Antimicrobial resistance

Antimicrobial resistance - Microorganisms have evolved in the presence of antibiotics, which are antimicrobial agents produced naturally by bacteria and fungi. They have therefore developed multiple resistance mechanisms (categorised in Fig. 6.14) to all classes of antimicrobial agent (antibiotics and their derivatives). Resistance may be an innate property of a microorganism (intrinsic resistance) or may be acquired, by either spontaneous mutation or horizontal transfer of genetic material from another organism. For some agents, e.g. penicillins, a degree of resistance occurs in vivo when the bacterial load is high and the molecular target for the antimicrobial is down-regulated (an ‘inoculum effect’).

Antimicrobial Resistance

Antimicrobial Resistance

The mecA gene encodes a low-affinity penicillin-binding protein, which confers resistance to meticillin and other penicillinase-resistant penicillins in Staph. aureus. It is common for plasmids to encode resistance to multiple antimicrobials, which may be transferred horizontally. Extended spectrum â-lactamases (ESBL) are encoded on plasmids, which are transferred relatively easily between bacteria including Enterobacteriaceae. Plasmid-mediated carbapenemases have been detected in strains of Klebsiella pneumoniae. Glycopeptide resistance in enterococci is also transferred on mobile genetic elements. Strains of MRSA have been described that exhibit intermediate resistance to glycopeptides, through the development of a relatively impermeable cell wall (GISA).

Factors implicated in the emergence of antimicrobialresistance include the inappropriate use of antibiotics when not indicated (e.g. in viral infections) inadequate dosage or treatment duration, excessive use of broad- spectrum agents, and use of antimicrobials as growth-promoters in agriculture. However any antimicrobial use exerts a selection pressure that favours the development of resistance. Combination antimicrobial therapy may reduce the emergence of resistance. This is recommended in treatment of patients infected with HIV, which is highly prone to spontaneous mutation (p. 406). 

Despite use of combination therapy for M. tuberculosis, multidrug-resistant TB (MDR-TB, resistant to isoniazid and rifampicin) and extremely drug-resistant TB (XDR-TB,  resistant to isoniazid and rifampicin, any fluoroquinolone, and at least one injectable antimicrobial antituberculous agent) have been reported worldwide and are increasing in incidence (p. 693).

Characteristics of successful pathogens

Characteristics of successful pathogens - Successful pathogens have a number of attributes. They compete with host cells and colonising flora by various methods including sequestration of nutrients, use of metabolic pathways not used by competing bacteria, or production of bacteriocins (small antimicrobial peptides proteins that kill closely related bacteria). Motility enables pathogens to reach their site of infection, often in sterile sites that colonising bacteria do not reach, such as the distal airway. Many microorganisms, including viruses, use ‘adhesins’ to attach to host cells at the site of infection. Other pathogens can invade through tissues.

Five pathogens were selected for testing in the prototype POCT
instrument: (a) Streptococcus Pneumonia, (b) Pseudomonas,
(c) Cadida, (d) Staphylococcus aureus, and (e) Escherichia coli.
Infections with any of these pathogens can lead to sepsis.
If a patient does not receive medical intervention within hours,
 death is imminent.

Pathogens

Pathogens may produce toxins, microbial molecules that cause adverse effects on host cells either at the site of infection or remotely following carriage through the blood stream. Endotoxin is a cell wall component released mainly following bacterial cell damage and has generalised inflammatory effects. Exotoxins are proteins released by living bacteria, which often have specific effects on target organs (Box 6.3.) Intracellular pathogens, including viruses, bacteria (e.g. Salmonella spp., Listeria monocytogenes and Mycobacterium tuberculosis), parasites (e.g. Leishmania spp.) and fungi (e.g. Histoplasma capsulatum), have the capacity to survive in intracellular environments, including after phagocytosis by macrophages. Pathogenic bacteria express different arrays of genes, depending on environmental stress (pH, iron starvation, O2 starvation etc.) and anatomical location. In quorum sensing, bacteria communicate with one another to adapt their replication or metabolism according to local population density. Bacteria and fungi may respond to the presence of an artificial surface (e.g. prosthetic device, venous catheter) by forming a biofilm, which is a population of organisms encased in a matrix of extracellular molecules. Biofilm-associated organisms are highly resistant to antimicrobial agents.

Genetic diversity enhances the pathogenic capacity of bacteria. Some virulence factor genes are found on plasmids or in phages and are exchanged between different strains or species. The ability to acquire genes from the gene pool of all strains of the species (the ‘bacterial supragenome’) increases diversity and the potential for pathogenicity. Viruses exploit their rapid reproduction and potential to exchange nucleic acid with host cells to enhance diversity. Once a strain acquires a particularly effective combination of virulence genes, it may become an epidemic strain, accounting for a large subset of infections in a particular region. This phenomenon accounts for influenza pandemics.

Drugs

Drugs - A huge investment has been made by the pharmaceutical industry in finding drugs for obesity. The side-effect profile has limited the use of many agents, but a few drugs are currently licensed (Box 5.28). There is no role for diuretics, or for thyroxine therapy without biochemical evidence of hypothyroidism.

Orlistat is Drug Obesity

Anti-obesity Drug Reductil Faces a Ban in Europe

Orlistat inhibits pancreatic and gastric lipases andthereby decreases the hydrolysis of ingested triglycerides, reducing dietary fat absorption by ∼30%. The drug is not absorbed and adverse side-effects relate to the effect of the resultant fat malabsorption on the gut: namely, loose stools, oily spotting, faecal urgency, flatus and the potential for malabsorption of fat-soluble vitamins. Orlistat is taken with each of the three main meals of the day and the dose can be adjusted (60–120 mg) to minimise side-effects. Its efficacy is shown in Box 5.29 and Figure 5.13; these effects may be explained because patients taking orlistat adhere better to low-fat diets in order to avoid unpleasant gastrointestinal side-effects. Sibutramine reduces food intake through β1- adrenoceptor and 5-HT 2A/2C (5hydroxytryptamine,serotonin) receptor agonist activity in the central nervous system. 

