies for evaluating health products and services. U.S. Food and Drug Administration Healthy Sex Site for international expert Wendy Maltz. HealthySex.com MedicineNet © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

This comprehensive site is written for the consumer by board-certified physicians and contains medical news, directory of procedures, medical dictionary, pharmacy, and first-aid information. MedicineNet.com Centers for Disease Control and Prevention - Injury Prevention and Control Provides information about preventing unintentional injuries and violence. Injury Prevention and Control National Council against Health Fraud Provides news and information about health fraud and quackery and links to related websites. National Council against Health Fraud National Health Information Center This website is a health information referral service providing health professionals and consumers with a database of various health organizations. National Health Information Center National Safety Council This site provides resources and fact sheets on issues related to public safety, the environment, the community, and the workplace. National Safety Council National Sexual Violence Resource Center This is a comprehensive collection and distribution center for information, statistics, and resources related to sexual violence. National Sexual Violence Resource Center Occupational Safety and Health Administration (OSHA) This U.S. Department of Labor site features a wealth of information on occupational safety and accident prevention, as well as a searchable database. Occupational Safety and Health Administration RAINN (Rape, Abuse & Incest National Network) Great information from an organization fighting against rape, assault, and incest. Rape, Abuse & Incest National Network

The Rape Crisis Center This private nonprofit organization provides support to victims of sexual violence and their families, including a 24/7 crisis hotline and several advocacy programs. The Rape Crisis Center The Survivors Page Extensive links to chat rooms, and info on self-injury, pregnancy, and sexual harassment in schools. Survivors' Stuff

Key Words acupuncture

informed consent

ayurveda

integrative medicine

chiropractic

medical history

complementary and alternative medicine (CAM)

naturopathy

evidence-based medicine

Pap smear

gingivitis

periodontitis

gum disease

plaque

health literacy

practice guidelines

health maintenance organization (HMO)

primary care

herbal medicine holistic home health care

outcomes

quackery self-care vital signs

homeopathy

Answers to Global Health Watch 1. b 2. b 3. counseling

14 Protecting Yourself and Your Environment Learning Objectives After studying this chapter in the text, the student should be able to: 14.1 Discuss the threats posed by unintentional injuries. 14.2 Outline the best practices for road safety. 14.3 Examine the statement that violence is a significant public health problem. 14.4 Discuss the consequences of campus violence on students. 14.5 Assess the impact of sexual victimization and violence. 14.6 Analyze the relationship between individual health and the health of our environment. 14.7 Assess the impact of pollutants on the surrounding environment. 14.8 Enumerate the health threats posed by polluted air. 14.9 Explain the importance of safe drinking water. 14.10 Explain the importance of breathing clean air when indoors. 14.11 Review the ways that exposure to toxic chemicals can be harmful. 14.12 Describe the threats to health from radiation. 14.13 Enumerate the factors that lead to hearing loss.

Chapter Summary This chapter is a primer in self-protection that can help safeguard or perhaps even save your life—on the road, on campus, and in potentially violent situations. It also explores the complex interrelationships between your world and your well-being, including major environmental threats such as air, water, and noise pollution. By realizing that you have a personal responsibility for the health of your environment, you are also helping to safeguard your own well-being.

Lecture Outline I.

Unintentional Injury A. The major threat to the lives of college students is not illness, but injury. B. Almost 75 percent of deaths among Americans 15–24 years old are caused by “unintentional injuries,” suicides, and homicides. C. Those who respond well in crisis have three underlying psychological attributes: 1. They believe that they can influence events. 2. They are able to find meaningful purpose in turmoil and trauma. 3. They know that they can learn from both positive and negative experiences.

II.

Safety on the Road A. Introduction 1. More than 37,000 people die in car crashes in the United States every year; another 2.35 million are injured or disabled. 2. The annual number of traffic fatalities has fallen in recent years, but the number of teenagers killed in car accidents has increased. 3. Teenage drivers and their passengers are at highest risk of vehicular accidents. a. Most accidents involving young drivers are due to three all-toocommon errors: i. Failing to scan the environment by looking ahead and to the left and the right while driving ii. Going too fast for road conditions (even if under the speed limit) iii. Being distracted by something inside or outside the vehicle B. Avoid Distracted Driving 1. This refers to any nondriving activity a person engages in that has the potential to distract him or her from the primary task of driving and increase the risk of crashing. 2. More than 9 people die and more than 1,153 are injured every day in the United States in crashes involving distracted driving. 3. The main types of distraction are: a. Visual b. Manual c. Cognitive d. Social

C. Don’t Text or Talk 1. Even if the cell phone is a hands-free model, using it while driving is as dangerous as driving drunk. a. Driving while dialing a cell phone makes the risk of a crash or nearcrash three times more likely than if a driver were not distracted; texting increases the risk twentyfold. 2. Many states have passed laws banning use of a cell phone to text or talk while driving. D. Stay Sober and Alert 1. The number of fatalities caused by drunk driving, particularly among young people, has dropped. The National Highway Traffic Safety Administration attributes this decline to: a. Increases in the drinking age b. Educational programs aimed at reducing nighttime driving by teens c. The formation of Students Against Destructive Decisions and similar groups d. Changes in state laws that lowered the legal blood alcohol concentration level for drivers under age 21 2. Falling asleep at the wheel is second only to alcohol as a cause of serious motor-vehicle accidents E. Buckle Up 1. Seat belts save an estimated 9,500 lives in the United States each year. F. Check for Air Bags 1. An air bag, either with or without a seat belt, has proved the most effective means of preventing adult death. G. Rein in Road Rage 1. Some strategies for reducing road rage include the following: a. Lower the stress in your life b. Consciously decide not to let other drivers get to you c. Slow down d. Modify bad driving habits one at a time e. Be courteous—even if other drivers are not f. Never retaliate g. If you do something stupid, show that you are sorry H. Cycle Safely 1. Per vehicle mile, motorcyclists are 35 times more likely to die in a crash than passenger car occupants.

2. The most common motorcycle injury is head trauma. a. This can cause physical disability, paralysis, general weakness, problems in reading and thinking, personality changes, and psychiatric problems such as depression, anxiety, uncontrollable mood swings, and anger. 3. Each year, bicycle crashes kill about 700 bicyclists and send 450,000– 587,000 to emergency rooms. III. Violence in America A. Overview 1. The World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or a group or community that either results in, or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” 2. Violence, a significant public health problem in this country, kills 55,000 people in the United States every year. 3. There are ethnic and racial differences in patterns of violence. 4. There is no simple answer to explain why a person becomes violent and punches, kicks, stabs, or fires a gun at someone else. a. Among the motives identified by psychologists are as follows: i. Expression. Some people use violence to release feelings of anger or frustration. ii. Manipulation. For some, violence is a way of controlling others or getting something they want. iii. Retaliation. Individuals may use violence to get back at those who have hurt them or their loved ones. B. Gun Violence 1. Gun violence causes an estimated 74,000 injuries and 32,000 deaths every year. 2. The most common form of fatal gun violence is suicide, which accounts for almost two-thirds of such deaths. C. Mass Shootings 1. Mass murder—the killing of four or more people at a single location—has emerged as a national concern, with far too many tragic shootings occurring at schools, college campuses, movie theaters, and public events in recent years.

2. Although there have been few studies, researchers have identified underlying psychosocial issues in mass shooters, including: a. Social alienation b. Problems with self-esteem c. Persecutory/paranoid outlook d. Narcissism e. Depression f. Suicidality g. Family dysfunction D. A Public Health Approach 1. Gun control remains one of the most controversial political issues, with intense disagreement about Second Amendment interpretations of the right to bear arms. 2. Medical groups are focusing on violence as a public health challenge involving sociocultural, educational, behavioral, and product safety issues rather than solely gun ownership. IV. Violence and Crime on Campus A. Introduction 1. According to the Bureau of Justice Statistics, college students are victims of almost half a million violent crimes a year, including assault, robbery, sexual assault, and rape. 2. Although this number may seem high, the overall violent crime rate has dropped from 88 to 41 victimizations per 1,000 students in the past decade. 3. College students ages 18–24 are less likely to be victims of violent crime, including robbery and assault, than nonstudents of the same age. 4. More than half of crimes against students are committed by strangers. 5. Male college students are twice as likely to be victims of violence as female students. 6. About three in four campus crimes are never reported to police. 7. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, originally known as the Student Right-to-Know and Campus Security Act, requires colleges to publish annual crime statistics for their campuses. a. However, the act excludes certain offenses, such as theft, threats, harassment, and vandalism, so the picture it presents may not be complete.

