American Medical Association Family Medical Guide – Read Now and Download Mobi

Table of Contents

Other Books by the American Medical Association

Title Page

Copyright Page

Foreword

American Medical Association

How to Use This Book

Part One: What You Should Know: Information to Keep You Healthy

Part Two: Your Healthy Body

Part Three: First Aid and Home Caregiving

Part Four: What Are Your Symptoms?

Part Five: Health Issues Throughout Life

Part Six: Diseases, Disorders, and Other Problems

Glossaries

PART ONE - What You Should Know

Healthy Eating

Eat Five a Day for Better Health

Reading Food Labels

Vitamins and Minerals

Exercise

The Benefits of Exercise

Three Types of Exercise

Are You at a Healthy Weight?

Body Mass Index

Stress

The Body’s Response to Stress

Aging Well

Preventing Alzheimer’s Disease

Osteoarthritis

How Your Joints Work

How Osteoarthritis Affects Your Joints

Exercise and Osteoarthritis

Heart Disease

Risk Factors for Heart Disease

Preventing Heart Disease

Cancer

What Is Cancer?

Preventing Cancer

Cancer Treatments

Genetics

Genetics: The future of medicine

The Dangers of Smoking

The Benefits of Quitting Smoking

Terrorism

Biological Attacks

Chemical Attacks

Radiological Attacks

PART TWO - Your Healthy Body

Chapter 1 - Diet and Health

Eating for Good Health

The Basics of Nutrition

Chapter 2 - Exercise, Fitness, and Health

The Health Benefits of Physical Activity

Three Kinds of Exercise

Physical Activity and Children’s Health

Chapter 3 - A Healthy Weight

Are You Overweight?

The Risks of Being Overweight

Losing Weight Sensibly

If You Are Underweight

Chapter 4 - Reducing Stress

How Your Body Responds to Stress

How Stress Can Make You Sick

Stress and Sleep

How to Handle Stress

The Relaxation Response

Chapter 5 - Staying Safe

Keeping Your Children Safe

Keeping Your Home Safe

Motor Vehicle Safety

Water Safety

Chapter 6 - Preventing Violence

Family Violence

Media Violence

Gang Violence

Elder Abuse

Sexual Assault

Chapter 7 - Complementary and Alternative Medicine

Alternative Medical Systems

Herbal Remedies and Dietary Supplements

Manipulative Therapies

Mind-Body Therapies

Energy Therapies

Atlas of the body

Diagnostic imaging techniques

Visual aids to diagnosis

Chapter 8 - Preventive Health Care

Routine Health Care

Self-Examinations

Common Examinations and Tests

PART THREE - First Aid and Home Caregiving

Chapter 1 - First Aid

Index to First-Aid Procedures

Chapter 2 - Home Caregiving

Preparing for Home Care

Caregiving Skills

Modifying the Home Environment

Care for the Caregiver

PART FOUR - What Are Your Symptoms?

How to Use the Self-Diagnosis Symptoms Charts

How to Find the Chart You Need

Chart-Finder Index

GENERAL All ages

Feeling generally ill

Unexplained weight loss

Overweight

Difficulty sleeping

Fever

Excessive sweating

Swellings under the skin

Itching without a rash

Feeling faint and fainting

Dizziness

Headache

Numbness or tingling

Twitching and trembling

Pain in the face

Confusion

Impaired memory

Difficulty speaking

Disturbing thoughts or feelings

Unusual behavior

Depression

Anxiety

Hallucinations

Nightmares

Hair loss

General skin problems

Facial skin problems

Itchy spots and rashes

Rash with fever

Raised spots and lumps

Painful eye

Disturbed or impaired vision

Earache

Noises in the ear

Hearing loss

Runny nose

Sore throat

Hoarseness or loss of voice

Coughing

Coughing up blood

Wheezing

Difficulty breathing

Toothache

Difficulty swallowing

Sore mouth or tongue

Bad breath

Vomiting

Recurring vomiting

Abdominal pain

Recurring abdominal pain

Swollen abdomen

Gas and belching

Diarrhea

Constipation

Abnormal-looking stools

Palpitations

Chest pain

Abnormally frequent urination

Abnormal-looking urine

Painful urination

Lack of bladder control

Backache

Cramp

Painful or stiff neck

Painful arm or hand

Painful leg

Painful knee

Painful shoulder

Painful ankles

Swollen ankles

Foot problems

MEN

Painful or enlarged testicles

Painful intercourse in men

WOMEN

Pain or lumps in the breast

Breast problems in new mothers

Absent periods

Heavy periods

Painful periods

Pelvic pain in women

Irregular vaginal bleeding

Abnormal vaginal discharge

Vaginal irritation

Abnormal hair growth in women

Painful intercourse in women

COUPLES - Infertility

CHILDREN

Waking at night in children

Crying in infants

Vomiting in infants

Diarrhea in infants

Skin problems in young children

Slow weight gain in young children

Fever in young children

Fever in children

Abdominal pain in children

Itching in children

Coughing in children

Swellings in children

Limping in children

OLDER PEOPLE - Over 65 years

Lack of bladder control in older people

Confusion in older people

PART FIVE - Health Issues Throughout Life

Chapter 1 - Children’s Health

Routine Health Care

Developmental Milestones

Health Concerns of Newborns and Infants

Congenital Heart Defects

Neural Tube Defects

Other Congenital Disorders

Disorders of the Digestive System

Neurological Disorders

Common Ear Problems in Children

Disorders of the Respiratory System

Blood Disorders

Disorders of the Urinary Tract and Reproductive Organs

Disorders of the Muscles, Bones, or Joints

Childhood Infections

Chapter 2 - Adolescent Health

Physical and Sexual Development at Puberty

Health Concerns During Adolescence

Adolescent Sexuality

Psychological, Emotional, and Behavioral Development

Chapter 3 - Sexuality

The Sexual Response Cycle

Sexual Orientation

Contraception

Sexually Transmitted Diseases

Sexual Problems

Chapter 4 - Infertility

The Causes of Infertility

Diagnosing Infertility

Treating Infertility

Chapter 5 - Pregnancy and Childbirth

Pregnancy

Prenatal Care

Health Concerns During Pregnancy

Complications During Pregnancy

Childbirth

Adjusting After Pregnancy and Childbirth

Chapter 6 - Dying and Death

Terminal Illness

Organ Donation

Advance Directives

Palliative Care

The Process of Dying

Practicalities of Death

The Mourning Process

PART SIX - Diseases, Disorders, and Other Problems

Chapter 1 - Disorders of the Heart and Circulation

Heart Disorders

Heart Rate and Rhythm Disorders

Heart Valve Disorders

Heart Muscle and Pericardium Disorders

Disorders of the Circulation

Chapter 2 - Blood Disorders

Anemia

Bleeding and Bruising

Leukemias

Lymphomas

Disorders of the Bone Marrow

Chapter 3 - Disorders of the Respiratory System

The Nose

The Throat

The Lungs and Chest

Infections of the Respiratory Tract

Chapter 4 - Disorders of the Brain and Nervous System

Disorders of Blood Vessels in the Brain

Structural Disorders of the Brain and Spinal Cord

Disorders of Brain Function

Degenerative Diseases of the Brain

Infections of the Brain and Nervous System

Other Brain and Nervous System Disorders

Sleep Disorders

Chapter 5 - Behavioral, Emotional, and Mental Disorders

Mood Disorders

Anxiety Disorders

Personality Disorders

Eating Disorders

Psychotic Disorders

Developmental Disorders

Addictions and Abuses

Chapter 6 - Disorders of the Digestive System

Disorders of the Mouth and Tongue

Disorders of the Esophagus

Disorders of the Stomach and Duodenum

General Abdominal Disorders

Disorders of the Small Intestine

Disorders of the Large Intestine

Disorders of the Anus

Infections of the Digestive Tract

Disorders of the Liver, Gallbladder, and Pancreas

Chapter 7 - Disorders of the Urinary Tract

Infections, Inflammation, and Injury

Cysts, Tumors, and Stones

Kidney Failure

Chapter 8 - Disorders of the Male Reproductive System

Disorders of the Testicles and Scrotum

Disorders of the Prostate Gland

Disorders of the Bladder, Urethra, and Penis

Chapter 9 - Disorders of the Female Reproductive System

Menstruation

Breast Disorders

Disorders of the Ovaries, Uterus, and Cervix

Disorders of the Bladder and Urethra

Disorders of the Vagina and Vulva

Chapter 10 - Hormonal Disorders

Disorders of the Pituitary Gland

Disorders of the Pancreas

Disorders of the Adrenal Glands

Disorders of the Thyroid and Parathyroid Glands

Chapter 11 - Disorders of the Immune System

HIV Infection and AIDS

Allergies

Autoimmune Disorders

Chapter 12 - Infections and Infestations

Generalized Infections

Infestations and Diseases Spread by Insect and Animal Bites

Travelers’ Infections

Chapter 13 - Genetic Disorders

Genetic Counseling

Chromosome Abnormalities

Autosomal Recessive Disorders

Autosomal Dominant Disorders

X-Linked Disorders

Chapter 14 - Disorders of the Bones, Muscles, and Joints

Sports Injuries

Disorders of the Muscles, Tendons, and Ligaments

Bone Disorders

Joint Disorders

Back and Neck Problems

Chapter 15 - Disorders of the Ear

Disorders of the Inner Ear

Disorders of the Middle Ear

Disorders of the Outer Ear

Chapter 16 - Eye Disorders

Focusing Disorders

Disorders of the Eyelids

Disorders of the Outer Eye

Disorders of the Inner Eye

Other Eye Disorders

Chapter 17 - Disorders of the Skin, Hair, and Nails

Skin Disorders

Disorders of the Hair and Nails

Chapter 18 - Cosmetic Surgery

Facial Surgery

Skin Rejuvenation

Breast Surgery

Body Contouring

Hair Replacement Procedures

Chapter 19 - Teeth and Gums

Tooth Decay

Going to the Dentist

Root Canal

Tooth Abscess

Discolored Teeth

Poorly Aligned Teeth

Dental Treatments

Missing Teeth

Problems Caused by Wisdom Teeth

Denture Problems

Periodontal Disease

Glossary

Drug Glossary

Credits

Index

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Complete Medical Encyclopedia

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Diabetes Cookbook

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Healthy Heart Cookbook

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Complete Guide to Men’s Health

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Guide to Talking to Your Doctor

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Guide to Home Caregiving

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Complete Guide to Your Children’s Health

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Complete Guide to Women’s Health

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Handbook of First Aid and Emergency Care

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Family Health Cookbook

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Essential Guide to Asthma

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Essential Guide to Depression

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Essential Guide to Hypertension

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Essential Guide to Menopause

This book is printed on acid-free paper.

Copyright © 2004 by the American Medical Association. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada

Design and production by Navta Associates Inc.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008.

The recommendations and information in this book are appropriate in most cases and current as of the date of publication; however, they are not a substitute for a medical diagnosis by a physician. For specific information about a health condition that you or a family member may have, the AMA recommends that you consult a physician. The names of organizations, products, and alternative therapies appearing in the book are given for informational purposes only. Their inclusion does not imply AMA endorsement—nor does the omission of any organization, product, or alternative therapy indicate AMA disapproval.

Limit of Liability/Disclaimer of Warranty: While the publisher and the author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor the author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

The information contained in this book is not intended to serve as a replacement for professional medical advice. Any use of the information in this book is at the reader’s discretion. The author and the publisher specifically disclaim any and all liability arising directly or indirectly from the use or application of any information contained in this book. A health care professional should be consulted regarding your specific condition.

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Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our web site at www.wiley.com.

Library of Congress Cataloging-in-Publication Data

American Medical Association family medical guide / American Medical

Association.

p. cm.

Includes bibliographical references and index.

ISBN 0-471-26911-5 (cloth)

1. Medicine, Popular. I. American Medical Association.

RC81.A543 2004

613—dc22

2004005764

Foreword

Every day, Americans hear news of the latest medical study or another medical breakthrough. These scientific advances, along with the latest techniques for diagnosing and treating diseases, are helping us live longer and in better health than ever before. With this all-new, completely revised fourth edition of our best-selling American Medical Association Family Medical Guide, you have the tools you need to make sense of this abundance of information, enabling you to take charge of your health and health-care needs and make informed medical decisions.

Reviewed by nearly 50 practicing physicians from a cross section of medical specialties and written in clear, easy-to-understand language, this guide provides up-to-date explanations about how specific diseases are diagnosed and treated. The book also explains what you can do to prevent many of the most common chronic diseases and how and why some lifestyle factors (such as diet and exercise—or smoking) can improve your health—or harm it.

We at the AMA believe that good medicine begins with a good patient-doctor relationship. This revised and updated edition of the American Medical Association Family Medical Guide will help you and your doctor work closely together to achieve years of good health for you and your family.

Michael D. Maves, MD, MBA
Executive Vice President, CEO
American Medical Association

American Medical Association

How to Use This Book

A wealth of information on health and disease is at your fingertips in this totally revised and updated fourth edition of the American Medical Association Family Medical Guide. To get the most benefit from the book, take some time to familiarize yourself with it—in terms of general information and specific health questions you may have. First, scan the Table of Contents on pages ix through xii for a quick overview of how the book is organized.

When looking up a topic, start with the index. The index contains multiple cross-references to many entries to make it easier for you to find the information you need.

Part One: What You Should Know: Information to Keep You Healthy

Part One is an all-new, full-color section that highlights and illustrates the most important current health issues, including preventive health topics such as nutrition, exercise, weight, and stress reduction, and cutting-edge information about cancer and genetics.

Part Two: Your Healthy Body

Part Two is a completely revised and expanded section that presents up-to-date information on preventive medicine. Families need accurate, easy-to-understand recommendations on topics that are critical to their long-term health. You will learn how and why lifestyle factors—for example, eating a healthy diet, exercising regularly, maintaining a healthy weight, reducing stress, and getting sufficient sleep—have such a profound effect on your health.

Between chapters 7 and 8, you’ll find a 32-page full-color section. This section contains an Atlas of the Body, Diagnostic Imaging Techniques, and Visual Aids to Diagnosis. The Atlas is a handy reference for locating bones, muscles, and other parts of the body. Diagnostic Imaging Techniques explains the different types of diagnostic imaging procedures your doctor might recommend, such as ultrasound and magnetic resonance imaging (MRI). This section describes how each diagnostic test is done and which disorders the test might help diagnose. Visual Aids to Diagnosis presents photos of sores, rashes, and other recognizable signs and symptoms, along with brief descriptions of the disorders or conditions to which they might be linked.

Part Three: First Aid and Home Caregiving

Part Three focuses on two important topics—First Aid and Home Caregiving. The First Aid section provides step-by-step advice on how to handle injuries and emergencies including choking, bleeding, burns, and heatstroke. The Home Caregiving section gives practical information to help you take care of a person who is ill or disabled. For example, you will learn how to modify your home to make it easier for you to care for an older family member who has a disabling chronic illness such as Alzheimer’s disease.

Part Four: What Are Your Symptoms?

The popular and always-helpful symptoms charts have been completely revised and updated for this edition. Organized like flow charts, the symptoms charts direct you through a series of questions with yes or no answers from a specific symptom to reach a possible diagnosis or recommendation. The charts help you decide when it’s important to call your doctor about a problem, when to go to a hospital emergency department immediately, or when to take care of the problem yourself at home.

The symptoms charts contain many cross-references to articles in other parts of the book, especially to Part Five (Health Issues Throughout Life) and Part Six (Diseases, Disorders, and Other Problems). To make the best use of the symptoms charts and to obtain a full explanation of a specific disorder or condition, follow the cross-references to the articles.

Part Five: Health Issues Throughout Life

Part Five is an all-new section that discusses common health concerns that can occur at any time of life. This section has comprehensive chapters on children’s health, adolescent health, sexuality, infertility, pregnancy and childbirth, and dying and death. Part Five and Part Six (Diseases, Disorders, and Other Problems), which are both packed with helpful information, are the heart of the book.

Part Six: Diseases, Disorders, and Other Problems

You will probably use Part Six more than any other part of the book because this is where you will find information about hundreds of diseases and disorders. To make it easy for you to find the information you’re looking for, the chapters in this part of the book are arranged by body system. The articles in these chapters have an easy-to-follow, straightforward format that usually includes the following headings: Symptoms (describes the most common symptoms and signs of the disorder), Diagnosis (explains how the disorder is diagnosed), Treatment (explores the treatment options for the disorder), and Prevention (tells how the disorder can be prevented, when prevention is possible).

Within the articles on specific diseases, you will also find cross-references to other parts of the book. Use these cross-references, along with the index, to add to your knowledge of or improve your understanding about a particular health problem or concern.

Glossaries

This section contains a general Glossary and a Drug Glossary. The general Glossary defines some common medical terms you might hear or read. The Drug Glossary has two sections—a section on drug classes (the groups into which drugs are categorized) and a section on the top 200 prescription drugs.

PART ONE

What You Should Know

Information to Keep You Healthy

Healthy Eating

A wealth of information exists about the fundamental link between diet and health. Although many people think that healthy eating means flavorless, unsatisfying meals, this does not have to be the case. A healthy diet includes plenty of vegetables, fruits, whole grains, legumes, and other high-fiber, high-nutrient foods; supplies the right number of calories; and limits saturated fat and trans fats (such as those found in stick margarine), salt, sugar, and alcohol. The components of a healthy diet translate easily into delicious meals that can appeal to the whole family. For more about a nutritious diet, see pages 35 to 44.

Eat Five a Day for Better Health

We have all heard from experts that eating at least five fruits and vegetables each day is one of the most important things we can do for our health, but only one out of four of us is actually eating this amount. Fruits and vegetables provide a wide assortment of vitamins and minerals, including the antioxidant vitamins—vitamin C, the carotenoids (beta carotene, lycopene, and lutein), and vitamin E—which fight cell damage from free radicals, a major cause of aging and most chronic diseases. Fruits and vegetables also provide fiber, an essential nutrient that promotes healthy bowel function and helps lower the risk of heart disease and some types of cancer. Fruits and vegetables are so good-tasting and so good for you that you should try to consume as many as you can. Five servings a day is the minimum for keeping you healthy (10 a day is better). Here are some tips to help you get your daily dose of fruits and veggies:

• Have one or two servings of fruit at breakfast every day.

• Choose a fruit or vegetable for a snack.

• Have a salad at lunch.

• Stock up on dried, canned, and frozen fruits and vegetables.

• Serve more than one vegetable for dinner.

Eat your colors

Fruits and vegetables come in an array of colors, and the color of a food usually says something about its nutritional value. Each food color confers specific health benefits, so consuming a variety of fruits and vegetables provides the biggest health gains.

BLUES AND PURPLES

Blueberries, blackberries, purple grapes, plums, raisins, and eggplants give you:

• A reduced risk of some cancers

• A healthy urinary tract

• A sharp memory

• A long, healthy life

GREENS

Kiwi, honeydew melons, spinach, broccoli, romaine lettuce, kale, green peas, brussels sprouts, cabbage, and Swiss chard give you:

• Strong bones and teeth

• Good eyesight

• A reduced risk of some cancers

WHITES

Pears, apples, bananas, jicama, mushrooms, cauliflower, onions, and garlic give you:

• A healthy heart

• A good cholesterol profile

• A reduced risk of some cancers

REDS

Watermelon, strawberries, raspberries, cranberries, cherries, tomatoes, and radishes give you:

• A sharp memory

• A healthy heart

• A healthy urinary tract

• A reduced risk of some cancers

YELLOWS AND ORANGES

Oranges, grapefruit, peaches, cantaloupe, mangoes, pineapples, yellow and winter squash, carrots, and corn give you:

• A healthy heart

• A healthy immune system

• Good eyesight

• A reduced risk of some cancers

Reading Food Labels

Nutrition facts panel

The nutrition facts panel is the part of a food package label that lists serving size, the number of servings in the package, the number of calories in a serving, and the percent of daily values (which are the same as the recommended daily allowances) of many important nutrients—fats, carbohydrates, protein, cholesterol, fiber, sugar, sodium, vitamins A and C, and the minerals iron and calcium (no daily values have been set for protein and sugar).

What you can learn from food labels

1. To make it easy to compare different brands of the same food, all serving sizes are required to be the same.

2. This line shows the total calories in one serving and the number of calories from fat contained in the serving.

3. This section displays the amounts of different nutrients in one serving so you can easily compare the nutrient content of similar products and add up the total amounts of a given nutrient that you eat in a day.

4. The percent of daily values are indicated for each nutrient. Percent of daily values are based on a diet of 2,000 calories per day.

5. This area shows the percent of daily values for vitamins A and C and the minerals iron and calcium.

6. This section helps you calculate your daily allowance of various fats, sodium, carbohydrates, and fiber for both a 2,000- and a 2,500-calorie-per-day diet.

7. The number of calories in 1 gram of fat (9), carbohydrate (4), and protein (4) are listed here.

8. The federal government has approved the use of certain health claims on packaged foods. Examples include:

• A diet low in fat and rich in fruits and vegetables may reduce your risk of some cancers.

• A diet rich in fruits, vegetables, and grains may reduce the risk of heart disease.

• A low intake of calcium is one risk factor for osteoporosis.

9. Terms such as “low,” “high,” and “free” on food labels must meet strict definitions. For example, a food described as “very low sodium” must have no more than 35 milligrams of sodium for every 50 grams of food.

Shared family meals serve up benefits

Eating together as a family improves communication, promotes a strong family bond, and gives children a secure sense of belonging. Shared meals also save money.

Vitamins and Minerals

This table describes the health benefits of the most important vitamins and minerals and some of the foods that contain these nutrients. Vitamins are divided into two categories—fat-soluble and water-soluble. Fat-soluble vitamins are found in fats and oils in foods and are stored in body fat. Water-soluble vitamins dissolve in water and mix easily in the blood. Your body stores only small amounts of water-soluble vitamins (the excess is eliminated in urine). Some vitamins are antioxidants, which protect against damage to cells by free radicals (molecules formed by normal cell processes). Antioxidants can help protect against disease and aging. The best way to get the vitamins and minerals your body needs is to eat a varied diet rich in low-fat, high-fiber vegetables, fruits, legumes, and whole grains; fish; and low-fat dairy products, poultry, and meats.

Exercise

Physical activity plays a crucial role in health. Regular exercise protects against the most common disorders—including heart disease, stroke, high blood pressure, obesity, type 2 diabetes, osteoporosis, colon cancer, and depression—and can help you live longer. Still, more than 60 percent of adults in the US fail to get the minimum recommended amount of exercise: half an hour to an hour of moderate activity such as brisk walking on most days of the week. You don’t have to do it all at one time: break up the time into 10- or 15-minute sessions scattered throughout the day. The activity you engage in doesn’t have to be strenuous to provide health benefits, especially if you have been inactive for some time. Of course, the more vigorous the activity, the more you will get out of it, but what is most important is becoming more active.

The Benefits of Exercise

If exercise were packaged in a pill, it would be the No. 1 prescribed medication in the US—and Americans would be much healthier. Even a small increase in your physical activity can substantially reduce your health risks, especially if you have been inactive. More activity—or activity that is more vigorous—will pay even bigger rewards. In addition, regular exercise provides the following health advantages:

• Lowers your risk of premature death.

• Reduces your risk of heart disease, high blood pressure, diabetes, and some cancers.

• Makes your heart pump more efficiently.

• Fights depression and anxiety.

• Improves strength, flexibility, and balance.

• Helps you maintain a healthy weight.

• Tones your muscles.

• Helps control your appetite.

• Keeps your mind sharp.

• Makes you look better.

• Boosts your self-confidence.

Fit Exercise Into Your Life

When you look at your busy life, a lot of things seem more important than exercise: your job, chauffeuring your kids to various activities, managing your household, or taking care of aging parents. And a lack of time may not be the only factor. Having too little money or social support—even bad weather—can all conspire against your best intentions to exercise. Here are some tips that might make it easier for you to begin an exercise program and stick with it:

• Choose an exercise you enjoy.

• Schedule time for exercise.

• Find a workout buddy or take an exercise class.

• Vary your activities to avoid boredom.

• Fight inertia by remembering how good exercise makes you feel.

If you don’t want to join a health club or can’t make the time for a long workout several times a week, try to incorporate exercise into your daily life in the following ways to accumulate 30 to 60 minutes of exercise every day:

• Climb up and down several flights of stairs at work once or twice a day.

• Take a brisk walk after dinner.

• Walk the dog.

• Pull your children around the neighborhood in a wagon or sled.

• Go to the local mall and walk.

• Park in a parking space farther from the store or office and walk to the building.

• Carry or push a golf bag instead of using a golf cart.

• Wash and wax the car.

• Do yard work.

• Clean the house.

• Jump rope.

• Mow the lawn with a hand mower.

• Lift hand weights, or do lunges, push-ups, and jumping jacks while you watch TV.

• On the weekends, organize a family bike ride, hike, or ball game. Go swimming, ice skating, or in-line skating together. Go dancing.

Making time for exercise

It’s easier to fit exercise into your busy schedule if you make it part of your daily routine. Try walking up and down several flights of stairs at work every day. It takes only a few minutes and it strengthens your heart, lungs, and bones.

Three Types of Exercise

Three different types of exercise—aerobic, flexibility, and strengthening—help you achieve different kinds of physical fitness. Aerobic exercise (such as walking, jogging, and cycling) increases your heart rate to deliver more oxygen to your muscles. Strengthening exercises (such as lifting weights and doing push-ups) build muscle and bone to increase strength. Flexibility exercises (such as stretching or yoga) improve your ability to move your joints through their full range of motion. Including all three types of activity in your exercise regimen will help you reach a high overall level of fitness that can improve your health and reduce your risk of several of the most common chronic diseases, including heart disease and diabetes.

Choosing activities you enjoy will help you stay with your exercise program. Variety is the key, so don’t limit yourself to one activity. Jog one day and swim or bike the next. Work out with weights one day and use a stair-climbing machine the next day. Vary your stretching exercises as well. Not only will you maintain your enthusiasm for exercising, you will also be less likely to get injured.

Aerobic exercise

Aerobic exercise includes any activity that uses the large muscles, such as those in the legs, in repetitive motion that can be sustained over a long period. Examples of aerobic activity include walking, jogging, cycling, swimming, skating, cross-country skiing, and stair climbing. Aerobic exercise causes your heart and lungs to work more efficiently as they supply more and more oxygen-rich blood to your working muscles. Aerobic exercise builds endurance and provides a number of other important health benefits, including:

• Improved heart and lung function

• Reduced heart rate

• Lower blood pressure

• Higher blood levels of HDL (good) cholesterol

• Reduced body fat

• Improved weight control

• Increased bone strength

• Improved sleep

Aerobic exercise changes your body composition by lowering your body’s percentage of fat and increasing its percentage of muscle, giving you a toned, fitter body. Aerobic exercise also protects against several of the most common chronic health problems, including heart disease, high blood pressure, diabetes, osteoporosis, and some cancers.

If you have been inactive, start your aerobic exercise program with walking. Walking is an excellent aerobic activity that is low impact (and therefore safe for your joints), builds cardiovascular fitness and bone strength, and requires only a pair of sturdy, well-cushioned shoes. At first, try walking 10 to 15 minutes a day on most days of the week. After you build your endurance, add 5 minutes to your daily walking time each week until you can walk up to 30 to 60 minutes a day. You don’t have to do all of your walking in one session. Break up the activity into shorter sessions that add up to 30 to 60 total minutes. Walk with a friend or relative so you can encourage each other to stick with the program.

To determine whether you’re working out at the right level of intensity, make sure you are exercising at your target heart rate (see page 47), the pulse rate that is best for your age and overall physical condition. Try to do some aerobic exercise on most days of the week. Warm up and cool down before and after you exercise. And remember that the health benefits of aerobic exercise remain only as long as you continue exercising. That is why your goal should be to develop an exercise program that you can stay with for the rest of your life.

Make exercise a family habit

Exercising together as a family will not only increase your and your children’s endurance, build stronger bones, and improve your overall health, it will also help forge a strong family bond. Include physical activities such as hiking in your family vacations.

Flexibility exercises

Flexibility is the ability to move your muscles and joints through their full range of motion. Some people are naturally more flexible than others, but you can always improve your flexibility with exercises that stretch specific muscles. Increased flexibility improves your ability to perform everyday activities, protects your muscles against pulls and tears, and helps relieve arthritis pain. It’s important to do stretches gently and slowly—don’t bounce. Do each stretch three times for maximum benefit.

Hip flexor/Quadriceps stretch

While standing, hold on to a sturdy chair back, a counter, or a railing with one hand. Bend one leg and, with the hand on that side, pull your foot up gently behind you, keeping your abdominal muscles pulled in and your knees close together. Maintain the position for at least 30 seconds. Repeat with the other leg.

Calf stretch

Stand about 2 to 3 feet from a wall and place your palms on the wall. Step forward with one foot. Keeping both feet flat on the floor and your toes pointing straight ahead, bend the forward leg at the knee and lean forward, keeping your back leg straight (far left). Maintain the position for at least 30 seconds. Repeat with the other leg. Now do a set bending (rather than straightening) the back leg (left); maintain the position for at least 30 seconds.

Back twist

Sit with your legs out in front of you on the floor. Cross one leg over the other with your knee bent and your foot flat on the floor. Keeping your back straight and your buttocks on the floor, take hold of the bent knee with the opposite hand and gently turn to the bent-knee side, rotating your hips and looking over your shoulder. Maintain the stretch for at least 30 seconds. Repeat on the other side.

Hamstring stretch

Sit with one leg extended in front of you and the other leg bent. Reach forward with both hands along your extended leg as far as it feels comfortable. Bend from your hips, keeping your back straight. Maintain the position for at least 30 seconds. Repeat with the other leg.

Side stretch

Sit cross-legged on the floor. Inhale and raise one arm to the ceiling and, exhaling, bend from the waist to the opposite side, sliding the other hand along the floor and keeping your buttocks on the floor. Maintain the stretch for at least 30 seconds. Inhale as you return to center, dropping your raised arm and lifting the other arm and repeating the bend to the other side.

Lower back and buttocks stretch

Lie on your back on the floor with one leg stretched out straight and the other leg bent. Pressing your lower back gently to the floor, reach behind the thigh of the bent leg and pull it slowly toward your chest. Maintain the position for at least 30 seconds and release. Repeat with the other leg.

Strengthening exercises

Strength-conditioning exercise is as beneficial for your heart as aerobic exercise, and is essential for keeping you fit and independent as you age. These exercises build muscle by forcing the muscles to work against the weight of your body or an object such as a weight. It’s a good idea to alternate strength-building exercises with aerobic exercise. Try to do the following exercises three times a week.

Triceps press

Sit on the floor with your knees bent at a 45-degree angle, your feet flat on the floor, hip-distance apart, and your hands on the floor behind you, fingertips pointing forward. Lift your hips off the floor (left). Bending at the elbows, lower your bottom until it almost touches the floor (right), hold for a count of five, and straighten the arms, returning to hips-up position. Do ten sets.

Modified push-up

Get on your hands and knees on the floor and shift your weight forward, with your hands aligned under your shoulders and your feet raised off the floor (top). Bending your elbows, lower your body from the knees up until your chest almost touches the floor, keeping your hands in the same position on the floor and using your abdominal muscles to keep your back straight (bottom). Still keeping your back straight, push up until your arms are almost straight (but not locked) at the elbows. Repeat as many times as you can without straining. (For an extra challenge, try holding each position for a few seconds.)

Abdominal curl

Lie on your back with your knees bent and your arms holding the backs of your thighs. Press the small of your back to the floor as you lift your head and upper body until most of your upper back is off the floor. Hold for a count of two. Lower your body to the floor, keeping the small of your back pressed to the floor to work your abdominal muscles and avoid straining your back. As your strength increases, increase the number of repetitions. A more difficult way to do sit-ups is with your arms over your chest and your hands on your shoulders, or with your hands placed lightly behind your neck.

Biceps curl

Standing with your back straight, your knees bent slightly, and your feet slightly apart, hold two hand weights (begin with 1- or 2-pound weights) up to your shoulders, with your elbows bent up at your sides (left). Slowly bring the weights down to your thighs, palms turned out (right). Slowly raise the weights back up to your shoulders, keeping your elbows at your sides. When you can repeat the exercise 12 times, increase the weights by 1 pound.

Pump-up

Standing with your back straight, knees bent slightly and feet slightly apart, hold two hand weights (with ends touching each other) at chest level, elbows bent out to the sides parallel to the floor and shoulders down (left). Lower the weights slowly to thigh level, keeping the ends of the weights together (right). Slowly raise the weights back up to your chest. When you can repeat the exercise 12 times, increase the weights by 1 pound.

Are You at a Healthy Weight?

The percentage of overweight Americans has been steadily increasing over the past several decades. Nearly two out of three adults and about 15 percent of children in the US are overweight. Most alarming, overweight children and adolescents are developing common chronic illnesses—such as heart disease, high blood pressure, and type 2 diabetes—that used to affect only adults.

Body weight results from the complex interaction of inherited, physical, behavioral, socioeconomic, and cultural factors. The major factors contributing to overweight are basic—eating too much and exercising too little. And many Americans tend to eat the wrong kinds of foods: foods that are highly refined, high in salt, and often high in saturated and trans fats and calories and low in fiber.

Health Risks of Being Overweight

Being overweight increases your risk of a number of chronic health problems, including heart disease, high blood pressure, diabetes, and some cancers. The way in which fat is distributed on your body can also increase your health risks. You are at greater risk of health problems if you tend to accumulate fat around your abdomen than if you tend to accumulate fat around your hips and thighs. The risks increase further if your waist is 35 inches or larger (if you’re a woman) or 40 inches or larger (if you’re a man). To determine if you are overweight, check the BMI chart on the next page. To determine if your child is overweight, have him or her evaluated by the doctor. Your doctor can work with you to develop an effective weight-loss plan.

How to Achieve and Maintain a Healthy Weight

Losing weight and keeping it off is difficult, so it’s important to set realistic goals that you can achieve and maintain. If you are overweight, even a moderate reduction in body weight—as little as 10 percent—can significantly improve your health.

The only healthy way to lose weight is to use more calories than you take in. For most people, this means eating less and being more physically active. Losing weight gradually—no more than 1 or 2 pounds per week—improves your chances of keeping it off successfully. Changing your diet and exercise habits gradually will help you to make those changes a permanent part of your life.

Avoid fad diets that promise quick weight loss. Any diet that sounds too good to be true probably is. For more information about losing weight, see page 53.

Be Active

Regular exercise contributes to weight loss, especially when combined with a healthy diet. In addition to weight control, regular exercise helps reduce blood pressure, helps prevent heart disease, helps control cholesterol and blood sugar levels, slows bone loss associated with aging, lowers the risk of some types of cancer, and helps relieve anxiety and depression.

When beginning an exercise program, choose activities you enjoy and can easily fit into your day. Begin exercising slowly, and gradually increase the intensity of your workouts. For example, begin with a 10-minute walk three times a week and work your way up to 30 to 60 minutes of brisk walking five times a week.

If you find it difficult to set aside an entire hour for exercise each day, try scheduling shorter exercise sessions—for example, two or three 20-minute sessions a day. If you miss a day or two, don’t be discouraged. Return to your exercise routine as soon as you can. To learn more about what regular exercise can do for you and your family, read the chapter Exercise, Fitness, and Health starting on page 45. Get all members of your family into an active lifestyle:

• Make time for the entire family to participate in regular physical activities that everyone enjoys. Try walking, biking, playing tennis, or in-line skating.

• Plan active family vacations such as hiking, camping, or skiing trips.

• Assign active household chores to every family member, such as vacuuming, mowing the lawn, or washing the car.

• Encourage all family members to enroll in a structured physical activity such as tennis, martial arts, gymnastics, or dancing.

• Limit sedentary activities such as watching TV, playing video games, and surfing the Internet.

Body Mass Index

Body mass index (BMI) is a calculated score that indicates the healthiness of a person’s weight. Although the BMI does not directly evaluate body fat percentage, the formula is related to the amount of fat a person carries and is calculated using the person’s height and weight. BMI can help determine a person’s health risks and is a generally reliable health gauge for people between ages 19 and 70. The index is less reliable, however, for competitive athletes or body builders (who may have a high BMI but whose body is made up mostly of muscle) and for women who are pregnant or breastfeeding.

What’s your BMI?

To learn your body mass index (BMI), find your height in the left-hand column in the chart below and read across the row from your height until you reach your weight. Then look at the number at the bottom of your weight column—this is your BMI. In general, the higher your BMI, the higher your health risks.

A healthy BMI is between 18.5 and 24.9. You are considered underweight if your BMI is less than 18.5, overweight if your BMI is between 25 and 29.9, and obese if your BMI is 30 or higher. The risks are even higher in men whose waist is larger than 40 inches and in women whose waist is larger than 35 inches.

Body Mass Index

Stress

Stress affects everybody, but some people react to it more strongly than others. When you experience stress, your body makes two hormones, cortisol and adrenaline, that help you deal with the tense situation. Over the long term, however, too much of these hormones produced for too long can cause anxiety and physical symptoms that can trigger or worsen illnesses such as high blood pressure, asthma, or heart disease. Persistent, prolonged stress can also adversely affect your immune system, making you more susceptible to infections and other illnesses.

A number of natural ways to reduce stress—such as deep breathing, yoga, meditation, biofeedback, exercise, and massage—have been proven to be effective. Try all of them until you find what works best for you. Cognitive-behavioral therapy (see page 710) provided by a mental health professional can also be helpful. If you feel overwhelmed by the stress in your life, talk with your doctor about effective stress-reduction methods (see page 58).

It’s Not All in Your Mind

Stress can affect your body in a number of ways. Chronic, long-term stress can be especially harmful. Learning how to manage your response to stress can help you avoid these damaging effects.

Hair

Some forms of baldness, such as alopecia areata, have been linked to stress.

Brain

Stress can trigger headaches and behavioral and emotional problems such as anxiety and depression. A persistent release of the stress hormone cortisol can kill brain cells directly, causing memory and learning problems.

Heart

Heaviness or pain in the chest (angina), rapid heartbeat, and abnormal heart rhythms can occur during or shortly after periods of stress.

Digestive tract

Stress can cause or worsen disorders or diseases of the digestive tract such as indigestion, peptic ulcers, and irritable bowel syndrome. Severe stress can slow digestion.

Abdominal fat

Prolonged or severe stress can cause fat to be deposited at the waist rather than on the hips and buttocks, increasing the risk of heart disease, cancer, type 2 diabetes, and other illnesses.

Bones

High levels of the stress hormone cortisol can cause bone loss.

Skin

Some people have outbreaks of skin problems such as eczema and psoriasis when they are under stress. Stress also can increase perspiration.

Mouth

Teeth grinding, mouth ulcers, and dry mouth seem to occur more often during times of stress.

Lungs

People with asthma often find that their condition worsens when they are under stress. Stress can also speed up breathing.

Bladder

Stress can trigger an urgent need to urinate.

Reproductive organs

Severe stress can suppress the reproductive system, causing absence of periods in women and erection problems and premature ejaculation in men.

Muscles

Minor muscular tics become more noticeable, especially on the face and hands, and muscles often become tense when a person is under stress.

Immune system

When a person is under stress, the immune system can become weakened, increasing the risk of infections and other illnesses.

Don’t Cheat on Sleep

When it comes to stress, sleep is like medicine, but sometimes you can get caught in a vicious circle. You can’t sleep because you feel stressed, and the lack of sleep causes more stress, which affects your sleep. Lacking sufficient sleep for a long period can have harmful effects on your mind and body. Lack of sleep can increase your risk of type 2 diabetes, lower your resistance to illness, and raise your blood pressure—all important reasons to take sleep more seriously.