Weight loss with sibutramine is 3–5 kg better than placebo with 6 months’ therapy and is associated with an improvement in lipid profile (see Box 5.29).Side-effects include dry mouth, constipation and insomnia. Unfortunately, noradrenergic effects of the drug can increase heart rate and blood pressure; these effects are especially undesirable in obese patients. Sibutramine is thus usually second choice after orlistat and cannot be used in those with hypertension or cardiovascular disease. There is insufficient evidence to recommend coprescription of orlistat and sibutramine.

Rimonabant is a cannabinoid receptor antagonist which acts in the hypothalamus to reduce appetite and may also have beneficial effects in peripheral tissues. Its efficacy in patients with obesity and type 2 diabetes is similar to orlistat (see Box 5.29), including reducing HbA1c by ∼1%. However, rimonabant may exacerbate or induce depression and has been associated with a small increased risk of suicide, which has prevented it being licensed in the US and has limited its use in Europe. Drug therapy is usually reserved for patients with high risk of complications from obesity (see Fig. 5.12), and its optimum timing and duration are controversial.

Although life-long therapy is advocated for many drugs which reduce risk on the basis of relatively short-term research trials (e.g. drugs for hypertension and osteoporosis), patients who continue to take antiobesity drugs tend to regain weight with time (see Fig. 5.13). This, together with finite health-care resources, has led to the recommendation in some guidelines that anti-obesity drugs are used in the short term to maximise the weight loss achieved with low-calorie diets (so that inevitable regain of weight starts from a lower baseline), but are not used in the long-term maintenance of weight.

Weight loss diets

Weight loss diets - In overweight people, adherence to the lifestyle advice above may gradually induce weight loss. In obese patients, more active intervention is usually required to lose weight before conversion to ‘weight maintenance’ advice above. A significant industry has developed in marketing diets for weight loss. These vary substantially in their balance of macronutrients (Box 5.27), but there is little evidence that they vary in their medium-term (1 year) efficacy.

eat vegetables regularly can lower weight

fitness weight loss

They all involve a reduction of daily total energy intake of ∼2.5 MJ (600 kcal) from the patient’s normal consumption. The goal is to lose ∼0.5 kg/week. Weight loss is highly variable, with patient compliance being the major determinant of success. There is some evidence that weight loss diets are most effective in their early weeks, and that compliance is improved by novelty of the diet; this provides some justification for switching to a different dietary regime when weight loss slows on the first diet. Vitamin supplementation is wise in those diets in which macronutrient balance is markedly disturbed.

Eat fruit for diet

In some patients more rapid weight loss is required, e.g. in preparation for surgery. There is no role for starvation diets, which risk profound loss of muscle mass and the development of arrhythmias (and even sudden death) secondary to elevated free fatty acids, ketosis and deranged electrolytes. Very low calorie diets (VLCDs) are recommended for short-term rapid weight loss, producing losses of 1.5–2.5 kg/week compared to 0.5 kg/ week on conventional regimes, but require the supervision of an experienced physician and nutritionist. The composition of the diet should ensure a minimum of 50 g of protein each day for men and 40 g for women to minimise muscle degradation. Energy content should be a minimum of 1.65 MJ (400 kcal) for women of height < 1.73 m, and 2.1 MJ (500 kcal) for all men and for women taller than 1.73 m. Side-effects are a problem in the early stages and include orthostatic hypotension, headache, diarrhoea and nausea.

Drugs A huge investment has been made by the pharmaceutical industry in finding drugs for obesity. The side-effect profile has limited the use of many agents, but a few drugs are currently licensed (Box 5.28). There is no role for diuretics, or for thyroxine therapy without biochemical evidence of hypothyroidism. Orlistat inhibits pancreatic and gastric lipases and thereby decreases the hydrolysis of ingested triglycerides, reducing dietary fat absorption by ∼30%. The drug is not absorbed and adverse side-effects relate to the effect of the resultant fat malabsorption on the gut: namely, loose stools, oily spotting, faecal urgency, flatus and the potential for malabsorption of fat-soluble vitamins.

Orlistat is taken with each of the three main meals of the day and the dose can be adjusted (60–120 mg) to minimise side-effects. Its efficacy is shown in Box 5.29 and Figure 5.13; these effects may be explained because patients taking orlistat adhere better to low-fat diets in order to avoid unpleasant gastrointestinal side-effects.

Smoking

Smoking - Smoking tobacco dramatically increases the risk of developing many diseases. It is responsible for a substantial majority of cases of lung cancer and chronic obstructive pulmonary disease, and most smokers die either from these respiratory diseases or from ischaemic heart disease. Smoking also causes cancers of the upper respiratory and gastrointestinal tracts, pancreas, bladder and kidney, and increases risks of peripheral vascular disease, stroke and peptic ulceration. Maternal smoking is an important cause of fetal growth retardation. 

Smoking can damage your health

Stop Smoking

Moreover, there is increasing evidence that passive (or ‘secondhand’) smoking has adverse effects on cardiovascular and respiratory health. When the ill-health effects of smoking were first discovered, doctors imagined that warning people about the dangers of smoking would result in them giving up. However, it also took increased taxation of tobacco, banning of advertising and support for smoking cessation to maintain a decline in smoking rates. In several European countries (including the UK), this has culminated in a complete ban on smoking in all public places—legislation that only became possible as the public became convinced of the dangers of secondhand smoke.  However, smoking rates remain high in many poorer areas and are increasing amongst young women. In many developing countries tobacco companies have found new markets and rates are rising. World-wide, there are ∼1 billion smokers, and 3 million die prematurely each year as a result of their habit.