B. Hazing 1. Hazing refers to any activity that humiliates, degrades, or poses a risk of emotional or physical harm for the sake of joining a group or maintaining full status in that group. 2. Its forms include verbal ridicule and abuse, forced consumption of alcohol or ingestion of vile substances, sexual violation, sleep deprivation, paddling, beating, burning, or branding. C. Hate or Bias Crimes 1. The term hate crime generally refers to a criminal offense committed against a person or property that is motivated, in whole or in part, by bias or prejudice against race, national or ethnic origin, religion, sexual orientation, or disability. 2. In the last decade, there have been reports of more acts of hate on college campuses, such as vandalism of minority students’ meeting places or painting of swastikas or racist words on walls. D. Microaggressions 1. While many minority students say that overt prejudice is rare and relatively easy to deal with, everyday insults, indignities, and demeaning messages, called microaggressions, can undermine their academic confidence and their ability to bond with the university. a. Microassaults: conscious and intentional actions or slurs, such as using racial or sexual epithets or showing preferential treatment to nonminority customers at shops and restaurants. b. Microinsults: verbal and nonverbal communications that subtly convey rudeness and insensitivity and demean a person’s racial heritage or identity. c. Microinvalidations: communications that subtly exclude, negate, or nullify the thoughts, feelings, or experiential reality of an individual. E. Shootings, Murders, and Assaults 1. Shootings of students and faculty have occurred at several campuses in recent years. However, they remain uncommon. 2. There are about 3,000 aggravated assaults—an attack with a weapon or one that causes serious injury—each year. 3. Strategies for keeping campuses safe: a. Enforcing codes of conduct b. Tougher sanctions, including expulsions, for serious misconduct c. Zero-tolerance policies for campus violence d. Building a sense of community e. Screening out students who pose a real threat © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

f. Warning students about criminal activity at orientation, through the campus newspaper, in residence halls, and through campus Internet communication devices F. Consequences of Campus Violence 1. Crime and violence take a great toll at colleges and universities. a. Violence can seriously injure people as well as claim lives. b. Moreover, victims of violent crime often suffer lasting psychological and emotional effects. V.

Sexual Victimization and Violence A. Introduction 1. Sexual victimization refers to any situation in which a person is deprived of free choice and forced to comply with sexual acts. 2. This is not only a woman’s issue; men are also victimized. 3. In recent years, researchers have come to view acts of sexual victimization along a continuum, ranging from street hassling, stalking, and obscene telephone calls to rape, battering, and incest. 4. The prevalence of sexual victimization and violence varies in different studies, but a meta-analysis of data found rates as high as 8.4 percent of forcible vaginal, anal, or oral intercourse using physical force or threat of force for college women and 0.7 percent for college men. B. Cyberbullying and Sexting 1. Cyberbullying is defined as an aggressive, intentional act carried out by a group or individual using electronic forms of contact repeatedly and over time against a victim who cannot easily defend him- or herself. a. As many as 20 percent of adolescents and young adults have reported being cybervictims or cyberbullies. 2. Sexting is defined as “the sharing of images or videos of sexually explicit content.” a. In the United States, about 7 in 10 of adolescents (ages 12–18) reported having received sexually oriented material, while two-thirds reported having sent it. C. Sexual Harassment 1. All forms of sexual harassment or unwanted sexual attention—from the display of pornographic photos to the use of sexual obscenities to a demand for sex by anyone in a position of power or authority—are illegal. 2. Nearly two-thirds of students experience sexual harassment at some point during college, including nearly one-third of first-year students.

3. Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) students, as well as those with physical disabilities such as deafness, are more likely than other students to be sexually harassed. 4. About half of college men and one-third of women admit that they have sexually harassed someone on campus. 5. If you encounter sexual harassment as a student, report it to the department chair or dean. D. Stalking 1. Stalking is defined as the “willful, repeated, and malicious following, harassing, or threatening of another person,” and is common on college campuses. 2. Stalking is not a benign behavior and can result in emotional or psychological distress, physical harm, or sexual assault. 3. College students are targeted because: a. They are young and still learning how to manage complex social relationships and may not see their behavior as stalking. b. College students tend to live close to each other and have a lot of unsupervised time. E. Intimate Partner (Dating) Violence 1. Intimate partner violence can occur between heterosexual, homosexual, or bisexual partners and can take different forms: a. Physical violence. The threat or the use of force, ranging from light pushes and slaps to punching and kicking. b. Sexual violence. The threat or the use of force to engage a partner in sexual activity without consent, an attempted or completed sexual act without consent, or abusive sexual contact. c. Psychological violence. The use of threats, actions, or coercive tactics that cause trauma or emotional harm to a partner. d. Social or intimate violence. Establishing control over a partner by means of threats, restrictions on behavior, and social isolation from friends and family. 2. Young women ages 18–24, regardless of whether they are in college, are frequent targets of intimate partner violence. a. Almost one in three undergraduate women at a college in the United States was assaulted by a male dating partner in the past year. 3. Risk Factors for Intimate Partner Violence a. Factors that increase the likelihood of intimate partner violence include the following: i. Gender © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

ii. Sexual minority iii. Violence in the family of origin iv. Emotional states and mental health v. Substance use and abuse vi. Sexual risk taking 4. Disclosure and Support a. Most victims of dating violence disclose what happened to at least one person, usually a friend, family member, classmate, coworker, or neighbor. F. Sexual Assault on Campus 1. According to its Campus Climate Survey Validation Study of more than 23,000 undergraduates at nine schools, 21 percent of female students have experienced a completed sexual assault since entering college. 2. Victims of sexual assault often suffer physical and emotional trauma that can linger for years and stretch into nearly every area of their lives. G. Changing the Campus Culture 1. Prevention of sexual violence begins with changes in attitudes by all members of a campus community. a. The “It’s On Us” Campaign: This public awareness effort emphasizes that everyone at every college and university in this country must accept responsibility and take action to end sexual violence on campuses. b. Bystander Training: Before the problem escalates, during an episode of threatened or actual sexual violence, or after the incident, bystanders can choose to respond by doing nothing, stepping in and helping a victim, or making the situation worse by offering overt or tacit encouragement to the perpetrator. i. “Bystander training” is being offered on campuses to help community members become more sensitive to issues of interpersonal violence and to teach prevention and intervention skills. H. Nonvolitional Sex and Sexual Coercion 1. Nonvolitional sex is unwanted sexual behavior that violates a person’s right to choose when and with whom to have sex and what sexual behaviors to engage in. a. The more extreme forms of this behavior include forced sex, childhood sexual abuse, and violence against people with nonconventional sexual identities.

2. Sexual coercion can take many forms, including exerting peer pressure, taking advantage of one’s desire for popularity, threatening to end a relationship, getting someone intoxicated, stimulating a partner against his or her wishes, or insinuating an obligation based on the time or money one has expended. 3. About 20 percent of students say they have coerced a partner into sex in the previous 12 months, and 24 percent of students report having been victims of sexual coercion. 4. Researchers use the term covictimization to describe experiencing both physical and sexual forms of intimate partner violence. a. In one study of college women, 64 percent were covictimized since adolescence, although not necessarily by the same partner. I. Incapacitated Sexual Assault and Date-Rape Drugs 1. In a recent study of about 600 female undergraduates, incapacitated sexual assault was associated with higher perceived drinking norms, more social drinking, more drinking before sexual activity, and more drinking to conform with peers. 2. College women often aren’t aware of the possibility that their drinks may be tampered with or that they may have been given a date-rape drug. 3. Many schools are alerting incoming female students about what researchers call “the red zone,” a period of time early in one’s first undergraduate year when women are at particularly high risk for unwanted sexual experiences. J. Rape 1. Rape refers to sexual intercourse with an unconsenting partner under actual or threatened force. 2. In 2012, the Justice Department updated the legal definition of rape as the penetration, no matter how slight, of the vagina or anus with any body part or object, or the oral penetration by a sex organ of another person, without the consent of the victim. 3. Sexual intercourse between a male over the age of 16 and a female under the age of consent (which ranges from 12 to 21 in different states) is called statutory rape. 4. In acquaintance rape, or date rape, the victim knows the rapist. 5. In marital or spousal rape, the perpetrator is the victim’s spouse. In stranger rape, the rapist is an unknown assailant. 6. Both acquaintance and stranger rapes are serious crimes that can have a devastating impact on their victims.