If you’re going through a high-stress period, one way to make sure you get a good night’s sleep is to shift your focus away from your daytime worries. When you go to bed at night, try to keep yourself from brooding over your daily problems and concerns. Things always seem worse in the middle of the night. Try to look at sleep as an escape from the stresses of the day, not a time for replaying them in your mind.

A midafternoon nap is another way to make up for insufficient sleep at night. Even a short, 20-minute nap will refresh you and improve your mental performance. Just make sure you finish your nap before 3 in the afternoon; napping later can make it harder to fall asleep at bedtime.

Try the tips on pages 57 and 58; they can help you improve your sleep. If you experience sleeplessness for longer than 6 weeks and these suggestions don’t seem to help, talk to your doctor. He or she may refer you to a sleep center for treatment.

The Body’s Response to Stress

When you are under stress, your body reacts with a cascade of biological responses that begins in a small, grape-sized area of the brain called the hypothalamus. Often referred to as the master gland, the hypothalamus produces many different hormones that tell other glands to jump into action or to quiet down. The hypothalamus communicates to your nervous system to signal the adrenal glands to release adrenaline (epinephrine), a brain messenger that increases alertness and energy and enables you to respond quickly to stress. The hypothalamus also tells a neighboring gland called the pituitary to signal the adrenal glands to release stress hormones (such as cortisol) to enable your body to defend itself. However, over time, if you are under constant stress, these stress-related chemicals (designed to help protect you from harm) can actually turn on your body and be damaging.

Yoga as a Stress Reliever

Yoga is a form of physical activity that helps the body and mind work together to achieve a state of deep relaxation. The practice can lower stress, relieve muscle tension, and increase flexibility. Yoga positions, known as postures, were created thousands of years ago to give the body stability and balance. The deep, controlled breathing that accompanies these postures has a calming effect on the nervous system. The focused attention needed to reach and sustain such postures also helps the mind attain balance. In addition to its physical and mental benefits, yoga has a spiritual aspect that can also increase feelings of well-being.

Western science has shown that yoga produces measurable stress-reducing benefits that can help control conditions such as heart disease, high blood pressure, and asthma. If you are interested in taking a yoga class, contact your local park district, health club, or senior center.

Aging Well

Americans are living longer and healthier, and are more likely to live into their 80s or 90s than ever before. As you grow older, the lifestyle choices you make can either raise or lower your chances of staying healthy and independent well into old age. In fact, your lifestyle choices have twice as much influence as your genes on how well you age and how long you live. Habits that can increase your longevity and improve your quality of life include eating healthfully, exercising regularly, maintaining social relationships, keeping your weight down, not smoking, drinking alcohol only moderately, and keeping your mind active. No matter what your age, it’s never too late to adopt these health-promoting habits and reap their benefits.

Strategies for Successful Aging

The following measures are among the most important things you can do to stay healthy as you age:

• Eat a nutritious diet. Consume a varied diet rich in fiber (foods such as vegetables, fruits, whole grains, and legumes) and low in saturated and trans fats, sugar, and salt.

• Exercise regularly. Engage in a combination of aerobic, weight-bearing, and stretching exercises for up to an hour most days of the week.

• Stay connected socially. Reach out to family and friends, join clubs, volunteer in your community, or start a second career.

• Maintain a healthy weight. Keeping your weight down lowers your risk of a number of chronic diseases, including heart disease, diabetes, and some cancers.

• Don’t smoke. Smoking is the No. 1 cause of preventable premature death in the US.

• Keep your mind active. Read books, take a class, do crossword puzzles, help your grandchildren with their homework, learn to play a musical instrument, or go to museums.

Stay engaged

When it comes to getting older, the more active you are, the healthier you are likely to be, both mentally and physically. Staying active does not mean only physical exercise. It also means staying involved with people and favorite activities.

Memory-Boosting Exercises

Memory loss is not a normal part of aging. It’s common to forget where you put your keys—at any age. You don’t need to worry about having a memory problem unless you forget what the keys are for. Practicing memory exercises such as the following can help you keep your memory sharp as you age:

• Memorize some poetry.

• Look at a photograph; then look away. Write down all the items in the photo that you remember—for example, how many people, animals, buildings, and other objects—and see how well you did.

• Pick up a paper clip, spool of thread, or other common object. Try to figure out a new use for the object.

• Draw a floor plan of your childhood home, complete with doors, windows, and furniture placement. Tell a story about an event that occurred there.

Preventing Alzheimer’s Disease

The following factors seem to have a protective effect against Alzheimer’s disease:

• Education People who attain a higher level of education tend to have a lower risk of Alzheimer’s disease than the general population.

• Mental activity Stimulating your mind may protect your brain from Alzheimer’s disease by giving you extra connections between cells.

• Physical exercise Exercise enlarges blood vessels, supplying more oxygen-rich blood to the brain.

• Vitamin E Eating foods rich in vitamin E—such as nuts, vegetable oils, whole grains, and green leafy vegetables—or taking vitamin E supplements may protect against Alzheimer’s by reducing the cell-damaging effects of molecules in the brain called free radicals.

• Folic acid Consuming adequate amounts of this B vitamin may help prevent Alzheimer’s disease by reducing the level in the brain of an amino acid called homocysteine. Elevated levels of homocysteine can damage cells in the area of the brain involved with learning and memory.

• Anti-inflammatory drugs Over-the-counter anti-inflammatory medications (such as aspirin and ibuprofen) help reduce inflammation in the brain. Inflammation can damage brain cells.

• Cholesterol-lowering medications People who take cholesterol-lowering medications called statins seem to be at significantly lower risk of Alzheimer’s disease than other people. The precise effect that elevated cholesterol has on the brain is unknown.

Staying fit as you age

Exercise is the best way to stop or reverse age-related loss of muscle, which can make even simple daily activities such as climbing stairs and getting up from a chair hard to do. Strength-building exercises using handheld weights, elastic exercise bands, or weight machines can help you maintain your independence and lower your risk of falls, even into your 90s. Go for frequent walks; walking regularly can significantly lower your risk of having a heart attack or stroke. At least four times a week, do the following exercises at home (for example, while you watch TV). If you’re over 50, talk to your doctor before starting an exercise program.

Head turn/Neck stretch

Sit with your back straight, feet flat on the floor, and head in an upright position. Turn your head gently and slowly to one side and hold for a count of 5. Turn your head slowly back to the center and then to the other side and hold for a count of 5. Repeat the sequence 5 to 10 times.

Head roll/Neck stretch

Sit with your back straight, feet flat on the floor, and head in an upright position. Roll your head gently and slowly in a circle from one side to the other, flexing your neck so you are looking up to the point where the wall meets the ceiling at the back of the circle and down at your chest at the front of the circle. Repeat the circle from the other direction. Repeat the sequence 5 to 10 times.

Leg lift/Leg extension

Leg lifts help tone the upper leg muscles. Sitting with your back straight, your knees bent, and both feet flat on the floor, lift one leg off the floor and extend it in front of you, making sure to pull in your abdominal muscles and center your weight over both hips. Bring the leg slowly back to the starting position. Repeat with the other leg. Work up to 10 to 15 repetitions with each leg.

Biceps curl

Sitting with your back straight and feet flat on the floor, hold two small hand weights (begin with 1-pound weights) with your arms bent, the weights up and in toward your shoulders (left). Slowly bring the weights down to the sides of your thighs (right) and then slowly bring them back up to your shoulders. When you can repeat the exercise 12 times, increase the weights by 1 pound.

Pump-up

Sit with your back straight and feet flat on the floor, holding the ends of two weights together at chest level, keeping your shoulders down and your elbows out (left). Lower the weights slowly to waist level, keeping the ends of the weights together (right). Raise the weights slowly to chest level again. When you can repeat the exercise 12 times, increase the weights by 1 pound.

Osteoarthritis

Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis, affecting more than 20 million Americans, mostly those over age 45. This form of arthritis is characterized by the breakdown of cartilage, the connective tissue that lines the inside surfaces of joints and that cushions the bones that meet in the joint. When the cartilage wears down, the bones in the joint rub together, causing pain and stiffness.

If you have osteoarthritis, you can still be active and enjoy good health. Learn as much as you can about the disorder and learn how to manage it so you have a sense of control. Your doctor will recommend the best treatment strategies for your condition, including medication, possibly. Your doctor will also recommend modifying lifestyle factors such as regular exercise, sufficient rest, and maintaining a healthy weight.

How Your Joints Work

Your joints are designed to permit free movement between or among two or more bones and to absorb shock when you move. A joint is made up of the following components:

• Cartilage The connective tissue that lines the joint.

• Joint capsule A saclike membrane that holds the bones and other joint parts together.

• Synovium A second, thinner membrane inside the joint capsule.

• Synovial fluid A liquid that lubricates the joint.

• Ligaments Cordlike tissues that connect one bone to another.

• Tendons Fibrous cords that connect muscle to bone.

• Muscles Bundles of cells that contract to produce movement when stimulated by nerves.

How Osteoarthritis Affects Your Joints

Osteoarthritis occurs most often in the joints of the hands, knees, hips, or spine, but it can occur in any joint. The knees, the body’s major weight-bearing joints, and the hips are very common sites of osteoarthritis. Osteoarthritis in the knees or hips can limit movement, making everyday tasks difficult. Hip-joint arthritis can produce pain in the groin, inner thighs, buttocks, or knees. Osteoarthritis in the spine can cause weakness or numbness in the arms and legs. Osteoarthritis in the fingers is one form of the disorder that seems to run in families, affecting more women than men, especially after menopause. Small bony knobs appear on the end and middle joints of the fingers, which can become gnarled, sore, and stiff.

A healthy joint

Inside a healthy joint, bones are encased in smooth cartilage. The bones and cartilage lie inside a protective joint capsule lined with a membrane (the synovium) that produces a liquid (synovial fluid) that makes movement easy and painless.

A joint with osteoarthritis

Osteoarthritis causes cartilage to wear away inside the joint. Pieces of bone (spurs) grow out from the edges of the bones that meet in the joint. The bones may begin to rub together, and moving the joint can cause pain and stiffness.

Osteoarthritis affects different people in different ways. In some people, the disease progresses quickly; in others, the process of joint degeneration takes years. The exact cause of osteoarthritis is unknown, but heredity seems to play a role in 25 to 30 percent of cases. A combination of factors—including aging, being overweight, injuring a joint, and stress placed on the joints during work-related or sports activities—probably work together to produce the wearing away of cartilage that is characteristic of the disease.

Exercise and Osteoarthritis

Although exercise may seem like a bad idea when your joints are stiff and painful, regular exercise can actually benefit joints affected by osteoarthritis. Regular exercise lessens pain, improves mobility, strengthens surrounding muscle, and increases flexibility. Exercise also improves your overall fitness and helps control your weight, relieving some of the pressure on overtaxed joints.

To avoid injury, it’s important to begin your exercise program slowly. Start with stretching exercises that increase your range of motion and enhance flexibility (see page 8). Then perform strength-conditioning exercises (see page 9).

You don’t have to go to a gym to lift weights—buy some handheld weights to use at home. Add walking, swimming, or bicycling to your routine. Gradually building up your endurance will enable you to exercise longer, and soon you will be stronger and more active and in less pain.

Water exercise is a good choice for people with osteoarthritis because the water supports the body, reducing stress on the hips, knees, and spine. Another good choice is yoga (see page 94), which gently increases joint flexibility as it tones and strengthens the surrounding muscles. Other types of exercise that can benefit people with osteoarthritis include t’ai chi and even jogging. Ask your doctor what exercises are best for you.

Where does osteoarthritis develop most often?

Osteoarthritis occurs most often in the joints of the fingers, at the base of the thumbs, and in the neck, lower back, knees, and hips.

The Warning Signs of Osteoarthritis

• Steady or intermittent joint pain

• Joint stiffness after getting out of bed or sitting for a long time

• Swelling in a joint

• A crunching sound when bone rubs on bone

Hot, red, or tender joints are usually a sign of another form of arthritis, called rheumatoid arthritis.

Exercise is good for your joints

Regular physical exercise such as walking is good for people with arthritis. It keeps the joints working as it strengthens the surrounding muscles and ligaments. Exercise can also reduce joint pain, although it can take 4 to 8 weeks of regular exercise before you experience significant pain relief.

Heart Disease

Your heart beats steadily 24 hours a day to pump oxygen-rich blood throughout your body. But if the arteries leading to your heart become clogged with a fatty substance called plaque, they become narrowed, reducing the supply of blood to the heart and causing heart disease. If a plaque ruptures, blood clots can form, blocking the artery and causing a heart attack. Heart disease is the No. 1 killer of both men and women in the US, but many women do not realize they are at risk. The good news is that you can reduce your chances of developing heart disease by adopting the heart-healthy lifestyle described here.

Risk Factors for Heart Disease

Some of the factors that can increase your chances of developing heart disease, such as family history, are not under your control. Many other risk factors, however, can be controlled.

Risk factors you cannot control

• Age In men, the risk of heart disease increases after age 45; in women, the risk increases after age 55.

• Family history Especially at a young age—a father or brother diagnosed with heart disease before age 55, or a mother or sister diagnosed before age 65.

• Race African Americans have a higher risk of heart disease than people of other races.

Risk factors you can control

• Smoking Smoking is a major risk factor for heart disease because it raises blood pressure, damages blood vessels, promotes blood clotting, and accelerates plaque formation in artery walls.

• High blood pressure High blood pressure (hypertension) puts extra stress on the heart and blood vessels.

• Undesirable cholesterol profile A high total cholesterol level, a low HDL (good) cholesterol level, or a high LDL (bad) cholesterol level can promote plaque formation on artery walls.

• Being overweight Excess weight increases the heart’s workload.

• Lack of exercise Regular exercise makes the heart stronger, keeps weight down, improves cholesterol levels, and lowers blood pressure.

• Diabetes Over time, diabetes damages blood vessels and boosts the risk of heart attack and stroke.

• Stress Unmanaged stress increases heart rate, can cause disturbances in heart rhythm, and can contribute to angina (chest pain from heart disease).

The more of these risk factors you have, the higher your risk of heart disease. Discuss your risk factors with your doctor and ask about steps you can take to avoid heart disease.

Preventing Heart Disease

Doctors have linked many common lifestyle activities to the development of heart disease. By controlling these lifestyle factors, you can prevent heart disease or greatly reduce your chances of getting it—even if you have a family history of the disorder.

What to Do If You’re Having a Heart Attack

If you or someone else is having a heart attack, don’t delay getting treatment—a heart attack does the most damage to the heart muscle in the first 2 hours. Even if you aren’t sure it’s really a heart attack because it feels like heartburn or indigestion, call for help anyway. It’s better to be wrong than to sustain serious heart damage because you waited too long. Acting quickly can save your life.

• At the first sign of symptoms, sit or lie down.

• If your symptoms last longer than 2 minutes, call 911 or your local emergency number and say you may be having a heart attack.

• If you have nitroglycerin tablets, take one every 5 minutes—up to three pills total.

• If you don’t have nitroglycerin, take an aspirin; it can thin the blood and may allow more blood to reach your heart.

• Don’t drive yourself to the hospital; wait for the emergency medical team to arrive. They have the special equipment needed to provide emergency care for a heart attack.

• Don’t smoke. Cigarette smoking is a major contributor to heart disease. One year after quitting, your risk of heart disease is cut in half; within about 5 years, your risk is equal to that of a person who has never smoked.

• Eat a healthy diet. Consume a diet that is low in saturated fat and trans fats, includes plenty of fruits and vegetables, and incorporates omega-3 fatty acids from fish several times a month. Limiting your intake of saturated fat (found in meat and full-fat dairy products) can lower your blood cholesterol level. Limit your salt intake (salt can raise blood pressure in some people), and drink alcohol in moderation (excessive drinking can raise blood pressure).

• Exercise regularly. Regular physical activity reduces your chances of having a heart attack by at least a third. Regular exercise lowers blood pressure, improves cholesterol levels, and reduces the risk of type 2 diabetes—all major risk factors for heart disease. Exercise also helps control weight.

• Maintain a healthy weight. Being overweight raises blood pressure and cholesterol and can lead to type 2 diabetes. Losing as few as 10 pounds helps lower the risk.

• Reduce stress. Several changes take place in your body when you are under stress. Your heart beats faster, more fat enters your bloodstream, your blood sugar level goes up, and blood clotting increases. All of these factors place an extra load on the heart. Stress also promotes poor health habits such as overeating, smoking, or forgetting to exercise. To counteract the effects of stress, try meditation, yoga, or deep-breathing exercises; have a massage; take a warm bath; exercise; and get plenty of sleep.

• Avoid smoky environments. Secondhand smoke at home or work can cause heart disease and worsen existing heart disease.

What Is a Heart Attack?

Blood reaches the heart through the coronary arteries. Fatty deposits called plaque can build up inside the walls of arteries, making them narrower. This process, called atherosclerosis, or hardening of the arteries, develops gradually over many years. If a plaque ruptures, a blood clot can form, reducing blood flow to the heart even more. If a clot suddenly cuts off most or all of the blood supply to the heart, a heart attack results. Cells in the heart muscle that don’t receive enough oxygen-carrying blood begin to die. The more time that passes without treatment to restore blood flow to the heart, the greater the damage to the heart muscle.

Sites of heart attack pain

The symptoms of a heart attack are sometimes hard to identify because a heart attack can feel different to different people. You could feel pain in any of the areas of the body shown here, or you could feel pain in only your arms, jaw, or back. Women’s symptoms, especially, can vary considerably from the classic signs of a heart attack. Women are more likely than men to experience dizziness, nausea, sweating, weakness, and faintness along with chest pain.

Chest pain that spreads to your neck or jaw

Crushing pain in your chest that radiates to your left shoulder

Deep, dull pain or a tight, heavy, or squeezing sensation under your breastbone

Chest pain that spreads to your back

Pay Attention to Angina

If too little blood reaches the heart because of narrowed arteries, chest pain (called angina) can develop. Angina can feel like erratic pain or heaviness, tightness, burning, or squeezing in the chest. The pain can be mild and intermittent or more pronounced and steady, and can start in the center of the chest and radiate to the left shoulder, arm, jaw, or lower teeth. Angina often occurs during physical exertion or times of stress. Angina is a sign that you have heart disease and are at risk of having a heart attack.

If you think you could have angina, tell your doctor right away. Getting prompt treatment for angina can prevent you from having a heart attack. The most common treatment for angina is a drug called nitroglycerin, which reduces the pain by widening the blood vessels to allow more blood to reach the heart.

Cancer

Cancer is the second leading cause of death in the US (after heart disease), causing more than half a million deaths each year. One out of two men and one out of three women develop some kind of cancer at some time in their life. Most cancers are diagnosed in people over age 55. Early detection and treatment increase your chances for a cure, so be sure to perform routine self-examinations (see page 137), have all the recommended screening tests (see page 143), and report any suspicious symptoms to your doctor.

What Is Cancer?

Cancer is a group of diseases characterized by the uncontrolled multiplication of cells that occurs when genes that control cell division or cell turnover (cell death and replacement) undergo mutations (changes). These genetic mutations are sometimes inherited or present at birth, but usually they result from environmental factors (such as radiation or cigarette smoke) that damage critical regulatory genes.

Cell turnover is a tightly balanced process that keeps the body healthy. In normal tissue, old or damaged cells die naturally before they can become cancerous or cause other problems, and are replaced by healthy new cells—a process called apoptosis. In cancer this balance is upset—when damage occurs to either the genes that tell cells when to stop dividing or to the genes that tell old or damaged cells when to die. The resulting increase in the number of cells creates a growing mass of tissue called a tumor. As more and more dividing cells accumulate, the tumor grows and can disrupt the normal functioning of surrounding tissue.

Cancer can originate anywhere in the body. Common sites include the lungs, breasts, lymph nodes, colon, bladder, and prostate gland. Cancer can spread through the body in two ways: Cancer cells from a tumor can invade neighboring tissues, and cancer cells from a tumor can penetrate blood vessels or lymphatic vessels, circulate through the bloodstream or lymphatic system, and invade healthy tissue in another part of the body.

What causes cancer?

Some people inherit genes that make them susceptible to developing particular types of cancer. Environmental factors that can trigger the changes in genes that lead to cancer include radiation, some chemicals, and some viruses and bacteria. For example, excessive exposure to radiation from sunlight has been linked to skin cancer. More than 60 different chemicals in cigarette smoke are known to cause cancer. The human papillomavirus, which causes the sexually transmitted disease genital warts, is responsible for most cases of cervical cancer in women, and the bacterium H. pylori causes many cases of stomach cancer.

Preventing Cancer

Many lifestyle factors can either raise or lower your risk of cancer. Although your genes also influence your susceptibility to developing cancer, genes are not necessarily destiny. Even if you have genes that could make you prone to cancer, the following measures can still help you reduce your risk and, at the same time, protect you from other common diseases:

• Don’t smoke or use other tobacco products. Cigarette smoking is the major cause of lung cancer and contributes to several other cancers, including cancer of the mouth, larynx, esophagus, stomach, pancreas, kidneys, and bladder. Use of smokeless tobacco has been linked to cancers of the mouth and throat.

• Eat a diet rich in vegetables, fruits, and whole grains. A number of substances such as antioxidants in plant foods (especially fruits, vegetables, and grains) have been found to interfere with the process that leads to cancer. Consuming foods that are low in fat (especially animal fat) may also help reduce cancer risk.

• Maintain a healthy weight. Being overweight increases the risk of some cancers, including cancers of the breast, uterus, and colon.

• Exercise regularly. Regular, vigorous exercise may reduce the risk of some cancers. Researchers don’t know exactly how physical activity prevents cancer but think that it may enhance the body’s immune system.

• Protect your skin from the sun. The risk of skin cancer, including melanoma (the most deadly type), can be greatly reduced by avoiding excessive sun exposure, wearing protective clothing in the sun, and using sunscreen.

• Drink alcohol only in moderation. Drinking excessive amounts of alcohol increases your risk of cancers of the mouth, throat, and esophagus—especially if you also smoke cigarettes. Together, alcohol and cigarettes make you 40 times more likely than nondrinking nonsmokers to develop these cancers.

• Engage in safer sex. The most common known cancer-causing virus in the US is the human papillomavirus (HPV), a sexually transmitted infection that causes cervical cancer in women.

• Have the recommended screening tests. Having regular cancer screening tests—such as a Pap smear (see page 140) to look for cervical cancer, and a colonoscopy (see page 767) to look for colon cancer—can detect potential problems early, when they are generally easier to treat and the chances for a cure are better.

When cancer spreads

If cancer cells enter blood vessels, they can be carried through the bloodstream to other parts of the body and invade healthy tissues there. The spread of cancer from one area of the body to another is called metastasis.

Most Common Cancers

Although more people have breast cancer or prostate cancer than lung cancer or colon cancer, lung cancer and colon cancer kill more people each year.

Cancer Treatments

When it comes to curing cancer, early detection and treatment are key. Treatment is more likely to be successful if it is done before cancer cells spread from the original tumor to other parts of the body. Cancer is most often treated with surgery, radiation therapy, or chemotherapy, or a combination of all three. Immunotherapy and stem cell transplants are being used increasingly to treat cancer.

Surgery

Conventional surgery is usually the first treatment recommended by doctors to remove a cancerous tumor and any surrounding tissue that may contain cancer cells. Less invasive surgical procedures are continually being developed that try to preserve as much healthy tissue and normal functioning as possible.

Laser surgery

A laser is a highly focused, powerful beam of light that can cut through tissue or vaporize cancers inside the body or on the skin without the need for a large incision. Laser surgery is also sometimes used to relieve symptoms such as breathing or eating problems that can result when large tumors press on the trachea (windpipe) or esophagus.

Cryosurgery

Cryosurgery uses extreme cold (liquid nitrogen spray or a very cold probe) to freeze and destroy abnormal cells. Cryosurgery is most often used to treat external cancers, such as those on the skin, or precancerous conditions, such as those affecting the cervix. However, doctors are using it increasingly to treat tumors inside the body, including tumors in the prostate gland.

Electrosurgery

High-frequency electric current is often used to destroy cancers of the skin and mouth. A procedure called LEEP/LLETZ (loop electrosurgical excision procedure or large-loop excision of the transformation zone) is used to remove abnormal tissue from the cervix.

Mohs surgery

Mohs surgery is a technique to remove cancerous tissue by shaving it off one layer at a time. After each layer is removed, it is examined under a microscope to look for cancer cells. When all the cells in a layer look normal under the microscope, surgery is stopped. This technique is used primarily for skin cancers that have recurred or that have developed around sensitive areas such as the eyelids, nose, or lips. Mohs surgery preserves as much healthy tissue as possible and has a high cure rate.

Experimental forms of cancer surgery

Researchers are investigating other procedures for removing or destroying cancerous tissue using high-intensity focused ultrasound (HIFU), microwaves or radio waves, and magnets.

Immunotherapy

Immunotherapy uses the immune system to fight cancer, either by stimulating a person’s immune system (active immunotherapy) or by administering disease-fighting immune system components (such as antibodies) manufactured outside of the body (passive immunotherapy). These techniques, which include cancer vaccines, are currently being studied for treatment of different types of cancer, including melanoma, kidney cancer, blood cancers (such as leukemias, lymphomas, and myelomas), breast cancer, prostate cancer, colon cancer, cervical cancer, and ovarian cancer.

Stem cell transplants and bone marrow transplants

Bone marrow is spongy tissue in the center of bones that makes all the blood cells in the body. Blood cells develop from immature cells called stem cells, which are found in the bone marrow and, in smaller amounts, circulating in the blood. If a cancer destroys bone marrow or if bone marrow is damaged from cancer treatment, doctors may recommend a stem cell transplant or bone marrow transplant (see page 624) to provide healthy new cells. Stem cell transplants are also used to treat cancers that don’t respond to normal doses of chemotherapy. After a person receives high doses of chemotherapy, he or she is given an infusion of stem cells to replace those that were destroyed.

Radiation therapy

Radiation therapy uses penetrating beams of high-energy radioactive waves or streams of radioactive particles to treat cancer. This radioactive energy, which is the same as that used in X-rays but in much higher doses, kills the cancer cells or keeps them from dividing. Healthy cells are also affected by radiation but, unlike cancer cells, healthy cells tend to recover from the effects of radiation.

More than half of all people with cancer are treated with some form of radiation. Radiation is often used before surgery to shrink a tumor or after surgery to block the growth of any cancer cells that could remain in the area around the tumor. Radiation therapy is also often combined with chemotherapy (see below).

Radiation therapy can be given either externally or internally. Most people receive the external form, in which a machine directs the high-energy rays at the tumor and a small margin of surrounding tissue. In internal radiation therapy, the radiation is provided by a source placed inside the body, such as an implant, an injection, or a medication.

Side effects from radiation therapy vary from person to person and depend on the dose of radiation and the area of the body being treated. The most common side effects—including fatigue, skin changes, and loss of appetite—usually clear up within a few weeks.

Stereotactic radiation therapy

Some newer radiation techniques are almost as precise as surgery. By aiming radiation at a cancer target from different angles, stereotactic radiation therapy can deliver a large, precise dose of radiation to a small tumor. The procedure is so precise that it is often called stereotactic surgery and the machine that delivers the energy waves is called a gamma knife (even though no incision is actually made). Stereotactic radiation therapy has been used mostly to treat tumors in the brain but is being investigated as a way to treat other types of cancer.

External radiation therapy

The most common type of machine used for external radiation therapy is the linear accelerator, which fires high-energy rays at a tumor to shrink it. In this photograph, the tumor is in the person’s head, which is stabilized by a steel frame.

Chemotherapy

Chemotherapy is the treatment of cancer with powerful drugs that can destroy cancer cells by preventing them from dividing. Two or more drugs are often given at the same time because they are more effective when combined.

Most people receive chemotherapy on an outpatient basis, usually at home, in a doctor’s office, or at a clinic. The drugs can be administered intravenously (through a vein), by mouth, in an injection, or in a skin patch.

During chemotherapy, healthy, normal cells that divide quickly (such as those in hair follicles) can be harmed by the drugs. This damage to healthy cells is the cause of most of the side effects of chemotherapy, including hair loss, fatigue, nausea and vomiting, diarrhea, constipation, pain, anemia, and confusion.

Doctors also treat cancer with drugs that work in other ways. For example, biological therapy uses substances that strengthen the body’s immune system to fight the cancer. Other drugs block the effects of specific hormones or other body chemicals that can promote particular types of cancer.

Genetics

Genes play a role in all diseases, including the common cold. Researchers have discovered many of the genes that cause inherited disorders, and they are beginning to find the genes that interact with environmental factors (such as lifestyle) to cause common health problems such as heart disease, cancer, and diabetes. Advances in genetics research will enable us to take steps to modify our habits to avoid many of these disorders. This new knowledge will also spark the development of more effective, more targeted treatments that have fewer adverse effects. The more you know about your genetic makeup, the better able you will be to make informed decisions about your health, your lifestyle, your medical care, and your reproductive options.

DNA: The blueprint of life

Each of us begins life as a single cell containing genetic information from each of our parents. This original cell divides to about 100 trillion specialized cells, each containing a complete set of genes identical to that in the original cell. Your unique set of about 30,000 genes is called your genome. Your genome orchestrates the activity of all the cells in your body, enabling them to work together in harmony to keep your body healthy and functioning normally.

Cells

You have many different types of cells in your body that perform different functions depending on their location—for example, in muscles, in the brain, in the stomach, or in fat. Although each of your cells contains exactly the same genes, cells differ from each other because different combinations of genes are switched on and off in each cell. These different gene combinations determine what proteins each cell makes and enable the cell to perform a specialized task.

Chromosomes

Inside the nucleus of every cell are structures called chromosomes. Chromosomes are long threads of genetic material made up of strands of deoxyribonucleic acid (DNA). You have 23 pairs of chromosomes; each of your parents contributed one chromosome to every pair. Each chromosome contains from several hundred to several thousand genes. Just before cells divide, the chromosomes make duplicate copies of themselves; the two copies of each chromosome are held together at a narrowed region called a centromere, which gives the chromosome an X shape.

Genes

Genes are the basic physical and functional units of heredity, which provide instructions for making proteins, the building blocks of the body. Scientists believe that genes make up only about 2 percent of the total genome; the rest consists of regions whose functions include keeping the chromosomes intact and regulating where, when, and in what quantity proteins are made.

The genetic code

The information carried by a gene is determined by the structure of its DNA. DNA is arranged in the form of a double helix, or ladder, with rungs supported by a twisting ribbon of sugar and phosphates. The two intertwined DNA strands are linked together by varying patterns of substances called nucleotide bases. There are four nucleotide bases—cytosine (C), guanine (G), adenine (A), and thymine (T).

Along each helix, or side of the ladder, the bases are arranged in groups of three, called base triplets, to form words of genetic text. For example, base triplets, such as TAC, CGG, and TCA, carry specific amino acids (the building blocks of proteins) to assembly points in a cell where they are strung together to make functioning proteins. To form the rungs of the DNA ladder, the bases can join in only two ways: C joins only with G, and A joins only with T.

If you think of the nucleotide bases as the letters of the genetic alphabet, then base triplets are the words, genes are the sentences, chromosomes are the chapters, and the genome is each organism’s book of life. The human genome contains a total of about 3 billion nucleotide base pairs.

Proteins: Building Blocks of the Body

Proteins are essential for life. Some proteins make up structures such as muscles and skin; other proteins—including enzymes, antibodies, and many hormones—dissolve in the body’s fluids and are carried to wherever they are needed. Genes control the production of proteins inside cells and provide the instructions for making specific proteins in precisely the right number and at precisely the right time. Different proteins have different functions in the body:

• Enzymes regulate the rate of chemical reactions in cells.

• Antibodies, produced by the immune system’s white blood cells, destroy invading microorganisms and provide protection against infections.

• Proteins in muscle cells provide mobility, pump blood through the body, and help move food through the digestive tract.

• Hemoglobin carries oxygen in red blood cells and gives the cells their red color.

• Hormones control a variety of biological processes, such as growth, sexual development, and the activities of some organs.

Genetics: The future of medicine

You will one day be able to learn from your unique genome what disorders you are at increased risk of developing, which will enable you to take steps to prevent them. Doctors will be able to prescribe drugs that are more precisely tailored to your individual genome. They would know, for example, what medication or combination of medications for high blood pressure would be most effective for you.

Eventually, scientists hope to find the genes that enable some people to live to 100 or older. Using the information they glean from the genes, they will be able to devise new treatments, drugs, special vitamin formulas, or even combinations of foods that could enhance the activity of the genes and increase healthy life expectancy for everyone—even those of us who were not born with the life-prolonging forms of these genes.

How Genes Are Transmitted

Your genes are continuously being copied inside your cells in a process of cell division called mitosis. Mitosis occurs thousands of times every second to make new cells to replace damaged, dying, or dead cells. Egg and sperm cells are different from other cells in the body and divide in a process called meiosis. Each egg or sperm cell contains half the DNA of body cells, and each is genetically unique. An egg and sperm combine at conception to form a cell with a full set of genes, half from each parent. This random mix of genetic information accounts for the limitless variety of people in the world.

The cycle of life

Genetic Testing

As you read and hear more and more about genetic testing, you may want to consider being tested for a condition that seems to run in your family. You may want to learn if you carry genes that increase your risk of developing a particular disorder later in life or of transmitting a severe, life-threatening genetic disorder to a child. For many diseases that are inherited through a single gene or pair of genes, tests are available to detect the genes in people who carry them, often from a simple blood test. The odds of passing one of these so-called single-gene disorders to offspring can be calculated relatively easily. However, for other diseases, the risks are more difficult to define, and the best course to follow is not always clear. To be able to make informed decisions, you will need to understand the implications the information has for you personally. For information about genetic counseling, see page 952.

Gene chips

Studying a person’s DNA from a small sample of his or her blood or saliva, scientists can detect a wide variety of genes that increase susceptibility to particular disorders. A genetic analysis is made by reading a person’s DNA on a gene chip.

The Dangers of Smoking

Cigarette smoking is the major cause of preventable death in the US, causing nearly half a million premature deaths each year. The smoke from a cigarette contains more than 4,000 chemicals—at least 60 of them known to cause cancer. Nicotine, the substance in tobacco that makes smoking highly addictive, raises your heart rate, irritates the lining of your blood vessels, and promotes blood clotting, increasing your risk of heart attack and stroke. The carbon monoxide in cigarette smoke reduces the level of oxygen in your blood.

Smoking causes nearly nine out of ten cases of lung cancer—the No. 1 cancer killer of both men and women—and causes other cancers, including cancer of the mouth, throat, esophagus, bladder, kidneys, cervix, and pancreas. Smoking is also responsible for most cases of emphysema and chronic bronchitis and is a major risk factor for heart disease, the leading cause of death in both men and women. Women over age 35 who both smoke and take birth-control pills increase their risk of having a heart attack or stroke.

Why You’re Hooked

Researchers have discovered why smokers have such a hard time quitting. Normally, your brain releases dopamine (a chemical that produces feelings of pleasure) when you perform a rewarding behavior, such as eating when you are hungry. The brain then quickly releases another chemical, called acetylcholine, which stops the release of dopamine.

When you smoke, nicotine triggers the release of dopamine but prevents the brain from turning it off by blocking the release of acetylcholine. As a result, the brain continues pumping out dopamine, making you feel better and better. After nicotine levels in the bloodstream fall, dopamine production declines. The brain, recalling the good feelings, wants more, producing cravings for another cigarette. These processes take place inside a part of your brain that scientists call the reward center.

The brain’s reward center

Two structures—the nucleus accumbens and the ventral tegmental area—deep in the brain’s reward center are responsible for the release of dopamine, which produces feelings of pleasure.

When the brain’s reward center works normally

	ON:  The reward center releases dopamine to reward a good behavior, such as learning a new skill (green arrows).
	OFF:  Minutes later, another brain chemical, acetylcholine, shuts dopamine production off (red arrows).

When nicotine interferes with the reward center

	ON:  Nicotine in the bloodstream causes the reward center to release a flood of dopamine (green arrows).
	NOT OFF:  Nicotine blocks the release of acetylcholine, so the reward center keeps releasing dopamine until blood levels of nicotine fall, producing craving for more nicotine (red arrows).

Deaths from cigarette smoking

This chart uses figures from the Centers for Disease Control and Prevention to show the number and causes of deaths attributed to smoking each year in the US. Of the nearly half a million smoking-related deaths, 7 out of 10 result from lung disease, especially lung cancer and emphysema, and from heart disease and stroke.

How Smoking Affects the Lungs

Smoking is the major cause of lung cancer and emphysema (a chronic lung condition in which damage to the tiny air sacs in the lungs makes breathing difficult). Chronic inflammation of lung tissue from cigarette smoke and tar residue left by the smoke triggers a cascade of changes in cells in the lungs that can lead to cancer, emphysema, or both. In this cross section of a lung with cancer (top), the white area in the upper lobe is cancerous tissue, and the blackened areas are deposits of tar. The lung with emphysema (bottom) has multiple cavities (produced by the destruction of air sacs) that are surrounded by black deposits of tar.

Lung with cancer

Lung with emphysema

The Benefits of Quitting Smoking

Even if you’ve been smoking for years, when you quit, your body begins a series of changes to repair the damage caused by smoking and to restore health to affected cells and organs.

How to quit smoking

Giving up smoking is not easy. But as hard as quitting may be, the results are well worth it. Take some time to think about the many health benefits of being an ex-smoker. This is an important first step in kicking the habit.

Make a Plan

Once you decide to give up smoking, set a target date to quit. Pick a time when you won’t be under a lot of stress. On the night before your quit date, throw away all of your cigarettes, matches, lighters, and ashtrays. Plan some special activities to help you get through the next few days without cigarettes. Try these tips:

• Avoid smoking triggers. Familiar activities, such as talking on the phone or drinking alcohol, can bring on the urge to smoke. Make a list of your triggers and avoid as many as you can. Try to avoid being around smokers, especially your smoking friends, until your cravings start to subside.

• Keep busy. Engage in activities that keep your hands busy (such as doing crossword puzzles). When you feel the need to put something in your mouth, chew gum, eat raw vegetables, or suck on a straw.

• Consider using a nicotine-replacement product. Nicotine patches, pills, and gum are available over the counter, and other products are available by prescription. These products are safe for most people, but talk to your doctor before using any of them because they can have side effects.

• Try a stop-smoking program. Contact a local hospital or the American Lung Association and ask about smoking cessation programs in your area.

Most people who quit smoking experience unpleasant side effects—including irritability, sleep loss, headaches, fatigue, depression, nervousness, anxiety, and difficulty concentrating—during the first 3 or 4 weeks after quitting. These symptoms result from the body’s withdrawal from nicotine and can be severe. Nicotine use causes changes in brain chemistry that make the brain crave higher and higher levels of stimulation and pleasure. Ask your doctor if the prescription medication bupropion could help you through these difficult few weeks.

If You Relapse

If you slip and smoke a cigarette or two after your quit date, don’t be hard on yourself. But try to get back on track quickly. Most people relapse several times before they quit for good. If you have a cigarette:

• Don’t be discouraged. Quitting smoking is difficult—a relapse doesn’t mean you can’t succeed.

• Learn from your experience. Figure out what triggered your urge to light up and try to avoid it.

