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BRIEF CONTENTS
11
12
13
PART ONE
Finding the Right Balance
1
NEW
Chapter
FOCUS ON
NEW
Promoting and Preserving Your
Psychological Health 36
MINDFULNESS, SPIRITUAL HEALTH, AND
SPIRITUAL INTELLIGENCE 61
3
Managing Stress and Coping with Life‘s
Challenges 75
4
Improving Your Sleep
14
15
Protecting Against Infectious Diseases
16
Reducing Your Risk of Cardiovascular
Disease 412
Protecting Against Sexually Transmitted
Infections 395
MINIMIZING YOUR RISK FOR DIABETES
17
18
Building Healthy Lifestyles
Reducing Risks and Coping with Chronic
Conditions 469
PART SIX
Reaching and Maintaining a Healthy
Weight 148
Facing Life‘s Challenges
19
20
ENHANCING YOUR BODY IMAGE
172
Improving Your Personal Fitness 185
9
10
Understanding Your Sexuality 232
Preventing Violence and Abuse 514
21
Preserving and Protecting Your
Environment 549
22
Preparing for Aging, Death,
and Dying 572
ANSWER TO POP QUIZ QUESTIONS
PROVIDING EMERGENCY CARE
Considering Your Reproductive
Choices 255
GLOSSARY
Avoiding Risks from Harmful Habits
REFERENCES
A-3
G-1
R-1
PHOTO CREDITS
FOCUS ON
CVR_DONA3794_16_SE_IFC.indd 458
A-1
NUTRITIVE VALUE OF SELECTED FOODS AND FAST
FOODS A-9
PART FOUR
RECOGNIZING AND AVOIDING ADDICTION
489
REDUCING YOUR RISK OF UNINTENTIONAL
INJURY 535
Creating Healthy and Caring
­Relationships
Building Healthy Relationships and
Communicating Effectively 213
Making Smart Health Care Choices
FOCUS ON
PART THREE
8
435
Reducing Your Cancer Risk 446
Nutrition: Eating for a Healthier You 119
FOCUS ON
374
FOCUS ON
102
PART TWO
7
Avoiding Drug Misuse and Abuse 346
Preventing and Fighting Disease
FOCUS ON
5
6
Ending Tobacco Use 326
PART FIVE
DIFFERENCE, DISPARITY, AND HEALTH:
ACHIEVING HEALTH EQUITY 23
2
This section
was reorganized
and coverage of
Aging, Death, and
Introduction
to
Dying
streamlined
Mindfulness
into a FOCUS
ON chapter.
Accessing Your Health 1
Drinking Alcohol Responsibly 304
290
INDEX
C-1
I-1
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Motivate students to become
actively engaged in their own health
Access to Health combines scientifically valid research and the most current information to encourage
healthy life choices. As a teacher, mentor, and researcher, author Rebecca J. Donatelle uses her friendly
writing style to address students’ concerns and motivate them to be savvy, critical consumers of health
information. The 16th Edition integrates mindfulness research, tools, and practices throughout the text;
a new chapter on difference, disparity, and health equity; and now provides access to MyDietAnalysis—a
diet and activity tracking tools that gives students an easy way to analyze their daily nutrient intake and
physical activity—in Mastering™ Health at no extra charge.
1
Help students connect what they
read in their textbook . . .
NEW! Mindfulness and You boxes
focus on mindfulness research and
applications in relation to high interest
topics such as sleep, technostress, mental
health, sexual dysfunction, etc.
In addition, a mindfulness theme has
been integrated throughout the text and
is signaled by a new mindfulness icon.
P. 58
NEW! Focus on Difference, Disparity
and Health Equity chapter challenges
students to think about issues of diversity and
health equity, and the actions they can take as
individuals and as a society to begin to remove
barriers and promote access to health for all.
P. 23
to themselves and their
communities
Why Should I
Care? opens each
P. 37
Making Changes
Today boxes
chapter and addresses
the relevance of health
issues to students’
lives by presenting
information on the
effects poor health
habits have on them in
the here and now.
MAKING CHANGES TODAY
give students
situation-specific
techniques for making
lasting changes to
health behaviors.
Challenge the Thoughts That Sabotage Change
Are any of the following thoughts holding you back? If so,
challenge them with the strategies below:
drinking, sex, eating habits, and the like. What is most
important to you? What actions can you take to act in line
with these values?
“I don’t have enough time!” Chart your hourly activities
for 1 day. What are your highest priorities and what can
you eliminate? Plan to make time for a healthy change
next week.
“I don’t think I can do it.” Just because you haven’t
done something before doesn’t mean you can’t do it
now. To develop some confidence, take baby steps and
break tasks into small segments of time.
“I’m too stressed!” Assess your major stressors right
now. List those you can control and those you can
change or avoid. Then identify two things you enjoy that
can help you reduce stress now.
“I can’t break this habit!” Habits are difficult to break,
but not impossible. What triggers your behavior? List
ways you can avoid these triggers. Ask for support from
friends and family.
“I’m worried about what others may think.” Ask
yourself how much others influence your decisions about
forward. The MAKING CHANGES TODAY box offers more strategies for changing self-talk.
Reward Yourself Another way to promote positive behavior change is to reward yourself for it. This is called
positive reinforcement. Each of us is motivated by different reinforcers, but some common examples include the
following:
■■
■■
■■
■■
■■
Consumable reinforcers are edible items, such as your
favorite snack.
Activity reinforcers are opportunities to do something enjoyable, such as going on a hike or taking a trip.
Manipulative reinforcers are incentives such as the promise
of a better grade for doing an extra-credit project.
Possessional reinforcers are tangible rewards, such as a new
electronic gadget.
Social reinforcers are signs of appreciation, approval, or love,
such as affectionate hugs and praise.
WHAT DO
YOU THINK?
What type of
The difficulty with employ
ing positive reinforcement
often lies in determining
which incentive will be most
effective. Your reinforcers may
initially come from others
P. 19
Journal Writing personal experiences, interpretations,
and results in a journal, notebook, or blog is an important skill
for behavior change. You can log your daily activities, monitor
your progress, record how you feel about it, and note ideas for
improvement.
Deal with Relapse Relapse is often defined as a return
of symptoms in a person thought to have been successfully
treated for a serious disease. But relapse can also be defined as a
return to a previous pattern of negative behavior (drinking, binge
eating, and so on) after successfully avoiding that behavior for a
period of time. For example, the American Cancer Society reports
that most people who try to quit smoking suffer a relapse.29 It
doesn’t mean that your program of change is a failure; behavior
change is a process, and setbacks are part of learning to change.
A few simple strategies can help you get back on track after a
relapse. First, figure out what went wrong. Every relapse begins
with a slip—a one-time mistake.30 What triggered that slip, and
how can you modify your personal choices or the aspects of your
environment that contributed to it? Second, use countering:
If you’ve been overeating ever since your relationship ended,
identify and choose other behaviors that comfort you. Third, a
relapse might be telling you that you need some assistance with
making this change; consider getting some professional help.
Let’s Get Started!
Help students make healthy
eating choices . . .
NEW! MyDietAnalysis is included with
Mastering Health at no additional
charge, and offers an up-to-date, accurate,
reliable, and easy-to-use program for your
students’ diet analysis needs. Featured is a
database of nearly 50,000 foods and multiple
reports. Students can track their diet and
activity intake accurately—anytime and
anywhere—from any device!
UPDATED!
­ utriTool
N
­Activities in the
nutrition chapter
allow students to combine and experiment
with ­different food
options and learn
firsthand how to build
healthier meals.
and encourage behavior change
Which Path
Would You Take?
Behavior Change
Activities allow
students to explore
various health choices
through an engaging,
interactive, low-stakes,
and anonymous
experience. These
activities show
students the possible
consequences of
various choices they
make today on their
future health. They
are assignable in
Mastering Health with
follow-up questions.
Behavior Change
Videos guide
students through the
best tips and practices
to put better decision
making into action
and review basic
fitness concepts. These
concise whiteboardstyle videos help
students with the steps
of behavior change,
covering topics such
as setting SMART
goals, identifying
and overcoming
barriers to change,
planning realistic
timelines, and more.
All videos include
assessment activities
and are assignable in
Mastering Health.
Give students anytime, anywhere
access with Pearson eText
Pearson eText is a simple-to-use, mobile-optimized, personalized reading experience available
within Mastering. It allows students to easily highlight, take notes, and review key vocabulary all in one
place—even when offline. Seamlessly integrated videos and other rich media engage students and give
them access to the help they need, when they need it. Pearson eText is available within Mastering when
packaged with a new book; students can also purchase Mastering with Pearson eText online.
For instructors not using Mastering, Pearson eText can also be adopted on its own as the main course
material.
NEW! Interactive Self-Assessments
are now embedded in the eText.
Improve learning with Dynamic
Study Modules
Dynamic Study Modules in
Mastering Health help students
study effectively—and at their own
pace—by keeping them motivated
and engaged. The assignable
modules rely on the latest research
in cognitive science, using methods—
such as adaptivity, gamification, and
intermittent rewards—to stimulate
learning and improve retention.
Each module poses a series of questions about a course topic. These question sets adapt to each student’s
performance and offer personalized, targeted feedback to help them master key concepts. With
Dynamic Study Modules, students build the confidence they need to deepen their understanding,
participate meaningfully, and perform better—in and out of class.
Instructor support you can rely on
Access to Health includes a full suite of instructor support materials in the Instructor Resources area
in Mastering Health. Resources include lecture outlines, clicker questions, and quiz show questions in
PowerPoint; animations, videos, and images to show in class; a test bank; and an instructor resource and
support manual with class discussion questions, video discussion questions, critical thinking questions, web
resources, and more.
Access to
Health
sixteenth edition
Rebecca J. Donatelle, Ph.D.
Courseware Portfolio Manager: Michelle
Yglecias
Editor-in-Chief: Serina Beauparlant
Content Producer: Deepti Agarwal
Managing Producer: Nancy Tabor
Courseware Director, Content Development:
Barbara Yien
Senior Courseware Analyst: Alice Fugate
Development Editor: Nic Albert
Courseware Analyst, Art: Jay McElroy
Courseware Editorial Assistant: Gillian Perry
Rich Media Content Producer: Keri Rand
Full-Service Vendor: Pearson CSC
Full Service Project Management: Pearson
CSC, Sharon Cahill
Copyeditor: Pearson CSC
Art Coordinator: Lachina Publishing Services
Design Manager: Mark Ong
Interior Designer: Elise Lansdon
Cover Designer: Elise Lansdon
Rights & Permissions Project Manager:
Pearson CSC
Rights & Permissions Management:
Ben Ferrini
Manufacturing Buyer: Stacey Weinberger,
LSC Communications
Director of Field Marketing:
Timothy Galligan
Director of Product Marketing: Allison Rona
Executive Field Marketing Manager: Mary
Salzman
Product Marketing Manager: Allison Rona
Cover Photo Credit: Aleksandar Georgiev/E+/Getty Images
Copyright © 2020, 2018, 2016, 2014 by Pearson Education, Inc. 221 River Street, Hoboken,
NJ 07030. All Rights Reserved. Printed in the United States of America. This publication is
protected by copyright, and permission should be obtained from the publisher prior to any
prohibited reproduction, storage in a retrieval system, or transmission in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise. For information
regarding permissions, request forms and the appropriate contacts within the Pearson
Education Global Rights & Permissions department.
Attributions of third party content appear on pages CR1 to CR2, which constitutes an
extension of this copyright page.
PEARSON, ALWAYS LEARNING and MasteringTM Health are exclusive trademarks in the U.S.
and/or other countries owned by Pearson Education, Inc. or its affiliates.
Unless otherwise indicated herein, any third-party trademarks that may appear in this work
are the property of their respective owners and any references to third-party trademarks,
logos or other trade dress are for demonstrative or descriptive purposes only. Such references
are not intended to imply any sponsorship, endorsement, authorization, or promotion of
Pearson's products by the owners of such marks, or any relationship between the owner and
Pearson Education, Inc. or its affiliates, authors, licensees or distributors.
Library of Congress Cataloging-in-Publication Data
Names: Donatelle, Rebecca J., 1950-author.
Title: Access to health / Rebecca J. Donatelle, Ph.D.
Description: Sixteenth edition. | Boston : Pearson Education, Inc., [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2018050203| ISBN 9780135173794 (student edition) |
ISBN 0135173795 (student edition)
Subjects: LCSH: Health.
Classification: LCC RA776 .D66 2020 | DDC 613--dc23 LC record
available at https://lccn.loc.gov/2018050203
ISBN 10: 0-135-17379-5 (Student edition)
ISBN 13: 978-0-135-17379-4 (Student edition)
ISBN 10: 0-135-45147-7 (Instructor’s Review Copy)
ISBN 13: 978-0-135-45147-2 (Instructor’s Review Copy)
BRIEF CONTENTS
PART ONE Finding the Right Balance
1 Accessing Your Health 1
FOCUS ON DIFFERENCE, DISPARITY, AND HEALTH: ACHIEVING HEALTH EQUITY
23
2 Promoting and Preserving Your Psychological Health 36
FOCUS ON MINDFULNESS, SPIRITUAL HEALTH, AND SPIRITUAL INTELLIGENCE
61
3 Managing Stress and Coping with Life’s Challenges 75
4 Improving Your Sleep 102
PART TWO Building Healthy Lifestyles
5 Nutrition: Eating for a Healthier You 119
6 Reaching and Maintaining a Healthy Weight 148
FOCUS ON
ENHANCING YOUR BODY IMAGE
172
7 Improving Your Personal Fitness 185
PART THREE Creating Healthy and Caring ­Relationships
8 Building Healthy Relationships and Communicating Effectively 213
9 Understanding Your Sexuality 232
10 Considering Your Reproductive Choices 255
PART FOUR Avoiding Risks from Harmful Habits
FOCUS ON RECOGNIZING AND AVOIDING ADDICTION
290
11 Drinking Alcohol Responsibly 304
12 Ending Tobacco Use 326
13 Avoiding Drug Misuse and Abuse 346
PART FIVE Preventing and Fighting Disease
14 Protecting Against Infectious Diseases 374
15 Protecting Against Sexually Transmitted Infections 395
16 Reducing Your Risk of Cardiovascular Disease 412
FOCUS ON MINIMIZING YOUR RISK FOR DIABETES
435
17 Reducing Your Cancer Risk 446
18 Reducing Risks and Coping with Chronic Conditions 469
Providing Emergency Care
PART SIX Facing Life’s Challenges
21 Preserving and Protecting Your Environment 549
22 Preparing for Aging, Death, and Dying 572
A-3
Nutritive Value of Selected
Foods and Fast Foods A-9
19 Making Smart Health Care Choices 489
20 Preventing Violence and Abuse 514
FOCUS ON REDUCING YOUR RISK OF UNINTENTIONAL INJURY
Answers to Pop Quiz
Questions A-1
Glossary
535
G-1
References
R-1
Photo Credits
Index
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CONTENTS
Preface
xxvii Acknowledgments
xxxiv
PART ONE Finding the Right Balance
1
ACCESSING YOUR HEALTH
1
Why Health, Why Now? 2
Choose Health Now for Immediate Benefits
Choose Health Now for Long-Term Rewards
Your Health Is Linked to Societal Health
2
3
5
What Is Health? 5
Models of Health
5
Wellness and the Dimensions of Health
What Influences Your Health?
Individual Behavior
8
8
Biology and Genetics
Social Factors
9
9
Access to Quality Health Services
Policymaking
6
10
11
How Does Mindfulness Influence Health? 11
Definitions of Mindfulness
11
Health Benefits of Mindfulness
The Practice of Mindfulness
12
12
How Does Behavior Change Occur?
Health Belief Model
12
12
Social-Cognitive Model
Transtheoretical Model
13
13
How Can You Improve Your Health Behaviors?
Step One: Increase Your Awareness
14
Step Two: Contemplate Change
14
Step Three: Prepare for Change
16
Step Four: Take Action to Change
Let’s Get Started!
STUDY PLAN
14
18
19
20
v
FOCUS ON D
ifference, Disparity, and Health:
Achieving Health Equity 23
Why Has Health Equity Become a Critical Issue in America?
24
Health Equity Is Attainment of the Highest Level of Health
for All 24
America: A Country of Increasing Diversity
24
Our Response to Difference Can Lead to Disparities in Health
Health Disparities Incur Enormous Costs
25
26
What Types of Health Disparities Occur in Vulnerable
Population Groups? 26
Disparities Affecting Certain Racial and Ethnic Groups
26
Disparities Affecting Men, Women, and Sexual and Gender
Minorities 27
Disparities Affecting Older and Disabled Americans
Disparities in Socially Excluded Populations
27
27
How Do the Social Determinants of Health Influence Health
Disparities In America? 28
Economic Stability and Educational Attainment
Social Interactions and Community Context
Neighborhood and Built Environment
28
29
30
How Can Your Actions Contribute to Health Equity?
31
Use Mindfulness to Examine Your Assumptions and Biases
Affirm the Benefits of Diversity
Learn to Communicate across Differences
Advocate for Yourself and Others
31
32
How Can Systemic Change Lead to Health for All?
Increase Access to Health Care
31
31
32
33
Reduce the Social Determinants That Contribute to Health
Disparities 33
Examples of Initiatives to Increase Health for All
33
STUDY PLAN 34
2
PROMOTING AND PRESERVING YOUR
PSYCHOLOGICAL HEALTH 36
What Is Psychological Health?
Mental Health
39
Emotional Health
Social Health
37
39
39
Spiritual Health
41
Keys to Enhancing Psychological Health
Self-Efficacy and Self-Esteem
Emotional Intelligence
Personality
41
41
42
43
Lifespan and Maturity
43
Happiness and the Mind–Body Connection
vi | CONTENTS
43
When Psychological Health Deteriorates
44
Mental Health Threats to College Students
Mood Disorders
45
Anxiety Disorders
49
Personality Disorders
Schizophrenia
45
50
51
Suicide: Giving Up on Life 51
Risk Factors for Suicide
52
Warning Signs of Suicide
Preventing Suicide
53
53
Seeking Professional Help
53
Mental Illness Stigma
54
Getting Evaluated for Treatment
Mental Health Professionals
What to Expect in Therapy
54
56
Pharmacological Treatment
STUDY PLAN
54
56
58
FOCUS ON M
indfulness, Spiritual Health, and
Spiritual Intelligence 61
What is Mindfulness? 62
What are Spirituality and Spiritual Intelligence?
Spirituality and Religion
Relationships, Values, and Purpose
Spiritual Intelligence
64
64
65
65
Health Benefits of Mindfulness and Spirituality:
What Does the Research Say? 66
Physical Benefits
66
Psychological Benefits
67
How Can You Integrate Mindfulness and Spirituality
Into Your Life? 67
Your Path to Mindfulness
68
Meditation Supports Mindfulness
69
Contemplation and Prayer Can Contribute to Spirituality
Meditative Movement Integrates Body and Spirit
Altruism
STUDY PLAN
3
71
71
72
73
MANAGING STRESS AND COPING
WITH LIFE’S CHALLENGES 75
What Is Stress?
77
Common Types of Stress
What Causes Stress?
77
78
CONTENTS | vii
The Stress Response: What Really Happens?
81
Physiology/Systems Theory: General Adaptation Syndrome
82
Psychological Theory: The Transactional Model of Stress
and Coping 83
Minority Stress Perspective
84
Yerkes-Dodson Law of Arousal
84
Do Men and Women Respond Differently to Stress?
Stress and Your Health
85
Stress and Cardiovascular Disease
Stress and Weight Gain
85
86
Stress and Hair Loss
86
Stress and Diabetes
86
Stress and Digestive Problems
86
Stress and Impaired Immunity
86
Stress and Your Mental Health
86
Individual Factors that Affect Your Stress Response
Appraisal
85
87
87
Self-Esteem
87
Self-Efficacy
88
Type A and Type B Personalities
88
Type C and Type D Personalities
89
Shift and Persist
89
Managing Stress in College: When Overwhelm Strikes
Taking A Mindful Approach to Stress
Developing a Support Network
Cultivating Your Spiritual Side
90
91
92
Managing Emotional Responses and Perceptions
Taking Physical Action
Managing Your Time
89
92
94
94
Consider Downshifting
95
Finding Calm: Relaxation Techniques for Reducing Stress
96
STUDY PLAN 99
4
IMPROVING YOUR SLEEP
Sleepless in America
102
103
Sleepless on Campus: Tired and Dragged-Out Students?
Why So Sleep Deprived?
The Importance of Sleep
Sleep and Health
105
105
106
The Processes of Sleep 107
Stages and Cycles of Sleep
Your Sleep Needs
Sleep Disorders
Insomnia
110
110
Sleep Apnea
111
Restless Legs Syndrome
viii | CONTENTS
107
108
111
104
Narcolepsy
112
Other Parasomnias
112
Getting a Good Night’s Sleep
112
Create a Sleep-Promoting Environment
Adjust Your Daytime Habits
112
114
Avoid Common Sleep Disruptors
114
Sleep Aids: What Works and What Doesn’t?
STUDY PLAN
116
117
PART TWO Building Healthy Lifestyles
5
NUTRITION: EATING FOR A
HEALTHIER YOU 119
Essential Nutrients for Health 120
Recommended Intakes for Nutrients
Calories
120
Water: A Crucial Nutrient
Proteins
121
122
Carbohydrates
Fats
120
123
124
Vitamins
127
Minerals
127
Beneficial Non-Nutrient Components of Foods
130
Nutritional Guidelines 131
Dietary Guidelines for Americans
132
MyPlate Food Guidance System
133
How Can I Eat More Healthfully?
Read Food Labels
133
134
Vegetarianism: A Healthy Diet?
135
Supplements: Research on the Daily Dose
Eating Well in College
Food Safety: A Growing Concern
140
Organic and Locally Grown Foods
Foodborne Illnesses
Food Irradiation
137
138
140
141
142
Food Sensitivities, Allergies, and Intolerances
Genetically Modified Food Crops
STUDY PLAN
6
142
143
145
REACHING AND MAINTAINING A
HEALTHY WEIGHT 148
Overweight and Obesity: A Growing Health Threat
Overweight and Obesity in the United States
An Obesogenic World
149
150
150
Health Risks of Excess Weight
151
CONTENTS | ix
Factors Contributing to Overweight and Obesity
152
Physiological, Genetic, and Hormonal Factors
152
Environmental Factors
155
Psychosocial and Socioeconomic Factors
Emerging Theories on Obesity Risks
155
157
Assessing Body Weight and Body Composition
Body Mass Index
157
158
Waist Circumference and Ratio Measurements
Measures of Body Fat
160
Managing Your Weight: Individual Roles
160
Understanding Calories and Energy Balance
Diet and Eating Behaviors
Including Exercise
159
161
161
163
Keeping Weight Control in Perspective
165
Considering Drastic Weight Loss Measures?
Trying to Gain Weight
165
169
STUDY PLAN 169
FOCUS ON Enhancing Your Body Image 172
Body Image
173
Many Factors Influence Body Image
Body Dysmorphic Disorder
173
176
Building a Positive Body Image
176
Disordered Eating and Eating Disorders 177
Anorexia Nervosa
Bulimia Nervosa
178
179
Binge-Eating Disorder
179
Other Disordered Eating
180
Treatment for Eating Disorders
180
Helping Someone with Eating Issues
181
Exercise Disorders 181
Compulsive Exercise
Muscle Dysmorphia
181
182
The Female Athlete Triad
Health at Every Size
182
182
STUDY PLAN 183
7
IMPROVING YOUR PERSONAL
FITNESS 185
Physical Activity for Health
186
Reduced Risk of Cardiovascular Diseases
188
Reduced Risk of Metabolic Syndrome and Type 2 Diabetes
Reduced Cancer Risk
x | CONTENTS
189
189
Improved Immunity
189
Reduced Risk of Low Bone Mass
Better Weight Control
189
189
Improved Mental Status and Reduced Stress
190
Improved Cognitive Function and Reduced Dementia Risk
Longer Lifespan
191
191
Fitness Components for Health, Wellness, and Physical Function 192
Health-Related Components of Physical Fitness
Skill-Related Components of Physical Fitness
192
192
Utilizing the Fitt Principle to Create Your Own Fitness Program
Set SMART Goals for Your Physical Fitness
Use the FITT Principle
193
193
The FITT Principle for Cardiorespiratory Fitness
194
The FITT Principle for Muscular Strength and Endurance
The FITT Principle for Flexibility
Committing to Physical Activity
200
201
What if I Have Been Inactive for a While?
201
Overcome Common Obstacles to Physical Activity
Incorporate Physical Activity into Your Life
Explore Activities for Functional Fitness
Taking in Proper Nutrition for Exercise
205
Fluids for Exercise and Recovery
206
Preventing and Treating Exercise Injuries
STUDY PLAN
202
202
204
205
Foods for Exercise and Recovery
Treating Injuries
195
198
Implement Your Fitness Program
Preventing Injuries
193
207
208
210
210
PART THREE Creating Healthy and Caring ­Relationships
8
BUILDING HEALTHY RELATIONSHIPS
AND COMMUNICATING
EFFECTIVELY 213
The Value of Relationships 214
Intimate Relations: When Connecting Gets Personal
Caring for Yourself
Family Relationships
Friendships
215
216
216
216
Romantic Relationships
216
Building Communication Skills 218
Learning Appropriate Self-Disclosure
Becoming a Better Listener
218
220
Using Nonverbal Communication
221
CONTENTS | xi
Connecting Digitally: Too Much of a Good Thing?
Managing Conflict through Communication
Relationships: For Better and Worse
221
222
223
Characteristics of Healthy and Unhealthy Relationships
Confronting Couples Issues
When and Why Relationships End
Coping with Failed Relationships
Partnering and Singlehood
Marriage
223
224
226
226
227
227
Cohabitation
228
Gay and Lesbian Marriage and Partnerships
Staying Single
229
229
STUDY PLAN 230
9
UNDERSTANDING YOUR
SEXUALITY 232
Your Sexual Identity: More Than Biology
Sexual Orientation
233
235
Sexual and Reproductive Anatomy and Physiology
236
Female Sexual and Reproductive Anatomy and Physiology
Male Sexual and Reproductive Anatomy and Physiology
Human Sexual Response
240
242
Sexuality and Aging
242
Sexual Dysfunction
243
Sexual Expression and Behavior
245
Sexual Behavior: Is There a “Normal”?