7. Over the course of 5 years, including summers and vacations, one of every four or five female students is raped. 8. In surveys of male university students, between 3 and 6 percent have been raped by other men; up to 25 percent have been sexually assaulted. 9. Women are raped because they encounter sexually aggressive men, not because they look or act a certain way.. 10. Types of Rape a. Marital rape is the most common form of rape and is a form of domestic abuse. b. Anger rape is usually on a total stranger, is motivated by hatred and a desire for revenge for the rejection the rapist feels he’s suffered from women. c. Power rape is generally a premeditated attack motivated by a desire to dominate and control another person. d. Sadistic rape is a premeditated assault that often involves bondage, torture, or sexual abuse. e. Gang rape involves three or more rapists. Men in close groups that drink and party together are more likely to participate in such assaults. The reasons may go beyond aggression and sexual gratification to the excitement and camaraderie the men feel while sharing the experience. f. Sexual gratification rape is usually an impulsive attack by someone willing to use physical coercion for the sake of sex. 11. Acquaintance, or Date Rape a. Nine in ten reported rapes and sexual assaults in the United States involve a single offender with whom the victim had a prior relationship. b. Factors that lead to this type of rape include: i. Personality and early sexual experiences ii. Situational variables (what happens during the date) iii. Rape myths iv. Social norms v. Drinking vi. Gender differences in interpreting sexual cues. 12. Stranger Rape a. Rape prevention consists primarily of making it as difficult as possible for a rapist to make you his victim. i. Do not advertise that you are a woman living alone. ii. Do not open your door to strangers. iii. Lock your car when it is parked, and drive with locked doors. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

iv. Avoid dark and deserted areas, and be aware of the surroundings when you are walking. v. Have house or car keys in hand as you approach the door. vi. Carry a device for making a loud noise. 13. Male Nonconsensual Sex and Rape a. No one knows how common male rape is because men are less likely to report such assaults than women. b. About 10 percent of acquaintance rape cases are men. 14. Impact of Rape a. Rape-related injuries include: i. Unexplained vaginal discharge, bleeding, infections, multiple bruises, and fractured ribs. b. Victims often develop chronic symptoms such as: i. Headaches, backaches, high blood pressure, sleep disorders, pelvic pain, and sexual fertility problems. c. Psychological scars of a sexual assault take a long time to heal. They include: i. Hopelessness, low self-esteem, high levels of self-criticism, and selfdefeating relationships. d. An estimated 30–50 percent of women develop posttraumatic stress disorder following a rape. K. What to Do in Case of Sexual Assault or Rape 1. According to recent estimates, only about 50 percent of dating violence victims report the assault to someone else. a. Of these, 88 percent tell a friend and 20 percent also contact criminal justice authorities. 2. Crisis hotlines or campus helplines can provide immediate assistance and referrals to sexual assault or domestic violence programs that provide shelter, counseling, support groups, legal assistance, and medical services. 3. Women who are raped should call a friend or a rape crisis center. a. A rape victim should not bathe or change her clothes before calling. b. All rape victims should talk with a doctor or health-care worker about testing and treatment for sexually transmitted infections and post intercourse conception. 4. Even an unsuccessful rape attempt should be reported because the information a woman may provide about the attack may prevent another woman from being raped.

VI. From Personal to Planetary Threats: The Environment and Your Health 1. The ecosystem is a community of organisms that share a physical and chemical environment. a. Our environment is a closed ecosystem, powered by the sun. 2. We cannot separate our individual health from that of the environment in which we live. B. Climate Change 1. The Intergovernmental Panel on Climate Change of the United Nations, made up of leading scientists from around the world, has reported with absolute certainty that the world’s climate is changing in significant ways and will continue to do so in the foreseeable future. a. These experts predict an increase in extreme weather events (such as hurricanes and heat waves), greater weather variability, and rising water temperatures. C. Global Warming 1. Earth’s average temperature increased about 1–2 degrees in the 20th century to approximately 59 degrees, but the rate of warming in the last three decades has been three times the average rate since 1900. 2. Seas have risen about 6–8 feet globally over the last century and are rising at a higher rate. 3. Certain gases in Earth’s atmosphere trap energy from the sun and retain heat somewhat like the glass panels of a greenhouse. D. The Health Risks 1. Global warming and related changes can imperil health indirectly through the following: a. More frequent and intense heat waves b. Flooding c. More extreme weather, such as hurricanes, tornadoes, cyclones, and tsunamis d. More severe droughts 2. Climate change can imperil health by changing patterns of infectious diseases, the supply of fresh water, and food availability. VII. The Impact of Pollution 1. Pollution is any change in the air, water, or soil that could reduce its ability to support life. 2. A pollutant is a substance or agent in the environment, usually the byproduct of human industry or activity that is injurious to human, animal, or plant life. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

a. Chronic affect may take years to develop or may be a recurrent or continuous reaction, usually after repeated exposure. 3. Mutagens are agents that cause alterations in the genetic material of living cells. a. Teratogens are mutagens that can cross the placenta of a pregnant woman and cause a spontaneous abortion or birth defects. b. Carcinogens are mutagens that cause cancer. 4. Health problems linked with pollution include: a. Headaches and dizziness b. Decline in cognitive functioning c. Eye irritation and impaired vision d. Nasal discharge e. Cough, shortness of breath, and sore throat f. Constricted airways g. Constriction of blood vessels and increased risk of heart disease h. Increased risk of stroke and dying from stroke i. Chest pains and aggravation of the symptoms of colds, pneumonia, bronchial asthma, emphysema, chronic bronchitis, lung cancer, and other respiratory problems j. Birth defects and reproductive problems k. Nausea, vomiting, and stomach cancer l. Allergy and asthma from diesel fumes in polluted air VIII. The Air You Breathe A. Breathing polluted air can do more than irritate: It can take months or even years off your life, particularly among the underprivileged who live in areas with dangerous levels of air pollution. 1. Pollutants destroy the hair-like cilia that remove irritants from the lungs. 2. Breathing in polluted air can increase the risk for heart attack by nearly 5 percent. IX. The Water You Drink A. Introduction 1. Fears about the public water supply have led many Americans to turn off their taps. 2. Each year the CDC reports an average of 7,400 cases of illness related to the water people drink.

3. The problem of lead-contaminated water in Flint, Michigan, made national headlines when researchers found that river water had corroded the city’s pipes so that lead leached into the water. B. Is Bottled Better? 1. Bottled water is second only to soft drinks as America’s favorite beverage. 2. .Medical researchers have not found a scientific reason to recommend bottled water. a. Dentists report an increase in cavities among children and teenagers who drink bottled water rather than fluoridated tap water. b. Despite images of mountain streams and glacier peaks on the labels, most comes from an urban water supply. C. Portable Water Bottles 1. The simplest, safest, most ecofriendly water container is a glass. 2. Disposable bottles made with made with polyethylene terephthalate pose a risk to the environment and may pose health risks as well. 3. Polycarbonate plastic and metal bottles are also an option. X.

Indoor Pollutants: The Inside Story A. Introduction 1. You may think of pollution as primarily a threat when you’re outdoors, but people in industrialized societies spend more than 90 percent of their time inside buildings a. Some sources—such as building materials and household products such as air fresheners—release pollutants more or less continuously. b. Wood-burning fireplaces and stoves also pose a risk to both indoor and outdoor air quality because the smoke contains fine particles that can injure the lungs, blood vessels, and heart. B. Environmental Tobacco Smoke 1. The mixture of smoke from the burning end of a cigarette, pipe, or cigar and a smoker’s exhalations contains over 4,000 compounds; over 40 of them are known to cause cancer. a. Despite indoor smoking bans in many areas, about 88 million nonsmokers in the United States are exposed to environmental tobacco smoke. 2. Secondhand smoke or passive smoking poses greatest risks for infants and young children, and youngsters with asthma or other respiratory problems.

3. Thirdhand smoke—tobacco residue contains cancer-causing toxins that stick to a variety of surfaces, where they can get into the dust, and picked up on the fingers. C. Radon 1. Created by the breakdown of uranium in rocks, soil, and water, radon is the second-leading cause of lung cancer. 2. When radon becomes trapped in buildings and concentrations build up indoors, exposure to the gas becomes a concern. D. Mold and Other Biological Contaminants 1. Bacteria, mildew, viruses, animal dander, cat saliva, house dust mites, cockroaches, and pollen can all pose a threat to health. 2. Mold is a type of fungus that decomposes organic matter and provides plants with nutrients. a. Common molds include Aspergillus, Penicillium, and Stachybotrys, a slimy dark green mold that has been blamed for infant deaths and various illnesses, from Alzheimer’s disease to cancer, in adults that breathe in its spores. E. Household Products 1. Products that clean, disinfect, degrease, polish, wax, and preserve contain powerful chemicals that can pollute indoor air during and for long periods after their use. 2. Exposure to bisphenol A (BPA), a controversial chemical commonly used to make plastics, may increase a healthy person’s risk of developing heart disease later in life. F. Formaldehyde 1. Formaldehyde is commonly used in building materials, carpet backing, furniture, foam insulation, plywood, and particle board. 2. This chemical can cause nausea, dizziness, headaches, heart palpitations, stinging eyes, and burning lungs. G. Pesticides 1. According to a recent survey, 75 percent of U.S. households used at least one pesticide product indoors during the past year. H. Asbestos 1. This mineral fiber has been used commonly in a variety of building construction materials for insulation and as a fire retardant. 2. The government has banned several asbestos products, and manufacturers have also voluntarily limited use of asbestos.