In reality, there is a complex hierarchy of systems that interact to cause smokers to initiate and maintain their habit. At the molecular and cellular levels, nicotine acts on the nervous system to create dependence, so that smokers experience unpleasant effects when they attempt to quit. So, even if they know it is harmful, the role of addiction in maintaining the habit is important. Influences at the personal and social level are just as important. Many individuals bolster their denial of the harmful effects of smoking by focusing on someone they knew personally who smoked until he or she was very old and died peacefully in bed. Such strong counterexamples help smokers to maintain internal beliefs that comfort them when presented with statistical evidence.

Weaning from respiratory support

Weaning from respiratory support - This is the process of progressively reducing and eventually removing all external ventilatory support and associated apparatus. The majority of patients require mechanical ventilatory support for only a few daysand do not need weaning; simple trials of spontaneous breathing via the endotracheal tube will usually indicate whether the patient can be successfully extubated or not. In contrast, patients who have required long-termventilatory support for severe lung disease, such as ARDS, may initially be unable to sustain even a modest degree of respiratory work because of residual decreased lung compliance and hence increased work of breathing, compounded by respiratory muscle weakness. These patients require weaning until respiratory muscle strength improves to the point that all support can be discontinued. 

Evidence-based guildines for weaning and discountinuing ventilatory support

Weaning techniques involve the patient breathing spontaneously for increasing periods of the day and a gradual reduction in the level of ventilatory support. This often involves graduation to partial support modesand then non-invasive modes of ventilatory support. The process of identifying patients able to progress to spontaneous breathing and extubation is carried out.

According to a ‘weaning protocol’. This entails deciding whether a patient can be safely subjected to a spontaneous breathing trial (Box 8.22). If the patient meets these criteria, he/she undergoes the breathing trial for 2–5 minutes. The ratio of the respiratory rate to tidal volume is calculated. If it is < 105 breaths/min/L, the patient continues the trial for a further 30-minute to 2-hour period before extubation. In the event of failure (increased respiratory rate; decreased tidal volume), gradual weaning of ventilation continues using synchronised intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV) or intermittent periods of spontaneous breathing. Non-invasive ventilation via a facemask can allow earlier extubation in certain groups, such as patients with COPD,

with weaning continuing after removal of the endotracheal tube. Despite the development of objective tests and indices of the patient’s ability to sustain spontaneous ventilation, the decision to extubate and the speed of weaning from mechanical ventilation still rely largely on clinical judgement.

Allostatic Load

Allostatic Load - As selye noted, the initial respon se of the body to stressful  circumstances may be arousal, but over time this response may give way to exhaustion, leading to comulative damage to to the organism, Building on these ideas, researchers have developed the concept allostatic load (McEwen & Stellar, 1993). This concept refers to the fact that physiological systems within the body fluctuate to meer demands from stress, a state called allostasis. Over time, allostatic load builds up, which in defined as the physiological costs of chronic exposure to fluctuating or heightened neural or neuroendocrineresponse that results from repeated or chronic.

Mornington Peninsula Chiropractors

Allostatic Load

This buildup of allostatic load that is, the longterm costs of chronic or repeated stress can  be assessed by a number of indicators (T. E. Seeman, Singer, Horwitz & McEwen, 1997). These include decreases in cellmediated immunity, the inability to shut off cortisol in response to stress, lowered heart rate variability, elevated  epinephrine levels, a high waist to hip ratio, volume of the hippocampus (which is believed to decrease with repeated stimulation of the HPA), problems with memory (an indirect measure of hippocampal functioning), high plasma fibrinogen, and elevated blood pressure. Many of these changes occur normally with age, so to the extent that they occur early, allostatic load may be thought of as accelerated aging of the organism in response to stress. Over time, this kind of wear and tear can lead to illness. These effects may be exacerbated by the poor health habits practiced by people under chronic stress. The damage due to chronic stress. The damage due to chronic or repeated stress is only  made worse if people also cope with stress via higher fat diet, less frequent exercise, and smoking, all of which stress can encourage (Ng & Jeffery, 2003).

The physiology of stress and, in particular, the recent research on the cumulative adverse effects off stress are important because they suggest the pathways by which stress exerts adverse on the body ultimately contributing to the likelihood of desease. The relationship of stress, both short and long term, to both acute disorders such as infection, and chronic disease is now so well etabilished that stress is implicated in most deseases, either  in their etiology, their course, or both. We explorer these processes more fully when we address different disease such as heart desease and hypertension in chapter 13 and cancer and arthritis in chapter 14. At this point, suffice it to say, stress is one of the major risk factors for desease that humans encounter. 

Effects of Long term Stress

Effects of Long term Stress - We have just examined some of the major physiological changes that occur in response to the perception of stress. What do these changes mean? Although the short-term mobilization that occurs in response to stress originally prepared humans to fight or flee, rarely do stressful events requre these kindsof adjustments. Consequently, in response to stress, we often experience the effects of sudden elevations of circulating stress hormones that, in certain respect, do not serve the purpose for which they were originallyintended.

Stress

many thoughts create stress

Over the long term, excessive discharge of epinephine and norepinephrine can lead to suppression of celular immune functions; produce hymodynamic changes,such as increased blood pressure and heart rate; provoke variations in normal heart rhythms, such as ventricular arrhythmias, which may be a precusrsor to sudden death: and produce neurochemichal imbalances that may contribute to the development of psychiatric disorders. The catecholamines may also have effects on lipid levels and free fatty acids, all of which may be important in the development of atherosclerosis.