Options for Sexual Expression
Variant Sexual Behavior
Drugs and Sex
237
245
246
250
251
Responsible and Satisfying Sexual Behavior
251
STUDY PLAN 252
10
CONSIDERING YOUR REPRODUCTIVE
CHOICES 255
Basic Principles of Contraception
256
Contraceptive Methods 257
Barrier Methods
257
Hormonal Methods
264
Intrauterine Contraceptives
Behavioral Methods
267
268
Emergency Contraception
269
Permanent Methods of Birth Control
xii | CONTENTS
269
Choosing a Method of Contraception
Abortion
271
273
The Abortion Debate
274
Emotional Aspects of Abortion
Methods of Abortion
274
274
Pregnancy 276
Planning for Pregnancy and Parenthood
The Process of Pregnancy
Prenatal Care
276
278
280
Childbirth 282
Labor and Delivery
283
Complications of Pregnancy and Childbirth
The Postpartum Period
284
285
Infertility 286
Causes in Women
Causes in Men
286
286
Infertility Treatments
286
Surrogate Motherhood
Adoption
STUDY PLAN
287
287
288
PART FOUR Avoiding Risks from Harmful Habits
FOCUS ON Recognizing and Avoiding
Addiction 290
What is Addiction? 291
Common Characteristics of Addiction
Addiction Affects Family and Friends
291
292
How Addiction Develops 292
The Physiology of Addiction
293
The Biopsychosocial Model of Addiction
Addictive Behaviors
295
Gambling Disorder
295
Compulsive Buying Disorder
Technology Addictions
Work Addiction
297
297
298
Exercise Addiction
Sexual Addiction
299
299
Multiple Addictions
300
Costs of Addiction
300
Recovering from Addiction
Intervention
300
300
Treatment for Addiction
300
Finding a Quality Treatment Program
Relapse
STUDY PLAN
294
301
301
302
CONTENTS | xiii
11
DRINKING ALCOHOL
RESPONSIBLY 304
Alcohol: An Overview
305
The Chemistry and Potency of Alcohol
Absorption and Metabolism
306
Blood Alcohol Concentration
Alcohol and Your Health
307
309
Short-Term Effects of Alcohol
309
Long-Term Effects of Alcohol
311
Alcohol and Pregnancy
Alcohol Use in College
305
312
313
High-Risk Drinking and College Students
Efforts to Reduce Student Drinking
Drinking and Driving
314
316
316
Abuse and Dependence 317
Identifying an Alcoholic
317
The Causes of Alcohol Use Disorders
Alcohol Use Disorder in Women
Alcohol and Prescription Drug Abuse
Effects on Family and Friends
Costs to Society
318
319
320
320
321
Treatment and Recovery
321
Family’s and Friends’ Roles in Recovery
Treatment Programs
322
322
STUDY PLAN 324
12
ENDING TOBACCO USE
Tobacco Use in the United States
Why People Smoke
327
327
U.S. Tobacco: Political and Economic Issues
College Students and Tobacco Use
Social Smoking
329
329
Most Student Smokers Want to Quit
Effects of Tobacco
Nicotine
330
Tar and Carbon Monoxide
Tobacco Use Disorder
331
331
331
Health Hazards of Tobacco Products
Cancer
xiv | CONTENTS
330
330
Tobacco Products
334
326
334
329
Cardiovascular Disease
Respiratory Disorders
334
335
Sexual Dysfunction and Fertility Problems
Other Health Effects
336
336
Environmental Tobacco Smoke
337
Risks from Environmental Tobacco Smoke
Tobacco Use and Prevention Policies
337
338
Quitting Smoking 338
Benefits of Quitting
339
How Can You Quit?
339
Breaking the Nicotine Addiction
Breaking the Smoking Habit
STUDY PLAN
13
339
341
343
AVOIDING DRUG MISUSE
AND ABUSE 346
Drug Dynamics 347
How Drugs Affect the Brain
Types of Drugs
347
348
Routes of Drug Administration
Drug Interactions
349
350
Drug Misuse and Abuse 350
Abuse of Over-the-Counter Drugs
351
Nonmedical Use or Abuse of Prescription Drugs
Use and Abuse of Illicit Drugs
351
352
Why Do Some College Students Use Drugs?
353
Common Drugs of Abuse 354
Stimulants
354
Marijuana and Other Cannabinoids
358
Depressants and Opioids (Narcotics)
Hallucinogens
Inhalants
360
363
365
Anabolic Steroids
365
Drug Abuse Treatment and Recovery
Treatment Approaches
366
366
Drug Treatment and Recovery for College Students
368
Addressing Drug Misuse and Abuse in the United States
Drugs in the Workplace
369
Preventing Drug Use and Abuse on Campus
Possible Solutions to the Drug Problem
STUDY PLAN
369
369
369
371
CONTENTS | xv
PART FIVE Preventing and Fighting Disease
14
PROTECTING AGAINST INFECTIOUS
DISEASES 374
The Process of Infection
375
Three Conditions Needed for Infection
375
Routes of Transmission: How Do Pathogens Gain Entry?
Risk Factors You Can Control
377
Hard-to-Control Risk Factors
377
Your Body’s Defenses Against Infection
Physical and Chemical Defenses
376
379
379
The Immune System: Your 24/7 Protector
379
When the Immune System Misfires: Autoimmune Diseases
Inflammatory Response, Pain, and Fever
Vaccines Bolster Immunity
381
381
Types of Pathogens and the Diseases they Cause
Bacteria
Viruses
384
384
388
Other Pathogens
390
Emerging and Resurgent Diseases
391
Mindfulness: A New Ally in Bolstering Defenses?
392
STUDY PLAN 393
15
PROTECTING AGAINST SEXUALLY
TRANSMITTED INFECTIONS 395
Sexually Transmitted Infections
What’s Your Risk?
396
397
Routes of Transmission
398
Common Types of Sexually Transmitted Infections
Chlamydia
399
Gonorrhea
400
Syphilis
401
Herpes
402
Human Papillomavirus (HPV) and Genital Warts
Candidiasis (Moniliasis)
404
Bacterial Vaginosis (BV)
404
Trichomoniasis
Pubic Lice
404
405
HIV/AIDS 406
How HIV Is Transmitted
406
Signs and Symptoms of HIV/AIDS
Testing for HIV: Newer Options
New Hope and Treatments
Preventing HIV Infection
STUDY PLAN 410
xvi | CONTENTS
409
409
407
408
399
403
380
16
REDUCING YOUR RISK OF
CARDIOVASCULAR DISEASE
412
Current Trends: Social and Economic Impact of CVD
413
U.S. Disparities: Differences by Age, Sex, and Race
An Emerging Global Threat
414
415
History and Future Goals: Ideal Cardiovascular Health
Essentials: Understanding the Cardiovascular System
The Heart: A Mighty Machine
418
Peripheral Artery Disease
Coronary Heart Disease
419
419
420
Angina Pectoris
421
Cardiomyopathy and Heart Failure
421
Congenital and Rheumatic Heart Disease
Stroke
417
417
Atherosclerosis
Arrhythmias
416
416
Understanding the Major Cardiovascular Diseases
Hypertension
415
422
422
Reducing Your CVD Risks
423
Metabolic Syndrome: Quick Risk Profile
Modifiable Risks for CVD
Nonmodifiable Risks
424
424
429
Other Risk Factors Being Studied
429
Diagnosing and Treating Cardiovascular Disease
430
Techniques for Diagnosing Cardiovascular Disease
430
Surgical Options: Bypass Surgery, Angioplasty, and Stents
431
Changing Aspirin Recommendations and Other Treatments
431
Cardiac Rehabilitation and Recovery
STUDY PLAN
431
432
FOCUS ON M
inimizing Your Risk
for Diabetes 435
What is Diabetes?
436
Type 1 Diabetes
437
Type 2 Diabetes
437
Prediabetes
439
Gestational Diabetes
439
What are the Symptoms of Diabetes?
Complications of Diabetes
Diagnosing Diabetes
Treating Diabetes
440
442
442
Lifestyle Changes
443
Medical Interventions
STUDY PLAN
440
443
445
CONTENTS | xvii
17
446
REDUCING YOUR CANCER RISK
An Overview of Cancer
447
How Does Cancer Develop?
How Is Cancer Classified?
What Causes Cancer?
448
448
449
Lifestyle Risks for Cancer
449
Genetic and Physiological Risks
450
Occupational and Environmental Risks
Infectious Diseases and Cancer Risks
Medical Factors
Types of Cancers
451
451
452
452
Lung Cancer
452
Breast Cancer
454
Colon and Rectal Cancers
Skin Cancer
455
456
Prostate Cancer
458
Ovarian Cancer
459
Cervical and Endometrial (Uterine) Cancer
Testicular Cancer
Leukemia
460
460
461
Lymphoma
461
Pancreatic Cancer
Facing Cancer
461
461
Detecting Cancer
461
Cancer Treatments
Cancer Survivors
462
465
STUDY PLAN 466
18
REDUCING RISKS AND COPING WITH
CHRONIC CONDITIONS 469
Coping with Chronic Lower Respiratory (Lung) Diseases
Chronic Obstructive Pulmonary Disease (COPD)
Asthma
472
474
Coping with Allergies
Hay Fever
474
476
Food Allergies
476
Coping with Neurological Disorders
Headaches
477
479
Seizure Disorders
481
Multiple Sclerosis
481
Parkinson’s Disease
481
Coping with Digestion-Related Disorders and Diseases
Irritable Bowel Syndrome
xviii | CONTENTS
471
483
481
Inflammatory Bowel Disease
483
Gastroesophageal Reflux Disease
484
Coping with Musculoskeletal Diseases
Arthritis and Related Conditions
Osteoporosis
484
485
Low Back Pain
485
Repetitive Motion Disorders
STUDY PLAN
484
486
487
PART SIX Facing Life’s Challenges
19
MAKING SMART HEALTH
CARE CHOICES 489
Taking Responsibility for Your Health Care
Self-Care
490
490
When to Seek Help
490
Assessing Health Professionals
Your Rights as a Patient
Conventional Health Care
491
492
492
Conventional Health Care Practitioners
Conventional Medication
494
495
Complementary and Integrative Health Care
Complementary Medical Systems
Mind and Body Practices
Natural Products
Health Insurance
499
501
502
Private Health Insurance
Managed Care
504
505
Government-Funded Programs
506
Insurance Coverage by the Numbers
508
Issues Facing Today’s Health Care System
Access
Cost
508
508
509
Quality
510
STUDY PLAN
511
20
497
498
PREVENTING VIOLENCE
AND ABUSE 514
Violence in the United States
Violence Overview
515
515
Violence on U.S. Campuses
Factors Contributing to Violence
516
518
What Makes Some Individuals Prone to Violence?
How Much Impact Do the Media Have?
518
519
CONTENTS | xix
Interpersonal and Collective Violence
Homicide
520
520
Hate and Bias-Motivated Crimes
Gang Violence
Cybercrime
Terrorism
520
522
522
523
Intimate Partner and Domestic Violence
Child Abuse and Neglect
Elder Abuse
524
525
Sexual Victimization
Bullying
523
525
528
Minimize Your Risk of Becoming a Victim of Violence
Self-Defense against Personal Assault and Rape
What to Do if Rape Occurs
530
530
531
Campus- and Community-Wide Responses to Violence
Prevention and Early Response Efforts
Changes in the Campus Environment
Campus Law Enforcement
531
531
531
531
Coping in the Event of Violence
532
STUDY PLAN 533
FOCUS ON R
educing Your Risk of
Unintentional Injury 535
Drug Overdoses and Other Poisonings
536
What’s behind the Opioid Overdose Epidemic?
Recognizing an Opioid Overdose
537
Preventing Unintentional Poisoning
Motor Vehicle Injuries
537
537
Your Choices Affect Motor Vehicle Safety
Motorcyclists Face Unique Risks
Improve Your Driving Skills
Recreational Injuries
Stay Safe in the Water
541
541
539
539
540
Stay Safe on Your Board or Skis
Avoid Falls
537
540
Follow Bike Safety Rules
Injuries at Home
536
540
541
Reduce Your Risk of Fire
542
Prepare for Natural Disasters and Severe Weather Events
Learn First Aid and CPR
543
Limit Your Exposure to Loud Noise
xx | CONTENTS
543
542
Injuries at Work
544
Protect Your Back
544
Maintain Alignment While Sitting
545
Avoid Repetitive Motion Disorders
STUDY PLAN
21
546
547
PRESERVING AND PROTECTING YOUR
ENVIRONMENT 549
Overpopulation: The Planet’s Greatest Threat
Global Population Growth
550
550
Measuring the Impact of People
551
Air Pollution 552
Components of Air Pollution
Photochemical Smog
Air Quality Index
554
Acid Deposition
555
Indoor Air Pollution
553
554
555
Ozone Layer Depletion
558
Climate Change 558
Scientific Evidence of Climate Change and Human-Caused Global
Warming 559
Reducing the Threat of Global Warming
Alternative Energy: Promising Future
560
560
Campus-Wide Actions to Spur Sustainability: Going Green
Water Pollution and Shortages
Water Contamination
561
562
562
Land Pollution 566
Solid Waste
566
Hazardous Waste
567
Radiation 567
Nonionizing Radiation
Ionizing Radiation
568
Nuclear Power Plants
STUDY PLAN
22
Aging
567
568
569
PREPARING FOR AGING, DEATH,
AND DYING 572
573
Redefining Aging
573
Older Adults: A Growing Population
574
Health Issues for an Aging Society
574
CONTENTS | xxi
Theories of Aging
575
Physical and Mental Changes of Aging
The Skin
576
576
Bones and Joints
Head and Face
576
577
The Urinary Tract
577
Heart and Lungs
577
The Senses
578
Sexual Function
578
Mental Function and Memory
578
Dementias and Alzheimer’s Disease
Depression
579
579
Strategies for Healthy Aging
Improve Fitness
579
580
Eat for Longevity
580
Avoid Alcohol and Drug Use and Abuse
580
Develop and Maintain Healthy Relationships
Enrich the Spiritual Side of Life
581
581
Financial Planning for Retirement
582
Understanding the Final Transitions: Dying and Death
Defining Death
582
The Process of Dying
Coping with Loss
582
583
What Is “Typical” Grief?
Grief and Trauma
584
584
Worden’s Model of Grieving Tasks
Children and Death
585
585
Life-and-Death Decision Making 585
The Right to Die
586
Rational Suicide and Euthanasia
Making Final Arrangements
586
587
Hospice Care: Positive Alternatives
Making Funeral Arrangements
Wills
Trusts
587
587
588
588
Organ Donation
588
STUDY PLAN 589
Answers to Pop Quiz Questions A-1
Providing Emergency Care
A-3
Nutritive Value of Selected Foods and Fast Foods
Glossary
G-1
References R-1
Photo Credits C-1
Index I-1
xxii | CONTENTS
A-9
582
FEATURE BOXES
MINDFULNESS
AND YOU
Which Is Best for Weight Loss? Diet,
Exercise, or Both? 163
139
222
Meditation Before Medication
Mindfulness, Not Medication
246
282
Mindfulness-Based Relapse
Prevention for Addiction
Recovery 302
322
Mindfulness for Smoking
Cessation 341
175
Is High-Intensity Interval Training
Right For You? 198
465
272
353
Have the Conversation Reduce Your
Risks of STIs 397
Relieving Pain with
Mindfulness? 486
The Surprising Academic Benefits of
Mindfulness Meditation 500
When Anger Flares: Mindful Cooling
Off Strategies 519
Environmental Mindfulness: It Starts
with You 553
Making Oral Sex Safe Condoms,
Dental Dams, and Abstinence 404
Q&A On HPV Vaccines 405
Body Piercing and Tattooing
Potential Risks 408
Emerging Concern Gut Bacteria a
Culprit in CVD Risk? 426
Being a Health Advocate for Yourself
Or Someone You Love 464
STUDENT
HEALTH TODAY
Gender-Based Disparities in
Mental Health 28
Overdosing on Self-Esteem?
42
College Success with
Learning Disabilities and
Neurodevelopmental
Disorders 47
An Epidemic of Fear in America
Stressing Ourselves Out
Needlessly, or Real Threat? 93
Gluten-Free Diets 144
Pedal or Pedestrian—Embrace Your
Personal Power! 205
Life Is an Open (Face)Book
Gambling and College
Students 296
Oxycontin and Vicodin Abuse
4
Coconut Oil Friend or Foe? 128
How Can Men Be More Involved in
Birth Control? 271
Let’s Talk About (Safer) Sex!
Putting a Little “Zen” Into Preventing
and Controlling T2D 443
Coping with Cancer
Thinspiration vs. Fitspiration
Hooking Up The New Norm or
Nothing New? 218
Mindfulness Restores Sobriety
HEADLINES
Shorter Lives, Poorer Health
Who Wins at Losing?
Characteristics of Successful
Losers 160
Evoking The Relaxation
Response 115
HEALTH
136
Be Wise About Size Flip Your
Restaurant Priorities 156
Beating Technostress Through
Mindfulness 80
Mindful Listening
Melatonin One Popular OTC Sleep
Medication 117
Nutrition Rating Systems
Mindfulness as Mental Health
Treatment 58
Mindful Eating
Medications As Sleep
Disruptors 116
The Placebo Effect Mind Over
Matter? 493
Choosing Surgery Elective
Procedures 495
220
Pornography Helpful, Harmful, or
Neither? 248
You Decide Should Taxpayers Fund
Planned Parenthood? 273
Childless by Choice 276
Alcohol and Energy Drinks
A Dangerous Mix 307
E-Cigarettes Health Risks and
Concerns 333
Marijuana Legalization
361
Antimicrobial Resistance
Bugs Versus Drugs 378
Vaccine Controversy Should Parents
Be Allowed to Opt Out? 382
Zika Virus New Sexually Transmitted
Threat? 400
Heart-Healthy Superfoods
427
Radiant Health or Chronic Illness What
Will Your Future Bring? 10
Hazing Over the Top and Dangerous
for Many 517
Newer Treatments for Cancer
Cutting Through the Pain
52
463
Be Eco-Clean and Allergen Free
Turning Down The Tunes
545
Treating Chronic Pain
How We Cope with Stress
91
Are You a Food Waster?
567
Feng Shui for Stress Relief
95
Preparing for Endings 587
Bringing the Gun Debate to
Campus 521
473
478
xxiii
Awash in Plastics Our Actions and Our
Responsibility 563
Learn to Say No and Mean It! 96
E-Concerns
Shake Your Salt Habit 131
569
Keeping Fit As We Age
581
Bulk Up Your Fiber Intake!
Minimizing the Chance of
Injury during a Motor
Vehicle Crash 539
125
Shopping to Save the Planet
Reduce Your Risk for Foodborne
Illness 143
HEALTH
IN A DIVERSE WORLD
Avoiding Mold
Water: Use Less
Keys to Successful Weight
Management 166
Aging Well
Plan It, Start It, Stick With It!
Social Media Meanness 224
He Says/She Says
When you Have a Problem
Disorders of Sexual
Development 234
TECH
& HEALTH
277
301
Tips for Drinking Responsibly 314
Being Transgender 236
Thinking and Talking about
Alcohol Use 321
Disability and Sex
Tips for Quitting Smoking
247
Women and Heart Attacks Different
from Men? 420
Maladies Specific to Women
471
Mindfulness Apps
340
Responding to an Offer of Drugs
355
Safe Is Sexy
Tracking Your Diet or Weight Loss?
There’s an App for That 165
398
423
Tips for Protecting Your Skin in the
Sun 459
Preventing Asthma Attacks
476
Using PERMA to Enhance Your
Happiness 45
Be Proactive in
Your Health Care
Finding Your Spiritual Side through
Service 73
Complementary Health Approaches
and Self-Care 504
Overcoming Test-Taking Anxiety
Minimize the Cost of Your
Health Care 506
88
A Mindful Rethinking of Your Thinking
Habits 92
Apps for the Relaxation
Response 96
Wired and Tired Technology’s Toll on
Our Sleep 106
What Can You Do to Reduce Your
Risks? 440
32
16
69
Reduce Your Risk of Infectious
Disease 377
A Simple Test for Stroke
Challenge the Thoughts that
Sabotage Change 19
Becoming Your Own Advocate
Surfing for the Latest In Health
What to Do When a Heart Attack
Hits 421
MAKING
CHANGES
TODAY
xxiv | FEATURE BOXES
574
201
Find the Right Class 206
Preparing for Pregnancy
563
Talking to Loved Ones When Someone
Dies 584
Physical Activity and Exercise for
Special Populations 197
219
558
Tips for Sensible Snacking 161
Ten Steps to a Positive Body
Image 176
Unique Stressors Facing International
Students 82
556
492
Stay Safe on All Fronts
532
Activity Trackers Which One Is Right
for You? 204
Love in the Time of Twitter
Consensual Texts
223
249
Reproductive Health Apps 265
Mobile Devices, Media, and
the Internet Could You
Unplug? 298
Smartphone Breathalyzers Better
Than BAC Apps? 318
Can Smoking Apps Help you
Quit? 343
Types of Drug Tests
370
Social Networking Safety 529
ASSESS YOURSELF
The Assess Yourself activities are available online at MasteringHealth.
Go to the MasteringHealth Study Area to find the chapter you want in the
drop-down menu, and there you will see the Assess Yourself activities.
Print them or save the PDF to your computer.
Chapter 1
How Healthy Are You?
FOCUS ON
Examining Assumptions, Perceptions
Chapter 2
How Psychologically Healthy Are You?
FOCUS ON
What’s Your Spiritual IQ?
Chapter 14 Test Your Infectious Diseases IQ
Chapter 3
How Stressed Are You?
Chapter 15 STIs: Do You Really Know What You
Chapter 4
Are You Sleeping Well?
Chapter 5
How Healthy Are Your Eating Habits?
Chapter 6
Are You Ready for a Weight-Loss Program?
FOCUS ON
Are Your Efforts to Be Thin Sensible—
Or S
­ pinning Out of Control?
Chapter 12 Tobacco: Are Your Habits Placing
You at Risk?
Chapter 13 Learn to Recognize Drug Use and
Potential Abuse
Think You Know?
Chapter 16 What’s Your Personal CVD Risk?
FOCUS ON
Are You at Risk for Diabetes?
Chapter 17 What’s Your Personal Risk for Cancer?
Chapter 18 Are You at Risk for Chronic Illness?
Chapter 7
How Physically Fit Are You?
Chapter 19 Are You a Smart Health Care Consumer?
Chapter 8
How Well Do You Communicate?
Chapter 20 Are You at Risk for Violence?
Chapter 9
What Are Your Sexual Attitudes?
FOCUS ON
Chapter 10 Are You Comfortable with Your Contraception?
FOCUS ON
Are You Addicted?
Chapter 11 What Is Your Risk of Alcohol Abuse?
Are You at Risk for a Motor Vehicle Crash?
Chapter 21 Are You Doing All You Can Do to Protect
the Environment?
Chapter 22 Are You Afraid of Death?
xxv
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A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
PREFACE
G
ot Health? If you are like most people, “health” is a
subliminal message that is constantly playing in the
back of your mind. When you sit down for dinner
and think about whether you should eat that bacon cheeseburger, the health tape is playing. When you ride the elevator
instead of walking up the stairs, it is there, gently nudging you
to do the “better” thing and find the stairway. Whether it be
the latest news headline or the latest app that pops up on your
mobile device, giving you tips about diet, exercise, stress, or
sleep, it is hard to avoid those healthy messages. Increasingly,
you are tracked, analyzed, or reminded about whether you
are living your best life and what you should be doing. Seemingly, with all that media bombardment and expert advice,
getting healthy and staying healthy would be easy and we’d
be the healthiest nation on Earth! Yet, soaring rates of obesity,
increases in mental health issues, rapidly rising violence rates,
skyrocketing cases of drug abuse, and evidence of devastating
effects of human-influenced climate change all indicate that
we are not doing better when it comes to health. In fact, even
though we spend the most on health care of any nation, even
though we pride ourselves on promoting health and wellbeing and provide amazing opportunities for people to change
behaviors and get healthy, too many of us are not heeding
those messages. Although we often know what we “should”
do, many of us find it difficult to get there. Why? The answer
to this is multifaceted. For many, the issues and information
seem complex and contradictory, and the pleasures of continuing certain behaviors trump the effort needed to be healthy.
Others lack the resources and supports necessary to change.
Still others don’t believe they are at risk and/or don’t have the
knowledge necessary to make choices that will promote health
and prevent disease. Whether by geography, genetics, illness,
disability, or physical and social environment, some face overwhelming risks. The facts are clear. Getting healthy and staying healthy are challenges for most of us. There is no quick
fix. It takes recognition of risks, knowledge, motivation, and
support systems to make positive health changes. The more of
each, the better! The good news is that no matter where you
are right now in terms of health, you can make the changes
that will work for you and enhance your chance for a healthy
future. You can also serve as an agent for change within your
family, your social networks, and your community. That
opportunity starts now.
My goal in writing Access to Health is to provide students
with just what that title says: access to health information
and strategies designed to help them on their journey toward
reaching their health potential. This book provides the most
scientifically valid information available to help students
be smarter in their health decision making, more positively
involved in their personal health, and more active as advocates for healthy changes in their communities. Change isn’t
something that just happens. Let’s face it—if it were easy
to lose weight, maintain a healthy diet, manage stress, and
exercise regularly, we wouldn’t have one of the costliest and
overburdened health care systems in the world, along with
epidemic rates of obesity, drug misuse, and other problems.
However, the good news is that governmental agencies, communities, schools, and increasing numbers of individuals are
taking steps (both small and large) to enhance, preserve, and
protect our health. The key is to know where to look for accurate information, which information you can trust, and how
to use the information to make the best choices for you and
others. In short, it takes knowledge, preparation, and effort;
therefore, this book places emphasis on empowering students
to identify their health risks, create plans for reducing those
risks, and make healthy lifestyle changes part of their daily
routines.
