Always Healthy Life

Heart Valve Disorders

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The heart has four chambers two small upper chambers (atria) and two larger lower chambers (ventricles). Each chamber is closed by a one-way valve. For various reasons these valves can malfunction, causing leakage (regurgitation) or failure to open properly (stenosis). The mitral valve, which allows blood to flow

from the left atrium to the left ventricle (the main pumping chamber of the heart), and the aortic valve, which allows blood to flow from the left ventricle to the aorta (the main artery of the body), are the most common sites for valve disease. These valves are under great strain from the powerful contractions of the left ventricle, which pumps blood throughout most of the body.

Mitral Valve Prolapse

Mitral valve prolapse is the most common valve disorder. Usually it is an inherited structural defect. The two parts, or leaflets, of the mitral valve thicken, preventing them from coming together properly. The leaflets bulge back into the left atrium as the ventricle contracts, allowing small amounts of blood to leak back

into the atrium. Prolapse is a term that means slippage out of position; in this case the valve leaflets have difficulty being in their correct position because they are too thick.

Most people with mitral valve prolapse experience no symptoms. Others may have a wide range of symptoms such as chest pain, palpitations (an awareness of one’s heartbeat), migraine headaches, dizziness, and fatigue that cannot be explained by the valve problem alone. Physicians diagnose mitral valve prolapse by using a stethoscope to listen to the characteristic clicking sound produced by the valves as they hit against one another. The condition also produces a heart murmur, or slight rushing sound, that the physician hears through the stethoscope when the heart contracts. Echocardiography (an ultrasound examination of the heart) allows a doctor to view the prolapse and determine its severity.

Most people with mitral valve prolapse do not need treatment. When symptoms such as extra heartbeats, a rapid heartbeat, or chest pain become bothersome, medications are prescribed to control them. In rare cases, when leakage becomes severe, surgical repair or valve replacement may be required. People with mitral valve prolapse are usually given antibiotics before dental or surgical procedures to decrease the risk that bloodborne bacteria will infect the heart valve.

Mitral Valve Regurgitation

Mitral valve regurgitation, also called mitral incompetence or mitral insufficiency, is leakage of blood back through the mitral valve into the left atrium each time the left ventricle contracts. This increases the volume and pressure in the left atrium, which, in turn, increases blood pressure in the vessels leading from the lungs to the heart. This results in lung congestion (fluid buildup). In the past, rheumatic fever was the most common cause of this condition. But with the advent of antibiotics, rheumatic fever is now rare in the United States, and the few cases that are seen are primarily in older people who had rheumatic fever in childhood. A more common cause of mitral valve regurgitation today is a heart attack, which can damage the supporting structures of the mitral valve. Mild cases of mitral valve regurgitation may not cause any symptoms. The condition may be recognized during a routine chest examination with a stethoscope, when a doctor hears a distinctive heart murmur caused by the blood leaking back into the left atrium when the left ventricle contracts. Diagnosis usually is confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart) and chest X rays that indicate the left ventricle is enlarged. Echocardiography (an ultrasound examination of the heart) can produce an image of the faulty valve and indicate the severity of the problem. Since the left ventricle has to pump more blood to make up for the blood leaking back into the atrium, it gradually enlarges to increase the force of each heartbeat. The enlarged ventricle may cause palpitations (awareness of one’s heartbeat), which is particularly noticeable when the person lies on his left side. The left atrium also tends to enlarge to accommodate the extra blood leaking back from the ventricle. A very enlarged atrium often beats rapidly in an irregular fashion (atrial fibrillation). This reduces the heart’s pumping efficiency, and the lack of proper blood flow through the atrium allows blood clots to form. If a clot becomes detached, it may be pumped out of the heart and block a smaller artery elsewhere in the body, possibly causing a stroke or other damage. Finally, severe regurgitation reduces the forward flow of blood, causing heart failure, which may lead to coughing, swollen legs, or shortness of breath on exertion. Treatment for this condition can take several forms. Repairing the valve can either eliminate or reduce the regurgitation enough to make the symptoms tolerable and prevent heart damage. Atrial fibrillation accompanying mitral valve regurgitation is usually treated with medications that slow the heart rate and help control the fibrillation. In severe cases, the valve may be replaced surgically.

Mitral Valve Stenosis

Mitral valve stenosis is a narrowing of the mitral valve opening that increases resistance to blood flow from the left atrium to the left ventricle. This resistance causes pressure to build up in the atrium; the pressure then backs up through the veins of the lungs, causing increased pressure and congestion in the lungs. The increased stress on the lungs can lead to shortness of breath and eventually to congestive heart failure. Typically, the valve leaflets fuse together. Surgery is needed to widen or replace the valve. Mitral valve stenosis is almost always the result of rheumatic fever, which is rare today in the United States, where most cases occur in older people who had rheumatic fever during childhood. However, rheumatic fever can sometimes occur after an untreated “strep” throat infection (infection with streptococcal bacteria). Mitral valve stenosis also can be congenital (present from birth). Infants born with this condition rarely live beyond age 2 unless they have surgery to correct the condition.

If stenosis is severe, blood pressure increases in the left atrium and in the veins in the lungs, resulting in heart failure and an accumulation of fluid in the lungs (pulmonary edema). A person with heart failure easily becomes fatigued and short of breath. At first, shortness of breath may occur only during physical activity. Later the symptoms may occur even during rest. Some people find that they can breathe comfortably only when they are propped up with pillows or sitting upright.

Some people with mitral valve stenosis have a plum-colored flush in their cheeks. High blood pressure in the veins of the lungs may cause a small vein or tiny capillaries to burst and bleed slightly or massively into the lungs. Enlargement of the left atrium can result in atrial fibrillation (an abnormally fast heartbeat). To diagnose mitral valve stenosis, a physician uses a stethoscope to listen for a characteristic heart murmur as blood rushes through the narrowed valve from the left atrium. Unlike a normal valve, which opens silently, a valve

affected by mitral valve stenosis often makes a snapping sound as it opens to allow blood into the left ventricle. The diagnosis of mitral valve stenosis is usually confirmed by electrocardiography (ECG; an examination of the electrical activity of the heart), a chest X ray showing an enlarged atrium, or echocardiography (an ultrasound examination of the heart). Sometimes cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) is performed to determine the extent and characteristics of the valve blockage. Treatment for mitral valve stenosis may include a variety of drugs. Betablockers, digoxin, and verapamil are used to slow the heart rate and control atrial fibrillation. Digoxin also strengthens the heartbeat if heart failure occurs. Diuretics are often prescribed to reduce the blood pressure in the lungs by reducing the volume of circulating blood. If medication does not reduce the symptoms adequately, surgical valve repair or replacement may be needed. People with mitral valve stenosis are given antibiotics before dental and surgical procedures to reduce the risk of a heart valve infection.

Aortic Stenosis

Aortic stenosis is an abnormal narrowing or stiffening of the aortic valve, which controls the flow of blood from the left ventricle to the aorta (the main artery of the body). As the valve narrows, the left ventricle has to beat harder to push the blood through the aorta and out into the body. The most common cause of aortic

stenosis is the gradual buildup of calcium deposits on the valve, a natural consequence of aging. Although this condition may appear at about age 60, it usually does not produce symptoms until age 70 or 80. Aortic stenosis also may result from childhood rheumatic fever. When rheumatic fever is the cause, aortic stenosis

usually is accompanied by mitral valve stenosis, mitral valve regurgitation, or both. In aortic stenosis, as the ventricle attempts to pump enough blood through the narrowed aortic valve, the left ventricle wall thickens, and the enlarged heart muscle requires an increasing blood supply from the coronary arteries. Eventually the blood supply to the heart becomes insufficient, causing angina (chest pain) on exertion. An insufficient blood supply can damage the heart muscle, reducing its ability to pump blood through the body. This reduced functioning can lead to congestive heart failure. A person with severe aortic stenosis may faint on exertion because the narrow valve prevents the ventricle from pumping enough blood out of the heart to the rest of the body. In diagnosing aortic stenosis, a physician will listen for the characteristic heart murmur through a stethoscope, note abnormalities in the pulse and electrical activity of the heart, and look for an enlarged heart as revealed by a chest X ray. Electrocardiography (ECG; an examination of the electrical activity of the heart), echocardiography (an ultrasound examination of the heart), and cardiac catheterization (a diagnostic test in which a thin, flexible tube is inserted into the heart through a blood vessel, to examine the heart) may be used to determine the severity of the stenosis. In adults with fainting, angina, and shortness of breath on exertion caused by aortic stenosis, the aortic valve is surgically replaced, preferably before the left ventricle is damaged beyond repair.

Preventing High Blood Pressure

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Anyone, regardless of age, sex, race, or heredity, can lower his or her risk of developing high blood pressure

or lower existing high blood pressure by taking the steps described here. Maintain a healthy weight. As your body weight increases, your blood pressure rises. In fact, being overweight can make you two to six times more likely to develop high blood pressure than if you maintain a desirable weight. It’s not just how much you weigh that is important; it also matters where your body stores excess fat. Your body shape is inherited from your parents, just like the color of your eyes and hair. Some people tend to store fat around their waists, while others store fat around the hips and thighs. “Apple-shaped” people who store extra fat at the waist appear to have higher health risks than “pear-shaped” people who store fat around the hips and thighs.

No matter where your extra weight is located, you can reduce your risk of developing high blood pressure by losing weight. Even a small weight loss can make a big difference. And if you are overweight and already have high blood pressure, losing weight can help you lower your blood pressure. To lose weight, you need to consume fewer calories than you burn. But don’t try to lose weight too quickly. The healthiest way to lose weight and keep it off is to do it gradually, by losing about a pound a week. By taking in 500 calories less per day and being more physically active, you should be able to lose about a pound (which equals 3,500 calories) a week. Losing weight and keeping it off involves making permanent lifestyle changes. Here’s how to eat healthfully and lose weight:

• Choose foods that are low in calories, sugar, and fat. Naturally, choosing lowcalorie foods cuts calories. But choosing foods low in fat also can cut calories. Fat is a concentrated source of calories, so eating fewer fatty foods will help reduce your calorie intake. Cutting back on butter, margarine, fatty salad dressings, fatty meats, skin on poultry, full-fat dairy products such as milk and cheese, fried foods, and sweets will also improve your cholesterol profile.

• Choose foods that are high in fiber. These include fruits; vegetables; wholegrain foods such as cereal, pasta, and bread; and dried peas and beans. Foods high in fiber are excellent substitutes for foods high in fat. The former are lower in calories and are a good source of essential vitamins and minerals.

• Limit serving sizes. When trying to lose weight, it’s not just the types of foods you eat, but how much you eat. To take in fewer calories, you need to limit your portion sizes. Try especially to take smaller helpings of high-calorie foods such as fatty meats and cheeses. And try not to go back for seconds. Today many restaurants take pride in serving large portions of food. This does not mean that you have to clean your plate. Choose the doggy-bag option; eat only half of what you are served and take the rest home for an excellent “free meal” the next day.

• Keep track of what you eat, when you eat, and why you eat. Write it down. Note whether you snack on high-calorie foods while watching television or if you skip breakfast and then eat a large lunch. Once you clearly see your eating habits, you can set goals for yourself—for example, cutting back on TV snacks or, when you do snack, having fresh fruit, low-fat or air-popped popcorn, or vegetables such as carrots and celery. If there’s no time to eat breakfast at home, take fruit, a bagel (skip the cream cheese), or whole-grain cereal with you to eat at work. Changing your eating habits will help you change your weight. Exercise regularly. Another way to lose weight and control blood pressure is through regular physical activity. Cutting down on fat and calories combined with regular exercise can help you lose more weight and keep it off longer than with either diet or exercise alone. Aerobic exercise provides added benefits. It helps improve the fitness of your heart, blood vessels, and lungs, which, in turn, protects you against heart disease. Activities such as stair climbing, bicycling, swimming, brisk walking, running, and jumping rope are called “aerobic,” which means that the body uses oxygen to make the energy it needs during the activity. Aerobic activities provide health benefits if done at the right intensity for at least 20 to 30 minutes, three to four times per week. If you think you don’t have time to exercise, try to exercise for two 15-minute periods or even three 10-minute periods during your day. You will still gain health benefits.

You need to see your doctor before starting an exercise program if you:

• have a health problem such as high blood pressure

• have angina (chest pain)

• tend to feel dizzy or faint

• have difficulty breathing after a mild workout

• are middle-aged or older and have not been active

• are planning a vigorous exercise program Otherwise, get up off the couch, get out, get active, and get fit.

Choose foods that are lower in salt. Most Americans take in more salt (sodium) than they need, which may help explain why the United States has higher rates of high blood pressure than countries where people eat less salt. Salt attracts water. Normally, if you have eaten too much salt, your kidneys eliminate the excess salt from your body along with a certain amount of water. But if your kidneys cannot get rid of the extra salt, your body retains the water that clings to the salt, which raises blood volume and, in some people, blood pressure. Certain people appear to be salt-sensitive, which means that their blood pressure goes up when they eat salt. Researchers think that about half of all people with high blood pressure are salt-sensitive and that as many as 70 to 80 percent of blacks are salt-sensitive. Other groups that seem to have a high incidence of salt sensitivity are older people, people who have diabetes, and people who are overweight. There is a good chance that if you are a member of one or more of these groups, decreasing your salt intake would be beneficial to your health. Research suggests that the average person needs only about 200 milligrams of sodium per day. Doctors recommend that people with high blood pressure take in no more than about 6 grams of salt per day, which equals about 2,400 milligrams of sodium, or about 1 teaspoon of table salt. A teaspoon of salt may seem like a lot to you, but remember that this refers to total salt intake for a day. This includes salt in processed and prepared foods, salt added during cooking, and salt sprinkled on food at the table. Americans eat an average of 4,000 to 6,000 milligrams of sodium each day, so many people could probably benefit from cutting back on their salt intake. The key to cutting back on salt is in teaching your taste buds to enjoy less salty foods. Here are a few tips for cutting back on salt:

• Check food labels for the amount of salt in the foods you buy. Choose foods that are low in sodium. Look for labels that say “sodium-free,” “very low in sodium,” “low sodium,” “light in sodium,” “reduced sodium,” “less sodium,” or “unsalted.” Then check the label for the amount of sodium per serving.

• Choose fresh or frozen vegetables, or canned vegetables labeled “no salt added.” Choose fresh poultry, fish, and lean meat rather than canned, cured, smoked, or processed varieties.

• Use herbs, spices, salt-free seasoning blends, and lemon juice instead of salt to add flavor to your food.

• Cook rice, pasta, and hot cereals without salt. Avoid using instant or flavored rice, pasta, and cereal mixes because they usually have added salt.

• Choose “convenience” foods that are low in sodium. Cut back on frozen dinners, packaged dinners such as macaroni and cheese, packaged mixes, canned soups or broths, and salad dressings, which often contain large amounts of sodium.