Secondhand Smoke

Secondhand smoke (also called passive smoking) is a combination of the smoke given off by cigarettes and the smoke exhaled by smokers. Secondhand smoke is classified as a cancer-causing agent and is responsible for about 35,000 deaths from heart disease and 3,000 deaths from lung cancer each year, primarily among nonsmoking spouses of smokers. Every year, nearly 300,000 cases of bronchitis and pneumonia in children under 18 months of age are directly linked to secondhand smoke, which is also responsible for triggering or worsening hundreds of thousands of cases of childhood asthma. Also, children who regularly breathe secondhand smoke are more likely than other children to have frequent ear infections and more dental cavities.

Medical Treatments for Quitting

For smokers who are highly addicted, many doctors recommend nicotine-replacement products. These products—such as nicotine gum, pills, and patches (available over the counter) and inhalers and nasal sprays (available only by prescription)—release small amounts of nicotine into the bloodstream to relieve withdrawal symptoms from nicotine and help reduce cravings for cigarettes. These products provide safer doses of nicotine than cigarettes—the nicotine enters the body less rapidly and in a lower concentration and does not have the thousands of harmful chemicals present in cigarette smoke. Over a period of about 6 to 12 weeks, the dose of nicotine is gradually reduced to slowly lower your craving.

The prescription antidepressant medication buproprion is another proven treatment for helping people quit smoking. Buproprion, taken in pills, acts in the brain, probably by blocking nicotine receptors, preventing them from triggering the release of the feel-good chemical dopamine (which produces the nicotine addiction). Buproprion seems to be most effective for smoking cessation in women and in people who have a history of depression. The drug can be taken along with nicotine replacement products. Together, the two treatments boost the chances of success.

Terrorism

For the average American, the risk of experiencing a terrorist attack firsthand is low. However, despite the low risk, you still may feel worried and frightened during a national security alert. One positive way to cope with your anxiety and fear is to talk about your feelings with family and friends. You will find that most people share your concerns and many will appreciate the opportunity to talk about them. If you continue to feel anxious or depressed or if you are unable to focus on your usual activities, talk to your doctor or a mental health professional. You can also take constructive steps to prepare for a possible terrorist attack (see below), which can help you feel more in control.

The federal government has identified a number of possible terrorist threats and has developed a national emergency response system to coordinate local and state emergency programs throughout the country in the event of terrorist attacks. Types of attacks that could occur involve biological agents (such as bacteria and viruses), chemicals, or radioactive materials.

How to Prepare for a Terrorist Attack

If a terrorist attack occurs, your local emergency response system will activate and local public health authorities will tell you what to do. Listen to news broadcasts to monitor the situation. Follow instructions from your local police and fire departments and from emergency workers on the scene. Although there is no way to predict exactly what might happen during a terrorist attack, there are a number of things you can do to prepare for an attack:

• Assemble emergency supplies. Have enough bottled water (1 gallon of water per person per day) and nonperishable foods (such as canned goods, nuts, dried fruit, and boxes of dry cereal) for at least 3 days. Include a first-aid kit, extra eyeglasses and medication, vitamin and mineral supplements, tools, a battery-powered radio, a flashlight, extra batteries, a manual can opener, toilet paper, paper towels, moist towelettes, bleach, soap, and bedding and a change of clothing for each person. If you can, store extra water in containers for washing. If there is a baby in the house, include ready-to-feed formula, baby food, and disposable diapers. Make a list of emergency phone numbers such as the local fire department and police department, a local hospital, and your doctor.

• Develop an emergency plan. Plan what your family would do in different emergency situations (for example, if you have to seek shelter at home, if you have to evacuate your house or apartment, or if an attack occurs when you are in a car). Designate a meeting place. Decide how family members will get in touch with one another if you are not together at the time of an attack or if you become separated. It might be helpful for each family member to have a cell phone. Name an out-of-town person for all family members to contact if local phone service is affected.

• Educate yourself beforehand. Learn the warning signals used by your community in an emergency. Find out the location of fallout shelters. Take classes in first aid and CPR.

There are also some things you should not do when preparing for a terrorist attack. Do not hoard antibiotics—they lose their effectiveness if overused and they don’t work against viruses. And don’t stock up on gas masks. They are not effective against all gases, they don’t protect you from chemicals absorbed through the skin, and (because many gases are odorless and colorless) you probably will not know when to use one. For more information, go to the US Department of Homeland Security Web site (www.ready.gov) or call 1-800-BE-READY.

Biological Attacks

It is unlikely that a bioterrorist attack would be widespread, at least initially, but some biological agents (such as smallpox) can spread from person to person once they enter a population. Biological agents are expensive and difficult to produce, require technical skill and special equipment to handle, and are difficult to deploy. The biological agents on the following page have been identified as those most likely to be used in a bioterrorist attack. If an attack has occurred and you develop symptoms, see a doctor immediately. Rapid detection and treatment are essential for survival.

Anthrax

Possible use as a biological weapon: Envelopes or packages containing anthrax can be sent through the mail, or released as an aerosol in an enclosed space or over a city.

Cause: The bacterium Bacillus anthracis.

Prevention: No vaccine is currently available for routine use for the general public. People exposed to anthrax who have not yet developed symptoms are given antibiotics along with the anthrax vaccine to prevent infection.

Incubation period: Symptoms usually develop within 7 days.

Symptoms:

Cutaneous (skin) anthrax: A small, painless bump that becomes a painless blister; the blister becomes a painless open sore with a black scab in the center.

Inhalation anthrax: Initial symptoms resemble cold or flu symptoms, including sore throat, mild fever, muscle aches, cough, or fatigue. Later symptoms include rapid pulse and severe difficulty breathing. Inhalation anthrax is often fatal.

Treatment: A 60-day course of treatment with antibiotics. The person is kept as comfortable as possible.

Botulinum toxin

Possible use as a biological weapon: Could be released as an aerosol in an enclosed space or over a city. Most potent known nerve toxin.

Cause: Toxin produced by the bacterium Clostridium botulinum.

Prevention: No vaccine is currently available for the general public.

Incubation period: Symptoms usually develop within 1 to 5 days.

Symptoms: Muscle weakness, double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness or paralysis, or respiratory failure.

Treatment: Botulism antitoxin stops progression of the disease. The person is kept as comfortable as possible. Breathing may be assisted with a ventilator.

Tularemia

Possible use as a biological weapon: Could be released as an aerosol in an enclosed space or over a city.

Cause: The bacterium Francisella tularensis.

Prevention: No vaccine is currently available for the general public.

Incubation period: Symptoms usually develop within 3 to 5 days (but can take as long as 14 days).

Symptoms: Sudden fever, chills, headache, muscle aches, joint pain, dry cough, weakness, severe difficulty breathing, or pneumonia.

Treatment: A 10- to 14-day course of treatment with antibiotics. The person is kept as comfortable as possible. Breathing may be assisted with a ventilator.

Hemorrhagic fevers

(Ebola, Marburg, Lassa, New World Arenaviridae, Rift Valley, Hantavirus, yellow fever, and others)

Possible use as a biological weapon: Could be released as an aerosol in an enclosed space or over a city. Most can be transmitted from person to person by inhaling infected droplets coughed into the air or through contact with infected body fluids.

Cause: A number of different viruses.

Prevention: Vaccine for yellow fever only. Avoid contact with infected people.

Incubation period: Depending on the virus, symptoms usually develop within 2 to 3 weeks (but can appear as quickly as within a few days or as long as 2 months).

Symptoms: Depending on the virus, initial symptoms usually include fever, fatigue, dizziness, muscle aches, weakness, and exhaustion. Symptoms can also include bleeding under the skin or from body openings, internal bleeding, shock, seizures, or kidney failure.

Treatment: Ribavirin (an antiviral drug) is available for Lassa fever virus, New World Arenaviruses, and Rift Valley fever virus. The person is kept as comfortable as possible. Some hemorrhagic fevers (such as Ebola) are usually fatal.

Plague

Possible use as a biological weapon: Could be released as an aerosol in an enclosed space or over a city. Can be transmitted from person to person by inhaling infected droplets coughed into the air.

Cause: The bacterium Yersinia pestis.

Prevention: No plague vaccine is currently available. Avoid contact with infected people. Taking antibiotics for 7 days protects those who have had close contact with an infected person.

Incubation period: Symptoms usually develop within 1 to 7 days.

Symptoms: Flulike symptoms including sudden fever, headache, and weakness, followed by shortness of breath, chest pain, cough, bloody or watery phlegm, respiratory failure, or shock.

Treatment: Antibiotics (given within 24 hours after the first symptoms appear). The person is kept as comfortable as possible. Breathing may be assisted with a ventilator. Fatal if not treated.

Smallpox

Possible use as a biological weapon: Could be released as an aerosol in an enclosed space or over a city.

Cause: The variola major virus.

Prevention: Vaccine.

Incubation period: Symptoms usually develop within 7 to 17 days.

Symptoms: High fever, headaches, body aches, and vomiting. A rash appears on the tongue and in the mouth; the rash turns into blisters that break open and spread the virus throughout the mouth and throat. The rash then spreads to the face, arms, legs, hands, feet, and trunk, and turns into pus-filled blisters. Blisters crust over and scab. Scabs begin to fall off, leaving scars.

Treatment: Vaccine (if given within 4 days of exposure). No antiviral treatment is available. The person is kept as comfortable as possible.

Chemical Attacks

A chemical attack is the deliberate release of a toxic gas, liquid (including aerosols), or solid particles (such as dry powders) into the atmosphere. Chemical agents can be released in bombs, sprayed from planes or boats, or discharged from a canister in an enclosed area (such as a building or the subway). A chemical agent can poison people directly or contaminate the environment. Most chemical agents cause symptoms immediately but some can take several hours or even days to have an effect. Symptoms depend on the type of chemical agent used. Chemical agents are classified into the following general categories based on how they affect the body:

• Damage the respiratory system, especially the lungs (phosgene or chlorine)

• Interfere with the body’s use of oxygen (cyanide)

• Affect the nervous system (sarin, malathion, soman, tabun, or VX)

• Stun or otherwise cause physical or mental incapacitation (fentanyl)

• Blister the skin (mustard gas)

• Cause irritation (such as chemicals used for crowd control) but usually not permanent or severe damage to health (tear gas, mace, or pepper spray)

Signs of a possible chemical attack:

• A number of people in an area seem to be sick or dying

• Many people have blisters or rashes

• Unusual numbers of birds, fish, insects, or animals are dying

• Vegetation is dead, discolored, or withered

• Strange odors

• An oily film or droplets on outdoor surfaces and water

• Unusual foglike clouds

• Spray devices such as metal canisters or other metal debris that look abandoned

What to do in case of a chemical attack:

• If you think you may have come into contact with a contaminated substance, seek medical help immediately.

• If you are at the scene of a chemical attack, call 911 or your local emergency number.

• If a chemical attack has occurred near your home, stay indoors unless authorities have told you to evacuate the area.

• Do not touch any suspicious substances; report them to the police.

• If the chemical is inside a building you are in, try to get out of the building without passing through the contaminated area.

Radiological Attacks

In a radiological attack, radioactive material could be released into the atmosphere in a number of ways. To contaminate a limited area, a concentrated radioactive material could be placed in a densely populated area and allowed to leak slowly, or a dirty bomb (an ordinary explosive device that contains radioactive material) could be detonated. A nuclear explosion, caused by detonating a nuclear bomb or by sabotaging a nuclear power plant, could cause widespread destruction and long-term contamination of air, water, and soil.

Experts predict that a radiological attack caused by a radioactive leak or a dirty bomb is far more likely than a nuclear explosion. The radioactive materials used in those types of attacks may be stolen from medical, industrial, or research facilities and are much easier to obtain than the weapons-grade uranium or plutonium required for a nuclear bomb.

If you are in a radiological attack:

• In case of a nuclear explosion, do not look at the flash—it could blind you.

• Try to get to a designated shelter.

• If advised by authorities to stay indoors, try to take cover below ground.

• Stay sheltered until local authorities say it is safe to go outdoors.

• If you are outdoors and can’t take cover, try to minimize exposure to the radiation by moving as far away from the explosion as possible as quickly as possible.

After exposure to a radiological substance:

• Remove irradiated clothing, wash the skin, and take other steps to decontaminate.

• Get medical treatment as soon as possible.

• If your doctor recommends it, take a potassium iodide tablet to help protect your thyroid gland (the part of your body that is most susceptible to damage from radiation).

• Have regular medical checkups at least once a year to screen for cancer; exposure to radiation increases the risk of cancer.

PART TWO

Your Healthy Body

Never before have we had such power to control our health. In generations past, the health benefits of regular exercise and the dangers of harmful habits such as smoking were largely unknown. Little was known about the importance of vitamins, antioxidants, fiber, or other nutrients, or the adverse effects of eating too much saturated fat. Today a wealth of information has enabled us to choose health-promoting lifestyle habits that can help us stay fit and live longer.

In this part, you will learn the basics of nutrition and how a healthful diet can help you to lower your risk of heart disease—the No. 1 killer of both men and women in the United States—as well as many of the other common chronic diseases, including type 2 diabetes and some cancers. The critical link between exercise and health, and how to use physical activity to maintain a sensible weight, are also explored. This part also describes ways to reduce stress and avoid harmful behaviors such as smoking and abusing alcohol or other drugs. Information on safety and preventing violence can help you protect your family both at home and when you’re away. Other helpful topics discussed here include preventive health care and alternative medicine.

1

Diet and Health

An unhealthy diet is a major factor contributing to the epidemics of obesity, high blood pressure, heart disease, stroke, type 2 diabetes, and some types of cancer. However, diet is one of the most controllable risk factors. You can reduce your risk of developing many chronic diseases by choosing nutritious foods more often and limiting your intake of calories, fat, salt, and sugar. A healthy diet also can help you keep your weight down and your energy levels up. But what constitutes a healthy diet? Nutrition experts agree that you can reduce your risk of many diseases by consuming a diet that contains plenty of fiber-rich vegetables and fruits, an abundance of whole grains, and low-fat sources of dairy, animal, and vegetable protein. This chapter teaches you the basics of good nutrition, explains how nutritional needs change as you get older, and shows you how to improve your diet to prevent disease.

Eating for Good Health

How do you choose nutritious foods to help your family maintain good health? Most doctors agree that the Dietary Guidelines for Americans (see page 37) offer good general guidelines for healthy people. You can tailor these guidelines to meet your individual needs by working with your doctor to identify your personal health risks. As part of a thorough physical examination, your doctor will check your weight, your blood pressure, your cholesterol levels, and your blood glucose (sugar) levels. He or she will ask about your family’s health history (see page 131), and calculate your body mass index (BMI; see page 11) and your waist-to-hip ratio to see how fat is distributed on your body. Using this information, you and your doctor can work together to adjust your diet to reduce your risk of disease.

If you have a high cholesterol level and a family history of heart disease, your doctor will probably suggest that you avoid or limit foods high in saturated fat and trans fats (see page 38), exercise regularly, and maintain a healthy weight. If you have a family history of diabetes or are overweight, your doctor will recommend increasing your physical activity and losing weight. If you have a family history of colon cancer or some other cancers, your doctor will recommend reducing your consumption of fat (especially animal fat), increasing your consumption of fiber-rich foods, and increasing your level of physical activity. Depending on your risk factors and your age and gender, the doctor will also tell you what screening tests you need regularly.

The Dietary Guidelines for Americans recommend a diet that is low in fat (especially saturated fat and trans fats) and high in fiber-rich whole grains, vegetables, and fruits. Children under age 2 need breast milk or higher-fat dairy or soy milk or formula to ensure proper brain development. But, after age 2, they should make the transition to low-fat foods. Try to eat at least five half-cup servings of vegetables and fruits and six half-cup servings of grain products and legumes each day. It also is important to eat a wide variety of foods to make sure you are consuming as many essential nutrients as possible. When applying healthy eating principles, consider your diet over several days, but choose wisely meal by meal. Choose low-fat, high-fiber foods more often and use low-fat cooking methods such as broiling and grilling instead of frying.

You don’t have to eliminate your favorite high-fat snacks, desserts, or fast foods altogether. If you occasionally indulge in pizza, a burger, or a dish of ice cream, enjoy it. Just try to eat more vegetables, fruits, whole grains, and low-fat foods at your next few meals, a concept known as “fat budgeting.” Healthy diets do include certain fats—such as monounsaturated fats—to make you feel full and to provide essential fatty acids.

In fact, some fats are beneficial, improving cholesterol levels and reducing the risk of heart disease. These protective fats come primarily from vegetable oils such as olive, canola, and soy (unsaturated fats); fatty fish such as salmon (omega-3 fatty acids); and some margarines (plant sterols). Other sources of good fats include nuts, seeds, and avocados.

Consume sugar, salt, and alcohol in moderation. Sugar causes tooth decay, and sugar-laden foods such as soft drinks, candy, and pastries contain lots of calories but few nutrients. Many sugary desserts are also high in saturated fat or trans fats. In addition, many fat-free desserts and snacks have replaced fat with sugar and actually have more calories than their full-fat alternatives. You can easily fill up on such foods and exceed your calorie quota, leaving little room for nutritious foods.

Consuming foods that are high in salt (sodium) can elevate blood pressure in salt-sensitive people and also can promote calcium loss from the bones, leading to osteoporosis (see page 989). Although not everyone is salt-sensitive (there is no test to determine if a person is sensitive to salt), your body needs only a very small amount of sodium (fewer than 500 milligrams a day). You can easily exceed the recommended daily allowance for sodium (2,400 milligrams a day), even without adding salt to your food. Processed and commercially packaged foods—including canned soup, pastas, and vegetables; hot dogs; lunch meats; processed cheeses; cereals; flavor packets in rice, dried soup, and noodle packages; crackers; and pretzels—contain high amounts of salt. Check the nutrition labels (see page 3) on packaged foods carefully to determine the sodium content, and look for reduced- or low-sodium versions in the supermarket.

Alcohol, like sugar, provides lots of calories but little or no nutrition. If you choose to drink alcohol, moderation is again the key. Men should have no more than two alcoholic drinks a day and women no more than one. One drink equals one 12-ounce can or bottle of regular or light beer, one 5-ounce glass of wine, or one mixed drink with 1½ ounces of 80-proof liquor. In addition to the many health risks related to excessive drinking, such as liver damage and an increased risk of accidents, excessive alcohol consumption can interfere with your body’s ability to absorb nutrients from the food you eat.

A Handful of Nuts Goes a Long Way

Nuts are delicious and, although they are high in fat and calories, they can help you lower your blood cholesterol level and even help you lose weight and keep it off—provided, of course, that you eat them in moderation and maintain an active lifestyle. The portion recommended for the most beneficial effects is 1 ounce a day (about a handful) of nuts or 2 tablespoons of peanut butter. In just a handful of nuts, you get vegetable protein and lots of vitamins—including B vitamins—and minerals—including potassium, magnesium, and phosphorus. Nuts also are packed with heart-healthy nutrients—fiber, vitamin E (an antioxidant that protects blood vessels from the harmful effects of free radicals, which can damage cells), folate (folic acid, which lowers the blood level of homocysteine, a blood chemical linked to heart disease), and copper (which improves cholesterol levels and lowers blood pressure). Just remember that an ounce of nuts also contributes about 200 calories.

The Basics of Nutrition

Carbohydrates, protein, and fat are the main components of a nutritious diet. The goal is to select the best sources in the right proportions every day. Read food labels (see page 3) carefully to find the amounts of these nutrients contained in food products.

USDA Dietary Guidelines for Americans

The Dietary Guidelines for Americans published by the US Department of Agriculture provide reliable, comprehensive nutrition advice. These guidelines show you how to get the nutrients you need to lead a healthier, more active life and to lower your risk for the most common chronic diseases, including heart disease, cancer, high blood pressure, and diabetes. To maintain optimum health:

• Aim for a healthy weight.

• Be physically active every day.

• Eat a variety of grains daily, especially whole grains.

• Eat a variety of fruits and vegetables daily.

• Store food properly.

• Eat a diet low in saturated fat and cholesterol and moderate in total fat.

• Choose beverages and foods that are low in sugar.

• Choose and prepare foods with less salt.

• If you drink alcoholic beverages, do so in moderation.

Carbohydrates

Carbohydrates are the main source of fuel for your body and should make up 45 to 65 percent of your daily calorie intake. Carbohydrates contribute sugar, starches, and fiber from plant foods and come in two forms—simple and complex. Your body absorbs simple carbohydrates—such as those in table sugar, most fruits, and the sugar in milk (lactose)—very quickly. Complex carbohydrates are absorbed more gradually and provide your body with a more constant supply of energy. Complex carbohydrates also help stabilize blood glucose levels, avoiding the up-and-down swings in glucose that can result from eating simple carbohydrates. For these reasons, most of the carbohydrates you eat should be complex carbohydrates from whole grains, vegetables, and whole fruits (including the skins).

Children and adults should consume about 130 grams of carbohydrates every day, which is the minimum amount necessary to get a sufficient amount of glucose to enable the brain to function properly. Most people get much more than this. Sources of added sugars are everywhere in the American food supply and in all food groups. Some obvious sources are candy, soft drinks, fruit drinks, pastries, and other sweets. Some not-so-obvious sources are salad dressings, cereals, ketchup, and breads. People who eat too many added sugars often take in too many calories and fewer of the essential nutrients than they need. Try to limit your intake of foods and beverages that have added sugars.

Fiber

Fiber, a substance in the cell walls of plants, is an especially important component of complex carbohydrates because it helps lower LDL (bad) cholesterol and reduces your risk of heart disease. Fiber can help you maintain a healthy weight. It also may help lower your risk of colon cancer and other digestive tract disorders such as diverticulosis (see page 772). Dietary fiber occurs in two forms—soluble and insoluble. Neither type is digestible, but they both serve important functions in your diet. Soluble fiber—found naturally in oats, barley, dried beans and peas (legumes), and some fruits—is the type that improves cholesterol. A grass called psyllium, which is added to some cereals and breads and is used in some over-the-counter stool softeners and laxatives, has also been shown to help lower blood cholesterol. Insoluble fiber—contained in whole-wheat bread, wheat bran, and fruit and vegetable skins—provides bulk to stool, helping it pass more easily through the digestive system. For this reason, insoluble fiber, along with plenty of fluid, helps prevent constipation.

Good Sources of Fiber

The recommended daily intake of fiber for adults up to age 50 is 38 grams for men and 25 grams for women; for adults over 50 (who usually eat less food), the recommendation is 30 grams daily for men and 21 grams for women. Children should have a dietary fiber intake equal to their age plus 5 grams per day. For example, a 6-year-old child needs about 6 plus 5 grams, or 11 grams of fiber per day. Read food labels to determine the fiber content of food products.

Protein

Protein is the major functional and structural component of all the cells in the body, and is essential for building, maintaining, and repairing tissues. Proteins are made up of 21 different amino acids, which can become enzymes, hormones, nucleic acids, or other molecules essential for life. Your body manufactures many of these amino acids, but some must be obtained from the food you eat and are called essential amino acids. Proteins from animal products—such as meat, fish, poultry, eggs, milk, and cheese—are known as complete proteins because they supply all of the essential amino acids.

If you want to limit your intake of animal products, however, eat more plant protein sources, including grains, legumes, nuts, and vegetables. Because none of these foods alone provides all of the amino acids, they are all considered incomplete protein sources. You can, however, get complete proteins by combining plant proteins, such as rice with beans, bread with peanut butter, corn tortillas with beans, and chili with corn bread. Also, you can combine any incomplete protein with dairy protein to further extend or enhance the incomplete protein. For example, macaroni and cheese, beans and cheese, or even whole-grain bread and milk provide good-quality protein.

How Much Protein Do You Need?

The amount of protein you need to fulfill your body’s requirements is surprisingly small. Most American adults consume more protein than they need. The recommended daily intake of protein is 63 grams for men and 50 grams for women. Growing children and women who are pregnant or breastfeeding require even more protein.

The more individualized recommendation for adults is 0.8 gram of protein per kilogram (2.2 pounds) of body weight. You can calculate your daily protein need using the following formula. For example, if you weigh 140 pounds:

• To get your weight in kilograms, divide your weight in pounds by 2.2 (140 ÷ 2.2 = 64 kilograms).

• To find out how many grams of protein you need each day, multiply your weight in kilograms by 0.8 gram (64 × 0.8 = 51 grams of protein).

There are 4 calories in each gram of protein. To find out how many calories of protein you should consume each day, multiply your daily gram allowance of protein by 4 calories (51 × 4 = 204 calories of protein). Based on your weight, you should get about 51 grams, or 204 calories, of protein each day. You can easily reach this target if you eat one 3-ounce serving of meat, poultry, or fish; consume a cup of yogurt; drink an 8-ounce glass of low-fat milk; and enjoy a handful of nuts each day. A 3-ounce serving of meat, fish, or poultry is about the size of your palm.

Fat

Your body uses the fat that naturally occurs in food to store energy and carry certain vitamins through the bloodstream. The structural units of fat, called fatty acids, are also used to make hormones. Fat makes you feel full, adds flavor to foods, and makes foods feel smooth in the mouth. It’s what makes ice cream taste creamy on your tongue, and it makes cakes and other baked goods soft.

Each type of dietary fat or oil is comprised of a combination of fatty acids, including smaller or larger amounts of saturated and unsaturated fatty acids. Some fats—especially monounsaturated fats (found in foods such as olive oil, canola oil, avocados, and nuts) and plant sterols (found in some soft margarines)—are good for you. However, some fats are harmful. Saturated fats (found in meat and full-fat dairy products) and trans fats (found in stick margarines and some commercially baked goods) produce the buildup of fatty deposits in blood vessels that can lead to heart disease. Try to avoid or limit these fats; replace them with healthy, plant-based fats.

Comparing Protein Sources

Try to consume less than 20 to 30 percent of your total calories from fat. (Infants and young children need a larger proportion of fat—25 to 40 percent of total daily calories.) Also, choose your fats wisely. As few of your calories as possible (less than 5 to 10 percent of total calories) should come from saturated fat and trans fats. Trans fats are found in partially hydrogenated vegetable oils, which are used in many margarines and shortenings to make liquid oils hard at room temperature. Trans fats may be even more harmful to the heart than saturated fats.

Trans fats are often used in packaged baked goods such as cakes, cookies, crackers, and pie crusts; in snacks such as potato chips; and in some dairy products, meats, restaurant fried foods, and fast foods. Consume as little of these fats as possible. Read food labels to find the amounts of trans fats in foods. Take the following steps to limit your consumption of these harmful fats:

• When buying processed foods, read the ingredient list and avoid those that list trans fats or hydrogenated or partially hydrogenated oils. Look for foods that contain unhydrogenated oils.

• Use naturally occurring unhydrogenated oils such as canola or olive oil.

• Choose the soft or liquid margarines sold in tubs or squeeze bottles instead of stick margarines or butter. Look for soft margarines with vegetable oil listed as the first ingredient and that contain no more than 2 grams of saturated fat per tablespoon. Tub margarines that contain plant substances called sterols or phytosterols or stanols have highly beneficial effects on blood cholesterol levels, primarily by lowering the level of harmful LDL. Eating 1 to 2 tablespoons of these margarines with your food each day can reduce total blood cholesterol by as much as 15 to 20 percent.

• Avoid fatty fried foods such as French fries and doughnuts, and snacks such as cookies, crackers, and chips.

Dietary Fat

Different dietary fats can have either beneficial or harmful effects on your blood cholesterol profile. Your blood contains lipo (fat) proteins that influence your risk of heart disease. One lipoprotein, called HDL cholesterol, is good for the heart. Another lipoprotein, called LDL cholesterol, can be harmful to the heart and can increase your risk of heart attack.

Blood cholesterol is a gummy substance your liver makes to help manufacture hormones and bile (a fluid that aids digestion). The liver makes most of the cholesterol from saturated fats that you consume in foods such as meats, baked goods, and full-fat dairy products. A smaller amount of cholesterol is absorbed into the bloodstream directly from cholesterol-containing foods such as egg yolks. The amount of cholesterol in your blood is determined not only by your diet, but also by hereditary factors. Some people inherit a susceptibility to elevated blood cholesterol.

Vitamins and Minerals

Vitamins are chemicals in food that your body needs to function normally. Minerals are elements absorbed by plant foods that are essential for your body in very small amounts. With the exception of vitamin D, your body cannot make vitamins or minerals, so you need to get them from the foods you eat. Some people can get sufficient amounts of vitamins and minerals from their diet, but many of us need to take a multivitamin/mineral supplement to ensure that we get all of the essential nutrients. Although food is the best source of nutrients, most doctors now recommend that most people take a daily multivitamin/mineral supplement.

While taking a daily multivitamin can be beneficial, it should not take the place of a healthy diet. Foods supply many nutrients—such as fiber, essential fatty acids, and antioxidants and phytochemicals—that are not present in supplements. Avoid taking massive doses of specific vitamins or minerals, which can be harmful and can increase or reduce your body’s absorption of other vitamins and minerals. For example, fat-soluble vitamins such as A and D (which are not eliminated in urine, as are the water-soluble vitamins) can cause serious health problems. Unless you are a menstruating woman or you have been diagnosed with iron deficiency anemia (see page 610), take a multivitamin that does not contain iron or that has no more than 15 milligrams of iron. Excess levels of iron are linked to an increased risk of heart disease.

Some Foods That Pack Lots of Nutrients

Nutrition experts recommend consuming a varied diet to make sure you meet all of your nutritional needs. The following foods seem to be especially dense in beneficial nutrients. Including them in your diet can go a long way toward ensuring good health and preventing disease.

Nutrition experts have acclaimed the antioxidant vitamins—vitamin C, the carotenoids (including beta-carotene, lycopene, and lutein) and vitamin E—for their ability to protect cells from damage caused by free radicals, harmful by-products of the body’s normal chemical processes. Damage from free radicals is linked to all the common chronic diseases, including heart disease, type 2 diabetes, cancer, and Alzheimer’s disease. Damage from free radicals also is responsible for aging. Free radical damage to cells occurs when free radicals outnumber antioxidants in the body. The key is to give antioxidants the upper hand by consuming lots of antioxidant-rich foods—through a diet rich in vegetables, fruits, and whole grains.

Minerals play a significant role in good nutrition. Some minerals, such as chromium, selenium, and zinc, are needed in such tiny amounts that they are called trace minerals. Your body needs other minerals in higher amounts. Magnesium, found in grains, vegetables, and meats, regulates your heartbeat and stimulates the activity of many enzymes (proteins that trigger chemical reactions). Iron, contained in red meat, spinach, and fortified cereals, helps carry oxygen from your lungs to every other part of your body.

Calcium: Essential at All Ages

Calcium, found in dairy products and calcium-fortified orange juice and other foods, is essential for strong bones and teeth and helps regulate the heartbeat and lower blood pressure. To build strong bones and teeth, children from birth to 6 months should get 400 milligrams of calcium a day, 600 milligrams a day from 7 to 12 months of age, and 800 milligrams a day from 1 to 10 years. Older children, adolescents, and young adults (ages 11 to 24, when the bones reach their peak density) should take in between 1,200 and 1,500 milligrams a day. Adult women and men need about 1,200 milligrams a day. Postmenopausal women need to consume 1,500 milligrams a day (1,000 milligrams daily if they are taking a bone-building medication); men should consume 1,200 milligrams a day after age 50.

Some people need more of certain vitamins and minerals and other nutrients than other people do. For example, children, teenagers, and adults over age 50 have an especially high requirement for calcium to build bones and to keep bones strong. To ensure proper brain development and to meet their rapid growth requirements, infants and toddlers need to consume more fat than older children and adults. Girls and women who are menstruating need adequate amounts of iron to replace that lost during menstruation. Women of childbearing age should make sure they get enough of the B vitamin folic acid (400 micrograms a day) to prevent birth defects.

Water

Water is an important but often overlooked nutrient. It does not provide energy or calories but, like fiber, it plays a critical role in the body’s ability to function normally. Water helps your body distribute nutrients to cells, regulate body temperature, and eliminate waste. Drink six to eight glasses of water each day—more if you consume drinks that contain caffeine or alcohol, both of which increase water loss from the body. Vigorous exercise and hot, humid weather can rapidly use up your body’s supply of fluid and increase your need for water, but they are not the only dehydrating factors. Living in a dry climate and dry, indoor heating in the winter can also increase the risk of dehydration and boost your water requirements.

Fluoridated water helps prevent tooth decay. Some parts of the United States have water supplies with naturally occurring fluoride; in others, municipalities add the mineral to the water supply. Many people drink bottled water because they think it’s safer. However, most bottled waters do not contain fluoride or naturally occurring minerals. Some supplemented bottled waters contain various nutrients, but they can be expensive and may not be as healthy as water from the tap.

The US government regulates the safety of American drinking water through established standards for water purity. Most public water supplies meet these standards. However, if water treatment systems break down, bacteria and other contaminants can reach unsafe levels. In these situations, local officials usually advise residents to boil their tap water before drinking it or using it for cooking. Lead that leaches from plumbing pipes, solder, or well pumps also can contaminate tap water, especially in older homes. To minimize the level of lead in the tap water in your home, run the cold water for 3 or 4 minutes the first time you use it each day. Always cook with cold tap water instead of hot tap water because hot water pulls lead out of pipes more easily.

Vegetarian Diets

With improved understanding about the role of nutrition in health, vegetarian diets are more popular than ever and are very healthy, as long as they supply adequate amounts of protein, vitamin B12, calcium, vitamin D, iron, and other essential vitamins and minerals that are more abundant in animal-based foods. Vegetarians are less likely than meat eaters to develop heart disease, high blood pressure, and some cancers, or to be overweight. But vegetarians can risk developing iron deficiency anemia (see page 610) or being malnourished if they are not knowledgeable about appropriate food choices.

There are three types of vegetarian diets—ovolactovegetarian, lactovegetarian, and vegan. Ovolactovegetarians consume eggs and dairy products along with plant foods. Lactovegetarians eat dairy products but not eggs. Vegans eat only plant foods and, for this reason, are most at risk for vitamin and mineral deficiencies; however, a vegan diet can be very healthy when plant-based foods are combined. A vegetarian diet for children and pregnant women must be planned very carefully to ensure that they consume sufficient calories, calcium, protein, and essential nutrients to meet all their vitamin, mineral, and amino acid (protein) needs.

If you’re not ready to be a full-time vegetarian, at least try eating a few vegetarian meals every week. Occasionally having pasta with a meatless sauce, bean or avocado burritos, or mushroom barley soup for lunch or dinner along with salads and fruits will vary your menu, save money, and provide huge health benefits.

Nutritional Needs Change Throughout Life

To a large extent, your age determines your nutritional needs. Newborns and infants have special nutritional needs that are best met by breastfeeding (see page 539). Doctors recommend that mothers breastfeed their babies for the first 12 months of life. Breast milk supplies better nutrition than commercial formula, promotes healthy brain development, and provides infection-fighting antibodies from the mother. Also, infants should not be given cow’s milk until they are 1 year old because it can cause an allergic reaction and is too concentrated for an infant’s digestive system.

Food Sensitivities

A food sensitivity is a reaction to an additive or ingredient in a food, but the reaction is not related to the immune system. Sulfites, substances that occur naturally in the fermentation of wine and are used as preservatives on fresh fruits and vegetables, are common additives that cause food sensitivity. Sulfites can trigger severe asthmalike symptoms such as shortness of breath and chest tightness. In the United States, foods and wine that contain sulfites must indicate it on their label. Flavor enhancers (such as monosodium glutamate) and food coloring (mainly yellow dye No. 5) can cause adverse reactions such as headaches. Sometimes a naturally occurring substance called histamine can cause a reaction known as histamine toxicity, which mimics an allergic reaction. Cheese, some wines, and tuna and mackerel sometimes contain large amounts of histamine.

Different people can have different reactions to the same foods. If you think you could be having problems with a particular food, see your doctor; he or she can help you identify the foods that trigger a reaction so you can avoid them.

Toddlers and preschoolers sometimes become picky eaters as their newfound independence propels them into a multitude of activities that seem much more interesting than eating. Start to teach good nutrition habits at this age. Offer your child a variety of foods without forcing him or her to eat any particular food. When deciding how much food to give your child, use this convenient rule of thumb: about 1 tablespoon of each food per meal for every year of age. For example, a typical dinner for a 5-year-old might be 5 tablespoons of chicken along with 5 tablespoons of a vegetable and 5 tablespoons of brown rice.

As your child enters school, he or she will still need lots of calories to fuel growth. However, the number of children in America who are overweight or obese is skyrocketing. Being overweight as a child can lead to health problems such as heart disease and diabetes—and Americans are developing these diseases at younger and younger ages. Limit your child’s intake of high-calorie, high-fat snacks, and encourage him or her to be physically active. In general, being physically active is a better solution for an overweight child than a diet that drastically cuts calories because of the risk of developing an eating disorder (see page 725) or of getting insufficient amounts of essential nutrients.

The accelerated body changes that occur during adolescence are sustained by good nutrition. During the rapid growth spurt between ages 15 and 19, athletic teenage boys can require 2,500 to 4,000 calories each day. By contrast, girls usually stop growing at 15 and can easily become overweight if they consume more than 2,000 calories a day. Many teenagers get most of their calories from fast food and junk food. Do what you can to influence your teenager’s food choices. Make nutritious food available at home. Offer healthy snacks, such as cut-up vegetables, fresh fruit, whole-grain cereals—or even last night’s leftovers. Resist the temptation to buy high-fat, high-calorie, sugar-laden snacks. Remind your teenager to have breakfast every day.

Once a person reaches about 25 years of age, nutritional needs stabilize and stay about the same until middle age and older. Eating a diet that is low in saturated fat and trans fats and high in fiber-rich whole grains, vegetables, fruits, and legumes remains the most sensible path. The average man needs about 2,500 calories each day; the average woman needs about 2,200 daily calories. Consume fewer calories if you are sedentary and more if you are very active.

Avoid weight gain as you age. Excess weight or a body mass index (BMI; see page 11) above the recommended range is always unhealthy and can increase your risk for the most common chronic health problems, including heart disease, high blood pressure, diabetes, and some types of cancer. Although metabolism (the chemical processes that take place in the body) slows down and calorie needs drop with age, your body still needs the same amount of vitamins and minerals. Stay as active as possible; exercise and physical activity can help you maintain muscle strength, boost your metabolism, and fight depression.

The ability to eat nutritiously can be compromised by age-related physical problems resulting from chronic conditions such as arthritis, deteriorating eyesight, and gum disease, or from taking some medications (which can affect your appetite). To make sure you continue to get all the nutrients you need as you age, take advantage of senior citizen programs in your community. Talk to your doctor or to a social worker at your local hospital to find out about available programs. Check with your local senior center to see if it offers inexpensive meals. Home-delivered meals, church-sponsored meal programs, and government-sponsored programs such as food stamps are other options to explore.

If You Are an Athlete

If you are very athletic, your calorie requirements are higher than those for people who are less active. If you train for endurance events such as a marathon or a triathlon, you may need to double your calorie intake each day. Some endurance athletes can develop anemia (see page 610) because vigorous exercise reduces the concentration of iron in the blood. Eating a balanced diet containing iron-rich foods such as fortified cereals and breads, lean beef, pork, the dark meat of poultry, and dried beans is usually enough to prevent sports anemia. Athletes may need slightly more protein than other people, about 1 gram (rather than 0.8 gram) per kilogram (2.2 pounds) of body weight. Protein supplements are unnecessary for athletes because most Americans already consume more protein than they need. However, athletes may need more calcium, potassium, magnesium, and other electrolytes (fluid-balancing minerals) because these minerals are lost in perspiration. Many runners eat lots of carbohydrates just before an event, but this practice is usually not beneficial unless the event is extremely physically demanding, like a marathon.