Access to Health is designed to help students quickly grasp
the information presented and understand its relevance to
their own lives and the lives of others. Exciting revisions have
been made to the art and design of the book in this new edition, with the purpose of capturing students’ interest, engaging them in the subject matter, helping them find the most
reliable resources available, and assisting them in weighing
their options as they face health challenges today and in the
future. In addition, there are six Focus On chapters that delve
into areas of health that are of practical importance to college
students but are not always given sufficient coverage in typical personal health texts. These Focus On chapters include two
exciting newcomers to the personal health text field: Difference, Disparity, and Health: Achieving Health Equity; and Mindfulness, Spiritual Health, and Spiritual Intelligence—each reflective
of critical, emerging areas recognized as being important to
improving health today. In addition, we have enhanced and
updated Focus On chapters on body image, addiction, diabetes, and unintentional injuries—all chapters of high interest
and relevance to today’s college students
Looking back to the time when I taught my first Personal
Health course as a teaching assistant in graduate school and
remembering the years of teaching countless numbers of
students in classes like this, I am amazed that we are now in
the 16th edition of Access to Health. Over the years, this text
has morphed considerably, as we have focused on meeting
the needs of an increasingly savvy student population facing
increasingly challenging and newer health threats. As I look
back at all of the efforts by so many health and publishing
professionals, I am filled with overwhelming gratitude for the
many contributions that have helped make this book one of
the most successful in the field. With each edition of the text,
I have listened to the thoughtful suggestions of instructors
and to the feedback from my own students and colleagues in
keeping the book relevant, timely, interesting, and accessible.
xxvii
and Think About It! questions) to specific numbered
Learning Outcomes and Mastering assets. Assignable
study plan items contain at least one multiple-choice
question per Learning Outcome and wrong-answer
feedback.
■■ Updated Prebuilt Assignments with 20 Pre-­
lecture Reading Questions per chapter ensure
that students come prepared for lecture by answering
­multiple-choice questions related to content within
the text.
I hope that this edition’s rich foundation of scientifically valid
information, its wealth of technological tools and resources,
and its thought-provoking features will stimulate you to share
my enthusiasm for personal health and to become actively
engaged in behaviors that will lead to better health for all.
NEW TO THIS EDITION
Access to Health, 16th edition, maintains many features that
the text has become known for, while incorporating several
major revisions and exciting new features. The most noteworthy changes to the text as a whole include:
New! Focus On Difference, Disparity, and Health: Achieving
Health Equity chapter challenges students to think about
issues of diversity and health equity, and the actions they can
take as individuals and as a society to begin to remove barriers and promote access to health for all.
■■ New! Mindfulness Theme, including why this topic is so
important to health, how to practice it, and potential current and long-range benefits, has been added as feature
boxes as well as integrated throughout the narrative and
signaled by a new mindfulness icon.
■■ New! Mindfulness and You boxes focus on mindfulness research and applications in relation to high-­
interest topics such as sleep, technostress, mental
health, sexual dysfunction, and so on.
■■ Expanded! Focus On Mindfulness, Spiritual
Health, and Spiritual Intelligence chapter has
expanded to include an introduction to mindfulness as
well as the definition of and recent research surrounding spiritual identity.
■■
New to Mastering Health
New! MyDietAnalysis is included with Mastering Health at
no additional charge, and offers an up-to-date, accurate,
reliable, and easy-to-use program for your students’ diet
analysis needs. Featured is a database of nearly 50,000
foods and multiple reports. Students can track their diet
and activity intake accurately—anytime and anywhere—
from any device!
■■ Pearson eText is a simple-to-use, mobile-optimized,
personalized reading experience available within Mastering. It allows students to easily highlight, take notes, and
review key vocabulary all in one place—even when offline.
Seamlessly integrated videos and other rich media engage
students and give them access to the help they need, when
they need it. Pearson eText is available within Mastering
when packaged with a new book; students can also purchase Mastering with Pearson eText online.
■■ Updated NutriTools Coaching Activities in the
nutrition chapter allow students to combine and experiment with different food options and learn firsthand
how to build healthier meals.
■■ Updated end-of-chapter Study Plans tie all end-ofchapter material (including Chapter Review, Pop Quiz,
Chapter-by-Chapter Revisions
Access to Health, 16th edition, has been updated line by line to
provide students with the most scientifically valid, comprehensive, and current information from well-designed professional
sources. We painstakingly review studies, compare conflicting results, and provide a balanced and thorough overview
of each topic as well as an overview of areas needing further
study. Health research is dynamic and ever-changing, and we
strive to be as up-to-date as possible as we go to press. In addition, we have enhanced and reorganized portions of the text to
improve the flow of topics; provided more thought-provoking
scenarios; and added, updated, and improved all figures, tables,
feature boxes, and photos to enhance the learning experience.
The following is a chapter-by-chapter listing of some of the
many “other” noteworthy changes, updates, and additions.
Chapter 1 Accessing Your Health
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xxviii | PREFACE
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New learning outcome addresses health benefits and general practice of mindfulness
New section on “How Does Mindfulness Influence
Health?”
Updated information on health disparities
Updated information and statistics on causes of death in
the United States
New information on abuse of prescription and illegal drugs
Updated examples of enabling and reinforcing factors for
behavior change
Updated table of leading causes of death by age group
Chapter 2 Promoting and Preserving
Your Psychological Health
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New research on the connection between loneliness and
social media use
New research on social isolation
Updated numbers of prevalence of PTSD among American
adults
Updated statistics pertaining to suicide rates globally
New Mindfulness and You box on potential positive
effects of mindfulness practice and mental health problems
Focus On Mindfulness, Spiritual Health,
And Spiritual Intelligence
■■
Expanded chapter focuses on the health benefits of mindfulness and spirituality
New information on the role of mindfulness in cancer coping and recovery
■■ New figure showing how meditation affects the body
■■ New mindfulness apps for students to explore
■■
Chapter 3 Managing Stress and Coping
with Life’s Challenges
Updated figure on stress levels by age
Updated figure and statistics on major causes of stress
■■ New information on biology and differences in stress
response
■■ Newly expanded section on stress in college students,
­particularly as it relates to adjusting to change
■■
■■
Chapter 4 Improving Your Sleep
Updated information on the most sleep-deprived states
and age groups
■■ Updated information on sleep deprivation on campus
■■ New information on emerging treatments for obstructive
sleep apnea
■■ New Mindfulness and You box on how mindfulnessbased stress reduction and how mindfulness strategies can
improve your sleep
■■
Chapter 5 Nutrition: Eating for
a Healthier You
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Updated learning outcome on strategies for healthful eating, including how to read food labels, the role of vegetarian diets and dietary supplements, eating mindfully, and
eating healthfully on campus
Updated information on protein consumption guidelines
Updated research on the health effects of saturated fats and
trans fats
Updated information on consumption of vitamins and
other dietary supplements
Updated statistics on consumption of sodium
New research on the health impacts of taking calcium
supplements
New information on probiotics
New research on vegetarian diets and reduced risks for
health problems
Updated information on the health and safety of
organic foods
Updated information on the causes and prevalence of
foodborne illnesses
New information on the safety of genetically
modified foods
New Mindfulness and You box with tips for mindful
eating
Chapter 6 Reaching and Maintaining
a Healthy Weight
Updated information on the prevalence of obesity
worldwide
■■ Updated information on the health risks of excess weight
■■
New information on the relationship between leptin levels
and weight gain, particularly as it relates to food-finding
behaviors
■■ New research on “social contagion” and social and behavioral factors of weight gain
■■ New section on mindless eating and being mindful of eating triggers
■■ Updated information on the latest weight loss apps and the
characteristics of individuals successful at losing weight
■■
Focus On Enhancing Your Body
Image
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Updated statistics on body dissatisfaction, dieting, and cosmetic procedures
New information on the relationship between social media
and body dissatisfaction
New information on weight bullying
Updated information on body dysmorphic disorder
Updated statistics on other specified feeding or eating
disorders
New information on treatments for eating disorders and
exercise disorders
Chapter 7 Improving Your Personal
Fitness
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New coverage of the WHO Global action plan on physical
activity and health 2018–2030: More active people for a
healthier world
Updated information on the correlation between sitting
and colorectal cancer
Updated information on the correlation between physical
activity and reduced inflammation
New figure on the perceived exertion scale
New suggestions for mindfully incorporating physical
activity into daily life
New figure charting 60-minute cardiorespiratory
workout plan
Chapter 8 Connecting and
Communicating in the Modern World
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New Mindfulness and You box on how mindful listening can improve relationships
Expanded information on social capital
Expanded information on passive, selective, and active
listening
New information on digital communication and social media
Updated statistics on differences in gender roles
Updated information on marriage, cohabitation, gay and
lesbian relationships, and singlehood
Chapter 9 Understanding Your
Sexuality
Expanded dimensions of sexuality, from cultural to
sociocultural
■■ New Mindfulness and You box on using mindfulness to
deal with sexual dysfunction
■■
PREFACE | xxix
Updated statistics pertaining to abstinence and a variety of
sexual behaviors among college students
■■ Updated information on drugs and sex
■■ Updated coverage of responsible and satisfying sexual
behavior, including health benefits
■■
Chapter 10 Considering Your
Reproductive Choices
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Reorganized chapter in a more logical sequence, to discuss
contraceptive methods before discussing pregnancy and
childbirth
New Mindfulness and You box discusses treatment of
depression during pregnancy
Updated information and tables on all contraceptive
methods
Photo and information on the new Hex condom
Expanded discussion of new IUDs on the market
Updated information on emergency contraception
Updated information on the legal, physical, and emotional
aspects of abortion
Revised chart on when women have abortions
New information on the importance of paternal health for
a healthy child
New information on the triple marker screen prenatal
test
Focus On Recognizing and
Avoiding Addiction
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Updated terminology on process addictions
New Mindfulness and You box on mindfulness-based
relapse prevention for addiction recovery
Updated discussion of psychological dependence
Expanded discussion of gambling among college students
Expanded discussion of technology addiction
Chapter 12 Ending Tobacco Use
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Chapter 13 Avoiding Drug Misuse
and Abuse
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Chapter 11 Drinking Alcohol
Responsibly
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New Mindfulness and You box on using mindfulness
techniques to maintain sobriety
Updated statistics on drinking habits of men and women,
including college students
New information on the link between excessive drinking
and heart damage
New statistics on the link between drinking alcohol and
breast cancer in women
Expanded discussion of fetal alcohol syndrome and fetal
alcohol spectrum disorder
Expanded discussion of how drinking alcohol can affect
academic performance
New information on pre-gaming, binge drinking, and
­calorie “saving” among college students
New statistics on alcohol-related accidents
Updated table on reported alcohol use by men and women
during the previous 30 days
New graph of fatally injured drivers with blood alcohol
­levels greater than or equal to 0.08 percent
xxx | PREFACE
New Mindfulness and You box on using mindfulness
techniques for smoking cessation
Updated statistics on smoking and tobacco usage in the
United States among different age groups
Updated information on tobacco advertising expenditures
and the impacts on various population groups
Expanded discussion of electronic cigarettes
Updated discussion of cancer, cardiovascular disease, gum
disease, macular degeneration, Alzheimer’s disease, and
other health conditions linked to tobacco
Updated information on smoke-free municipalities and
how smoking bans improve the health of non-smokers
Updated graph on trends in smoking among college students
Updated table on the prevalence of smoking among various population groups
New table on coping strategies for common smoking
­withdrawal problems
Updated information on opioid abuse and overdose
Updated information and statistics on the use and abuse of
over-the-counter and prescription drugs
Updated statistics and information on all categories of illegal drugs
Updated information on caffeine consumption among college students
New information on legalization and use of marijuana,
including its relationship to accidents
Expanded discussion of heroin and fentanyl
New information on social, recreational, and social media
support systems for recovering addicts
New information on vaccines for addictive drugs
Updated information on using naloxone to treat opioid
overdose
Chapter 14 Protecting Against
Infectious Diseases
Updated recommended vaccination schedule
Updated coverage of the prescription of antibiotics, prevalence of antibiotic resistance, and new developments in
antibiotic drugs
■■ Updated statistics on the prevalence of C. diff., meningitis,
and tuberculosis
■■ New section on the potential benefits of mindfulness practices in fighting off infectious diseases
■■
■■
Chapter 15 Protecting Against Sexually
Transmitted Infections
Updated figure and information on estimates of new
HIV diagnoses in the United States for the most affected
subpopulations
■■ Updated statistics surrounding the prevalence of major
STIs, particularly among student populations
■■ New coverage of genital ulcerative disease
■■
■■
■■
New section on bacterial vaginosis
New recommendations for HIV testing, as well as coverage
of emerging diagnostics
Chapter 16 Reducing Your Risk of
Cardiovascular Disease
■■
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Updated figure and statistics on the percentage breakdown
of deaths attributable to cardiovascular disease
New coverage of the social, economic, and individual burden of cardiovascular disease
New and alarming figures pertaining to declines in the
numbers of Americans with ideal cardiovascular health
Updated CHD prevalence data
Discussion of the distinction between stable and unstable
angina
Updated MetS prevalence data
Updated information about the changing recommendations for the use of omega-3 fatty acids in reducing CVD risk
Focus On Minimizing Your Risk
for Diabetes
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Updated figure and statistics on the percentage and number
of the U.S. population with diagnosed diabetes
Updated information on the costs and prevalence of diabetes in the United States and globally
New section on latent autoimmune diabetes in adults, or
“type 1.5 diabetes”
Updated information on the relationship between short
sleeping and type 2 diabetes
Updated information on the relationship between obesity
and children and type 2 diabetes in adults
Updated section on gestational diabetes
New research in the battle to cure type 2 diabetes
New Mindfulness and You box on mindfulness-based
interventions as complementary strategies for reducing the
risk of diabetes
Chapter 17 Reducing Your Cancer Risk
■■
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Updated statistics pertaining to new cancer cases and
cancer deaths in the United States
New information on the relationship between obesity and
cancer
Updated recommendations for the use of mammograms
Coverage of new breast cancer detection methods, including 3D mammograms and breast ultrasound
New section on molecular breast imaging
New research on functional foods as health enhancers
Updated information on changing recommendations for
routine PSA tests
New Mindfulness and You box on mindfulness interventions and survivor care
Chapter 18 Reducing Risks and Coping
with Chronic Conditions
■■
Updated statistics and figure on the proportion of college
students diagnosed with or treated for chronic conditions
■■
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Updated statistics and figure on asthma prevalence by age,
sex, and race/ethnicity
Updated statistics on individuals with COPD and rates
among women
New coverage of aspirin-induced allergies
New research on the relationship between excessive cell
phone use and headaches
New section on multiple sclerosis
New section on Parkinson’s disease
Updated Mindfulness and You box on ways to relieve
pain with mindfulness
Chapter 19 Making Smart Health
Care Choices
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New coverage of how long-term mindfulness meditation
can improve the structure and function of the brain
Expanded information on patient rights and informed
consent
Updated statistics on the use of prescription drugs
Updated statistics and information on complementary,
alternative, and holistic health approaches
Updated discussion of mind and body practices
Updated and expanded discussion of health insurance
Updated discussion of the Affordable Care Act
Updated table on the benefits and risks of common dietary
supplements
Chapter 20 Preventing Violence
and Abuse
■■
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New discussion of meanness
Updated violent crime statistics
Updated information on substance abuse and violent crime
Updated information on the jarring discrepancy between
reported numbers of hate- and bias-motivated crime and
anonymous surveys of the same
New coverage of the Nationwide Suspicious Activity
Reporting Initiative
New coverage of “yes means yes” policies rolled out in a
number of states
New Mindfulness and You box on strategies for
cooling off
Focus On Reducing Your Risk of
Unintentional Injury
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Expanded coverage of unintentional injuries, now the third
leading cause of death in the United States
New discussion of the opioid overdose epidemic
Expanded guidelines for preventing unintentional
poisoning
Expanded coverage of motor vehicle injuries
Updated discussion of the risks of distracted driving and
texting while driving
Updated information on skateboarding, snowboarding,
and skiing injuries
Expanded coverage of the role of alcohol in boating injuries
Updated statistics on falls and fires
PREFACE | xxxi
Chapter 21 Preserving and Protecting
Your Environment
Updated statistics on global population growth
New Mindfulness and You box on environmental
mindfulness
■■ New Health Headlines box on the effects of single-use
plastics
■■ Updated coverage of indoor air quality, particularly as it
relates to schools
■■ Updated research on potential health effects of radiofrequency waves
■■
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Chapter 22 Preparing for Aging, Death,
and Dying
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Updated statistics on life expectancy and causes of death
Updated information on health care costs and living
arrangements for older Americans
Expanded discussion of osteoporosis
New discussion of age-related hearing loss
New research on how meditation may affect the aging brain
New information on trusts and organ donation
New chart showing the increase in the number of Americans aged 65 and older from 1900 to 2060
■■
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TEXT FEATURES AND
LEARNING AIDS
Access to Health, 16th edition, includes the following special
features, all of which have been revised and improved upon for
this edition:
■■
■■
■■
■■
■■
■■
Numbered learning outcomes at the beginning of each chapter are tied to each major chapter section, helping students
navigate each chapter and measure their progress against
specific learning goals and helping instructors assess the key
information and skills students are meant to take away from
each chapter.
What Do You Think? critical thinking questions within
the chapter prompt students to reflect on personal and societal issues relating to the material they have just learned.
Mindfulness and You boxes focus on mindfulness
research and applications in relation to high-interest topics such as sleep, technostress, mental health, and sexual
dysfunction.
Why Should I Care? feature now opens every chapter
and leads students to recognize the relevance of health
issues and the upcoming chapter content to their own lives
in the here and now.
Did You Know? figures call attention to statistics that are
relevant to the lives of college students in a fun and informative format.
Assess Yourself callouts at the end of every
chapter direct students to online self-assessment worksheets in Mastering Health, where they can assess their current health behaviors to better set goals and follow through
on behavior change.
xxxii | PREFACE
■■
■■
Making Changes Today boxes give students specific
strategies for making lasting changes to their health
behaviors.
Tech & Health boxes cover key new technology innovations, from medical tests to calorie-counting smartphone apps and other devices that can help students stay
healthy.
Student Health Today boxes offer current data and
information about health trends specific to college students, including potential risks and safety issues that affect
students’ lives.
Health Headlines boxes highlight new discoveries and
research, as well as interesting trends in the fields of public
and personal health.
Health in a Diverse World boxes expand discussion of
health topics to diverse groups within the United States
and around the world, as well as spurring discussion about
key disparity issues facing many populations.
A running glossary in the margins defines terms where
students first encounter them, emphasizing and supporting understanding of material.
Media callout boxes indicate when podcasts, videos,
and assessments are available online in Mastering Health
for use with the book.
The end-of-chapter Study Plans help students target
their studying and master key chapter concepts by explicitly tying the chapter learning outcomes to the Chapter
Review points that wrap up chapter content, the Pop
Quiz multiple-choice questions and Think About It!
discussion questions that encourage students to evaluate
and apply new information, and the Accessing Your
Health on the Internet sections offer more opportunities to explore areas of interest.
The appendices at the end of the book include practical
information on providing emergency care and a table of
nutritive values for selected foods and fast foods.
A Behavior Change Contract for students to fill out is
included in the back of the book.
SUPPLEMENTARY MATERIALS
Available with Access to Health, 16th edition, is a comprehensive set of ancillary materials designed to enhance learning
and to facilitate teaching.
Instructor Supplements
■■
Mastering Health with Pearson eText
Mastering Health is the teaching and learning platform
that empowers you to reach every student. By combining
trusted author content with digital tools developed to
engage students and emulate the office-hour experience,
Mastering personalizes learning and improves results for
each student. With a variety of activities available, students
can actively learn, understand, and retain even the most
difficult personal health concepts.
Before class, assign adaptive Dynamic Study Modules
and pre-lecture reading questions to ensure that students come prepared to class, having done the reading.
■■ During class, Learning Catalytics, a “bring your own
device” student engagement, assessment, and classroom
intelligence system, allows students to use their smartphone, tablet, or laptop to respond to questions in class.
With Learning Catalytics, you can assess students in real
time using open-ended question formats to uncover students’ misconceptions and adjust lectures accordingly.
■■ After class, assign an array of engaging assignments,
such as Which Path Would You Take? activities, ABC
News Videos, Video Tutors, Behavior Change Videos,
and much more. Students receive wrong-answer feedback personalized to their answers, which will help
them get back on track.
For more information on Mastering Health, please visit
www.masteringhealth.com.
■■
Instructional Resource Materials
(download only)
The following supplements are available for download from the Mastering Instructor Resource Area. Contact your Pearson rep for access
information and instructions if you don’t have a Mastering account.
The Instructor Resource Materials enable instructors to
prep for their course and deliver a dynamic lecture. These valuable downloadable resources include the following:
Video Tutors, ABC News Health and Wellness Lecture
Launcher Videos, and Behavior Change Videos.
■■ Twenty-five brief Video Tutors, plus 51 ABC News Videos,
each 5 to 10 minutes long, and 10 whiteboard-style
Behavior Change Videos, help instructors stimulate
critical discussion in the classroom.
■■ Media-Only PowerPoint slides for easy importing
of videos, animations, and NutriTools
■■ Video introduction to Learning Catalytics
■■ Clicker questions
■■ Quiz Show questions
■■ PowerPoint Lecture Outlines
■■ PowerPoint step-edit Image Presentations
■■ Files for all illustrations and tables and selected photos
from the text
■■ Instructor Resource and Support Manual. Easier to
use than a typical instructor’s manual, this key guide provides a step-by-step visual walk-through of all the resources
available to you for preparing your lectures. Also included
are tips and strategies for new instructors, sample syllabi,
and suggestions for integrating Mastering Health into your
classroom activities and homework assignments. Microsoft
Word and PDF files for the Instructor Resource and Support
Manual are available for downloading.
■■ Microsoft Word, PDF, and RTF files for the Test Bank
■■ TestGen Computerized Test Bank, which includes all
the questions from the printed test bank in a format that
allows instructors to easily and intuitively build exams and
quizzes
Teaching with Student Learning Outcomes. This feature provides essays from 11 instructors who teach using student learning outcomes. They share goals and suggestions
for developing good learning outcomes and give tips and
suggestions for how to teach personal health in this manner.
■■ Teaching with Web 2.0. From Facebook to Twitter and
blogs, students are interacting with technology constantly.
This handbook gives tips on how to incorporate technology in your course.
■■ Great Ideas! Active Ways to Teach Health & Wellness.
This manual provides ideas for classroom activities related to
specific health and wellness topics, as well as suggestions for
activities that can be adapted to various topics and class sizes.
■■ User’s Quick Guide with easy instructions for both experienced and new faculty members to get started with the various instructor resource materials and Mastering Nutrition
■■
Student Supplements
■■
■■
■■
■■
■■
■■
■■
■■
Mastering Health Student Study Area also provides students with self-study material like access to the Pearson eText,
practice quizzes, flashcards, videos, MP3s, and much more to
help them get the best grade in your course at their own pace.
Dynamic Study Modules in Mastering Health assess
students’ performance and activity in real time. They use
data and analytics that personalize content to target students’ particular strengths and weaknesses. And, because we
know students are always on the go, Dynamic Study Modules
can be accessed from any computer, tablet, or smartphone.
Behavior Change Log Book and Wellness Journal.
This assessment tool helps students track daily exercise and
nutritional intake and create a long-term nutrition and
fitness prescription plan. It includes behavior change contracts and topics for journal-based activities.
Eat Right! Healthy Eating in College and Beyond.
This handy, full-color booklet provides students with practical guidelines, tips, shopper’s guides, and recipes that turn
healthy eating principles into blueprints for action. Topics
include healthy eating in the cafeteria, dorm room, and fastfood restaurants; planning meals on a budget; weight management; vegetarian alternatives; and how alcohol affects health.
Live Right! Beating Stress in College and Beyond.
This booklet gives students useful tips for coping with a
variety of life’s challenges both during college and for the
rest of their lives. Topics include sleep, managing finances,
time management, coping with academic pressure, relationships, and a closer look at advertised products that
promise to make our lives better.
Digital 5-Step Pedometer. Take strides to better health
with this pedometer, which measures steps, distance (miles),
activity time, and calories and provides a time clock.
MyDietAnalysis. Powered by ESHA Research, Inc.,
MyDietAnalysis features a database of nearly 50,000 foods
and multiple reports and is available via single sign-on in
Mastering Health at no extra charge. It allows students to
track their diet and activity using up to three profiles and
to generate and submit reports electronically.
PREFACE | xxxiii
ACKNOWLEDGMENTS
L
ooking back, it is hard for me to believe that Access to
Health is in its 16th edition! Thinking about how this
book has evolved since the first edition, and how the
personal health textbook market has undergone remarkable
changes, I am excited and humbled to know that through
the work of so many outstanding professionals, this one may
be the best one yet! Whereas this edition of Access To Health
remains a foundation and springboard for information, the
ability to communicate with students through the Internet
and a wide range of other media and devices, such as smartphones and tablets, provides textbook authors and publishers
entirely new and exciting ways of teaching, sharing and building upon text information, motivating students to become
actively engaged in the learning experience, and covering upto-the-minute health topics in every class. Today’s text offers
opportunities for student engagement and thought-provoking
exercises that do more than test basic factual data. Access to
Health is also designed to help students understand complex
issues surrounding health so they can make better decisions
related to health care and behaviors.
To maximize student learning, we sought input from faculty members and experts in technology and e-learning—
those who work with students daily and who understand how
to engage today’s learners with written and visual content.
We also interviewed students and asked them about how they
used technology in their learning and incorporated their recommendations into our student-centered approach.
Producing a text that students actually want to pick up and
read—one that they find interesting and that encourages critical thinking and learning and doesn’t just re-hash information
that they already know—is no small task. In fact, in addition to
having an author and contributors with the professional training and expertise in the scientific foundations of the health
field, it takes a small army of publishing professionals and
media specialists who take the basic information and make it
come alive for the reader. Each step in the planning, the developing, and the marketing and sales of a high-quality textbook
and supplemental materials requires a tremendous amount of
work from many skilled and dedicated professionals. I often
think how fortunate I have been to work with the many gifted
and talented professionals who make up the Pearson family.
Upon reflection, there have been so many names and faces
along the way—from people who have carried a tremendous
amount of responsibility from beginning to end to those
who have quietly worked behind the scenes on special tasks,
in many cases, to make Access to Health a resounding success
from the first edition to this one. I owe each of them tremendous gratitude, for without their efforts, this book may have
languished on the shelves along the way. From my perspective,
Pearson personnel personify key aspects of what it takes to be
successful in the publishing world: (1) skill and competence;
xxxiv
(2) a work ethic exemplifying high standards, drive, and motivation; (3) creativity and commitment to excellence; (4) a
vibrant, youthful, and enthusiastic approach; and (5) personalities that motivate an author to continually strive to produce
market-leading texts.