• Buy low-sodium, reduced-sodium, or no-salt-added versions of canned soups, dried soup mixes, or bouillon; canned vegetables and vegetable juices; low-fat cheeses; margarine; condiments such as ketchup or soy sauce; crackers and baked goods; processed lean meats; and snack foods such as chips, pretzels, and nuts.

• Rinse canned foods, such as tuna, to remove excess sodium. Drink alcoholic beverages only in moderation. Drinking too much alcohol can lead to the development of high blood pressure. To prevent high blood pressure, or if you already have high blood pressure, limit yourself to no more than two drinks per day. A drink is defined as 11⁄2 ounces of 80-proof distilled spirits, 5 ounces of wine, or 12 ounces of beer (regular or “lite”). Do not use tobacco. Although it is not a direct cause of high blood pressure, smoking puts you at risk of developing the disease. The chemicals in tobacco smoke can damage the artery walls, making them more susceptible to plaque formation. Plaques narrow the arteries and interfere with blood flow to the heart,

brain, and other organs and tissues. Blood clots can form on the rough surface of a plaque. A blood clot or plaque can block an artery, causing a heart attack or a stroke. The nicotine in tobacco is a powerful stimulant that causes the heart rate to increase, the arteries to constrict, and blood pressure to rise. Smoking also affects cholesterol levels in the blood: it can increase LDL (“bad” cholesterol) levels and decrease HDL (“good” cholesterol) levels. All of these tobacco induced effects can contribute to the development of high blood pressure. Although it is sometimes promoted as a smoke-free alternative to cigarettes and cigars, smokeless tobacco also puts you at risk of developing high blood pressure. The nicotine, sodium, and licorice contained in smokeless tobacco products all can raise blood pressure. Considering these health risks, it makes sense to give up your tobacco habit now. Here are some other factors that may help prevent high blood pressure:

• Potassium. A certain amount of potassium is essential for proper body function. Eating foods rich in potassium may help protect some people from developing high blood pressure. Many people get enough potassium from eating fruits, vegetables, dairy products, and fish, so potassium supplements are rarely needed. Too much potassium can disturb your heart rhythm.

• Calcium. People with low calcium intake have higher rates of high blood pressure. It is best to get the calcium you need 1,000 to 1,500 milligrams per day for adult men from the foods you eat. Low-fat and nonfat dairy products such as milk, yogurt, and cheese are excellent sources of calcium. It has not been proven that taking calcium supplements helps prevent high blood pressure.

• Magnesium. A diet low in magnesium may make your blood pressure rise. However, doctors do not recommend taking magnesium supplements to help prevent high blood pressure. The amount of magnesium you get in a healthy diet is enough. Magnesium is found in whole grains; green, leafy vegetables; nuts; seeds; and dried peas and beans.

• Fish oils. A type of fat called omega-3 fatty acids is found in fatty fish such as mackerel and salmon. Evidence suggests that eating fish at least twice a week can help reduce high blood pressure. Talk to your doctor if you are considering taking fish oil supplements. Most fish, if not fried or prepared with added

fat, are low in saturated fat and calories and are a good source of essential nutrients.

• Fats, carbohydrates, and protein. Varying the amount and type of fats, carbohydrates, and protein in the diet has little if any effect on blood pressure. But for overall heart health, it is crucial to limit the amount of fat in your diet, especially the saturated fat found in foods such as fatty meats and full-fat dairy products. Saturated fats raise your blood cholesterol level, and a high cholesterol level is another risk factor for heart disease. Foods high in fat are usually also high in calories. Foods high in complex carbohydrates (starch and fiber) are often low in fat and calories so eat these foods in moderate amounts instead of eating high-fat foods. Always check food labels.

• Caffeine. The caffeine found in coffee, tea, and colas may cause blood pressure to rise, but only temporarily. In a short time your blood pressure will return to its previous level. Unless you are sensitive to caffeine, you do not have to limit caffeine intake to prevent high blood pressure.

• Garlic and onions. Increased amounts of garlic and onions have not been found to affect blood pressure. Of course, they are rich in antioxidants and are tasty substitutes for salty seasonings.

• Stress management. Stress can make blood pressure go up for a while and over time may contribute to high blood pressure. Stress management techniques such as biofeedback, meditation, and relaxation can help you to deal positively with the stress-producing events in your life, and may help you control your blood pressure.

High Blood Pressure

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High blood pressure, or hypertension, increases your chances of developing heart disease or kidney disease and of having a stroke. About one in every four American adults has high blood pressure but may not be aware of it. It is often called “the silent killer” because it usually causes no symptoms. However, high blood pressure is easy to diagnose, and there are practical steps you can take to bring your blood pressure under control. Blood pressure is the force of blood pushing against the walls of the arteries that carry blood throughout your body. It is measured in millimeters of mercury, or mm Hg, using an instrument called a sphygmomanometer (pronounced sfig'mo-mah-nom'e-ter). Blood pressure is highest when the heart contracts (beats) and pumps blood into the arteries. This is called the systolic pressure. Between beats, when the heart is resting, the pressure falls. This is called the diastolic pressure. A blood pressure reading is always given as a combination of these two pressures; the high (systolic) pressure is written above or before the low (diastolic) pressure. For example, if your blood pressure reading is 120 over 70, it is written as 120/70 mm Hg; 120 is the systolic pressure, and 70 is the diastolic pressure.

Different activities make your blood pressure rise or fall. For example, normally, blood pressure rises when you are exercising and falls when you are resting. A blood pressure reading of 140/90 mm Hg or lower is generally considered normal. High blood pressure is classified according to guidelines that reflect the levels at which blood pressure begins to pose significant health risks. The guidelines for classifying blood pressure are shown in the following table:

A diagnosis of high blood pressure is based on two or more blood pressure readings taken at separate visits to the doctor’s office. If your systolic pressure falls into one category and your diastolic pressure into another, the higher reading will be used to classify your blood pressure. For example, a blood pressure of 160/90 mm Hg would be classified as stage II. A reading of 170/120 mm Hg would be classified as stage III. Because diastolic pressure represents the lower and more constant level of pressure in the arteries, physicians may emphasize it more, especially in younger people. However, the systolic blood pressure is more important for determining the risk of heart attack or stroke. People with high blood pressure have elevated blood pressure most of the time. Their blood is pushing against the walls of their arteries with higher than normal force. If left untreated, high blood pressure can lead to:

• Atherosclerosis. Uncontrolled high blood pressure causes the artery walls to thicken and lose elasticity. This encourages formation of fatty deposits on the artery wall, which narrow the channel and interfere with blood flow throughout

the body. In time, atherosclerosis can lead to a heart attack or a stroke.

• Enlarged heart. High blood pressure causes the heart to work harder. Over time this causes the heart muscle to thicken and stretch. The heart becomes less efficient and has to work harder and harder to pump blood throughout the body. Eventually this can result in heart failure.

• Kidney damage. The kidneys act as filters to rid the body of wastes. Over a number of years, high blood pressure can narrow and thicken the blood vessels of the kidneys. The kidneys then filter less blood, and waste builds up in the bloodstream. This could lead to kidney failure. When kidney failure occurs, dialysis (a technique to remove waste products from the blood and excess fluids from the body) or a kidney transplant may be necessary.

• Stroke. High blood pressure can weaken the walls of the arteries or cause them to thicken. A weakened artery wall in the brain could break, causing a hemorrhage. If a blood clot blocks one of the narrowed arteries, a stroke may occur. In most cases, the cause or causes of high blood pressure are unknown. This type is known as primary or essential hypertension. Primary hypertension cannot be cured, but it can be controlled. Secondary hypertension is caused by, or is “secondary” to, another disease. For example, some cases of high blood pressure can be traced to tumors of the adrenal gland, chronic kidney disease, or hormone abnormalities. Secondary hypertension can be cured by treating its underlying cause.

Dealing with End-of-Life Decisions

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Over the course of a lifetime, men face a variety of inevitable stresses that create emotional responses. Dealing with death and dying presents some of life’s greatest emotional stress. There are two ways in which a man finds himself confronting the issues surrounding death and dying: as someone caring for a dying person, most often a parent, and as someone who is facing his own death. In both roles he must find ways to deal with his grief. Grief affects each person differently but typically involves four stages shock, denial, depression and withdrawal, and acceptance. If you are grieving, it is important for your emotional health to talk about your feelings to a family member or a close friend, to others in a support group, or to a counselor. “Bottled up” emotions can lead to depression, withdrawal from friends and society, sudden irrational outbursts, feelings of anger and resentment, insomnia, and even physical illness. Here are some positive steps you can take to deal with grief:

• Rest, eat a healthy diet (see page 43), and keep warm (emotional stress will make your body temperature drop). Avoid caffeine and alcohol because they can add to your stress.

• Use relaxation techniques. Try deep breathing. People who are under stress tend to hold their breath or to breathe shallowly, which can cause fatigue and anxiety.

• Express your feelings. Talk to family, friends, members of a support group, or clergy.

• Accept help. Let others care for you. Let your friends and family make a meal for you, do some housework, or just listen to you. Such support can be healing for them as well as for you.

• Take as much time as you need. Grieving has no time frame.

• Think about how your life has changed and what that means for the future.

Family Caregiving

A large part of the stress related to the dying of family members has to do with the challenges of providing care. People who have a terminal illness usually have important and wide-ranging needs for assistance in addition to the medical care they receive from physicians and other healthcare workers. A majority of people

who are dying require home nursing care, help with transportation, homemaking services, and personal care. In many cases their families must take on the substantial burden of caring for them. In some cases, home healthcare programs may help. Traditionally, women have provided most of the home care, even when the family member is the man’s parent or grandparent. But today, with most women working outside the home, men and members of religious or civic organizations have an opportunity to be more actively engaged in caring for the dying. People are relying increasingly on paid workers to provide the nonmedical care needed by family members who are dying.

Hospice Care

Hospice care is a life-affirming approach to caring for people who are in the final phase of a terminal illness. Hospice regards death as a natural part of life, and emphasizes the comfort and quality of life of a dying person. The focus is on relieving pain and controlling other symptoms. With hospice care, a dying person is allowed to live his or her last days with dignity, pain-free and alert, surrounded by loved ones at home or in a homelike setting. In general, a person becomes eligible to enter a hospice program when a doctor has determined that he or she has 6 months or less to live and refers him or her to a hospice program. Family members, friends, clergy, or healthcare professionals also can make referrals. Under the supervision of a doctor, an interdisciplinary team doctors, nurses, therapists, counselors, social workers, clergy, healthcare aides, and volunteers works closely with the dying person to provide medical care and support. The team deals with the person’s medical, emotional, and spiritual needs. And because the entire family is regarded as the “unit of care,” the hospice team also provides support and assistance to the person’s loved ones. Members of the hospice team are available to assist the person and his or her loved ones 24 hours a

day, 7 days a week. After the person has died, the hospice program also provides grief counseling to the survivors.

Advance Directives

When a person becomes seriously ill and is no longer able to make decisions about his or her healthcare, those decisions are usually made by a close family member or by the person’s doctor. Advance directives are legal documents designed to help ensure that healthcare decisions made on a person’s behalf are consistent with his or her preferences. Advance directives may provide either general guidelines or specific instructions. Although advance directives do not go into effect until the person is unable to make his or her own healthcare decisions, the forms should be prepared and signed long before they are needed. When the person is in a hospital or a nursing home, emotional factors may make it challenging to talk about the forms (and the issues involved). These documents should be reviewed and updated regularly. The person can revise or withdraw his or her advance directives at any time. Advance directive forms are available through hospital social service departments and from state or local medical societies and bar associations, or you can consult a lawyer to produce your own living will and durable power of attorney for healthcare. Because requirements for advance directives vary from state to state, you should consider talking to a lawyer when preparing or filling out these documents. Be sure to tell the doctor and the person you have chosen to make your healthcare decisions about your advance directives. Give each of them a copy, and keep a copy for yourself. The most common types of advance directives are living wills, durable powers of attorney, do-not-resuscitate orders, and organ and tissue donor cards:

• A living will is a document that indicates a person’s wishes regarding lifesustaining medical treatments. It is prepared by a competent person and goes into effect only when the person is unable to speak for himself or herself. A living will guides medical professionals and family members so they can make healthcare decisions that are consistent with the person’s beliefs. A living will can be revised or withdrawn by the person at any time. You should consult a lawyer when preparing a living will because legal requirements vary from state to state.

• A durable power of attorney for healthcare is a document in which a competent person gives another person (called a healthcare proxy) the power to make healthcare decisions for him or her. It goes into effect only in the event that the person is unable to make such decisions. The durable power of attorney can be withdrawn by the person who initiated it at any time.

• A do-not-resuscitate (DNR) order states that no one should perform heroic measures, including CPR and the use of mechanical life support equipment, to restart a person’s heart should it stop. The document must be signed by the person if he or she is competent (or by his or her healthcare proxy if he or she is not competent) and by his or her doctor. In some cases, doctors recommend that people wear a special bracelet or necklace that communicates their DNR status to emergency responders. The person should keep a copy of the document in his or her home in a prominent place where it will be noticed by emergency medical personnel called to the home; the doctor should keep a copy in the person’s medical records at all times to make sure that the person’s wishes are respected. DNR orders can be withdrawn at any time by the patient, as long as he or she is competent.

• Anorgan and tissue donor card informs medical personnel that your organs and tissues may be used for transplant in the event of your death. Many states provide an opportunity to register as an organ and tissue donor when you apply for a driver’s license or state identification card. Your donor status is then indicated on the license or identification card. Be sure to tell your loved ones that you are a registered donor.

Relationships

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People have a strong need to connect with others, and the central task of adulthood involves the ability to master relationships. Both men and women have a similar need to be close. But the way in which many boys are raised and socialized in our society sometimes makes it difficult for them to recognize and acknowledge this. Boys want to be like their fathers and loved by them. Similarly, boys have normal and natural wishes to be close to and to feel loved by their mothers. Many men grow up wanting to be closer to their mother and father, yet some may feel they have to hold back to feel manly. Unfulfilled attachment needs can create a great deal of inner sadness or anger, which can continue into adulthood. For many males, a struggle with competence, independence, stoicism, and public performance can evolve, obscuring their ability to be responsive to those they love. They may have a strong drive to prove their competence. But even as they achieve competence, the urge to connect does not disappear.