The most important thing to remember when you are exercising or competing in an athletic event is to drink enough fluids. Water loss from breathing and perspiration can quickly dehydrate you, especially in hot or humid weather. Drink liquids before exercising, every 15 minutes during your workout, and for about 2 hours afterward. Water is the best thirst-quenching liquid, although sports drinks can replace the electrolytes lost during vigorous exercise. But be aware that many sports drinks contain a lot of sugar.

2

Exercise, Fitness, and Health

If doctors could prescribe only one treatment to ensure a long, healthy life, it would be exercise. Regular exercise provides many health benefits, including a reduced risk of heart disease, high blood pressure, diabetes, some cancers, and most of the other common chronic diseases that can affect us as we age. The sedentary lifestyle of increasing numbers of Americans is a serious public health problem in this country. Even if you have been sedentary for years, it’s never too late to gain health benefits from exercise.

The Health Benefits of Physical Activity

The human body is designed for movement. We inherited the same efficient mechanisms our primitive ancestors needed for hunting food, traveling long distances on foot, and building shelter. Today, however, most of us drive our cars to the grocery store and sit in offices or classrooms for a large part of the day. Our lack of exercise triggers the processes that lead to common chronic diseases, including osteoporosis, heart disease, high blood pressure, type 2 diabetes, and cancer. Physical activity can help prevent these debilitating chronic diseases and keep you healthy in the following ways:

• Increases the efficiency of your heart and lungs.

• Raises the level of helpful HDL cholesterol and lowers the level of harmful LDL cholesterol in your blood.

• Helps you control your weight.

• Improves sleep.

• Reduces stress, improves your mood, and lowers your risk of depression.

• Boosts the strength and tone of your muscles.

• Builds strong bones.

• Increases the flexibility of your joints.

• Improves your self-image.

• Increases your energy level and endurance.

• Improves your posture.

• Slows the aging process.

• Improves your quality of life as you age.

Exercise also has beneficial effects on the brain. Physical exercise seems to stimulate the growth of brain cells, especially in an area of the brain called the hippocampus, which plays an important role in memory and learning. Physical activity also may improve the brain’s defenses against infection.

The Institute of Medicine has established exercise guidelines that set a goal of 1 hour a day of activity, including both low-intensity activities of daily life (such as walking or housecleaning) and more vigorous exercise (such as jogging, swimming, or cycling). If your job is sedentary, you can achieve this goal by, for example, walking at a pace of 4 miles per hour for a total of 60 minutes every day, or by engaging in a high-intensity activity such as jogging for 20 to 30 minutes 4 to 7 days a week. These guidelines are recommended for all children over age 6 and for all adults.

If you have been largely sedentary and start on a moderate exercise program, you can cut your risk of premature death in half. Spread short exercise sessions throughout your day, as long as the total adds up to about 60 minutes. For example, walk your dog briskly for 20 minutes in the morning and 10 minutes more at night. Add a 20-minute walk and a 10-minute stair-climbing session during your lunch hour and you’ve met your goal.

All types of physical activity are good for you and will lower your risk of heart disease and other illnesses as long as you do them regularly. Of course, the more exercise you do, and the more vigorous, the greater the health benefits. Increase your activity level gradually by adding more vigorous exercises, such as jogging or swimming, to your walking regimen.

People tend to become less active as they get older, but the need for physical activity does not diminish with age. In fact, you will see positive results even if you don’t start exercising until you are older. Previously sedentary people who begin exercising in their 50s, 60s, or older can significantly reduce their risk of dying of a heart attack, even if they already have a heart condition. Exercise also increases the flexibility of your joints and the strength of your muscles, reducing your risk of fractures and enabling you to stay active and independent as you age.

Incorporate more physical activity into your daily routine. Get off the bus a stop or two early and walk the rest of the way to work. Use the stairs instead of the elevator whenever you can. Go for bike rides with your children, and take family walks after dinner. Do your own yard work and gardening. In bad weather, walk around the local shopping mall a few times. On weekends, plan active outings such as hiking, skiing, or ice-skating instead of going to the movies. Ride a stationary bike or use hand weights while you watch TV. Take the family on a hiking or biking vacation.

WARNING!

When to Stop Exercising

Although exercise provides numerous health benefits, it is important to know when to stop. Regular exercise can reduce your risk of a heart attack and early death from heart disease, but overexercising can cause a heart attack, especially if you have been sedentary and you have one or more risk factors for heart disease (such as high blood pressure or angina). If you feel any unusual symptoms or if you have difficulty breathing; feel dizzy; feel pain or pressure on the left side or middle of your chest, or on the left side of your neck, shoulder, or arm; or have an irregular heartbeat, stop exercising immediately. Call 911 or your local emergency number, or have someone take you to the nearest hospital emergency department.

Most physical activities do not demand any particular athletic skills. In fact, many people who dislike participating in sports are surprised to find that exercises such as brisk walking are enjoyable. If you have been inactive for a long time, start exercising gradually to build up your endurance. Stretch before and after your workouts (see page 8), and warm up before each session and cool down afterward by walking at a moderate pace. If you are healthy, you probably don’t need to see your doctor before beginning an exercise program as long as you increase your exercise gradually. But you should talk to your doctor before you significantly increase your physical activity if:

• You have a heart condition and your doctor has recommended only medically supervised exercise.

• You have had chest pain within the past month.

• You get dizzy when you exercise.

• You get extremely breathless after only mild exertion.

• You take medication for a heart condition or for high blood pressure.

• You have bone or joint problems that could be worsened by exercise.

• You have diabetes that requires you to take insulin injections.

• You are middle-aged or older, have not been physically active, and plan to start exercising vigorously.

If you feel any pain in your joints or experience any other symptoms when exercising, stop exercising and see your doctor right away.

Three Kinds of Exercise

Doctors classify exercise into three types: aerobic, strength conditioning, and flexibility. Each type of exercise has a different effect on the body, and you should try to include all three in your fitness regimen.

Aerobic Exercise

Aerobic exercise refers to any activity that uses oxygen to fuel your muscles. When you do aerobic exercise, your moving muscles and joints send messages to your brain that stimulate your heart to beat faster and your lungs to breathe heavier to take in more oxygen. Aerobic exercise makes your heart work harder, increasing its efficiency even when you are at rest. Any repetitive activity that uses the large muscles of your arms and legs for a sustained period of time is aerobic. Examples of aerobic exercise include brisk walking, running, step and aerobic classes, jumping rope, bicycling, climbing stairs, swimming, rowing, skating, and cross-country skiing.

Aerobic exercise is a good way to reduce the relative amount of fat on your body and boost the amount of muscle. It also burns excess calories, which helps you control your weight. People who maintain a healthy weight have a reduced risk of heart disease, diabetes, some cancers, and other health problems that have been linked to being overweight or obese.

Aerobic exercise also improves your mood. People who do aerobic exercise regularly say that they feel better emotionally and mentally. When you engage in aerobic activity, your body produces chemicals called endorphins, which alter brain chemistry to brighten your mood and reduce pain. If you are like most people, you will feel relaxed after aerobic exercise and you will sleep better.

Doctors recommend engaging in aerobic exercise for 30 to 60 minutes every day. Try to reach a heart rate (beats per minute) that is 50 to 80 percent of the maximum rate for your age. This rate is called your target heart rate (see below). If your heart rate does not reach this range, adjust the intensity of your activity until it does.

Remember to warm up for 5 minutes before every exercise session and to cool down afterward. Begin by stretching the muscles and joints in your spine, arms, and legs and then walk, jog, or bike slowly to raise your heart rate slightly and prepare it for the more intense activity to come. Warm-up and cool-down exercises can increase your flexibility and help prevent injury to your muscles and joints.

Finding Your Target Heart Rate

It’s easy to calculate your target heart rate. Let’s say that you’re 40 years old. First, subtract your age from 220 (220 - 40 = 180). The resulting number (180 beats per minute) is your maximum target heart rate. To find your target heart rate range, multiply that number by 50 percent to find the low end and 80 percent to find the high end (180 × 0.50 = 90 and 180 × 0.80 = 144). Your target heart rate range is 90 to 144 beats per minute.

The easiest way to check your heart rate is to count your heartbeats for 6 seconds right after an exercise session and multiply that number by 10 to find the number of heart beats in a minute. To count your heartbeats, place the tips of your middle and index fingers (don’t use your thumb) on your throat to one side of your Adam’s apple or on the inside of your wrist. As soon as you feel your pulse, start counting the beats for 6 seconds. Multiply the number of beats by 10. If your rate is below or above your target heart rate range, adjust your exercise by making it more or less strenuous.

Taking your pulse

To take your pulse, place the tips of your middle and index fingers (not your thumb) on your throat to one side of your Adam’s apple (top) or on the inside of your wrist (bottom). When you feel your pulse, start counting the heartbeats.

Staying Strong as You Age

Muscle-building exercises continue to be essential to good health as you age. As you get older, you lose up to half a pound of muscle every year, and the muscle is replaced by fat. This process translates into a 1 to 2 percent loss of strength each year. Over time, the loss in strength can reduce your ability to move, ultimately resulting in a loss of physical independence in old age. Performing strengthening exercises regularly two or three times a week does the following:

• Improves your balance, reducing falls.

• Strengthens your bones, reducing your risk of osteoporosis and fractures.

• Boosts your metabolism (the chemical processes that take place in your body), increasing the rate at which you burn calories.

• Relieves pain from arthritis.

• Improves your state of mind.

• Strengthens your heart.

• Helps you sleep better.

• Improves the quality of your life.

Even if you don’t start until your 80s or 90s, strength conditioning will help you perform daily tasks—such as lifting grocery bags or getting up from a chair—that can get more difficult as you get older. A small change in muscle size can make a big difference in strength, which can help you remain independent.

Keep in mind that if you stop doing aerobic exercise for more than 2 weeks or so, you will start to lose some of the health benefits you have gained. To stay at your more fit level, stick with your aerobic exercise program. Vary your workouts so you won’t get bored. Jog or walk briskly a few times each week, swim for a couple of days, and then use a stationary bike or rowing machine for the remaining days of the week. Do an aerobics routine with a video. Think of ways to modify your routine to keep you motivated.

Strength-Conditioning Exercise

Strength-conditioning exercises make you fit by building muscle strength and can be as beneficial for your heart as aerobic exercise. Weight training (using free weights or weight machines) is an efficient way to strengthen your muscles. However, doing sit-ups, push-ups, pull-ups, lunges, and leg lifts can accomplish the same goal. Strength-conditioning exercises are sometimes referred to as resistance exercises because they force your muscles to work against, or resist, an object such as a 10-pound weight or the weight of your body.

You don’t have to buy any special equipment to build muscle. Lift soup cans or books. Of course, you can buy inexpensive hand and ankle weights or a resistance band at your local sporting-goods store to use at home. Joining a health club will give you access to a variety of weight machines that can condition all of your muscle groups.

If you work out with weights or a weight machine, start with the heaviest weight you can manage to perform 8 to 15 repetitions without stopping. You may have to begin with weights as light as 1 or 2 pounds. Starting with weights that are too heavy can injure your muscles. Exhale as you lift or push the weight, and inhale as you relax. Never hold your breath during strengthening exercises because doing so can affect your blood pressure. Stop if you feel any pain while exercising. Gradually work your way up to heavier weights. (Lighter weights will increase your endurance but not your strength.) Keep using the weights until you can perform a set of 8 to 15 lifts two or three times without stopping between repetitions. Rest between the sets.

For best results, exercise all of your major muscle groups at least twice a week. Don’t work on the same muscle group 2 days in a row; give your muscles time to rest between workouts. Muscle soreness is natural for a day or two after doing muscle-building exercises.

Overtraining

Some people—especially those who are training for long-distance endurance events such as a marathon or triathlon—exercise too much without resting between workouts. Up to 60 percent of people who train for such events may exercise to the point of exhaustion, or overtrain. Overtraining can produce changes in the balance of hormones in your body and can suppress your immune system. Common symptoms of overtraining include fatigue, reduced athletic performance, sleep problems, muscle soreness, increased susceptibility to infection, or depression. Women who overtrain can experience potentially serious complications, including absence of periods (see page 846) and osteoporosis (see page 989).

Rest is the usual treatment for overtraining. Your doctor may recommend that you stop exercising for up to 2 weeks to allow your body to repair itself.

Flexibility Exercise

As you age, you become less able to move your muscles and joints through their full range of motion. Eventually, decreasing flexibility in your joints can reduce your ability to perform everyday tasks. Exercises such as stretching can help keep your muscles and joints flexible and easier to move. Stretching also protects your muscles from injury as you exercise or perform your daily routine.

You can increase your overall flexibility by making stretching a regular part of your warm-up and cool-down routines (see page 8). Stretching also can prevent or relieve muscle pain or cramps that can occur after vigorous exercise, especially in people who have just begun exercising after a period of inactivity.

The most important muscles to stretch are the hamstring (in the back of the thigh), lower back, and shoulder muscles. When you are stretching, keep the following tips in mind:

• Don’t stretch so far that you feel discomfort or pain; pain is a sign that you have stretched too far.

• Stretch slowly and smoothly; avoid bouncing or jerking.

• Hold the stretch. When you have reached a full stretch, hold the position for 30 seconds so your muscles and joints get the full benefit of the stretch.

Exercise-Related Problems

Weight-bearing exercises such as walking or jogging can put a lot of stress on your joints and muscles. Although everyone is at risk when starting an exercise program or when increasing the level of intensity or duration of an activity, overweight people are especially vulnerable to discomfort, pain, or injury from exercise. The most common preventable exercise-related injuries are sprains, strains, inflammation, and pain. If you have a serious injury, such as a broken bone, call 911 or your local emergency number or have someone take you to the nearest hospital emergency department.

Yoga and pilates are excellent forms of exercise for stretching and toning muscles because they put the joints through their full range of motion. These forms of exercise can also improve circulation, relieve tension, and reduce stress. You can probably find a yoga or pilates class at your local health club or community center; many businesses provide exercise classes for their employees. You can also learn the basic yoga postures and pilates exercises from videotapes and books.

Physical Activity and Children’s Health

Exercise is as good for children as it is for adults, and the habit of exercising regularly in childhood can lead to an active life in adulthood. Children who engage in regular physical activity gain a number of health benefits, including strong bones, muscles, and joints; lower blood pressure and improved cholesterol levels; weight control; improved self-image; and improved ability to handle stress. Many of these health benefits extend into adulthood. For example, exercising regularly before puberty may reduce the risk of bone fractures and heart disease later in life.

Encourage your children to stay physically active without pressuring them. Give your child a say in the kinds of activities he or she wants to engage in. Make sure the activities are appropriate to the child’s physical, mental, emotional, and social maturity. When helping him or her decide, consider the following guidelines:

• Ages 2 to 5 Children learn how to run, jump, throw, and catch. Encourage games that use these skills, but keep them simple and don’t encourage competition with other children.

• 6 to 9 years Children use the skills learned earlier to participate in simplified versions of games and sports. Continue to discourage competition in the early elementary grades. Instead, make sure every child participates.

• 10 to 12 years Motor skills and mental abilities are better developed at this age. Children can learn strategy and play organized team sports.

When your child exercises or participates in sports, make sure that he or she wears the proper clothing and uses the right equipment for the activity, including shoes that give good support and traction. Make sure your child has a sturdy bicycle and a helmet that fits properly, and make sure he or she wears it. Mouth guards are essential for protecting the teeth during contact sports such as football and soccer. Because of the way their bones and muscles grow, children and adolescents are prone to muscle tightness, especially in the hamstrings and quadriceps. For this reason, teach your child to stretch before exercising to prevent muscle and joint injury.

Because of their smaller size, children are more susceptible to dehydration than adults. Offer your child plenty of water—even before he or she feels thirsty—especially in hot, humid weather, and send a sports drink along to summer athletic games. Make sure your children wear sunscreen while exercising or participating in any activity outdoors, especially during the summer months.

3

A Healthy Weight

In the United States, two out of three adults and nearly 15 percent of children are overweight. Being overweight increases your risk of developing a number of common chronic illnesses, including heart disease, high blood pressure, type 2 diabetes, and some types of cancer. Overweight children are developing these disorders at younger and younger ages.

Obesity is a complicated chronic disorder caused by a combination of inherited, physical, behavioral, socioeconomic, and cultural factors. People seem to inherit a preset weight range below which it is difficult to stay. While it is possible to keep your weight down near the lower end of your inherited weight range, it would be difficult to stay below it permanently.

Are You Overweight?

Determining if you are at a healthy weight involves the number of pounds you weigh and the percentage of your body that is made up of fat. The way in which fat is distributed on your body—around your waist or around your hips—can also influence your health risks. Women naturally have more body fat than men, especially around the hips and thighs. There is no easy way to measure the amount of fat on your body, but in general, the more active you are, the less your percentage of body fat is likely to be. To find your healthy weight, check the body mass index (BMI) chart on page 11.

The Risks of Being Overweight

Being overweight is a major risk factor for a number of chronic disorders. Where on your body you carry excess weight can also influence your risk of health problems. People who tend to accumulate fat around their waistline are at greater risk of disorders such as high blood pressure, high cholesterol, type 2 diabetes, heart disease, and stroke than are people who tend to accumulate fat around their hips and thighs. Women are at increased risk of health problems if their waistline is larger than 35 inches; men if their waistline is larger than 40 inches. Your risk of health problems increases if your BMI (see page 11) is 25 or greater.

If you already have a health problem associated with being overweight, losing weight will probably help you control it. Even a 10 percent reduction in body weight has health benefits. For some disorders, such as type 2 diabetes and high blood pressure, weight loss can help reduce or even eliminate the need for medication. Even if you are overweight, if you exercise regularly, you can still gain benefits from physical activity, such as a reduced risk of heart disease.

Heart Disease

Being overweight is a major risk factor for heart disease. Although not all the mechanisms involved are known, several factors link obesity to heart disease:

• Being overweight increases the level of total cholesterol and other fats called triglycerides in the blood, which can cause fatty deposits to build up in artery walls.

• Being overweight lowers the blood level of HDL (good) cholesterol, which keeps blood vessels healthy.

• Being overweight increases the risk of diabetes, which increases the risk of having a heart attack.

High Blood Pressure

Being overweight is the No. 1 factor contributing to high blood pressure. In a large percentage of people who have high blood pressure, losing even a modest amount of weight—just 10 pounds—can often bring blood pressure down to a healthy level. Blood pressure readings go down within the first 2 or 3 weeks of weight loss. The percentage of a person’s weight that is made up of fat seems to affect blood pressure more than does total body weight. For this reason, strengthening exercises (see page 9) such as weight lifting, push-ups, and leg lifts, which build muscle and reduce body fat, can help keep blood pressure down.

Type 2 Diabetes

More than 16 million Americans have type 2 diabetes, and about a third of them don’t know it because the disorder causes no symptoms in the early stages. Type 2 diabetes tends to run in families, but being overweight is a stronger risk factor than heredity. This means that even if you have a family history of diabetes, you can prevent it or delay it by keeping your weight within a healthy range and getting plenty of exercise. Long-term effects of diabetes include blindness, kidney disease, and poor circulation (which frequently results in amputation of lower limbs). People with diabetes also have an increased risk of heart disease, stroke, and high blood pressure.

Cancer

Being overweight appears to increase a person’s chances of developing some types of cancer, including cancer of the gallbladder, colon, prostate, uterus, kidney, ovary, and breast. Obesity has also been linked to cancers of the liver, pancreas, rectum, and esophagus. Doctors don’t know exactly how obesity increases the risk of cancer because the mechanisms vary for different types of cancer and because obesity results from a complex interaction of inherited and lifestyle factors, any of which could influence the risk of cancer.

For example, kidney cancer is more likely to develop in people who have high blood pressure, which is common in people who are obese. Obesity’s role in esophageal cancer appears to be the link between obesity and gastrointestinal reflux disease (GERD; see page 750), which causes inflammation in tissues in the esophagus; chronic inflammation can cause precancerous changes in cells. Some cancers, such as colon cancer, breast cancer, and prostate cancer, seem to result from the interaction of a combination of factors such as diet, weight, and physical activity.

If you have a family history of any type of cancer, especially in a relative who developed cancer before age 60, you should be especially diligent about maintaining a healthy weight. Your doctor also will recommend regular screening tests such as a colonoscopy (see page 767) for colon cancer and a mammogram (see page 141) for breast cancer, usually beginning at about age 40.

Joint Problems

Joint problems frequently develop in people who are overweight. Excess weight increases pressure on the joints in the knees, hips, and lower back, causing the cartilage (the tissue that cushions and protects the joints) to gradually wear away, leading to a type of arthritis called osteoarthritis (see page 996). Over time, the joint damage can become so severe and painful that the joint may have to be surgically replaced (see page 1000). Inflammation of the tendons (tendinitis; see page 984) is also common in overweight people. The tendons can become sore and inflamed from such routine activities as walking. Losing weight reduces wear and tear on joints and tendons and can often help relieve the pain of osteoarthritis.

Sleep Apnea

Sleep apnea (see page 636) is a potentially life-threatening condition that is closely linked to being overweight. The disorder can cause breathing to stop for brief periods of 20 seconds or more several times a night during sleep. Sleep apnea can lead to congestive heart failure (see page 570) because the condition forces the heart to work harder to supply oxygen to the tissues. Weight loss often diminishes or eliminates sleep apnea.

Gallbladder Disease

The risk of developing gallstones (small, hardened masses of cholesterol, calcium salts, and bile pigments) rises as a person’s weight increases. Although doctors don’t fully understand why this occurs, they think that being overweight causes the liver to produce more cholesterol than usual, and excess cholesterol can form gallstones. People who are overweight also may have an enlarged gallbladder that does not empty normally or completely, which increases their risk of developing gallstones. People who carry excess body fat around the abdomen seem to be at greater risk of having gallstones than people who have excess fat around their hips and thighs.

Yet, although it may seem to be a contradiction, rapid weight loss also increases a person’s risk of developing gallstones. Doctors think that losing weight too quickly changes the balance of bile salts and cholesterol in the gallbladder, which increases the risk of gallstones. Also, following a very-low-fat diet or skipping meals can decrease contractions of the gallbladder, preventing it from emptying bile often enough, which can promote gallstone formation. The risk is higher when weight loss exceeds 3 pounds a week—a good reason to lose no more than 1 to 2 pounds a week.

Metabolic Syndrome

Metabolic syndrome is a set of symptoms that refers to a group of factors that, together, indicate a very high risk of developing diabetes and heart disease. Metabolic syndrome is extremely common, affecting about one in every three people between ages 40 and 60. The syndrome increases the likelihood of early death not only from heart disease, but from all causes. A diagnosis of metabolic syndrome is made when a person has at least three of the following five symptoms:

• A waist measurement of at least 40 inches for men and 35 inches for women

• A blood level of triglycerides (a type of fat) of 150 milligrams per deciliter (mg/dL) or higher

• A blood level of HDL (high-density lipoprotein), the good cholesterol, below 40 mg/dL in men and below 50 mg/dL in women

• Blood pressure equal to or higher than 130/85 millimeters of mercury (mm Hg)

• A fasting blood glucose level of 110 mg/dL or higher

Doctors think that lifestyle factors, especially being overweight, play a major role in the development of metabolic syndrome. The two major underlying causes of the syndrome seem to be eating a high-calorie, high-fat diet and not getting enough exercise. You can reduce your risk of having metabolic syndrome by consuming a low-fat, high-fiber diet that includes plenty of fresh vegetables and fruits, legumes, and whole grains, and by making 1 hour of physical activity part of your daily routine.

People who lose and regain weight repeatedly also seem to increase their risk of developing gallstones, especially when the losses and gains exceed 10 pounds—the more weight lost and regained during a cycle, the greater the risk of gallstones. The reasons for this are unclear, but doctors think that a rise in cholesterol during the weight-loss phase of the cycle may be responsible.

Losing Weight Sensibly

Many people have tried dieting and exercising to lose weight with only modest success. Losing weight is difficult, and going off of a diet is common, especially during holidays and on other special occasions. Successful weight loss depends on setting realistic goals. For example, losing 10 percent of your total body weight within 6 months is a sensible goal that you can probably reach and, most important, maintain. The sense of accomplishment you get from reaching your goal will encourage you to keep the weight off and possibly lose more.

Fad diets that promise quick and easy results usually deliver nothing but disappointment. Such diets can even harm your health. For example, diets that eliminate entire food groups such as carbohydrates can cause you to become deficient in essential nutrients such as amino acids. High-protein diets are often high in saturated fat, which can raise cholesterol levels. The surest way to lose weight and keep it off is by eating fewer calories and being more physically active. Follow the healthy eating advice in the Dietary Guidelines for Americans (see page 37).

Doctors recommend losing about 1 to 2 pounds per week. To lose 1 pound per week, you need to burn 3,500 calories more in a week than you take in. You can achieve this by reducing the number of calories you eat by 500 to 1,000 per day or by boosting the number of calories your body burns by the same amount, through increased physical activity. You can lose weight even faster by both reducing calories and exercising more. For example, an inactive 200-pound person who continues to take in the same number of calories but begins walking briskly 1½ miles each day will lose about 14 pounds in a year. By decreasing his or her calorie intake at the same time, he or she will lose substantially more.

About three fourths of the calories you burn every day are used to meet your body’s basic needs—sleeping, digesting food, and breathing. Any additional physical activity will burn extra calories. You use only a small number of calories when you sit quietly, but you can burn many more when you walk, ride a bike, jog, swim, lift weights, or play tennis. Engaged in the same activity, a heavier person burns more calories per minute than a lighter person does. For example, a person who weighs 150 pounds burns one third more calories than does a person who weighs 100 pounds. Working harder or faster at a given activity only slightly increases the number of calories you burn. Increasing the amount of time you spend on the activity is a better way to burn more calories.

WARNING!

Over-the-Counter Weight-Loss Drugs

Many over-the-counter weight-loss drugs contain phenylpropanolamine (PPA), which is also found in some over-the-counter nasal decongestants. (In 2004, the FDA banned the use of ephedra, also called ma huang, in over-the-counter products.) PPA can increase the risk of stroke from bleeding in the brain. Read all package labels carefully, and do not buy any over-the-counter drugs that contain PPA.

If you plan to start a weight-loss program to lose more than 20 pounds, it’s a good idea to talk to your doctor first, especially if you have a health problem, are significantly overweight, or have been inactive for a long time. In the meantime, here are a few helpful suggestions for successful weight loss:

• Get support from friends and family.

• Focus on the many positive health benefits you will get from losing weight.

• Eat smaller, more frequent meals.

• Don’t skip meals, especially breakfast.

• Set reasonable goals.

• Make gradual changes in your diet and level of physical activity.

• Exercise for at least 1 hour each day.

If You Are Underweight

Some people are underweight because of an eating disorder (see page 725) or because they have a condition, such as cancer, that causes weight loss. Because they need to maintain their weight or even add pounds, they have to take in more calories each day than they burn.

If you are underweight, you can do a number of things to gain additional pounds. Choose high-calorie foods, but make sure that they are rich in nutrients; good examples are peanut butter, cheese, and milk shakes. Eat high-calorie fruits such as bananas, dried fruit, and canned fruit in syrup. Eat high-calorie vegetables such as olives, avocados, and corn. Eat two or three snacks between the three main meals of your day, but leave plenty of time between your meals and snacks so that you don’t feel stuffed.

Add extra calories to your meals by using milk instead of water in soups and sauces. Put a slice of cheese over a baked potato or on your sandwich. Mix wheat germ or powdered milk into casseroles. Make high-calorie shakes with fruit juice, yogurt, and bananas, or buy liquid nutritional supplements.

4

Reducing Stress

The stress response is how the body reacts to threatening, overwhelming, or challenging circumstances. People can experience stress in many different types of situations, positive or negative. Some types of stress—the kind you experience when training for an athletic event, practicing for a piano recital, or meeting a deadline at work—can be useful because you learn or benefit from the experience. Other types of stress—losing a job or being unable to pay your bills—can be emotionally devastating and can affect your health.

The length of time stress lasts is the major factor in how harmful it can be to your health. Acute stress can be severe, but it doesn’t last very long. You may have a tight deadline at work, but as soon as it’s over, your body recovers from the pressure. In fact, in a situation such as this, the stress response is helpful—it prepares you to meet the challenge. Your nervous system stimulates the production of two stress hormones—cortisol and adrenaline—and increases your heart rate and blood pressure to keep you alert and energized to get the job done.

The most harmful kind of stress is chronic stress—uncontrollable stress that continues with no end in sight. Having a demanding job, caring for a loved one with Alzheimer’s disease, or living in extreme poverty are common sources of chronic stress. Long-term situations that are unpredictable, such as living with an abusive spouse, can also produce chronic stress. Traumatic events such as rape, a natural disaster, or military combat can cause a severe psychological disturbance called posttraumatic stress disorder (see page 720).

Chronic stress generates feelings of helplessness and hopelessness that can lead to major depression (see page 709). Constant stress can cause many other health problems, including irritable bowel syndrome (see page 765), high blood pressure, heart disease, and infertility (see page 493). Learning how to handle the stress in your life can help keep your mind and body healthy.

How Your Body Responds to Stress

The human body is designed to cope with sudden, short-term threats. Early humans had to fight for food and shelter and deal with attacks from predators to survive. Their bodies responded to an immediate threat by energizing them and sharpening their attention so they could either stand and fight or escape the danger (called the fight-or-flight response). Today your body responds in the same way—not only to a threat, but also to other pressures such as demands from your employer, children, and family.

When you face a potential threat, your emotions and senses alert a small center in your brain called the hypothalamus. The hypothalamus signals the pituitary gland in the brain and the adrenal glands (two small glands that sit on top of the kidneys) to release a number of different hormones. These hormones work together with your autonomic nervous system, the part of the nervous system that controls involuntary activities of your body such as breathing and heart rate, to prepare your body to respond to the threat.

Cortisol is one of the most important hormones the body releases in response to stress. Cortisol performs a number of functions in the body, but during stress it pumps glucose (sugar) into the bloodstream to fuel the body for action. It also temporarily suppresses some systems of the body that are not critical to the fight-or-flight response, such as the immune system. (See page 13 to learn how the actions of cortisol during chronic stress can adversely affect your health.)

At the same time, your body releases the hormone adrenaline (epinephrine), causing heart rate and breathing to increase, the airways and the blood vessels in the muscles to widen, and the pupils in the eyes to dilate (widen). Blood flows to the brain and muscles, where energy is needed most. Body processes that are not required for the threat response—such as digestion, growth, reproduction, and the immune response—shut down temporarily. Now your body is ready to face or retreat from the challenge.

Once the stressful event is over, your body returns to normal. Your pupils contract, your heart rate and breathing slow, and digestion proceeds as usual. Because the stress response was designed primarily as a survival mechanism, it activates easily but takes a long time to shut down, and you may need to make a conscious effort to bring your body back into equilibrium. Your nervous system triggers the relaxation response. Harnessing this power consciously can help you better handle the stress in your life (see page 59).

Each person’s response to stress differs, influenced by a combination of such factors as heredity; childhood experiences; personality; diet, exercise, and sleep habits; having or not having close personal relationships; and income level and social status. Some people seem less able to cope with life’s pressures, especially people who experienced severe stress during childhood.

One person may overreact to a relatively minor source of stress (such as missing a bus), activating a cascade of stress hormones that elevates his or her blood pressure and heart rate, while another person might shrug off the situation. Genes, personality, and reactions learned during childhood explain the differences between people’s responses to stress. A person may have inherited an overly sensitive stress response or may have learned to respond in this way from one or both parents. The answer probably lies somewhere between the two—an interaction of genetic makeup and experiences.

How Stress Can Make You Sick

The human body is not able to handle the constant release of powerful hormones triggered by chronic stress. The brain can easily become overloaded with the constant release of the stress hormone cortisol, which can kill brain cells directly, impairing a person’s ability to remember and learn. The constant release of cortisol makes us feel fatigued but we can’t sleep; then we get anxious and depressed.

Most people are aware of the psychological effects of stress, such as an inability to think clearly, make sound judgments, and remember. But stress also can produce angry outbursts, hostility, impatience, and reduced self-esteem, and can lead to depression and a wide range of physical problems, including headaches, indigestion, stomachaches (especially in children), and backaches. Stress can also cause dizziness, a rapid heartbeat, ringing in the ears, and muscle tightness.

Even more serious, stress can contribute to the development of heart disease by damaging the arteries. The increase in blood pressure that occurs during a stress response exerts so much force on the linings of the arteries that it injures them, triggering an immune system response and making the artery walls susceptible to the buildup of plaque—deposits of fat, cholesterol, calcium, and other substances. As these deposits build up, they make the arteries narrower and less able to carry blood to the heart.

The constant release of cortisol during chronic stress also causes high blood sugar (glucose) levels, triggering the release of the hormone insulin, which regulates the body’s use of glucose for energy. The excessive, long-term release of insulin can eventually make the body resistant to the effects of the hormone, a condition that causes glucose to build up in the blood. This buildup of glucose in the blood can lead to type 2 diabetes (see page 894).

Are You Under Too Much Stress?

If you are trying to cope with a stressful situation, you may be at increased risk of stress-related illness. Keep in mind that positive changes (such as getting married or having a baby) can produce stress just as easily as negative changes. Here are some examples of common stressful situations:

• Someone close to you died.

• You recently were divorced or separated.

• You or a family member has been hospitalized recently.

• You got married recently.

• You lost your job or retired.

• You are having sex problems.

• You just had a baby.

• Your finances recently became a lot better or worse.

• You changed jobs.

• A child has left home recently or come back home.

• You got a promotion at work.

• You moved, or are remodeling your house.

• Your job is at risk.

• You have taken on substantial debt, such as a mortgage.

Take steps to manage your stress before it overwhelms you or makes you sick. See the next page for the best ways to handle the stress in your life.

Stress and Sleep

Doctors have known for many years that lack of sleep can cause foggy thinking and poor concentration. But lack of sleep also can lead to potentially serious health problems. For example, chronic lack of sleep can place you at risk of developing type 2 diabetes (see page 894). Cortisol, a stress hormone that regulates the blood sugar glucose, seems to be to blame. Prolonged sleeplessness causes the body to continuously release cortisol into the bloodstream. This, in turn, causes a rise in glucose in the blood that prompts the body to release more and more insulin in an attempt to lower the glucose level. Over time, the increased production of insulin leads to insulin resistance, a condition in which the cells no longer respond to the effects of insulin; insulin resistance usually leads to type 2 diabetes. An excess of insulin in the blood also encourages the body to store fat, boosting the risk of obesity.

The chronic release of stress hormones caused by sleep deprivation affects your immune system, making you more susceptible to colds and infections. Also, because your immune system helps your body fight cancer, reduced immune system function from insufficient sleep can put you at increased risk of developing cancer.

Chronic lack of sleep can also accelerate the aging process. When you don’t get enough sleep, your brain doesn’t make the normal amounts of hormones, producing hormone levels similar to those of a much older person. However, subsequently getting a full night’s sleep reverses this aging effect, returning hormone levels to normal.

To get a full night’s sleep, try going to bed earlier than you usually do. Use some of the time you might spend relaxing in front of the TV for needed sleep. Keep your bedroom cool (but not cold); most people find it difficult to sleep in a room that is too hot.

If you have trouble getting a good night’s sleep, the following strategies may be helpful:

• Go to bed and get up at the same time every day—even on weekends—so you can program a sleep schedule into your body’s biological clock.

• Allow enough time each day for at least 8 hours of sleep.

• Engage in relaxing activities before bed. Read a book, listen to soft music, or do relaxation exercises (see page 59).

• Use your bed only for sleep and sex so your mind associates your bed with sleeping and relaxation.

• Drink a glass of fat-free milk before bed. The amino acid tryptophan in the milk will help make you feel sleepy.

• Don’t take work-related reading material to bed with you.

• Don’t watch an exciting TV show or read a book that is stimulating, frightening, or violent right before bed.

• Don’t exercise late in the day. Exercise increases alertness.

• Don’t drink alcohol late in the evening. Alcohol disrupts the sleep cycle.

• Don’t drink anything containing caffeine and don’t smoke for a few hours before bed. Caffeine and nicotine both stimulate the central nervous system.

• Don’t go to bed hungry or on a full stomach. Being hungry stimulates you, while being full can make you uncomfortable and restless.

If you continue having difficulty sleeping and it affects your daily routine, talk to your doctor. Insomnia may signal an emotional problem such as anxiety (see page 718) or depression (see page 709). For other possible causes of sleep problems, see the symptom chart on page 212.

How to Handle Stress

No one can avoid stress, but you can deal with it in effective ways that can help prevent health problems. You can learn coping mechanisms to help you manage your time better and change your response to situations that tend to cause you stress. You also can learn how to relieve stress and tension by counteracting the stress response with the relaxation response.

Manage Your Time

You will feel that you have more control over things if you manage your time better. Set goals and break large projects down into smaller, more manageable tasks so you feel that you’re accomplishing something. Organize your closet, your desk, your kitchen, and any other storage area so you can find things right away. Plan what you’re going to wear the next day the night before so you don’t have to rush in the morning. Do tedious tasks first to get them out of the way and limit procrastination. Establish a routine and follow it. If you can, delegate tasks to others. All these techniques can save time and minimize stress.

Exercise Regularly

Regular, vigorous exercise defuses stress by boosting the brain’s output of chemicals that counteract the effects of stress hormones. Exercise also gives you a sense of accomplishment, which increases your self-esteem. Improved muscle strength and fitness and the potential for weight loss also can make you feel better about yourself. Exercise fights depression and makes you more alert.

What kind of exercise is best? A combination of aerobic exercise—such as brisk walking, jogging, or swimming—and strengthening exercises such as weight training provide the most health benefits. For more information about exercise and how to incorporate it into your daily routine, see page 6.

Get More Sleep

Getting more sleep will help improve your judgment and make you feel better during the day. A good night’s sleep will also keep down the levels of stress hormones. Try to get at least 8 hours of sleep most nights.

Try not to think about your problems late at night. You will probably sleep better if you can relax for a few hours before going to bed. For many people, worries and concerns can seem overwhelming in the middle of the night. For additional suggestions on how to deal with sleep problems, see the previous page.

Eat a Healthy Diet

Eat a low-fat, high-fiber diet that contains plenty of fruits, vegetables, legumes, and whole grains. Avoid high-sugar, high-fat snack foods, which usually are also high in calories. That doughnut may give you a short-term boost but will soon make you feel weak and irritable as your blood sugar level plunges a few hours later. Limit your consumption of foods or drinks that contain caffeine; avoid them completely in the late afternoon and evening. Drink alcohol only moderately (one drink a day for women and two drinks a day for men) because it can disrupt your sleep. Also, because alcohol is a depressant, it can trigger depression in susceptible people.

Maintain a Positive Outlook

A negative attitude can make every task seem daunting. Although it can be difficult if you’re feeling low, try to replace negative thoughts with positive ones. For example, look at obstacles as challenges, and defeats as opportunities to try harder. Avoid negative people because it’s easy to be drawn into their pessimistic way of thinking. Seeing the humor in a situation can help lighten your mood.

Be Assertive

To get what you need, be assertive—but not aggressive. Aggressive behavior can be unhealthy for your relationships as well as for your health. Learn to ask for what you want. Don’t be afraid to say no to additional work you can’t possibly handle or to the person who always wants to chat during the work-day and keeps you from doing your work. Keep in mind that being assertive doesn’t mean being angry or rude, taking advantage of someone, or hurting someone’s feelings.