In particular, I am indebted to my Content Producer, Deepti
Agarwal, who has worked on several editions of Access to Health
and Health: The Basics and has never missed a beat in ensuring that these projects are top-notch works that reflect her outstanding editorial skills, scheduling proficiency, and attention
to detail. She is a “rare gem” in the project management area,
and her work ethic is among the best of all those great individuals with whom I have worked over the years. Deepti was
able to juggle numerous responsibilities and organizational
tasks, provide thoughtful recommendations, and problemsolve along the way to keep the team on task to produce a final
manuscript on a tight schedule—all the while gently nudging
the author (me!), who has a slight tendency to get carried away
and want to add more and more in a limited space. In short,
Deepti did a fantastic job in making this edition continue as a
leading text in the field.
In addition to Deepti, I am thankful to Nic Albert and Alice
Fugate, development editors, who did their usual outstanding jobs of editing/organizing material, refining manuscript,
recommending changes to manuscript, and all of the other
aspects of preparation. Both Nic and Alice provided excellent
text refinement, provided great insight on important changes,
and worked closely with us to develop a fresh, cutting-edge
edition. Their painstaking attention to detail, superb writing/
editing skills, and overall contributions were truly amazing. In
short, Deepti, Nic, and Alice are part of the “dream team” that
makes an author’s work both easier and better. Thank you all. I
couldn’t do it without you!
Joanne Boehme also played a key role in refining material,
synthesizing narrative when I got carried away and keeping
the text and other manuscript components clean and concise
for students. Another key individual whom I would like to
acknowledge is someone who has been with my projects either
directly or indirectly over many years and editions: Barbara
Yien, Courseware Portfolio Director. In so many ways, whether
helping with project development, ensuring that the right
team is brought in to assist, having a historical perspective
that contributes to future decisions, and being a rock-solid,
caring individual, Barbara is the glue that holds so many projects together, worrying about the details, helping when issues
arise, and providing a solid dose of wisdom and humor when
both are needed! Knowing that she is there working behind
the scenes to help projects run smoothly is a special bonus that
is much appreciated by me and others. Thank you, B
­ arbara, for
all the things you have done to make these books a success
over the years.
Although many acquisitions editors play a more detached
role in project management and development, I was fortunate
in being able to work with a hands-on and enthusiastic editor
on this edition. Much appreciation and many thanks go to
senior acquisitions editor Michelle Yglecias. Whether traveling to assist with adoptions, dealing with issues that inevitably
arise in a changing health marketplace, or securing necessary resources to stay on top of a competitive field, Michelle
has been key to the success of my books and the health list
at the Pearson publishing enterprise. A tireless worker, an
enthusiastic advocate for authors and her staff, Michelle has
been a driving force in moving the Access to Health series into
the twenty-first century of technologically savvy textbooks.
Clearly, she “gets it” when it comes to keeping a steady hand
on the pulse of the personal health market and what instructors are looking for and what students need.
Although these individuals were key contributors to the
finished work, many other people also worked on this revision
of Access to Health. In particular, I would like to thank Sharon
Cahill of SPi Global, who put everything together to make a
polished finished product. Sharon worked wonders in giving
the book an exciting and fresh new look, both inside and out.
Editorial Assistant Gillian Perry gets major kudos for supporting the editorial team, as does Timothy Hainley, Senior Rich
Media Content Producer, and Rich Media Content Producer
Keri Rand, who developed a comprehensive Mastering Health
program. Additional thanks go to the rest of the team at
­Pearson, especially Design Manager Mark Ong and Rights and
Permissions Manager Ben Ferrini.
The editorial and production teams are critical to a book’s
success, but I would be remiss if I didn’t thank another key
group who ultimately help determine a book’s success: the
textbook representative and sales group and their leaders,
Director of Product Marketing, Allison Rona, and Executive
Field Marketing Manager, Mary Salzman. Allison and Mary
talk with faculty daily and provide the editorial and author
teams with helpful advice and many good ideas. In keeping
with my overall experiences with Pearson, the members of the
marketing and sales staff are among the best of the best. I am
very lucky to have them working with me on this project with
each book, and I appreciate their time, skill, and dedication
even more. This is truly a great group of publishing professionals. Thank you to every one of you!
CONTRIBUTORS TO THE
SIXTEENTH EDITION
Many colleagues, students, and staff members have provided
the feedback, reviews, extra time, assistance, and encouragement that have helped me meet the rigorous demands of publishing this book over the years. Whether acting as reviewers,
generating new ideas, providing expert commentary, or revising chapters, each of these professionals has added his or her
skills to our collective endeavor. I would like to thank other
key contributors to chapters in this edition. As always, I would
like to give particular thanks to Dr. Patricia Ketcham, who has
helped with the Access to Health series since its beginnings. As
past president of the American College Health Association,
former Associate Director of Health Promotion in Student
Health Services at Oregon State University, and currently serving as Senior Analyst for the Center for Education Innovation,
Evaluation and Research in Oregon, Pat provides a current and
unique perspective on key campus challenges and the innovative ways in which campuses are responding to a wide range
of student health issues. Her outstanding evaluation skills
and knowledge of programming effectiveness help to provide
cutting-edge strategies for individual and community health
promotion. Although she has been instrumental in the development and updating of several different chapters over the
years, for this edition she used her skills in careful revisions of
Chapter 8, “Building Healthy Relationships and Communicating Effectively”; Chapter 9, “Understanding your Sexuality”;
Focus On, ”Recognizing and Avoiding Addiction”; Chapter 11,
“Drinking Alcohol Responsibly”; Chapter 12, “Ending Tobacco
Use”; Chapter 13, “Avoiding Drug Misuse and Abuse”; and
Chapter 22, “Preparing for Aging, Death, and Dying.”
Dr. Tanya Littrell is a full-time faculty member and Department Chair in the Fitness Technology and Physical Education
Department at Portland Community College in Portland, Oregon. Dr. Littrell has a master’s degree in human performance/
exercise physiology and a doctoral degree in exercise science/
exercise physiology and has been teaching lifetime fitness
classes since 1998. As a co-author on Get Fit Stay Well with Pearson, Tanya, to our delight, agreed to be a contributing author
for Focus On. ”Enhancing Your Body Image,” and Chapter 7,
“Improving Your Personal Fitness,” in this edition of Access to
Health. Tanya has the academic, scientific, and research experience and skills to know what students are looking for in these
areas, and her chapters reflect her expertise and detail-oriented
approach to improving student
Dr. Susan Dobie, Associate Professor in the Department of
Health, Physical Education and Leisure Sciences at the University of Northern Iowa, has worked with our team for several
recent editions, providing several outstanding chapter revisions. Susan utilized her expertise in the health promotion and
health behavior areas to provide one of the most comprehensive and scientifically accurate chapters in the field in revising
Chapter 10, “Considering Your Reproductive Choices.” As an
educator, mentor, and researcher, Dr. Dobie provided detailed,
cutting-edge information in an interesting and well-written
update designed to engage students and provide thought-­
provoking learning experiences.
Finally, Laura Bonazzoli, development editor and author,
provided a thorough and timely revision of Chapter 1, “Accessing Your Health”; and used her background and experience in co-developing and writing two innovative and new
to the field chapters: Focus On, “Difference, Disparity, and
Health: Achieving Health Equity,” and Focus On, “Mindfulness, Spiritual Health, and Spiritual Identity.” Additionally,
Laura updated and enhanced Chapter 5, “Nutrition: Eating
for a Healthier You”; Chapter 19, “Making Smart Health Care
Choices”; and Focus On, “Reducing Your Risk of Unintentional
Injury.” Laura has worked on Access to Health for several years
ACKNOWLEDGMENTS | xxxv
now, and I am always amazed at her diligence, work ethic, creativity, and attention to detail. It has been a pleasure to work
with her in conceptualizing/developing Focus On “Difference,
Disparity, and Health: Achieving Health Equity” and watching
the chapter come to life under her expert writing and interesting approach to the topic. Likewise, she was able to take existing mindfulness material and meld this material and her own
into what is the first real mindfulness chapter in a personal
health book. She is the best!
The above contributors were brought on board because of
their history of working with college students, as well as their
vital, enthusiastic approach to student learning. Importantly,
they are all experts in subject-matter content and have proven
academic training and research background in related fields.
Thank you to each of you for your help in making this edition
of Access to Health one of the best yet!
REVIEWERS FOR THE
SIXTEENTH EDITION
With each new edition of Access to Health, we have built on the
combined expertise of many colleagues throughout the country who are dedicated to the education and healthy behavioral
changes of students. I thank the many reviewers of the past
15 editions of Access to Health who have made such valuable
contributions. I want you, the instructors who have used and
reviewed the book over the years, to know that I am grateful
for your support and guidance. You are an essential resource
xxxvi | ACKNOWLEDGMENTS
for knowing how to best stimulate students to learn, grow, and
tackle the health challenges that lie ahead of them.
For the 16th edition, reviewers who have helped us continue this tradition of excellence include the following:
Linda Romaine, Raritan Valley Community College
Marty Cooper, Itawamba Community College
Diane Klein, Tennessee Wesleyan University
Will Stern, University of TN–Chattanooga
Sherry Sank, Diablo Valley College
Kristen Colchico, Diablo Valley College
Erin Ladoceour, SUNY at Cortland
Maria Hrycenko, Monmouth University
Nikki Bonanni, Ithaca College
Melissa Mesman, Kennesaw University
Contributors to Instructor Supplements
and Mastering Health
Brenda Moore, Ozarks Technical Community College
Laura Bonazzoli, Development Editor
Nic Albert, Development Editor
Pardess Mitchel, Harper College
Nikki Bonanni, Ithaca College
Dr. Ronita Ghatak, Hunter College
Amber Emanuel, University of Florida
Many thanks to all!
Rebecca J. Donatelle, Ph.D.
1
ACCESSING YOUR
HEALTH
LEARNING OUTCOMES
LO1
Describe the immediate and long-term rewards of
healthy behaviors and the effects that your health
choices may have on others.
LO2
Compare and contrast the medical model of health and
the public health model, and discuss the six dimensions
of health.
LO3
Identify modifiable and nonmodifiable personal,
social, and environmental factors that influence your
health.
LO4
Describe mindfulness, summarizing its health benefits
and general practice.
LO5
Compare and contrast the health belief model, the
social-cognitive model, and the transtheoretical model
of behavior change, and explain how you might use
them in making a specific behavior change.
LO6
Identify your own current risk behaviors, the factors that
influence those behaviors, and the strategies you can
use to change them.
1
WHY
Improving your health enhances your life. Academic and career success, supportive relationships, a zest for living, and reduced risks for disease and disability can
help you maximize your “healthy years.” Much of who you are and what you will
become is in your hands!
SHOULD I CARE?
G
ot health? That may sound like a simple question,
but it isn’t. Health is a process, not something we
just “get.” People who are healthy in their 60s,
70s, and beyond aren’t just lucky or the beneficiaries of hardy genes. Most have set the stage for good health by
making it a priority in their early years. Whether the coming
decades are filled with good health, productive careers, special
relationships, and fulfillment of life goals is influenced by the
health choices you make—beginning right now.
reported impediments to academic success (FIGURE 1.1). Similarly, drinking alcohol reduces your academic performance
and sharply increases your risk of unintentional injuries—not
only motor vehicle accidents, but also falls, burns, and drownings. This is especially significant because, for people between
the ages of 15 and 44, unintentional injury—whether related
to drug overdose, motor vehicle accidents, or any other factor—is the leading cause of death (TABLE 1.1).
It isn’t an exaggeration to say that healthy choices have
immediate benefits. When you’re well nourished, fit, rested,
and free from the influence of nicotine, alcohol, and other
drugs, you’re more likely to avoid illness, succeed in school,
maintain supportive relationships, participate in meaningful work and community activities, and enjoy your
leisure time.
LO 1 | WHY HEALTH,
WHY NOW?
Describe the immediate and long-term rewards of healthy behaviors
and the effects that your health choices may have on others.
Every day, the media remind us of
health challenges facing the world,
the nation—maybe even your campus or community. You might want to
ignore these issues, but you can’t. In
the twenty-first century, your health is
connected to the health of people with
whom you directly interact, as well as
to people you’ve never met, and to the
well-being of your local environment,
as well as the entire planet. Let’s take a
look at how.
Choose Health
Now for Immediate
Benefits
Almost everyone knows that overeating leads to weight gain or that smoking
causes lung cancer. But other choices
you make every day may influence your
well-being in ways you’re not aware of.
For instance, did you know that scientific research is increasingly finding
that the amount of sleep you get each
night can influence your weight, your
susceptibility to chronic diseases, your
ability to ward off colds, your mental
health, your social interactions, and
your driving? What’s more, inadequate
sleep is one of the most commonly
2 | PART ONE | Finding the Right Balance
33.1%
Stress
25.1%
Anxiety
Sleep
difficulties
21.4%
16.8%
Depression
Cold/flu/
sore throat
13.8%
12.9%
Work
Extracurricular
activities
10.8%
Concern for friend/
family member
10.0%
Internet use/
computer games
9.0%
Relationship
difficulties
8.9%
0
10
20
30
40
Percent
FIGURE 1.1 Top Ten Reported Impediments to Academic Performance—Past
12 Months In a recent survey by the National College Health Association, students
indicated that stress, anxiety, poor sleep, and other factors had prevented them from
performing at their academic best.
Source: Data are from American College Health Association, American College Health Association—
National College Health Assessment II (ACHA-NCHA II) Reference Group Data Report, Spring 2017
(Baltimore, MD: ACHA, 2017).
TABLE 1.1 | Leading Causes of Death in the
United States in 2015, Overall and by Age
Group (15 and older)
All Ages
Number of Deaths
Diseases of the heart
633,842
Malignant neoplasms (cancer)
595,930
Chronic lower respiratory diseases
155,041
Accidents (unintentional injuries)
146,571
Cerebrovascular diseases (stroke)
140,323
Aged 15–24
Accidents (unintentional injuries)
12,514
Suicide
5,491
Assault (homicide)
4,733
Malignant neoplasms (cancer)
1,469
Diseases of the heart
997
Aged 25–44
Accidents (unintentional injuries)
37,613
Malignant neoplasms (cancer)
14,613
Diseases of the heart
13,909
Suicide
13,883
Assault (homicide)
7,758
Aged 45–64
Malignant neoplasms (cancer)
159,176
Diseases of the heart
111,120
Accidents (unintentional injuries)
40,987
Chronic liver disease and cirrhosis
22,152
Chronic lower respiratory diseases
21,802
Aged 65+
Diseases of the heart
507,138
Malignant neoplasms (cancer)
419,389
Chronic lower respiratory diseases
131,804
Cerebrovascular diseases
120,156
Alzheimer’s disease
109,495
Source: Data from National Center for Health Statistics, Health, United
States, 2016 (May 2017), www.cdc.gov/nchs/data/hus/hus16.pdf#019.
Choose Health Now
for Long-Term Rewards
Successful aging starts now. The choices you make today are
like seeds: Planting good seeds means you’re more likely to
enjoy the fruits of a longer
and healthier life. In contrast, poor choices increase
the likelihood of a shorter
life, as well as a lower quality
of life.
Personal Choices
Influence Your Life
Expectancy Accord-
mortality The proportion of
deaths to population.
life expectancy Expected
number of years of life remaining at a given age, such as at
birth.
chronic disease A disease
that typically begins slowly,
progresses, and persists, with
a variety of signs and symptoms that can be treated but
not cured by medication.
ing to current mortality rates
and death statistics—which
healthy life expectancy
reflect the proportion of
Expected number of years of
deaths within a population—
full health remaining at a given
the average life expectancy
age, such as at birth.
at birth in the United States
is projected to be 78.6 years for a child born in 2016.1 In other
words, we can expect that American infants born today will live
to an average age of over 78 years, much longer than the 47-year
life expectancy for people born in the early 1900s. That’s because
life expectancy a century ago was largely determined by our susceptibility to infectious disease. In 1900, three of the four leading
causes of death were infectious diseases: Tuberculosis, pneumonia, and diarrhea accounted for nearly 1 out of every 4 deaths.2
With the development of vaccines and antibiotics, life expectancy increased dramatically as premature deaths from infectious diseases decreased. As a result, the leading cause of death
shifted to chronic diseases such as heart disease, cancer, chronic
lower respiratory diseases, and cerebrovascular disease (which
leads to strokes). At the same time, advances in diagnostic technologies, heart and brain surgery, and radiation and other cancer
treatments, as well as new medications, continued the trend of
increasing life expectancy into the twenty-first century.
78.6
YEARS
is the LIFE EXPECTANCY in the
United States.
Unfortunately, life expectancy in the United States has
fallen in the past 2 years, from a peak in 2014 of 78.9 years to
the current 78.6. This drop might seem insignificant, but public health experts call it “alarming” because other economically developed nations have not seen a decline, and U.S. life
expectancy is now several years below that of many comparable
nations.3 What factors are thought to contribute to the decline
in U.S. life expectancy? See HEALTH HEADLINES on page 4.
Personal Choices Influence Your Healthy
Life Expectancy Another benefit of healthful choices
is that they increase your healthy life expectancy, that is,
the number of years remaining at a given age without disability,
CHAPTER 1 | Accessing Your Health | 3
HEALTH
HEADLINES
Shorter Lives, Poorer Health
E
very 2 years, the Organisation
for Economic Co-operation and
Development (OECD), an intergovernmental
association of economically advanced
countries, publishes a report comparing
overall health and life expectancy among
their 35 members and 9 partners. Among
the sobering findings of their 2018 report is
the fact that Americans are dying at earlier
ages than people in most other OECD
countries and are experiencing poorer
health.
For example, on average, life expectancy among all OECD countries averages
80.6 years, with 27 countries—including
Japan, Korea, Israel, Australia, Canada,
and all countries of Western Europe—having life expectancies greater than that of
the United States. Intriguingly, Americans’
lower life expectancy applies only to those
younger than age 65; that is, an American
who reaches age 65 can expect to live another 19.3 years, which is about the OECD
average. This suggests that our reduced
life expectancy overall must be due to factors affecting us earlier in life. These are
thought to include:
Infant mortality. The United States has
an infant mortality rate (death before
the first birthday) higher than that of
most peer countries: 5.8 deaths per
1,000 live births versus the OECD
average of 3.9.
■■ Deaths due to obesity and chronic
disease. The United States also has
the highest rate of obesity of any OECD
country: 38.2 percent versus the OECD
average of 19.4 percent. Because
obesity is a key risk factor for diabetes,
it’s not surprising that we also have
the third highest incidence of diabetes,
which significantly limits life expectancy. Obesity is also a risk factor for
■■
health-related quality of
life Assessment of impact
of health status—including
elements of physical, mental,
emotional, and social
function—on overall quality
of life.
■■
■■
■■
■■
cardiovascular disease and cancer,
and the United States has higher death
rates from these diseases than 20 other
OECD countries.
Deaths of despair. Although our
suicide rate is about average among
OECD countries, it has been rising
among non-Hispanic white Americans,
as have deaths due to unintentional
drug overdoses and alcohol-related
liver failure. These so-called deaths of
despair have increased only among
non-Hispanic whites ages 25 to 54,
and predominantly those living outside
large urban areas and having a high
school education or less. Moreover,
non-Hispanic whites living in rural
areas have also seen increased death
rates from cardiovascular disease and
from respiratory disease, an increase
matched by no other subpopulation in
America. Researchers speculate that
these deaths are fueled by stress and
hopelessness due to reduced economic opportunities, family dysfunction, and lack of social support, which
in turn increase “soothing” through
food, drugs, tobacco, and alcohol.
Firearms. The United States has a
higher rate of firearm ownership, and a
higher homicide rate, than other OECD
countries. Deaths due to homicide are
higher among younger Americans than
older Americans.
Our car culture. The United States has
a higher rate of traffic fatalities, which
also are more common in young or
middle adulthood. Moreover, the infrastructure in our communities tends to
be designed for driving rather than for
walking or cycling, discouraging physical
activity and promoting social isolation.
Our lack of universal health care
coverage. In all but 7 OECD countries,
chronic pain, or significant
illness. One dimension of
healthy life expectancy is
health-related quality of life
(HRQoL), a concept that goes
beyond mortality rates and
life expectancy and focuses on
4 | PART ONE | Finding the Right Balance
95 percent or more of the population
has health care coverage for a core set
of services. Only Greece has a lower
level of population coverage than the
United States.
■■ Our fragmented system of health
care delivery. The U.S. health care
system devotes fewer resources to
public health and primary care than
other OECD countries, despite spending almost $10,000 per person for
health care, compared to the OECD
average of $4,000.
■■ Our unequal society. The United
States has a higher level of poverty
and income inequality than most other
OECD countries. Since 1980, life
expectancy has increased by more
than 5 years for the wealthiest Americans but has declined for the poorest,
in part because spending on health
care in the United States is not evenly
distributed.
If citizens of other OECD countries
can enjoy better health and longer lives,
Americans can, as well. As you learn
about health-promoting behaviors in this
text, be sure to put them into practice. For
more on America’s unequal access to
health and health care, see Focus On: Difference, Disparity, and Health: Achieving
Health Equity.
Sources: OECD, “Health at a Glance: 2017”
(February 2018), http://dx.doi.org/10.1787/health_
glance-2017-en; E. M. Stein, K. P. Gennuso,
D. C. Ugboaja, and P. L. Remington, “The Epidemic
of Despair among White Americans: Trends in the
Leading Causes of Premature Death, 1999–2015,
American Journal of Public Health (October 2017),
http://ajph.aphapublications.org/doi/full/10.2105/
AJPH.2017.303941; and A. Smith and F. Cocco,
“The Huge Disparities in US Life Expectancy in
Five Charts,” Financial Times (January 27, 2017).
Available at www.ft.com/content/80a76f38e3be-11e6-8405-9e5580d6e5fb.
the impact health status has on physical, mental, emotional,
and social function. HRQoL can apply to both individuals and
groups. Closely related to HRQoL is well-being, which assesses
the positive aspects of a person’s life, such as positive emotions
and life satisfaction.4 Not only physical health, but good living
conditions, quality relationships, and opportunities to realize
one's potential contribute to a sense of well-being.
LO 2 | WHAT IS HEALTH?
Compare and contrast the medical model of health and the public
health model, and discuss the six dimensions of health.
Over the centuries, different ideals—or models—of human
health have dominated, and different definitions and dimensions of health have been recognized.
Models of Health
Our current model of health has broadened from a focus on
the individual physical body to an understanding of health as
a reflection not only of ourselves, but also of our communities.
What is meant by quality of life? Hawaiian surfer Bethany
Hamilton lost her arm in a shark attack while surfing at
age 13, but that hasn’t prevented her from achieving her
goals as a professional surfer.
Your Health Is Linked to Societal
Health
Our personal health choices affect the lives of others. For
example, overeating and inadequate physical activity contribute to obesity. But along with its associated health problems
that affect individuals, obesity impacts the U.S. health care system and the U.S. economy overall. According to the U.S. Centers for Disease Control and Prevention, the medical costs of
obesity in the United States are nearly $150 billion each year.5
In addition, obesity costs the public indirectly. These indirect
costs include reduced tax revenues because of income lost
from absenteeism and premature death, increased disability
payments because of an inability to remain in the workforce,
and increased health insurance rates as claims rise for treatment of obesity itself as well as its associated diseases.
Smoking, excessive alcohol consumption, and drug abuse
also place an economic burden on our communities and society. Moreover, these behaviors burden caregivers who make
financial, social, and emotional sacrifices to take care of those
disabled by diseases.
At the root of the concern that individual health choices
cost society is an ethical question causing considerable debate:
To what extent should the public be held accountable for an
individual’s unhealthy choices? Should we require individuals to somehow pay for their poor choices? Of course, in some
cases, we already do. We tax cigarettes and alcohol, and several
U.S. cities now tax soda and other sugary drinks, which have
been blamed for rising obesity rates. On the other side of the
debate are those who argue that smoking and drinking are
addictions that require treatment, not punishment, and that
obesity is a multifactorial disorder, with heredity, sociocultural
factors, the food environment, public policy, and individual
choices all contributing. Are behaviors that influence health
always entirely within our control? Before we explore these
questions further, it’s essential to understand what health
actually is.
Medical Model Prior to the twentieth century, perceptions of health were dominated by the medical model, in
which health status focused primarily on the individual and his
or her tissues and organs. The surest way to improve health was
to cure the individual’s disease, either with medication to treat
the disease-causing agent or through surgery to remove the diseased body part. Thus, government resources focused
well-being An assessment
on initiatives that led to treatof the positive aspects of a
ment, rather than prevenperson’s life, such as positive
emotions and life satisfaction.
tion, of disease.
Public Health Model
In the early decades of the
1900s, researchers began to
recognize that entire populations of poor people in
certain areas were victims of
environmental factors over
which they had little control:
polluted water and air, a lowquality diet, poor housing,
and unsafe work settings. As
a result, researchers began
to focus on an ecological
or public health model,
which views diseases and
health The ever-changing
process of achieving individual
potential in the physical, social,
emotional, intellectual, spiritual,
and environmental dimensions.
medical model A view of
health in which health status
focuses primarily on the
individual and a biological or
diseased-organ perspective.
ecological or public health
model A view of health in
which diseases and other
negative health events are seen
as a result of an individual’s
interaction with his or her social
and physical environment.
Negative health events can be caused by people’s
interactions with the physical environment.
CHAPTER 1 | Accessing Your Health | 5
other negative health
events as a result of an
The Ten Greatest Public Health
Achievements of the 20th Century
individual’s
interaction with his or her
• Vaccinations
health promotion The
• Motor vehicle safety
social and physical
combined educational, organi• Workplace safety
environment.
zational, procedural, environ• Control of infectious diseases
Recognition of the
mental, social, and financial
• Reduction in cardiovascular
supports that help individuals
public health model
disease (CVD) and stroke deaths
and groups reduce negative
enabled health offi•
Safe and healthy foods
health behaviors and promote
cials to move to control
• Maternal and infant care
positive change.
contaminants in water,
• Family planning
risk behaviors Actions that
for example, by build• Fluoridated drinking water
increase susceptibility to negaing adequate sewers,
• Recognition of tobacco as a
tive health outcomes.
health hazard
and to control burnwellness The achievement
ing and other forms
of the highest level of health
of air pollution. In the
possible in each of several
early 1900s, colleges
dimensions.