The Changing Male Image

Attempts to describe behavior associated with male expectations often result in a series of negatives, such as men don’t cry, men don’t show their feelings, or men are never scared. Positive ways of describing masculine behavior have traditionally focused on characteristics such as physical strength, aggressiveness,
and independence. Cultural or ethnic expectations, socioeconomic success, individual achievement, and education level heavily influence the perception of male characteristics. Men who are married tend to live longer than men who are single. Does this mean that marriage is the healthiest form of relationship for men? Not necessarily. But it does mean that a stable, long-term relationship includes features that positively affect many men’s emotional and physical health. Role expectations for men in Western societies traditionally have emphasized protection and provision. In colonial times, physical strength was essential to survival. Along with these expectations was the premise that a man should hold a leadership position in the family and should be in charge of both household and community affairs. Many of these male role expectations remain today;
many men see themselves as the primary provider for their families. This view is often reinforced by their partners. However, cultural role expectations for men are changing. This has become a potential source of anxiety for both men and women. Some men may learn that providing financial support is not enough to satisfy their partner, although their ability to provide may still be used as a measure of both their worth and their suitability as a partner. Most women also expect to have emotional support, mutual respect, stability,
and a satisfying sexual life as part of their relationship. Working women expect greater participation by their partner in household chores and child rearing. Tension in marriage is often the result of different role expectations and unfulfilled needs. The role behaviors and values you learned during childhood may not
work in your relationship today. Men who remain well adjusted and healthy throughout life seem to have mastered the following values:
• intimacy achieving an interdependent, mutually responsible, committed relationship
• satisfying work—engaging in work that is valued and rewarding
• parenting accepting responsibility for the physical and emotional health and well-being of children
• leadership—taking responsibility for being a positive role model and inspiration to others

• integrity—following a code of moral values

Being a Father

In the past, fathers were expected to play a limited role in their childrens’ lives. Once a child was conceived, the father’s role was often defined primarily in terms of supporting the mother, both financially and emotionally. Often he was the major disciplinarian. Childcare was considered women’s work. The father’s
responsibility was to be a role model for his sons, to impart sexual knowledge to them at the appropriate time, and to be a good provider. He often represented the disciplined, serious side of life. Today, a new awareness of the importance of fathers is having a beneficial effect on the lives of children. Fathers are crucial to the emotional and intellectual growth of their children. Fathers contribute to the welfare of their families in
many different ways—providing financial support or assistance; providing emotional support for their partner; performing household and childcare tasks; nurturing a caring, committed relationship with their partner; and having frequent and positive personal contact with their children.

Bonding with Your Child

In the past, many fathers of newborns sometimes found it difficult to bond with their infants and to express their feelings. Today, however, most fathers are bonding with their children and playing a nurturing role in their lives. Most fathers want to be involved, even occasionally volunteering to stay home from work to spend more time with their baby. When fathers become involved during the pregnancy, delivery, and postpartum period, their involvement with and attachment to their infants are strong. The period immediately after delivery is especially conducive to the development of psychological ties between parents and their newborns. Fathers experience the same feelings of warmth, devotion, protectiveness, and pleasure at
physical contact with their children that mothers do.

Divorce

If your marriage fails, it does not mean that you are a failure or that your role as a father is diminished. Try not to let your contact with your children drop off after your divorce. Children are at risk when they grow up without their father. They are more likely than children who have regular contact with their fathers to have psychological problems, abuse drugs and alcohol, live in poverty, and fail in school. Almost half of all divorced fathers have not seen their children in the past year. Keep in mind that your child needs and wants your continued love and emotional support even if you are no longer living together as a family.

Blended Families

A blended family, or stepfamily, includes a couple with one or more children from a previous relationship. Half of all people in the United States will experience a stepfamily relationship at some time in their lives as a stepparent, remarried parent, or stepchild. Children in blended families have strong emotional connections to a parent who lives in another household or to a parent who has died. In many cases, a child moves back and forth between two households that often have very different rules and expectations. This adjustment period can be even more stressful than a divorce or living in a single-parent home. Children may feel angry, anxious,
or depressed and worry that they won’t be able to have as much contact with either parent. Blended families in which both adults have children from previous relationships have the biggest problems to overcome. Children in these families may worry that their own parent will have less time to spend with them, that they will have to share their bedroom or possessions with a stepsibling they hardly know, or that their place in the family hierarchy will change. Rules and family routines may be different. All these new experiences can put stress on a child. He or she may display his or her feelings through disruptive behavior, or perform poorly in school. Give your child time to adjust to the situation, to become familiar with the new family members, and to get used to the working structure of the household. Stepfamilies who work together to solve problems eventually find a living arrangement they can all be happy with. Once you make it through the difficult early
years, you will probably find that being part of a stepfamily is an enriching, fulfilling experience. Here are some tips for helping to make living in a stepfamily rewarding for everyone involved:
• Put a priority on the couple relationship; a secure relationship between the two adults is essential for a successful blended family. In many stepfamilies, couples spend so much time dealing with child issues that they don’t nurture their own relationship.
• Agree with your partner on a few important rules and spell them out to the children. Always support each other in front of the children.
• Be patient in establishing a relationship with a stepchild—it takes time. And be cautious when taking on a parenting role, especially with a teenager, who may never accept you as a parent. Your stepchildren are more likely to treat you with respect and courtesy if you treat them the same way.
• Supervision of children is especially important in a blended family, especially when their ages vary. It can be tempting for an older child to stretch the rules with a younger or smaller stepsibling when the two are left alone.
• Have regular family meetings to discuss the week’s activities or any problems that might come up. Open communication helps establish healthy relationships among all family members.
• Take most of the responsibility for disciplining your own child. Give the stepparent time to establish a trusting relationship with your child before beginning to set rules for him or her. Discipline all children in the household equally and fairly.
• Resolve any personal differences between a stepparent and a stepchild or between stepsiblings promptly and directly; unresolved problems tend to get worse over time.
• Set aside time for one-on-one activities between family members. Stepchildren need to spend time alone with their parent; stepparents should do things alone with stepchildren; and the two adults should spend time alone with each other.
• Participate in a support group for stepfamilies. You’ll see that you are not alone and can learn a lot from the experiences of other stepfamilies.
• If your children are part of their other parent’s stepfamily, support that family and cooperate with both of the adults involved. Competition and tension between two households can cause the children to suffer emotionally.

Stress Management

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Doctors don’t know all of the ways that stress and illness are connected, but they do know that the central nervous system (the brain and the spinal cord) and the immune system can influence one another during stress. Short-term positive stress can be invigorating, stimulating us to respond positively to meaningful challenges and opportunities. Short-term negative stress can be life-saving, causing us to flee dangerous situations. The brain releases hormones into the bloodstream, causing the heart to beat faster, the face to flush, and the arm and leg muscles to tighten, allowing the person to run away or escape. Once the danger is over, the body repairs damaged areas and returns to its prestressed state. In long-term stress, the hormones continue to be released but the body does not have time to make repairs or to rest and recuperate. This is the type of stress that creates health problems. Under constant stress, a person becomes so conditioned to expect potential problems that his or her body tightens and remains in that state until the stress stops. Under this long-term stress state, the body can develop stress-related problems. Many connections between stress and chronic conditions are known. Stress increases blood levels of adrenaline and cortisol, two so-called stress hormones. Cortisol can suppress the immune system, making people more susceptible to infectious diseases such as colds and flu. The effects of stress on the circulatory system (a quicker pulse, narrowed blood vessels, and thickened blood) can make people more susceptible to heart rhythm irregularities, angina (chest pain), high blood pressure, and stroke. Muscles tighten as stress starts, often causing intense headaches, backaches, and gastrointestinal problems. Stress also can cause testosterone levels to decrease and blood vessels in the penis to constrict, often resulting in erection problems. The rush of hormones caused by a stressful situation can bring on an asthma attack in a person with a history of asthma. Stress also draws the blood supply away from the abdominal area and encourages overproduction of acids in the digestive system, often leading to indigestion and other gastrointestinal problems. Other problems related to stress include insomnia and irritability. The number of hours worked does not seem to cause as much stress as do two other occupational factors: lack of control and inadequate social support. Men who have little control over the demands of their jobs feel more stress than those who have more control. Men who also experience a low level of social support from coworkers have even more problems. What is stressful to one person may be relaxing to another. Some people, for example, like to keep busy all the time, while others need to take frequent breaks. Some people can keep track of multiple tasks, while others prefer to do tasks in sequence. If you are under stress, it is important to recognize it and deal with it in a positive way. Here are some tips to help you relieve stress:

• Exercise regularly. You can decrease stress and release tension through regular exercise or other physical activity. Running, walking, swimming, dancing, playing tennis, or working in your garden are some activities you may want to try.

• Talk about your stress. For example, talk to a friend, family member, teacher, or boss about what is bothering you. If that does not help to resolve the problem, consider seeking help from a professional therapist or counselor. Ask your doctor for a referral, or contact the employee assistance program at work.

• Know your limits. If a stressful situation gets beyond control, walk away. Return to deal with the situation when you have calmed down.

• Take care of yourself. Get plenty of rest and eat a healthy diet. If you feel irritable and tense from lack of sleep or if you are not eating properly, you will be less able to deal with stressful situations.

• Take time for yourself. Take a break from regular work and do something you enjoy. Just relax.

• Be a participant in life. Help yourself by helping others. Share your abilities with other members of your community by volunteering.

• Prioritize your tasks. To keep your schedule from overwhelming you, make a list of your tasks and check them off as you complete them.

• Be cooperative. If things do not go your way, try compromise rather than confrontation. A little give and take on both sides can help you meet your goals and make everyone feel better.

• Cry if you need to. Crying can be a healthy way to bring relief to your tension or anxiety.

• Create a quiet scene in your mind. You can’t always get away, but you can try closing your eyes and letting

your mind wander. A quiet country scene painted mentally can temporarily take you out of the turmoil of a stressful situation and help you to relax. Listening to beautiful music or reading a good book may help you achieve the same results.

• Avoid self-medication. When you need them, you can use prescription or over-the-counter medications to

relieve stress temporarily, but realize that they don’t remove the conditions that caused the stress in the first place. Becoming overly reliant on drugs or alcohol can only complicate matters in the long run. They may be habit forming, or they may interfere with your body’s ability to function normally.

• Learn to relax by using a specific relaxation strategy, such as meditation or deep-breathing exercises. Participate in activities you can enjoy without competing. Cycle, swim, or walk the dog. Forget about always

winning. Relaxation can stimulate the release of endorphin's brain chemicals that promote feelings of well-being. Relaxation strategies work by blocking conscious thoughts, resulting in decreased tension, lower heart and breathing rates, and slower metabolism. Several relaxation techniques, such as meditation, guided imagery, muscle relaxation, and deep breathing, can be used to relieve stress and bring on the relaxation response. If you feel that you are under severe or long-term stress, seek help immediately. Talk about your problems with your doctor. He or she can treat any stress related disorders you may have developed and will refer you to the appropriate mental health professional.

How to Get a Good Night’s Sleep

Sleep is a basic requirement for good health. The mind and the body need sleep to perform maintenance and repair. Even one night of disrupted or missed sleep can drastically alter a person’s chemical balance and cause daytime sleepiness and fatigue. The results of such sleep deprivation can reduce productivity as well as increase the chances of accidents at home or at work. Most adults need 7 to 8 hours of sleep each night, although sleep requirements may differ from one person to the next. For example, some people may feel rested after 5 or 6 hours of sleep, whereas others may still feel sleepy after 9 or more hours of sleep. In general, people tend to sleep less soundly as they age. They may wake up more frequently and have a harder time getting back to sleep. Many older men may find that they simply don’t need as much sleep as they did when they were younger. Overweight men may have problems getting a good night’s sleep. Snoring also may contribute to a loss of sleep. Sleep apnea (a condition characterized by brief episodes of interrupted breathing during sleep) is another common reason for losing sleep. Many people who have sleep apnea find it difficult to stay awake during the day. However, the most common reason for an occasional night of lost sleep is worry or anxiety. Here are some helpful tips for getting a good night’s sleep:

• Stick to a regular schedule for going to bed and getting up. Going to bed and getting up at the same time help set your biological clock.

• Do not sleep late on weekends, and avoid napping during the day.

• Make your bedroom exclusively a place for sleep and sex. This means no TV, work, or serious discussions while in bed. Keep your bedroom comfortable, dark, quiet, and not too warm (about 60 to 65 degrees Fahrenheit).

• Exercise during the day so your metabolism has slowed by bedtime and you are ready for sleep.

• Avoid stimulants such as caffeine, nicotine, and alcohol, and rich, heavy meals before bedtime.

• If you are not lactose intolerant, drink a warm glass of milk just before bedtime. But don’t drink so much that a full bladder disturbs your sleep.

• Have sex before bedtime; it may have a relaxing effect.

• Take a warm bath just before bedtime to help you relax.

• Set aside some quiet time about an hour or so before bedtime.

• If you still can’t fall asleep, get up and read or do a simple chore until you become tired.

Physical and Emotional Health: How They Interact

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Doctors are not sure exactly how physical and mental health influence each other, but growing scientific evidence suggests that the mind/body connection is real. For example, the so-called fight or flight response, in which the nervous system and the adrenal glands flood the body with the hormone adrenaline when you are frightened, increases both heart rate and blood flow to the muscles. This response prepares the body to deal with apparent danger. In this case, the survival response is helpful. However, when a person is under constant stress, the body steadily releases a hormone called cortisol, which can cause long-term damage to the brain and other organs. The harmful effects of this hormone include an increased tendency for blood to clot, a surge in the pressure on coronary arteries, increased blood pressure, and other demands on the heart and blood vessels. There has been a recent surge of interest in the mind/body connection by physicians to see if positive health effects can be obtained from relaxation techniques such as meditation. The increasing complexity and pace of life and the awareness that long-term stress has a negative physiological effect on the body have triggered the exploration of relaxation techniques. By combining knowledge of meditative techniques from Eastern cultures with Western scientific techniques, doctors have developed a form of meditation that may have positive effects on blood pressure and heart disease. Meditation appears to lower metabolism decreasing breathing rate, heart rate, and blood pressure. An understanding of the connection between the mind and the body becomes clearer as new techniques are found to examine and to measure the

nervous system’s subtle control over changes in the circulatory system. The positive response of the circulatory system to a variety of relaxation techniques, such as meditation and biofeedback, can now be explained partly in physiological terms. In addition to high blood pressure, meditation has been shown to benefit people who have chronic pain, tension headaches, asthma, insomnia, and other stress-related problems. Interest in the mind/body connection has now expanded into studying the possibility of using mental techniques to strengthen the immune system. The immune system fights germs such as viruses and eliminates cells that are damaged, are turning cancerous, or have become cancerous. Researchers are trying

to determine whether stress that accompanies major, life-changing events such as divorce or moving into a nursing home can lead to changes in the immune system that make people more vulnerable to infection, heart disease, or other illnesses. Factors that can contribute to a negative response of the immune system include whether a person feels in control of a given situation and whether a person feels lonely. One technique being tested to teach the immune system to work better is biofeedback, in which special instruments that measure the body’s vital signs amplify the signs that represent relaxation, in order to train the person to recognize and replicate them. Biofeedback is being used in studies of people with diabetes who are under stress; the aim is to substitute relaxation exercises for additional insulin injections needed to deal with the stress. Other research is focused on relieving chronic lower back pain and muscle pain. Guided imagery is a system that uses symbols to imagine the desired physical changes occurring in the body during the treatment of asthma and cancer. Some people who repeatedly imagine a healing process may be able to boost their immune system. For example, a person might imagine his or her healthy white blood cells as white knights on horses subduing a source of infection. Or a patient with cancer might see his or her white blood cells as a computer game, gobbling up the cancer cells. Some people with AIDS (acquired immunodeficiency syndrome) or with cancer use complementary therapies such as meditation and massage to supplement their medical and surgical treatments. Keep in mind, however, that few alternative and complementary therapies have been proven safe and effective through rigorous scientific testing, and some can be very expensive. If you are thinking about trying an alternative treatment, talk to your doctor. Some therapies can be harmful, especially if you forgo conventional medical treatment for a serious illness. Never stop taking a prescription medication unless your doctor tells you to.