I. Lead 1. People are exposed to lead, a long-recognized health threat, through air, drinking water, food, contaminated soil, deteriorating paint, and dust. 2. Although lead exposure has declined, about 2.6 percent of children ages 1–5 still have dangerous levels of lead in their blood. a. Boys are at greater risk than girls because female hormones may protect the brain against lead’s harmful effects. J. Carbon Monoxide and Nitrogen Dioxide 1. Carbon monoxide (CO) gas—which is tasteless, odorless, colorless, and nonirritating—can be deadly. a. Every year an estimated 10,000 Americans seek treatment for CO inhalation; at least 250 die because of this silent killer. XI. Chemical Risks A. Various chemicals, including benzene, asbestos, and arsenic, have been shown to cause cancer. 1. Risks can be greatly increased with simultaneous exposures to more than one carcinogen. 2. An estimated 50,000–70,000 workers die each year of chronic diseases related to past exposure to toxic substances. 3. Endocrine disruptors—chemicals that act as or interfere with human hormones, particularly estrogen. a. Scientists are investigating their impact on fertility, falling sperm counts, and cancers of the reproductive organs. 4. Exposure to toxic chemicals causes about 3 percent of developmental defects. B. Electromagnetic Fields (EMFs) 1. These are the invisible electric and magnetic fields generated by an electrically charged conductor. 2. Epidemiological studies have revealed a link between exposure to highvoltage lines and cancer, especially leukemia, in electrical workers and children. C. Cell Phones 1. The Federal Communications Commission (FCC), has stated that “the available scientific evidence does not show that any health problems as associated with using wireless phones. There is no proof, however, that wireless phones are absolutely safe.”

D. Microwaves 1. There’s no evidence that existing levels of microwave radiation encountered in the environment pose a health risk to people. 2. There is concern about the safety of chemicals in plastic wrapping and plastic containers used in microwave ovens. a. These chemicals leak into food. b. Some of these chemicals have caused cancer in mice. E. Ionizing Radiation 1. Ionizing radiation is radiation that poses enough energy to separate electrons from their atoms leaving charged ions. 2. Its effects on health depends on many factors including the amount, length of exposure, type, part of the body exposed, and the health and age of the individual. XII.

Your Hearing Health A. Overview 1. Hearing loss is the third most common chronic health problem, after high blood pressure and arthritis, among older Americans. 2. Nearly 22 million Americans between ages 20 and 69 have irreversibly damaged hearing because of excessive noise exposure. B. How Loud Is That Noise? 1. Loudness or the intensity of sound is measured in decibels (dB). 2. Prolonged exposure to any sound over 85 dB (the equivalent of a power mower or food blender) or brief exposure to louder sounds can harm hearing. 3. The noise level at rock concerts can reach 110–140 dB, about as loud as an air-raid siren. C. Effects of Noise 1. Noise-induced hearing loss is 100 percent preventable and it is irreversible. 2. Hearing aids are the only treatment, but they do not correct the problem; they just amplify sound to compensate for hearing loss. 3. Tinnitus is ringing in the ear. D. Are Earbuds Hazardous to Hearing? 1. The dangers to your hearing depend on how loud the music is and how long you listen. 2. Ask yourself the following questions to see if you need your hearing checked. a. Do you frequently have to ask people to repeat themselves?

b. Do you have difficulty hearing when someone speaks in a whisper? c. Do people complain that you turn up the volume too much when watching television or listening to music? d. Do you have difficulty following conversation in a noisy environment: e. Do you avoid groups of people because of hearing difficulty: f. Have your friends or family suggested that you might have hearing loss? E. Hearing Loss 1. About one in five 6- to 19-year-olds has impaired hearing. 2. In a recent study, as many as one quarter of college student suffered mild hearing loss. 3. Hearing loss generally increases with age, affecting one-third of Americans ages 65–74 and almost half of those over age 75.

Discussion Questions •

Ask students to describe what “feeling safe” and “being safe” mean to them. How are they different? How can you make your environment safe? What things can you do within your home to make it physically and emotionally safe for you?

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Ask students to cite the factors that influence an individual’s risk of an accident. Which of these are most common in a college student’s day-to-day activities? Why are college students prone to these types of accidents? What can be done to reduce a person’s susceptibility to each?

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Ask students to share with the class a brief sketch of the safety procedures of their office or workplace. How was this information communicated to employees? Who enforces these safety issues? How adequate are these procedures? What suggestions would students make to improve the safety procedures discussed in class?

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Discuss the factors (biological, developmental, etc.) that contribute to violence. What kind of prevention efforts are used to target these risk factors?

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In order to help curb violence in America, ask the class how they feel about violence being censored in the media. What about in music? In advertisements that degrade men or women?

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Ask students to brainstorm methods to prevent violence in our community. What can we do in our individual homes? At school? In the work environment? What about road rage? How does this contribute to violence as a whole? What can we do if we get upset while driving?

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Ask the class who is responsible when partner abuse occurs? What is spousal rape? When can it occur? Does the law adequately protect the victim and her or his family? What measures can be taken to protect the spouse?

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Acknowledging the harassment policies that exist on your campus, ask students whether they feel that the laws are too strict or not harsh enough. What can be done to help curb this problem? What can they do if they feel like they have been harassed? What if it is an instructor?

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After discussing the types of rapists and some common motives the rapist might use, ask the class who is responsible when rape occurs. Can they think of any situations or scenarios where the victim is responsible? Use this discussion to clarify myths and reinforce facts about this crime. If you or someone you know has been raped, what should you do? How might you talk the victim into getting help? What are your resources?

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Do you feel that our water supply is safe and healthy? Do you feel that there are benefits or hazards to drinking bottled water?

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Ask students if they feel the foods that we consume are generally safe or if they feel more comfortable consuming organic foods.

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Discuss the benefits versus the costs of consuming organic foods. Is the higher price worth the possible health benefits? Ask students if they know what GMO food is? Do they feel the procedure for creating GMO food has been researched enough?

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Discuss with students what your state’s laws are concerning environmental health and safety. Do they feel that local laws are too strict or not strict enough?

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Ask the class with whom they believe the responsibility for a clean environment lies: the government or the consumer.

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Define pollution, including acute and chronic effects to pollutants. Think about what you are doing to contribute to all types of pollution in our society. What can you do to reduce pollution?

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Describe global warming. List the major sources for greenhouse gas emissions. What policies are in place to help lower greenhouse gas emissions?

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Describe noise pollution and discuss the impact of noise pollution on health. Create a chart of decibel levels and list your most common exposures to noise pollution. Do you already suffer from hearing loss due to exposure to loud noises? If so, discuss why.

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Discuss with students the most common biological weapons that have been a threat to our society in most recent history. What harm could be caused? What is being done to prevent a biological attack on our society?

Classroom Activities Activity #1: Risky Sexual Behavior Purpose: To examine ways in which students may be putting themselves in potentially risky situations and at risk for date rape.

Time: One class period.

Method: 1.

Students should examine all the possible factors that may put them at risk for acquaintance or date rape, looking closely at situational variables, drinking, and drug use.

List the resources available on your campus for those who have been victims of sexual violence.

Discussion: 1.

As a student, have you ever placed yourself in a risky situation that could have led to date rape? Have you ever been in a situation where you could have taken advantage of another individual? What kept you safe in these situations?

Do you feel that your school provides enough information and resources for individuals who are victims of date rape or sexual violence? What more should be done to protect students?

Activity #2: Protecting Your Hearing Purpose: Reviewing exposure to noise and identify risks for hearing loss.

Time: One class period.

Introduction: Review actual exposure to the many different causes of hearing loss and determine susceptibility.

Method: 1.

Students should examine their exposure to noise and different sounds.

They should list personal exposures, such as listening to music and attending concerts, blow dryers, as well as possible environmental exposures.