FIGURE 1.2 The Ten Greatest Public Health Achievements
began offering courses of the Twentieth Century
in health and hygiene. Over time, public health offiSource: Adapted from Centers for Disease Control and Prevention, “Ten Great Public
cials began to recognize and address many other forces
Health Achievements in the 20th Century,” Accessed March 8, 2018, www.cdc.gov/
affecting human health, including hazardous work con- about/history/tengpha.htm.
ditions; negative influences in the home and social environment; discrimination; stress; diet; sedentary lifestyle; and
advances, and individual actions have worked to improve our
cost, quality, and access to health care.
overall health status greatly in the past 100 years. FIGURE 1.2
By the 1940s progressive thinkers began calling for polilists the ten greatest public health achievements of the twenticies, programs, and services to improve individual health
eth century.
and that of the population as
a whole—shifting focus from
SEE IT! VIDEOS
treatment of individual illCan simply being kind
ness to disease prevention.
improve your health?
For example, childhood vacWatch Helping Others
cination programs reduced
In 1968, biologist, environmentalist, and philosopher René
Could Be Good for Your
the
incidence
and
severity
of
Dubos proposed an even broader definition of health. In his
Health, available on
infectious
disease;
installaPulitzer Prize–winning book, So Human an Animal, Dubos
Mastering Health.
tion of safety features such as
defined health as “a quality of life, involving social, emotional,
seat belts and airbags in motor
mental, spiritual, and biological fitness on the part of the indivehicles reduced traffic injuries and fatalities; and laws govvidual, which results from adaptations to the environment.”7
erning occupational safety reduced injuries to and deaths of
This concept of adaptability, or the ability to cope successfully
American workers. In 1947 at an international conference
with life’s ups and downs, became a key element in our overall
focusing on global health issues, the World Health Organizaunderstanding of health.
tion (WHO) proposed a new definition of health: “Health is
Later, the concept of wellness enlarged Dubos’s definithe state of complete physical, mental, and social well-being,
tion of health by recognizing levels—or gradations—of health
not just the absence of disease or infirmity.”6 This new defi(FIGURE 1.3). To achieve high-level wellness, a person must
nition definitively rejected the old medical model.
move progressively higher on a continuum of positive health
The public health model also began to emphasize health
indicators. Those unable to achieve these levels may slip into
promotion—policies and programs that promote behaviors
illness, premature disability, or death.
known to support good health.
Health-promotion programs
identify people who are engagIrreversible
Chronic Signs of
Signs of
Improved Optimal
ing in risk behaviors (those
wellness/
disability
illness
illness
health/
health/
that increase susceptibility
well-being
and/or death
wellness wellness
to negative health outcomes)
and motivate them to change
their actions by improving
Neutral
their knowledge, attitudes, and
point
skills. Numerous public policies and services, technological FIGURE 1.3 The Wellness Continuum
disease prevention Actions
or behaviors designed to keep
people from getting sick.
Wellness and the Dimensions
of Health
6 | PART ONE | Finding the Right Balance
Intellectual health. This dimension encompasses the ability to think clearly, reason objectively, analyze critically,
and use brainpower effectively to meet life’s challenges. It
involves being open minded and nonjudgmental, having
a thirst for knowledge, being culturally competent and
multi-culturally aware, and acknowledging that there are
often no simple answers to life’s questions. It also means
using your awareness and knowledge to create a better life
for yourself and others.
■■ Emotional health. This is the feeling component—being
able to express emotions when appropriate, and to
control them when not. It also includes emotional
intelligence, which is the ability to identify and manage
emotional responses in positive ways. Self-esteem,
self-confidence, trust, and love are all part of emotional
health.
■■ Spiritual health. This dimension involves creating and
expressing meaning and purpose in your life. This may
include believing in a supreme being or following a particular religion’s teachings, or simply feeling that you are
part of a greater spectrum of existence. The capacities to be
mindful of and contemplate life’s experiences and to care
about and respect all living things are aspects of spiritual
health.
■■ Environmental health. This dimension entails understanding how the health of the environments in which you live
can positively or negatively affect you; protecting yourself
from hazards in your own environment; and working to
preserve, protect, and improve environmental conditions
for everyone.
■■
Intellectual health
En
vir
on
me
nta
l he
alt
h
So
cia
lh
ea
lth
h
alt
he
al
on
oti
Em
l
ua
irit
Sp
h
alt
he
Physical health
FIGURE 1.4 The
Dimensions of Health When
all dimensions are balanced
and well developed, they
support your active, thriving
lifestyle.
Watch Video Tutor:
Dimensions of Health
Today, the words health and wellness are often used interchangeably to mean the dynamic, ever-changing process of
trying to achieve one’s potential in each of six interrelated
dimensions (FIGURE 1.4):
Achieving wellness means attaining the optimal level of
Physical health. Physical health includes features like the
well-being for your unique limitations and strengths. For
shape and size of your body, how responsive and acute your
example, a disabled person may function at his or her optimal
senses are, and your body’s ability to function at optimal
level of physical and intellectual performance; enjoy satisfying
levels with adequate sleep and rest, nutrition, and physical
activity. It also includes your ability
to avoid, manage, or heal from injury
or illness, cope with challenges, and
maintain equilibrium in the face of
adversity. More recent definitions of
physical health encompass a person’s
ability to perform activities of daily
living (ADLs), or those activities that
are essential to function normally in
society—including things like getting
up out of a chair, bathing and dressing
yourself, cooking meals, and getting
around without assistance.
■■ Social health. The ability to have a
broad social network and maintain
satisfying interpersonal relationships
with friends, family members, and
partners is a key part of overall wellness. Successfully interacting and
communicating with others, includDeveloping and maintaining healthy friendships is an important part of social and
ing in various social situations, are
emotional health.
part of social health.
■■
CHAPTER 1 | Accessing Your Health | 7
relationships; and be engaged in environmental concerns.
In contrast, a person who spends hours lifting weights to perfect the size and shape of each muscle, but pays little attention
to others, may lack social or emotional health. The perspective
we need is holistic, emphasizing the balanced integration of
mind, body, and spirit.
Individual
behavior
Health
services
LO 3 | WHAT INFLUENCES
YOUR HEALTH?
Biology and
genetics
Health
outcomes
Identify modifiable and nonmodifiable personal, social,
and environmental factors that influence your health.
If you’re lucky, aspects of your world conspire to promote
your health: Everyone in your family is slender and fit; there
are locally grown, organic fruits and vegetables for sale at the
neighborhood farmer’s market; and a new bike trail opens
along the river (and you have a bike!). If you’re not so lucky,
aspects of your life make getting and staying healthy much
more challenging: Everyone in your family is overweight;
there are only cigarettes, alcohol, and junk food for sale at the
corner market; and you wouldn’t dare bike alongside the river
for fear of being mugged. In short, seemingly personal choices
aren’t always totally within an individual’s control.
Public health experts refer to the factors that influence
health as determinants of health, a term the U.S. Surgeon
General defines as “the range of personal, social, economic,
and environmental factors that influence health status.”8
The Surgeon General’s health promotion plan, called Healthy
People, has been published every 10 years since 1990, with the
goal of improving the quality and increasing the years of life
for all Americans. The overarching goals set out by the newest
version, Healthy People 2020, are as follows:
Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
■■ Achieve health equity, eliminate disparities, and improve
health of all groups.
■■ Create social and physical environments that promote
good health for all.
■■ Promote quality of life, healthy development, and healthy
behaviors across all life stages.
■■
Healthy People 2020 classifies health determinants into
five categories: individual behavior, biology and genetics, social factors, policymaking, and health services
­(FIGURE 1.5). It also includes
strong language about reducing health disparities that
determinants of health The
range of personal, social,
exist between populations
economic, and environmental
based on racial or ethnic
factors that influence health
background, income and
status.
education, and many other
health disparities Differences
factors. Health disparities
in the incidence, prevalence,
are the subject of Focus On:
mortality, and burden of
Difference, Disparity, and
diseases and other health
Health: Achieving Health
conditions among specific
population groups.
Equity.
8 | PART ONE | Finding the Right Balance
Policymaking
Social
factors
FIGURE 1.5 Healthy People 2020 Determinants of
Health The determinants of health often overlap with one
another. Collectively, they impact the health of individuals and
communities.
Individual Behavior
Individual behaviors can help you attain, maintain, or regain
good health, or they can lead to deteriorating health and premature disease. Because most behaviors are within your power
to change, health experts refer to them as modifiable determinants. Modifiable determinants significantly influence your
risk for chronic disease—they are responsible for 7 out of 10
deaths in the United States.9 Incredibly, just four modifiable
determinants are responsible for most chronic disease and premature death (FIGURE 1.6). These are:10
Lack of physical activity. Research suggests that 10 or more
hours of physical inactivity each day more than double the
risk of death from any cause.11
■■ Poor nutrition. Multiple studies have linked diets low in
fruits and vegetables with an increased risk of death from
any cause.12
■■ Excessive alcohol consumption. Alcohol causes 88,000
deaths in adults annually through cardiovascular disease,
liver disease, cancer, and other diseases, as well as alcohol
poisoning, motor vehicle accidents, and violence.13
■■ Tobacco use. Tobacco smoking and the cancer, high blood
pressure, and respiratory disease it causes are responsible
for about 1 in 5 deaths of American adults.14
■■
On the flip side, a recent study tracking more than 36,000
adults for 14 years found that those who maintained at least
four healthful behaviors, such as eating a nourishing diet,
engaging in physical activity, and avoiding smoking and excessive alcohol consumption, had a 66 percent reduced risk of
death from any cause, as well as reduced risks for cancer, cardiovascular disease, and diabetes.15
Another major contributor to disease and mortality among
Americans is our rising abuse of prescription and illegal drugs,
FIGURE 1.6 Four Leading Causes of Chronic Disease in the United
States Lack of physical activity, poor nutrition, excessive alcohol consumption,
and tobacco use—all modifiable health determinants—are the four most
significant factors leading to chronic disease among Americans today.
especially opioid pain relievers
and heroin. Between 1999 and
What can one person
2015, the number of overdose
do to fight childhood
deaths involving these drugs
hunger? Watch Viola
quadrupled. Every day, 142
Davis Fights to End Child
Americans die from an opioid
Hunger, available on
overdose.16
Mastering Health.
Other modifiable determinants include stress levels,
exposure to toxic chemicals in the home and work environments, use of over-the-counter medications, sexual behaviors
and use of contraceptives, sleep habits, and hand hygiene and
other simple infection control measures. In addition, climate
change, which has contributed to a rise in emerging infectious
diseases, malnutrition, and many other global health problems, is modifiable with individual behavior change and with
changes in policies and programs.
We explore these and many other behaviors in later chapters. For more on how the choices you make today can affect
how long you live, and how long you live well, check out the
STUDENT HEALTH TODAY box on page 10.
SEE IT! VIDEOS
linking aspects of our diet, physical activity, and other behavioral choices to our cells’
ability to use our genes to build proteins that
influence our health. In the future, research
into epigenetics might help us gain more control over our genetic inheritance.
Non-modifiable determinants also refer
to certain innate characteristics, such as your
age, race, ethnicity, metabolic rate, and body
structure. Your sex is a key biological determinant: As compared to men, women have
an increased risk for low bone density and
autoimmune diseases (in which the body
attacks its own cells), whereas young and
middle-aged men have an increased risk for
heart disease compared to young and middleaged women. Your own history of illness and
injury also classifies as biology; for instance, if
you had a serious knee injury in high school,
it may cause pain with walking and exercise, which in turn may predispose you to
weight gain.
Social Factors
Social factors include both the social and physical conditions
in the environment in which people are born or live. Some
examples are exposure to crime, violence, mass media, technology, and poverty, as well as availability of healthful foods,
transportation, living wages, social support, and educational
or job opportunities. Physical conditions include the natural
environment; good lighting, trees, or benches; and the construction of and conditions within our community buildings,
workplaces, schools, and homes.
Economic Factors Even in affluent nations such
as the United States, people in lower socioeconomic brackets
have, on average, substantially shorter life expectancies and
more illnesses than do people who are wealthy.17 For example,
residents of an affluent county in the southeastern United
States can expect to live, on average, 12 to 14 years longer
than residents of a poor county a few hundred miles away.18
Economic disadvantages exert their effects on human health
within nearly all domains of life, including:
Lacking access to quality education from early childhood
through adulthood.
■■ Living in poor housing with potential exposure to asbestos,
lead, dust mites, rodents and other pests, inadequate sanitation, unsafe drinking water, and high levels of crime.
■■ Being unable to pay for nourishing food, warm clothes,
and sturdy shoes; heat and other utilities; medications and
medical supplies; transportation; and counseling services,
fitness classes, and other wellness measures.
■■
Biology and Genetics
Biological and genetic determinants are things you can’t
typically change or modify. Health experts frequently refer
to these factors as nonmodifiable determinants. Genetically
inherited traits are important nonmodifiable determinants.
They include single-gene disorders such as sickle-cell disease,
hemophilia, and cystic fibrosis, as well as predispositions to
certain conditions—such as allergies and asthma, cardiovascular disease, diabetes, and certain cancers—that are linked
to gene variants. Although we cannot influence the structure
of our genes, the emerging field of epigenetics is increasingly
The Built Environment
As the name implies, the
built environment includes anything created or modified by
human beings, including buildings, roads, recreation areas,
CHAPTER 1 | Accessing Your Health | 9
STUDENT
HEALTH TODAY
E
very 2 years, American athletes gather
to compete in the Senior Games. In
the summer of 2017, gold medalists Saundra Rue and Charles Allie—both in their
70s—won the 50-meter dash in 8.35 seconds and 6.92 seconds, respectively. How
do these athletes stay so fit? And what will
your future bring?
Research into healthy aging has identified multiple factors that appear to most
strongly influence your chances of living
a longer and healthier life. These can be
clustered into four groups:
Lifestyle choices. Earlier in this chapter, we identified the four behaviors that
most significantly increase your risk for
chronic disease (see FIGURE 1.6).
In contrast, a healthful diet, regular
exercise, no smoking, and alcohol
avoidance or moderation can help
maintain your HRQoL as you age.
Moreover, diet, exercise, smoking, and
alcohol intake influence body weight,
and both underweight and obesity
significantly impair health. Population
research suggests that, compared with
people who are normal weight, those
who are underweight or severely obese
lose an average of over 5 years of
healthy life expectancy.
■■ Social relationships. A large body of
research evidence over many decades
■■
Radiant Health or Chronic Illness
What Will Your Future Bring?
has supported a link between social
integration—feeling that you participate in and are supported by a community—and healthy aging. Recent
studies have found that the higher an
individual’s degree of social integration, the lower the risk of physiological markers associated with chronic
disease, such as high blood pressure,
abnormal blood cholesterol levels,
abdominal obesity, and inflammation.
In contrast, social isolation is linked
with increased risks for these
markers.
■■ Life skills. Research suggests that
five life skills—conscientiousness,
emotional stability, determination, control, and optimism—contribute to an
individual’s subjective sense of health
and well-being, more close relationships, less social isolation and loneliness, less depression, better ability to
perform activities of daily living, and
reduced markers of chronic disease.
These characteristics are referred to as
“skills” because researchers consider
them modifiable rather than fixed. See
Chapter 2 for more information on
the role of optimism, emotional intelligence, and other psychological factors
in your health.
■■ Meaning and purpose in life. A
number of studies have found that a
transportation systems, electric transmission lines, and communications cables.
Researchers in public health have increasingly been promoting changes to the built environment that can improve
the health of community members.19 These include increased
construction of parks, sidewalks, pedestrian-only areas, bike
paths, and public transit systems to which commuters typically walk or bike. Some communities are enticing supermarkets to open in underserved neighborhoods to increase
residents’ access to fresh fruits and vegetables.
Pollutants and Infectious Agents
Physical
conditions also include the quality of the air we breathe, our
land, our water, and our foods. Exposure to toxins, radiation,
and infectious agents via the environment can cause widespread harm within a region and, with the rise of global travel
and commerce, affect the health of people around the world.
10 | PART ONE | Finding the Right Balance
sense of meaning and purpose—or
“usefulness”—predicts a longer and
more healthful life. In one study,
for example, people who reported
that they did not feel useful were
three times more likely to become
disabled and four times more likely
to die during the seven-year study
period than people who reported
feeling useful. Several studies have
shown that meaning and purpose
are fostered by work, volunteerism,
family commitments, and participation
in creative and performing arts, from
painting and writing to singing and
acting, and that such engagement
reduces the risk for cognitive as well as
physical decline.
Sources: H. Jia, M. M. Zack, and W. W. Thompson,
“Population-Based Estimates of Decreases in
Quality-Adjusted Life Expectancy Associated with
Unhealthy Body Mass Index,” Public Health Reports
131, no. 1 (2016): 177–84; Y. C. Yang et al., “Social
Relationships and Physiological Determinants of
Longevity across the Human Life Span,” Proceedings of the National Academy of Sciences 113,
no. 3 (January 2016): 578–83; A. Steptoe and J.
Wardle, “Life skills, wealth, health, and wellbeing in
later life,” Proceedings of the National Academy of
Sciences 114, no. 17 (April 2017): 4354–59;
K. Williamson, “Aging in Good Health: Lives of
Meaning and Purpose,” United Neighborhood ­
Houses (September 2017), Available at http://
pssusa.org/wp-content/uploads/2017/11/Agingin-Good-Health-UNH-Report-2017.pdf.
Recent outbreaks of the Ebola and Zika viruses, for example,
are grim reminders of the need for a proactive international
response for disease prevention and climate change.
Access to Quality Health
Services
The health of individuals and communities is also determined
by access to quality health care, including not only services
for physical and mental health, but also accurate and relevant
health information and products such as eyeglasses, medical
supplies, and medications. Although the 2010 Patient Protection and Affordable Care Act (ACA) reduced the numbers of
uninsured Americans from 44 million in 2013 to 27.6 million
by the end of 2016, millions remained without insurance, and
the current status of health insurance coverage in the United
States is uncertain.20
27.6
MILLION
Americans are currently WITHOUT health
insurance.
Access to health services is also affected by policymaking—
including health insurance legislation. As just noted, implementation of the 2010 ACA has increased Americans’ access to
quality care.
LO 4 | HOW DOES
MINDFULNESS INFLUENCE
HEALTH?
Describe mindfulness, summarizing its health benefits and general
practice.
The built environment of your community can promote positive
health behaviors. Wide bike paths and major thoroughfares
closed to automobile traffic encourage residents to incorporate
healthy physical activity into their daily lives.
In addition to the uninsured, there are millions of
underinsured—individuals who have some coverage but not
enough. They may have plans with a high annual deductible
or a high copayment for services; as a result, they cannot afford
to pay the difference between what their insurance covers and
what their providers and medications cost. People who are
uninsured or underinsured tend to delay care or try other costsaving measures, such as taking only half of the prescribed
dose of their medications, that may put their health at risk.
Policymaking
Public policies and interventions can have a powerful and
positive effect on the health of individuals and communities.
Examples include policies banning tobacco sale to minors
or smoking in public places, laws mandating seat belt use in
motor vehicles and helmets for bike and motorcycle riders,
policies that require you be vaccinated before enrolling in
classes, and laws that ban cell phone use while driving. Health
policies serve a key role in protecting public health and motivating individuals and communities to change, particularly
when there are rewards (or penalties) for sticking (or not sticking) to the policies.
A veritable explosion of media outlets have been promoting a shift to mindful behavior as a path to optimal
health. If you have seen these claims, you may be wondering
whether or not they’re backed by evidence. In fact, a significant
and growing body of research supports the potential benefits
of mindfulness in enhancing overall health and well-being;
thus, this text focuses significant attention on mindfulness.
In this section, we explore definitions of mindfulness, provide an overview of scientific evidence linking it to health, and
introduce its general practice. See Focus On: Mindfulness and
Spiritual Health to learn specific techniques for developing
mindfulness. In later chapters of this text, Mindfulness and
You features provide further research, resources, and tips for
including mindfulness as part of a comprehensive plan for living your best, most healthful life.
Definitions of Mindfulness
Definitions of mindfulness vary, but most share certain essential components. These include being present in the moment
through awareness of yourself—your sensations, thoughts,
and feelings—and your environment; and through avoidance
of evaluation, qualification, and judgment. Some proponents
have called mindfulness an extended “stop and smell the roses”
moment—one that can become a total approach to daily life.
Others describe it as a way of looking at yourself and the world
with gentleness and compassion rather than judgment.
Although mindfulness has become increasingly popular
recently, it is not new. It is
mindfulness Awareness of
believed to have originated
the present moment, including
around 1500 bce or earlier as
sensations, thoughts, feelings,
an element of the Hindu pracand the environment, without
tices of yoga and meditation.
evaluation, qualification, or
Buddhism, which evolved from
judgment.
CHAPTER 1 | Accessing Your Health | 11
you are, your view of the world, and
your place in it; and cultivate an
appreciation for the fullness of each
moment you live.21 Key to mindfulness is focusing—bringing your complete attention to the present rather
than rehashing the past or dwelling
on future fears. In fact, one of the
clearest descriptions found in popular media is “Keep your feet in the
now!” However, the precise path to
mindfulness differs for each person.
It might include formal actions,
such as carving out times to meditate or perform yoga. Alternatively,
it might comprise informal actions,
such as increasing your attention
in your relationships, your food
choices, your regard for the environment, or your compassion for
Decades of research link mindfulness to improvements in every dimension of health.
others, or pausing to acknowledge
the things in your life that you’re
thankful for. Again, later chapters
Hinduism around 600 bce, incorporated mindfulness as a core
of this book provide specific skills for helping you develop
practice. Today, individuals who practice mindfulness may folmindfulness.
low one of these religions, another religion, or no religion at all.
Health Benefits of Mindfulness
The current surge in interest in mindfulness can be explained
in part by the growing body of research evidence linking the
practice to improved health. Studies associate mindfulness
with pain relief, for example, as well as stress reduction, lower
levels of anxiety and depression, improved memory and
attention, weight loss, better sleep, reduced risks for cardiovascular disease, and more satisfying relationships. In your
reading you may encounter specific studies linking mindfulness to these improvements in health.
The Practice of Mindfulness
How many times have you walked to class without noticing
anything in your path as your mind rehashed the quarrel you
just had with your roommates or a romantic encounter the
night before? You reached your destination but couldn’t have
explained how you got there or what you passed along the
way. In class, you hear the instructor talking, but afterwards
you have no idea what was said. Sound familiar? If so, there
are steps you can take to tune in to life around you and gain a
greater appreciation for yourself and your place in the world.
The following is a brief introduction to get you started.
You can practice mindfulness at any time, in any
belief Appraisal of the relaplace. According to mindfultionship between some object,
ness guru Jon Kabat-Zinn, it
action, or idea and some
requires only a willingness to
attribute of that object, action,
or idea.
do two things: examine who
12 | PART ONE | Finding the Right Balance
LO 5 | HOW DOES BEHAVIOR
CHANGE OCCUR?
Compare and contrast the health belief model, the social-cognitive
model, and the transtheoretical model of behavior change, and
explain how you might use them in making a specific behavior
change.
Now that you’ve read about some of the health benefits of
mindfulness, perhaps you would like to become more mindful in your daily life. Or maybe your dream is to stop smoking,
cut down on your alcohol intake, or lose weight. The question
is: How? Over the years, social scientists and public health
researchers have developed a variety of models to illustrate
how individual behavior change occurs. We explore three of
those here.
Health Belief Model
We often assume that when rational people realize their
behaviors put them at risk, they will change those behaviors
and reduce that risk. However, it doesn’t work that way for
many of us. Consider the number of health professionals who
smoke, consume junk food, and act in other unhealthy ways.
They surely know better, but their “knowing” is disconnected
from their “doing.” One classic model of behavior change proposes that our beliefs may help to explain why this occurs.
A belief is an appraisal of the relationship between some
object, action, or idea (e.g., smoking) and some attribute of
that object, action, or idea (e.g., “Smoking is expensive, dirty,
and causes cancer” or “Smoking is sociable and relaxing”).
Psychologists studying the relationship between beliefs and
health behaviors have determined that although beliefs may
subtly influence behavior, they may or may not cause people
to behave differently. In the 1950s, social psychologist Irwin
M. Rosenstock and colleagues developed a classic theory,
the health belief model (HBM), to show when beliefs affect
behavior change.22 The HBM holds that several factors must
support a belief before change is likely:
■■
■■
■■
■■
■■
Perceived seriousness of the health problem. The more
serious the perceived effects are, the more likely it is that
action will be taken.
Perceived susceptibility to the health problem. People who
perceive themselves at high risk are more likely to take preventive action.
Perceived benefits. People are more likely to take action if
they believe that this action will benefit them.
Perceived barriers. Even if a recommended action is perceived to be effective, the individual may believe it is too
expensive, difficult, inconvenient, or time-consuming.
These perceived barriers must be overcome or acknowledged as less important than the perceived benefits.
Cues to action. A person who is reminded or alerted about
a potential health problem—by anything from early symptoms to an e-mail from a health care provider—is more
likely to take action.
People follow the HBM every day. Take the example of
smoking. Older people are likely to know smokers who have
developed serious heart or lung disease and are thus more likely
to perceive tobacco as a threat to their health than are teenagers. The greater the perceived threat of health problems caused
by smoking, the greater the chance a person will avoid it.
However, many chronic smokers know the risks, yet continue to smoke. Why? According to Rosenstock, some people
do not believe they are susceptible to the problem and therefore are not motivated to change their behavior. They also may
feel that the immediate pleasure outweighs the long-term risk.
Social-Cognitive Model
The social-cognitive model (SCM) developed from the work
of several researchers over decades, but it is most closely associated with the work of psychologist Albert Bandura.23 Fundamentally, the model proposes that three factors interact in a
reciprocal fashion to promote and motivate change. These are
the social environment in which we live; our thoughts (or cognition), including our values, beliefs, expectations, and so on;
and our behaviors. We change our behavior in part by observing models in our environments—from childhood to the present moment—reflecting on our observations, and regulating
ourselves accordingly.