Stop Stressing Star Livi

Corticosteroids  have immunosuppressive affects, which can compromise the functioning of the immunensystem. Prolonged cortisol secretion has also been related to the destruction of neurons in the hippocampus. This destruction can lead to problems in verbal functioning, memory, and concentration, (Starkman, Giordani, Brenent, Schork & Schreingart, 2001) and may be one of the merchanisms by which the senility that sometimes occurs in old age sets in. Pronounced HPA activation is common in depression, with episodes of cortisol secretion being more frequent and of longer duration among depressed than nondepressed people, although it is not entirely clear whether HPA activation is a cause or an effect of these disorders. Another longterm consequence of the endocrine abnormalities that result from chronic HPA activation is the storage of fat in central visceral areas, rather than to the hips. Accumulation leads to a high waist-to-hip ratio, which is used by some researchers as a maker for chronic stress (Bjorntorp, 1996).

Which of these responses to stress have implications for desease? Several researchers (Dienstbier, 1989; Frankenhaeuser, 1991) have suggested that the health consequences of HPA axis actvation. Sympathetic adrenal in response to stress may not be a pathway for desease; HPA activation may be required as well. Some researchers have sugessted that this reasoning explains why exercise, which produces sympathetic arousal but not HPA activation, is protective for health rather than health compromising.

Stress may also impair the immune system capacity to respond to hormonal signals that terminate inflammation. A study that demonstrates this point compared 50 healthy adults, half of whom were parents of cancer patients and, the other helf, parents of healthy children. Childhood cancer is known to be one of the most stressfulevents that parents encounter. The parents of the cancer patients reported more stress and flatter daily slopes of cortisol secretion than was true for the parents of healthy children. Moreover, the ability to suppress production of a proinflammatory cytokine called IL-6 was diminised among parents of the cancer patients. Because proinflammatory cytokines are implicated in a broad array of desease, these findings suggest that the impaired ability to terminate inflammantion may be another pathway by which stress affects illness outcomes (G. E. Miller, Cohen, & Ritchey, 2002).

Selye's General Adaptation Syndrome

Selye's General Adaptation Syndrome - Anhother important early contribution to the field of stress is Hans Selye's (1956, 1976) work on the general adaptation syndrome. Although Selye initially intended to explore the effects of sex hormones on physiological functioning, he became interested in the stressful impact his interventions seemed to have. Accordingly, he exposed rats to a variety of stressors-such as extreme cold and fatigue and observed their physiological responding. In particular, they all led to an enlarged adrenal cortex, shrinking of the thymus and lymph glands, and ulceration of the stomach and duodenum. Thus, whereas Cannon's work explored adrenomedullary responses to stress specifically, catecholamin secretion Selye's work more closely explored adrenocortical responses to stress.

General Adaptations Stages

From these observation, selye (1956) devloped his concept of the general adaptation sydrome. He argued that, when an organism confronts a stressor, it mobilizes it self for action. The respose it self is nonspecific with respect to the stressor; that is, regardless of the cause of the threat, the individual will respond with the same physiological pattern of reactions. Over time. with repeated or prolonged exposure to stress, there will be wear and tear on the system.

Adaptation Syndrom

The general adaptation syndrome consists of three phases, In the first phase, alarm, the organism becomes mobilized to meet the threat. In the second phase, resistance, the organism makes efforts to cope with the threat, as through confrontation. The third phase, exhaustion, occurs if the organism fails to evercome the threat and depletes its physiological resources in the process of trying. These phases are pictured in figure.

General Adaptation Syndrom

The subtantial impact of Selye's model on the field of stress continues to be felt today. One reason is that it offers a general theory of reactions to a wide variety of stressors over time. As such, it provides a way of thonking about the interplay of physiological and environmental factors. Second, it posits physiological mechanism for the stress-illness relationship. Specifically, Selye believed that repeated or prolonged exhaustion of resources, the third phase of the syndrome, is responsible for the physiological damage that lays the groundwork for desease. In fact, prolonged to repeated stress has been implicated in a broad array of disorders, such as cardiovascular disease, arthiritis, hypertension, and immune-releated deficiencies.

Cognitive Behavioral Treatments

Cognitive Behavioral Treatments - A variety of behavior modification techniques have been incorporated into alcohol treatment programs (NIAAA, 2000a). Many programs include a self-monitoring phase, in which the alcoholic or program drinker begins to understand the situations that give rise to and maintain drinking, Contigency contracting is frequently employed, in which the person agrees to a phychologically or financially costly outcome in the event of failure. Motivational enhacement procedures have also been included in many cognitive-behavioral interventions with alcoholics and problem drinkers, because responsibility and the capacity to change rely entirely on the client. Consequently, working to provide individualized feedback about the patient's drinking and the effectivenes of his or her efforts can get the client motivated and on board to continue a program of treatment that may be more resistant to the inevitable temptations to relapse (NIAAA, 2000a).

not drink alcohol

alcohol can kill you

Some program have included medications for blocking the alcohol-brain interactions that may contribute to alcoholism. One such medication is naltrexone, which is used  as an aid to prevent relapse among alcoholics. It blocks the opioid receptors in the brain, thereby weakening the rewarding effects of alcohol. Another drug, acamprosate (Campral), has also shown effectiveness in treating alcoholism and may help alcoholics maintain abstinence by preventing relapse. It seems to achieve effects by modifying the action of GABA, a neurotransmitter (Elchisak, 2001). Other drugs  are being evaluated as well. Although drugs have shown some success in reducing alcohol consumption in conjuction with cognitive-behavioral interventions, successful maintenance requres patients to continue taking the drugs on their own, and if they choose not to do so, they reduce the effectiveness of the chemical treatment.