Emotional Health and Well-being

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As a boy, you were probably taught not to cry, but to act tough and “be a man.” Although attitudes are changing in our society, many males are still brought up not to express their emotions, learning that any display of feeling (other than anger) is a sign of weakness. While living up to the traditional, aggressive masculine identity may give a man certain advantages in a competitive society, it also can explain why the rates of substance abuse, domestic violence, homicide, suicide, sexual abuse, automobile accidents, and stress-related chronic illness are higher in men than in women. If a man has not learned to properly deal with

and express his emotions, then stressful situations may lead to inappropriate responses such as anger or violence. If you have a son, it’s important to teach him not to shut down his feelings, because such an emotional disconnection can lead to a lack of empathy, sympathy, and the ability to express himself productively. This stereotypical male image, combined with exposure to violent television programs, movies, and video games, may promote violent and remorseless behavior in boys. It also can lead to an emotional disorder such as depression. Remember that your son needs your time and understanding. Spend as much time with him as you can and encourage him to be caring rather than tough. Don’t force him to suppress his

emotions. Instead, tell him it’s okay to cry and teach him by example to feel empathy for other people. Fortunately, there are many hopeful signs for men with an emotional disorder, including new ways of diagnosing emotional problems and more effective methods of treating them. The social stigma once linked to emotional problems has lessened considerably as medical science has come to understand the biological basis of these disorders. Of course, not all emotional problems can be classified as a disorder. We all feel stress to varying degrees in a variety of situations. In terms of major stresses, men are just as likely as women to undergo an emotional upheaval during a time of divorce or from the loss of a job. The death of a spouse or parent will trigger a natural and extended period of bereavement as a man comes to grips with the loss of his life partner or family member. The best way to ensure your own emotional health is to find practical ways to handle stress and restrain your feelings of anger. This section will give you important information about stress management and the control of anger. In the final analysis, your emotional health is more under your own control than you think. The key is learning effective ways to exercise this control.

Addictive Gambling

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Compulsive gambling is an addiction, like alcohol dependence or other drug addiction. Because no physical substance is ingested, gambling has been called the purest form of addiction. Although it is strictly psychological, the uncontrollable impulse to gamble can become overwhelming and eventually cause major

disruption in a person’s life—including loss of job, financial ruin, a broken home, criminal activity, and loss of self-respect and the respect of others. Many people have the potential to become addicted to gambling. The term “problem gambling” includes but is not limited to the condition known as compulsive gambling. Gambling, like other addictions, is a progressive illness that cannot be cured, only kept under control. The growth and popularity of state lotteries, as well as gambling casinos on America’s rivers and lakes (and land-based casinos in some states), has made gambling easily available. Horse racing, dog racing, and private illegal gambling operations attract many additional gamblers. You may be addicted to gambling if five (or more) of the following factors apply to you:

• being preoccupied with gambling (such as reliving past gambling experiences, planning the next gambling venture, thinking of ways to get money for gambling, or fantasizing about how to spend the money once you win)

• wanting to gamble with increasing amounts of money to achieve the desired level of excitement

• trying repeatedly, but unsuccessfully, to control, cut back on, or stop gambling

• being restless or irritable when attempting to cut down on or stop gambling

• using gambling as a way of escaping problems or of relieving feelings of helplessness, guilt, anxiety, or depression

• returning another day to get even after losing money gambling

• lying to family members, a therapist, or others to conceal the extent of your involvement with gambling

• committing illegal acts such as forgery, fraud, theft, or embezzlement to finance your gambling

• losing a significant relationship, job, or educational or career opportunity because of gambling

• relying on others to provide money to relieve a desperate financial situation caused by gambling Many addicted gamblers have the following personality traits:

• An inability or an unwillingness to accept reality. This attitude can lead them to escape into the world of gambling.

• Emotional insecurity. A compulsive gambler finds that he or she is most emotionally comfortable when gambling.

• Immaturity. Many gamblers seem to have a hard time accepting responsibility. They want to have all the good things in life without any great effort on their part.

If you think you may have a problem with gambling, talk to your doctor. He or she may be able to refer you to a mental health professional who can help you overcome your addiction. For more information, contact the National Council on Problem Gambling, Inc. (800-522-4700) or Gamblers Anonymous (213-386-8789) or consult your local telephone directory.

Unsafe Driving Habits

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Risky behavior is involved in the traffic accidents that kill more than 40,000 Americans each year. Driving while drunk accounts for the majority of serious traffic accidents, and more than half of all road-related fatalities are automobile passengers who might have lived had they used seat belts. Never drive under the influence of alcohol. It slows your reaction times, distorts your vision, and impairs your judgment. And never use other psychoactive drugs (those that alter your mind or behavior, such as marijuana or methamphetamine) while driving. Be sure to read the labels on all prescription and over-the-counter medications for warnings about how they could affect your ability to drive.

Safety with Seat Belts

Every motor vehicle crash has two collisions. The first is a collision of the car with another object. But the second is more important in terms of life and death. That’s when the driver or passenger collides with the vehicle’s interior or is thrown out of the vehicle to collide with the ground, another car, or an object such as a wall. Ejection from a vehicle occurs 10 times more often to occupants who are not wearing seat belts. The best protection for people in a collision is to use lap belts and shoulder restraints. In a head-on collision, these safety restraints can dramatically reduce the chance of injury to the head or the face and cut in half the

risk of serious or fatal injury. Every person in the car must wear a seat belt. It’s the law, and it can save your life. If you transport small children (age 6 and under), be sure your car is equipped with a child safety seat for each child. Be sure the child safety seat is installed and secured to the vehicle’s backseat the way the manufacturer recommends. Children always must ride in the backseat. Children who are too large for a child

safety seat must wear a seat belt. Children who are not protected by safety restraints face increased risk of serious injury. (Traffic injuries are a leading cause of death for children.) During a crash, an unrestrained child becomes an uncontrolled missile that can crash through a windshield or careen into any object or person in the vehicle. Do not consider air bags a substitute for safety belts. Air bags are designed to inflate only during head-on collisions and are useful only as supplements for seat belts. Also, air bags offer no protection during multiple crashes, rollovers, or side collisions. Air bags have been the cause of a number of serious injuries to children and several deaths. They are one of many reasons that children always should ride in back.

Road Rage

Another type of risky behavior that has emerged in recent years is known as “road rage.” It is estimated that as many as 1,500 people are killed or injured on American highways each year as a result of aggressive driving. No single profile fits all aggressive drivers, but they are three times more likely to be male than female, generally between ages 18 and 26, and usually have no record of crime, violence, or illegal drug use.

Although the risks of becoming a victim of road rage are small, if you encounter a threatening driver, the most important thing you can do is defuse the situation by not reacting. Staying safe on the road is a two-part process. Avoid behaviors that could be interpreted as confrontational, such as:

• sudden acceleration

• blocking the passing lane

• tailgating

• braking or swerving, which could cause you to lose control of your car

• cutting off another driver or failing to signal when changing lanes

• making obscene gestures

• failing to dim high beams for oncoming traffic

• taking up multiple parking spaces or damaging another vehicle while parking

All drivers need to control their stress to avoid situations in which they become angry with discourteous or aggressive drivers. A few simple changes in the way you approach driving can significantly reduce stress, including:

• altering your schedule to avoid congestion

• improving the comfort of your vehicle

• concentrating on being relaxed (but not to the point of being distracted)

• not driving when you are angry, upset, or overtired

As a driver, you cannot control traffic, only your reaction to it. Give the other driver the benefit of the doubt. Assume that other drivers’ mistakes are not intentional or aimed at you personally.

How to Quit Alcohol, Drugs and Smoking

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If you are a smoker, kicking the habit could be the single most important thing you do for your health and your family’s health. It’s not easy, but millions of people have quit smoking on their own. Many programs are now available to help. The American Cancer Society (800-227-2345) and the American Lung Association (800-LUNG-USA) offer excellent support resources and information for those who want to quit on their own. You can also check your Yellow Pages for listings of other smoking treatment programs and support groups. Most successful stop-smoking programs suggest that you tackle the job in three stages: preparation, quitting, and reinforcement. The following tips will help you prepare to quit smoking:

• Choose a target date to quit, such as a birthday or an anniversary, and stick to it.

• Make a list of reasons for quitting, and review it carefully.

• Note your smoking habits and routines; plan activities that would disrupt them.

• Condition yourself physically: start a modest exercise program, drink more fluids, and get plenty of rest.

• Think of alternative activities to do when the urge to smoke is strong.

• Go public with your intentions to quit, and gain the support of friends and family.

• If possible, get someone to quit with you. The following tips will help you quit smoking:

• Don’t be discouraged by the thought of never smoking again; think one day at a time.

• Clean your clothes to rid them of the cigarette smell.

• Get rid of all cigarettes, ashtrays, and lighters at home, in your car, and in your office at work.

• On the day you quit, keep busy: go to a movie, exercise, take long walks, buy yourself a treat, or do something special to celebrate.

• Visit the dentist and have your teeth cleaned.

• The first few weeks, spend as much free time as possible in places where smoking is not allowed.

• Avoid alcohol, coffee, and other beverages associated with smoking, but drink large quantities of water and fruit juice. Once you have successfully quit smoking, here are some tips for helping you stay away from cigarettes:

• Keep healthy substitutes handy, such as carrots, sunflower seeds, raisins, or sugarless gum.

• Learn how to relax quickly and deeply: make yourself limp; visualize a soothing, pleasing situation; and get away from it all for a moment.

• Participate in activities that make it hard to smoke such as jogging or swimming.

• Do things that keep your hands busy such as crossword puzzles or gardening; while watching television, play with a paper clip, a pencil, or a rubber ball.

• Stretch a lot.

• Pay attention to your appearance.

• Never allow yourself to think that “one cigarette won’t hurt.”

• Get up from the dinner table as soon as you’re finished eating and brush your teeth.

• If you are concerned about gaining weight, join an exercise group, plan menus carefully, and weigh yourself weekly; don’t try to lose weight, just try to maintain your acquitting weight. Keep in mind that the benefits of giving up cigarettes far outweigh the drawbacks of gaining a few pounds. Most smokers successfully quit only after several attempts. You may be lucky enough to quit on your first try, but if not, don’t give up. Try again. A number of products are now available to help break the smoking habit. These include nicotine patches, nicotine gum, nicotine inhalers, and drugs such as ibuprofen hydrochloride. The patches and gum provide a low dose of nicotine that can be used to wean your body off the drug. Ibuprofen hydrochloride is a nicotine-free pill that can help reduce your urge to smoke. Other approaches to quitting smoking include hypnosis, acupuncture, behavior modification, and meditation. Your physician can give you more information on smoking cessation programs and products.

Illegal Drugs

In addition to the physical and social problems caused by dependence on drugs such as alcohol, people who become dependent on an illegal substance risk penalties for violating drug control laws and their personal safety when procuring drugs. Those who use underutilized needles also risk exposure to HIV, hepatitis,

and other sexually transmitted diseases that are transmitted through contaminated blood. More than other addictive substances, illegal drugs are a powerful force behind criminal activity that destroys families and neighborhoods, and overwhelms prisons. If you feel you are unable to stop using illegal drugs on your own, you will need professional help to quit. Although quitting is something only you can do, it is not likely that you can quit by yourself. Talk to your doctor, or call your local hospital or clinic to ask about their drug treatment programs.

Cocaine

Whether sniffed as a powder, injected as a liquid, or smoked (freebasing), cocaine acts as both a stimulant and a local anesthetic, producing a rush of euphoria and energy. Its effects wear off quickly, often leading users to take another dose in a short time. Cocaine is derived from the leaves of the South American coca bush. Crack cocaine, the purest form of the substance, is especially lethal because its effects are more intense and can lead to cardiac arrest. The euphoria caused by cocaine use is intense but short-lived and usually followed by depression as the drug wears off. The drug causes the coronary arteries to constrict, boosting blood pressure and, with it, the risk of heart attack, stroke, and seizures. Regular use of cocaine often causes nervousness, insomnia, inability to concentrate, fatigue, depression, or anxiety; some people become aggressive, violent, or paranoid. Side effects include nausea and vomiting, bleeding of mucous membranes, and cold sweats. Cocaine also can cause hallucinations, abnormal heart rhythm, coma, and death. A very ill person who is dependent on cocaine may need to be hospitalized. All people who are addicted to cocaine should seek counseling and rehabilitation to overcome their addiction.

Club Drugs

So-called club drugs such as ecstasy, rohypnol, GHB, and ketamine are synthetic drugs made in illegal production facilities. These drugs are being used increasingly by teens and young adults as part of a nightlife scene at nightclubs, bars, and “raves.” Many young people experiment with a variety of these drugs together. Combining any of these drugs with alcohol can lead to severe reactions and death. Ecstasy comes in pill form and also can be inhaled or injected. The effects of ecstasy are similar to those of amphetamines and cocaine. Psychological effects include confusion, depression, sleep problems, severe anxiety, and paranoia. Physical effects include muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating. Use of the drug is associated with increases in heart rate and blood pressure. Ecstacy also has been linked to long-term damage to those parts of the brain that are critical to thought, memory, and pleasure. Rohypnol, GHB, and ketamine depress the central nervous system, inducing a state of dazed relaxation. They have been implicated in cases of date rape; because they are often colorless, tasteless, and odorless, they can be slipped easily into an unsuspecting victim’s drink. Rohypnol can be fatal when mixed with alcohol or other depressants. Abuse of GHB can produce withdrawal effects such as insomnia, anxiety, tremors, and sweating, and can cause coma and seizures, especially when combined with ecstacy. Sometimes ketamine is used as an alternative to cocaine and usually is snorted.

Heroin

Heroin is an opiate, which means it comes from the opium poppy. Like other opiates, it can be eaten, inhaled, smoked, or injected. Because the body quickly builds up a tolerance to heroin, users can become addicted rapidly. The euphoric and tranquilizing effects of heroin come at a high price: regular use can lead to kidney dysfunction, pneumonia, lung abscesses, and brain disorders, depending on how the drug is taken. Those who inject the drug also risk skin abscesses, phlebitis (inflammation of a vein, often accompanied by formation of a blood clot), scarring, hepatitis, and HIV infection. The drug methadone, itself addictive but much less so than heroin, is often used to treat heroin addiction; the person may need to take it for the rest of his or her life. Methadone treatment is usually given on an outpatient basis under a physician’s supervision.