Make Time for Leisure Activities

Plan some time each day for yourself, even if it’s just a few minutes to read a book or magazine or take a long bath. On your days off, do something fun with your family or a friend. Take a vacation every year or at least try to get away for a long weekend. If you can’t leave town, take time off work to relax at home, finish projects, or enjoy hobbies or other activities.

Concentrate on the Present

Don’t brood about things that happened in the past. Holding on to regrets, anger, or old grudges is especially harmful because it can keep you from enjoying life. Don’t worry about the future. Think about the future in terms of changes you can make. Try not to worry about circumstances you cannot control.

Take Action

Once you have decided what to do about a problem, act quickly and decisively. Being proactive can give you a sense of accomplishment and can often immediately eliminate a source of stress. However, don’t act impulsively—especially if you are angry. Wait until you have calmed down and worked out a sensible plan before you take action.

Don’t Play the Blame Game

Avoid blaming other people for your problems. Even if you have been treated badly, holding on to feelings of anger, frustration, or hostility can be harmful to your health. Also, blaming other people prevents you from making positive, constructive changes that can help you avoid similar problems in the future.

Get Help

If you feel that you can no longer cope, get help. Talk to your doctor, contact your hospital social services department, or go to a community mental health agency for a referral to a mental health professional. You also may benefit from joining a support group for people who have similar problems. Your doctor may recommend counseling to help you learn more positive ways to deal with stress or may prescribe medication such as an antidepressant. Medication can sometimes be effective for treating stress, but it is most effective when used in conjunction with one-on-one counseling or therapy.

The Relaxation Response

Developed by Herbert Benson, MD, at Harvard Medical School in the early 1970s, the relaxation response is a simple technique that draws on the meditative practices of Eastern philosophies. The relaxation response has been shown to reverse the effects of stress on the body. It is a simple technique that you can complete in about 20 minutes.

If you are experiencing stress, try to do this exercise twice a day (but wait until at least 2 hours after your last meal):

1. Sit quietly in a relaxed position.

2. Close your eyes.

3. Starting at your feet, consciously relax your muscles. Work your way up your body, relaxing your legs, pelvic region, back, chest, arms, neck, and face.

4. Breathe naturally with your mouth closed. Be conscious of your breathing. Say the word “one” silently to yourself every time you exhale.

5. If distracting thoughts enter your mind, ignore them and concentrate on your breathing. Let the thoughts pass.

6. Stay relaxed and concentrate on your breathing. Keep repeating “one” to yourself for 10 to 20 minutes.

7. When you are finished, don’t get up right away. Stay seated for a few minutes, first with your eyes closed and then with your eyes open, to gradually refocus on your surroundings.

8. Don’t worry about whether you have done the exercise correctly. Just allow the relaxation to occur at its own pace.

If you don’t have time to do the relaxation response exercise twice a day, or if you find yourself in an especially stressful situation, try to do the following exercise. This shorter exercise is especially helpful when you feel overwhelmed by events in your life and need a quick calming fix. You can do it anywhere—waiting in line, stopped at a red light, or on hold on the telephone.

1. Relax and focus on your breathing. Count slowly to yourself backward from 10 to zero, one number per breath.

2. When you reach zero, pause for a moment before resuming your activities.

3. If you don’t feel relaxed, repeat the exercise.

5

Staying Safe

Where you live, what you do for a living, and how you spend your leisure time are some of the factors that affect your health and safety. You can take a number of practical steps to help ensure that you and your family are safe at home and on the road. Many of these measures are simple—such as using seat belts each and every time you drive. Others—such as developing a home fire evacuation plan—require preparation and vigilance over time. If you use a commonsense approach to safety and supervise your young children, you can be assured that your family will remain relatively safe.

Keeping Your Children Safe

Young children rely on adults to protect them from accidents and injury because they lack the judgment and experience to protect themselves. A child’s natural curiosity and exuberance make him or her more prone to potential danger. Supervise your young child at all times while, at the same time, teaching him or her safe behavior—for example, by explaining why something, such as touching an electrical outlet, is dangerous. You can reduce your child’s chances of serious injury by making his or her environment as safe as possible. In addition, make sure that your child knows his or her address and telephone number by age 3 or 4 and how to dial 911 in an emergency.

Preventing Choking and Suffocation

A child can choke on any small object. Small toys, batteries, the tops of pens, safety pins, coins, push-pins, and earrings are just a few of the items that can cause choking. Keep all items that could cause choking out of the reach of young children. Also, children under 4 should not play with any toy that is less than 2¼ inches long.

Preventing children from choking on small objects

Young children, especially children under age 4 (who tend to put things into their mouth), have the highest risk of choking on small parts of toys or small toys. A device is available that tests small objects or toys to see if they pose a choking hazard. Or use the cardboard tube inside a roll of toilet paper. Place the toy or part in the tube or tester; if the toy or part fits, a child can choke on it.

Infants and children can easily suffocate if their mouth and nose become blocked. Keep plastic bags away from your children. Don’t put pillows or stuffed toys in your young child’s bed, and don’t put him or her to sleep on a water bed. Always put an infant to sleep on his or her back.

Children under age 2 can easily choke on food. A child’s chewing skills are not fully developed until about age 4. Teach your children early on to take small bites of food and to chew food thoroughly. For very young children, cut food into bite-size pieces and watch them while they eat. Don’t allow children of any age to talk, walk, or run if they have food in their mouth. Do not allow children to eat in a moving vehicle. If you must eat while traveling, pull over to the side of the road. Encourage children to sit down at the table to eat.

Foods that can cause choking

Never give hard foods such as nuts, hard candy, seeds, popcorn, or raw carrots or celery to children younger than 4 because they usually cannot chew them properly. Other foods young children can choke on include cookies, raisins, and pieces of raw vegetables or fruit. Cut up softer foods such as grapes or hot dogs and other meats into small pieces, or don’t give them to your child at all.

Uninflated or broken latex balloons are the No. 1 cause of choking in children. Young children are attracted to colorful, uninflated, or broken balloons and may put them in their mouth. The rubber can become lodged in a child’s windpipe, where it obstructs breathing. Never let your children—especially those under age 4—play with latex balloons. To prevent choking, purchase polyester film balloons for children’s parties because they don’t burst as easily and tend not to break into small parts.

Keeping Your Child Safe Around Pets

Choose pets carefully if you have children. Dogs and cats that are calm and like to be petted are usually good with children. Animals that seem nervous, unfriendly, or afraid can be unpredictable around children and don’t make good pets. Pets that become aggressive toward a child (for example, growling or attempting to bite the child) may be capable of causing serious injury. Supervise infants and children under 5 at all times around pets because pets can be jealous and because young children do not always know how to act around animals. Half of all dog bites to children are caused by the family dog. Get obedience training for your dog, and train it to obey commands from all family members. Keep a cat’s nails trimmed or get it declawed.

Tell your child to always ask for the owner’s permission before approaching an unfamiliar animal. Because dogs can get aggressive when they are defending their territory or themselves, tell children never to put their hands in a place where a dog is confined (such as a pen, car, or yard).

Demonstrate to your child how to safely approach and pet an animal. Keep your arms straight down at your sides, with your hands visible. Speak softly to the animal while lifting your arm slowly and letting the animal sniff your hand. If the animal seems receptive to more contact, gently and slowly touch the side of the animal’s head and start petting by scratching the animal behind the ears. Never put your hand on top of an animal’s head immediately. Stop right away and slowly back away if the animal shows any signs of aggression.

To be safe around animals, teach your children the following precautions:

• Walk slowly and keep quiet when around strange animals. Never scream or run.

• Avoid staring directly at or teasing an animal.

• Recognize the signs of a disturbed, angry, or frightened animal. For example, avoid dogs that are barking, growling, or showing their teeth; cats that are hissing; and cats or dogs that have their tails up or straight and their ears back.

• Never disturb an animal while it is eating—for example, don’t put your hand near a food bowl while the animal is eating.

• Don’t attempt to take a toy or bone out of a dog’s mouth.

• Don’t disturb an animal while it is sleeping.

• Never tease, hit, poke, or throw things at an animal or pull an animal’s tail or ears.

• Don’t touch or pick up strange animals. Stay away from baby animals because adult animals are protective of their young.

• Get an adult’s help if you see animals fighting. Don’t try to break up a fight between animals.

• After playing with animals (including turtles and other reptiles), keep your hands away from your mouth, and wash your hands immediately. Try to avoid letting an animal lick your face.

Childproofing Your Home

Hazards in the home injure or kill 2.5 million children nationwide every year. You can prevent injury to your children by childproofing your home before they learn to walk. Use the following guidelines to tackle this project, but keep in mind that no safety device is completely childproof. You still need to closely watch your young children to keep them safe.

• Buy safety latches and locks for cabinets and drawers in the kitchen and bathroom to prevent poisoning and other injuries. These inexpensive devices can stop your child from gaining access to household cleaners and other chemicals, medicines, and sharp objects such as knives. Make sure the latches and locks are sturdy enough to withstand pulling by small hands.

• Put up safety gates to keep children away from stairs and other dangerous areas in the home. At the top of the stairs, anchor the gate to the wall with screws so it can’t be dislodged. Check the gate to ensure that it has no openings large enough for a child’s head to fit through.

• In the kitchen, turn all stovetop pot handles inward when cooking so your child cannot reach up and pull down a pot.

• Set your water heater temperature no higher than 120°F to prevent scalding, or buy an antiscalding device for your faucets.

• Install spring-loaded electrical outlet covers to prevent electric shock and electrocution.

• Cut your window blind and drapery cords to prevent a child from strangling in the cord loops. You can also install cord cleats or tension devices to keep cords out of reach. Check at your local hardware store. You can get free replacement tassels, cord stops, and tie-down devices from the Window Covering Safety Council (1-800-506-4636).

• Put safety bumpers on the corners and edges of furniture and fireplace hearths to prevent injury should your child fall on them. Remove any furniture that has sharp corners and edges.

• Minimize your child’s exposure to lead (see page 425).

• Have your garage door professionally inspected to make sure that it is pinch-resistant and has properly working photo eyes and reversing mechanism. Teach children never to play with the garage door or its control panel or remote controls.

• Don’t keep a gun in the house (see page 72).

Crib and High-Chair Safety Standards

New cribs and high chairs must pass rigorous government safety standards before they can be sold, but many parents buy or borrow used cribs and high chairs or use cherished family heirlooms. Before you accept an older crib or high chair, check it to make sure it meets the following standards:

Cribs

• Slats are no more than 2½ inches apart.

• Surfaces contain no lead-based paint.

• End panels have no cutout patterns.

• Corner posts are flush with end panels.

• Mattress fits snugly and extends to all sides of the crib.

• Drop side has a locking latch that does not release accidentally.

• Mattress can be lowered as child gets older so he or she cannot climb out or fall out.

High chairs

• Waist- and crotch-restraining straps are present and do not connect to the tray.

• Tray locks firmly.

• Legs are wide apart, and the base is stable.

• All parts are securely attached.

• Chair locks so it cannot collapse with the child inside.

• Edges are rounded.

Protecting Children From Falls

Active, curious children are prone to falls. Hazards that are clear to adults may not be obvious to children. Supervision is still the best way to prevent injury. Give children extra guidance, especially when they are learning to walk. Make your home a safer place for children by following this simple advice:

• Never leave infants alone on beds or changing tables. Strap infants and toddlers securely into high chairs and strollers. Put guardrails on the beds of young children.

• Don’t use infant walkers. Not only can they roll down stairs, but they can also delay a child’s development of motor skills and may encourage a child to walk on his or her toes.

• Bolt safety gates to the wall at the top of stairs.

• Do not let children play on balconies or fire escapes.

• Install window locks or guards on all windows, or keep windows closed and locked when children are present.

• Supervise your children closely at all times while grocery shopping. Don’t let children of any age play with, push, climb in and out of, or ride on the outside of a grocery cart. Always strap babies and toddlers into a grocery cart; switch to another cart if the belt is broken or missing. Never let a child stand up or lean over while sitting in a cart. Children who weigh more than 35 pounds should not ride in the baby seat of grocery carts (even when the child is strapped in, his or her weight can make the cart top-heavy and tip it over).

Toy Safety

Toys can help a child have fun and learn. However, some toys pose a hazard to young children because they have small parts or can cause a fall. More than 100,000 children are treated at hospital emergency departments every year for injuries caused by toys. Sixty percent of these children are under age 4. Injuries often occur when a young child misuses or plays with a toy designed for older children. Boys are more susceptible than girls to injury from a toy. Most toy-related injuries occur to the head and face. Latex (rubber) balloons (see page 62), which cause choking, are by far the most dangerous toy. Riding toys such as toy cars, scooters, and bicycles account for a large proportion of toy-related injuries and deaths. Most injuries occur when a child falls from the riding toy, but they also occur when the child rides the toy into traffic or into a body of water.

Here are some tips to help you choose toys that are both fun and safe for your child:

• Look for toys that are designed for your child’s age group.

Falls From Windows

Unsupervised young children can easily fall from an open window. In the United States, 15,000 children are injured every year and 15 to 20 die after falling from a window. Five times more children who live in apartment buildings—especially those without air conditioning—fall from windows than children who live in single-family homes. A child can be injured or killed falling from a window of any height, even from a first-floor window onto a soft surface.

To keep your child from falling out of an open window, install window guards or window stops. The metal bars of most window guards are spaced no more than 4 inches apart. The guards screw into the side of a window frame, come in different sizes to fit various window types, and can be adjusted for width. Some window guards are designed to be opened easily by an adult (allowing escape from a fire) but are difficult for a young child to open. Window stops are metal locks installed on the sash of a window that can be positioned to allow windows to open no more than 4 inches.

Take these steps now to prevent your child from falling out of an open window:

• Teach your child not to lean on or play near windows.

• Don’t leave young children unsupervised in a room with an open window, even if the window is covered by a screen. Screens are designed only to keep insects out, and are not strong enough to keep a child from falling out of a window.

• Move furniture away from windows to discourage children from climbing up to them.

• If you must open a window, do so from the top instead of the bottom.

• Install (or ask your landlord to install) window guards or window stops that allow windows to open only a few inches.

Injuries From Trampolines

Trampolines have become a significant source of injury in children and adolescents. Visits to hospital emergency departments for injuries sustained on home trampolines nearly tripled from 1991 to 1999. Most injuries (including sprains, fractures, cuts, and scrapes) involve the arms, legs, and face, but a few cases of paralysis and death also have occurred. These injuries usually occur when children collide with another person on the trampoline, land improperly, fall or jump off the trampoline, or fall on the springs or frame. Most doctors believe that trampolines of any kind—outdoor or indoor—are unsafe, and doctors often discourage parents from buying them or allowing their children to play on them.

• Don’t let your child play with an inflated, uninflated, or broken latex balloon.

• Avoid toys with sharp edges or points, that shoot objects, or that are made of brittle plastic that could break into small pieces or leave jagged edges.

• Throw away plastic bags and wrappings immediately; a child can put these over his or her head and suffocate.

• Use a toy box with a lid that stays open in any position so it cannot fall on your child’s head.

• Check your child’s toys from time to time for broken parts and potential hazards. Repair or throw away damaged or dangerous toys.

• Instruct older children to keep their toys away from younger siblings and friends.

• Teach your child to put toys away when finished playing with them so no one trips or falls on them.

• Make sure your child wears a helmet every time he or she rides a bicycle, skateboard, or scooter.

• Check with the US Consumer Product Safety Commission (www.cpsc.gov) for toy recalls.

Bicycle Safety

To make each bike ride safe and fun, buy your child a bike that is the right size—not one that he or she needs to grow into. Adjust the seat and handlebars to fit your child properly. Your child should be able to put the balls of both feet on the ground while sitting on the seat. Check to make sure that all of the bike’s parts—including the brakes—are secure and in working order. If the bike you buy is used or if your child is using an older bike, have it tuned up and adjusted at a bicycle shop.

Never let your child ride a bike without a helmet, or with a helmet that does not comply with government product safety standards. Bicycle helmets can lower the risk of serious head injury by 85 percent. Choose a helmet that fits snugly and sits flat on the child’s head. If necessary, use the extra padding that comes with the helmet to ensure a proper fit. You can remove the padding as your child grows.

Most children are not ready to ride a bike without training wheels until they are 5 or 6 years old. Don’t purchase a bike with hand brakes for your child until he or she is older and a more experienced rider.

Children under age 9 should not be allowed to ride in the street. Children between ages 9 and 12 should ride in the street only when accompanied by an older adolescent or an adult. More than 70 percent of all motor vehicle collisions involving bicycles occur near driveways or at street or alley intersections, so tell your child to be especially vigilant at all intersections. Children under age 12 should walk, not ride, a bike through an intersection. They should stop at the intersection; look left, right, and then left again; and then walk their bike across the street before beginning to ride.

If you allow your older child to ride in the street, encourage him or her to wear brightly colored or reflective clothing or reflective tape on his or her ankles, wrists, back, and helmet and to avoid riding at night. Make sure that his or her bike has front and rear reflectors, and install bright lights on the front and back of the bike. No child should ever wear headphones while riding because they block out the sound of traffic.

The correct way to wear a bicycle helmet

Bicycle helmets are meant to be worn flat on top of the head, not tilted back at an angle. Make sure that the helmet fits securely and does not block your child’s field of vision. The chin strap should be snug, and the buckle should stay fastened throughout the ride. You can adjust the helmet’s fit with padded inserts and by loosening or tightening the chin strap.

Bike riders must obey the same traffic laws as drivers of motor vehicles. Teach your child how to signal for turns and to follow other rules of the road. Stress that he or she should always ride in the direction of traffic. Riding against traffic may cause motorists to drive across your child’s path or pull into him or her. When riding with your child in the street, observe all traffic laws, not just for safety’s sake, but also to set a good example.

A child in a bike passenger seat should not weigh more than 40 pounds or be taller than 3 feet 4 inches. When taking a child for a ride on a bike, use a rear-mounted seat that is firmly fastened over the back wheel. The seat should come with spoke guards that prevent the child’s feet and hands from getting caught in the wheel. Make sure that your child wears a bike helmet. Infants under 1 are too young to ride in a rear-mounted seat. Don’t carry an infant in a frontpack or backpack carrier that you wear because it will make you top-heavy as you ride, increasing your chances of toppling over with the baby.

If you tow your child in a buggy behind your bike, always strap him or her into the buggy and put a bike helmet on his or her head. Attach a flag on a long pole to the back of the buggy so that other riders and drivers can see you. Always ride on a bike path or street that has little traffic.

Scooter, In-Line Skate, and Skateboard Safety

Scooters, in-line skates, and skateboards account for a large proportion of childhood injuries. Children may be tempted to try difficult stunts while lacking the balance and body control needed to execute them safely. They also can collide with another rider or a pedestrian. Protective gear and common sense go a long way toward avoiding injury during these activities.

Scooters

Lightweight, foot-propelled or motorized scooters can cause injuries requiring a visit to the hospital emergency department. Eighty-five percent of scooter injuries occur in children under age 15. Falls resulting in bone fractures and dislocations, especially in the arms and hands, cause most of the injuries.

To prevent serious injury from a scooter-related fall, instruct your child to wear protective gear when riding a scooter, including a helmet that complies with government safety standards and knee and elbow pads. Check to see that the handlebars and foldable steering column are locked in place and that all nuts and bolts are secure. Encourage your child to ride his or her scooter on smooth, paved surfaces away from traffic (never in the street), avoiding water, gravel, or sand that could cause skidding and falls.

In-line skates

More than 100,000 people go to hospital emergency departments every year seeking treatment for injuries sustained while in-line skating. Skating safely on in-line skates depends on two factors—wearing protective gear and learning how to stop correctly. To prevent injury when in-line skating, your child should always wear a helmet that complies with government safety standards, knee and elbow pads, wrist guards, and gloves. Teach him or her to stop properly by using the brake pads, which are on the heels of most in-line skates: Put one foot in front of the other, raise the toes of the front foot, and push down on the brake with the heel.

Give your child the following tips: Always skate on smoothly paved surfaces, away from traffic. To avoid falls, don’t skate on water or gravel. Never skate at night when visibility is poor because you can’t see obstacles in your path, and drivers can’t see you.

Skateboards

Tens of thousands of people, mostly boys under age 15, are treated in hospital emergency departments for skateboard-related injuries every year. A third of the injuries occur in children who have been skate-boarding for less than a week. Common skateboard injuries include sprains, fractures, bruises, and cuts and scrapes from falls. Riding on irregular surfaces, performing risky stunts, and lack of experience, balance, and body control (which is common in children under 15) are factors that contribute to injuries. Falls and collisions with objects or vehicles such as cars can be fatal.

To lower your child’s risk of being injured while riding a skateboard, teach him or her to follow these safety guidelines:

• Check your skateboard after each use. Make sure it doesn’t have any broken or loose parts, sharp edges, or cracked wheels. If it does, don’t use it again until it has been fixed by a qualified repair-person.

• Wear protective clothing such as a helmet; slip-resistant, closed-toe shoes; elbow and knee pads; wrist guards; gloves; and a padded jacket and shorts. Protective gear is not required to conform to government safety guidelines, so be careful when making a selection. Choose gear that fits properly and does not obstruct your hearing or vision.

• Stay away from irregular surfaces. More than half of all skateboard injuries occur from riding on holes, bumps, rocks, or debris. Check the area where you intend to ride. Better yet, use a designated skateboard park.

• Don’t show off. Difficult stunts take careful practice in an area designed for skateboards. Never hitch a ride from a bicycle, car, or other moving vehicle.

• Learn how to fall. If you lose your balance, crouch down low (to shorten the distance you fall), avoid stiffening your body, and roll with the fall. Try to land on the fleshy parts of your body (such as the thighs or buttocks) instead of trying to break the fall with your arms or hands.

Playground Safety

Playgrounds are exciting areas for children to explore and develop motor and social skills. But no national regulations exist for the manufacture or installation of playground equipment, although the federal government has established voluntary guidelines for equipment and ground surfaces. When taking your children to a public playground, it’s up to you to check the equipment to make sure it is safe. Look for the following playground safety features:

• Surfaces around the playground equipment should have at least 12 inches of wood chips, mulch, sand, or pea gravel, or be made of safety-tested rubber material.

• The protective surface should extend at least 6 feet from play equipment in all directions. Surfaces around swings should extend to twice the height of the suspending bar both in front and in back.

• Play structures that are more than 30 inches high should be spaced at least 9 feet apart and have guardrails to prevent falls.

• Openings in guardrails or between ladder rungs should be less than 3½ inches or more than 9 inches.

• Sharp points or edges on hardware such as bolt ends should not protrude from the equipment.

• Tripping hazards such as tree roots or stumps or exposed concrete footings should be eliminated.

Don’t let young children climb higher than 4 feet (5 feet for older children) because, at greater heights, even recommended surfaces cannot adequately absorb a child’s fall. Check your neighborhood playgrounds regularly to make sure the equipment and surfaces are in good condition. Always keep an eye on your children at the playground because supervision is the best way to prevent injuries.

Child Safety Seats

In the United States, motor vehicle collisions are the No. 1 cause of death among children. The best way to protect your child from the risk of injury and death on the road is by using a child safety seat. When purchasing a child safety seat, select one that is right for your child’s age and weight, and make sure it fits in your car. Before buying a car seat, try it out in your car to make sure it can be installed properly. Nearly four out of five child safety seats are used improperly because the methods of attachment in different types of motor vehicles vary widely. The three most common mistakes people make when installing car seats are failing to belt the seat into the vehicle tightly enough, keeping the harness straps too loose, and not placing the harness retainer clip at the level of the child’s armpit.

All child safety seats manufactured after September 2002 have been standardized. Every new vehicle sold in the United States includes an installation system that uses upper tethers and lower anchors to secure child safety seats. The system, called LATCH (which stands for “lower anchors and tethers for children”), makes it unnecessary to use seat belts to install car safety seats. However, owners of vehicles manufactured before September 2002 must still use the seat-belt method of installation. And parents still have to use seat belts to fasten booster seats for children who weigh 40 to 60 pounds.

Types of Child Safety Seats

Infant-only seats and convertible infant-toddler seats

Child safety seats for infants under 20 pounds come in two types—infant-only seats and convertible infant-toddler seats. Infant-only seats are more portable and may be more comfortable, but babies outgrow them in the first year, so you will need to buy another safety seat. You can use a convertible infant-toddler safety seat in a rear-facing position until your infant weighs 20 pounds. Then you can use it facing forward when your child weighs 20 to 40 pounds. No matter what type of seat you choose, infants always must face the rear of the vehicle to protect their head, neck, and back in a collision.

Booster seats

Booster seats are designed for children who are too big for a child safety seat but too lightweight and short to use just the vehicle’s seat belts. Children need a booster seat if they weigh 40 to 60 pounds or are shorter than 4 feet 9 inches. Riding buckled up in a vehicle without a booster seat forces the shoulder belt to fall across the child’s neck. To avoid this discomfort, many children place the shoulder belt under their arms, which can cause serious injury in a collision. Booster seats raise the child up so the shoulder belt falls across the chest and shoulder. The seats come in two types—high-backed, belt-positioning booster seats, and shield booster seats. For either type, make sure the child uses both the lap belt and the shoulder belt, not just the lap belt, for proper protection.

School Bus Safety

A school bus is a relatively safe mode of transportation for children. Even when a school bus is involved in a collision, its occupants are unlikely to sustain serious or fatal injury. But your child can be at risk of being hit by a school bus if he or she does not follow school bus safety procedures. Teach your child the following guidelines to make the ride a safe experience every day:

• While waiting for the bus, stay out of the street and alleys and keep at least 3 feet away from the curb.

• Stay away from the curb and wait to board until the bus has stopped completely and the driver opens the door.

• Use the handrail when getting on the bus.

• Make sure your scarf, book bag, and coat don’t get caught in the door of the bus.

• Find a seat right away, sit down and rest your back against the back of the seat, and buckle your seat belt.

• Keep your personal belongings out of the aisle.

• Don’t put your arms, hands, or head out the window.

• Wait for the bus to stop completely before unbuckling your seat belt and getting out of your seat.

• If you have to cross the street in front of the bus, walk along the side of the street until you can see the bus driver before walking across the road. Wait until he or she signals that it is OK to cross. Look both ways when you reach the center line of the road.

• Always stay away from the rear wheels of the bus.

School bus danger zones

A school bus that is stopped on the side of a street creates several danger zones in which it is impossible for the bus driver—and passing drivers—to see pedestrians. Unless they are getting on or off the bus, children should stay at least 10 feet away from the bus on all sides (diagonal lines). Children are the least able to be seen by the bus driver when they are next to the front of the bus and on the right side along the back (shaded area).

Stranger Danger

Tens of thousands of children are reported missing each year. Teach your children not to talk to or get into a car with someone they don’t know. Talk to your young children about being observant and cautious around strangers, even seemingly friendly ones (but be careful not to scare them). Adolescents also are vulnerable, so talk to your teenagers about personal safety. Share the following guidelines with your children:

• Always tell your parents where you are going and when you will return. If your plans change, call your parents to tell them where you will be.

• Avoid talking to people you don’t know or don’t know well. Some strangers pretend they need directions, or help with something. Don’t feel guilty about not answering a stranger—adults should ask other adults (not children) for help. Strangers may tell you that your parents are in trouble and that they will take you to your parents. Don’t be tricked into going anywhere with anyone you don’t know.

• Never, ever get into a car with a stranger.

• Don’t take anything from a stranger.

• Don’t accept a message from your parents through another person unless he or she uses a code word that you and your parents have decided on ahead of time.

• Always travel with at least one friend, whether you are walking or riding your bike.

• Never give anyone you don’t know well your name, phone number, or address—in person or over the telephone.

• Don’t take shortcuts through woods, empty lots, empty buildings, or dark alleys.

• If you are home alone, keep the door locked and don’t let anyone in—even someone you know—unless your parents have told you it’s OK to do so.

• If you feel that you are in danger, run to a nearby house, restaurant, or store to ask for help.

• If a stranger grabs you, fight back and yell, “I don’t know you!” or “You’re not my mom (dad)!” Keep fighting and yelling. Make as much noise as you can.

• Tell your parents if an adult has asked you to keep something a secret—that person might be threatening your safety or that of a friend.

• Tell an adult you trust if you see anyone acting suspiciously around a playground, school, or public rest room.

Internet Safety

Advances in computer technology allow children to have access to new sources of information on the Internet. These same advances can expose them to pornography and violence and leave them vulnerable to exploitation by online sexual predators. To lower the chances of your child being victimized, take the following steps:

• Keep the computer in the den or family room—not in your child’s bedroom—so the screen is visible to all family members.

• Use blocking software and other parental control devices provided by your service provider.

• Explain the possibility of online sexual exploitation, especially in chat rooms, to your child.

• Ask your child to show you his or her favorite Web sites and discuss his or her choices.

• Check your child’s e-mail messages from time to time, and tell your child why you are doing so.

• Find out if computer safeguards are used by your child’s school, the library, and the parents of your child’s friends.

• Teach your children never to arrange a face-to-face meeting with strangers they chat with online, never post photographs of themselves on the Internet, and never give out identifying information such as a telephone number.

Here are some signs that your child might be engaging in potentially risky behavior on the Internet:

• Your child turns the computer screen off or changes it when you come into the room.

• Your child spends long periods of time online, especially at night.

• You find pornography on your child’s computer.

• Your child gets or makes phone calls to numbers you don’t recognize, especially long distance.

• Your child gets mail or gifts from someone you don’t know.

• Your child uses an online account belonging to someone else.

If you notice any of these signs, talk to your child about your suspicions openly. Explain that even if your child is a willing participant, he or she is not at fault because the adult always bears full responsibility for such exploitation. If your child ever receives child or adult pornography online or in the mail or if anyone ever sexually solicits your child, call your local police and the Federal Bureau of Investigation.

Keeping Your Home Safe

Many people are injured in their own homes. This section covers basic safety guidelines you can use to make your home as safe as possible. Go through your home room by room to check for safety hazards, especially those that might not be easily visible. Taking a few simple measures, such as installing carbon monoxide detectors and keeping stairs free of clutter, can eliminate many potential dangers.

Preventing Falls in the Home

Falls are the leading cause of accidental death and one of the major causes of injury and death among people older than 65. Most fatal falls occur within the home, mainly on stairs and steps, or from beds and ladders. People over 65 are at increased risk of falling because of reduced vision, slower reaction times, and medical conditions and medications that can affect balance.

You can lower the chances of falls in your home by taking a few simple precautions to fallproof your home. Take steps now to reduce clutter and eliminate slippery surfaces. For ways to protect children from falls, see page 64. Here are some examples of things you can do to make your home safer:

• Outside Repair any damaged steps or broken pieces of concrete on sidewalks. Rake or sweep away slippery, wet leaves from sidewalks, stairs, and porches. Eliminate ice from these areas during the winter.

• All rooms Keep electrical and telephone cords away from where people walk. Pick up toys, clothes, newspapers, books, and any other items that don’t belong on the floor. Pack away and store extra furniture. Keep your floors clean and dry, and don’t wax them. Make sure lighting is adequate. Teach pets not to jump on you or weave between your legs. Arrange your furniture to provide open walkways. Eliminate glass tables, which can shatter during a fall, and furniture that has unprotected sharp edges. If you use area rugs, make sure they have a nonskid backing.

• Kitchen and bathroom Clean up spills and wipe away standing water immediately. Don’t climb onto the counter to reach items on a high shelf; use a sturdy step stool. Place a night-light in the bathroom and in the hallway that leads to it. Place a rubber mat or nonskid stickers in the tub.

• Stairways Pick up clutter and toys on the stairs. Install handrails on both sides. Put a night-light on the stairway. Consider installing a carpet runner if the wooden steps are slippery.

Protecting older people from falls

As people get older, they can become more susceptible to falls because of increased use of medications, disorders that affect the joints (such as arthritis) or nervous system (such as Parkinson’s disease), and age-related changes such as decreased vision and hearing. Add such factors as reduced muscle strength and poorly designed living spaces, and the chances of falling rise significantly. Falls can result in serious injuries, such as hip fractures, that can make the difference between a person’s being able to live independently and losing his or her independence. To reduce the risk of falling, changes may have to be made to an older person’s home. The nature and extent of the changes will depend on his or her physical condition and needs. These changes could be as uncomplicated as moving furniture or as extensive as adding a room. The most important changes to consider are providing adequate lighting, removing clutter, and altering or eliminating slippery surfaces.

Older people need more light than younger people to see properly. Place high-watt bulbs in lamps, and install night-lights in hallways and bathrooms and on stairs. Spatial perception also declines with age, so it’s a good idea to have noticeable color contrast between the floors and walls (preferably light carpeting or flooring and dark walls) to prevent bumping into walls. Mark the edge of each stair tread with a contrasting color, and paint or carpet the first and last step with a different color as a cue that steps are beginning or ending. Make sure there is enough contrast between the threshold and the adjoining floor to minimize tripping. Install handrails on both sides of all stairways, including those outside the front and back doors of the home.

Try to minimize changes in the surfaces of floors. Shag carpeting is especially dangerous because it can get caught on toes, canes, and walkers. Avoid using area rugs that can slip or that can trip a person when the edges turn up.

In the bathroom, install two grab bars in the tub or shower area, one positioned for support when getting in and one inside for exiting. They should be parallel to the floor, and their height should be determined by the height of the person most likely to use them. Be sure to attach the grab bars to an underlying stud so they do not pull away from the wall when in use. Put another grab bar next to the toilet in a position that is best for the user. Make sure the bathroom floor has rough, slip-resistant tile because an older person may not be able to wipe up spills and splashes right away. Place a rubber mat or slip-resistant stickers inside the tub.

Older people who use a wheelchair or walker will benefit from wider doors. If possible, increase the door widths to 30 inches, especially in the bathroom. Install a ramp up to the front door for wheelchair access.

Using Medications Safely

When you take different medicines, it can be difficult to remember what each drug is for, how to take it, and when. Expired medications have a way of accumulating, and may lose their potency or undergo a potentially dangerous change in their chemical makeup. You and your family should learn about the medicines you take—both prescription and over the counter—to make sure that you are using them correctly. Here are some tips to help you avoid costly or life-threatening mistakes:

• Make a checklist of all the medicines you take every day, including the name, amount, and times you take them. Put one copy with your medications and another in your wallet.

• Check the label on the container before you take a drug to make sure it is the right one. Never take medications in the dark.

• Take the medication exactly as your doctor prescribed it.

• Don’t take medications that are past their expiration date. Check the dates and throw away any medications that have expired.

• Never take medication that has been prescribed for someone else.

• Don’t stop taking a drug unless your doctor says it is OK to do so—even if you feel better.

• Don’t mix alcohol and medications.

• List all the drugs you are currently taking, and ask your doctor or pharmacist if they can interact when taken together. (Try to use just one pharmacy.)

• Tell your doctor right away about any unwanted side effects.

• Keep medications in a cool, dry place (preferably not in the bathroom medicine cabinet).

• Keep medicines in their original container. (Prescription bottles reduce the amount of light, which can affect some medications.) If you’re using a pill organizer, ask your doctor if it’s OK to mix the drugs inside the compartments. (When mixed together, some pills interact chemically.)

• Tightly close lids, use child-resistant caps if children live in or visit the home, and keep medications away from children.

Carbon Monoxide Poisoning

Carbon monoxide, a colorless, odorless gas, is the most common cause of death from poisoning in the United States, killing almost 300 people each year. Carbon monoxide is produced when a fuel burns incompletely, and it can easily escape from a defective or improperly vented home heating system. Inhaling carbon monoxide can cause flulike symptoms such as headache, dizziness, nausea, and light-headedness. These early symptoms can quickly progress to seizures, unconsciousness, and death. Entire families have died during the night from carbon monoxide poisoning caused by faulty heating systems.

The following measures can help prevent carbon monoxide poisoning in your home:

• Have new furnaces and gas appliances (such as water heaters) installed professionally.

• Have your furnace inspected and cleaned every year.

• Install a carbon monoxide detector on each floor of your home, including the basement.

• Check the carbon monoxide detector once a month, and replace the batteries at least once a year.

• Make sure all space heaters are properly vented.

• Never use gas or charcoal grills or kerosene lamps indoors.

• Camping equipment (such as portable heaters, lanterns, and stoves) can also emit carbon monoxide. Never use them indoors or while sleeping in a tent or camper.

• Don’t run your car in a closed garage, because vehicle exhaust contains carbon monoxide.

If your carbon monoxide detector alarm goes off, call the fire department immediately (even if you think it may only be a low battery) and evacuate your family from your home until the fire department gives you permission to go back inside.

Gun Safety

Half of all homes in the United States contain a firearm. But the risk to the people in the home, especially to children, far outweighs any security benefits—most shooting victims are family members or friends, not intruders. A person living in a home with a gun is 18 times more likely to be killed by the gun than is a stranger. The risk is higher if the home environment includes a person who is violent or verbally abusive, abuses alcohol or drugs, or is depressed. Each year, nearly 6,000 Americans under age 20 die of gun-related injuries, including unintentional injury, homicide, or suicide. For each child killed by a gun, four others are wounded, many so badly that they become permanently disabled.

To protect your family from gun-related injury, don’t keep a gun in your home. If you are concerned about protection, take other steps to protect your home and family—buy a home security system, put reinforced bars on your windows and dead-bolt locks on your doors, add outdoor lighting, and start a neighborhood watch program.

Many unintentional injuries occur because a curious child or adolescent plays with or handles an improperly stored gun. If you feel the need to keep a gun in your home for security purposes, or if you keep one or more for hunting, lower your family’s risk of injury and death by storing it unloaded (with a gun lock in place) in a locked cabinet or drawer. Make the key available only to responsible adults. Don’t tell your child where the gun is stored, because he or she may be tempted to show it off to friends. Keep the ammunition in a separate locked cabinet.

Teach your children never to touch a gun, and tell them to call you or another adult if they ever find one, even if they think it may be a toy. When your children are invited to another child’s house to play or if they are going to the home of a baby-sitter, ask if there is a gun in the home and if it is properly stored. If the gun is not properly stored, invite the other child or the baby-sitter to your home.

Fire Safety

More than 4,000 people in the United States die in fires each year, and an additional 25,000 are injured. Bedrooms are common sites for fires to start—especially electrical fires—and most home fires occur at night when people are asleep. Many fires occur when extension cords are overloaded or portable space heaters are placed too close to bedclothes or draperies. Other common causes of fires are children playing with matches and smokers falling asleep with a lit cigarette.

Preventing home fires

Fire is a major cause of injury and death and can rob you of your home and your most treasured possessions. Take steps now to protect your family and home from fire:

• Keep matches and lighters locked away from children.

• Keep bedding, clothes, curtains, and other combustible items at least 3 feet away from space heaters.

• Make sure electrical cords are not frayed, especially cords on electric blankets.

• Don’t overload wall outlets.

• Never smoke in bed.

• Replace any mattress made before 1973. (Federal mattress flammability standards were raised in 1973.)

• Install smoke detectors (see below) on every floor of your house. Have one close to the bedrooms.

• Avoid planting trees or shrubs that can catch or spread fire easily. Consider planting fire-resistant plants around your home.

• Have your home heating system checked by a professional every year.

• Place a fire screen in front of your fireplace.

• Get your chimney cleaned and inspected each year.

• Consider installing residential fire sprinklers.

Smoke Detectors Save Lives

Smoke detectors—small, battery-powered devices that sound an alarm when exposed to smoke or fire—dramatically increase your chances of survival in a fire. Install a smoke detector on every floor of your home, and make sure one is installed near the bedrooms. Test the smoke detector every month by pressing the test button on the front of the alarm. Change the batteries once a year. Smoke detectors need to be replaced about every 10 years, or according to the manufacturer’s guidelines.