Many successful treatment programs have attempted to provide alcoholics with strees management techniques that they can subtitute for drinking because, as note earlier, alcohol is sometimes used as a method  of coping with stress. Because the occurrence of a major stressful event within the firts 90 days after treatment can trigger relapse among apparently recovered alcoholics (Marlatt & Gordon, 1980), stress management techniques can help the alcoholic get through events that raise temptation to relapse. For example, relaxation training, assertiveness training, and training in social skill help the alcoholic or problem drinker deal with problem situations without resorting to alcohol.

In some cases, family therapy and group counseling are offered as well. The advantage of family counseling is that it cases the alcoholic's or problem drinker's transition back into his or her family (NIAAA, 2000a).

Apnea

Apnea - Many of the problem related to sleep d istruption have so do with amount of sleep, but in other cases, quality of sleep is the culprit. Recently, researchcers have recognized that sleep apnea, an air pipe blockage that disrupts sleep, can comparamise health. Each time that apnea occurs, the sleeper stops breathing, sometimes for as long as 3 minutes, until he or she suddenly wakes up, gasping for air. some people are awekened dozens, even hundreds, of time each night without realizing it. Researchers now believe that sleep apnea triggers thousands of nighttime deaths, including heart attacks. Apnea also contributes to high rates of accidents in the workplace and on the road and to irritability, anxiety, and depresion. Sleep apnea is difficult to diagnose because the symptoms, such as grouchiness, are so diffuse, but fitful, harsh snoring is one signal that a person may be experiencing apnea.

Sleep Apnea

Sleep Apnea can disturb the sleep of others

Is there any treatment for apnea? Because apnea is caused by excessive tissue in the back of the throat, which blocks the air passage, doctors can in servers cases cut out some of this throat tissue. Other patients sleep with a machine designed to keep airways open or wear sleeping masks that blow air down the throat all night. Such methods improve cognitive functioning chief casualty of the excaustion produced by chronic obstructive sleep apnea (Bardwell, Ancoli-Israel, Berry, & Dimsdale, 2001). Although sleep apnea is chronic problem for some people, many people also get it occasionally, particularly following a night of heavy drinking or smoking (S. Baker, 1997). The medical community is just beginning to understand how problematic chronic obstructive sleep apnea can be.

The next year promise to enligten us more fully as to the health benefits of sleep and liabilities of disordered sleeping. For those with persistent sleep problems, a variety of cognitive-behavioral interventions are available that typically make use of relaxation therapies (Perlis et al., 2000;Perlis, Shape, Smith, Greenblatt, 2001). Such programs also recommed better sleep habits, many of which can be undertaken on one's own (Gorman, 1999; S.L. Murply, 2000). How can we sleep better?see 4.5

4.5 A Good Night's Sleep

• Get regular exercise, at least three times a week.
• Keep the bedroom cool at night
• sleep a ncomfortable bed that is big enough
• Establish a regular schedule for awakening and going to be
• Develop nightly rituals that can get one ready for bed, such as taking a shower
• Use a fan or other noise geneator to mask background sound
• Don't consume too much alcohol or smoke
• Don't eat too much or too little at night.
• Don't have strong smells in the room, as from incense, candles, or lotions.
• Don't nap after 3 p.m
• Cut back on coffeine, especially in the afternoon or evening 
• If awakened, get up and read quietly in another place, to associate the bad with sleep, not sleeplessness.

Sleep and Health

Sleep and Health - More than 14 million Americans, most over 40, have major sleep disorders-most commonly, insomnia (Nagourney, 2001). Thirty-nine percent of adults sleep less than 7 hours a night on weeknight, 36% of people over 15 report at least occasional insomnia, and 54% of people over 55 report insomnia at least once a week (Weintrauch, 2004). For women, sleep disorders may be tied to hormonal levels to related to menopause (Manber, Kuo, Cataldo, & Colrain, 2003).

Lack of sleep is Insomnia

Better sleep means better health

Enough Sleep the Body will be Fresh

It has long been known that insufficient sleep (less than 7 hours a night) affects cognitive fungtioning, mood, performance in work, and quality of life (Pressman & Orr, 1997). Any of us who has spent a sleepless night tossing and turning over some problem knows how unpleasant the following day can be. Poor sleep can be a particular problem in certain high-risk occupations, with nightmares as one of the most commons symptoms. This is especially  true for occupations such as police work, in which police officers are exposed to traumatic events (Neylen et al., 2002). 

Increasingly, we are also recoginizing the health risks of inadequate sleep (Leger, Scheuermaier, Phillip, Paillard, & Guilleminault, 2001). Cronic insomnia can compromise the ability to secrete and respond to insulin (suggesting a link between sleep and diabetes), it can increase the  risk of developing coronary heart desease (Bonner & Arand, 1998), and it can reduce the efficacy of flu shots, among its other detrimental effects (Center for the Advancement of Health, January 2004; Weintraub, 2004). More than 70.000 of the nation's annual automobile crashes are accounted for by sleepy drivers, and 1,550 of these are fatal each year. In one study of healthy older adults, sleeps disturbances predicted allcause mortality over the next 4 to 19 years of follow-up (Dew et al., 2003). Even just six nights of poor sleep in a row can impair metabolic and hormonal function, and over time, chronic sleep lost can aggravate the severity of hypertension and Type II diabetes (K. Murphy, 2000).