Students should also include any work-related noise exposure.

Students should list any hearing difficulties that they have experienced.

Students will develop a list of strategies for preventing hearing loss.

Discussion: 1.

Were students surprised by the amount of noise they were exposed to?

Do they participate in activities that specifically affect hearing loss, for example, playing in a band?

Do they listen to music at inappropriate levels?

Are they willing to make changes in order to protect their hearing now?

Activity #3: Cell Phones and Safety Purpose: To help students understand the importance of staying safe while using a cell phone.

Time: One class period.

Method: 1.

Students should list all activities they engage in while also talking on their cell phones. Examples include driving, walking to class, working, riding a bike, etc.

Students should list any negative consequences or dangers they may have experienced as a result of using cell phones while participating in another activity.

Discussion: 1.

Do students use their cell phones at inappropriate times?

Have they ever been involved in an automobile accident due to cell phone use?

Have they ever been distracted because of cell phone use?

What can students do to lower their risk of accident or injury because of cell phone use?

Activity #4–6:Environmental Field Trips Purpose: Field trips serve as powerful reinforcers of your lesson. Based on the learning curve theory, within 10 years after the completion of your course, most students will have forgotten your name and any factual information presented in class, but they may recall a memorable field trip.

Time: One class period per trip.

Environmental Field Trips: Prior to the field trips, have students prepare and submit three questions of interest on an index card to be asked during the field trip. 1. Arrange to visit a large organic garden or farm. Ask the tour guide to compare and contrast commercial gardening/farming with organic farming in terms of moneysaved (cost vs. benefits), environmental benefits, health benefits, etc. 2. Begin a local tree-planting project in your community with your classes. Investigate places where trees may be planted in your locality. For $1.00, you can purchase one tree from the National Arbor Day Foundation, 100 Arbor Ave., Nebraska City, NE 68410 (402-474-5655). 3. Have students identify several locations in the community/campus that can be used to check air pollution. Use a thin layer of petroleum jelly on scraps of cardboard to detect particles of pollution. Check the cards a day or two later for a visual record of the particles (by darker colors) and note the differences in the various locations. Use cards as visual evidence of pollution when you approach the school or city about your concerns.

Discussion: 1. How did these activities make you feel about our environment? 2. Can you make a difference in our environment? How? 3. What are the different “levels” of our environment? How do they interact with each other? For instance, how does planting trees affect our communities? Households?

References, Readings, and Resources Association for Safe International Travel. http://asirt.org/initiatives/informing-roadusers/road-safety-facts/road-crash-statistics. Bennett, S., & Banyard, V. L. (2016). Do friends really help friends?: The effect of relational factors and perceived severity on bystander perception of sexual violence. Psychology of Violence, 6.1, 64. doi: 10.1037/a0037708. Bird, E. R., et al. (2016). The role of social drinking factors in the relationship between incapacitated sexual assault and drinking before sexual activity. Addictive Behaviors, 52, 28–33. doi: 10.1016/j. addbeh.2015.08.001. Bose, S., & Diette, G. B. (2016). Health disparities related to environmental air quality. In Health Disparities in Respiratory Medicine (pp. 41–58). Springer International Publishing, Switzerland. Butts, J. A., et al. (2015). Cure violence: A public health model to reduce gun violence. Annual Review of Public Health, 36, 39–53. Centers for Disease Control and Prevention. Preventing Violent Deaths in America. www.cdc.gov/features/ViolentDeathsAmerica/. Dardis, C. M., et al. (2014). An examination of the factors related to dating violence perpetration among young men and women and associated theoretical explanations: A review of the literature. Trauma, Violence, and Abuse. doi: 10.1177/1524838013517559 Edwards, K. M., et al. (2015). Physical dating violence, sexual violence, and unwanted pursuit victimization: A comparison of incidence rates among sexual-minority and heterosexual college students. Journal of Interpersonal Violence, 30(4), 580–600. doi: 10.1177/0886260514535260. Jiang, W., et al. (2016). Daily music exposure dose and hearing problems using personal listening devices in adolescents and young adults: A systematic review. International Journal of Audiology, 55(4), 1–9. doi: 10.3109/14992027.2015.1122237. Moshammer, H., et al. (2015). Early prognosis of noise-induced hearing loss. Occupational and Environmental Medicine, 72, 85–89. doi: 10.1136/ oemed-2014-102200.

Naeem, Z. (2015). Health risks associated with mobile phone use. International Journal of Health Sciences. Pellai, L. A., et al. (2015). Epidemiology of sexting. Minerva Pediatrica, 67(1), 1. doi: 10.1007/ s11904-015-0280-x. Preidt, R. (2013, March). Phones, texting may be as dangerous as alcohol for drivers. MedlinePlus. Retreived from http://www.nlm.nih.gov/medlineplus/. Rhodes, N., Pivik, K., & Sutton, M. (2015). Risky driving among young male drivers: The effects of mood and passengers. Transportation Research Part F: Traffic Psychology and Behaviour, 28, 65–76. doi: 10.1016/j.trf.2014.11.005. Robbins, A. (2016). How to Understand the Results of the Climate Change Summit: Conference of Parties21 (COP21) Paris 2015. Journal of Public Health Policy, 37, 129–132. doi: 10.1057/jphp.2015.47. Wintemute, G. J. (2015). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 36, 5–19.

Films and Videos Accidents Happen: What to Do When You’re in a Car Accident (Even if you’re a safe driver, car accidents are an inevitable part of life. The average driver will go through three to four accidents in a lifetime. And when an accident happens, all drivers involved have certain responsibilities.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Breaking the Wall of Coal: How Climate Science Calls for Radical Changes in Energy Policy (On the long and winding road to more sustainable energy and climate policies, the year 2015 saw several unexpected and positive developments—the largest fossil fuel divestment campaign in history reached its peak and led to trillions of dollars being pulled out of coal, gas, and oil companies.) © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Climate Wars: Planet Oil (As we entered the 21st century, the world was guzzling oil, coal, and gas like never before. In this concluding episode, Iain Stewart argues we face a stark choice. Do we continue feed our addiction—suck Planet Oil dry—and risk catastrophic climate change, or do we go hell for leather for alternative energy sources; nuclear, renewables, to make the transition from our fossil fuel past to a low carbon future.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Consent on Campus (From the Ivy League to public universities to community colleges, sexual assault on college campuses has become a sweeping nationwide epidemic impossible to ignore.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Conquer Silence: Restore Hearing (More than 31.5 million Americans have some degree of hearing loss, and an estimated three out of every 1,000 children in the United States may be born with hearing loss. Whether it’s present at birth, or happens suddenly or gradually over time, hearing loss can leave a person feeling isolated from friends and family.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

F: 800.678.3633 E: Films Media Group Courts, Not Campuses, Should Decide Sexual Assault Cases: A Debate (What is the best way to handle cases of sexual assault on campuses? U.S. law forbids any school receiving federal aid to discriminate on the basis of sex, and many schools have implemented policies to prevent sexual harassment and assault. But are colleges the right authority to investigate and resolve cases of sexual assault on campuses?) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Dirty Little Secrets: The Impact of Fine Particle Pollution (To most people, air pollution is a global issue. But what about the air we breathe every day—on the street, at work, and in our homes? This program studies fine particle air pollution and its public health hazards.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Environmental Issues and Human Impact (This video looks at urgent environmental concerns facing planet Earth and what people can do to repair the degradation humans have caused. Air and water pollution, the effects of pollution on health and the environment, deforestation and loss of wetlands, ozone depletion and global warming, and the negative impact of agriculture, construction, and recreation/tourism are discussed.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group From Hilltops to Oceans: Stemming the Flow of Water Pollution © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

(Environmental mismanagement on land has become a grave threat to life in the world’s oceans. This two-part series circumnavigates the globe to report on efforts to remediate oceanic dead zones: the locations where fertilizer runoff, raw sewage, and other biohazards have driven the oxygen from marine ecosystems—and all animal life along with it.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Gunned Down (FRONTLINE goes inside the politics of America’s gun debate. Veteran filmmaker Michael Kirk investigates the NRA, its political evolution and influence, and how it has consistently succeeded in defeating new gun control legislation.) FRONTLINE – Gunned Down Nuclear Meltdown Disaster (NOVA reveals the minute-by-minute story of the Fukushima nuclear crisis—the one you know about, and the one you likely don’t: the perilously close call at the other Fukushima nuclear power plant a few miles away) NOVA – Nuclear Meltdown Disaster Rape on the Night Shift (FRONTLINE investigates the sexual abuse of immigrant women—often undocumented—who clean the malls where you shop, the banks where you do business and the offices where you work.) FRONTLINE – Rape on the Night Shift Secrets of the Oceans: Climate Control (When it comes to regulating global temperatures, forget the Amazon rainforest. It’s the oceans that really deserve the title of “lungs of the planet.” Their plankton provides us with oxygen.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