The best way to protect your family’s safety in a fire is to have an escape plan that you practice every month. Plan at least two ways out of every room. If your secondary exit must be through a window, make sure you’ll be able to get to the ground safely. If necessary, buy a collapsible ladder that you can quickly and easily hook on the windowsill and hang out the window. If you have security bars or window guards on your windows, make sure they are the kind that have a quick-release device so they can be opened quickly in an emergency. Check all of your windows to make sure they are not painted shut or otherwise stuck in a closed position.

When you practice your escape plan, rehearse feeling your way out of the house in the dark or with your eyes closed. Practice feeling the doors (not only to be able to find them if you’re blinded by smoke, but also to feel if they are hot before exiting through them). Practice crawling low to the ground. Designate a meeting place outside of your house (such as at the end of the driveway or near a certain tree) where family members can meet after everyone has gotten out safely.

What to do in a fire

In a home fire, every second counts. A small fire can go out of control and become a major fire in less than 30 seconds. In only a minute, your house can fill with smoke and become engulfed in flames. The thick, black smoke produced by a fire produces total darkness, making escape more difficult. Room temperatures in a fire can quickly soar to 600°F at eye level, and inhaling superheated air can scorch your lungs. To safely escape a home fire, remember the following tips:

• Leave immediately. Don’t try to save your valuables.

• Stay low and keep your mouth covered. Crawl on the floor, under the smoke (which contains toxic gases that can disorient or overcome you).

• Feel closed doors for heat. Use the back of your hand to feel the top of the door, the doorknob, and the door frame. If they feel hot, use another escape route.

• Stop, drop, and roll. If your clothing catches fire, stop running, drop to the ground, and roll over and over until the fire goes out.

• Stay out. Once you are out of the fire, don’t go back in for anything.

• Call 911 from a neighbor’s house.

Home fire extinguishers

Fire extinguishers can put out a small fire in your home or contain it until firefighters arrive. Put a fire extinguisher on each floor of your home where the risk of fire is the greatest, such as in the kitchen and near the fireplace and furnace. Place it out of the reach of children and near an escape route. Read the manufacturer’s instructions so you will know how to use it if you have to.

Fire extinguishers come in different types, or classes. Each type puts out particular kinds of fires. Older fire extinguishers use colored geometric shapes with letter designations and two-word descriptions to differentiate the types of extinguishers. Class A extinguishers are identified by the capital letter A, a green triangle, and the words “ordinary combustibles” and can extinguish fires involving items such as cloth, paper, or wood. Class B extinguishers are identified by a capital B, a red square, and the words “flammable liquids” (such as grease, oil, gasoline, or oil-based paint). Class C extinguishers—identified by a capital C, a blue circle, and the words “electrical equipment”—put out fires involving electrical wiring, appliances, fuse boxes, and circuit breakers. Class D extinguishers are identified by a capital D, a yellow star, and the words “combustible metals.”

Many fire extinguishers can put out more than one type of fire and are labeled accordingly. Newer fire extinguishers use self-explanatory pictures and two-word designations to identify the types of fires they fight. The labels may also show a diagonal red line through a picture of a type of fire the extinguisher is not suitable for; for example, a diagonal red line through an illustration of an electrical plug and electrical outlet on fire means that the extinguisher should not be used to put out electrical fires. Some extinguishers can put out all types of fires.

High-rise fires

If you live or work in a high-rise building, become familiar with the special fire-safety and prevention measures required for these structures. Take part in fire drills, and practice escaping from your building on your own. The following simple fire-safety steps can help prevent loss of life in a high-rise fire:

• Learn your building evacuation plan and practice it.

• Recognize the sound of your building’s fire alarm and know the emergency number to call in your area. Don’t assume that someone else has already called for help.

• Never lock or prop open fire doors in halls or stairways.

• Install smoke alarms in your apartment or condominium.

If a fire occurs in a high-rise building in which you live or work, try to stay calm and follow these procedures:

• If you are in an apartment or office, feel all doors you use to escape to see if they are warm. If a door feels warm, don’t open it. Stay in the room and stuff cloths or tape in the cracks around the door, and cover vents to keep smoke out. Call the fire department and tell them where you are trapped; then wait to be rescued.

• If the door is not warm, stay low while opening it a bit to see if there is smoke or fire in the hallway.

• If you don’t see smoke or fire, follow your building’s evacuation plan to escape.

• Take the stairs down to the ground floor; never take an elevator.

• If you don’t hear the building’s fire alarm, pull the nearest fire alarm.

• If smoke or flames block your way out, go to a site far from the source.

• Once you are out of the building, stay out. Don’t go back for anything until the fire department says it is OK to do so.

• Tell the firefighters if you know of anyone who is trapped in the building.

Safety With Fireworks

Every year, thousands of people are treated in hospital emergency departments for fireworks-related injuries, and some die. Most of the injured are boys between ages 5 and 14 who play with fireworks such as bottle rockets and sparklers, which are sold legally in many states. Burns to the eyes, hands, and face are the most common injuries. Children lack the physical coordination to handle fireworks safely. The safest way to prevent injury from fireworks is not to buy them and to keep them out of your home and away from children. Enjoy fireworks displays at a local show put on by professionals who are trained to use them safely.

Motor Vehicle Safety

Driving defensively may not be enough to keep you safe on the road. Collisions and breakdowns can make you vulnerable to injury from passing vehicles. Alcohol is a factor in more than 40 percent of all fatal motor vehicle crashes, and nearly 300,000 people are injured in alcohol-related collisions each year. The best defense is to wear your seat belt each and every time you drive. Don’t forget to buckle up your children in an age-appropriate safety seat (see page 67), and never let a child age 12 or under ride in the front seat because of the risk of injury and death from a passenger-side air bag (see right).

Seat Belts Save Lives

Seat belts save thousands of lives each year. If you are not wearing a seat belt and you hit something or slam on your brakes, your vehicle will stop but you will keep moving until you hit the windshield, the dashboard, or the back of a front seat. Wearing a seat belt prevents your body from being thrown around inside or out of the vehicle and can help the driver maintain control of the vehicle in a collision. Buckle up on every trip, no matter how short, and teach your children how to buckle up correctly. Here’s the right way to wear a seat belt:

• Adjust the lap belt to fit low and tight across your hips and pelvis, not across your abdomen.

• Place the shoulder belt snugly across your chest, away from your neck.

• Never put the shoulder belt behind your back or under your arm.

After a Collision

Each year, about one in every eight drivers has a motor vehicle collision. Many are minor rear-end collisions. If your vehicle is rear-ended and you don’t feel safe or are uncomfortable getting out of your vehicle in traffic, signal to the other driver to follow you and then drive to the nearest police station, convenience store, or gas station to look at the damage and exchange insurance information. Some states require vehicles involved in a collision to remain at the site.

The following tips can help keep you safe when you are involved in a more serious collision:

• Stop your vehicle if it is safe to do so, and then carefully move it out of traffic if you can.

• Turn off the ignition of all vehicles involved in the collision.

• Check all the people in each of the vehicles to see if they need medical help.

• Call the police and, if necessary, call emergency medical assistance.

WARNING!

Air Bag Safety for Children

Air bags can save lives in a collision, but they inflate with a force powerful enough to kill or severely injure a child or small adult riding or driving in the front seat. Air bags can inflate after only a slight impact. Also, so-called smart air bags—which are designed to adjust their inflation force according to the size of the passenger or driver (or switch off entirely if the passenger is a young child)—are not 100 percent reliable. Any number of circumstances (such as humidity, shifting body weight on or off seats, the added weight of a child seat, extra tension in safety belts, and reclined seats) can cause air bags to deploy when they shouldn’t, or not to inflate when they should. All children age 12 or under (including infants) should ride in the backseat to prevent serious injury or death from inflation of the vehicle’s air bag.

If Your Vehicle Breaks Down

If your vehicle breaks down along a busy road or highway, your greatest danger is getting hit by a passing vehicle. The problem is worsened by the elimination of roadside shoulders, which were designed as a place for disabled vehicles to stop but, in many places, are now being replaced with additional driving lanes. The following steps can minimize the danger if your car breaks down on the highway:

• Pull off the road as far as possible.

• Turn on your hazard lights and the interior dome light.

• Put a white handkerchief or cloth on the antenna, and raise your hood.

• Don’t stand next to or behind your car, and don’t walk along the highway. If you can, wait on the other side of the guardrail, well away from the highway. Or wait for help inside your vehicle with the doors locked. If you have a flare, place it behind your stalled car.

• If you have a cell phone, call your auto club, a towing service, or the police.

• If someone offers help, don’t get in his or her car. Ask the person to call the police.

Driving in Bad Weather

To lower the chances of having your car break down during bad weather, winterize your vehicle according to the suggested maintenance schedule in your owner’s manual before winter begins. Regularly check your windshield wipers, lights, and fluid levels (including your windshield-washer solvent). Put snow tires on your car, if needed. Make sure the vehicle’s brakes and transmission are functioning properly. Lubricate the door locks and trunk lock to prevent them from freezing.

Prepare an emergency survival kit containing the following items, and keep it in the backseat or trunk of your car:

• Windshield scraper and brush, and snow shovel (in case of snow showers)

• Booster cables

• Flashlight and extra batteries

• Blankets or sleeping bags

• High-calorie, nonperishable food (such as dried fruit)

• First-aid kit

• Knife

• Extra clothing (in case yours gets wet)

• Small metal container and waterproof matches to melt snow for drinking water

• Bag of sand or cat litter for tire traction

• Tool kit

• Tow rope

• Compass and road maps

If a severe storm is forecast, ask yourself if the driving trip is really necessary. If you must drive a long distance and your trip cannot be delayed, listen to weather forecasts (both before you leave and on your car radio as you drive) to find out about current road conditions, or call your state’s weather hot line for current information.

Use these guidelines to increase your chances of reaching your destination safely:

• Tell your family or a neighbor where you are going, the route you plan to take, and when you expect to arrive. When you get to your destination, call the person and tell him or her that you have arrived safely.

• Fill your gas tank before you leave to prevent ice from blocking the fuel lines, which could keep the car from starting.

• Ask someone to go along so you don’t have to drive alone.

• Clear your windows of snow and ice. Don’t start out until your windshield is defrosted.

• Be ready to turn back if weather conditions become threatening.

• In fog, drive with your headlights set on dim, or use fog lights. (Bright lights reflect off the fog, which can decrease visibility.) If the fog gets too dense, pull off the road and wait for the fog to lift. Don’t drive at very slow speeds in fog because you can get rear-ended.

• In snow or icy conditions, slow down and keep more distance than usual between your vehicle and the one in front of you.

• Watch for slick spots on bridges and overpasses and in shaded spots.

• If the pavement is slick, start slowly from a stop and brake gently and early. If you have antilock brakes, do not pump your brakes. If your car begins to slide, keep your foot off the gas pedal and brake. Steer into the direction of the skid until you feel the tires’ traction; then straighten out the vehicle.

• If a snowplow is coming toward you, stay to the right to allow room for the center line to be cleared. If the snowplow is in front of you, stay back to avoid being sprayed with salt or sand. Pass with care and only when you can see the road ahead of the plow; blowing snow can hide an oncoming vehicle.

Water Safety

Water is an inviting place for family fun, whether at the beach, at a pool, or on a lake or river. But drownings and water-related injuries can occur quickly. The most important step you can take to keep your family safe in and around water is to make sure that every member of your family knows how to swim.

To stay safe whenever you are swimming, boating, or engaging in other water sports, follow these water-safety tips:

• Learn to swim.

• Swim only in supervised areas.

• Obey all posted rules and signs.

• Don’t drink alcohol.

• Check the weather conditions; stop swimming in bad weather.

• Know what to do in an emergency.

• Don’t swim too far from safety.

• Make sure a pool is deep enough for diving or jumping by easing yourself into the water first.

• Wear a life jacket when boating or rafting.

• Protect yourself from the sun.

Water Safety for Kids

In the United States, drowning is the leading cause of accidental death in children under age 4. A young child can drown in a few seconds in 1 inch of water left in a bucket or wading pool. Even older children are at risk—drowning is a common cause of death in children under age 15. Follow these simple measures to protect children from water accidents:

• Always supervise children closely when they are around water, and make sure they wear a US Coast Guard-approved life preserver or life jacket whenever they are in a boat or near a body of water. Don’t rely on inflatable toys or water wings to keep a child afloat.

• Never leave young children alone in the tub, even for a few seconds. Bathtub seats are not safety devices and can tip over, trapping a child underwater.

• Empty the bathtub and all buckets immediately after use.

• Install a toilet lid lock to prevent children from falling into the toilet.

• Sign children up for swimming lessons at about age 5. Children younger than 5 are not yet ready to learn how to swim and may take risks around water.

• Teach children never to swim alone.

• Warn children about the dangers of walking or skating on frozen lakes or rivers.

Home Swimming Pools

Nationwide, hundreds of drownings occur in home swimming pools each year. Most of the casualties are children under age 5. Young children are unpredictable and need to be supervised constantly around water. It takes only a second for a child to become submerged—with no time to scream for help. Some simple measures can lower the chances of having an accident in your home pool:

• Never leave a child in a pool unattended.

• Keep a phone by the pool so you can call for help quickly.

• Learn cardiopulmonary resuscitation (CPR), and insist that all your baby-sitters learn it too.

• Don’t get a home swimming pool until your youngest child is 5 years old.

• Encircle your pool with a self-locking fence that is at least 48 inches tall and has vertical bars spaced no more than 4 inches apart. The fence should completely separate the pool from the house. Don’t leave furniture or toys near the fence that a child could climb on to reach the pool.

• Keep a pole, rope, and personal flotation device near the pool for rescue purposes.

• Make sure that no standing water has collected in the pool cover; drownings can occur in inches of water.

• Prevent electric shock by keeping electrical appliances away from the pool.

At the Beach

The beach is a great place to take your family for recreation. To make each trip to the beach as safe as possible, follow these beach-safety measures:

• Stay inside the designated swimming area, preferably in sight of a lifeguard.

• Don’t swim alone.

• Check beach conditions for bad weather or other potential hazards.

• Don’t swim near piers, rafts, docks, pilings, or diving platforms—you could injure your head, neck, or spine, or someone could dive into you. Also, rip currents (seaward-moving water currents, which are difficult to swim against) tend to intensify around fixed objects such as piers.

• If caught in a rip current, swim parallel to shore until you are out of the current. Don’t try to swim against the current.

• Be alert for dangerous aquatic life such as jellyfish.

• Stay close to the shore so you have enough energy to swim back.

6

Preventing Violence

Violence is a major public health problem in the United States. The homicide rate is at least two to three times higher in the United States than in any other industrialized nation, and the homicide rate among Americans under age 24 is nearly eight times higher.

This chapter focuses on violence in the home. Family violence includes spouse abuse, child abuse, and elder abuse, but it also extends to violence in the media, which has been shown to increase aggressive behavior in children. You will learn how to prevent violence within your family, what to do if someone you know becomes a victim of violence, and how to protect yourself from sexual assault. You also will find tips on teaching your children to solve problems without resorting to violence.

Family Violence

In the United States, most violence is committed in the home by family members—men against their partners, parents against their children, or adult children against their elderly parents. Spouse abuse, also called domestic violence or battering, is the most common form of family violence and the most common cause of injuries to women. Each year, millions of children and as many as half a million elderly Americans become victims of abuse.

Spouse Abuse

Spouse abuse is recurring coercive behavior intended to intimidate a partner through physical battering (including slapping, punching, kicking, or choking), emotional abuse, sexual assault, or enforced social isolation. Restricted access to or deprivation of food, money, transportation, or employment also is considered spouse abuse. The abuse usually escalates in frequency and severity.

In most cases of spouse abuse, women are abused by their male partner. Women who are at the highest risk of being battered are those who are single, separated, or divorced; who are between ages 17 and 28; who abuse alcohol or other drugs; who are pregnant; or who have excessively jealous or possessive partners.

Spouse abuse occurs in all racial, ethnic, and socioeconomic groups. One out of four American women is abused by a partner at some time in her life. Spouses are not the only victims of domestic violence. Child abuse (see next page) also occurs in up to half of all homes in which a spouse is abused.

Many people who are victims of battering hesitate to seek help or leave their situation. They feel ashamed and humiliated and fear that seeking help will jeopardize their safety or their children’s safety by making their partner angry and triggering more violence. Others are prevented from getting help because they are not allowed out of the house or because they lack the money or transportation to leave. Some battered spouses, because they witnessed spouse abuse in their homes during childhood, fail to recognize that their own relationship is abusive. Cultural, ethnic, and religious factors may make it difficult for a spouse to leave an abusive relationship.

Many abusers grew up in families in which they witnessed spouse abuse or experienced child abuse. Use of alcohol and illegal drugs also contribute to violence because mind-altering substances can severely impair judgment and lower inhibitions.

If your partner ever uses violence against you—even once—take it seriously. You are not to blame for being abused. If you are a victim of domestic violence, talk to your doctor. He or she can treat any injuries and can give you the phone numbers of local organizations that can provide help. Don’t allow shame or embarrassment to keep you from getting the help you need. Call your local spouse abuse center or battered women’s shelter and ask what you should do. If you feel that your life is threatened, call the police. You also can call the National Coalition for Domestic Violence hot line at 1-800-799-7233.

Child Abuse

Because they are young and dependent on adults for care and guidance, children are vulnerable to abuse. Child protective services agencies across the United States receive nearly 3 million reports of child abuse every year, but because many more cases go unreported, the actual incidence of child abuse is thought to be much higher. About three American children die each day from abuse or neglect. Child abuse or neglect is the No. 1 cause of death in children under age 5.

The abuser usually is a child’s parent or caregiver, and the problem occurs in all racial, ethnic, and socioeconomic groups. Child abuse is a repeated pattern of any of the following types of abusive behavior:

• Physical neglect Failure to meet a child’s physical needs, including lack of supervision; inadequate food, shelter, or clothing; abandonment; denial of medical care; or poor hygiene. Physical neglect is the most common form of child abuse.

• Emotional neglect Failure to give a child affection and the guidance needed to develop emotionally by ignoring him or her, withholding affection or attention, or withholding praise.

• Educational neglect Failure to enroll a child in school, or overlooking or encouraging truancy.

• Emotional abuse Impairing a child’s emotional development by screaming, name-calling, shaming, belittling, or telling the child that he or she is bad or worthless.

• Sexual abuse Sexual exploitation of a child, including sexual contact between an adult and a child, child pornography, child prostitution, or on-line solicitation of a child for sexual purposes.

• Physical abuse Slapping, punching, shaking, burning, biting, choking, throwing, whipping, or paddling a child, whether or not an injury results. Any intentional injury to a child.

The incidence of all types of child abuse is roughly equal among boys and girls, with the exception of sexual abuse, which occurs more frequently to girls than to boys.

Various factors contribute to child abuse, including parental use of alcohol or other drugs, poverty, inadequate parenting skills, and violence within the family. (Some experts also consider witnessing violence in the home to be a form of child abuse.) Children with special needs are especially vulnerable to abuse because their caregivers may be unprepared to provide adequate care or consider them less valuable than other children.

Corporal punishment (such as spanking) has the same effect on children as child abuse. Younger children, especially, cannot distinguish between being spanked as punishment and being spanked in anger. Although spanking a child may make him or her obey immediately, it will not affect a child’s behavior over the long term, teach him or her right from wrong, or prevent future misbehavior. Being disciplined with violence teaches children to resolve problems with violence. For these reasons, you should never use corporal punishment to discipline a child. Instead, give your child a time-out or take away a privilege. Some states allow corporal punishment in schools; if your child’s school allows corporal punishment, protect him or her by working with the school to eliminate this practice.

Child abuse can have serious, long-lasting consequences for a child and can lead to a psychological disorder called posttraumatic stress disorder (see page 720). Girls who are sexually abused are at especially high risk of smoking, abusing drugs, dropping out of school, stealing, engaging in sexual activity at a young age, or having multiple sexual partners. Many children who were abused have difficulty forming and maintaining healthy relationships in adulthood.

If you know a child who you think may be a victim of abuse or if you think you may be at risk of abusing a child yourself, get help. Call your local child protective services agency or the national child abuse hot line at 1-800-4-A-CHILD (1-800-422-4453).

Teaching Your Child Nonviolent Problem-Solving

Young children often express their needs and emotions without thinking about how they affect other people. Teach your child to be assertive enough to have his or her needs met, without being aggressive. The following steps can help your child become a person who is thoughtful and considerate of other people:

• Give your child plenty of love, respect, and attention. He or she will feel secure and will imitate your behavior when interacting with others.

• When your child says or does something hurtful to another person, ask him or her to think about how the other person must be feeling and to apologize.

• Teach your child to use positive problem-solving skills such as talking instead of yelling or hitting.

• Teach your child to treat everyone with respect.

• Don’t use corporal punishment to discipline your children. Violence doesn’t change behavior in the long run and teaches children to resolve problems with violence.

• Don’t let your child watch violent TV shows, movies, DVDs, or videotapes or play violent interactive video or computer games. Frequent exposure to media violence increases aggressive behavior in children.

• Never allow your child to carry a weapon for self-defense. Knives or guns can easily be stolen or cause unintentional injury.

Media Violence

More than half of all current television programming contains some type of violence. Two thirds of programming targeted to children contains violence. Exposure to violence on television can have a long-term negative impact on children. In addition to desensitizing children to violence, viewing violence on television may increase aggression, as children try to imitate the violence they see. They may learn to accept violence as a legitimate way of solving problems. Seeing violent images on TV also can make a child afraid. Movies, music videos, interactive video games, and computer games are additional sources of violent images.

The two most important things you can do to protect your children from media violence are to prohibit them from watching TV programs and playing video games with violent content. Here are some additional tips:

• Never put a TV or video game player in your child’s bedroom.

• Watch what your children are watching so you can monitor their viewing and talk about the programs.

• Teach your children the difference between real life and the fantasy portrayed on TV. Tell them about the real-life consequences of the violent acts they see in the media. Talk about nonviolent ways the characters could have solved their problems.

• Don’t buy violent video games or computer games for your children.

• Don’t take your children to movies or let them watch rented movies that are not recommended for children.

• Write letters to TV station program managers to request better programming for children.

Gang Violence

A street gang is a group of young people who engage in antisocial, destructive, or violent behavior, often involving criminal activity. A street gang typically claims a particular city block or street corner as its turf and vigorously defends it. Gang problems occur primarily in large cities, but gang activity is occurring increasingly in the suburbs and in rural communities. Although the majority of gang members are boys, girls organize and are involved in their own gangs in many areas.

Much violence occurs between gangs and inside the gang itself. For example, gangs often initiate new members through vicious beatings and may expect new members to commit violent crimes such as armed robbery, rape, drive-by shootings, or even murder to gain acceptance by the group. Sometimes innocent bystanders become victims of gang violence.

You can make a difference by volunteering to work with young people, serving as a mentor, or providing opportunities for young people to engage in productive neighborhood projects and activities. Be vigilant about potential gang activity by always removing graffiti on your property and asking the police to discourage young people from loitering. Organize a neighborhood watch program and always report gang activity to the police. Find out what the local gang colors and styles of dress are, and discourage your children from wearing them so they won’t be mistaken for a gang member.

Elder Abuse

Experts estimate that more than 450,000 older Americans living at home are abused or neglected every year. People age 80 or older experience abuse and neglect two to three times more often than younger people, and older women are abused more often than older men. Two thirds of all abusers of the elderly are their adult children or spouses. The most common forms of elder abuse include:

• Neglect Failure to provide or pay for care, shelter, or other necessities for an older person.

• Emotional abuse The use of insults, threats, humiliation, social isolation, or verbal assaults to inflict emotional pain.

• Physical abuse The use of physical force to inflict pain, injury, or impairment.

• Abandonment Desertion of an older person at a hospital, nursing home, shopping center, or other public location by a caregiver.

• Financial exploitation Personal use of an older person’s financial resources by a caregiver.

• Sexual abuse Any kind of nonconsensual sexual contact with an older person, as well as taking sexually explicit photographs.

Signs of elder abuse can vary widely, ranging from bruises or broken bones and untreated bedsores to sudden changes to a will or bank account. Older people and their caregivers share a complex relationship in which the caregiver has power over the person’s basic needs. This power can easily deteriorate into control or coercion, especially when family members are not equipped to handle the role of caregiver, are under extreme stress, or have personal problems such as substance abuse or emotional disorders.

If you provide care for an older person and you feel that you cannot handle your caregiving responsibilities, talk to the person’s doctor or to a social worker at your local hospital. They can refer you to community resources, such as respite care, that can provide needed help. If you suspect an older person might be a victim of neglect or abuse, call your local police department, your local public health department, or your state or local area agency on aging.

Sexual Assault

Sexual assault is any type of forced or nonconsensual sexual contact, including rape and forced touching or fondling. Rape is a crime of violence and aggression during which an offender (usually a man) forces a victim (usually a woman) to have sexual intercourse as a way of expressing dominance and control. Women are more likely to be raped by someone they know—a friend, a boyfriend, a date, or a neighbor—than by a stranger.

Do what you can to help people who have been victims of sexual assault. Work with others to prevent future sexual assaults. For example, ask your neighborhood group, school, employer, church, or library to sponsor a talk on rape prevention. Volunteer your time at a rape crisis center.

Protecting Yourself From Sexual Assault

To protect yourself from sexual assault—by someone you know or by a stranger—take the following precautions:

• Take self-defense classes.

• Set clear limits in your romantic relationships.

• Understand that sexually provocative actions and dress could invite unwanted attention.

• Don’t let alcohol or other drugs impair your judgment.

• If a situation makes you feel uncomfortable, leave.

• When walking, be aware of your surroundings.

• At home, keep doors and windows locked, especially at night. Install a peephole in your front door. Never open the door to strangers.

• Check the identification of all service people before allowing them into your home. Don’t admit anyone with whom you have not made an appointment in advance.

• Be vigilant in isolated areas such as apartment building laundry rooms, parking lots and garages, and your workplace after hours.

• Don’t walk or jog alone in deserted areas or at night.

• Have your key ready as you approach your door or car.

• Park in well-lighted areas and check the backseat of your car before getting in.

• Never pick up a hitchhiker or offer a ride to a casual acquaintance.

What to Do If You Are Sexually Assaulted

Most experts say that fighting back and trying to run away are the best defenses against rape. A rapist is motivated by the need to overpower and control you; he wants you to be compliant. Fight back, scream, and try to run away if you are attacked.

Take the following steps if you have been raped:

• Report the rape immediately to the police or to a rape crisis center to increase the chances that the rapist will be caught. Most sexual offenders repeat their crime until they are caught.

• Preserve the physical evidence. Don’t shower or bathe, change clothes, brush your teeth, or wash or throw away any of your clothing until the police tell you that it’s OK to do so.

• Immediately go to a hospital emergency department, a rape crisis center, or your doctor’s office for medical treatment.

• Seek professional help to cope with your feelings.

• Don’t blame yourself.

7

Complementary and Alternative Medicine

Complementary and alternative medicine refers to healing approaches or philosophies that are generally not offered by conventional medical institutions or Western medical schools. People use these treatments in a variety of ways—alone or in combination with other alternative therapies, instead of conventional treatments, or, most often, in addition to conventional treatments.

If you are using an alternative therapy or are considering trying one, tell your medical doctor. Using an alternative therapy as a substitute for conventional therapy without receiving an accurate diagnosis from a doctor can be harmful to your health. In addition, combining some treatments can be dangerous. For example, some herbs can interact with prescription or over-the-counter medications. Although results from an increasing number of studies on alternative therapies are being published in mainstream medical literature, there remains a general lack of understanding about how conventional and alternative therapies function together. Ask your doctor for scientific information about the safety and effectiveness of a particular treatment you are considering, or consult a reliable source, such as the National Center for Complementary and Alternative Medicine at the National Institutes of Health, for guidance.

The complementary and alternative approaches discussed here are a few examples of the more popular treatments people are trying. These discussions are not endorsements by the American Medical Association of any treatments or therapies. The most widely used alternative treatments include herbal therapies and dietary supplements, acupuncture, mind-body therapies such as meditation, and manipulative therapies such as massage and chiropractic.

Alternative Medical Systems

Alternative medical systems are complete systems of medical theory and practice that have developed outside of conventional medicine. Some systems, such as homeopathy and naturopathy, evolved inside Western culture. Others, such as Chinese medicine and Ayurveda, developed in Eastern cultures. Other traditional medical systems exist in Native American, African, Middle Eastern, and South American and other cultures. Fragments of these medical systems still exist in the folk medicine practices of many of the people in these cultures, as well as those of many immigrants to the United States.

Homeopathy

Developed in Germany in the 1790s by a physician, homeopathy is based on the theory that “like cures like.” According to this theory, natural ingredients that produce certain symptoms in a healthy person can cure the same symptoms in a sick person when the substances are highly diluted and given in small doses. Homeopathic doctors believe that the more highly diluted the substance, the stronger the medicine. They consider medicines produced in this way to be safer, producing fewer side effects than conventional medicines. The homeopath takes into account the person’s personality and mental and emotional states before prescribing a remedy. Homeopathy is used to treat a wide variety of illnesses. Its theoretical base has not been proven by medical science. A variety of published studies on homeopathy have had mixed results.

Naturopathy

Naturopathy is an alternative medical system in which practitioners use natural healing forces in the body to help the body cure itself. Typical therapies include changes in diet, massage, water therapy, light therapy, soft tissue manipulation, and exercise as well as interventions such as acupuncture (see below) and minor surgery. Naturopathy views disease as an alteration in the process by which the body stays healthy and emphasizes the reestablishment of health over the treatment of disease. The effectiveness of naturopathy has not been proven scientifically.

Chinese Medicine

Traditional Chinese medicine is an ancient system of health care that is based on the concept of chi, or qi (pronounced “chee”), the vital energy that flows throughout the body in specific pathways called meridians. According to this theory, disease occurs when the balance of chi is disrupted in the body. Chinese medicine uses a constellation of herbal remedies, nutritional therapy, physical exercises such as t’ai chi, meditation, acupuncture, acupressure, and massage to bring chi back into balance, a process that is thought to cure disease.

Acupuncture

Acupuncture is a Chinese medical technique in which a practitioner punctures the person’s skin with very fine needles at points along the meridians through which chi travels to relieve the blockage of the body’s vital energy. Sometimes the needles are twirled, warmed, or stimulated electronically. The needles have tapered tips and usually do not draw blood or cause bruising when placed into the skin. In the United States, acupuncture is used primarily for pain disorders, including back pain and migraines, and is sometimes used as an anesthetic. In China the technique is used widely to treat many medical problems and as an anesthetic during surgery.

Moxibustion and cupping are two treatment methods that are closely related to acupuncture. Both use the meridian system central to acupuncture theory and are often performed at the same time as acupuncture. In moxibustion, practitioners burn a herb called mugwort over the skin or on the acupuncture needles to intensify their effects. In cupping, a substance is burned under a glass or bamboo cup, which is then placed over an acupuncture site. The process causes suction that draws blood to the surface of the skin.

In Western medicine, there is no equivalent to the concept of chi, and researchers are looking for a scientific explanation for acupuncture’s effectiveness. The meridians along which the needles are placed do not correspond to the nervous system or any other major body system. However, acupuncture treatments for pain have been shown by imaging techniques such as magnetic resonance angiography (MRA) to produce changes in the body that seem to be associated with pain relief.

Acupressure

Another component of ancient Chinese medical practice, acupressure is the application of sustained fingertip pressure on specific points of the body (meridians) to prevent or alleviate disease by balancing the flow of the body’s vital energy (chi). The fingertips may be rotated slightly to activate the flow of energy. Acupressure, which is based on the same concept of meridians as acupuncture, is used to treat headaches, pain in the lower back, and a number of other problems.

A Japanese offshoot of acupressure called shiatsu also uses finger pressure on the meridians of the body, but applies different techniques to stimulate the flow of energy. Shiatsu was developed in Japan centuries ago.

Ayurveda

Ayurveda, which means “knowledge of life,” is an ancient medical system dating back to 3000 BC and is still practiced in India today. Ayurveda attempts to restore the innate harmony of a person by treating the body, mind, and spirit equally. As in Chinese medicine, health is believed to be determined by the balanced flow of the life force, called prana in India. Traditional Ayurvedic treatments include diet (which recommends some foods and restricts others), fasting, exercise, meditation, herbal remedies, massage, sun exposure, and controlled breathing exercises. Yoga (see page 94) is an important practice of Ayurvedic medicine. If illness cannot be cured using such methods, stronger treatment is given, including purges, emetics (drugs that induce vomiting), and enemas.

Folk Medicine

Folk medicine is the treatment of illness according to the traditional practices of the people of a given culture. Virtually every culture has its own traditional folk medicine practices. Folk remedies typically use herbs and other natural substances. Treatment may be given in the person’s home or at the home of a local healer. Many folk remedies have been used for thousands of years and may have health benefits that are poorly understood by medical science. Others may be useless or harmful.

While folk medicine may be appropriate in its traditional setting, it can be dangerous when taken out of its cultural context and practiced by someone outside of the culture. Always talk to your doctor before trying any folk medicine practice.

Herbal Remedies and Dietary Supplements

Plants have been used for centuries to prevent and cure diseases and disorders and to relieve pain. Many drugs in use today are derived from plants, but the Food and Drug Administration (FDA) also has approved more than 200 plant products for sale as dietary supplements. In the United States, dietary supplements are regulated as foods, not drugs. This means that the FDA does not require dietary supplements to undergo the same rigorous approval process required of prescription and over-the-counter medications before they appear on the market. In addition, manufacturers are not required to provide the FDA with evidence that their dietary supplements are safe or effective before marketing them. However, the FDA can remove a supplement from the market if it determines that the product is unsafe.

As with pharmaceutical drugs, the effects of herbs can vary greatly from one person to another, influenced by factors such as weight, sex, age, and general physical condition. In addition, the effects of herbs can be more subdued than those of pharmaceutical drugs, and herbs tend to have less noticeable side effects. But unlike most standard medications, herbal remedies can contain potentially harmful substances because of the lack of regulations for production. A manufacturer’s growing conditions, storage, handling, and preparation also can affect potency.

Always let your doctor know about any herbal remedies or dietary supplements you are taking. Don’t self-medicate with herbs or supplements without talking to your doctor first and getting a diagnosis. Some of these products can have harmful interactions with prescription and over-the-counter medications. For example, ginkgo biloba can cause excessive bleeding when taken with anticlotting medications such as aspirin or warfarin.

Some doctors recommend that people stop using supplements for at least 3 weeks before having elective surgery. Although adverse effects are rare, taking some herbs or dietary supplements before undergoing surgery can be harmful. Some supplements can speed or slow heart rate, intensify the effects of anesthesia, inhibit blood clotting, or cause the body to reject a transplanted organ.

The herbs and supplements discussed here are among the most common in the United States. Research has supported the use of some of these substances. For others, however, there is no scientific proof of effectiveness.

Aloe Vera

The gel of the aloe vera plant is used to treat burns and heal skin infections. Companies that make skin-care and cosmetic products incorporate aloe into many of their preparations, including hand lotions and shaving creams. The dried outer leaf of the aloe plant is ingested as a powder or dissolved in liquids to aid digestion and relieve constipation. Aloe may cause intestinal cramping, so you should not consume it if you have an inflammatory intestinal disorder (see page 764) such as Crohn’s disease or ulcerative colitis or if you have an intestinal obstruction. Do not take aloe during pregnancy because it can trigger contractions of the uterus. Children younger than age 12 should not consume aloe because of its laxative effect.

Black Cohosh

Also known as black snakeroot or bugbane, black cohosh is a traditional Native American remedy for snakebites and gynecologic disorders. Derived from a plant from the buttercup family, black cohosh is used as a dietary supplement to treat hot flashes and other symptoms of menopause, such as mood swings, insomnia, and vaginal dryness. It also is taken for the relief of premenstrual syndrome (PMS; see page 850).

Alternative Therapies for Menopause

Deciding whether to use alternative therapies after menopause is a decision that many women face as they get older. Hormone therapy (see page 853) with estrogen is very effective in relieving symptoms of menopause—such as hot flashes and vaginal dryness—but some forms of hormone therapy carry small but known health risks, especially with long-term use. Many women are considering alternatives to hormone therapy in hopes of alleviating their symptoms and possibly reducing the risks of heart disease and osteoporosis.

Options that postmenopausal women have explored include natural or plant estrogens, acupuncture, and herbal supplements such as black cohosh, red clover, hops, dong quai, and ginseng. Of the herbal supplements, black cohosh seems to be the most effective in reducing symptoms of menopause, but not enough evidence exists to determine whether any of these therapies are safe over the long term. Limited studies have shown that plant estrogens—such as those present in soy products, wild yams, and flaxseed—may benefit some women who have hot flashes. With so many women seeking effective alternatives to estrogen, researchers are studying many of these plant substances to understand their effects on women’s health. The best course is to talk to your doctor about your personal risks and the possible benefits and risks of using hormone therapy or alternative therapies to reduce your menopausal symptoms.

Several scientific studies have shown that black cohosh improves menopausal symptoms. However, most of these studies have been short-term, and little is known about the long-term effects of the supplement. For this reason, you should not take black cohosh for more than 6 months, and must not take it if you are pregnant or breastfeeding. Side effects can include stomach discomfort, headaches, and possible weight gain.

Cayenne

Also called capsicum, capsaicin, or red hot pepper, cayenne is an antioxidant that when eaten stimulates blood flow and metabolic rate and strengthens the heartbeat. It may also reduce blood cholesterol and triglyceride levels. Cayenne tastes hot, but it actually lowers body temperature by stimulating the cooling center of the hypothalamus in the brain. When applied to the skin, cayenne first stimulates and then blocks pain receptors. It is used as an active ingredient in creams and lotions to decrease pain associated with conditions such as arthritis (see page 996), fibromyalgia (see page 985), and shingles (see page 936). Although eating foods seasoned with hot pepper (such as cayenne) does not cause ulcers, people who have ulcers sometimes have discomfort after eating spicy foods.

Chamomile

When taken internally, usually in the form of tea, chamomile is a digestive aid and mild sedative. It contains a compound called coumarin, which relieves muscle spasms, including spasms of the intestine. Allergic reactions to chamomile are common, especially in people who are allergic to rag-weed. Externally, chamomile extract is used in cosmetics to treat inflammation of the skin and mucous membranes. But avoid using chamomile around the eyes because it can cause irritation.

Vitamin Megadoses

Taking large doses of some vitamins—especially antioxidants (nutrients that destroy cell-damaging substances called free radicals)—is a popular way to try to prevent disease, maintain health, and slow aging. Theoretically, antioxidants such as selenium and vitamins C and E can prevent disease and slow aging by blocking damage to cells. However, there is little scientific evidence to support these theories.

Fat-soluble vitamins—such as vitamins A, D, E, and K—are stored in the body’s fat cells. If you take too much of a fat-soluble vitamin, it can build up in your body and cause harm. Most vitamins work together with other nutrients to finely balance the complex chemical processes in your body. Taking too much of one vitamin or mineral without a similar increase in the other nutrients can upset this delicate balance. It is best to get most of your vitamins and minerals from a varied diet that contains plenty of fruits and vegetables, supplemented by a daily multivitamin that contains the recommended doses of vitamins and minerals.