Sleep deprivation has a number of adverse effects on immune functioning. For example, it reduces natural killer cell activity, which may, in turn, lead to greater receptivity to infection (Irwin et al., 1994), and it leads to reduced counts of other immune cells as well (Savard, Laroche, Simard, Ivers, & Morin, 2003). Poor sleep compromises human antibody response to hepatitis A vaccination (Lange, Perras, Fehm, & Born, 2003). Shift workers, who commonly experience disordered sleep when they change from one shift to another, have a high rate of respiratory tract infections and show depressed cellular immune function, Even modest sleep disturbance seems to have these adverse effects, although after a night of good sleep, immune functioning quickly recovers (Irwin et al., 1994

Treating Anorexia

Treating Anorexia - Initially, the chief target of therapy is to bring the patient's weight back up to a safe level, A goal that must often be undertaken in a residential treatment setting, such as a hospital. To achieve weight gain, most therapies use behavioral approaches, such as operant conditioning. Usually, operant conditioning provides positive reinforcements, such as social visits in return for eating or weight gain. However, behavioral treatments in a hospital setting alone may fail to generalize to the home setting (Garfinkel & Garner, 19820 because of family and environmental factors that may induce or maintain the nehavior.

balanced meals can be avoided illness anorexia

Once weight has been restored to a safe level, additional therapies are needed. Family therapy may be initiared to help families learn more positive methods of communicating emotion and conflict. Psychotherpy to improve self-esteem and to teach skills for adjusting to stress and social preasure may also be incorporated into treatment (A. Hall & Crisp, 1983). The outlook for anorexic patients receiving therapy intervention reporting success rates of 85% (Minuchen, Rosman, & Baker, 1978). Other interventions have tried to address social norms regarding thinness directly (for example, Neumarksztainer et al., 2003). For example, one study gave women information about other women's weight and body type, on the grounds that women with eating disoders often wrongly believe that other women are smaller and thinner than they actually are (Sanderson, Darley, & Messinger, 2002). The intervention succeeded increasing women's estimates of their actual and ideal weight (Mutterperl & Sanderson, 2002).

Because of the health risks of anorexia nervosa, research has increasingly moved toward prevention; yet the factors that may prevent new cases from arising may be quite different from those that lead students who already have symptoms to seek out treatment (Mann et al., 1997). An eating disorder prevention program aimed at college freshman presented the students with classmates who had recorvered from an eating disorder, described their experience, and provide information. To the researchers' dismay, following the intervention, the participants had slightly more symtomsof eating disorders than those who had not participated. The program may have been ineffective because, by reducing the stigma of these disorders, it inadvertently normalized the problem. Consequently, as Mann and her collegues (1997) concluded, ideal strategies for prevention may require stressing the health risks of eating disorders, whereas the strategies for inducing symptomatic women to seek treatment may involve normalizing the behavior and urging women to accept treatment.

Taking a Public Health Approach

Taking a Public Health Approach - The increasing prevalence of obesity makes it evident that shifting from a treatmentmodel to a public health model that shifting from a treatment model to a public health model that emphasizes prevention will be essential for combating this problem (Battle & Brownell, 1996). Although cognitive-behavioral methods are helping at least some people lose weight, clearly weight-loss programs are not a sufficient attack on the problems of overweight and obesity.

the public health approach to prevention

Prevention with families at risk for producing obese children is one important strategy. If parents can be trained early to adopt sensible meal planning and eating habits that they can convey to their children, the incidence of obesity may ultimately decline.

Although obesity has proven to be very difficult to modify at the adult level, behavioral treatment of childhood obesity has an impressive record of success. It may be easier to teach children healthy eating and activity habits than to teach adults, Programs that increase activity levels through reinforcements for exercise are an important componen of weight-control programs with children (L. H. Epstein, Saelens, Myers, & Vito, 1997). Interventions that reduce TV watching can also reduce weight in children (T. N. Robinso, 1999). Moreover, because parents regulates children's access to food, problems in self-control are less likely to emerge with children. Whether treatment of childhood obesity will have long-tern effects on adult weight remains to be seen (G. T. Wilson, 1994).

Another approach to obesity that emphasizes prevention programs for normal-weight adults. If exercise can be increased, diet altered in a healthy direction, and good eating habits developed, the weight gains that often accompany the aging process may be prevented (L. H. Epstein, Valoski, Wing, & McCurley, 1994). This approach may be particularly succesful for women during menopause, as weight gain is very common during this time (SimkinSilverman, Wing, Boraz, & Kuller, 2003).

Like many healts habits, social engineering strategies may become part of the attack on this growing problem. The Word Health Organization has argued for several changes, which include food labels that contain more nutrition and serving size information, a special tax on foods that are high in sugar and fat (the so-called" junk food' tax), and restriction of advertising to children or requiring health warnings (Arnst, 2004).

The internal Revenue Service has already declared that a person diagnosed by a physician as obese can claim fees paid to weight-loss programs as a tax deduction (Kristof, 2002). In fact, the rulling permits an individual to deduct the cost of the diagnosis, cure, mitigation, treatment, or prevention of the desease. Clearly the rulling covers formal weight-loss programs. It is not yet clear if it would cover gym memberships or exercise equipment, for example. Some individuals have even gone so far as to sue fast food places and food companies. Although these suits may be found to lack merit. the pressure they bring on the industry to engage in responsible food marketing practices and scutiny of theirs products, may ultimately be of benefit (Nestle, 2003)

Why Is Diet Important?

Why Is Diet Important? - Dietary  factors have been implicated in a broad array of diseases and riks for disease. Perhaps the best known is the relation  of dietary factors to total serum cholesterol level and to low-density lipid proteins is particular (McCaffery et al., 2001). Although diet is only one determinant of a person's lipid profile, it can be an important one because it is controllable and because elevated total serum cholesterol and low density lipid proteins are risk factors for the development of coronary heart disease and hypertensions. Of dietary recommendations, switching from trans fats (from meat and dairy products) to polyunsaturated fats and monounsaturated fats is one of the most widely, recommended course of action (March, 2002). Diet may be implicted in sudden death, because danger from arterial clogging may increase dramatically after a high-fat meal (G. J. Miller et. al., 1989). Salt has been linked to hypertension and to cardiovascular disease in some individuals as well (Jeffery, 1992).

five food to lower choleterol

Lower Cholesterol Naturally

Dietary habits have also been implicated in the development of several cancers, including colon, stomach, pancreas, and breast (Steinmetz, Kushi, Bostick, Folsom, & Potter, 1994). Dietary modification is also important for polyp prevention among individuals at risk for colorectal cancers, specifically a low-fat, high-fiber diet (Corle et al., 2001). Estimates of the degree to which diet contributes to the incidence of cancer exceed 40% (Fitzgibbon, Stolley, Avellone, Sugerman, & Chaves, 1996).