For instance, if we observe a family member successfully
quitting smoking, we are more apt to believe we can do it, too.
In addition, when we succeed in changing ourselves, we feel
more powerful, and this in turn may promote further behavior change. For instance, after we’ve successfully quit smoking,
we may feel empowered to increase our level of physical activity. Moreover, as we change ourselves, we become a model for
others to observe. Thus, we are not just products of our environments, but producers.
The SCM is often used to design health promotion programs. For example, one public health initiative in the southeastern United States used the SCM to develop a nutrition
and physical activity afterschool program for preteens. The
program supported participants in mastering certain physical
activities and self-regulating their eating habits. Participants
improved not only their eating and activity patterns, but also
their body weight, cardiovascular endurance, mood, and ability and confidence in regulating their behaviors.24
Transtheoretical Model
Why do so many New Year’s resolutions fail before Valentine’s
Day? According to Drs. James Prochaska and Carlos DiClemente, it’s because most of us aren’t really prepared to take
action. According to their transtheoretical model of behavior
change (also called the stages-of-change model), behavior change
usually does not succeed if we start with the change itself.
Instead, we must go through a series of stages to adequately prepare ourselves for that eventual change.25 These stages include
the following:
1. Precontemplation. People in the precontemplation stage
2.
3.
4.
5.
6.
have no current intention of changing. They may have
tried to change a behavior before and given up, or they
may be in denial and unaware of any problem.
Contemplation. In this phase, people recognize that
they have a problem and begin to contemplate the need
to change. People can languish in this stage for years,
realizing that they have a problem but lacking the time
or energy to make the change.
Preparation. Most people at this point are close to taking action. They’ve thought about what they might do
and may even have come up with a plan; therefore, they
are more ready for action than are those who haven’t
prepared.
Action. In this stage, people begin to follow their action
plan.
Maintenance. During this stage, people work toward
making the changes begun in the action stage a permanent part of their life. It is important throughout
the maintenance stage to be aware of the potential for
relapse and to develop
health belief model (HBM)
strategies for dealing
Model for explaining how bewith it.
liefs may influence behaviors.
Termination. By this
social-cognitive model
point, the behavior is so
(SCM) Model of behavior
ingrained that constant
change emphasizing the role of
vigilance may be unnecsocial factors and thought proessary. The new behavior
cesses (cognition) in behavior
change.
has become an essential
part of daily living.
transtheoretical model
We don’t necessarily go
through these stages sequentially. They may overlap, or
we may shuttle back and forth
Model of behavior change that
identifies six distinct stages
people go through in altering
behavior patterns; also called
the stages-of-change model.
CHAPTER 1 | Accessing Your Health | 13
Termination
Maintenance
Action
Preparation
Contemplation
Precontemplation
FIGURE 1.7 Transtheoretical Model People don’t move
through the transtheoretical model stages in sequence. We may
make progress in more than one stage at one time, or we may
shuttle back and forth from one to another—say, contemplation
to preparation, then back to contemplation—before we succeed
in making a change.
This is also a good time to take stock of the health determinants in your life: What aspects of your biology and behavior
support your health, and which are obstacles to overcome?
What elements of your social and physical environment could
you tap into to help you change, and what elements might
hold you back? Making a list of the health determinants that
affect you—both positively and negatively—should greatly
increase your understanding of what you might want to change
and what you might need to do to make that change happen.
Step Two: Contemplate Change
Once you’ve increased your awareness of the behaviors that
contribute to wellness and the health determinants affecting you, you may find yourself contemplating change. In this
stage, the following strategies may be helpful.
Examine Your Current Health Habits and
Patterns Do you routinely stop at fast-food restaurants
for breakfast? Smoke when you’re feeling stressed? When considering behavior you may want to change, ask yourself the
following:
■■
■■
■■
■■
from one to another—say, contemplation to preparation, then
back to contemplation—before we become truly committed
to making the change (FIGURE 1.7). Still, it’s useful to recognize “where we are” with a change, so that we can consider the
appropriate strategies to move us forward.
LO 6 | HOW CAN YOU IMPROVE
YOUR HEALTH BEHAVIORS?
Identify your own current risk behaviors, the factors that influence
those behaviors, and the strategies you can use to change them.
To successfully change a behavior, you need to see change not
as a singular event but instead as a process by which you substitute positive patterns for new ones—a process that requires
preparation, has several stages, and takes time to occur. The
following four-step plan integrates ideas from each of the
above behavior change models into a simple guide to help you
move forward.
Step One: Increase Your
Awareness
Before you can decide what you might want to change, you
need to learn what researchers know about the behaviors that
contribute to and detract from your health. Each chapter in this
book provides a foundation of information focused on these
factors. Check out the Table of Contents at the front of the book
to locate chapters with the information you’re looking for.
14 | PART ONE | Finding the Right Balance
■■
How long has this behavior existed, and how frequently do
I do it?
How serious are the long- and short-term consequences of
the habit or pattern?
Why do I engage in this problematic behavior?
What kinds of situations trigger the behavior?
Are other people involved in this behavior? If so,
how?
Health behaviors involve personal choice, but are also
influenced by other determinants. Some are predisposing
factors—for instance, if your parents smoke, you’re more likely
to start smoking than someone whose parents don’t smoke.
Some are enabling factors—for example, peers who drink
alcohol enable one another’s drinking. Identifying the factors
that encourage or discourage a habit is part of contemplating
behavior change.
Various reinforcing factors can support or undermine
your effort to change. If you decide to reduce your intake of
sweets, but your roommate loves to bake cookies, then you
may lose your resolve. In such cases, it can be helpful to
employ the social-cognitive model and deliberately change
aspects of your social environment. For instance, you could
suggest that you and your roommate explore recipes for
healthful snacks.
Identify a Target Behavior
To clarify your think-
ing about the various behaviors you might like to target,
ask yourself these questions:
SEE IT! VIDEOS
■■
What do I want? Is your
ultimate goal to lose
weight? To exercise more?
To reduce stress? To have a
How can you change your
habits and stick with it?
Watch New Year’s
Resolutions, available on
Mastering Health.
Remember that, according to the HBM,
your beliefs affect your ability to change. For
example, when reaching for another cigarette, smokers sometimes tell themselves,
“I’ll stop tomorrow,” or “They’ll have a cure
for lung cancer before I get it.” These beliefs
allow them to continue what they’re doing.
To put it another way, they dampen motivation. As you contemplate change, consider
whether your beliefs are likely to motivate
you to achieve lasting change. Ask yourself:
Do you believe that your current pattern of
behavior could lead to serious consequences?
The more severe the threat to you, the more
motivated you’ll be to change your behavior. For example, smoking can cause cancer,
emphysema, and other deadly diseases. The
fear of developing those diseases can help you
stop smoking. But what if cancer and emphysema were just words to you? In that case, you
Your friends can help you stay motivated by modeling healthy behaviors, offering
could research the tissue destruction, pain,
support, joining you in your change efforts, and providing reinforcement.
loss of function, and emotional suffering they
cause. Doing so might increase your motivation.
Over
70
countries
have laws requiring cigarette packages to
lasting relationship? You need a clear picture of your target
display
graphic
warning
labels (GWLs) with images of the physioutcome.
cal
effects
of
smoking,
from
diseased organs to chests sawed open
■■ Which change is the greatest priority at this time? Rather
for
autopsy.
Research
clearly
shows that these GWLs have reduced
than saying, “I need to eat less and start exercising,” identhe
adoption
of
smoking
among
adolescents and young adults
tify one specific behavior that contributes significantly to
and
have
increased
smoking
cessation
among established smokyour greatest problem, and tackle that first.
ers.
Countries
have
reported
that
25,
50,
and even 60 percent of
■■ Why is this important to me? Think through why you want
current
smokers
have
attempted
to
quit
as
a result of the GWLs.26
to change. Are you doing it to improve your health? Your
Even though motivation is powerful, by itself it’s not
academic performance? Your appearance? It’s best to target
enough
to achieve change. Motivation has to be combined
a behavior because it’s right for you rather than because
with
common
sense, commitment, and a realistic understandyou think it will help you win others’ approval.
ing of how best to move from point A to point B. Readiness is
Learn More about the Target Behavior the state of being that precedes behavior change. People who
are ready to change possess the knowledge, skills, and external
Once you’ve clarified exactly what behavior you’d like to
and internal resources that make change possible.
change, you’re ready to learn more about that behavior. This
text will help, and this is a great time to learn how to gain
access to accurate and reliable health information on the
Internet (see the TECH & HEALTH box on page 16).
As you conduct your self-assessment, don’t limit your focus
to the behavior and its health effects. Learn all you can about
aspects of your world that might support or pose obstacles
to your success. For instance, let’s say you decide you want to
meditate for 15 minutes a day. Would others in your dorm or
apartment be interested in meditating with you? What about a
meditation group? On the other hand, do you live in a supernoisy building? Are you afraid your friends might think meditating is weird? In short, learn everything you can about your
target behavior now, and you’ll be better prepared for change.
Assess Your Motivation and Your Readiness to Change Wanting to change is an essential prerequisite of the change process, but to achieve change, you need
more than desire. You need real motivation, which isn’t just a
feeling, but a social and cognitive force that directs your behavior.
Develop Self-Efficacy One of the most important
factors influencing health status is self-efficacy, an individual’s
belief that he or she is capable of achieving certain goals or of
performing at a level that may influence events in life. In general, people who exhibit high self-efficacy approach challenges
with the confidence that they can succeed. In turn, they may be
more motivated to change and more likely to succeed. Prior success will lead to expectations of success in the future. In short,
take small steps, experience success, and build on it!
Conversely, someone with low self-efficacy may give up easily or never even try to change a behavior. These people may
have failed before, and when
the going gets tough, they are
motivation A social, cognimore likely to revert to old pattive, and emotional force that
directs human behavior.
terns of behavior. Following
the behavior change methods
self-efficacy Belief in one’s
in this chapter should help you
ability to perform a task successfully.
develop greater self-efficacy.
CHAPTER 1 | Accessing Your Health | 15
TECH
& HEALTH
Surfing For the Latest In Health
T
he Internet can be a
wonderful resource for
quickly finding answers to
your questions, but it can
also be a source of much
misinformation. To ensure
that the sites you visit are
reliable and trustworthy,
follow these tips:
■■
Look for websites
sponsored by an official
government agency, a
university or college, or
a hospital or medical
center. Government
sites are easily identified Find reliable health information at your fingertips!
by their .gov extensions, college and university sites typinonprofits usually have URLs ending
cally have .edu extensions, and many
with an .org extension.
■■ Search for well-established, profeshospitals have an .org extension (e.g.,
the Mayo Clinic’s website is www.
sionally peer-reviewed journals such as
mayoclinic.org). Major philanthropic
the New England Journal of Medicine
foundations, such as the Robert Wood
or the Journal of the American Medical
Johnson Foundation, the Kellogg
Association. Although some of these
Foundation, and others, often provide
sites require a fee for access, you can
information about selected health topoften locate concise abstracts and
ics. National nonprofit organizations,
information that can help you conduct
such as the American Heart Associaa search. Your college may make these
tion and the American Cancer Society,
journals available to you at no cost.
■■ Consult the Centers for Disease
are often good, authoritative sources
of information. Foundations and
Control and Prevention (CDC) or the
Cultivate an Internal Locus of Control
People who have a strong internal locus of control believe
that they have power over their own actions. They are driven
by their own thoughts and true to their own beliefs. In contrast, people who believe that external circumstances largely
control their situation have an external locus of control. They
may easily succumb to feelings of anxiety and disempowerment
and give up. For example, a recent study among cancer patients
found that, compared to those with a high internal locus of control, people with an external locus of control were more likely to
perceive their cancer as a threat they felt unable to manage, and
to respond with depression to
their diagnosis.27
locus of control The location,
Having an internal or
external (outside oneself) or
external locus of control can
internal (within oneself), that
vary according to circuman individual perceives as the
stance. For instance, someone
source and underlying cause of
who learns that diabetes runs
events in his or her life.
16 | PART ONE | Finding the Right Balance
National Library of
Medicine’s MedlinePlus
for information on a
wide variety of health
topics.
■■ For a global perspective on health issues,
visit the World Health
Organization.
■■ Another site offering
reliable health information for college students
is Columbia University’s
Go Ask Alice!
■■ The nonprofit health
care accrediting organization Utilization
Accreditation Review
Commission (URAC) has more than
50 criteria that health sites must satisfy to display its seal. Look for the
“URAC Accredited Health Web Site”
seal on websites you visit.
■■ Finally, gather information from two or
more reliable sources to see whether
facts and figures are consistent. Avoid
websites that try to sell you something,
whether products such as dietary
supplements or services such as medical testing. When in doubt, check with
your own health care provider or your
health education instructor.
in his family may resign
himself to developing the
disease one day. On this
front, he would be demonstrating an external locus of
control. However, the same
individual might exhibit
an internal locus of control
when resisting a friend’s
pressure to smoke.
Step Three:
Prepare for
Change
WHAT DO
YOU THINK?
Do you have an
internal or an external
locus of control?
■■ Can you think of some
friends whom you would
describe as more internally
or externally controlled?
■■ How do people with the
different views deal with
similar situations?
You’ve contemplated change for long enough! Now it’s time to
set a realistic goal, anticipate barriers, reach out to others, and
commit. Here’s how.
Set SMART Goals
Unsuccessful goals are vague
and open ended—for instance, “Get into shape by exercising more.” In contrast, SMART goals are:
■■
■■
■■
■■
■■
Specific. “Attend a Tuesday/Thursday aerobics class
at the YMCA.”
Measurable. “Reduce my alcohol intake
on Saturday nights from three drinks to
two.”
Action oriented. “Volunteer at the animal shelter on Friday afternoons.”
Realistic. “Increase my daily walk from
15 to 20 minutes.”
Time oriented. “Stay in my strengthtraining class for the full 10-week
session, then reassess.”
Knowing that your SMART goals are
attainable—that you can achieve them within
the current circumstances of your life—increases
your motivation. This, in turn, leads to a better
chance of Success and to a greater sense of selfefficacy, which can motivate you to succeed even
more.
Use Shaping A stepwise process of
making a series of small changes,
shaping can help you achieve
To reach
your goal. Suppose your goal is
your behavior
to jog 3 miles every other day,
change goals,
but you haven't exercised reguyou need to take
larly in years. Shaping would
things one step
dictate a process of slow, proat a time.
gressive steps, such as walking 1
mile every other day at a relaxed
pace for the first week, walking
at a faster pace the second week,
adding another mile the third
week, and so forth.
Current habits didn’t develop overnight, and they won’t
change overnight, either. Start slowly to avoid hurting yourself. Master one step before moving on to the next, and be willing to change the original plan if it proves too uncomfortable.
Anticipate Barriers to Change
Recognizing
possible stumbling blocks in advance will help you prepare
fully for change. In addition to negative social determinants,
aspects of the built environment, or lack of adequate health
care, barriers to change can include:
Overambitious goals. Remember the advice to set realistic
goals? Even with the strongest motivation, overambitious
goals can derail change. Assess your current abilities, and
make sure the planned change is realistic for you.
■■ Self-defeating beliefs and attitudes. As the HBM explains,
believing you’re immune to the consequences of a bad
habit can keep you from committing to change. Likewise,
■■
thinking you are helpless to change your habits can
undermine efforts.
■■ Lack of support and guidance. If you want to
cut down on your drinking, socializing with
peers who drink heavily may be a powerful
barrier to that change. To succeed, you need
to connect with people who share your values
and can support your efforts to change.
■■ Emotions that sabotage your efforts
and sap your will. Sometimes the bestlaid plans go awry because you’re
having a bad day or are fighting with
someone. Emotional reactions to life’s
challenges are normal, but don’t let
them derail your efforts to change. If
you’re experiencing severe psychological distress, seek counseling to help you
address the underlying issues before
trying to change other aspects of your
health.
Enlist Others as Change Agents
The social-cognitive model recognizes that modeling, or learning from role models, is a key component of successful behavior change. Observing a
friend who is a good conversationalist, for example,
can help you improve your communication skills.
Change agents commonly include the following:
Family members. From the time
of your birth, your observations
of your parents and other
family members have influenced your food choices,
activity patterns, and
many other behaviors
and values. Positive
family role models can be powerful aids in avoiding smoking, for example, or coping with disappointment. If positive family role models are not available to support your
efforts, turn to friends and professionals.
■■ Friends. As you leave childhood behind, your friends
increasingly influence your behaviors. If your friends prioritize exercise, for example, you’re more likely to do the
same. Thus, friends who share your personal values can
greatly support your behavior change.
■■ Professionals. Consider enlisting support from professionals such as your health or PE instructor, coach, or health
care provider. As appropriate, consider the counseling
services offered on campus, as well as community services
such as smoking cessation
programs, support groups,
shaping Using a series
and your local YMCA.
■■
Sign a Contract
It’s
time to get it in writing! A formal behavior change contract
of small steps to gradually
achieve a particular goal.
modeling Learning specific
behaviors by watching others
perform them.
CHAPTER 1 | Accessing Your Health | 17
known as imagined rehearsal to
reach their goals. Careful mental
and verbal rehearsal of how you
intend to act will help you anticipate problems and greatly improve
your chances of success.
Learn to “Counter” Cou­
nt­­ering means substituting a desired
behavior for an undesirable one. If
you want to stop eating junk food,
for example, compile a list of substitute foods and places to get them
and have this ready before your
mouth starts to water at the smell of
a burger and fries.
Control the Situation
Any behavior has both antecedents and consequences. Antecedents are the aspects of the situation
that come beforehand; these cue or
stimulate a person to act in certain
ways. Consequences—the results of
­behavior—affect whether a person
will repeat that action. Both antecedents and consequences can be
physical events, thoughts, emotions, or the actions of other people.
Once you recognize the antecedents of a given behavior, you can
FIGURE 1.8 Example of a Completed Behavior Change Contract A blank version is
employ situational inducement
included in the back of the book and in Mastering Health for you to fill out.
to modify those that are working
against you—you can seek settings, people, and circumstances
serves many powerful purposes. It functions as a promise to
that support your efforts to change, as well as avoid those
yourself and as an organized plan that lays out your goals, start
likely to derail your change.
and end dates, daily actions, and any barriers you anticipate.
It’s also a place to brainstorm strategies, list sources of support,
and remind yourself of the
Change Your Self-Talk There is a close connecbenefits of sticking with the
imagined rehearsal Practicing,
tion between what people say to themselves, known as selfprogram. To get started, fill
through mental imagery, to
talk, and how they feel. According to psychologist Albert Ellis,
out the Behavior Change Conbecome better able to perform
most emotional problems and related behaviors stem from
tract at the back of this book.
a task in actuality.
irrational statements that people make to themselves when
FIGURE 1.8 shows an examcountering Substituting
events in their lives are different from what they would like
ple of a completed contract.
a desired behavior for an
them to be.28
undesirable one.
For example, suppose that after doing poorly on a test you
situational inducement
say to yourself, “I can’t believe I flunked that easy exam. I’m
Attempts to influence a
so stupid.” Now change this irrational, negative self-talk into
behavior through situations and
rational, positive statements about what is really going on:
occasions that are structured to
“I really didn’t study enough for that exam. I’m certainly not
exert control over that behavior.
As you begin to put your plan
stupid; I just need to prepare better for the next test.” Rational
self-talk The customary
into action, the following
self-talk will help you recover more quickly from disappointmanner of thinking and talking
behavior change strategies
ment and take positive steps to correct the situation.
to yourself, which can affect
can help.
Another technique for changing self-talk is to practice
your self-image.
blocking and stopping. For example, suppose you are preocpositive reinforcement
Visualize the New cupied with thoughts of your ex-partner, who has recently left
Presenting something positive
­Be­havior Athletes and you for someone else. You can block those thoughts by focusfollowing a behavior that is
artists often use a technique
ing on the actions you’re taking right now to help you move
being reinforced.
Step Four:
Take Action
to Change
18 | PART ONE | Finding the Right Balance
MAKING CHANGES TODAY
Challenge the Thoughts That Sabotage Change
Are any of the following thoughts holding you back? If so,
challenge them with the strategies below:
drinking, sex, eating habits, and the like. What is most
important to you? What actions can you take to act in line
with these values?
“I don’t have enough time!” Chart your hourly activities
for 1 day. What are your highest priorities and what can
you eliminate? Plan to make time for a healthy change
next week.
“I don’t think I can do it.” Just because you haven’t
done something before doesn’t mean you can’t do it
now. To develop some confidence, take baby steps and
break tasks into small segments of time.
“I’m too stressed!” Assess your major stressors right
now. List those you can control and those you can
change or avoid. Then identify two things you enjoy that
can help you reduce stress now.
“I can’t break this habit!” Habits are difficult to break,
but not impossible. What triggers your behavior? List
ways you can avoid these triggers. Ask for support from
friends and family.
“I’m worried about what others may think.” Ask
yourself how much others influence your decisions about
forward. The MAKING CHANGES TODAY box offers more strategies for changing self-talk.
Reward Yourself Another way to promote positive behavior change is to reward yourself for it. This is called
positive reinforcement. Each of us is motivated by different reinforcers, but some common examples include the
following:
■■
■■
■■
■■
■■
Consumable reinforcers are edible items, such as your
favorite snack.
Activity reinforcers are opportunities to do something enjoyable, such as going on a hike or taking a trip.
Manipulative reinforcers are incentives such as the promise
of a better grade for doing an extra-credit project.
Possessional reinforcers are tangible rewards, such as a new
electronic gadget.
Social reinforcers are signs of appreciation, approval, or love,
such as affectionate hugs and praise.
The difficulty with em­ploy­
ing positive reinforcement
WHAT DO
often lies in determining
THINK?
which incentive will be most
effective. Your reinforcers may
What type of
initially come from others
reinforcers would
(extrinsic rewards), but as you
most likely get you to change
see positive changes in youra behavior: money, praise, or
self, you will begin to reward
recognition from someone?
and reinforce yourself (intrin■■ Why would it motivate you?
sic rewards). Keep in mind
■■ Can you think of options to
that reinforcers should folreinforce behavior changes?
low a behavior, but beware of
overkill. If you reward yourself
with a movie every time you go jogging, this reinforcer will soon
lose its power. It would be better to give yourself this reward after,
say, a full week of adherence to your jogging program.
YOU
Journal Writing personal experiences, interpretations,
and results in a journal, notebook, or blog is an important skill
for behavior change. You can log your daily activities, monitor
your progress, record how you feel about it, and note ideas for
improvement.
Deal with Relapse Relapse is often defined as a return
of symptoms in a person thought to have been successfully
treated for a serious disease. But relapse can also be defined as a
return to a previous pattern of negative behavior (drinking, binge
eating, and so on) after successfully avoiding that behavior for a
period of time. For example, the American Cancer Society reports
that most people who try to quit smoking suffer a relapse.29 It
doesn’t mean that your program of change is a failure; behavior
change is a process, and setbacks are part of learning to change.
A few simple strategies can help you get back on track after a
relapse. First, figure out what went wrong. Every relapse begins
with a slip—a one-time mistake.30 What triggered that slip, and
how can you modify your personal choices or the aspects of your
environment that contributed to it? Second, use countering:
If you’ve been overeating ever since your relationship ended,
identify and choose other behaviors that comfort you. Third, a
relapse might be telling you that you need some assistance with
making this change; consider getting some professional help.
Let’s Get Started!
After you acquire the skills to support successful behavior change,
you’re ready to apply those skills to your target behavior. Place
your behavior change contract where you will see it every day
and where you can refer to it as you work through the chapters in
this text. Consider it a visual reminder that change doesn’t “just
happen.” Reviewing your contract helps you to stay alert to
relapse A return to a previous
potential problems, consider
pattern of negative behavior
your alternatives, and stick to
after successfully avoiding that
behavior for a period of time.
your goals under pressure.
CHAPTER 1 | Accessing Your Health | 19
STUDY PLAN
ASSESS YOURSELF
mean the dynamic, ever-changing
process of trying to achieve one’s
potential in each of six interrelated
dimensions: physical, social, intellectual, emotional, spiritual, and
environmental.
How healthy are you? Want
to find out? Take the How Healthy
Are You? assessment available on
Mastering Health.
CHAPTER REVIEW
|
LO 1 Why Health, Why
Now?
Choosing good health has immediate benefits, such as reducing
the risk of injury and illnesses and
improving academic performance;
long-term rewards, such as prevention of chronic disease and a longer
and more healthful life; and societal
and global benefits, such as reducing
the global disease burden.
■■ For the U.S. population as a whole,
the leading causes of death are heart
disease, cancer, and chronic lower
respiratory diseases. In the 15- to
24-year-old age group, the leading
causes are unintentional injuries,
suicide, and homicide.
■■ The average life expectancy at birth
in the United States is 78.6 years. This
represents a dramatic increase over
the past century; however, unhealthy
behaviors related to chronic disease
and addiction to drugs and alcohol
have contributed to a recent decline
in U.S. life expectancy and in healthy
life expectancy and health-related
quality of life (HRQoL).
|
LO 3 What Influences Your
Health?
■■
■■
|
■■
Mindfulness—giving nonjudgmental
attention to the present moment—
enhances health in all dimensions.
Formal activities such as meditation
can help you develop mindfulness.
Informal actions such as acknowledging gratitude or paying attention
while eating are also effective.
|
LO 5 How Does Behavior
Change Occur?
■■
■■
20 | PART ONE | Finding the Right Balance
Health is influenced by factors called
determinants. The Surgeon General’s
health promotion plan, Healthy
People, classifies determinants as
individual behavior, biology and
genetics, social factors, policymaking, and health services. Disparities
in health among different groups
contribute to increased risks.
LO 4 How Does Mindfulness
Influence Health?
LO 2 | What Is Health?
The definition of health has changed
over time. The medical model
focused on treating disease, whereas
the current ecological or public
health model focuses on factors contributing to health, disease prevention, and health promotion.
■■ Today, the words health and wellness
are often used interchangeably to
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
Models of behavior change include
the health belief model, the socialcognitive model, and the transtheoretical (stages-of-change) model.
A person can increase the chance
of successfully changing a healthrelated behavior by viewing change
as a process involving several steps
and components.
|
LO 6 How Can You
Improve Your Health
Behaviors?