Coenzyme Q-10

Coenzyme Q-10, also known as ubiquinone, is a compound made naturally by the body. It helps cells produce energy and acts as an antioxidant, protecting cells from damaging free radicals (harmful by-products of the body’s normal chemical processes). Naturally made quantities of coenzyme Q-10 in the body decrease as people age. Coenzyme Q-10 is marketed in the United States as a dietary supplement in pill form that protects the heart and stimulates the immune system. Coenzyme Q-10 may also be beneficial as an addition to conventional treatments for cancer and congestive heart failure. No serious side effects have been reported from the use of coenzyme Q-10; it does, however, lower the effectiveness of the anticlotting drug warfarin, so you should not take coenzyme Q-10 if you are taking warfarin.

Melatonin

Melatonin is a hormone produced by the pineal gland in the brain at night, when it is dark, to help regulate the sleep-wake cycle. The level of the hormone falls in the morning, when it is light.

Some people take melatonin supplements to help ease the symptoms of jet lag (brought on by a change in time zone that disrupts the sleep-wake cycle) or as a temporary sleep aid. However, there are no definitive studies proving melatonin’s effectiveness for either jet lag or insomnia, and doctors caution that taking it could reduce the body’s own production of the hormone. Also, because melatonin can interact with other hormones, it should not be taken by women who are pregnant or breastfeeding, or by children. In people with asthma, the supplement may increase asthma symptoms during the night. Possible side effects associated with melatonin include headache, diminished sex drive and fertility, and excessive sleepiness.

If you are thinking about taking melatonin, talk to your doctor. Melatonin may interact with some medications, and the long-term effects of taking melatonin supplements are not known. Also, like all supplements, its manufacture is not regulated by the FDA, and dosages have not been standardized.

Echinacea

Also called purple coneflower, echinacea was initially applied to the skin as a folk remedy to heal wounds. Today it is taken internally to boost the immune system and to treat upper respiratory infections such as colds and the flu. Studies testing its effectiveness in reducing cold symptoms have had mixed results. Echinacea can cause allergic reactions in some people or interfere with immune-suppressing drugs (such as those prescribed to prevent rejection after an organ or tissue transplant).

Ephedra

Also called ma huang, ephedra is a herbal Chinese medicine used for treating asthma and hay fever. Ephedra contains chemicals that have powerful stimulating effects on the nervous system and heart. Because ephedra suppresses appetite and burns fat, it was frequently used as a weight-loss supplement. The supplement was implicated in several deaths, and, for this reason, the FDA banned its use in products in 2004.

Green Tea

Green tea is a drink made from the steamed and dried leaves of the Camellia sinesis plant, a shrub that is native to Asia. The Chinese have been drinking green tea for thousands of years to promote health. Green tea is used to relieve stomach problems (including vomiting and diarrhea), to prevent tooth decay, and to reduce blood pressure and cholesterol levels. Because green tea contains cancer-fighting antioxidants, some researchers think it may protect against some cancers. Research is ongoing to understand the effects of green tea against cancer. In some people, green tea can cause allergic reactions. Because green tea contains caffeine, you should not drink more than 2 cups a day if you have an irregular heartbeat or panic attacks.

Evening Primrose Oil

Evening primrose oil, extracted from the seeds of the primrose plant (a tiny wildflower), is sometimes used for breast pain and the skin conditions allergic dermatitis and eczema. It is also used to reduce the symptoms of premenstrual syndrome (PMS) and menopause, rheumatoid arthritis, nerve damage from diabetes, asthma, and headaches. There is no scientific evidence showing that the supplement is beneficial. Do not use evening primrose oil with an antiseizure medication because it can lower the medication’s effectiveness.

Feverfew

The herb feverfew is a folk remedy used to help regulate the menstrual cycle. Some people take it to treat migraine headaches and the symptoms of rheumatoid arthritis. Do not use feverfew with nonsteroidal anti-inflammatory drugs or with anticlotting medications such as warfarin or aspirin because it can increase bleeding. Because feverfew can induce menstruation, it should not be used during pregnancy.

Garlic

The cloves of the garlic plant are thought to have antibacterial, antiviral, and antifungal effects. These immune-boosting effects may also help prevent some cancers. People use garlic to treat a variety of conditions including colds and other upper respiratory infections. Garlic contains an ingredient that has been shown to lower cholesterol and triglyceride levels, help prevent blood clots, and possibly help lower blood pressure.

The only known side effects of garlic are allergic reactions in some people, stomach upset, and bad breath. You should not use garlic with anticlotting medications such as warfarin or aspirin (because it can increase bleeding) or if you are breastfeeding (because it can alter the taste of breast milk and possibly cause colic in your infant).

Ginger

Ginger ingested as a powder or in liquids is taken to prevent motion sickness and to relieve nausea and vomiting, including that caused by chemotherapy, pregnancy, or anesthesia. It is considered a natural anti-inflammatory and can be helpful for inflammatory conditions such as rheumatoid arthritis. Ginger can cause mild stomach upset or allergic reactions in some people. Do not use ginger with anticlotting medications such as warfarin or aspirin because it can increase bleeding.

Ginkgo Biloba

The dried leaf of the ginkgo tree taken internally as a powder or dissolved in liquids is an antioxidant that may help improve blood circulation. Scientific studies have shown that ginkgo biloba may be helpful for people who have mild to moderate dementia, but it appears to be ineffective in enhancing memory in healthy older people. Do not use ginkgo biloba with anticlotting medications such as warfarin or aspirin because it can increase bleeding.

Ginseng

Ginseng is taken internally to increase stamina, lower blood cholesterol, stimulate immune function, and lower blood glucose. Ginseng may also heighten the effects of the female hormone estrogen or corticosteroids (which relieve inflammation). Do not take ginseng if you have diabetes (unless your doctor says it’s OK to do so), if you have high blood pressure (because it can raise blood pressure), or if you are taking anticlotting medications such as warfarin or aspirin (because it can increase bleeding). When used with the antidepressant phenelzine sulfate, ginseng can cause headaches and possibly manic episodes.

Goldenseal

Goldenseal is taken to treat colds, flu, sore throat, and other upper respiratory or sinus infections and to relieve digestive problems such as peptic ulcers or colitis. It is also used as a topical antiseptic. Do not ingest goldenseal during pregnancy (because it stimulates the involuntary muscles of the uterus) or while breastfeeding (because it can cause jaundice in nursing infants). In large doses, goldenseal can cause upset stomach, high blood pressure, and seizures.

Kava

Kava, a plant found throughout the islands of the South Pacific, where it is considered a relaxing intoxicant, is used in the United States to relieve muscle tension and reduce anxiety. Long-term use of the herb in high doses has been associated with a skin condition called kava dermopathy (characterized by scaly sores on the skin). In some European countries, kava has been linked to liver damage, and kava-containing products have been removed from the market. For this reason, you should not use products containing kava if you have liver disease or liver problems or if you are taking drugs that can affect the liver (including some drugs used for chemotherapy). The FDA is investigating the relationship between the use of kava and liver damage.

Saw Palmetto

Saw palmetto is used primarily for treating conditions that involve the male reproductive system, usually benign prostatic hyperplasia (see page 832) or prostatitis (see page 831). The herb seems to work by blocking the conversion of the male hormone testosterone into a form of the hormone that is thought to enlarge the prostate. The herb also is being marketed to treat male pattern baldness. Use of the herb can be traced back centuries to Native Americans of Florida, who used the berries of the plant as a food staple.

Saw palmetto can cause stomach problems or headaches, and the tannic acid contained in it can inhibit the body’s absorption of iron.

Shark Cartilage

Cartilage tissue taken from sharks is a controversial alternative cancer treatment that gained popularity in the 1980s after a study showed that a substance in shark cartilage could block the growth of blood vessels that nourish cancerous tumors. However, shark cartilage has not been proven scientifically to be of benefit to people with cancer. Treatment with shark cartilage is undergoing clinical trials (testing on people) to determine definitively if claims about its benefits have any merit. Because shark cartilage has few side effects, cancer patients do not harm themselves by trying this approach, as long as it doesn’t replace a conventional cancer treatment.

St John’s Wort

St John’s wort is used for treating mild to moderate depression, inflammation, and anxiety. However, studies conducted in the United States by the National Institutes of Health (NIH) have found it to be ineffective for relieving depression. Applied to the skin, St John’s wort is used to treat mild burns and other superficial wounds.

In high doses, the herb can cause extreme sensitivity to sunlight. The tannic acid in St John’s wort can inhibit the body’s absorption of iron. Do not use St John’s wort with antidepressants, birth-control pills, digoxin (a heart disease drug), anti-retroviral medications (such as AIDS drugs), or cyclosporine (an immune-suppressing drug) because it can interfere with the effects of these medications.

Aromatherapy

Aromatherapy is the practice of using essential oils from plants to promote health and well-being. While the practice dates back thousands of years, the modern form of aromatherapy was developed in France in the 1920s by a physician and a chemist. Today many French doctors incorporate essential oils in their treatment plans for patients. Essential oils are extracted and distilled from the leaves, flowers, twigs, and roots of plants such as eucalyptus, geranium, rose, and lavender. The oils are then used in massages, baths, compresses, or salves. They may also be applied to the skin in creams, inhaled in steam, or dispersed into the air using an air pump, candle, or water spray.

Odors can affect the limbic system of the brain (which governs emotions), and it is thought that aromatherapy exerts its effects in this way. Therapeutic claims for aromatherapy include improvement in mood, skin conditions, fatigue, joint problems, and pain. Such claims have not been studied or verified by medical research. Aromatherapy is not meant to be used as a substitute for medical care, but as a way to promote relaxation and relieve stress.

Valerian

Valerian is a herb that is widely used in Europe as a sleeping aid. It seems to have few side effects but in rare cases can cause headaches, heart palpitations, and insomnia. Valerian should not be used with barbiturates because it intensifies their sedative effects.

Manipulative Therapies

Manipulative therapies attempt to treat illness by manipulating or moving parts of the body. Manipulative therapies include chiropractic, massage therapy, and reflexology. Osteopathic medicine is included in this section, even though it is part of mainstream medical practice, because of its emphasis on the study and treatment of the musculoskeletal system through manipulation. Chiropractic focuses on the relationship between the structure of the body (primarily the spine) and how the body works. It is based on the belief that health can be restored through manipulation of the spine. Massage therapists manipulate the soft tissues of the body to relieve so-called restrictions (tightenings) and return the tissues to normal function.

Manipulative therapies have had varying degrees of success at treating chronic diseases, but are generally recognized as being effective for the treatment of lower back problems and pain.

Chiropractic

Chiropractic is a system of therapy based on the theory that disease results from a lack of normal nerve function. Treatment focuses on the physical adjustment and manipulation of the muscle, tissue, and joints of the spinal column instead of using medication or surgery. To diagnose a medical problem, chiropractors usually take a health history, order X-rays of the spine, and perform a physical examination of the back. Once a diagnosis is made, the chiropractor then manually adjusts the vertebrae of the spine suspected of causing the problem. The number of treatments needed and the length of visits vary.

Chiropractic seeks to bring the skeletal structure into balance to restore or increase the range of motion of the spinal column. It can be effective in treating lower back problems, but claims that it can also treat such medical problems as high blood pressure, heart disease, or diabetes have not been proven scientifically.

Osteopathic Medicine

Osteopathic medicine is similar to conventional medical practice, with an emphasis on the study of the musculoskeletal system (bones, muscles, tendons, tissues, nerves, and the spinal column). Osteopathic medicine takes a holistic approach to health care, teaching that the human body is a unified system and that the musculoskeletal system plays a central role in a person’s overall health.

A doctor of osteopathy (DO) is a fully trained and licensed physician who has attended a 4-year osteopathic medical school and served a 1-year internship and a 2- to 6-year residency in a specialty area, as medical doctors (MDs) do. An osteopath can prescribe drugs and is qualified to practice all branches of medicine and surgery. Osteopaths use manipulation techniques such as stretching and thrusting in addition to conventional drugs and therapies to treat illness.

Craniosacral therapy

Craniosacral therapy is a form of osteopathic manipulation that involves gentle manual manipulation of the cranial (skull) bones to relieve tightening of the tissues that surround the brain and spinal cord. Osteopaths think that relieving this tightening (which they call restriction) allows the cerebrospinal fluid that bathes these structures to flow smoothly, thereby correcting the neurologic dysfunction. Studies have demonstrated the effectiveness of craniosacral therapy in treating cerebral palsy, seizure disorders, attention deficit disorders, headaches, and other neurologic disorders. The therapy is also effective in treating ear infections in children.

Massage Therapy

In massage therapy, the practitioner manipulates the soft tissues of the body to improve health and well-being. Massage is believed to enable the body to heal itself by increasing the circulation of blood and lymph (a body fluid that plays an important role in the immune system) and by normalizing the tissues of the nervous system and the musculoskeletal system. Massage can also help relax tightened muscles and eliminate the lactic acid that can accumulate in muscles after vigorous exercise. As a form of relaxation therapy, massage provides important psychological benefits.

There are three main types of massage: Swedish massage, pressure point therapy, and sports massage. Swedish massage is a traditional, gentle, whole-body massage that uses large, gliding strokes. In pressure point therapy—including deep tissue massage, neuromuscular therapy, acupressure, and shiatsu—concentrated finger pressure is applied to parts of the body that are in pain or have been injured. Sports massage concentrates on muscle groups that have been used excessively for a particular sport and is especially useful for improving athletic performance, relieving injuries, and promoting recovery.

A massage therapy session usually lasts 1 hour. You probably will be asked to remove as much clothing as you are comfortable removing and then lie down on a padded massage table. The therapist will then drape a cloth across your body, exposing one area at a time to be massaged. A lotion or oil may be applied to your skin to facilitate the motion of the therapist’s hands.

Massage therapy

Massage manipulates the muscles to increase blood flow and reverse the buildup of lactic acid in the muscles that accumulates after vigorous exercise.

Reflexology

Reflexology is an ancient form of therapy based on the theory that certain areas of the feet correspond to certain glands, organs, and systems of the body. Stimulation of these areas through finger and hand pressure is believed to have beneficial effects on the corresponding body part. Proponents of reflexology claim that it can improve a wide variety of health conditions, but it is primarily used as a stress-reduction technique. The effectiveness of reflexology has not been proven scientifically.

Feldenkrais

Feldenkrais is a method of movement therapy named after an Israeli scientist who, after injuring his knee, faced surgery that posed the risk of his not being able to regain movement in the joint. He considered the odds unacceptable and began to study human function, eventually developing the theory that physical dysfunction results when a faulty learned movement is repeated over and over throughout a person’s life. These faulty movements can be corrected, the theory goes, when a person becomes more aware of them and learns specific small movements that, with practice, eventually become larger, more complex, more efficient movements that replace the previous damaging ones. Conditions that have benefited by the Feldenkrais approach include back pain, cerebral palsy, chronic fatigue syndrome, head and neck pain, irritable bowel syndrome, and stroke.

Mind-Body Therapies

Mind-body therapies use a number of techniques that are believed to increase the mind’s ability to heal the body. The most common forms of alternative mind-body therapies are guided imagery, meditation, prayer, yoga, and art and music therapy. Relaxation therapy, another popular mind-body technique, is discussed on page 59. Hypnosis and biofeedback are not included in this section because they are now generally accepted by the medical profession. Another mind-body technique that has become an accepted part of mainstream medical practice is cognitive-behavioral therapy (see page 710).

Mind-body therapies have been shown to provide many health benefits, including relieving stress, understanding illness, and restoring a person’s sense of control.

Guided Imagery

Guided imagery refers to the use of the imagination to produce positive images that may bring about healing changes in the body. The process is often guided by the voice of a practitioner or by a voice recording that leads the person to visualize a suggested relaxing or healing scenario (such as being on a beach) in which healing can begin. The theory behind guided imagery is that the body will react as if the positive image is real, and undergo healthful changes. Guided imagery is used in hospitals and other health care settings for its proven benefit in managing pain, reducing anxiety, and strengthening the immune system.

Meditation

Meditation is a technique in which a person rests or sits quietly, usually with his or her eyes closed, and performs mental exercises that help focus attention, achieve relaxation, and increase mental awareness. The person often reaches this state by silently focusing on his or her breathing or on a word or an object. The stillness of mind and deep relaxation achieved during meditation help relieve stress and can have a beneficial effect on many medical conditions, including high blood pressure and heart disease. Meditation is also used to help relieve chronic pain, headaches, and respiratory problems such as asthma.

Prayer

Several scientific studies have shown that prayer may have an objective and positive effect on health outcomes. In these studies, the health of people who were prayed for improved substantially more than that of people who were not prayed for. This outcome occurred whether or not the person who was ill knew about the praying or believed in the power of prayer. Medical science cannot explain the connection between prayer and healing. However, many doctors encourage it because it can strengthen an ill person’s emotional and psychological well-being and give encouragement to caregivers and loved ones.

Yoga

Yoga is a good way to increase your joint flexibility and muscle tone while learning to relax and counteract stress.

Yoga

Yoga is a discipline developed in India over thousands of years that teaches a series of body postures and movements, breathing techniques, and meditation to calm the mind and relax the body. The goal of practitioners is to reach a state of harmony between the mind and the body that leads to spiritual enlightenment. This state of harmony is also believed to produce optimal health.

The physical benefits of yoga include increased flexibility, better balance, and stronger muscles. Yoga has been shown to reduce blood pressure, breathing rate, and anxiety. Yoga is also helpful for fighting insomnia, increasing range of motion in the joints, and decreasing pain in people with osteoarthritis (see page 996) or carpal tunnel syndrome (see page 699). The sustained focus of attention that yoga requires may help improve the mental abilities of older people.

Yoga postures should be learned from a practitioner and then practiced at home. If you are pregnant or have a chronic disorder such as high blood pressure, you may have to modify or avoid certain postures.

Art Therapy, Music Therapy, and Dance Therapy

Sometimes doctors use art, music, and dance to treat emotional and physical problems in a way that complements more conventional drug and therapy treatments. Art, music, and dance therapies attempt to release the healing potential of the creative arts. These therapies are frequently used in hospitals, nursing homes, psychiatric facilities, and hospices to ease pain, promote relaxation, and treat depression. Therapists are trained in the creative arts as well as in human development, psychological theory, and physical therapy.

Art therapy increases a person’s self-awareness and may help him or her cope better with symptoms. Music therapy uses the emotional response generated by music to achieve these results. Also, listening to or playing music can reduce heart rate and blood pressure and can lower the levels of stress hormones released by the body. Dance therapy uses movement to express emotions and promote well-being.

Energy Therapies

Energy therapies seek to restore health by affecting energy fields originating in and extending out from the body. The existence of such energy fields has not been proven scientifically. Some types of energy therapy—including Reiki and therapeutic touch—attempt to manipulate the energy fields by placing the hands in or through these fields. Electronic field therapies, on the other hand, use magnetic fields or electric current fields to treat illness or manage pain. Research exploring these phenomena is ongoing.

Reiki

Reiki, which means universal life force energy, is a method of natural healing that attempts to direct the flow of chi, or qi (pronounced “chee”), believed to be the vital energy that circulates throughout the body, to promote physical and spiritual well-being. Developed in Japan in the late 19th century, Reiki principles probably originated from a branch of Tibetan Buddhism. The healing abilities they bring are believed to be transmitted from teacher to pupil, not taught.

During a Reiki healing, the practitioner places his or her hands on the sick person and “wills” Reiki energy to flow. The energy is supposed to flow naturally and “know” where to go in the sick person’s body to promote healing. The practitioner believes that he or she is only the facilitator of the energy and does not consciously intervene in the healing process. Although no large-scale studies have proven the effectiveness of Reiki, the National Institutes of Health is studying the practice to determine if it can help relieve pain and increase exercise tolerance in people who have diabetes and improve the quality of life in people who have AIDS.

Therapeutic Touch

An outgrowth of the ancient healing therapy called the “laying on of hands,” therapeutic touch is the manipulation of a person’s energy field to induce healing by passing the hands a few inches above the person’s body. Developed in the 1970s by a nurse and a natural healer, therapeutic touch is practiced primarily in the nursing community, but is gaining growing acceptance in the medical community. The therapy is based on the theory that the human body, the mind, and the emotions form a harmonious and ordered energy field that is balanced during times of health but that falls out of balance during illness. By passing the hands over a person’s energy field, the practitioner directs and rebalances this energy.

During the process, the ill person sits or lies down comfortably while the practitioner runs his or her hands up and down the person’s body a few inches above the skin to identify energy imbalances. Therapeutic touch has not been scientifically proven to bring about healing, although anecdotal reports from people who have undergone the procedure have been positive. Some studies suggest that therapeutic touch may help relax people who have dementia and may help substance abusers remain drug-free.

Electromagnetic Field Therapy

Electromagnetic field therapy uses magnets or magnetic fields and more unconventional methods, such as pulsed fields and alternating or direct electrical current fields, to treat illness. Practitioners of electromagnetic field therapy believe that they can use such fields to alter the behavior of cells in the body to induce positive health changes. For example, pulses of electromagnetic fields may be used to prevent bone loss or to restore bone mass. Electromagnetic fields also have been used to treat asthma, cancer, and migraine headaches, and to manage pain. Because electromagnetic field therapies have not been studied by medical science, their effectiveness is not known.

Atlas of the body

This atlas illustrates the anatomy of the major organs and systems of the body and provides brief descriptions of each. For more information about a specific body system or to learn about the symptoms, diagnosis, and treatment of a specific health problem, consult the index at the back of the book.

Torso

The upper part of the torso is the chest, which contains the heart and lungs. The chest is separated from the lower part of the torso—the abdomen—by the diaphragm, a dome-shaped sheet of muscle. The edge of the diaphragm is attached to the bottom of the rib cage.

Inside the abdomen are the organs of the digestive system and the urinary system. The digestive system is composed of the digestive tract—the tube running from the mouth to the anus that processes the food you eat—plus two other organs, the liver and the pancreas, which aid digestion by manufacturing digestive fluids. The urinary system includes the kidneys, ureters, bladder, and urethra. The lower part of the abdomen, cradled within the hipbone, is called the pelvis. See also Organs of the Lower Abdomen, page 107.

Muscles

The more than 600 muscles in your body are composed of bundles of interlocking fibers that have the ability to contract (shorten) and relax (lengthen). The skeletal muscles are attached (directly or with a tendon) to two or more bones; when these muscles contract, the bones move. A group of muscles can often work together—one contracts, another relaxes, and nearby muscles provide stability.

Front view

Back view

Immune System

Your immune system provides your body with a wide variety of mechanisms—both internal and external—that protect you from disease-causing microorganisms such as viruses and illnesses such as cancer. The immune system is a complex, tightly orchestrated network of proteins, cells, organs, and the lymphatic vessels, all of which work together to keep you healthy.

Lymphatic system

The major organs of the immune system are called lymph nodes. Lymph nodes—clustered in your neck, armpits, and groin—contain white blood cells called lymphocytes that mount the response against potentially harmful invading microorganisms such as viruses or bacteria. Like all blood cells, white blood cells are produced in the soft marrow inside bones. White blood cells leave the bone marrow and are carried in the blood to the lymph nodes.

A system of fluid-filled ducts (called lymphatic vessels) channels white blood cells from the lymph nodes back into the bloodstream. White blood cells patrol the entire body—circulating in the blood, lymph nodes, and lymphatic vessels—to watch for harmful microorganisms and to remove damaged cells.

The thymus, an organ that lies behind the breastbone, is where a group of lymphocytes called T cells grows to maturity. The spleen, a fist-sized organ in the upper left corner of the abdomen, contains large numbers of white blood cells, including many lymphocytes. The tonsils and nearby adenoids (not shown) and the appendix are clumps of lymphoid tissue that provide lines of defense at sites in the body where potentially harmful microorganisms are likely to enter or multiply.

Bones

Your bones and muscles work together to support your body and enable you to move. The average human skeleton has 206 bones—32 bones in each arm, 31 in each leg, 29 in the skull, 26 in the spine, and 25 in the chest. In some people, the number of bones varies slightly from the norm—for example, about 5 percent of us have an extra pair of ribs, and some of us may have a few extra bones in our hands or feet or may be missing one or more bones.

Bones meet at joints, of which there are several types. Fixed joints, such as those in the skull, hold the bones firmly together. Partly movable joints, such as those between the bones of the spine, allow limited flexibility. Freely movable joints, such as in the jaw, hip, knee, or shoulder, provide variable flexibility in several planes of movement.

The skeletons of men and women differ very little. Men’s bones are generally slightly larger and heavier than women’s bones. The cavity in the female pelvis, surrounded by the hipbones and sacrum, is wider than the cavity in the male pelvis, to accommodate the passage of a baby during delivery.

Heart and Blood Vessels

Blood delivers life-sustaining oxygen and other vital nutrients to cells throughout the body and carries away wastes produced by the cells. The pumping action of the heart keeps the blood in constant circulation, sending it to the lungs to pick up a fresh supply of oxygen and then pushing it back out to the organs and tissues. Every minute, the heart pumps about 5 quarts of blood through the entire circulatory system.

Heart

The heart is a muscular organ about the size and shape of a fist, consisting of two side-by-side pumps. The right side sends blood from the veins into the lungs, where the blood receives fresh oxygen. The oxygen-rich blood then enters the left side of the heart, which pumps it through the aorta and out to the entire body.

Circulatory system

The circulatory system consists of the heart, lungs, and blood vessels. Your veins (blue in illustration) carry used, oxygen-depleted blood to the right side of your heart, which pumps it to the lungs for a fresh supply of oxygen. The newly oxygenated blood returns to the left side of the heart and is pumped through the aorta, a large blood vessel that directs blood to a system of arteries (red in illustration) that deliver the blood to tissues throughout the body. The veins return the used blood to the heart and the process starts again, about 10,000 times every day.

Brain and Nervous System

The nervous system has two major parts—the central nervous system and the peripheral nervous system. The brain and spinal cord make up the central nervous system, which coordinates all the body’s interactions with the environment. The brain, which is the most complex organ of the body, regulates most of your body’s functions. Each area of the brain is responsible for different functions, such as language, vision, movement, or emotions. The peripheral nervous system consists of nerves that radiate from the brain and spinal cord to all parts of the body. The peripheral nerves transmit information from different parts of the body to the brain and carry messages back to those parts of the body from the brain. The brain is always working, even during sleep.

Nervous system

The central nervous system is made up of the brain and spinal cord. The nerves that radiate from the spinal cord to the rest of the body make up the peripheral nervous system.

Brain

The brain lies inside a rigid, bony container called the skull. The two cerebral hemispheres, the cerebellum, and the brain stem are the major components of the brain. The cerebral hemispheres make up nearly 90 percent of brain tissue. Each hemisphere is about 6 inches from front to back, and together they measure about 4½ inches across. The hemispheres consist of intricate folds of nerve tissue that have a total surface area equal to that of a large newspaper spread.

The cerebellum, which lies beneath the back of the cerebral hemispheres, is concerned with muscle coordination. Like the cerebral hemispheres, the cerebellum consists of nerve cells and is divided into two hemispheres.

The brain stem contains tracts of nerve fibers that connect the brain to the rest of the body by way of the spinal cord. The brain stem also controls breathing and heart rate.

Spinal cord

The spinal cord is covered by three layers of protective membranes called the meninges. The spinal cord has a central canal that contains cerebrospinal fluid. Spinal nerves send and receive messages about body sensation and move to and from the brain by way of the spinal cord. A column of bones called vertebrae surrounds and protects the spinal cord. The vertebral column enables you to stand upright and maintain your balance.

Urinary Tract

The urinary tract filters waste products and excess fluid from the bloodstream and eliminates them from the body in urine. The kidneys filter out excess water, salts, and waste products from the blood, and the remaining substances are reabsorbed into the blood in the exact amounts the body needs. The kidneys then expel the excess water, salts, and waste products as urine (through tubes called ureters) into the bladder, where it is stored until you feel the urge to urinate. Urine is expelled from the body through a narrow tube called the urethra.

Male and female urinary tracts

The urinary tracts differ somewhat in males and females. A male’s urethra is much longer than a female’s, and the male bladder sits higher in the pelvis.

How the kidneys work

The kidneys play a role in regulating blood pressure, producing red blood cells, and filtering waste from the body. Blood first passes through the tiny blood vessels in the cortex, which remove waste products from the blood. The filtered blood flows into small tubes (in the medulla) that reabsorb the nutrients and water that the body needs. The filtered and replenished blood returns to the circulation, and the leftover waste by-product (urine) collects in the renal pelvis. Urine drains through the ureter into the bladder, where it is stored until it is eliminated from the body.

Organs of the Lower Abdomen

The organs of the lower abdomen are involved primarily with reproduction and with removing wastes from the body (in urine and stool). The lower abdominal organs are sometimes called the pelvic organs. Except for the reproductive organs, these organs function the same way in both males and females.

The bladder, a muscular sac that is about 3 inches in diameter when full, stores urine until it is eliminated from the body through a tube called the urethra. The urethra is much longer in males than in females. Digested food passes from the stomach through the intestines and out of the body via the rectum and anus.

Male reproductive organs

In addition to the visible male genitals—the penis and testicles—a system of glands and ducts is located inside the abdomen. The internal male reproductive organs, which produce, store, and transport sperm, are the prostate gland, two seminal vesicles, and two tubes called the vas deferens.

Female reproductive organs

The female reproductive organs are located inside the pelvis. The ovaries, which contain a female’s eggs, are connected to the uterus on either side by a fallopian tube. During each menstrual cycle, a mature egg travels from an ovary through a fallopian tube into the uterus (ovulation).

Diagnostic imaging techniques

Diagnostic imaging is a branch of medicine that helps doctors diagnose medical disorders and is often used in addition to a physical examination and laboratory tests. For example, after taking a health history and performing a physical examination on a person who has a chronic cough, a doctor may recommend a chest X-ray to determine the cause of the cough. For a person who may have had a stroke, a doctor might recommend computed tomography (CT) or magnetic resonance imaging (MRI) to examine the brain. These procedures can often find the cause of symptoms or narrow down the possible causes. In many imaging techniques (such as angiography), contrast mediums (dyes) or contrast agents (such as air or water) are used to make specific parts of the body easier to see.

X-rays, discovered in 1895, were the first imaging technique used for diagnosing medical problems. Ultrasound, which was developed in 1952 to evaluate fetuses and monitor pregnancies, uses sound waves to create an image. Diagnostic imaging advanced significantly in the 1960s with SPECT (single photon emission computed tomography), in the 1970s with the introduction of conventional CT scans, in the 1980s with MRI and PET (positron emission tomography), and in the 1990s with functional MRI (fMRI). New imaging techniques continue to be developed.

Using viewing devices called endoscopes, which are inserted directly into the body, doctors can see inside the body to evaluate tissues and organs and to perform procedures.

Imaging the Brain

With computerized imaging techniques such as MRIs and PET scans, doctors can look inside the living, thinking brain. These newer imaging techniques have improved the ability of doctors to diagnose and locate the site of brain disorders. The techniques have also enabled them to understand the relationship between different areas of the brain, to learn about the functions of specific areas of the brain, and to develop new treatments for brain disorders.

Brains of aggressive and nonaggressive teens

For these images, a technique called functional MRI (fMRI) shows brain activity (orange areas at top of images) in teens who have disruptive behavior disorder (which makes them aggressive) and in healthy, nonaggressive teens as they play a violent video game. The images show less activity in the frontal lobe of a teen with the behavior disorder (left) than in the frontal lobe of the healthy teen (right), indicating that the teen with the disorder is less able to inhibit the violent emotions triggered by the video game.

Brain hemorrhage

This three-dimensional angiogram shows a brain after a type of stroke caused by a hemorrhage, or bleeding inside the brain. The white areas are major arteries. The large yellow area in the center is the hemorrhage.

Brain during a migraine

This single photon emission computed tomography (SPECT) scan of a brain was taken during a migraine headache. Areas of high brain activity are yellow or red. Areas of low activity are gray or blue. Migraines usually affect one side of the brain. The grayish area at the lower left is an area of reduced blood flow (and low brain activity) from the migraine.

X-Rays

X-rays are high-energy electromagnetic waves that have a shorter wavelength than visible light or radio waves. When a beam of X-rays is passed through the body, some parts of the body absorb more radiation than other parts, producing a darker, shadowy image on the X-ray film, or radiograph. X-ray images can also be viewed on a fluorescent screen, or monitor. Dense structures (such as bone) allow few X-rays to pass through, so these structures appear lighter, or white, on the film. Fat and other soft tissues absorb less radiation, and so they look somewhat gray. Hollow structures (such as the lungs) allow even more radiation to pass through, making them appear darker, or black, on film.

Structures that are hollow (such as the intestines and blood vessels) can show up more clearly on X-rays if they are filled with a contrast medium (dye) such as barium sulfate, which blocks the X-rays. For example, for an X-ray examination of the upper digestive tract, a person fasts for several hours and then drinks a barium sulfate liquid. As the barium moves through the digestive tract, it highlights the outlines of the esophagus, stomach, and upper intestine on the X-ray film. For an

X-ray examination of the lower intestine, barium is introduced into the intestine through the rectum (called a barium enema). Iodine is used as a contrast medium to examine the thyroid gland, blood vessels, and urinary tract.

THE PROCEDURE

Before an X-ray examination, you may be asked to remove some of your clothing to help produce a better X-ray image. The part of your body to be examined will be positioned between the X-ray machine and the film, usually touching or very close to the machine. The technician will position you or immobilize the body part to obtain the best possible view. Several images may be taken from various angles. The X-rays themselves cause no discomfort because you cannot feel X-rays pass through your body.

The parts of your body not being examined may be shielded from the X-rays in some way (such as with a lead apron) to protect them from exposure to radiation. Your exposure to the radiation lasts only a fraction of a second. Because of a small risk of tissue damage from exposure to radiation, X-rays are performed only when necessary, and never during pregnancy.

Skull

This X-ray shows the dense bone of a healthy human skull, which encloses and protects the brain. Because X-rays provide little information about the brain itself, they are used primarily to diagnose and evaluate skull fractures.

Mammogram

Mammography uses low doses of X-rays to produce images of the soft tissues of the breast to detect abnormal growths such as tumors. This mammogram shows a cancerous tumor (bright white spot) in its early stages.

Broken arm

This X-ray shows severe fractures of both bones in the lower arm—the radius and the ulna.

Pacemaker in chest cavity

In this X-ray of the chest, the hollow lungs are the two large dark areas, and the heart is barely visible between the lungs. A pacemaker, which is implanted just beneath the skin, is attached to the heart with wires to regulate the heartbeat.

Lower spine and pelvis

The vertebrae of the spi ne and the thick hip bones are easy to see on this X-ray. The tailbone of the spine can be seen faintly in the hollow between the hip bones.

Angiography

Angiography is an imaging procedure used to examine blood vessels, particularly arteries (arteriography). Angiograms can help doctors diagnose blood vessel disorders and are frequently performed before surgery on a blood vessel to locate the sites of blockages or other problems. Before an angiogram, a contrast medium (dye) containing iodine (which shows up on X-rays) is injected through a thin, flexible tube (catheter) inserted through a small incision into the femoral artery in the groin, the brachial artery in the elbow, or one of the carotid arteries in the neck. A rapid series of X-ray pictures is then taken of the arteries. Any abnormalities in the arteries will show up on the X-rays.

Magnetic resonance angiography (MRA) uses MRI (page 113) with angiography. In MRA, specific radio-pulse sequences are used (usually without using X-rays and usually without injecting a contrast medium) to create and enhance images.

THE PROCEDURE

If you are having an angiogram, you will be asked to lie very still on an examining table. The area in which the catheter is inserted will be numbed with an anesthetic. A needle is inserted through the skin into the artery, and a long, thin wire with a soft tip is inserted through the needle. The needle is then removed and the catheter threaded over the wire into the blood vessel. When the contrast medium is injected, you will feel a sensation of warmth for a few seconds. The procedure lasts from a few minutes to a few hours. After the examination, you may be asked to lie still for a few hours. Angiography poses a slight risk of damage to blood vessels (at the site of the injection or anywhere along the blood vessel during passage of the catheter) and a risk of an allergic reaction to the contrast medium.

Aneurysm in a carotid artery

This angiogram reveals an aneurysm, an abnormal ballooning of a weakened area in the wall of an artery (red area on left), as viewed from the back of the head. This aneurysm is in a carotid artery (one of two main arteries that supply blood to the head and neck). If an aneurysm in the brain ruptures, it can cause a stroke.

Narrowed coronary artery An angiogram of the arteries of the heart (called a cardiac arteriogram) is used to diagnose heart disease. In this image, the contrast medium reveals a narrowed section in the left coronary artery (arrow) that has reduced blood flow to that part of the heart muscle. A total blockage can cause a heart attack. The long, pink, unbroken areas in the image are healthy blood vessels.

Inflamed arteries in legs

This angiogram (taken with MRA) shows diseased arteries (dark pink areas) in the legs of a person with arteritis (inflammation in the walls of the arteries). The arteries in the legs originate in the iliac arteries of the groin (the groin is the brownish, circular area at top center).

Arteries to the kidneys

The arteries that supply blood to the kidneys (the renal arteries) are red in this angiogram. The kidneys appear yellow. The renal arteries branch off the abdominal aorta (the large red blood vessel running vertically down the center of the image). The vertebrae of the spine and several ribs are barely visible.

Ultrasound

Ultrasound is an imaging procedure that uses high-frequency sound waves to produce an image. Although ultrasound was initially used to view fetuses, it is now used to examine every organ of the body, including the heart (an echocardiogram). Because ultrasound does not pose a risk of exposure to radiation, it is increasingly taking the place of conventional X-rays (see page 109) for diagnosing many different conditions. In ultrasound, sound waves are directed into the body through a wandlike device called a transducer, which is moved around the skin over the area to be examined. Ultrasound produces clear images of soft tissues and fluid-filled organs (such as the ovaries) but is less useful for examining organs filled with gas or air (such as the lungs). Also, ultrasound waves do not penetrate bone. The ultrasound images are displayed on a computer screen. Ultrasound is often used to guide the positioning of a needle during a biopsy (removal of a small piece of tissue for microscopic examination).

Doppler ultrasound is an ultrasound technique that can evaluate movement such as blood flow through the beating heart of a fetus or through arteries and veins. Because flowing blood cells in a blood vessel reflect sound waves, the speed and direction of blood flow through the vessels can be measured and analyzed with ultrasound. This information is displayed on a screen as a graph. Doppler ultrasound is often used along with or, in some cases, instead of angiography (see previous page).

THE PROCEDURE

If you are having an ultrasound of the abdominal area, you will be asked to fast for at least 12 hours before the procedure. If the scan involves the pelvic area (such as to examine pelvic organs or to view a fetus), you will be asked to drink three or four glasses of water about 20 to 30 minutes before the examination to fill your bladder (so it will reflect sound waves). The technician will spread a gel on your skin over the area to be examined; the gel provides good contact for the transducer and allows it to move easily and smoothly over the skin. The room is darkened slightly to make the images on the computer screen clearly visible to the technician. Most ultrasounds take about 15 to 30 minutes. The procedure is very safe and has no known side effects or risks.

Gallstone in gallbladder

This ultrasound scan of the gallbladder (the dark oval area at the top of the image) shows a gallstone (arrow) inside the gallbladder. Gallstones form when bile (which is stored in the gallbladder) hardens. The major component of most gallstones is cholesterol.

Four-month-old fetus

During pregnancy, ultrasound is a safe method for determining the approximate age, rate of growth, and position of a fetus. This ultrasound image is of a healthy 4-month-old fetus (the head of the fetus is at the left, facing up).