Marijuana

The most widely used illegal drug is marijuana, made from the leaves of the hemp plant. The drug is typically smoked in joints (cigarettes). People use marijuana to feel good and to relax. The drug can cause a distorted sense of time and a reduced ability to think and communicate clearly. Other side effects can include problems with depth perception and short-term memory, impaired motor abilities, bloodshot eyes, dry mouth, and with chronic use paranoia, panic, and hallucinations. Like cigarette smoke, marijuana smoke impairs the lung’s defenses against infection and can lead to bronchitis and emphysema. Smoking marijuana may pose even more of a cancer danger than cigarettes because marijuana smoke contains more of a potent cancer-causing substance than tobacco smoke and because people who smoke marijuana inhale the smoke more deeply into their lungs. Heavy, long-term use of marijuana can cause a psychological addiction that can lead to loss of energy, ambition, and drive. People who are psychologically addicted to marijuana tend to have difficulty dealing with normal, everyday stress.

LSD

Lysergic acid diethylamide (LSD) is a powerful hallucinogen that induces a wide range of psychological effects, which can be enjoyable, terrifying, or both. “Bad trips” can cause paranoia and panic, but even ordinary episodes of LSD use can involve:

• depressed appetite

• loss of sexual desire

• distorted perceptions

• difficulty communicating

• feelings of paralysis

• hyperactivity

• dilated pupils

• increased heart rate and blood pressure

• sleeplessness

• tremors

In whatever form it is taken (blotter paper, sugar cubes, gelatin squares, or small tablets) the effects of LSD are unpredictable, in part because it is impossible to know the exact dose you are getting and in part because the effects are influenced by the user’s personality and mood. A single dose of LSD can last for 12 to 18 hours, and many users experience flashbacks recurring memories of some aspects of their experiences using the drug for up to a year. LSD is not considered to be addictive but, like addictive drugs, LSD can produce

tolerance, which causes people who use the drug regularly to take increasingly higher doses to get the same effects. In susceptible people, LSD use may contribute to the development of mental disorders such as schizophrenia and severe depression.

Physiological Effects of Smoking

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Scientists now understand the details of how and why smoking is able to exert so many different negative effects on many parts of the body. The smoke from a lighted cigarette contains a mixture of more than 3,000 different substances that are dangerous to living tissue. In addition, tobacco products contain hundreds of chemical additives used as flavors and fillers. No federal agency currently has the authority to require the tobacco industry to reveal the names of these additives, or to remove them from tobacco products if they are found to be harmful. These substances in cigarettes include tars, nicotine, and gases such as carbon monoxide, nitrogen oxide, and hydrogen cyanide. Together, these substances interact to create a huge number of different chemical compounds that have harmful effects on the body. Tobacco tar is made up of hundreds of chemicals that have been shown to cause cancer. Nicotine is the addictive substance in tobacco. The signs of addiction include tolerance (the need to take larger doses to produce the same effects), physical dependence, continued use despite known harmful effects, euphoric effects, relapses following drug abstinence, and recurrent drug cravings. Nicotine is inhaled, along with tars and carbon monoxide, in tobacco smoke. Nicotine in smokeless tobacco is absorbed through the mucous membranes in the mouth (chewing tobacco) or the nose (snuff). Nicotine acts primarily on the nervous system, often causing an increased heart rate and elevated blood pressure. Nearly 90 percent of the nicotine found in cigarettes is inhaled and absorbed into the bloodstream. In addition to its effects on the respiratory system and the gastrointestinal system, nicotine also affects the brain, the spinal cord, and the peripheral nervous system. Nicotine can stimulate, then depress, the production of saliva, constrict the air passages in the lungs, and increase cholesterol levels in the bloodstream. Carbon monoxide is a deadly gas that is a by-product of burning tobacco. It is the same pollutant that is found in automobile exhaust. Carbon monoxide is deadly because it displaces the oxygen molecules in red blood cells, making oxygen less available to your muscles, brain, heart, and other organs. It also damages the lining of arteries, causing atherosclerosis (the buildup of fatty deposits called plaque in the inner lining of the arteries that supply blood to the heart). As a result, the heart must pump harder to deliver an adequate supply of oxygen to the cells. Smokeless Tobacco Smokeless (chewing) tobacco has been making a gradual resurgence in the United States for the past 20 years. Advertisers have presented smokeless tobacco as a healthier alternative to smoking, using the macho image of tobacco-chewing cowboys and athletes to promote their products. Apparently these advertisements have been effective, as indicated by an increase of 52 percent in sales of smokeless tobacco since 1978. It is estimated that 7 million to 11 million Americans, mostly males, use smokeless tobacco. Smokeless tobacco comes in three forms: loose leaf, plugs, and snuff. Chewing tobacco may be packaged as loose-leaf tobacco, which is sold in a pouch. The user places the tobacco between the cheek and the gum, and when a certain amount of tobacco juice and saliva are accumulated in the mouth, it is spit out. Chewing tobacco also can be found as plug tobacco, which is a solid brick form of tobacco. The user cuts off a piece with a knife and chews it, and again, spits it out. Snuff is a finely ground tobacco, sold in cans, that is put on the back of the hand and sniffed through the nose. It also can be placed between the cheek and

the gum. Despite its macho appeal to men, few women find tobacco chewing attractive. Users of smokeless tobacco may not experience the effects of carbon monoxide, but the substance has plenty of other harmful effects, including:

• damage to the soft and hard tissues in the mouth

• excessive abrasion of tooth surfaces

• presence of nitrosonornicotine, a cancer-causing agent

• increase in heart rate and blood pressure

• development of leukoplakia, a disease that results in thick, white patches on the cheek, tongue, and other parts of the mouth

• cancer of the inner lining of the cheek

• suppressed immune response

• increase in the number of dental cavities

• inflammation of the gums

• cancers of the pharynx, esophagus, bladder, and pancreas

• darkened teeth and bad breath

Secondhand Smoke Breathing in smoke from someone else’s tobacco presents a significant risk to a nonsmoker’s health. Exposure to so-called secondhand smoke (sometimes referred to as passive smoking) is a significant cause of heart disease, stroke, lung cancer, and respiratory problems such as bronchitis. Two different types of smoke enter the air when a person smokes: exhaled smoke and the smoke that comes directly from the burning tobacco. This second, more dangerous type of smoke is what hovers in the air in smoke-filled rooms. Secondhand smoke is especially harmful to infants and young children. Smoking by parents is known to worsen asthma in children and even to trigger asthma attacks. Children without asthma whose parents smoke have far more respiratory illnesses coughs, colds, middle ear infections, pneumonia, and bronchitis than children of nonsmokers.

Alcohol and Other Drugs

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Dependence on alcohol and other drugs, also called addiction, poses a triple threat to the dependent person and to society as a whole. It increases the probability that a person will do something potentially harmful, such as acting in a violent or careless manner. It leads to impaired judgment that affects certain everyday activities, such as driving a car, thereby increasing the risk of injury or death. And it creates chemical imbalances in the brain and the body that increase the risk of illness and death. Nicotine, the drug found in cigarettes and other tobacco products, is extremely addictive.

Drug Dependence

A person who uses a drug for other than a recommended or prescribed purpose is said to be abusing that drug. Drug dependence (or addiction) is an uncontrollable craving for a particular substance, which can, in some cases, take over a person’s life. A person who is psychologically dependent on a drug experiences emotional distress when the drug is withdrawn. Physical dependence means that the body has adapted to the presence of the drug, causing symptoms of withdrawal when deprived of it. Drugs that can cause addiction fall into three general categories: those that depress the central nervous system, those that stimulate the central nervous system, and those that produce hallucinations and also affect the central nervous system.

Drugs That Depress the Central Nervous System

A person who is addicted to a drug that depresses the central nervous system is both psychologically and

physically dependent.

• Examples are opiates such as codeine, heroin, and morphine; barbiturates; alcohol; and antianxiety drugs.

• Short-term effects include euphoria, relief from pain, and prevention of withdrawal symptoms.

• Long-term effects include depression, malnutrition, constipation, and, when injected from a contaminated needle, an increased risk of infection with HIV or hepatitis B.

• Withdrawal symptoms for opiates include weakness, sweating, and chills, progressing to vomiting, diarrhea, and sometimes cardiac collapse, which can be fatal. Withdrawal symptoms for barbiturates and antianxiety drugs include tremor, anxiety, restlessness, and weakness, sometimes progressing to hallucinations and seizures. Withdrawal symptoms for alcohol include trembling hands, sweating, nausea, and, in some cases, cramps and vomiting. Other severe withdrawal symptoms for alcohol may include confusion, hallucinations,

and seizures.

Drugs That Stimulate the Central Nervous System

Tolerance builds up quickly with drugs that stimulate the central nervous system, which means that a person must take increasingly large doses to achieve the same effects.

• Examples are cocaine and amphetamines.

• Short-term effects include excitation, sleeplessness, hyperactivity, and euphoria.

• Long-term effects include hallucinations, delusions, and depression.

• Withdrawal symptoms include severe depression, sleeplessness, mood swings, headaches, muscle pain, apathy, and drug cravings that may last up to a year. Drugs That Produce Hallucinations Hallucinogens do not produce physical dependence, so there are no withdrawal symptoms, but they may produce psychological dependence and genetic damage.

• Examples are LSD and mescaline.

• Short-term effects include exhilaration, sensory distortion, illusions, paranoia, and panic.

• Long-term effects include flashbacks. Some people are more susceptible than others to drug dependence for reasons that may include both genetic and environmental factors. Heavy use of any addictive drug may encourage the use of other drugs; adolescents who use alcohol, tobacco, or marijuana are more likely than their peers who don’t use these drugs to use cocaine or heroin eventually. In general, the younger people are

when they start and the more types of drugs they use, the greater their risk of addiction. People start taking a drug for a variety of reasons. They may be having problems coping with a difficult situation, such as divorce or unemployment. They may be bored or curious or under pressure to conform to the behavior patterns of their peers. Most do not realize that they are risking becoming dependent on the drug. Dependence not only causes physical problems such as lung and heart disease from tobacco smoking and liver disease from drinking excessive amounts of alcohol, but it also contributes substantially to the breakdown of families, to unemployment, and—in some cases—to crime. Effective treatment for drug dependence consists of both physical detoxification and mental and social rehabilitation. Detoxification, or withdrawal of the drug gradually over a period of a week to 10 days, is usually done in a controlled setting such as a hospital, where the person’s physical symptoms can be treated. Sometimes a less harmful drug with similar effects is substituted, such as methadone for heroin. Formal rehabilitation programs, which may include therapeutic communities and may use self-help groups such as Narcotics Anonymous or Alcoholics Anonymous, have been shown to greatly increase a person’s chances of staying off drugs permanently.

Alcohol

Alcohol is the most commonly used drug in the United States. Nearly 14 million Americans are dependent on it or have other problems associated with drinking. These problems cost the nation more than $100 billion annually in medical care and lost productivity. Alcohol accounts for one of every 20 deaths and one of every four hospital stays. Nearly 60 percent of all violent acts—including murders, child abuse, family abuse, and other felonies—are associated with the consumption of alcohol. Alcohol dependence is a chronic disease characterized by a tendency to drink more than was intended, unsuccessful attempts to stop drinking, and continued drinking in the face of adverse consequences. Moderate drinking—two drinks a day for men—has been found to have health benefits. Statistically, moderate drinkers live longer than both nondrinkers and heavy drinkers, reflecting alcohol’s ability to reduce some of the risks associated with heart attack, stroke, and diabetes. For example, alcohol lowers low-density lipoprotein (LDL), the “bad” cholesterol, and elevates high-density lipoprotein (HDL), the “good” cholesterol that protects against clogged arteries. Alcohol also helps prevent the formation of blood clots and increases estrogen production in postmenopausal women. Many people, however, find it impossible to drink in moderation. If you have questions about the benefits versus the risks of having one or two drinks a day, talk to your physician.

Alcohol’s Effects on the Brain

Alcohol exerts its effects by altering the function of different chemical messengers (neurotransmitters) in the brain. The initial effects of alcohol are to mildly sedate the brain: the drinker becomes a little less inhibited and anxious. The second and third drinks affect the brain’s pleasure center, located in the lower midbrain, producing an emotional high. The pleasure center evolved in all animals to ensure survival. Although the mechanism is not fully understood, sex, eating, and other behaviors that enhance evolutionary adaptation and survival produce pleasurable feelings that make people want to repeat those behaviors again and again. Sensory inputs and thoughts are sorted out by the pleasure center in the brain and tagged as being good (pleasurable) or bad (hurtful or unimportant). Good things are remembered, unimportant things forgotten, and bad things feared. This is one of the ways we learn, but it is also the process that underlies addiction to alcohol and, very likely, other drugs. Once rewarded for something, such as alcohol intake, with an emotional high, we want to do it again. Alcohol does not affect all people in the same way. Genetic differences may account for variations in the way the pleasure center responds to alcohol. There is, however, no single “alcoholism gene.” Most likely, many genes are involved in a person’s response to alcohol, and these genes interact in different combinations with environmental influences, such as peer pressure and the availability of alcohol. As the genetic contribution to alcohol becomes better understood, it may be possible to test for genetic susceptibility to alcoholism. Men are four times more likely than women to become dependent on alcohol. As with other addictions, those who cannot stop drinking eventually have difficulty maintaining personal relationships and taking care of themselves. People who are dependent on alcohol often fail to eat properly or get adequate rest, which can lead to serious health problems.

Codependence

Family members and friends who act in ways that allow a person to continue to misuse alcohol or other drugs are considered to be codependents or enablers. These people often make excuses for the addicted person’s behavior, such as calling in sick to work for him or her, to hide the problem from others. A person who is codependent may plead with a loved one to stop using alcohol or other drugs but rarely does anything else to help the person change the harmful behavior. The best thing family and friends can do is to encourage the person who is addicted not only to stop taking drugs but also to enter a treatment program. Threats to withdraw regular contact or support, combined with professional intervention or counseling, may be the only way to persuade him or her to seek help.

Prevention and Treatment

The following steps can help prevent the development of alcohol dependence:

• Limit your drinking to no more than two drinks a day.

• Drink slowly; do not have more than one drink per hour.

• Never drink to relieve anxiety, tension, or depression, or on an empty stomach.

• Do not feel embarrassed for refusing an alcoholic drink at a social occasion. No single form of treatment works for everyone who is dependent on alcohol. Several different approaches may be used, often in combination:

• Psychological treatment usually involves psychotherapy on a one-on-one or family basis, or is carried out in groups using a variety of talk therapies.

• Social treatments often address problems at work and include family members in the treatment process.

• Physical treatment, needed by some people who are dependent on alcohol, may use a deterrent drug such as disulfiram to sensitize the person to alcohol. The drug causes extremely unpleasant symptoms when a person drinks, so that he or she eventually becomes reluctant to do so.