■■
When contemplating a behavior
change, it is helpful to examine
current habits; learn about a target
behavior; and assess motivation and
readiness to change. Developing
self-efficacy and an internal locus
of control is essential for maintaining motivation. When preparing to
change, it is helpful to set SMART
goals that employ shaping; anticipate barriers to change; enlist the
help and support of others; and sign
a behavior change contract. When
taking action to change, it is helpful
to visualize new behavior; practice
countering; control the situation;
change self-talk; reward oneself; and
keep a log, blog, or journal.
POP QUIZ
|
LO 1 Why Health, Why
Now?
1. What term is used to describe the
expected number of years of full
health remaining at a given age,
such as at birth?
a. Healthy lifespan
b. Healthy life expectancy
c. Health-related quality of life
d. Wellness
LO 2 | What Is Health?
2. Everyday tasks, such as walking up
the stairs or tying your shoes, are
known as
a. dimensions of health.
b. healthy life tasks.
c. functional abilities.
d. activities of daily living.
3. Janice describes herself as loving
and trusting, and she displays
both high self-esteem and high
self-confidence. The dimension of
health this relates to is the
a. social dimension.
b. emotional dimension.
c. spiritual dimension.
d. intellectual dimension.
|
LO 3 What Influences Your
Health?
4. Healthy People 2020 is a(n)
a. blueprint for improving the
quality and years of life for all
Americans.
b. projection for life expectancy
rates in the United States in the
year 2020.
c. international plan for achieving
health priorities for the
environment by the year 2020.
d. set of health-related goals that
states must achieve in order
to receive federal funding for
health care.
|
LO 4 How Does
Mindfulness Influence
Health?
5. Which of the following statements
about mindfulness is true?
a. The technique of mindfulness
was discovered and developed
by Jon Kabat-Zinn in the late
1970s.
b. Although there has been a surge
of interest in mindfulness in the
past decade, very little research
links the practice to improved
health.
c. Meditation is a helpful but not
essential tool for developing
mindfulness.
d. One technique that is
recommended for developing
mindfulness is to contemplate
your perfection.
|
LO 5 How Does Behavior
Change Occur?
6. The social-cognitive model of
behavior change suggests that
a. understanding the seriousness of
and our susceptibility to a health
problem motivates change.
b. contemplation is an essential
step to adequately prepare
ourselves for change.
c. behavior change usually does
not succeed if it begins with
action.
d. the environment in which we
live—from childhood to the
present—influences change.
7. According to the transtheoretical
model of behavior change, which
of the following occurs during the
preparation stage?
a. The person recognizes that a
health problem exists.
b. The person identifies steps he or
she might take to improve health.
c. The person takes initial actions
toward a goal.
d. The person works to maintain
positive changes.
|
LO 6 How Can You
Improve Your Health
Behaviors?
8. Suppose you want to lose 20
pounds. To reach your goal,
you take small steps. You start
by joining a support group and
counting calories. After 2 weeks,
you begin an exercise program
and gradually build up to your
desired fitness level. What behavior
change strategy are you using?
a. Shaping
b. Visualization
c. Modeling
d. Reinforcement
9. Jake is exhibiting self-efficacy when
he
a. believes that he is solely
responsible for his shoulder
injury.
b. is doubtful that his injured
shoulder will ever allow him to
bench-press 125 pounds.
c. believes that he can and will be
able to heal from his shoulder
injury and bench-press 125
pounds within 1 year.
d. believes that he does not possess
personal control over this
situation.
10. The aspects of a situation that
cue or stimulate a person to act in
certain ways are called
a. situational reinforcers.
b. antecedents.
c. consequences.
d. cues to action.
Answers to the Pop Quiz can be found on page
A-1. If you answered a question incorrectly,
review the section identified by the Learning Outcome. For even more study tools, visit
Mastering Health.
THINK ABOUT IT!
|
LO 1 Why Health, Why
Now?
1. How healthy is the U.S. population
today? What factors influence our
life expectancy?
LO 2 | What Is Health?
2. How are the words health and
wellness similar? What, if any,
are important distinctions
between these terms? What
is health promotion? Disease
prevention?
|
LO 3 What Influences Your
Health?
3. Of the multiple determinants of
health, which do you think make
the greatest contribution to your
health, and to your risk for disease?
Why?
|
LO 4 How Does
Mindfulness Influence
Health?
4. Could mindfulness help
you improve your academic
performance this semester? If so,
how? If not, why not?
|
LO 5 How Does Behavior
Change Occur?
5. What is the health belief model?
How may this model be working
when a young woman decides to
smoke her first cigarette? Her last
cigarette?
|
LO 6 How Can You
Improve Your Health
Behaviors?
6. Using our four-step plan for
behavior change, discuss how you
might act as a change agent to help
a friend cut down on consumption
of sodas, bottled teas, and other
sugary drinks as part of a healthy
lifestyle. Why is it important that
your friend be ready to change
before trying to change?
CHAPTER 1 | Accessing Your Health | 21
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics and issues related to personal
health.
CDC Wonder. This is an online database
for comprehensive information from the
Centers for Disease Control and Prevention
(CDC), including special reports, guidelines,
and access to national health data.
http://wonder.cdc.gov
Foundation for a Mindful Society.
The Mindful website offers inspiration,
information, and connection for anyone
who wishes to develop mindfulness.
www.mindful.org
22 | PART ONE | Finding the Right Balance
Mayo Clinic. This reputable resource for
specific information about health topics,
diseases, and treatment options is provided
by the staff of the Mayo Clinic. It is easy to
navigate and is consumer friendly.
www.mayoclinic.org
National Center for Health Statistics.
This resource contains links to key reports;
national survey information; information
on mortality by age, race, gender, and
geographic location; and other important
information about health status in the United
States. www.cdc.gov/nchs
Health Finder. This is an excellent resource
for consumer information about health.
www.healthfinder.gov
World Health Organization. This
resource provides global information on the
current state of health around the world,
such as illness and disease statistics, trends,
and illness outbreak alerts. www.who.int/en
WHICH PATH
WOULD YOU TAKE?
Free time after class? How will
you choose to spend it? Go to
Mastering Health to see how your
actions today affect your future health.
FOCUS ON
DIFFERENCE, DISPARITY, AND HEALTH:
ACHIEVING HEALTH EQUITY
LEARNING OUTCOMES
LO1
Define health equity and explain why it has become a critical issue in twentyfirst-century America.
LO2
Identify the populations most vulnerable to health disparities in the United
States, and provide examples of health disparities recognized in these
groups.
LO3
Identify the social determinants of health that most strongly influence health
disparities in the United States.
LO4
Discuss specific actions you can take to promote health equity on campus,
in your community, and in your personal life, including how to use
mindfulness to examine your biases and increase your respect for
difference.
LO5
Describe the systemic changes required to enable the United States to
progress toward good health for all, and provide examples of national
and community-based initiatives currently underway toward achieving
this goal.
WHY
SHOULD I CARE?
Health
disparities lead to
preventable disease and premature
death. They cost our economy
billions of dollars annually, while
depriving us of the full participation
of each member of our society. In
contrast, working toward health
equity challenges your assumptions,
hones your interpersonal skills,
and generally expands your world.
Importantly, moving populations
toward improved health and greater
opportunity ultimately benefits all of
us while helping control health care
costs.
23
T
he United States is one of the
most diverse countries in
the world, home to over 327
million unique individuals.
These individuals represent an almost
unfathomable complexity of differences in race and ethnicity, socioeconomic status, educational attainments,
sexual orientation, gender identity,
age, religion, abilities, and disabilities.
They also represent differing attitudes,
beliefs, fears, values, goals, and dreams.
These individuals live in a country
where our founders proclaimed, in the
Declaration of Independence, that we
are all created equal. It is ironic, then,
that the United States has consistently
ranked lowest in health equity among
the world’s 11 wealthiest industrialized
nations.1 What is health equity, and
why are we so low on the health equity
scale? Why should we care? This chapter explores why some of us live longer
and thrive in life, while others barely
survive. Furthermore, it challenges us
to think about what we can do individually and collectively to move toward
health equity.
LO 1 | WHY HAS
HEALTH EQUITY
BECOME A CRITICAL
ISSUE IN AMERICA?
Define health equity and explain why it
has become a critical issue in twenty-firstcentury America.
In Chapter 1, you learned that one
of the primary goals of the U.S. Surgeon General’s health promotion
plan Healthy People 2020 is to achieve
health equity, eliminate disparities, and
improve the health of all groups.2 What
does this mean, and why does it matter?
health equity A condition characterized by
an absence of avoidable or remediable differences in health and the attainment of optimal
health for all.
diversity A condition characterized by
varied composition, especially in terms of
culture, race/ethnicity, religion, sexual orientation, and the like.
24 | PART ONE | Finding the Right Balance
Health Equity Is
Attainment of the
Highest Level of
Health for All
The World Health Organization (WHO)
defines equity as “the absence of avoidable or remediable differences among
groups of people.”3 A society characterized by health equity has worked to
prevent or reverse conditions such as
persistent poverty and discrimination
that undermine health. Informed by
the values of fairness and justice, such
a society values health as an essential
resource for each individual’s development, and as an important public
good.4 Healthy People 2020 states that
health equity is attainment of the optimal level of health for all people.5
Clearly, then, a society lacking health
equity has a high level of health disparities. Recall from Chapter 1 that health
disparities are differences in health that
are “closely linked with social, economic,
and/or environmental disadvantages.”6
These differences result from an unequal
distribution of social resources, from education to housing to jobs that provide
adequate health insurance and a living
wage.7 Thus, health disparities are fundamentally unjust, reflecting an unfair
distribution of health risks and health
resources.8
America: A Country
of Increasing
Diversity
America is a country of increasing
racial and ethnic diversity. In 2016,
61.3 percent of Americans were nonHispanic whites (referred to in some
research as Caucasians); 17.8 percent
were Hispanic or Latino; 13.3 percent
were non-Hispanic blacks (referred to
in some research as African Americans);
5.3 percent were Asian Americans; and
the rest were American Indian/Alaska
Natives and others.9 About 27 percent
of all people living in the United States
today are immigrants, including their
U.S.-born children.10
A national survey of first-year college students found that racial and
ethnic diversity is characteristic of U.S.
campuses, as well: Although the survey did not account for mixed heritage,
overall the percentage of first-year college students who identified themselves
as Hispanic/Latino, Asian American, or
Native American/Pacific Islander/Alaska
Native was higher than their group’s prevalence in the population at large. African
­Americans made up 13 percent of college
students, a statistic that closely matches
their prevalence in the U.S. population.11
Immigration is expected to continue to diversify the U.S. population
throughout the twenty-first century.
The U.S. Census Bureau projects that
by 2060, the population will increase
by about 98 million, and the percentage of non-Hispanic whites will decline
by more than a quarter (FIGURE 1).
The Hispanic population will increase
substantially, while other population
groups will see modest changes. In
2044, a “majority-minority crossover”
will occur, and non-Hispanic white
Americans will make up less than 50
percent of the U.S. population.12
America’s age composition is also
changing. The population of Americans
under age 18, for example, is expected
to increase only slightly between 2014
and 2060, from 74 million to 82 million. In contrast, the population of
Americans age 65 or older is expected
to more than double, from 46 million
to 98 million.13 These increasing numbers of older adults will challenge us to
expand age-appropriate health care and
other social and community services,
from transportation to nutritious meals
to programs that encourage social interaction and reduce isolation. Without
these supports, many older people will
move further away from health equity.
Americans are diversifying in selfidentity as well. According to phone
surveys, the percentage of Americans
identifying as LGBTQ (lesbian, gay,
bisexual, transgender, queer) more than
doubled between 2000 and 2017, from
2 percent to 4.1 percent, and among
Millennials (born between 1980 and
1998), the percentage is now 7.3 percent.14 In a recent nationwide survey of
first-year college students, 8.2 percent
identified as LGBTQ.15 The LGBTQ category has itself diversified, especially
for false assumptions, misperceptions, unrecognized biases,
43.6%
and stereotyping, in which a
generalized and typically neg17.8%
Hispanic
ative attribute is assigned to an
28.6%
individual of a different popu13.3%
lation group. These thought
Non-Hispanic
Black
patterns in turn can lead to
13.0%
othering, that is, interacting
5.3%
with people who are different
Asian
American
9.1%
as if they were intrinsically
inferior to us in ways that
2.6%
Two or More
make them less deserving of
Races
4.9%
our respect and care.
Such ways of thinking can
American Indian/ 1.3%
also contribute to discriminaAlaska Native 0.6%
tion and other social injustices;
trigger struggles for power and
70
0
10
20
30
40
50
60
control; increase the threat
Percent of the Total Population
of violence; and reduce every
American’s potential to thrive
FIGURE 1 The racial and ethnic diversity of the U.S. population is expected to increase
physically, emotionally, intelbetween 2016 and 2060.
lectually, and socially. ConSources: U.S. Census Bureau, “Quick Facts: Race and Hispanic Origin,” 2018, Available at www.census.gov/
sider how misperceptions and
quickfacts/fact/table/US/PST045216?; S. L. Colby and J. M. Ortman, “Projections of the Size and Composition of the
unrecognized biases might
U.S. Population: 2014–2060,” U.S. Census Bureau, March 2015, Available at www.census.gov/content/dam/Census/
library/publications/2015/demo/p25-1143.pdf.
influence our choices as individuals. For example, how
on U.S. college campuses, to include
might they influence whether to rent
LGBTQIAA+ (lesbian, gay, bisexual,
an apartment to a lesbian couple, hire
transgender, queer, intersex, asexual,
an older adult, or even converse with
ally, inclusive). Gender identity itself is
a classmate wearing a headscarf? They
in flux: Americans are identifying as bialso inform the actions we take as a socigender, gender fluid, or gender queer or
ety; for example, community members
Our differences have the potential to
are rejecting the concept of gender altomay oppose a measure to invest in highenrich us, enabling us to learn from each
gether (agender). In short, sexual and
quality low-income housing in their
other and pool our resources to meet
gender minorities make up an increasneighborhood because of unrecognized
the complex challenges of our changing
ing proportion of the U.S. population.
biases against people they consider
world. However, our differences also have
Religious identity is also diversify“others.”
the potential to divide us. In social psying. The percentage of Americans who
In these ways, our individual and
chology, difference is the recognition of
identify as Christian has been declining
collective responses to difference can
another person as being unlike us in some
for decades, while those who identify as
reduce opportunities, lead to injustices,
important way. Because we can never
non-Christian religious have increased.
and create a society characterized by
fully know another as he or she really is,
In 2007, Muslims represented just 0.4
health disparities.
this ability to recognize difference is very
percent of the U.S. population. Now,
limited: We can base it only on our obser1.6 percent of Americans are Muslim.16
vations of the person’s appearance and
The percentage of Americans who are
behavior. Notice that our society tells us
religiously unaffiliated (atheists, agnoswho or what is different. For example, the
tics, or “nothing in particular”) has
difference The recognition of another
Nigerian American author Chimamanda
been rising as well, from about 15 perperson as being unlike oneself in some
17
Ngozi Adichie observes that Africans livcent in 2007 to 22.8 percent. About 36
important way.
ing in many African countries do not dispercent of Americans ages 18 to 49 are
stereotyping Assigning a generalized and
tinguish one another by skin color. Only
unaffiliated, and this generational trend
typically negative attribute to an individual
18
when they move to America do Africans
is expected to continue.
of a different population group.
What are the implications of
with dark skin become “black” and thereothering Interacting with people who
America’s increasing diversity for our
­
fore different.19
are different as if they were intrinsically
health and well-being? That depends in
Any encounter with someone who
inferior, less deserving of respect, or even
threatening.
part on our response.
is different brings with it the potential
Non-Hispanic
White
61.3%
2016
2060
Our Response to
Difference Can Lead
to Disparities in
Health
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 25
Health Disparities
Incur Enormous
Costs
Every person who dies young, is
avoidably disabled, or is unable to
function at their optimal level not
only represents a personal and family tragedy but also impoverishes our
communities and our country. We are
all deprived of the creativity, contributions, and participation that result
from disparities in health status.20
The above quotation from Thomas
Frieden, former director of the Centers
for Disease Control and Prevention
(CDC), highlights the human costs of
health disparities. These disparities also
have significant financial costs. Racial
and ethnic health disparities alone are
estimated to cost the U.S. economy an
estimated $35 billion in direct medical
expenditures, $10 billion in lost productivity, and nearly $200 billion in
premature deaths.21 These costs occur
when chronic diseases such as type 2
diabetes are not prevented, diagnosed
at their earliest stages or appropriately
managed; when patients without access
to primary care seek treatment in the
most costly type of medical facility—
the hospital emergency department;
when inadequate health education contributes to unprotected sex, tobacco use,
and other risky health behaviors; and
when people with substance abuse and
mental health disorders are not able to
access treatment programs and therefore leave the workforce, never enter the
workforce, or become victims of overdose or suicide.
LO 2 | WHAT
TYPES OF HEALTH
DISPARITIES OCCUR
IN VULNERABLE
POPULATION
GROUPS?
Identify the populations most vulnerable
to health disparities in the United States,
and provide examples of health disparities
recognized in these groups.
Healthy People 2020 identifies the people
who are especially vulnerable to health
disparities as those “who have systematically experienced greater obstacles
to health based on their racial or ethnic
group; religion; socioeconomic status;
gender; age; mental health; cognitive,
sensory, or physical disability; sexual
orientation or gender identity; geographic location; or other characteristics historically linked to discrimination
or exclusion.”
Within each of the above categories, certain subgroups tend to have
higher levels of certain types of disease, disability, and death. As you read
the following examples, bear in mind
that there are innumerable differences
between individuals within any group.
We may speak of “the Jewish experience” or “the experience of poverty,”
but all individuals are unique and their
experiences can vary dramatically.
Even health statistics from government
agencies such as the CDC are only averages and, as such, do not reflect the vast
differences between the people those
statistics represent.
Disparities
Affecting Certain
Racial and Ethnic
Groups
Compared to non-Hispanic whites, nonHispanic blacks, Hispanics/Latinos, and
American Indians/Alaska Natives tend
to experience a significantly higher
prevalence of, and mortality rates due
to, certain chronic conditions. Here are
some examples.
Non-Hispanic Blacks Between
45 and 46 percent of all adult nonHispanic blacks have high blood pressure (hypertension), as compared to 32
to 34 percent of non-Hispanic whites
and 28 to 30 percent of Hispanics.22 All
told, nearly half of adult non-Hispanic
blacks (46 to 48%) have some form of
cardiovascular disease, including hypertension, coronary heart disease, heart
failure, and stroke. Cardiovascular disease is the number one cause of death in
the United States.
Other striking disparities affecting non-Hispanic blacks include the
following:
■■
The experiences of each individual in a population group are unique.
26 | PART ONE | Finding the Right Balance
Diabetes. The rate of diabetes among
non-Hispanic blacks (14%) is higher
than that of any other racial/ethnic
group except American Indians/
Alaska Natives, and 6 percent higher
than the rate among non-Hispanic
whites.23
Cancer. Non-Hispanic blacks have
the highest mortality rate and shortest survival of any U.S. racial/ethnic
group for most cancers. As compared
to non-Hispanic whites, for example,
the mortality rate among nonHispanic blacks for all cancers combined is 24 percent higher for males
and 14 percent higher for females.24
■■ HIV/AIDS. Whereas the estimated
HIV/AIDS diagnosis rate for the total
U.S. population is 13.8 per 100,000,
the rate among non-Hispanic blacks
is 49.4; moreover, their mortality rate from HIV/AIDS is 19.4 per
100,000, versus just 2.5 for nonHispanic whites.25
■■
Hispanics/Latinos
Tuberculosis disproportionately strikes racial/
ethnic minority groups in the United
States, but the rate among Hispanics/Latinos exceeds that of all other
racial/ethnic groups, accounting for
29 percent of total cases. Hispanics/
Latinos also have the highest rates for
cancers associated with infections,
such as liver, stomach, and cervical
cancer.26
American Indians/Alaska
Natives Life expectancy among
American Indians/Alaska Natives is 4.4
years shorter than the national average,
in part because of their higher-thanaverage mortality rate from many
chronic conditions, including diabetes, liver disease, and respiratory disease, and from accidental injuries and
homicide. Moreover, their suicide rate
(20.2 per 100,000) is nearly double the
national average.27
Non-Hispanic Whites As we
discussed in Chapter 1, non-Hispanic
whites ages 25 to 54, especially those
living outside large urban areas, experience a disproportionate number of
“deaths of despair” due to unintentional drug overdose, alcohol-related
liver failure, and suicide.28 Largely
because of these deaths, the mortality rate among non-Hispanic whites
increased between 1999 and 2015, while
it declined among all other racial and
ethnic groups.29
Disparities Affecting
Men, Women, and
Sexual and Gender
Minorities
The WHO finds “robust evidence” that
men tend to be in worse health than
women worldwide.30 For example,
there is a global gap in life expectancy
of nearly 6 years between men (67.5
years) and women (73.3 years). These
differences are thought to reflect men’s
greater exposure to occupational hazards; more risk-taking behaviors; higher
rates of smoking, alcohol abuse, and
other health-related behaviors associated with norms of masculinity; and
lower likelihood of visiting a physician
or reporting symptoms of disease.31
Women have their own disparities.
For example, although men and women
have similar heart disease rates, survival
rates following a heart attack are lower
in women.32 Common autoimmune
disorders, in which an individual’s
immune system attacks normal body
tissues, are from 2 to 15 times as prevalent in women versus men of the same
age. The differences are thought to be
due to genetic, hormonal, and environmental factors.33 There are also gender
disparities in mental health: The WHO
reports that, globally, depression is
twice as common in women as in men,
and is thought to be more persistent in
women; anxiety affects more women
than men; and because of sexual violence, women have much higher rates
of post-traumatic stress disorder.34
For more on mental health disparities affecting women, see the HEALTH
HEADLINES box on page 28.
Disparities also affect sexual and
gender minorities (SGM) in the United
States, and subgroups within this population. Smoking rates, for example,
are higher among SGM (20.6%) than
among heterosexuals (14.9%), but
rates are highest among transgender
Americans (35.5%), possibly because
of higher levels of stress.35 Heavy alcohol consumption is also more common
among SGM, as are overweight/obesity,
short sleep, and unintentional injury
rates.36 Clinical depression and suicide
are more prevalent among SGM than
heterosexuals, but are even more common among transgender individuals
compared to non-transgender SGM.37,38
Disparities Affecting
Older and Disabled
Americans
More than 1 in 8 Americans have a disability, and efforts to achieve health
equity need significantly more attention
at all levels of society. Disabilities vary
widely across demographic groups and
geography, with difficulties in hearing,
vision, cognition, walking, or climbing stairs as well as difficulty with selfcare and independent living affecting
millions. Older Americans have more
disability than younger Americans; however increasing numbers of people from
all age groups are affected. American
Indians or Alaskan Natives are the most
likely group to be living with a disability
(nearly 18%), followed by non-Hispanic
blacks (14%), and whites (14%).39
Disparities in Socially
Excluded Populations
Social cohesion supports health throughout a population, building bridges of
support between people of different
incomes, education levels, or access to
power. In contrast, socially excluded
populations—people who are homeless,
people with substance abuse disorders,
sex workers, and prisoners—can appear
to be outside the social fabric completely.40 These groups have a mortality
rate nearly 8 times higher than the average for men, and nearly 12 times higher
than the average for women.41 Prisoners, for example, have unusually high
rates of mortality from unintentional
injuries and poisonings, including from
drug overdose. The risk factors for such
deaths may stem from adverse childhood
experiences, including exposure to abuse
and neglect, as well as mental illness,
substance abuse, poverty, or other factors, suggesting that, to reduce such disparities, we must address “the causes of
the causes.”42 This means understanding
the social, economic, and environmental
disadvantages to which health disparities are closely linked.
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 27
HEALTH
HEADLINES
T
he WHO identifies gender as “a
critical determinant of mental health
and mental illness.” Why?
Let’s begin with biology. Researchers
speculate that fluctuating levels of the female reproductive hormones estrogen and
progesterone might make women more
vulnerable to mental health problems such
as anxiety and depression. This is due to
the hormones’ effects on neurotransmitters (chemicals that help relay messages
within the nervous system and therefore
are important in thinking, emotions, and
behavior). Also, in response to stress,
women experience a more “blunted”
engagement of the HPA axis, a regulatory
system involving the hypothalamus in the
brain, the pituitary gland, and the adrenal
glands.
But these biological factors aren’t the
whole story. Researchers also point out
that gender influences the amount of
power and control men and women have
over their socioeconomic status and their
LO 3 | HOW DO
THE SOCIAL
DETERMINANTS
OF HEALTH
INFLUENCE HEALTH
DISPARITIES IN
AMERICA?
Identify the social determinants of health
that most strongly influence health
disparities in the United States.
Indicators of health disparities, such
as rates of disease and death, are outcomes of a system that doesn’t value
privilege Advantages and rights, often
unearned, that are available to only some
members of a society.
social determinants of health Social,
economic, and physical conditions in the
environments in which people live that affect
a range of health, functioning, and quality-oflife outcomes and risks.
28 | PART ONE | Finding the Right Balance
Gender-Based Disparities In
Mental Health
position in society. As compared to men,
women experience greater pressure to
maintain multiple roles; greater exposure
to body shaming; more gender discrimination, domestic violence, and sexual abuse;
and a higher incidence in general of life
events that cause a sense of loss, inferiority, humiliation, or entrapment.
One of the most significant risk factors
for mental health problems in women is
sexual violence. Women who experience
sexual assault or sexual harassment often
report feelings of inferiority, humiliation,
and grief. Globally, at least 1 in 5 women
experiences rape or attempted rape in her
lifetime. In addition, in a recent poll taken
in the United States, 6 of every 10 women
reported having been sexually harassed
by a man. Victims of sexual assault or
sexual harassment are at increased risk
for depression, anxiety, post-traumatic
stress disorder, substance abuse, and
suicide. Sexual violence is discussed in
detail in Chapter 20.
individuals equally. This inequity in
valuing increases the health risks to
certain populations while decreasing
their access to the resources that could
help them to thrive. In contrast, certain other populations have privilege,
that is, resources and rights, sometimes
unearned, that are denied or are less
available to others. For example, children born into affluent families may
have a nourishing diet, excellent educational opportunities, and access to highquality health care. These resources
support health. Children born into
families in which they are valued and
nurtured, even if they are not wealthy,
also have resources that support health,
including social connectedness and an
overall sense of safety and security.