A poor diet may be especially problematic in conjunctions with other risk factors. Stress, for example, may increase lipid reactivity (Dimsdale & Herd, 1982). Lipid levels may influence intellectual functioning; in particular, serum cholesterol concentration may be an indicator of levels of brain nutrients important to mental effycience (Muldoon, Ryan, Matthews, & Manuck, 1997).

The good news is that canging one's diet can improved health. For example, a diet high in fiber may protect against obesity and cardivascular disease by lowering insulin levels (Ludwig et al., 1999). A diet high in fruits, vegetables, whole graints, peas and beans, poultry, and fish and low in refined grains, potatoes, and red and processed meats has been shown to lower the risk of coronary heart disease in women (Fung, Willett, Stampfer, Manson, & Hu, 2001). Modification in diet can lower blood cholesterol level (Carmody, Matarazzo, & Itsvan, 1987), and these modifications may, in turn, reduce the risk for atherosclerosis. A relatively recent class of drugs, called statins, subtantially reduces cholesterol in conjuction with dietary modification. In fact, the effects of statins are so rapid that low-density lipoprotein (LDL) choleterol is lower within the firts month after beginning use. Together, diet modification and a statin regimen appear to be highly successful for lowering cholesterol.

Sunsreen Use

Sunsreen Use - The past 30 years have seen a nearly fourfold increase in the incidence of skin cancer in the United Stated. More than I millionnew cases of skin cancer will be dianosed this year alone. Although common basal cell and squamous cell carcinomas do not typically skill, malignant melanoma takes approximately 7,000 lives each year (Factsof Life, July 2002). In the last two decades, melanoma incidence has risen by 155%. Moreover, these cancers are among the most preventable cancer we have. The chief risk factor for skin cancer is well known: excessive exposure to ultraviolet radiation. Living or vacationing in southern latitudes, participating in outdoor activities, and using tanning salons all conribute to dangerous sun exposure (J. L. Jones & Leary, 1994).

 sunscreen use overcome skin cancer

Sunscreen Use

Sun protective behaviors are practiced consistently by less than one third of American children and more than three quarters of U.S. teens get at least one sunburn each summer (Facts of Life, July 2002). As a result, health psycologists have increased their efforts to promote safe practices. Typically, these efforts have included educational interventions designed to alert people to the risks of skin cancer and to the effectiveness of suncreen use for reducing risk (for example, R. C. Kats & Jernigan, 1991). Based on what we know about attitudinal interventions with other health habits, however, education alone is unlikely to be entirely successful (Jones & Leary, 1994).

Problem with getting people to engage in safe sun practices stem from the fact that tans are parceived to be attractive, In fact, young adults perceive people without tans (Facts of Life, July 2002). Young adults who are especially concerned with their physical appearance and who believe that tanning enhances their attractiveness  are most likely to expose themselves to ultraviolet radiation through tanning (Leary & Jones, 1993). Even people who are persuaded of the importance of safe sun habits often practice them incompletely. Many of us use an inadequate sun protection factor (SPF), and few of us apply sunscreen as often as we should during outdoor activities (Wichstrom, 1994). Nonetheless, the type of skin one has-burn only, burn then tan, or tan without burning is the strongest influence on likelihood of using sun protection (Clarke, Williams, & Arthey, 1997), suggesting that people are beginning to develop some understanding of their risk.

Benefits of Exercise

Benefits of Exercise - The health of aerobic exercise are subtantial (see table 4.1). A mere 30 of exercise a day can decrease the risk of cronic disease including heart disease and some cancers including breast cancer (Center for the Advancement of Health, March 2004). Exercise, coupled with dietary change, can cut the risk of Type II diabetes in high-risk adults significantly. However, two thirds of American adults do not achieve the recomended levels of physical activity, and about one fourth of American adults do not engage in any leisure-time physical activity (Center for the Advecement of Health, April 2002). Physical inactivity is more common among women than men, among African Amercans and Hispanics than Whites, among older than younger adults ( R. E. Lee & King, 2003), and among those with lower versus higher incomes (Center for the Advancement of Health, 2002). Sixty-four percent of men and 72% of women do not have any regular leisure time source of physical activity and two thirds of older adults are not as active as they should be (Facts of life, March 2004).

aerobic exercises for Healthy

aerobic exercises for beautiful body shape

Table 4.1 Health Benefits of Regular Exercise

• Increases maximum oxygen consumption.
• Decreases resting heart rate.
• Decreases blood pressure (in some)
• Increases strenght and efficiency of heart (pumps more blood per beat)
• Decreases use of energy sources, such as glutamine.
• Increases slow have sleep.
• Increases HDL, inchanged total cholesterol.
• Decreases cardiovascular disease
• Decreases obesity
• Increases longevity
• Decreases menstrual cycle length, decreases estrogen and progesterone.
• Decreases risk of some cancer.
• Increases immune system functions.
• Decreases negative mood.

Perhaps more suprising is the fact that health practitioners do not uniformly recommend physical exercise, even to their patients (Center for the Advancement of Health, 2000; Leveille et al. 1998); yet studies show that a physician recommendation is one of the factors that lead people to increase their exercise (Calfas et al., 1997).