• Self-help organizations such as Alcoholics Anonymous (AA) are a particularly helpful form of support for people who are trying to quit drinking. Some people require medical help in getting through physical withdrawal when they stop drinking. This process of detoxification, which takes 4 to 7 days, is usually followed by long-term treatment.

If you answered yes to any of these questions, you may be addicted to alcohol. If you think that you—or someone you love—has a drinking problem, seek help immediately. Stopping now will significantly improve your life and your health, no matter how long you have been drinking. Here is how you can get help:

• Ask your doctor for the name of a healthcare professional who specializes in treatment for alcohol dependency.

• Call the employee assistance program where you work.

• Call nearby hospitals or a local mental health center to ask if they provide a program for alcohol addiction.

• Call the local chapter of AA, a support group of alcoholics who meet regularly to help each other stop drinking and stay sober.

• If you are concerned about the drinking of a family member or a friend, call the local chapter of Al-Anon, a support group for relatives and friends of alcoholics.

Tobacco

Smoking, directly and indirectly, causes more death and illness in the United States than any other single activity. Each year, more than 300,000 Americans die of smoking-related illnesses, including lung cancer, emphysema, and heart disease. Although the incidence of smoking among men has declined to about 32 percent from its peak of 54 percent in the mid-1950s, smoking remains one of the most difficult habits to kick. Much of what is known today about the harmful effects of tobacco was learned from medical studies of the effects of cigarette smoking on the lungs. The effects of smoke from cigars and pipes are also dangerous,

although in somewhat different ways.

Harmful Effects of Smoking

The risk of developing lung cancer is 10 times greater for cigarette smokers than for nonsmokers. Decades of study in many countries have shown a direct link between smoking and lung cancer. Since cigar and pipe smokers do not inhale as much tobacco smoke, they have a slightly lower risk of lung cancer, but the risk is still significantly higher than it is for nonsmokers. Tar and nicotine, as well as smoke, play a role in the development of lung cancer. The risks for lung cancer increase proportionately with the number of cigarettes smoked, the length of time the person has smoked, the age at which the person started smoking, and the amount of smoke inhaled. Other types of cancer caused by cigarette smoking include cancers of the throat, esophagus, bladder, kidney, pancreas, and mouth. Pipe and cigar smokers also have an increased risk for cancers of the lip and mouth. Since some of the tars in tobacco are swallowed, there is also an increased risk of stomach cancer. Respiratory diseases associated with smoking include chronic bronchitis, sinusitis, and emphysema. Each year in the United States, these diseases account for tens of thousands of deaths from respiratory failure. Cigarette smoking slows down the action of the cilia, tiny hairlike projections that line the airways and help clean the lungs. When the cilia are immobilized, dust and dirt particles are able to invade the lungs and cause inflammation. As a result, cigarette smokers also have more chronic coughs, phlegm production, wheezing, and other respi-ratory symptoms. People with allergies and asthma are particularly vulnerable to the negative effects of cigarette smoke. For men, the most significant health hazard of smoking is coronary artery disease—the most common cause of death in men in the United States. A young man who smokes 20 cigarettes a day is three times more likely than a nonsmoker to develop coronary artery disease. The risk increases proportionately with the number of cigarettes smoked. Smokers have been shown to have severe and extensive narrowing of their coronary arteries, the vessels that deliver blood to the heart muscle. They also have higher blood levels of LDL (low-density lipoprotein), the “bad” cholesterol, and are more likely to have high blood pressure. Smoking lowers the threshold for the onset of angina, chest pain associated with heart disease, and is a major risk factor for peripheral vascular disease, which affects the arteries of the legs, causing painful neuropathy (degeneration of the nerve endings). Smoking also affects the arteries leading to the brain, thereby increasing the risk for stroke.

Risky Behavior of Teenagers

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The greatest number of deaths among teenagers are attributable to accidents, unintentional injuries, homicides, and suicides. This means that most deaths among teenagers are related to their behavior, rather than to disease or other natural causes. Other examples of national trends in risky behavior among teenagers

include the following:

• Across all races, teenage boys die more frequently than teenage girls because of accidents, injuries, homicides, or suicides.

• Adolescents are starting risky behavior at an earlier age.

• Cigarette smoking among teenagers is on the increase, even as smoking is declining for all other age groups.

• After a decline in illicit drug use among teenagers, it is again on the increase.

• More than two thirds of students have had sexual intercourse by their senior year of high school (although the incidence of teenage pregnancy is decreasing).

The greatest danger to male teenagers seems to be that a significant percentage of them multiply their risks by engaging in more than one risky behavior. Teens who become involved in one risky behavior at an early age are more likely to take other risks. For example, boys or young men who use drugs or have school problems or past criminal involvement are more likely to be sexually active. The higher incidence of problem behaviors among teenage males suggests that the origin of these behaviors rests in genetic differences between boys and girls and in differences in social expectations about behavior. Levels of the male hormone testosterone may influence the development of problem behavior in 13-year-old boys. But the association between hormone levels and problem behavior does not persist as boys get older. During this later period, problem behavior seems to be self-perpetuating, independent of testosterone levels at that time, and more influenced by social and psychological factors. Also, there is evidence that risky behavior is also on the rise among adolescent females in urban areas across the United States, a trend that cannot be explained by testosterone levels. Boys and young men who strongly endorse a traditional view of masculinity appear to be more likely to engage in risky behaviors, such as getting suspended from school, drinking, using drugs, having multiple sexual partners, forcing someone to have sex, or not using condoms consistently. Mistaken beliefs about being tough and getting respect, which are traditionally part of the popular concept of manhood in the United States, may lead young men to engage in behaviors that endanger their health. Preventive health programs around the United States have typically focused on single behaviors or problems, but new approaches to prevention are emerging. For example, new prevention efforts are more broadly based and deal more with the interrelationships among various types of risky behaviors within the context of the family, neighborhood, and peer group in which these risky behaviors arise.

Avoiding Risky Behavior

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A wide variety of behaviors are considered risky, which means that they have a high probability of causing or leading to personal harm and, in some cases, death. People usually choose to engage in risky behavior because of the immediate enjoyment it offers and because they are able to convince themselves that the risks are small, or that the risks can be prevented, avoided, or controlled. They may not consider the possible long-term consequences of their behavior. Risk-taking is also sometimes encouraged by others. For example, peer pressure is strong during adolescence because that period is seen as a time of becoming independent and testing limits. There are risks associated with nearly every activity in which the consequences are unknown or uncertain. Risky behavior can include everything from adventurous activities such as skydiving or mountain climbing to routine activities such as driving to work. Some behaviors, such as gambling or gang activity, carry an identifiable risk of loss or harm that occurs each time they are performed. For other activities, such as cigarette smoking, the resulting harm often occurs in the longer term. Because of this delayed impact, people often ignore or deny the risk involved. Many of the health risks for today’s children and adolescents are related to behavior and lifestyle. For example, risky behaviors (such as drug use and smoking) and failure to follow the basics of a healthy lifestyle (such as exercising regularly and eating a healthy diet) can contribute to poor health in both children and adolescents. A variety of personality traits have been identified in young children that can be used to predict risky behavior later in life. These traits include tolerance for deviance, rebelliousness, nontraditional values, emphasis on autonomy, inability to delay gratification, deemphasis on achievement, selfcenteredness, and low self-esteem. Environmental influences on behavior during childhood include parental and peer attitudes and behavior and the impact of the wider environment (such as the media). Even in younger children, multiple influences can affect the use of (or intention to use) alcohol and other drugs. In many cases, a child’s intentions to use alcohol can be predicted by whether his peers drink (or whether he thinks they do), whether family members drink, the child’s involvement in family drinking, and the child’s tendency toward risk-taking.

Developing a Good Relationship with Your Doctor

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In the past, many people saw the same doctor for years sometimes for most of their lives. Today, people are much more mobile, making a long-standing patient-doctor relationship more difficult. People move to new locations, accept new jobs, and change healthcare coverage. Any of these situations may require a change of doctors. Some health plans restrict your choice of doctors to those who participate in their plans. Seeing a specialist may entail getting a referral from your primary care doctor. Choosing a new doctor takes more than just a word-of-mouth recommendation from a friend. You need to think carefully about what you are looking for when changing doctors. The area of medicine in which a doctor specializes is an important consideration. If you have a particular medical problem, such as heart disease, you will probably want to see a cardiologist (a doctor who specializes in diseases of the heart). If you are generally healthy, an internist (a doctor who specializes in the care of adults) or a family physician is probably the best choice. You may also

prefer a male doctor over a female doctor. Some people choose a doctor based on the hospital to which he or she admits patients. The location of the doctor’s office also is a factor. It should be easy to reach from your home or workplace, especially if you rely on public transportation. Once you have narrowed your choices, find out more about the doctors you are considering. Important information includes where they trained, how long they have been practicing, and their specialty area and whether they have been certified by the board in that specialty. To become board-certified, a doctor must have had at least 7 years of medical

training and must pass a comprehensive examination in his or her specialty (such as plastic surgery or otolaryngology). provides helpful information such as medical training, specialty, and board certification for more than 650,000 physicians in the United States. The least reliable source of information about doctors is probably paid advertising. After you have compiled a list of doctors, you will need to check their credentials.

There are several good sources of information about doctors. Three reference books—Directory of Medical Specialists, Compendium of Certified Medical Specialists, and The Official ABMS Directory of Board Certified Medical Specialists that list board-certified physicians by location are available at your local public library. You also can call your local hospital or the offices of the doctors you are considering to find out the following information:

• Training. Where did the doctor attend medical school? Has he or she completed a residency? If so, where?

• Board certification. Make sure that your physician has been certified by an appropriate certifying board, such as the American Board of Internal Medicine, the American Board of Surgery, or the American Board of Dermatology.

• Hospital privileges. To treat patients at a given hospital, a doctor must gain official approval of his or her peers at that hospital. At which hospital in your community does the physician have staff privileges? Contact the hospital to verify this information.

• Experience. For example, if the doctor is a surgeon, how many times has he or she performed the type of surgery you are planning to have? When was the most recent time? The surgeon you select should be up to date on the surgery you are considering.

• Professional society membership. Perhaps the most important organization to which a physician can belong is his or her specialty society the group that represents the medical specialty practiced by the doctor. Specialty societies certify their members and require that they participate in continuing medical education and adhere to a strict code of ethics. Once you have made your choice, your next step is to develop a good working relationship with your doctor. A good relationship depends on effective communication between you and your doctor. Before you see your doctor for a scheduled visit, think about what you are going to say. Write down important questions you have or symptoms you want to tell the doctor about so you won’t

forget them. When describing your symptoms, be specific; explain when they started and what you experience when the symptoms occur. Write down the names of all the medications you are taking, including over-the-counter drugs and vitamin or mineral supplements. Remember to bring your notes with you. Don’t hold back any information when the doctor asks you questions about your diet, alcohol or other drug use, smoking, or sexual activity. These factors can affect your health, and the doctor needs to know about them to get a full understanding of your condition and treat your problems appropriately. If you feel embarrassed about talking over sensitive subjects, it’s all right to tell your doctor about your discomfort. Rest assured that all of your conversations with your doctor will remain confidential. Your doctor needs to communicate well with you by fully answering all of your questions and explaining medical terms and procedures in language you can understand. He or she also needs to treat you with respect and keep waiting times to a minimum. If you feel that you are not getting all the information you need to follow your doctor’s instructions or that your appointment times are too rushed to address all of your medical concerns, try to talk to your doctor about

the problem before switching to another doctor. Keeping an established relationship is much easier and more valuable than starting all over again.

Immunizations

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Immunizations are not just for children. They continue to be important in adulthood to protect you from several dangerous infectious diseases, although the number of immunizations you need drops dramatically after age 16. The three most important immunizations are those for tetanus, influenza (flu), and pneumococcal disease (a type of pneumonia). Tetanus is a bacterial infection that affects the central nervous system and can be life-threatening. The bacteria that cause tetanus are found in soil, dust, and animal feces and usually enter the body through an open cut. The bacteria produce a toxin, or poison, in the body that attacks the nervous system, stiffening the muscles. Tetanus is commonly called lockjaw because the muscles in the jaw and neck are affected first. You should get a booster shot of the tetanus vaccine every 10 years throughout adulthood. Influenza, commonly called the flu, is an infection caused by a virus that affects the respiratory system. Symptoms include fever, chills, headache, muscle aches, and a sore throat. Influenza is spread from person to person through direct contact, such as shaking hands, or by inhaling droplets containing the virus in the air after an infected person coughs or sneezes. New strains of influenza virus

appear every year, so you must get a shot of the influenza vaccine yearly, in the fall, just before the flu season starts. Doctors recommend the influenza vaccine for all men over age 65 and for younger men who have medical problems such as heart disease, lung disease, or diabetes or who have close contact with high-risk

people. Pneumococcal disease is caused by a bacterium. It can lead to pneumonia and a number of other serious complications. The most common symptoms are fever, chills, chest pain, a bluish cast to the lips and under the nails, and a cough. You should have a “pneumonia shot” if you are age 65 or over or if you have a

long-term health problem such as heart or lung disease, diabetes, or kidney disorders. The vaccine is taken once and provides long-term immunity; it can be taken at any time of the year. A person should be revaccinated if he received pneumococcal vaccine in childhood and has a chronic condition such as sicklecell

disease. Some men may need additional immunizations, depending on several factors. Hepatitis is a potentially serious inflammation of the liver caused by different viruses. The hepatitis A virus is transmitted through food touched by an infected person or in water that has become contaminated with raw sewage. The vaccine for hepatitis A is administered in two doses. Men traveling to countries in which the disease is common should get the first dose at least 4 weeks before departure, but preferably much earlier because the second dose is given 6 to 12 months after the first. The hepatitis B virus is spread through contact with an infected person’s blood or other body fluids. Healthcare workers who may be exposed to a patient’s body fluids, dialysis patients, people with HIV, and men who live with people infected with hepatitis B are at risk of getting the disease and should be immunized. The hepatitis B vaccine is given in three doses. The second dose is administered 1 month after the first, and the third dose is given 5 months after the second. A chickenpox (varicella) vaccine is now available for children and for adults who never contracted the disease in childhood. Chickenpox is a very contagious disease that causes only fever and an itchy rash in children. Although rare in adults, chickenpox can be much more serious when contracted in adulthood, causing sterility in men. Ask your doctor if he or she recommends that you get immunized for chickenpox. The vaccine is given in two doses, the second dose 1 to 2 months after the first.

Common Screening Tests

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Sometimes a physical examination of your body is not enough to tell your doctor the full condition of your health. In such cases the doctor may order a number of common screening tests. Blood tests and urinalysis help the doctor find out if all of the components of your blood or urine are at normal levels. Scanning techniques such as X rays, magnetic resonance imaging (MRI), ultrasound scanning, and computed tomography (CT) scanning produce pictures of the inside of your body without surgery to give your doctor important information about your overall health. If your doctor has ordered one of these tests for you and you don’t understand what exactly is going to happen, ask questions so you can feel more comfortable about having the procedure. Diagnostic techniques are changing rapidly, and newer techniques will undoubtedly be available in the near future.