E: Films Media Group Surviving a Car Crash (For every new car built this year, another will be involved in a collision, and more than a million people around the world will die as a result. This program vividly demonstrates what happens to the car and the passengers during a crash; using highspeed cameras that capture crash sequences, it shows the three stages of impact and the resulting injuries.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Using the Law to Save Us: Roger Cox (This episode of The Green Interview features Roger Cox, a Dutch lawyer and author, who led the Dutch Climate Case, the groundbreaking suit brought against the Netherlands on behalf of the Urgenda Foundation and 900 Dutch Citizens. In 2015, the case concluded with an unprecedented verdict in which the district court in The Hague ordered the Dutch government to reduce its greenhouse gas emissions more dramatically than it had intended, arguing it had a duty of care to its citizens.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group

Internet Resources Power Shift Network The Power Shift Network is bringing together leaders—from the smallest campus groups to the largest national organizations—to fight for climate, clean energy, and social justice. Power Shift Network Global Warming: Early Warning Signs Includes a map that illustrates the local consequences of global warming. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Climate Hot Map Hearing Loss Association of America The Hearing Loss Association of America (HLAA) is the nation’s leading organization representing people with hearing loss. Hearing Loss Association of America National Center for Environmental Health (NCEH) CDC's National Center for Environmental Health (NCEH) plans, directs, and coordinates a national program to maintain and improve the health of the American people by promoting a healthy environment and by preventing premature death and avoidable illness and disability caused by noninfectious, nonoccupational environmental, and related factors. National Center for Environmental Health American Lung Association – Health Effects of Secondhand Smoke The American Lung Association is the leading organization working to save lives by improving lung health and preventing lung disease. Health Effects of Secondhand Smoke U.S. Environmental Protection Agency (EPA) The mission of the EPA is to protect human health and the environment. U.S. Environmental Protection Agency

Keywords carcinogen

microwaves

covictimization

mutagen

cyberbullying

nonvolitional sex

decibel (dB)

pollutant

ecosystem

pollution

electromagnetic fields (EMFs)

rape

endocrine disruptors

sexting

hazing

sexual coercion

ionizing radiation

sexual harassment

microaggressions

stalking

Answers to Global Health Watch 1. b 2. a 3. seatbelt

15 A Lifetime of Health Learning Objectives After studying this chapter in the text, the student should be able to: 15.1 Discuss life expectancy in the United States. 15.2 Examine the factors that influence successful aging and the characteristics of old age. 15.3 Explain the physiological changes involved in aging. 15.4 Assess different ways to prepare for medical crises and the end of life. 15.5 Discuss the emotional and psychological responses to dying. 15.6 Describe the process of dying. 15.7 Discuss the reasons why people commit suicide. 15.8 Outline some practicalities of death. 15.9 Summarize the effects of grief at the death of a loved one.

Chapter Summary This chapter explores the meaning of death, describes the process of dying, provides information on end-of-life issues, and offers advice on comforting the dying and helping their survivors.

Lecture Outline I.

An Aging Nation A. Overview 1. By 2030, the number of Americans over age 65 will more than double to 70.3 million (20 percent of the total population). 2. Despite gains in life expectancy and survival rates, Americans live shorter lives and experience more injuries and illnesses than people in other highincome countries.

3. Seniors in the United States have more chronic health problems and take more medications than seniors in 10 other industrialized countries, according to a recent global survey. B. Will You Live to Be 50? 1. As an American you—regardless of your age, gender, race, ethnicity, education, and socioeconomic status—are less likely to hit the half-century mark than your peers in 16 other affluent countries a. If you do survive to celebrate your 50th birthday—and the odds are nonetheless good that you will—you’re likely to be in much worse health than citizens of America’s “peer” nations. 2. The difference in life expectancy each of these health hazards can make is: a. High blood pressure: 1.5 for men, 1.6 for women. b. Obesity: 1.3 years for men and for women. c. High blood sugar: 0.5 years for men, 0.3 years for women. d. Smoking: 10 years for both men and women. II.

Successful Aging A. Overview 1. Although aging—the characteristic pattern of normal life changes that occurs as humans, plants, and animals grow older—remains inevitable, you can do a great deal to influence the impact that the passage of time has on you. 2. According to research on “exceptional longevity” (survival to at least age 90), the key factors to living long and well are maintaining a healthy lifestyle (including regular exercise, weight management, and smoking avoidance) and avoiding or delaying chronic illnesses. B. Physical Activity: It’s Never Too Late 1. Lack of physical activity, dangerous even for the young, becomes deadly among the old. 2. Simply sitting for prolonged periods increases “all-cause mortality,” the risk of dying for any reason, in both sexes and all age groups regardless of general health, body mass index, and physical activity levels. 3. Exercise slows many changes associated with advancing age, such as loss of lean muscle tissue, increase in body fat, and decrease in work capacity. 4. According to the U.S. surgeon general, physical activity offers older Americans the following benefits: a. Greater ability to live independently b. Reduced risk of falling and fracturing bones c. Lower risk of dying from coronary heart disease

d. Reduced blood pressure e. Fewer symptoms of anxiety and depression. f. Improvements in mood and feelings of well-being 5. No one is ever too old to get in shape. C. Nutrition and Obesity 1. Obesity is the most common nutritional disorder in older persons. 2. Over 65 persons face diabetes, heart disease, stroke, and arthritis, all exacerbated by obesity. D. The Aging Brain 1. The brain does and can repair itself. 2. Cognitive Aging a. Mental ability does not necessarily decline along with physical vigor. b. Older people who remain mentally and physically healthy think just as quickly and sharply as college students. c. The brain, like the body, may begin to show signs of aging in middle age. d. Watching your weight also can help keep your brain sharp. 3. Memory a. Memory loss and cognitive problems are becoming less common among older Americans. E. Women at Midlife 1. Reproductive Aging a. Medical specialists have identified several stages that characterize the aging of the female reproductive system. i. Late reproductive stage. Declines in fertility and changes in the menstrual cycle. ii. Early menopausal transition. Increased variability in menstrual cycles. iii. Late menopausal transition. Hormonal changes and amenorrhea, or lack of menstrual bleeding, for 60 days or longer. iv. Early postmenopause. Five to eight years after the final menstrual period, when hormones fluctuate and then stabilize. v. Late postmenopause. Limited changes in reproductive hormones. b. Menopause is the complete cessation of ovulation and menstruation for 12 consecutive months. c. For many women, perimenopause—the four-to-ten-year span before a woman’s last period—is more baffling and bothersome than the years after.

d. Hormonal shifts can trigger an array of symptoms. i. Night sweats and hot flashes are the most common symptoms. e. A woman’s habits and health history also have an impact. 2. Menopause a. About 10–15 percent of women breeze through this transition with only trivial symptoms and another 10–15 percent are virtually disabled. b. Race and ethnicity profoundly affect women’s experiences. c. Dwindling levels of estrogen subtly affect many aspects of a woman’s health, from her mouth (where dryness, unusual tastes, burning, and gum problems can develop) to her skin (which may become drier, itchier, and overly sensitive to touch). d. A woman’s clitoris, vulva, and vaginal lining begin to shrivel, sometimes resulting in pain or bleeding during intercourse. e. In the United States, the average woman who reaches menopause has a life expectancy of about 30 more years. 3. Hormone Therapy a. HT is no longer recommended for reasons other than short-term relief of symptoms, such as hot flashes and night sweats. b. Combination therapy increases the risk of breast cancer, heart disease, blood clots, and stroke. c. Black cohosh, the most popular herbal treatment, is no more effective than a placebo in relieving hot flashes and other menopausal symptoms. F. Men at Midlife 1. Men experience a decline by as much as 30 to 40 percent in their primary sex hormone, testosterone, between the ages of 48 and 70. 2. This change, sometimes called andropause, may cause a range of symptoms, including decreased muscle mass, greater body fat, loss of bone density, flagging energy, lowered fertility, and impaired virility. 3. Low testosterone: There is little scientific evidence that normally decreasing testosterone levels are responsible for many changes that take place in older men. 4. Prostate problems: After age 40, the prostate gland, which surrounds the urethra at the base of the bladder, enlarges. a. This condition called benign prostatic hypertrophy occurs in every man. b. Medical treatments for benign prostatic hypertrophy include drugs, and possible surgical treatment. © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