Heart

An ultrasound of the heart (called an echocardiogram) can help diagnose heart abnormalities. This echocardiogram shows a healthy heart. The four chambers of the heart are numbered, and appear as dark spaces surrounded by the walls of the chambers: 1 indicates the right ventricle; 2, the left ventricle; 3, the right atrium; and 4, the left atrium.

Vein in leg

This Doppler ultrasound shows blood flow (orange) through the longest vein in the body—the vein in the leg from the foot to the groin that drains blood back to the heart.

CT scanning

Computed tomography (CT) uses a combination of X-rays (see page 109) and a computer to create images. A CT scanner uses X-rays in a different way than a conventional X-ray machine does. Instead of taking an X-ray photograph, a CT scanner sends large numbers of X-ray beams from many directions through the part of the body being examined, records the amount of radiation that has been absorbed, and uses an internal computer to construct an image. In CT, the computer produces a series of horizontal or vertical (or even three-dimensional) cross-sectional slice images of the body. These images offer clear pictures of all the organs in the part of the body being studied. CT scanning is able to create more fully defined pictures of the head and body than conventional X-rays and has reduced the need for uncomfortable, invasive, and risky diagnostic procedures such as exploratory surgery.

A newer type of CT—called electron beam tomography (EBT)—is ten times faster than any other scanning technique. EBT is also called spiral, or helical, tomography. The EBT X-ray tube revolves around the body, allowing a continuous flow of images. The data are collected on a computer, and can be enhanced to provide clearer and more detailed images than those produced with conventional CT. Three-dimensional images can be created by combining many cross-sectional slice images. Because of its speed, EBT reduces the amount of time a person is exposed to radiation. Full-body scanning with EBT is being used to diagnose heart disease, lung disorders, and tumors at early stages, before they cause symptoms.

Prostate cancer

This is a view of a male pelvis showing an enlarged, cancerous prostate gland (green). The bones of the pelvis are the red areas on either side of the prostate. The rectum is the circular blue area below the prostate. The bladder is the yellow oval (slightly indented by the enlarged prostate) directly above the prostate.

THE PROCEDURE

Before you have a CT scan, a technician may inject a contrast medium (dye), such as iodine, into a vein in your arm to help get a better image of the blood vessels and any tumors. If your abdomen and pelvis are being scanned, you will be asked to drink a weak solution of barium sulfate (another contrast medium) to expand your intestines and improve the image. The technician will also position you (or the scanner) to get the best image possible. You will be asked to lie very still on a table while you are inside the scanner. CT scanning is painless. However, the procedure may take an hour or more, depending on the number of angles and exposures required.

Liver cancer

The large brownish mass at left is a liver to which cancerous tumors (red spots) have spread from the colon. The spine (at the top) and the ribs (surrounding the internal organs) are yellow.

Pancreatic cancer

CT scans are useful for revealing small pancreatic tumors or swelling of the pancreas caused by inflammation. Here, a cancerous tumor of the pancreas (green) is evident. Also seen are the ribs and spine (white); the aorta (red), which is the major artery that carries blood away from the heart; and a vena cava (blue), one of the two major veins that drain blood from the body into the right side of the heart.

MRI

Magnetic resonance imaging (MRI) makes cross-sectional images by measuring changes in the body’s natural magnetic field as parts of the body are exposed to strong magnets and various radio frequencies. Using these techniques, a doctor can examine the structure and appearance of internal organs. Like computed tomography (CT) scanning (see previous page), MRI uses a computer to construct images from information recorded by the scanner. In MRI, however, the information is not provided by X-rays. Instead, the person being examined is placed inside a powerful magnet, which arranges the nuclei of some of the hydrogen atoms in the body in a precise pattern (like iron shavings around a magnet). A pulse of radio waves is then passed through the person’s body, moving the nuclei of the aligned hydrogen atoms briefly out of alignment. The nuclei then return to their original pattern, emitting radio signals as they do so. Different tissues such as tumors emit a more or less intense signal. These signals are detected by the machine and analyzed by the computer. The information is then used by the computer to construct an image. MRI can sometimes produce more detailed three-dimensional images than CT.

MRI technology includes magnetic resonance angiography (MRA) and magnetic resonance spectroscopy (MRS). MRA, like other types of angiography (see page 110), is used to evaluate blood flow but does not use dyes or radioactive tracers. MRS is different from conventional MRI in that MRS uses a continuous band of radio waves to excite hydrogen atoms in a variety of chemical compounds other than water. The compounds absorb and emit radio energy at certain frequencies (or spectra) that can be used to identify them. A color image is created by assigning a color to each distinct spectral emission. MRS is used to produce color images of brain function and to identify the chemical composition of diseased tissue.

Functional magnetic resonance imaging (fMRI)—also called brain mapping—uses the same MRI scanner hardware to provide noninvasive images of the brain’s activity, and to detect changes resulting from biological function. Functional MRI tracks blood flow in the brain. The more active an area of the brain is, the more blood flows to it. Functional MRI enables doctors to take a series of images in quick succession and to analyze the differences between them. It also allows doctors to identify the parts of the brain that “light up” (are active) when a person is asked to perform specific tasks or is exposed to certain stimuli.

THE PROCEDURE

Because the MRI scanner creates a very strong magnetic field, you cannot carry or wear any metal objects (such as jewelry, eyeglasses, or hair clips) during the examination. Make sure you let your doctor know if you have any metal implants (such as artificial joints, plates, screws, or clips), metal attachments (such as dental braces), or electrical devices (such as a hearing aid), which could be affected by the magnet. It is especially important to tell your doctor if you have a pacemaker because the magnet can make the pacemaker stop working. Although MRI is not known to pose any health risks to a fetus, tell your doctor before having the procedure if you are (or could be) pregnant.

Prostate cancer

This MRI scan of a male pelvis shows an enlarged prostate gland (dark brown) with a cancerous tumor (black kidney-shaped area). The bones of the pelvis (on either side of the prostate) are yellow. The rectum (blue) is below the prostate. The reddish brown areas are muscle.

Lung cancer

This side view of a lung shows a cancerous tumor (yellow area) that is extending into the neck.

For an MRI, you lie on your back on a narrow padded table with a cushion under your knees. You are given a signal button to alert the technician if you begin to feel uncomfortable during the test. (If you don’t like confined spaces, ask your doctor for a sedative before the test.) Because the scanner is very noisy, you are given earplugs or headphones to help block the noise. You may be given a contrast medium through a needle inserted into a vein. You must lie still during the MRI, and you may be asked to hold your breath occasionally. In closed MRI, the table slides into a narrow tunnel inside the scanner. In open MRI, the scanner is quieter and less confining. MRI is painless, and the test can last from 20 to 90 minutes or longer.

Knee joint

MRI can provide clear images of the structures in a joint. This is a side view of the knee joint; the gray areas are the two long bones that meet in the joint (the femur and tibia) and the kneecap (at right on the image).

Nuclear Medicine Imaging

Nuclear medicine imaging (also called radionuclide scanning) shows not only what organs or other structures of the body look like but also evaluates how they function. In nuclear medicine imaging, a small amount of a radioactive substance (called a radionuclide or radioisotope—or tracer) is either swallowed or injected into a blood vessel. The doctor chooses a tracer that confines itself to the organ being examined (for example, iodine concentrates in the thyroid gland). After entering the bloodstream, the tracer travels to the target organ, emitting very small amounts of gamma rays (similar to X-rays). The gamma rays are detected by an instrument called a gamma camera. Depending on the type of tissue, an abnormality may absorb more or less radiation than healthy tissue. For example, a cancerous tumor may absorb more radiation, while dead heart tissue will absorb less. The information is then analyzed by computer and constructed into an image of the organ called a gamma scan (also called a scintiscan or scintigram).

Brain during a dream

In this image, PET scanning has produced a slice image of the brain during a dream. In the REM (rapid eye movement) sleep phase (when dreaming occurs), the brain is active (red areas). The blue areas indicate low brain activity.

Brain

In this image, PET data (brightly colored areas) are combined with three-dimensional MRI scans of the left and right sides of the brain to show the activity in the brain when a person hears a language he or she knows well. The front of the brain is at the far left and far right of the two images. Red and green areas indicate the auditory (hearing) areas of the brain; yellow, the language or word areas; and pink, the area of the brain responsible for speech (Broca’s area).

Radionuclide scanning can also be used with a computer to help form images with techniques such as single photon emission computed tomography (SPECT). In SPECT, cross-sectional images of the body (usually the brain) are created using a gamma camera that rotates around the person. PET (positron emission tomography) scans combine nuclear scanning with chemical analysis to show blood flow and chemical processes in action. In SPECT/PET, chemicals such as the sugar glucose (the brain’s energy source) and key neurotransmitters (brain cell messengers) are made slightly radioactive and injected into the person. As they work in the brain, the chemicals emit photons (particles of light) that can be picked up like X-rays. SPECT and PET are often used to study the working brain.

THE PROCEDURE

Because the radioactive chemicals used during nuclear imaging can affect a fetus, tell your doctor before the procedure if you are (or could be) pregnant. After the radioactive tracer is swallowed or injected, you may need to wait for it to travel through your bloodstream and collect in the target organ before you are examined by the gamma camera. Because this may take several hours, you may be allowed to leave the facility and return later to take the scan. While you are having the scan, you lie or sit on the examination table, and the gamma camera is moved close to the area being examined. You must stay very still during the scan, but you may be asked to change positions; the technician will reposition you and the camera if necessary. The amount of time the procedure takes varies from about 1 to 5 hours. In some cases, a second or third scan is required. Radionuclide scanning is painless (except for the injection of the tracer). The tracer quickly breaks down into harmless substances and is eliminated from the body.

Thyroid gland

This is a gamma scan (front view) of the two lobes of a healthy thyroid gland (located at the base of the neck). The radioactive tracer has highlighted areas of activity in the gland. Areas of high activity are green or red; areas of low activity are blue.

Lower legs and feet

This image is a gamma scan of the bones in the lower legs and feet. Bone shows up on the image in blue or yellow.

Bone cancer

This gamma scan shows a side view of the head, neck, and upper chest of a person who has cancer that has spread to the vertebrae in the neck (white area). Cancerous bone appears as bright “hot spots” on the image because the radionuclide tracer concentrates in cancerous bone more strongly than it does in normal bone.

Endoscopy

An endoscope is a thin (usually flexible) viewing tube that enables a doctor to examine the inside of the body directly. Endoscopes have a light source, flexible bundles of glass or plastic fibers (called fiberoptic bundles) that transmit light, an eyepiece at one end, and lenses or a video computer chip at the other. Endoscopes also have a suction channel and a channel or tube through which instruments can be passed and manipulated.

Calcium deposits in knee

A thin, rigid type of endoscope (called an arthroscope) is used to see directly inside a joint. This arthroscopic image shows calcium deposits inside a knee joint.

Uterus

This image is the inside of a uterus as seen through a special endoscope called a hysteroscope. The hysteroscope is guided into the uterus through the vagina and cervix.

Endoscopes are used to view the upper airways and lungs (bronchoscope); the esophagus, stomach, and first part of the small intestine (gastroscope); the abdominal cavity (laparoscope); the entire large intestine (colonoscope); the lower part of the large intestine and rectum (sigmoidoscope); the bladder (cystoscope); the cervix and uterus (hysteroscope); and the joints, particularly the knee (arthroscope).

THE PROCEDURE

If the endoscopic examination is of some part of the digestive tract, you may be asked to fast for a certain amount of time (usually overnight) before undergoing the procedure. Depending on the type of examination (usually the more invasive the procedure, the more uncomfortable it may be), you may be given a mild sedative, either intravenously or by mouth, or a local or general anesthetic. The doctor will then insert the endoscope directly through a natural opening in the body (such as the mouth or anus) or insert it through a small incision and guide it to the area being examined. The procedure usually takes about 30 to 60 minutes.

Colon cancer

Doctors can use two types of endoscopes to see the inside of the colon (large intestine) directly—a colonoscope to view the entire large intestine, and a sigmoidoscope to see just the lower third. This image is of a cancerous growth (the dark pink area in the upper part of the image) on the inside wall of the large intestine.

Visual aids to diagnosis

The purpose of this section is to help you identify visual signs of illness. The color photographs on the following pages show some skin, eye, and nail disorders or problems. As a backup to the photographs, review the appropriate symptoms chart (see pages 201 to 369). If you are concerned about any symptom, talk to your doctor.

While you are looking at these photographs, keep in mind that many skin, eye, and nail problems look similar to one another. Symptoms can vary from person to person, and your symptoms may not resemble those shown here. But doctors are familiar with the full range of a disorder’s visual signs and can usually make an accurate diagnosis based on these signs.

Birthmarks

Strawberry hemangioma

A strawberry hemangioma (see page 1058) is a raised bright-red patch of skin that grows in the first few months of life and may bleed easily. After 6 to 10 months, the mark begins to shrink and fade. Most disappear by the time a child is 5 years old.

Stork bites

Stork bites, which are common, are flat, salmon-colored skin patches made up of blood vessels. They most often appear on the forehead, eyelids, upper nose, and the back of the neck in newborns. They may become darker when the baby is crying and turn white when pressed. Stork bites usually disappear by the time a baby is 18 months old.

Port wine stain

A port wine stain (see page 1058) is a flat or pebbled patch of purplish red skin that usually occurs on the face and may cover a large area. A port wine stain usually remains the same throughout life but may fade over time.

Mongolian spot

Mongolian spots (see page 1058) are bluish patches on a baby’s buttocks or lower back. The spots affect mostly babies of African or Asian descent, but they can also occur in white babies, usually in those of Hispanic or Mediterranean descent. They usually disappear by the time a child is 5 years old.

Café au lait spots

Café au lait spots are flat pigmented patches of skin that usually join and appear as a single patch. They are present from birth and remain unchanged throughout life. The presence of several café au lait spots may be a symptom of a genetic disorder called neurofibromatosis (see page 968).

Abnormal Coloration

Vitiligo

In vitiligo (see page 1072), irregularly shaped patches of skin lose all of their normal color and become much paler than the surrounding skin, although the texture of the skin remains the same. The unpigmented skin patches are often symmetrical mirror images on each side of the body. Vitiligo seems to result from an abnormal immune response. In most cases, the loss of pigment is permanent.

Jaundice

Jaundice (see page 785) is yellowing of the skin (as on the chest here) and the whites of the eyes, usually caused by liver disorders. Jaundice results from a buildup in the blood of bilirubin, a yellowish brown pigment that is normally removed from the bloodstream by the liver and excreted in bile.

Age spots

Age spots (see page 1059), also called liver spots or solar lentigos, are flat, tan to dark brown or black patches of skin caused by long-term sun exposure. They usually develop by middle age in areas of skin (such as the hands, face, and chest) that have been repeatedly exposed to the sun.

Cherry angiomas

Cherry angiomas (see page 1059) are flat or dome-shaped small red spots on the skin that are caused by leaks in blood vessels. Although they can first appear in early adulthood, cherry angiomas usually result from a loss of elasticity in the skin that occurs as people age.

Dysplastic nevi

Dysplastic nevi are large, round moles that have not been present from birth. They usually appear around puberty but can occur at any age. Dysplastic nevi usually have irregular borders with indistinct margins and may be slightly asymmetrical. They can be varying shades of tan or brown and darker in the center. Dysplastic nevi should be examined regularly by a doctor because they can become cancerous (malignant melanoma; see page 1069).

Normal moles

Moles are round or oval spots on the skin that are pigmented with melanin, the substance that gives skin, hair, and eyes their color. Moles are very common. They can be flat (top left and right) or evenly raised (bottom left and right) and are usually clearly outlined against surrounding skin. Large moles may have coarse hairs growing out of them. Some people have many moles all over their body (dysplastic nevi; above right). Some moles can become cancerous (malignant melanoma; see page 1069).

Skin Cancer

Basal cell carcinoma

Basal cell carcinoma (see page 1068) is a common form of skin cancer usually caused by overexposure to the sun. Basal cell carcinomas grow slowly, rarely spread, and are seldom life-threatening. They vary in appearance but usually start as small, flat nodules that gradually turn into ulcers (open sores) with raised edges. A close-up of one type of basal cell carcinoma is shown here (left). Basal cell tumors frequently appear on the face, usually around the eyes, near the nose (center) or on the nose (right) and on other sun-exposed areas (including the back, chest, arms, and legs).

Squamous cell carcinoma

Squamous cell carcinoma (see page 1069) is a common skin cancer that is rarely life-threatening. Squamous cell tumors start as small, firm, usually painless lumps or patches and can resemble warts or ulcers (open sores). They are associated with sun exposure and can occur anywhere on the body but are common on the backs of the hands (as shown here) or on the lips. In rare cases, squamous cell tumors can spread to other parts of the body and can be fatal, especially if they develop in a scar from a burn or vaccination.

MALIGNANT MELANOMA

Malignant melanoma

Malignant melanoma (see page 1069) is the most deadly form of skin cancer. It is sometimes associated with exposure to the sun but can occur anywhere on the body, including parts of the body that are normally not exposed to the sun. Malignant melanomas most often appear on the face, upper trunk, or legs, and usually grow from existing moles, although they can also develop on seemingly normal skin. Malignant moles may bleed and can resemble sores that don’t heal.

Asymmetry

Cancerous moles are often asymmetrical—one half of the mole looks different from the other half if you draw an imaginary line horizontally or vertically through the center of it.

Border

The outline of a cancerous mole can be uneven or have poorly defined edges and may change over time. Normal moles have clean borders.

Color

Melanomas can be very dark and can contain shades of tan, brown, white, red, or blue. They can also change color.

Diameter

Moles or colored areas of skin that grow larger than ½ inch across (about the width of a pencil eraser) may be a sign of malignant melanoma, although smaller moles can also indicate malignant melanoma.

Dermatitis

Irritant dermatitis

Irritant dermatitis (see page 1062) is a nonallergic form of contact dermatitis caused by exposure to any substance (including soap and water) that damages the skin or strips it of its protective oils. Symptoms include dry, itchy, irritated skin. Irritant dermatitis is common in adults with sensitive skin.

Poison ivy

Touching plants such as poison ivy, poison oak, and poison sumac (see page 169) can cause a severe case of al lergic contact dermatitis in most people, although sensitivity declines with age. Symptoms develop within 24 to 48 hours of exposure and include patches of red bumpy skin or blisters that itch intensely and eventually break open and release a watery discharge. The oil from the plant that causes the initial rash can spread from the area of contact to other parts of the body.

Infantile eczema

Infantile eczema (see page 1062) is a form of atopic dermatitis that causes skin inflammation in infants and small children. It produces an itchy rash or small red pimples, and can be accompanied by oozing blisters that crust over. Infantile eczema can occur anywhere on the body but usually develops on the cheeks or chin, behind the knees, or on the insides of the elbows.

Diaper rash

Diaper rash (see page 386) is slight redness to severe inflammation of the skin around the thighs, genitals, and buttocks in babies (left). It can sometimes be accompanied by a yeast infection that causes tender sores and oozing pimples (right). Skin contact with urine and stool, along with moisture and chafing from the diaper itself, can cause diaper rash.

Eczema

Eczema (see page 1062) appears as red, itchy lumps or blisters on the skin that sometimes join to form patches. When eczema is persistent, the skin in the affected area may become dry and lighter or darker than the surrounding skin, and may look like leather. In nummular eczema, the patches of skin are round, raised, and flaky. The legs (left) and hands (right) are commonly affected sites.

Seborrheic dermatitis Seborrheic dermatitis (see page 1063) is chronic skin inflammation that makes the skin red, flaky, and itchy. In adults, it usually affects the scalp, face, and neck, but it can occur anywhere on the body. Dandruff is a form of seborrheic dermatitis.

Allergic contact dermatitis

Allergic contact dermatitis (see page 1062) is an allergic reaction to a substance such as hair dye, metal, or wool (as on neck in the image at far left). The itchy, flaky skin of allergic contact dermatitis is limited to the area of contact. A metal button made of nickel caused the rash in the illustration at right.

Lumps and Bumps on or Under the Skin

Acne

Acne (see page 1065) is a chronic skin condition in which various types of blemishes recur persistently on the upper part of the body, mostly on the face. Acne blemishes include small dark plugs imbedded in the skin (blackheads), small red lumps, tiny raised white spots (whiteheads), and small to large firm swellings (nodules and cysts). Acne is common in adolescents but can occur at any age.

Shaving bumps

Shaving bumps (known medically as pseudo-folliculitis) are ingrown hairs (see page 1075) that can develop when the sharp ends of shaved hair grow back into the skin and become trapped under the skin. The small, hard bumps that appear around hair follicles cause slight inflammation and are common in men with curly hair. If the hair follicles become infected, the condition is called folliculitis (see page 1076).

Warts

Warts (see page 1060) are small areas of persistent viral infection in the upper layer of skin. The typical common wart is a hard lump with a rough, cauliflowerlike surface (top left). Warts on the bottom of the feet are called plantar warts (top right). Tiny black flecks may be visible in the body of the wart. Flat-topped, flesh-colored warts occur mainly on the wrists, the backs of the hands, and the face (left). Flat warts can itch.

Seborrheic keratoses Seborrheic keratoses (see page 1063) are dark, sometimes rough-surfaced lumps that often appear on the skin in large numbers later in life. They are harmless but can resemble malignant melanoma (see page 1069), a life-threatening form of skin cancer. Seborrheic keratoses are sometimes called seborrheic warts.

Actinic keratoses

Actinic keratoses (see page 1069) are small wartlike growths that develop on sun-exposed areas of the body. They are not actually skin cancer but must always be removed because they can become cancerous.

Epidermal cysts

Epidermal cysts (see page 1070), also called sebaceous cysts, usually appear as soft, smooth, sometimes yellowish lumps just beneath the surface of the skin. Sometimes a small dark dot can be seen in the skin over the center of the cyst. Epidermal cysts usually occur on the scalp, face, neck, or ears. They are harmless but can grow large and can become infected.

Keloids

When skin is injured, the damage is repaired by scar tissue. Keloids (see page 1071) are raised, hard, itchy scars caused by an abnormality in the healing process. Keloids are more common in dark-skinned people.

Boils Boils are infected hair follicles that start as red lumps under the skin and gradually become bigger and more painful as they swell with pus.

Hives

Hives (see page 1066) usually take the form of one or more raised, red, itchy patches of skin called wheals that have clearly defined edges. They are caused by allergic reactions to food, medication, cosmetics, or heat or cold. Hives usually disappear after a few hours but can recur.

Dermatographism

Dermatographism is an allergic reaction that is activated when the skin is scratched or otherwise touched with a finger or object. The resulting marks are hives that follow exactly where the skin has been touched. The red, raised, itchy patches (wheals) from these types of hives may not appear immediately and can develop up to several hours after the skin was touched.

Infections and Inflammatory Conditions

Pityriasis rosea

Pityriasis rosea (see page 1071) usually starts as one or two oval patches (left) called herald patches on the chest (right) or back. Over a few weeks, similar (usually smaller) patches appear and may spread to the upper arms and the thighs. The rash is sometimes itchy and may have a slightly scaly surface and appear orangish red in people with light skin and dark brown in people with dark skin.

Ringworm

Ringworm is a tinea (a fungus) infection (see page 1073) that is marked by red, itchy, ring-shaped rashes. The characteristic rings form when the fungus spreads uniformly outward, leaving normal skin in the center.

Psoriasis

Psoriasis (see page 1064) consists of patches of thick, raised skin that are pink or red and covered with silverish white scales. Small patches may join to form larger patches. In rare cases, the affected area can be slightly itchy or sore. Common sites for psoriasis are the knees (left), elbows, and scalp (right). When psoriasis affects the head, lumps can appear on the scalp and temporary hair loss can occur. Psoriasis can also affect the nails.

Athlete’s foot

Athlete’s foot is a tinea (a fungus) infection (see page 1073) that causes itchy, cracked skin on the feet, usually between and under the toes. The skin may peel away and occasionally blister.

Rosacea

In rosacea (see page 1066), the face (usually the skin on the cheeks and nose) becomes abnormally red and flushed, and pus-filled pimples develop on the affected areas. In some cases, the nose becomes large and bulbous and the eyes become red.

Systemic lupus

Systemic lupus erythematosus (see page 920) is a chronic disease that causes inflammation of connective tissues such as tendons and cartilage. Systemic lupus causes a red, itchy, butterfly-shaped rash over the cheeks and the bridge of the nose.

Discoid lupus

Discoid lupus erythematosus, the more common form of lupus (see page 1072), affects exposed areas of skin. In discoid lupus, the rash starts as red, circular areas of thick skin, usually on the face, behind the ears, and on the scalp. The affected area may eventually scar.

Shingles

Shingles (see page 936), caused by the herpes zoster virus, usually appears as a rash around an eye (left) or in a narrow strip on one side of the body such as around the waist, on a shoulder, or down the hip (right). Before the rash appears, a person will feel burning or stinging in the affected area. The rash is made up of many small blisters that usually dry up and scab over within a week. A shingles rash that occurs near an eye can cause severe pain, redness, and tearing.

Lichen planus

Lichen planus (see page 1071) usually occurs as a rash of tiny, purplish red lumps on the inside of the wrist. The cause is unknown.

Impetigo

Impetigo (see page 1067) is a highly contagious bacterial infection that usually appears as small blisters around the mouth and nose, although the blisters can appear anywhere on the body. The infection spreads quickly. The blisters eventually break open and form a yellowish brown crust.

Molluscum contagiosum

Molluscum contagiosum (see page 1061) is a harmless, highly contagious viral infection characterized by small, shiny, circular, pearly lumps. The lumps have a tiny depression in the center that produces a white, waxy substance when squeezed. The infection is most common in children but can also be transmitted sexually.

Anthrax lesion

Cutaneous anthrax (see page 1074) usually begins as an itchy, swollen sore that resembles an insect bite on exposed skin areas such as the head, neck, or hands. The sore forms a blister, which develops into an ulcer that eventually turns into a scab.

Cellulitis

Cellulitis (see page 1067) is a skin and tissue infection caused by bacteria that usually enter the skin through a wound or other break in the skin. The affected area is often hot, red, and tender, and red lines may run from the infected area to nearby lymph glands. The face, neck, and legs are the areas affected most frequently.

Folliculitis

Folliculitis (see page 1076) is inflammation of hair follicles resulting from a bacterial infection. It can occur almost anywhere on the skin but frequently occurs on the neck, thighs, buttocks, or armpits, causing boils (see page 1060). In men, a severe form of folliculitis can produce pus-filled blisters on the face in the beard area.

Varicose ulcers

Varicose ulcers are open, infected sores caused by twisted, swollen veins in the legs (varicose veins; see page 602) that result from insufficient circulation to the legs. Varicose ulcers usually appear around or on the ankle.

Bites and Infestations

Scabies

Scabies (see page 938) is an itchy skin condition caused by the bites of scabies mites that burrow under the skin and lay eggs. The bites cause small red bumps; the burrows look like thin white lines. The bites usually occur in warm, moist areas of the skin such as on the genitals, buttocks, wrists, and around the waist and between the fingers.

Flea bites

Flea bites produce small, inflamed, itchy spots on the skin. Fleas usually bite around the ankles or lower part of the legs, although the bites can occur anywhere on the body. The area may also be swollen and turn white when pressed.

Lyme disease

Lyme disease (see page 942) is caused by a bacterium that is transmitted by the bites of infected ticks. A red dot may appear at the site of the bite. The dot gradually gets larger and forms a circular red rash. Other symptoms include fever, headache, and muscle and joint aches.

Tick bite

To feed on blood, ticks use their hooked mouthparts to pierce and attach themselves to the skin. After they finish feeding, they drop off, leaving a small wound and an area of inflammation.

Mouth and Lip Disorders

Canker sores

Canker sores (see page 743) are small, round, painful ulcers (open sores) that usually occur inside the mouth, on the tongue, or around the lips. Canker sores can be white, gray, or yellow and are surrounded by red, inflamed tissue.

Cold sores

Cold sores (see page 744) are small blisters caused by a herpes virus. They frequently occur on or around the lips but can occur anywhere. The blisters, which are usually preceded by a tingling sensation, are small at first but eventually grow larger and break open and crust over within a few days. An area of inflamed, red skin surrounds the blisters.

Gum damage from smokeless tobacco Smokeless tobacco can cause changes in the mouth and gums such as discolored teeth, tooth abrasion, receding gums (exposing the roots of the teeth), and loss of supporting bone and gum tissue. The damage may be permanent. Using smokeless tobacco can also lead to other mouth conditions, such as leukoplakia (see page 744) or oral cancer (see page 747).

Oral cancer

Oral cancer (see page 747) is usually caused by smoking cigarettes or cigars or by using smokeless tobacco. Cancer on the lips or just inside the mouth (left, squamous cell carcinoma) can also be caused by sun exposure. Signs include a painless or painful discolored area or lump anywhere in the mouth, including on the tongue, that does not heal within a couple of weeks.

Leukoplakia

Leukoplakia (see page 744) is a disorder of the mucous membranes of the mouth in which raised, white patches develop in the mouth or on the tongue. The condition results from chronic irritation caused by smoking, using smokeless tobacco, poor dental hygiene, poorly fitting dental appliances, or a jagged tooth. If left untreated, leukoplakia can lead to oral cancer (see page 747).

Nail and Scalp Disorders

Paronychia

In paronychia (see page 1077), the cuticles and nail fold become swollen, inflamed, and painful as a result of a bacterial or fungal infection. Abscesses called whitlows make the base of the nail swell. In some cases, the nails are also thick and powdery.

Psoriasis of the nails Some skin disorders can also affect the nails. When psoriasis (see page 1064) affects the nails, they become pitted, rough, and abnormally thick.

Clubbed nails

Clubbed, or spoon-shaped, fingernails often occur in people with lung or heart disease and occasionally in people with inflammatory bowel disease (see page 1078). The tips of the fingers are bulbous and rounded. (Fingernails and fingertips that have been rounded since birth usually do not result from an underlying disorder.)

Bald patches on the scalp Hair loss that occurs in round patches on the scalp may result from a condition called alopecia areata (see page 1076), which can be triggered by stress.

Eye Disorders

Jaundice

Jaundice (see page 785), a condition resulting from too much of a pigment called bilirubin in the blood, causes the skin and the whites of the eyes (above) to turn yellow. Jaundice usually results from liver disorders.

Corneal ulcer

A corneal ulcer (see page 1037) is a break or open sore in the outer layer of the cornea (the clear, protective covering at the front of the eye). An ulcer on the cornea may make the white of the eye turn pink or red. In some cases, an ulcer can appear as a whitish patch that may impair vision.

Cataract

A cataract (see page 1041) is a clouding of the normally clear lens of the eye. An advanced, or mature, cataract resembles a gray or misty-looking circle within the normally black pupil. Cataracts can reduce vision.

Conjunctivitis

In conjunctivitis (see page 1038), a membrane called the conjunctiva (the membrane that lines the eye) becomes painful, red, and inflamed. The eye may feel gritty and itchy and have a sticky discharge. In some cases, the eye may be sensitive to light.

Ectropion

In ectropion (see page 1035), the lower eyelid hangs away from the eyeball, giving the appearance that the eyelashes are turned outward. The inner surface of the eyelid is exposed and the lining and the eyeball become sore and dry. A person with ectropion has excess tearing because the tears cannot drain properly.

Pterygium

A pterygium is a thickening of the conjunctiva (the membrane that lines the eye), causing it to grow and cover part of the cornea (the clear, protective covering at the front of the eye), usually in a winglike or fanlike pattern. Pterygiums usually appear on the inner corner of the eye and may grow large enough to interfere with sight. In some cases, pterygiums become red and irritated.

Chalazion

A chalazion (see page 1034) is a painless swelling (cyst) on the upper or lower eyelid that can grow to the size of a pea (although most are much smaller). If the cyst becomes infected, the eyelid can become red, painful, and more swollen. Chalazions are caused by blockage of the glands that lubricate the edges of the eyelids.

Entropion

In entropion (see page 1035), either the upper or the lower eyelid turns inward. The eyelashes rub on the surface of the eyeball, causing pain and irritating the eyeball. Entropion can cause extreme discomfort and lead to eye inflammation.

Xanthelasma

Xanthelasma (see page 1035) is a condition in which small, yellowish deposits of fatty material grow in the skin around the eyes, usually near the nose. The fatty deposits are harmless but, in rare cases, can be a sign of an abnormally high level of cholesterol in the blood.

Stye

A stye (see page 1034) is an infected eyelash follicle. A follicle in the eyelid becomes red, inflamed, and painful as it fills with pus.

Exophthalmos

Exophthalmos (see page 1054) is the medical term for eyes that appear to stare or to protrude from their sockets, exposing more of the whites of the eyes than usual. Exophthalmos can make closing the eyes difficult. Protruding eyes are a symptom of a number of disorders but are usually a symptom of hyperthyroidism (see page 901). The bulging is caused by a buildup of tissue behind the eyeballs that pushes them forward in their sockets.

8

Preventive Health Care

One of the most important things you can do is to take responsibility for keeping yourself healthy. Although genes play a role in all diseases, lifestyle factors—such as exercise habits and diet—are even more important influences on your health risks. Your doctor can help you evaluate your health risks and recommend steps to take to reduce them. See your doctor regularly to make sure you have all the recommended checkups, screening tests, and vaccinations. In general, the earlier a disorder is diagnosed and treated, the better the outcome.

Routine Health Care

You may need to choose a new doctor for a number of reasons: a move to another community, your doctor’s retirement or relocation, new health insurance requirements, the need for a specialist, a problem with your current doctor, or to get a second opinion. Try to explore your options while you are well so that you don’t have to rush into a decision during a crisis. Get a copy of your medical records from your former doctor or ask his or her office to send them to your new doctor. Everyone wants his or her doctor to be well trained, competent, and accessible. Compassion and high ethical standards are also important qualities in a doctor and are basic to good health care.

How to Choose a Doctor

If you are in a health insurance plan, or if you need a doctor who will accept Medicare, the range of doctors you can choose from may be restricted. With this in mind, ask friends and relatives if they have had good experiences with their doctors. What do they like about their doctors? (Remember, however, that what they like about their doctors may not be the same qualities you are looking for.) Ask your current doctor or other health care professionals for recommendations. Find out from local medical societies which doctors are currently accepting new patients. Locate a medical center that specializes in a particular area of health you’re interested in, and ask your doctor for a referral to the center or call the center yourself and find out how to get an appointment.

Many organizations (such as hospitals) have no-fee physician-referral services. You can also get information from doctor-selection services online or over the telephone. Most of these services organize their information according to type of practice and location. Others also provide information about a doctor’s background, education, training, and professional achievements.

Doctor Finder

You can locate doctors in your area by specialty through a physician-referral service called Doctor Finder, or AMA Physician Select, from the American Medical Association Web site (www.ama-assn.org/aps/amahg.htm). This service provides basic professional information about virtually every licensed physician in the United States, including more than 690,000 doctors of medicine (MDs) and doctors of osteopathic medicine (DOs). All credential data have been verified for accuracy and authenticated by accrediting agencies, medical schools, residency training programs, and licensing boards.

Here are some other things to consider when choosing a doctor:

• What kind of doctor do you need?

• Do you have a personal preference concerning culture, gender, or age? For example, do you want a doctor who comes from a similar background or speaks the same language as you do? Would you prefer a doctor who is the same sex as you or close in age?

• Do you need a doctor who is skilled in performing a particular procedure or in treating a particular illness?

• Is the doctor’s office easily accessible? Are his or her office hours and days of operation convenient? How far in advance would you have to make an appointment?

• Does your doctor have a good reputation among other doctors?

• Does he or she have privileges at a good hospital?

• How many years of residency training or fellowship has he or she completed?

• Is he or she certified by a medical specialty board?

What Does It Mean to Be Board-Certified?

To become board-certified, a doctor must complete at least 7 years of medical training (4 years of medical school plus 3 years or more of residency) and pass a comprehensive examination in his or her chosen specialty, such as surgery or internal medicine. Only when the doctor passes the examination is he or she board-certified. To find out if a doctor is board-certified, call the American Board of Medical Specialties (ABMS) at 866-275-2267, or visit the ABMS Web site (www.abms.org).

Talking to Your Doctor

When you see a new doctor for a routine physical examination, he or she will ask you a series of questions to find out what diseases or disorders you and your closest family members have had. Your answers to these questions make up your health history. This is valuable information your doctor needs to evaluate your current health status, determine what screening tests you might need, diagnose and treat any disease or disorder you might have, and recommend steps you can take to prevent future health problems.

Also be ready to provide your doctor with information about previous medical care, dates of immunizations, and your lifestyle. Have this information in writing—don’t rely on your memory.

To help determine if any diseases or disorders run in your family, try to learn as much as possible about the health history of your close relatives. Ask them about health problems they have now or may have had in the past. To learn about the health problems of a family member who has died, ask another family member or contact the person’s local health department to obtain a death certificate, which lists the cause of death.

After you have interviewed all of your relatives, use the information you have gathered to construct a family health history tree like the one on the next page. You and your doctor can then review the information in the finished tree to identify any patterns in the health of your family and evaluate your health risks.

Your Health History

Create your own written personal health history so you can monitor your medications and any changes in your health. Fill out the personal health history form on pages 132 to 134. Take your written personal health history with you each time you have an appointment with a new doctor or other health care professional. The information can help your doctors become familiar with you, your health, and your health care needs. The more completely you fill out the form, the better able your doctor will be to determine your health care needs.

Family Health History Tree

Personal Health History

Current Nonprescription Medications

Vaccinations

Make the Most of a Doctor Visit

Time is valuable—for both you and your doctor—so make the most of your doctor visit. Be on time for your appointment, and make your questions clear and brief. Listen carefully to the answers; take notes if you have to. Try not to get off the subject. Deal only with present health concerns; your doctor will ask you about past health concerns if they are related to your current health. Identify and describe your symptoms clearly. Answer questions completely and truthfully. Ask questions, especially if your doctor uses words or medical terms you don’t understand. Go over the list of medications you are currently taking—make sure you include all vitamins and other nutritional supplements. Also, discuss any alternative therapies or self-treatments you are using.

Your doctor makes his or her diagnosis based on your symptoms, a physical examination, and, often, test results. After he or she identifies your health problem, make sure you understand the diagnosis—and don’t leave until you do.

After the doctor’s visit, think about what you have learned. Call your doctor or his or her assistant or nurse if you still have questions or if you are not sure what you heard. Try to learn as much as you can about your disorder and about any recommended tests or treatment options by reading books or pamphlets and researching on the Internet. Make sure the information is from a reliable source, such as the federal government, a reputable national health organization such as the American Medical Association, or an organization that provides information about your specific disorder. Talk to other people who have the disorder.

When to Get a Second Opinion

Your health insurance company may insist that you get a second opinion before you have surgery or some other procedure. If your insurance plan requires a second opinion, the insurance company may help you find a doctor and will pay for the cost of the doctor’s appointment. In many cases Medicare will pay for the cost of a second opinion.

If you are the one who wants a second opinion, you may have to pay for it yourself. But don’t let cost be the deciding factor. You have a right to get a second opinion. Try to choose a doctor for a second opinion who is not affiliated or associated with your primary doctor, and make sure that the second doctor receives a copy of your medical records so you don’t have to repeat any diagnostic tests or procedures.

Follow your doctor’s instructions completely and carefully. Take responsibility for improving your health by improving your lifestyle. You may be able to monitor some conditions at home between appointments. For example, you can use a blood pressure monitor at home to check your blood pressure or test your blood regularly for glucose if you have diabetes. Don’t hesitate to call your doctor if you have any problems with your treatment or any other aspects of your care.