Blood Test

A sample of your blood can provide many clues about the quantity and quality of the individual blood cells and whether your blood can clot normally. To obtain a sample of your blood, a medical technician will draw blood with a needle and syringe from your forearm and send it to a laboratory. At the laboratory, your blood will be analyzed in several ways. Tests will be done to check the number of your red blood cells and the concentration of hemoglobin inside them. Hemoglobin is the substance in red blood cells that carries oxygen throughout the body. A low red blood cell count or too little hemoglobin indicates anemia. Blood tests also will be conducted to detect the number of white blood cells, which have a major part in defending the body against infection. If an infection is present, the number of white blood cells in your blood will rise. The appearance of your blood cells is also important. Abnormally shaped red or white blood cells can signal the presence of diverse conditions such as sickle-cell disease, leukemia, or mononucleosis. Finally, your blood will be checked to see how well it clots by examining the number of blood cells called platelets, which help stop bleeding.

Cholesterol Levels Elevated levels of the fats known as cholesterol in your blood increase your risk for heart disease. When the excess fats build up inside the walls of your arteries, they narrow the arteries, obstructing blood flow to your heart. When the heart receives less blood, it gets less oxygen, which is transported by red blood cells. Your heart sends out warning signals in the form of pain and discomfort known as angina. When the blockage in the arteries supplying blood to your heart causes severe obstruction, resulting in a heart attack, the heart muscle can become permanently damaged.
Cholesterol comes in two forms: low-density lipoprotein (LDL), the “bad” cholesterol, and high-density lipoprotein (HDL), the “good” cholesterol. Somewhat like a delivery truck, LDL cholesterol carries most of the fat in your blood and deposits the excess inside your artery walls. Like a garbage truck, HDL cholesterol removes fat from your blood, preventing it from building up in your arteries. When testing your cholesterol levels, your doctor measures your total blood cholesterol as well as your LDL and HDL levels by taking a sample of your blood and having it analyzed in a laboratory. A desirable total blood cholesterol level falls under 200 milligrams per deciliter of blood. Doctors consider cholesterol levels above 200 to be high. One in five Americans has a total cholesterol level of 240 or greater, placing that person at risk of a heart attack. Your LDL cholesterol levels should be under 100,
and HDL levels should be 40 or higher. The higher your HDL level, the lower your risk for heart disease. All men over 20 years of age should have their total cholesterol levels checked at least once every 5 years. Your level of LDL cholesterol also should be tested if your HDL is less than 40 or if your total cholesterol is 240 or higher—200 if you have two or more risk factors for heart disease. Talk to your doctor about your personal risk factors for heart disease. Don’t hesitate to ask him or her anything you do not understand about cholesterol testing.

Urinalysis

Your urine provides crucial information about the presence of any disorders of the kidneys or bladder. If your doctor orders a urinalysis, you will be asked to pass some urine and collect a midstream sample (urinate for several seconds before collecting the sample of urine) in a small container, either at home or in the doctor’s office. If you are uncircumcised, you should pull back your foreskin and wash the tip of your penis with soap and water before urinating to ensure that your urine remains sterile. Your urine may be tested in a laboratory or in the doctor’s office, using special strips that the doctor can dip into the urine to test for any abnormalities. The presence of particular substances such as blood or
sugar in the urine can indicate certain diseases. For example, the presence of protein in the urine can signal some types of kidney disease.

X ray

The most common scanning test is the X ray, in which electromagnetic radiation passes through a body part to produce a picture of internal structures on film. X rays are a good way of showing dense areas of the body, such as bones or a tumor, that allow only a few rays to pass through. These dense areas show up as white areas on the film. Doctors use X rays to examine the chest, skull, and spine
and to view a bone that may have been fractured. Even organs filled with fluid, gas, or air—such as the arteries, colon, or bladder—can be viewed with X rays if the organs are first enhanced with a special liquid dye called a contrast medium. The contrast medium is injected, swallowed, or inserted through the anus; then the doctor or technician takes a series of X rays as the contrast medium moves
through the organ to facilitate viewing. Getting an X ray is safe because today’s X-ray equipment minimizes your exposure to radiation.

MRI
Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to produce a picture of the inside of the body. When you undergo an MRI, you lie on a table that slides into a rounded scanner containing a doughnut-shaped magnet that creates a magnetic field. Radio waves are sent to the part of your body to be viewed. The atoms in your body respond by emitting energy, and a magnetic field detector measures this energy and sends it to a computer, which translates the signal and creates a picture that your doctor can read. The procedure can take from 30 to 90 minutes and is painless, but the magnetic field can interfere with a pacemaker, hearing aid, or metal implants, so your doctor needs to know if you have any of these devices in your body. MRI scanning poses no known health risks.

Ultrasound
Ultrasound scanning uses sound waves to produce pictures of internal body structures. Doctors often use an ultrasound scan to diagnose disorders of the heart, kidneys, bladder, gallbladder, and pancreas. If your doctor orders an ultrasound scan, you will be asked to lie on a table, and the ultrasound technician will spread a gel on your skin over the area to be scanned. The technician will then move a handheld instrument called a transducer over the area, sending sound waves into your body. The sound waves bounce off of your internal organs, and the transducer transforms the waves into an image on a screen or on paper. Ultrasound is risk-free and is not painful.

CT Scan

Computed tomography (CT) scans take hundreds of X-ray images of the body from different directions that a computer then converts into cross-sectional pictures on a screen. CT scans can pick up details of abnormalities that a conventional X ray cannot detect. Doctors often order a CT scan to check for tumors or other abnormalities in the brain, liver, spleen, lungs, kidneys, pelvis, or lymph nodes (a part of the body’s immune system). During a CT scan, you lie on a table that moves into a circular machine. A tube revolves around the machine, taking multiple, low-dose X-ray images from many angles. The procedure takes about 20 minutes. Although a CT scan takes a vast number of images, the amount of radiation generated in a CT scan can be the same as or even less than that from a traditional X ray.

Routine Physical Examinations

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Your doctor uses the routine physical examination to assess your current physical condition and to identify any undiagnosed disorders. A routine physical examination also helps your doctor become familiar with you and your health risks or medical problems. The frequency with which you see the doctor for a routine checkup varies, depending upon your age and whether you already have a medical condition. Before beginning the examination, the doctor will take a complete medical history by asking you a series of questions about your lifestyle habits, general health, and family health history. Taking a thorough medical history often takes as long as the physical examination itself but is just as important. When you go to the doctor’s office for a routine physical examination, a nurse or other healthcare worker will weigh you and take your temperature to find out if you have a fever, which could signal an infection. He or she also will take your blood pressure, using an inflatable cuff, pressure gauge, and stethoscope. A blood pressure reading measures how forcefully your circulating blood pushes against the walls of the blood vessels with each contraction of your heart. The reading records the pressure in the vessels both when the heart pumps blood (the systolic pressure) and when it rests (the diastolic pressure). The reading is expressed in two numbers in millimeters of mercury (mmHg)—for example, 120/80 mmHg, which is a reading within the normal range. The first number indicates the systolic pressure; the second number, the diastolic pressure. The higher the pressure in your blood vessels, the higher the reading. You will be asked to undress and put on a cloth or paper gown. The doctor will begin by examining your skin, checking for any paleness, flushing, yellowish or bluish cast, rashes, dryness, bruising, or broken capillaries (tiny blood vessels). He or she will examine your face, which can display a number of unusual signs, such as puffy eyes, and your neck, checking for swollen glands or an enlarged thyroid (a gland just below your larynx—your voice box—that has an important role in controlling the chemical processes in your body). Next, your doctor will look inside your mouth with a small flashlight and a tongue depressor to examine your tongue, teeth, and gums. The condition of your mouth can reveal a number of clues about your general health. For example, red, cracking areas on your lips can signal a vitamin B deficiency. The doctor also will check your throat as far back as possible. By using an illuminated instrument called an ophthalmoscope, he or she will look into your eyes to see the retina lining the back of your eyes. Another lighted instrument, known as an otoscope, helps your doctor peer into your ears, to check for any inflammation or a possible perforation of the eardrum. Listening to your chest with a stethoscope allows your doctor to assess not only the nature of your heartbeat but also the condition of your lungs. Any abnormal heart sounds will alert your doctor to the possibility of an enlarged heart, poor blood flow through the heart, or a disorder of the heart valves. When listening to your breathing with the stethoscope, the doctor listens for wheezing, crackling, or other sounds that could signal the presence of a lung disorder such as asthma. The doctor will probably also tap your chest and place his or her hands against your chest and ask you to cough so he or she can detect any fluid in the chest. This process is called percussion. Taking your pulse is an important part of the examination because your heart rate can reveal heart or circulation problems. The doctor will want to examine your abdomen, feeling and tapping it to detect any tenderness, abnormal masses, or fluid accumulation. He or she will continue to press on different parts of your abdomen and ask you to respond if you feel any tender areas. The doctor is also checking for the correct positioning of the spleen and the liver. As part of his or her examination of your digestive system, the doctor will probably perform a rectal examination. Your doctor will first cover his or her hands with disposable plastic gloves and lubricate the area to be examined with a cream or jelly. The doctor will gently and carefully place his or her fingers inside your rectum to feel for any tumors in the rectum or prostate. Many prostate tumors are first detected in this way. If the doctor notices any signs that indicate that you may have a disorder of the nervous system, he or she will assess your motor ability, or ability to move, by observing the way you walk. He or she may also ask you to move your arms and legs in various ways to see whether there is a difference in movement between the two sides of your body. Testing the reflexes at your wrists, knees, ankles, and soles of your feet will also tell your doctor important information about the proper functioning of your nervous system. To complete the physical examination, the doctor may order blood, urine, stool, or other tests (see next page) to help detect any abnormal conditions. Typical blood tests include the complete blood cell count, cholesterol testing, and a blood glucose test. The collected body fluids are sent to a laboratory for analysis. The doctor may also order X rays or other scans, depending on your condition. After your doctor examines you, he or she will write down his or her findings, along with the information obtained during the medical history, in your medical record. The doctor will also write down his or her orders to other healthcare workers in the office about your medications, diet, tests, and recommended treatments. Your medical record serves as a means of communication for all of the doctors, specialists, nurses, therapists, and other healthcare workers who care for you. It is a confidential and legal document maintained by professional records management workers. If you would like to have a copy of your medical record, contact the medical records department of your doctor’s office or hospital.

Preventive Healthcare

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In addition to eating a healthy diet and exercising, seeing your doctor regularly for recommended screening tests is a good way to stay healthy. Regular medical checkups are an important preventive health measure. During your periodic checkup, your doctor can detect any medical problems in the early stages so they can be treated promptly. Your doctor uses numerous medical tests and screenings to check for any health problems. Before deciding which tests to order, your doctor will perform a comprehensive physical examination and will take a medical history, which is a record of every factor that might affect your health. To complete the medical history, your doctor will ask you a series of questions about your personal habits, your family health history, any medical problems you had in the past, and any symptoms you might be experiencing at present. When answering your doctor’s questions, it is important to provide as much information as you can without holding back any relevant facts. Don’t be afraid to ask your doctor questions if you don’t understand something he or she has said.
The most common tests performed in men over 40 include the PSA (prostate specific antigen) test for prostate cancer, the fecal occult blood test for colon cancer, and a series of tests that screen for the presence of heart disease or your risk of having it. Such tests may include measuring your blood pressure and the levels of cholesterol in your blood; an electrocardiogram, which measures the electrical activity in your heart; and a stress test, which evaluates the heart’s response to physical exercise. If you have a family history of a certain disease that has a strong hereditary component, such as diabetes, you also may undergo a screening for that disorder. For example, in the case of diabetes, the doctor would perform a test known as a glucose tolerance test As you get older, you probably will need more tests during your regular checkups because common disorders such as heart disease and cancer occur more frequently in older people. Use this section of the book to learn about the various tests and screenings your doctor might order so you can become better informed.

When You Need to Gain Weight

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Some men are underweight because of an eating disorder or because of treatment for a chronic disease such as cancer. They need to maintain their weight and add more pounds. For these men, taking in more calories than they burn is the answer. As simple as this may sound, underweight men often have to struggle with this concept. Some of these men experience appetite loss from chemotherapy or radiation therapy taken for cancer. Others struggle with an overwhelming fear of being fat that compels them to restrict their intake of food while burning

calories by obsessively exercising. If you are underweight, there are a number of steps you can take to gain additional pounds. Between your three meals a day, consume two or three snacks. Include highcalorie foods that are rich in nutrients, such as peanut butter and milk shakes. Space your meals and snacks so that you eat more without feeling overly full. Use the Food Guide Pyramid as your guide to healthy eating, consuming the highest recommended number of servings. For example, try eating 11 servings of grains and three servings of dairy products every day. Choose high-calorie fruits (bananas, dried fruit, and canned fruit in syrup) and vegetables (olives, corn, and avocados).

Add extra calories to your meals by incorporating high-calorie, nutrient-rich foods into recipes. Use milk instead of water in soups and sauces. Put a slice of cheese on your sandwich or over a baked potato. Mix wheat germ or powdered milk into casseroles. Make high-calorie shakes with whole milk, yogurt, and bananas.

Make meal and snack times as pleasant as possible to eliminate feelings of boredom, loneliness, or stress that may be affecting your appetite. Put fresh flowers on the table. Invite a friend or a neighbor over for lunch or dinner. Play music that you like during meals. These practical tips can make the difference between struggling to eat and eating well.

Losing Weight Sensibly

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Many overweight men have tried dieting and exercising to lose weight, with only modest success. Backsliding is easy, especially during the holidays or on special occasions. Successful weight loss depends on setting attainable goals and having reasonable expectations of meeting them. Losing 10 percent of your total body weight is an example of a sensible goal that you will be likely to reach. The sense of accomplishment that you feel will encourage you to keep the weight off and lose more if you desire. Most people should lose weight gradually; a rate of 2 pounds per week is about right. If you have a serious weight-related health problem that requires you to lose weight faster, do so only under your doctor’s supervision. How much you weigh is determined by a number of factors, including the amount and type of food you eat, whether you exercise, whether you eat in response to stress, your genetic makeup, your age, and your health. If you want to lose pounds and maintain a reasonable weight, you need to deal with all of these issues. Eating less and exercising are both critical to any weight-loss program, but if you eat out of boredom or fatigue, you will have a lot of difficulty

keeping those pounds off permanently. Losing weight requires permanent changes in your lifestyle changes that might be tough to make. Fad diets that offer quick and easy results usually deliver only empty promises.