G. Sexuality and Aging 1. The fittest men and women report more frequent sexual activity. 2. Aging does cause some changes in sexual response: a. Women produce less vaginal lubrication. b. An older man needs more time to achieve an erection or orgasm and to attain another erection after ejaculating. c. Both men and women experience fewer contractions during orgasm. d. None of these changes reduces sexual pleasure or desire. III. The Challenges of Age A. Mild Cognitive Impairment (MCI) 1. An estimated 10–20 percent of those age 65 and older may suffer mild cognitive impairment (MCI), which causes a slight but noticeable and measurable decline in cognitive abilities, including memory and thinking skills. 2. No medications are currently approved to treat it. 3. Coping strategies to slow down impairment a. Exercise b. Reduce cardiovascular risk factors c. Participate in mentally stimulating and socially engaging activities B. Alzheimer’s Disease 1. About 15 percent of older Americans lose previous mental capabilities, a brain disorder called dementia. 2. Sixty percent of these suffer from the type of dementia called Alzheimer’s disease, a progressive deterioration of brain cells and mental capacity. 3. Age is the top risk factor for Alzheimer’s, but cognitive decline may begin up to 6 years before it is evident. 4. A person with the disease typically lives 8 years after the onset of symptoms. 5. Women are more likely to develop Alzheimer’s than men. 6. Regular exercise and weight management may lower the likelihood of Alzheimer’s. a. A healthful diet—rich in nuts, fish, tomatoes, poultry, and dark green leafy vegetables and low in high-fat foods, red meat, and butter—may help protect the brain. 7. The early signs of dementia—insomnia, irritability, increased sensitivity to alcohol and other drugs, and decreased energy and tolerance of frustration—are usually subtle and insidious.

8. The FDA has approved several prescription drugs for people with mild to moderate dementia, including Aricept®, Exelon®, Reminyl®, and Namenda®. a. Although these medications do not cure or halt the progression of Alzheimer’s, they may improve cognitive and daily functioning. C. Osteoporosis 1. Osteoporosis, a condition in which losses in bone density become so severe that a bone will break after even slight trauma or injury. a. One in every two women and one in every four men over 50 will have an osteoporosis-related fracture in their lifetimes. IV. Preparing for Medical Crisis and the End of Life A. Overview 1. When facing a serious, potentially life-threatening illness, people typically have practical, realistic goals, such as maintaining their quality of life, remaining independent, being comfortable, and providing for their families. A. Advance Directives 1. Every state and the District of Columbia has laws authorizing the use of advance directives to specify the kind of medical treatment individuals want in case of a medical crisis. 2. These documents are important because, without clear indications of a person’s preferences, hospitals and other institutions often make decisions on an individual’s behalf. 3. The two most common advance directives are health-care proxy and living wills. a. Health-Care Proxy i. A health-care proxy is an advance directive that gives someone else the power to make decisions on your behalf. b. Living Will i. These indicate whether they want or do not want all possible medical treatments and technology used to prolong their lives. ii. Most states recognize living wills as legally binding, and a growing number of health-care professionals and facilities offer patients help in drafting living wills. c. The Five Wishes i. Helps the aged, the seriously ill, their loved ones, and caregivers prepare for medical crisis.

ii. Persons using this document can specify: (a) Which kinds of medical treatments they do or do not want (b) How comfortable they want to be made (c) How they want people to treat them (d) What they want loved ones to know d. DNR Order i. You can also sign an advance directive specifying that you want to be allowed to die naturally—you do not want to be resuscitated in case your heart stops beating. 4. The Gift of Life a. If you’re at least 18 years old, you can fill out a donor card agreeing to designate, in the event of your death, any organs or tissues needed for transplantation. b. The donation takes effect upon your death and is a generous way of giving others the possibilities for life that you have had yourself. V.

Death and Dying A. Overview 1. According to medical statisticians, your risk of death doubles every 8 years after about age 20 or 30. B. Death Literacy and Education 1. Death used to be such a taboo subject that people for a long time avoided even mentioning it, let alone treating it as a subject worthy of study and discussion. a. This attitude is changing as communities and individuals develop greater “death literacy,” defined as the knowledge and skills that make it possible to understand and act upon end-of-life and death care options. b. “Death education,” which consists of a variety of educational activities and experiences related to death, dying, and bereavement, becomes more widespread in colleges and schools for health professionals. C. Defining Death 1. Death has been broken down into the following categories: a. Functional death: the end of all vital functions, such as heartbeat and respiration. b. Cellular death: the gradual death of body cells after the heart stops beating. c. Death: the moment when the heart stops beating.

d. Brain death: the end of all brain activity, indicated by an absence of electrical activity (confirmed by an electroencephalogram, or EEG) and a lack of reflexes. e. Spiritual death: the moment when the soul, as defined by many religions, leaves the body. 2. Most states have declared that an individual is considered dead only when the brain, including the brain stem, completely stops functioning. 3. Brain-death law prohibits a medical staff from “pulling the plug” if there is any hope of sustaining life. D. Emotional Responses to Dying 1. Kübler-Ross identified five typical stages of reaction that a person goes through when facing death: a. Denial b. Anger c. Bargaining d. Depression e. Acceptance 2. Several stages may occur at the same time, and some may happen out of sequence. 3. An individual’s will to live can postpone death for a while. 4. The family of a dying person experiences a spectrum of often wrenching emotions. 5. As patients confront reality, they eventually can “let go and be.” VI. Suicide A. Suicide increases with age and is most common in persons aged 65 years and older. B. One of the main factors leading to suicide is illness, especially terminal illness. C. A great deal of debate centers on quality of life, yet there is no reliable or consistent way to measure this. VII. Grief A. Introduction 1. An estimated 8 million Americans lose a member of their immediate family each year. 2. Death of a loved one produces a wide range of reactions, including anxiety, guilt, anger, and financial concern.

3. According to the stage theory of grief, individuals respond to the loss of a loved one by progressing through several steps, just like people facing death. a. Shock–numbness b. Yearning–searching c. Disorganization–despair d. Reorganization 4. All of these reactions can occur simultaneously, although most peak within 6 months. 5. Bereavement is not a rare occurrence on college campuses, but is largely an ignored problem. B. Grief’s Effects on Health 1. Men and women who lose partners, parents, or children endure so much stress that they’re at increased risk of serious physical and mental illness, and even of premature death. 2. Studies of the health effects of grief have found the following: a. Grief produces changes in the respiratory, hormonal, and central nervous systems and may affect functions of the heart, blood, and immune systems. b. Grieving adults may experience mood swings between sadness and anger, guilt and anxiety. c. They may feel physically sick, lose their appetite, sleep poorly, or fear that they’re going crazy because they “see” the deceased person in different places. d. Friendships and remarriage offer the greatest protection against health problems. e. Some widows may have increased rates of depression, suicide, and death from cirrhosis of the liver. f. Grieving parents, partners, and adult children are at increased risk of serious physical and mental illness, suicide, and premature death. 3. Sometimes grief progresses from an emotionally painful but normal experience to a more persistent problem called complicated grief, which may require professional treatment.

Discussion Questions •

Discuss some of the possible reasons for the increase in life expectancy in the United States. Discuss specific things that students can do right now to increase their own life expectancy.

•

Ask students if they have had a personal experience with Alzheimer’s disease. If this was a personal friend or loved one, how did it feel to see that person slowly lose their ability to remember? Did they personally seek help from a support group? Discuss steps that can be taken to lower the likelihood of Alzheimer’s disease?

•

Ask students how accurate they believe Kübler-Ross’ stages of grief are. Which stage do they think would be the most difficult to deal with? Does each person experience these stages at the same rate? In the same order?

•

“The way a person faces death is often a mirror of the way he or she has faced other major stresses in life: those who have had the most trouble adjusting to other crises will have the most trouble adjusting to the news of their impending death.” Ask the students to reflect upon this statement and discuss their reactions to it.

•

If a terminally ill family member or friend was suffering and asked for your help in ending their life, would you assist them? Should the medical establishment use heroic measures to prolong the life of a terminally ill patient? When, if ever, does a patient have the right to die?

•

Ask students if any have a will. How many have signed organ donor cards? Who has communicated to others how they would like their body handled after they die? Assuming most college-aged students have probably not thought about any of these issues, ask the class to discuss the advantages and disadvantages of planning for their death. What is the process of giving up your organs once you have passed?

•

Ask the class whether they feel there is any difference in the way a family copes with their grief when their loved one has been cremated rather than buried? What factors does one consider when choosing between cremation and a burial?