Aerobic exercise has been ried to increases in cardiovascular fitness and endurance (B. Alpert, Field, Goldstein, & Perry, 1990) and to reduced risk for heart attack (Paffenbargert, Hyde, Wing, & Steinmetz, 1984). Exercise is considered to be the most important health habit for the elderly, and cardiovascular benefits of exercise have been found even for preschoolers (B. Alpert et al., 1990). Other health benefits of exercise include increased efficiency of the cardiorespiratory system, improved physical work capacity, the optimization of body weight, the improvement or maintenance of muscle tone and strenght, an increase in soft tissue in joint flexibility, the reduction or control of hypertensions, improved cholesterol level, improved glucose tolerance, improved tolerance of stress, and reduction in poor health habits, including cigarette smoking, alcohol consumption, and poor diet (Center for the Advancement of Health, 2000b; Ebbesen, Prkhachin, Mills, & Green, 1992). People who obtain regular, vigorous exercise may also have lower rates of certain froms of cancer (Brownson, Chang, Davis, & Smith, 1991). 

Changing Health Behaviors through Social Engineering

Much behavior change occurs not through behaviorchange programs but through social engineering. Social engineering involves modifying the environment in ways that effect people's ability to practice a particular health behavior. These measures are called passive because they do not require an individual to take personal action. For example, wearing seat belts is an active measure that an individual must take to control possible injury from an automobile accident, whereas airbags, which inflate automatically on impact, represent a passive measure.

Social Engineering with Provide Vaccinations for children for health

Many health behaviors are already determined by social engineering. Banning the use of certain drugs, such as heroin and cocaine, and regulating the disposal of toxic wastes are examples of health measure that have been mandated by legislation. Both smoking and alcohol consumption are legally restricted to particular circumstances and age groups. Requiring vaccinations for school entry has led to more than 90% of children receiving most of the vaccinations they need (Center for the Advancement of Health, October 2002).

Many times, social engineering solutions to health problems are more succesful than individual ones. We could urge parents to have their children vaccinated againts the major childhood disorders of measles, in influenza, hepatitis, diphtheria, and tetanus, but requiring immunizations for school entry has been very succesful. We could intervene with parents to get  them to reduce accident risks in the home, but approaches such as using safety containers for medications and making children's clothing with fire-retardant fabrics are more successful (Fielding, 1978). Lowering the speed limit has had far more impact on death and disability from motor vehicle accident than interventions to get people to change their driving habits (Fielding, 1978). Raising the drinking age from 18 to 21 is more successsful in reducing alcohol-related vehicular fatalities than are programs designed to help the drunk driver (Ashley & Rankin, 1988). Fallout from the current negotiations between the tobacco industry and the federal government are likely to lead to further restrictions on smoking, especially those restrictions designed to limit exposure to secondhand smoke.

The prospects for contuined  use of social engineering to cahnge health habits are great. Controlling what is contained in vending machines at schools, putting a surcharge on foods high in far and low in nutritional value, and controlling advertising of high-fat and high cholesterol product, particularly those directed to children, should be considered to combat the enormous rise in obesity that has occurred over the past 2 decades (M. F Jacobson & Brownell, 2000), Indeed, as the contributions of diet and obesity to poor health and early death become incresingly evident, social engineering solutions with respect to food salex and advertising may well emerge. 

Health Promotion and the Ederly

Health Promotion and the Ederly - Ford's lifestyle is right on target. One the chief focuses of recent health promotion efforts has been the elderly. At one time, prejudiced beliefs that such health promotion efforst would be wasted in the old age limited this emphasis, however, policy makers now recognize that a healthy elderly population is essential for controlling health care spending and insuring that country's re sources can sustain the increasingly elderly population that will develop over the next decades (Maddox & Clark, 1992; Schaie, Blazer, & House, 1992).

Among the elderly, health habits are major determinant of whether
 an individual will have a vigorous or an infirmed old age

Health promotion efforts with elderly have focused on several behaviors: maintaining a healthy, balanced diet; developing a regular exercise regimen; taking steps to reduce accidents; controlling alcohol consumptions; eliminating smoking; reducing the inappropiate use of prescription drugs; and obtaining vaccinations againts influenza (Facts of Life, Oktober 2002; kahana et.al., 2002; Nichol et al.,2003).

Exercise is one of the most important health behaviors because  exercise helps keep people mobile and able to care for themselves. Even just keeping active also has health benefits. Participating in social activities, running errands, and engaging in other normal activities that probably have little effect on overall fitness nonetheless reduce the risk of mortality, perhaps by providing social support or a general sense of self-efficacy (T. A. Glass, deLeon, Marottoli, & Berkman, 1999). Among the very old, exercise has particularly beneficial long-term benefits, substantially increasing the likelihood that the elderly can maintain the basic activities of daily living (Kahana et al., 2002).

Controlling alcohol consumption is an important target for good health among the elderly as well. Some elderly people develop drinking problems in response to age-related issues, such as retirement or loneliness (Brennan & Moos, 1995). Others may try to maintain the drinking habits they had throunghout their lives, which become more risky in old age. For example, metabolic chenges related to age may reduce the capacity for alcohol. Moreover, many older people are on medications that may interact dangerously with alcohol. Alcohol consumption increases the risk of accidents, which, in conjuction with oesteoporosis, can produce broken bones, which limit mobility, creating further health problems (Sheahan et al., 1995). Drunk driving among the elderly represents a problem, inasmuch as diminished driving capacities may be further impaired by alcohol. The elderly are at risk for depression, commonly thought of as a mental health problem, can have effects on physical health as well (Wrosch, Schulz, & Heckhausen, 2002).