Such diets may even be harmful to your health. Be especially wary of any diet that eliminates an entire food group, such as carbohydrates, because you could become deficient in essential nutrients. The only proven way to lose weight is to cut your intake of calories especially high-fat foods and to increase your physical activity to burn more calories. The healthy eating advice presented in the Food Guide Pyramid and the Dietary Guidelines for Americans to eat a diet that is low in fat; includes plenty of whole grains, vegetables, and fruits; minimizes salt and sugar; and includes alcohol only in moderation—is even more important for men who need to lose excess weight. The first thing you should do when thinking about starting a diet is to see your doctor. He or she can tell you whether your health status allows you to undertake a weight-loss program safely. Work with your doctor to determine the type of diet that is best for you. Your doctor may want to perform a physical examination or certain tests before you begin dieting, depending on your health.

When deciding on the type of weight-loss plan you want to begin, consider several factors. Do you want to lose the weight on your own or join a commercial weight-loss program? Before choosing a commercial weight-loss program, ask the following questions. Does the program require periodic check-ins or meetings? Is the location easy to get to, and are meeting times convenient? Do staff members have appropriate training and credentials? If you need any medication or nutritional supplements, do they have unwanted side effects? Be sure to get a full accounting of all the costs involved with the program you are considering. If you choose to lose weight on your own, you need to become aware of your eating habits so you can learn to control or modify them. A good way of raising awareness about your eating habits is to keep a detailed journal of the food you eat, how much you consume, and when you eat. As you take in fewer calories, charting your weight loss will build your motivation. Looking back at your food journal entries, you can sometimes see eating patterns emerge because you ate when you were feeling depressed, anxious, or angry instead of because you were hungry. You will probably be surprised at your eating habits. This new awareness will inspire you to change not only how much you eat but also the way you eat. A strong support network is key to successful weight loss. Enlist your partner, children, siblings, coworkers, and friends to help you get through the most difficult periods. Plan low-fat, lower-calorie meals with your partner. Find a buddy who is also trying to lose weight so you can share experiences and exercise together. It’s a lot easier to fall back into your old eating habits when you don’t have anyone to answer to but yourself. If you do return to your old eating habits, don’t be too hard on yourself. It can be especially difficult to stick to your diet at restaurants, dinner parties, and on holidays. Resolve to start fresh the next day, and consider your temporary lapse a learning experience. Exercise is one of the most important components of any weight-loss plan because it burns excess calories, increases your energy level, and improves your mood. Make time in your day for 30 minutes of physical activity every day. If you have been very inactive, start by taking a couple of flights of stairs rather than using the elevator or by parking farther from your destination so you can walk part of the way. Spend less of your time on activities that use little energy, such as watching television, and more time on activities that get you moving, such as yard work. Then, with your doctor’s permission, gradually begin doing some type of exercise that you enjoy. It could be brisk walking, bicycling, swimming, jogging, or working out on exercise machines at a health club whatever your doctor recommends as appropriate to your age and overall health. Remember that the activity does not have to be done all at once. You will burn the same amount of calories in three 10-minute exercise sessions as you will during 30 consecutive minutes. Keeping a record of your exercise sessions is a good way to combat a lack of motivation. You can also write down the health-related improvements, such as easier breathing, that you have noted. Overweight men often feel discomfort or pain when beginning an exercise program. If this happens to you, try switching to non–weight-bearing activities such as bicycling or swimming. Doctors may prescribe medications or even surgery to help some severely overweight men, or men whose weight poses a very high health risk, attain a

more reasonable weight. Most drugs prescribed for weight loss work by suppressing your appetite. They are most effective if you use them as part of a weight-loss program that emphasizes consuming fewer calories and exercising more to burn excess calories and fat at the same time you are taking the drug. Weight-loss drugs work differently in different people and all have side effects, which are usually mild. You should carefully talk over your options with your doctor to determine whether weight-loss medication is right for you. Doctors perform surgery to treat obesity only in cases in which the person’s health risk from being overweight is extremely serious. This type of surgery can promote weight loss in two ways. In the most common type of surgery for obesity, commonly called stomach stapling, the surgeon closes off or removes part of the stomach to restrict the amount of food the person can eat. In the second type, the surgeon connects the stomach to a lower portion of the small intestine, bypassing the first section, known as the duodenum, so that food is less effectively digested and absorbed. This type of surgery usually causes vitamin and mineral deficiencies. Weight loss is significant after either type of surgery, but men who have surgery to correct obesity need to see their doctor regularly for the rest of their lives to monitor their condition. Because any type of surgery has health risks, you and your doctor need to weigh the risks and benefits of this type

of surgery to determine if it is the best option for you.

The Health Risks of Being Overweight or Underweight

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More than half of all American men are overweight, and a third of all American men are obese (weigh more than 20 percent more than their ideal body weight). Being overweight is a major risk factor for a number of chronic diseases, including heart disease, high blood pressure, stroke, diabetes, and certain forms of cancer.

Even a small reduction—as little as 10 percent—in body weight can decrease your chances of developing the most common chronic disorders as you get older. If you already have a health problem, losing weight can help you manage your condition. In some disorders, such as diabetes, weight loss can help reduce and even eliminate the need for medication. Heart disease is the number one cause of death in American men. High blood pressure is a major risk factor for stroke, which can lead to permanent disability and death. You can reduce your risk of developing heart disease, high blood pressure, and stroke if you keep your weight within a healthy range. However, the number of pounds you weigh is not the whole story. You also need to know where your body stores fat. If you are like most men, your body stores fat around the abdomen, and a large amount of abdominal fat raises your likelihood of developing heart disease and diabetes. Regular aerobic exercise is the best way to get rid of abdominal fat. Also, if your waist measures more than 40 inches, you are more likely to develop heart disease, high blood pressure, or diabetes. Your body mass index is another important indicator of heart disease risk. Strive to maintain your BMI between 18.5 and 24.9 for optimal health. Obesity is the top contributing factor to high blood pressure. Losing a modest amount of weight—even just 10 pounds—could return blood pressure levels to normal in many of the millions of men who have high blood pressure. Men who take blood pressure medication could substantially reduce or even eliminate their need for the drugs if they lost a modest amount of weight. Blood pressure readings go down within the first 2 or 3 weeks of such a weight loss. The percentage of your body weight made up of fat seems to affect your blood pressure more than total body weight, so exercise that builds muscle, such as strength conditioning exercises, also can help keep your blood pressure lower. More than 16 million Americans have type 2 diabetes ; one third of them do not know that they have the disease because it has no symptoms in the early stages. Type 2 diabetes is characterized by increased levels of sugar in the blood because the body does not respond adequately to the effects of the hormone insulin, which regulates blood sugar levels. Diabetes can eventually produce serious complications, such as blindness, kidney disease, and poor circulation (which sometimes leads to amputation of the lower limbs). Men who have diabetes also have higher rates of heart disease, stroke, and high blood pressure than do men who do not have the disease. Uncontrolled diabetes also can cause life-threatening events such as diabetic coma. Type 2 diabetes tends to run in families, so if you have relatives who have diabetes, your own risk of developing the disease rises. But being overweight is an even stronger risk factor than heredity. Regardless of family history, overweight men are twice as likely to develop diabetes as men who are not overweight. This means that, even if you have a family history of diabetes, you can prevent or at least delay the onset of the disorder by keeping your weight within a healthy range and by increasing your level of physical activity. If you already have diabetes, losing weight and exercising regularly can help control your blood sugar levels and could make it possible for your doctor to decrease the amount of medication you need to control your diabetes. Colorectal cancer is the second most common cause of death from cancer in the United States, and being overweight increases your risk of developing the disease. Although some risk factors, such as family history, are beyond your control, being overweight is not one of them. If you have a family history of colorectal cancer, you should be especially careful about maintaining a reasonable weight. And be sure to limit your consumption of red meat and animal fat; a high-fat diet that includes large amounts of meat also increases your risk for this type of cancer. Being overweight puts extra pressure on your joints, especially those in your knees, hips, and lower back. Because of this extra pressure, the cartilage (the tissue that cushions and protects the joints) gradually wears away, causing a form of arthritis known as osteoarthritis. Over the years, the damage to the joint may be so extensive that the joint must be replaced surgically. This damage is permanent and cannot be reversed. Inflammation of the tendons, called tendinitis, is another common problem in overweight people. Tendons can become irritated and inflamed (especially the Achilles tendon, which stretches from your calf to your heel) from simple, everyday activities such as walking. Losing weight decreases the stress on your joints and tendons and reduces wear and tear. Weight loss also may reduce the pain and inflammation of osteoarthritis. Sleep apnea is a serious condition that is closely linked to being overweight. The condition can cause you to snore heavily and to stop breathing for short periods during sleep. Breathing can halt for 20 seconds or more, sometimes causing the skin to turn blue. Sleep apnea often causes daytime sleepiness and can be a factor in heart failure because of chronically low oxygen levels in the blood. Weight loss usually improves the condition. Another health risk of being overweight is gallbladder disease and gallstones. The risk of gallbladder disease rises as your weight increases, although doctors do not yet fully understand the connection between the two. Ironically, weight loss itself, especially if it is too rapid, can actually increase your chances of developing gallstones. A modest weight loss of about 2 pounds a week is less likely to cause gallstones. Although less common than in women, eating disorders such as anorexia nervosa and bulimia nervosa affect men, too. Estimating the number of men affected can be difficult because men don’t often talk about such problems or seek help for them. However, the incidence seems to be increasing as a new generation of men becomes more concerned about body image. Of the people being treated for eating disorders, about 10 percent of those with anorexia and about 20 percent of those with bulimia are men. Eating disorders are most common in men who are distance runners, wrestlers, and football players. The symptoms of anorexia (self-starvation, an irrational fear of being fat, compulsive exercise) and of bulimia (binge eating followed by self-induced vomiting or laxative abuse) are the same in both men and women. However, men often develop an eating disorder as a result of a desire to enhance sports performance or to overcome past weight problems, whereas women often develop an eating disorder as a result of an unrealistic body image. Also, body building and weight lifting have a much larger part in the excessive exercising that men with an eating disorder undertake than they do for women. Some men with an eating disorder use anabolic steroids (see page 14) to increase muscle tone and to improve strength. The affected man can become so obsessed with exercise that he begins to display exercise addiction, characterized by acute anxiety when he misses a workout and preferring exercise over time spent with family

or friends. The underlying causes of an eating disorder include a lack of self-esteem, an inability to handle stress, and sometimes sexual abuse in childhood. The man feels that controlling his intake of food gives him more control over his life in general. Most men with an eating disorder first develop it in adolescence. Although homosexual men often face pressure to be thin and attractive, placing them at a higher risk for developing an eating disorder than heterosexual men, homosexual men make up only about 20 percent of all men who have an eating disorder.

In addition to severe weight loss, anorexia can produce decreased blood levels of the hormone testosterone. The problem can become so serious that the body’s major organ systems are affected. As many as 10 percent of all people with anorexia die of the disorder. The binge-purge behavior that is characteristic of

bulimia can interfere with the delicate balance of chemicals in the body. Fatigue, seizures, and an irregular heartbeat can result. Stomach acid contained in vomit can damage the lining of the esophagus (the muscular passage that connects the mouth and the stomach) and corrode tooth enamel. A relatively new type of eating disorder, called muscle dysmorphia, has emerged. This condition appears mainly in body builders who, in spite of being very muscular, fear that they look thin and out of shape. The disorder arises from the same body-image issues as those contributing to anorexia and bulimia in women. If you think you may have an eating disorder, see your doctor right away. The doctor will conduct a thorough examination to find out how severely you are affected. He or she will assess your weight and ask you a number of questions, including whether you binge and then purge yourself of food and if you use laxatives, diuretics (drugs that cause the body to pass water), diet pills, or anabolic steroids. The doctor will perform a comprehensive physical examination, including laboratory testing to find out if any hormonal imbalances are present. If your doctor determines that you have an eating disorder, he or she will probably recommend a combination of psychotherapy, nutritional education, and counseling to treat your condition. Hospitalization may be required in severe cases.

How to Determine Your Ideal Weight

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Check the following weight-for-height table to find out if your weight falls into the healthy range. Look up your height on the left side of the table, and move across the table to find your weight. If your weight is not in the healthy range for your height, you are more likely to develop weight-related health problems.

Weights above these ranges are less healthy for most people. The farther you are above the healthy weight range for your height, the higher your risk of weight-related health problems. A weight slightly below the range may be healthy for some people but sometimes results from health problems, especially when weight loss is unintentional.

Maintaining a Healthy Weight

2012-06-10T17:42:00.002-07:00

Being overweight is a major health problem in the United States, and there are many good reasons to keep your weight within a healthy range. You will feel better, look better, and have more energy than men who are overweight. Having more energy makes you more likely to exercise, which can help you fall asleep faster and sleep more restfully. But the most important reason to keep your weight within a healthy range is that you will lower your risk for certain chronic diseases, including heart disease, high blood pressure, diabetes, and certain forms of cancer. Doctors no longer believe that it is acceptable to gain a few pounds as you age. Maintaining your weight at a reasonable level throughout your life is key when it comes to reducing your risk for disease. Many overweight men have difficulty reaching their healthy body weight, and the more you weigh above your ideal weight, the harder it can be to lose the extra pounds. It is encouraging to learn, then, that losing even a relatively small amount of weight can reduce your chances of developing heart disease or stroke. For example, reducing your weight by just 10 percent can improve the efficiency of your heart, lower your blood pressure, and reduce the level of cholesterol in your blood. In fact, you can increase your overall health by losing as few as 10 to 20 pounds. Slow and steady weight loss of no more than 2 pounds per week is the safest way to lose weight. Too rapid a weight loss can cause you to lose muscle mass rather than fat tissue and also can increase your chances of developing other health problems, such as gallstones, gout, and nutrient deficiencies. Making long-term improvements in your diet combined with exercising more is the best way to lose weight and keep it off. When trying to lose or maintain weight, look at your eating habits and try to improve them. Follow the eating guidelines recommended in the Food Guide Pyramid for the best dietary advice. Physical activity is also essential to weight control. Try to exercise for at least 30 minutes every day; start exercising slowly, and gradually increase the intensity of your workout.

If you are not currently overweight, but if weight problems appear to run in your family, you still need to watch your weight. Men who have close family members, such as grandparents, parents, and siblings, with weight-related health problems such as diabetes are more likely to develop similar health problems. If you are not sure of your risks of developing a weight-related health problem, talk to your doctor. Although most men with a weight problem are those who struggle to lose extra pounds, a small percentage of men are actually underweight for their height. Men tend to diet for different reasons than women to improve athletic performance, for example and some men develop eating disorders, such as anorexia or bulimia, from extreme dieting, although these conditions are much less common in men than in women. Keeping your weight within a healthy range over the years requires self-control and a commitment to your health. If you are already overweight, work with your doctor to develop a safe and effective weight loss plan that can help you keep your weight down over the long term. If you are underweight, your doctor can help you plan a diet that will allow you to gain weight sensibly.