•

Take the time to explore diversity and death by asking students in the class to share how various cultures deal with death and dying. Are there any traditions that are shocking to the students? Why or why not?

Classroom Activities Activity #1: How Does the Media Portray Death? Purpose: To create an awareness of our beliefs about death and grieving.

Time: Two class periods.

Introduction: Introduce the stages of grieving for both those who may be experiencing death and for the loved ones of the individual dying.

Method: 1.

View a film that’s main theme is about dying (e.g., Dying Young, Tuesdays with Morrie, and Terms of Endearment). You may even want to select a movie that involves the death of a pet (e.g., Where the Red Fern Grows). If you are short on time, you may want to play the record “Unbreak My Heart” by Tony Braxton, or a similar song.

Discussion: 1.

Once you have viewed the film, ask your students what their immediate reactions are to the movie.

What feeling is it that they are identifying with? When they see a movie like this, do they relate it to a similar experience or loss?

Does the media accurately portray our emotions, or do we reflect the media’s portrayal?

What can we learn from those who are nearing death?

Do we grieve differently when death is sudden versus over a period of time?

How do movies like this help us to prepare for the inevitable?

Activity #2: Funeral Home Visit Purpose: To explore feelings and attitudes about death.

Time: One class period.

Introduction: Introduce to the class the decisions that go into planning a funeral and how grief often plays a role in the decision-making process of how to take care of our loved ones.

Method: 1.

Arrange with a local funeral director to visit their facility to discuss the options in death.

Be sure all students have directions and a ride to the funeral home of choice.

Ask the director to show you the variety of options and their particular role.

Discussion: 1.

You may want the director to address issues of cost, laws regarding burial, and the typical services provided if students do not ask on their own.

After the visit, gather students to discuss their feelings about being in the funeral home.

How does it make them feel to know more about the process?

What are students’ concerns about death? How can these be somewhat relieved?

Activity #3: Guest Speaker Purpose: 1.

To understand more about advance directives, DNR documents, and living wills.

To learn what other options are available or needed to prepare for a death of a parent, themselves, or another family member or close friend.

Time: One class period for the guest speaker and 15–20 minutes for a follow-up discussion.

Introduction: Invite an attorney or certified estate planner who specializes in these documents to come and speak to the class.

Method: 1.

Have the guest speaker address the differences between advance directives, power of attorneys, DNR, living wills, wills, and trusts.

Allow time at the end of the presentation for students to ask questions.

Discussion: 1.

Based on the information presented by the guest speaker, the text, and what has been presented in class, have the students make a personal inventory of documents that they may need to complete either for themselves or for someone else in their family, (parents, children, etc.).

Require them to create a plan for completing these documents by having them order the documents based on which are the most important to complete.

Have them research and find resources that can help them to develop these documents (these can be online or in person).

Ask the class to share resources and tips that they found in their research that would help them create and organize these important documents.

Activity #4: Personal Experience with Loss Purpose: To reflect on feelings and attitudes about death.

Time: One class period.

Method: 1.

Students should think back to the most recent loss of a loved one that they have experienced.

Have students write down who this person was, how long ago they experienced this loss, and if they went through the five emotional responses to dying.

Discussion: 1.

What are students’ concerns about death?

Did this loss cause them to think about their own death? Have they considered being an organ donor?

References, Readings, and Resources Albom, M. (2004). The five people you meet in heaven. New York: Hyperion. Albom, M. (2003). Tuesdays with Morrie. New York: Hyperion. Beard, R. L. (2016). Living with Alzheimer’s: Managing memory loss, identity, and illness. New York: New York University Press. Cherry, K. E., et al. (2016, February). Social factors and healthy aging: Findings from the Louisiana healthy aging study (LHAS). Kinesiology Review, 5(1), 50–56. http://dx.doi.org/10.1123/kr.2015-0052. Clayton, A. H., & Harsh, V. (2016). Sexual function across aging. Current Psychiatry Reports, 18.3, 1–9. doi: 10.1007/s11920-016-0661-x. Goveas, J. S., et al. (2016). Predictors of optimal cognitive aging in 80+ women: The women’s health initiative memory study. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 71(Suppl. 1), S62–S71. doi: 10.1093/gerona/glv055 Jones, L. (2016). Care of people when they face death and dying: definitions, international context and the development of research. In J. Round (Ed.), Care at the end of life (pp. 3–15). New York: Springer. doi: 10.1007/978-3-319-28267-1_1 Kübler-Ross, E. (1975). Death: The final stage of growth. Englewood Cliffs, NJ: Prentice Hall. National Research Council and Institute of Medicine. (2013). U.S. Health in International Perspective: Shorter lives, poorer health. Panel on understanding cross-national health differences among high-income countries, Steven H. Woolf and Laudan Aron (Eds.). Commit- tee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press. Woods, N. F., et al. (2016). Aging well: Observations from the women’s health initiative study. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 71(Suppl. 1), S3–S12.

Films and Videos Being Mortal © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

(FRONTLINE follows renowned New Yorker writer and Boston surgeon Atul Gawande as he explores the relationships doctors have with patients who are nearing the end of life. In conjunction with Gawande’s new book, Being Mortal, the film investigates the practice of caring for the dying, and shows how doctors—himself included—are often remarkably untrained, ill-suited, and uncomfortable talking about chronic illness and death with their patients.) FRONTLINE – Being Mortal The Grey Lane (Canada and other Western nations are grappling with the emotionally charged question of what to do about older people behind the wheel. While many seniors are superbly safe drivers, statistics show those 75 and older cause more crashes than teenagers per kilometer driven.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Halting Dementia (The global population is aging and the number of people with dementia is shockingly on the rise. Leading research reveals that dementia, which was considered impossible to treat after onset, can be managed using unconventional approaches.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Life and Death in Assisted Living (More and more elderly Americans are choosing to spend their later years in assisted living facilities, which have sprung up as an alternative to nursing homes. But is this loosely regulated, multibillion dollar industry putting seniors at risk? In a major investigation with ProPublica, FRONTLINE examines the operations of the nation’s largest assisted living company, raising questions about the drive for profits and fatal lapses in care.) FRONTLINE – Life and Death in Assisted Living © 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Lily: We Are All Getting Older (A follow-up study to Lily: A Longitudinal View of Life with Down Syndrome (44930), this poignant program is a loving portrait of Lily at age 49. It captures Lily’s sweetness, good humor, and comfort in the life her family and professionals have supported.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Preventing Dementia (How can dementia be prevented? While research on dementia prevention is making significant progress, Mild Cognitive Impairment (MCI), a pre-dementia phase, has been receiving attention as key point toward preventive methods.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group Seeking Quality of Death (How do you want to die? Japan has become a “super-aged society.” Today, longer life has been achieved and dying of old age continues to rise, as many illnesses are now curable due to advances in medical care.) Films Media Group 132 West 31st Street, 16th Floor New York, NY 10001 P: 800.322.8755 F: 800.678.3633 E: Films Media Group The Suicide Plan (In this groundbreaking 90-minute film, FRONTLINE explores the underground world of assisted suicide and takes viewers inside one of the most polarizing social issues of our time—told not only by the people choosing to die, but also by their “assisters,”

individuals and right-to-die organizations that put themselves in legal jeopardy by helping others to die.) FRONTLINE – The Suicide Plan

Internet Resources AARP: Coping with Grief and Loss AARP is an organization that helps people 50 and over improve the quality of their lives; this particular part of their website provides articles on grief and loss. AARP – Grief and Loss Hospice Foundation of America End-of-life care resources for professionals, patients, and families. Hospice Foundation of America MedlinePlus – Advance Directives Provides an organized set of links to living will (advance directive) websites. Advance Directives National Funeral Directors Association Provides information related to funeral costs and arrangements. National Funeral Directors Association National Hospice and Palliative Care Organization A nonprofit membership organization committed to improving end of life care and expanding access to hospice care. National Hospice and Palliative Care Organization National Institute on Aging This government site features a comprehensive array of resources on aging, including publications on a variety of geriatric health topics, current news events, and a resource directory for older people. National Institute on Aging RealAge RealAge content is now a part of Sharecare. Links are available for health topics, health guides, assessments, and doctor visit guides. RealAge

The Administration on Aging (AoA) This site has information for seniors and their families on promoting healthy lifestyles and general aging topics. The Administration on Aging

Key Terms advance directives

hormone therapy (HT)

aging

living will

Alzheimer’s disease

menopause

black cohosh

mild cognitive impairment (MCI)

dementia

perimenopause

do-not-resuscitate (DNR) orders

Answers to Global Health Watch 1. a 2. d 3. sleep well