Conditions that affect—positively or
negatively—access to and distribution
of health-related resources are known
as the social determinants of health
(SDOH).43 You encountered them in
Chapter 1. Here, we’ll take a closer look
at how they influence health and health
Finally, some unexpected factors
may contribute to the greater prevalence
of depression and anxiety in women—
namely, women are more likely to disclose
mental health issues to their primary care
provider, and physicians are more likely
to diagnose depression in women than
men, even when the patients present with
similar signs and symptoms.
Sources: World Health Organization, “Gender
and Women’s Mental Health,” 2018, www.who.
int/mental_health/prevention/genderwomen/en/;
A. Riecher-Rossler, “Sex and Gender Differences
in Mental Disorders,” The Lancet Psychiatry 4, no.
1 (January 2017): 8–9; K. Frankovic, “Six in Ten
Women Say They’ve Been Sexually Harassed by a
Man,” November 2017, YouGov US, https://today.
yougov.com/news/2017/11/10/six-ten-womensay-theyve-been-sexually-harassed-ma/; and D.
Thompson, “Sexual Harassment Toxic to Mental
and Physical Health,” December 4, 2017, Web MD,
www.webmd.com/women/news/20171204/sexualharassment-toxic-to-mental-physical-health#1.
disparities (FIGURE 2) both directly and
indirectly. A low-income individual, for
example, may be unable to afford a prescription for a drug to treat his asthma.
Less directly, the individual’s housing
options may be limited to neighborhoods with high levels of air pollution
that exacerbate the asthma. The SDOH
are interconnected. Discrimination,
for example, can influence educational
attainment, housing, employment
options and thus income, and other
SDOH.44
Economic Stability
and Educational
Attainment
In the decades after World War II,
income gains were broadly shared
throughout American society. However,
between 1962 and 2016, the gap between
the rich and the poor widened dramatically. In 2016, the richest 1 percent
of U.S. households owned more wealth
40.6
Neighborhood
and Built
Environment
Health and
Access to
Affordable, Quality
Heath Care
Economic
Stability
SDOH
Educational
Attainment
FIGURE 2
Social Interactions
and Community
Context
Social Determinants of Health (SDOH)
than the bottom 90 percent of households combined.45
In 2017, the U.S. Census Bureau
defined poverty as a household income
of $12,752 or less per year for a single person and $19,173 for a family of three.46 A
single parent with two children working
full-time at the federal minimum wage
($7.25 an hour) would earn $15,080
a year—well below the poverty line.
Although a majority of U.S. states have
set their minimum wage above $7.25 an
hour, many states abide by the federal
minimum wage. To learn the minimum
wage in your state, search for the “state
minimum wage chart” at www.ncsl.org.
Decades of research support a close
association between poverty and poor
health.47 Many poor Americans, for
example, experience hunger; in 2016,
12.3 percent of U.S. households were
food insecure, meaning that they lacked
access to sufficient food for all household
members.48 In addition, poor Americans
are more likely to reside in food deserts,
communities with low or no access to
food stores that sell fresh fruits and vegetables, whole-grain breads, fish, and
other nutritious foods. Living in a food
desert increases the risk for health problems such as obesity and obesity-related
diseases. Low-income communities may
also have low walkability, lower-performing schools, poorer-quality health care
facilities, and higher than average levels
of pollution and violence.49
Low educational attainment—a
distinct SDOH—is correlated with low
income. The U.S. Bureau of Labor Statistics reports that Americans with only
a high school diploma had median
weekly earnings of $678 in 2015 compared to $1,137 for Americans with
a bachelor’s degree. Unemployment
among Americans with only a high
school diploma was also nearly double
that of Americans with a bachelor’s
degree.50 Additionally, young adults
from families in the highest income
bracket (highest 25%) are eight times
more likely to obtain a bachelor’s degree
by age 24 as young adults from families
in the lowest (25%) income bracket.51
Education enhances health in part
because it increases opportunities for
jobs with better working conditions,
sick leave, paid vacation, health insurance coverage, and other benefits, as
MILLION AMERICANS
live in POVERTY.
This represents 11.6%
of American adults
and 18% of America’s
children.
well as higher salaries and thus the ability to afford better housing, food, and
other essentials.
By reducing access to society’s
resources, poverty contributes to significant and chronic stress, which leads
to physical and mental health problems
that begin in childhood and typically
persist throughout the lifespan.52 One of
the most striking poverty-related health
disparities is in life expectancy. Males
with income in the lowest 10 percent
have an average life expectancy 14 years
below that of males with income in the
top 10 percent; for females, the gap is
13 years.53 Other disparities linked to
poverty include an increased risk for
preterm birth and infant mortality54;
impaired neurological development in
children55; reduced access to needed
medical care, dental care, and prescription drugs56; and higher rates of chronic
disease and disability.57 In 2014, over
37 percent of impoverished Americans
ages 18 to 64 living at or below the poverty line had at least one disability, compared to 17 percent of middle-income or
affluent Americans.58
Social Interactions
and Community
Context
Our social interactions and community environment strongly influence
our health. Such factors include our
food insecure Lacking reliable access to
sufficient food for all household members.
food desert A community in which residents lack ready access to fresh, healthful,
and affordable food.
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 29
The minority-stress theory attempts to explain the link between stress and the
discrimination experienced by members of minority groups. According to this
theory, even the anticipation of discrimination can trigger the stress response.
level of social support, social norms and
attitudes (including prejudice, discrimination, racism, and bullying), cultural
influences, language barriers and levels
of literacy, incarceration rates, and availability of community-based resources.59
Among these factors, discrimination has emerged as a key contributor
to stress and stress-related symptoms
and poor health.60 A recent report
from the American Psychological Association identified an increased risk for
discrimination among members of the
following five groups: the poor, the disabled, racial/ethnic minorities, LGBT
Americans, and older Americans.61 The
minority-stress theory attempts to explain
the link between frequent exposure to
culture The collective attitudes, beliefs,
values, and behaviors that distinguish one
group of people from another.
health literacy The ability to obtain, process, and understand health information and
services needed to make appropriate health
decisions.
30 | PART ONE | Finding the Right Balance
discrimination—such as being stopped
unfairly by police, passed over for a job
promotion, discouraged by a teacher,
or even treated discourteously—and
stress levels that reduce health. Even the
anticipation of discrimination increases
stress; for example, an older worker who
is accustomed to being honest might
feel the need to lie about age on a job
application to get hired. Americans who
report experiencing extreme levels of
stress are twice as likely to also report
fair or poor health, compared to those
with low stress levels.62 (See Chapter 3
for more on the link between stress and
health.)
Culture—the attitudes, beliefs, values, and behaviors characteristic of a
group of people—can also influence
health. Culture is transmitted through
language, material objects, art, rituals,
institutions, and other modes and is
passed from generation to generation as
people adapt to social and environmental changes. Individuals may hold culturally based beliefs about what causes
disease, what is appropriate treatment,
or whether to seek care at all. Culturally
based behavior patterns can also affect
trust of and communication with health
care providers and health-related lifestyle
choices such as diet and levels of physical activity. Although culture is a widely
acknowledged determinant of health,
it’s important to recognize that we are all
individuals engaging in complex and varied behaviors, any one of which may or
may not be culturally influenced.
Language barriers and illiteracy can
also affect health. Health literacy is the
ability to obtain, process, and understand health information and services
needed to make appropriate health
decisions.63 It includes the ability to
understand, for example, instructions
about prescription drugs, appointment
slips, health education brochures, physician instructions, and insurance and
consent forms.64 People with low health
literacy also may have problems communicating with health care providers
and may be less able to make informed
health care decisions. In consequence,
they are more likely not to obtain recommended vaccinations and health
screenings; may make medication
errors; may suffer complications from
poor disease management; and may be
more likely to be hospitalized. They also
have a higher mortality rate.65
Neighborhood and
Built Environment
Neighborhood characteristics, such as
walkability, the presence of food stores
that offer plenty of healthy choices,
and density of recreational facilities,
also influence health.66 Multiple studies have linked rural environments
with reduced opportunities for physical
activity and increased levels of obesity
and chronic disease.67,68
Another aspect of the built environment that can contribute to health
disparities is the level of industrial
and traffic pollution in air, water, and
soil.69,70 After the Environmental Protection Agency’s discovery in 2015 of
lead contamination in the public water
supply in Flint, Michigan—where over
40 percent of the population lives below
Affirm the Benefits
of Diversity
Access (or lack of access) to grocery stores that offer plenty of healthy choices can
influence the health of an entire community.
the poverty line—municipal water systems in other low-income communities
across the United States also were found
to be contaminated with lead.71
Exposure to neighborhood violence
is another powerful SDOH, contributing directly to traumatic injuries and
deaths and indirectly to disparities in
mental and physical health, as well
as increased risks for several chronic
diseases.72–76
LO 4 | HOW CAN
YOUR ACTIONS
CONTRIBUTE TO
HEALTH EQUITY?
Discuss specific actions you can take
to promote health equity on campus, in
your community, and in your personal
life, including how to use mindfulness to
examine your biases and increase your
respect for difference.
The factors that contribute to health
disparities are complex and interconnected, and solutions can seem overwhelming, especially when viewed from
a systems perspective. But health disparities can be addressed on a smaller
scale—in your own neighborhood and
your own mind.
Use Mindfulness
to Examine Your
Assumptions and
Biases
A highly effective strategy for challenging the beliefs and attitudes
that limit us is to cultivate mindfulness.
Participants in mindfulness training programs enhance their ability to recognize
their own unconscious biases; to control
their responses to their biases once
­activated; and to respond with compassion to the unconscious aspects of their
own and other people’s behavior.77,78
Another study offering a single session of
mindfulness training to college students
found that those who received the training demonstrated reduced racial and age
biases and fewer negative behaviors that
commonly result from such biases.79
The researchers attributed this reduction
in bias to a dampening of the brain’s
activation of automatic negative associations. In other words, when we pay close
attention to what is actually occurring in
our minds and our surroundings, we disable habitual neurological pathways by
which we perceive and respond to
others.80
The Assess Yourself at the end of this
chapter offers steps for examining your
assumptions, perceptions, and biases.
Were you raised in a region with a
population largely sharing the same
language, culture, religion, and race or
ethnicity? Even if you’re from a tremendously diverse area, did you stick to your
own group most of the time? If so, you
might find the diversity of campus life
exhilarating—or challenging. It can be
stressful to take a class with an instructor whose primary language isn’t English or to work on a team project with
people of different ages, backgrounds,
or abilities. Understanding and affirming the benefits of diversity can help.
Diversity is a teacher. Interacting
every day with other people who are
different from you challenges your
assumptions; exposes you to new ideas,
values, and experiences; and generally expands your world. The skills you
develop in working across differences
are likely to improve your career prospects, perhaps even preparing you for
international job opportunities. As
you compare and contrast your values,
beliefs, and personal history with those
of other people, you discover more
about yourself. This deeper self-awareness can in turn support you in making
decisions about your coursework, social
life, and future plans.81 Finally, building relationships with people who are
different from you can expose you to
new foods, new sports, new music, new
authors—and a lot of fun!
Learn to
Communicate across
Differences
In a landmark 2016 study, researchers
went door-to-door in Miami to engage
residents in a single 10-minute conversation about their perceptions of
transgender people. During the conversations, the residents were encouraged to share their own experiences
of discrimination and to actively take
the perspective of others. These conversations reduced transphobia more
significantly than Americans’ average
decrease in homophobia from 1998 to
2012, and the effects persisted 3 months
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 31
later.82 Thus it’s clear that effective communication can help people bridge differences. Here are some suggestions for
how to begin.
A first step is for all participants to
agree to conduct the conversation with
honesty, civility, and mutual respect.
Next, all participants should share
their goals for the conversation. Before
the conversation begins, it may also be
helpful to take a moment to acknowledge that each speaker’s age, gender
identity, race or ethnicity, abilities and
disabilities, life experiences, and countless other factors have contributed to
who they are in this moment, including
how they perceive others in the group
and how they in turn are perceived.
All participants should be encouraged
to speak. When others are speaking, be
mindful. Try your best to stop your inner
monologue and truly listen instead of
thinking about what you can say next.
Pay attention not only to the content of
the person’s message, but also to what
the person’s tone of voice and body language seem to be saying. Each time your
mind begins to wander, return it to the
other person. After the person has finished speaking, you and others in the
conversation can summarize what you
believe you heard. Was this summary
close to what the person actually said? If
not, the group can ask for clarification.
Close with a conversation about
the conversation; that is, share your
MAKING CHANGES TODAY
Becoming Your Own Advocate
If you have experienced othering, stereotyping, or discrimination, you might be
tempted simply to accept the situation and move on. But a healthier way to
respond is to become your own advocate. Here are some suggestions:
Actively reject the negative messages you’ve received. Remind yourself of
your goodness, your core values, and your life purpose.
Discuss the experience with family members, friends, members of student
diversity groups, and leaders at campus diversity centers or with a mental
health professional.
If you are likely to engage in the future with an individual who has treated you
unfairly, decide in advance how you would like your interactions to change.
Make mental or written notes about the message you want to communicate
and how to do it calmly, clearly, and effectively.
Remember that you have a right to speak up for your interests. Someone else
disagreeing with you or becoming defensive does not negate the importance
of your needs or your right to make them known.
If you believe you have been discriminated against in housing or employment,
file a complaint. For example, for job discrimination, contact the U.S. Equal
Opportunity Employment Commission at www.eeoc.gov.
Remember that you are helping others by speaking out.
observations about your process of communication and questions and suggestions for future conversations.
Advocate for Yourself
and Others
In addition to practicing mindfulness
and communicating across differences,
you can contribute to health equity by
advocating for yourself and others. To
do that, it helps to be able to recognize
othering and discrimination when it
happens to you and to take action to
protect your health and change your
interactions in the future. For strategies,
see the MAKING CHANGES TODAY box.
LO 5 | HOW CAN
SYSTEMIC CHANGE
LEAD TO HEALTH
FOR ALL?
Describe the systemic changes required
to enable the United States to progress
toward good health for all, and provide
examples of national and communitybased initiatives currently underway toward
achieving this goal.
Civility, honesty, and mutual respect are necessary to successful communication.
32 | PART ONE | Finding the Right Balance
“Health for all” means living in communities that offer opportunities to
thrive, physically, mentally, economically, and socially. It means access to
healthy nutrition, physical activity, safe
and affordable housing, education from
early childhood through adulthood,
jobs that pay living wages, career opportunities, social support, community
Members of minorities are more likely to seek care from health care
providers of their own race or ethnicity.
resources, freedom from discrimination, high-quality health care, and
other social resources. This is where, as
a society, we want to go. The question is:
How do we get there?
Increase Access to
Health Care
In 2014, the U.S. Surgeon General published a National Prevention Strategy
on the elimination of health disparities.
One of its key recommendations was to
increase access to health care, especially
among the communities at greatest
health risk.83
Public health experts have proposed
the following initiatives to achieve a more
equitable distribution of health care:
Increase minority providers. Members of minorities are more likely to
seek care from health care providers of their own race or ethnicity.84
Educational programs and policies
should encourage minority Americans (racial or ethnic minorities,
LGBT Americans, and disabled
Americans) to pursue careers in the
health professions.85
■■ Increase diversity training. All health
care providers should be required to
undergo diversity training to improve
their ability to communicate health
information in the language and at
the appropriate literacy level of the
■■
client they are serving.86 Mindfulness
training can also help: A recent study
found that mindfulness training
helped health care providers recognize and reduce their biases.87
■■ Increase preventive services. Municipalities, employers, school districts,
and health care organizations
should partner to offer preventive
services such as mental health services, dental exams and cleanings,
vision care, vaccinations, blood pressure screenings, and other services
for underserved populations.
■■ Expand access to health insurance.
The national initiative that has
had perhaps the greatest effect on
increasing access to health care for
all population groups is the Affordable Care Act (ACA), which was
signed into law in 2010 and implemented in stages. Under the ACA,
the number of uninsured Americans
dropped from 44 million in 2013 to
27.6 million by the end of 2016.88
Reduce the Social
Determinants That
Contribute to Health
Disparities
In addition to increasing access to highquality care, we must reduce the SDOH
that significantly contribute to health
disparities. Because these determinants
are intertwined, they must be counteracted by “structural interventions” such
as educational reform, improved housing, public health programs, economic
investment, and reform of our criminal
justice system.89
The Surgeon General’s National Prevention Strategy recommends, for example, that key community representatives
meet with professionals from a range of
community organizations to identify
the community’s health needs and the
barriers to meeting those needs.90 Specific strategies to reduce SDOH affecting the physical environment include
construction of high-quality, safe, and
affordable housing; identifying and
working to remediate sources of pollution; increasing neighborhood walkability; building parks and playgrounds;
establishing after-school programs for
tutoring, physical activity, and social
support; offering incentives to chain
grocers to open food stores that provide
plenty of healthy options; building
community gardens; supporting meetings between law enforcement officers
and community members to foster collaboration and establish neighborhood
watch programs; and using libraries and
community centers to increase health
literacy. Each of these strategies has the
potential to reduce health disparities.
Together, they could be transformative.
Examples of
Initiatives to Increase
Health for All
In the latter decades of the twentieth
century, with the recognition that health
disparities exist, several national and
community-level initiatives were implemented to improve “health for all.” Here,
we review some of the most significant.
National Initiatives
In 1979,
the Healthy People initiative was
launched with the publication of Healthy
People: The Surgeon General’s Report on
Health Promotion and Disease Prevention,
a document that established national
goals for reducing injuries, preventable
disease, and premature death.91 Other
initiatives have followed, including the
creation in 1985 of the U.S. Department
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 33
standards for construction of public housing and businesses; changes to zoning
ordinances to avoid the release of pollutants within a reasonable distance of residential neighborhoods; and support for
public transportation to increase accessibility to supermarkets, health care facilities, and schools and colleges. State and
municipal policies or legislation can also
reduce health disparities by increasing the
minimum wage, banning environmental
tobacco smoke in public spaces, authorizing the construction of new community
health care facilities, improving neighborhood walkability, or supporting farmers
markets and community gardens.
Community gardens can help to increase access to nourishing food and reduce
health disparities.
of Health and Human Services Task Force
on Black and Minority Health92 and new
reports on health disparities from the
Surgeon General, the National Academy
of Medicine, and the CDC. Although
these reports set goals and objectives for
reducing health disparities, only minimal
progress has been made toward meeting
those goals because accountability and
funding have been inadequate.
City, County, and State
Initiatives City, county, and state
governments can employ a variety of
approaches to improve health equity.
These efforts include improvements in
STUDY PLAN
ASSESS YOURSELF
of others? Want to find out?
Take the Examining Assumptions,
Perceptions, and Biases assessment
available on Mastering Health.
CHAPTER REVIEW
|
LO 1 Why Has Health Equity
Become a Critical
Issue in America?
■■
Health equity, which is informed
by the values of fairness and justice,
is attainment of the optimal level
of health for all people. Health
34 | PART ONE | Finding the Right Balance
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
disparities are differences in health
that are tied to persistent and unjust
social, economic, and/or environmental disadvantages. Our society’s
evolving diversity brings with it an
increased potential for false assumptions, misperceptions, unrecognized biases, discrimination, and
stereotyping.
How do your biases affect
your health and the health
|
LO 2 What Types of Health
Disparities Occur in
Vulnerable Population
Groups?
■■
Initiatives on Campus College
can provide unique opportunities to students from underserved communities to
develop more healthful habits via access
to the student health center, fitness
facilities, security services, and campus dining halls with healthful meal
options. Some campuses have community gardens, and some have a food
pantry for student use. Conduct some
research on campus-based programs to
advance health equity, and recommend
model programs for your own campus.
People especially vulnerable to health disparities include
those who have systematically
experienced greater obstacles to
health based on their racial or
ethnic group; gender, sexual orientation, or gender identity; age; or
other characteristics.
|
LO 3 How Do the Social
Determinants of
Health Influence
Health Disparities in
America?
■■
Conditions that affect—positively or
negatively—access to and distribution of health-related resources are
known as the social determinants
of health. Some of the most significant are persistent poverty, low
educational attainment, discrimination and minority stress, and healthrelated neighborhood characteristics
such as walkability, presence of
supermarkets, level of pollution, and
neighborhood violence.
|
LO 4 How Can Your Actions
Contribute to Health
Equity?
■■
The practice of mindfulness can help
you pay close attention to what is
occurring in your mind and your
surroundings and thereby reduce
bias. Learning techniques to communicate across difference—including listening mindfully—can help
you communicate more effectively
with people of different population
groups.
|
LO 5 How Can Systemic
Change Lead to Health
for All?
■■
Increasing health equity will require
increasing everyone’s access to highquality health care. We must also
implement structural interventions
to reduce the social determinants
of health that contribute most
significantly to health disparities,
including poverty, low educational
attainment, discrimination, pollution, and violence. National, state,
county, and local initiatives are all
important.
POP QUIZ
|
LO 1 Why Has Health Equity
Become a Critical
Issue in America?
1. Assigning a generalized and
typically negative attribute
to an individual of a different
population group is known as
a. othering.
b. stereotyping.
c. negating.
d. discriminating.
|
LO 2 What Types of Health
Disparities Occur in
Vulnerable Population
Groups?
2. Which of the following population
groups has a life expectancy 4.4
years lower than the national
average, in part because of higherthan-average mortality rates due
to chronic disease, accidental
injuries, and homicide?
a. Women
b. American Indians/Alaska
Natives
c. Sexual and gender minorities
d. Non-Hispanic whites living in
large urban areas
|
LO 3 How Do the Social
Determinants of
Health Influence
Health Disparities in
America?
3. Which of the following
social determinants of health
contributes significantly to chronic
stress?
a. Poverty
b. Discrimination
c. Exposure to violence
d. All of the above
|
LO 5 How Can Systemic
Change Lead to Health
for All?
5. Which of the following initiatives
would be most likely to achieve
a more equitable distribution of
health care?
a. Conduct research into the
root causes of neighborhood
violence.
b. Increase taxes on tobacco
products.
c. Establish educational programs
and policies to encourage
members of minority groups
to pursue careers in the health
professions.
d. Raise the age for Medicare
eligibility to 75 years.
Answers to the Pop Quiz can be found on
page A-1. If you answered a question incorrectly, review the section identified by the
Learning Outcome. For even more study tools,
visit Mastering Health.
|
LO 4 How Can Your Actions
Contribute to Health
Equity?
4. Which of the following is thought
to be an effect of mindfulness
training?
a. It can more effectively activate
habitual neurological pathways
by which we perceive and
respond to others.
b. It can help reinforce negative
stereotypes.
c. It can reduce the brain’s
activation of automatic
negative associations.
d. It can increase negative
behaviors that result from
biases.
FOCUS ON | Difference, Disparity, and Health: Achieving Health Equity | 35
2
PROMOTING AND
PRESERVING YOUR
PSYCHOLOGICAL HEALTH
LEARNING OUTCOMES
LO1
Define each of the four components of psychological
health, and identify the basic traits shared by
psychologically healthy people.
LO4
Discuss risk factors and possible warning signs of
suicide, as well as actions that can be taken to help a
person contemplating suicide.
LO2
Discuss the roles of self-efficacy and self-esteem,
emotional intelligence, personality, maturity, and
happiness in psychological well-being.
LO5
Explain the different types of treatment options and
professional services available to those experiencing
mental health problems.
LO3
Describe and differentiate among psychological
disorders, including mood disorders, anxiety disorders,
obsessive–compulsive disorders, posttraumatic stress
disorder, personality disorders, and schizophrenia, and
explain their causes and treatments.
36 WHY
Mental health problems on today’s college campuses are reaching epidemic proportions, potentially outstripping the ability of campus counseling centers to effectively
provide fast, essential support. Record numbers of students reporting difficulties
with depression, anxiety, stress, sleep difficulties, and more serious problems such as violence and self-injury have raised significant concerns among campus leaders and counseling centers about how best to meet increasing demands. Mental health problems can affect
every aspect of a person’s life, including relationships, academics, career potential, and overall
well-being. Stigma surrounding mental illness keeps many people from reaching out for help.
Knowing the signs and symptoms of someone who is struggling (including yourself) and where
to go for help is key to avoiding serious problems.
SHOULD I CARE?
M
ost students describe their college years as
among the best of their lives, but they may
also find the pressure of grades, finances, and
relationships, along with the struggle to find
themselves, to be extraordinarily difficult. Psychological distress caused by relationship issues, family concerns, academic
competition, and adjusting to college life is common. Experts
believe that the anxiety-inducing campus environment is a
major contributor to poor health decisions such as high levels
of alcohol consumption, sleeplessness, and overeating. These,
in turn, can trigger even more anxiety, affecting academic success and overall health.
Psychological Health
Emotional
health (Feeling)
Spiritual
health (Being)
Social
health (Relating)
Mental
health (Thinking)
LO 1 | WHAT IS PSYCHOLOGICAL
HEALTH?
Define each of the four components of psychological health, and
identify the basic traits shared by psychologically healthy people.
Psychological health is the sum of how we think, feel, relate,
and exist in our day-to-day lives. Our thoughts, perceptions,
emotions, motivations, interpersonal relationships, and
behaviors are a product of our experiences and the skills we
have developed to meet life’s challenges. Psychological health
includes mental, emotional, social, and spiritual dimensions
(FIGURE 2.1).
Most experts identify several basic elements psychologically healthy people regularly display:
They feel good about themselves. They are not typically
overwhelmed by fear, love, anger, jealousy, guilt, or worry.
They know who they are, have a realistic sense of their
capabilities, and respect themselves even though they realize they aren’t perfect.
■■ They feel comfortable with other people, respect others,
and have compassion for others. They enjoy intimate,
stable, satisfying and lasting personal relationships and do
not take advantage of others or allow others to take advantage of them. They can give love, consider others’ interests,
take time to help others, and respect personal differences.
■■ They are “self-compassionate.” They acknowledge their
“humanness.” Instead of judging and criticizing themselves
■■
FIGURE 2.1 Psychological Health Psychological health
is a complex interaction of the mental, emotional, social,
and spiritual dimensions of health. Possessing strength and
resiliency in these dimensions can maintain your overall wellbeing and help you weather the storms of life.
for inadequacies or shortcomings, self-compassionate
individuals cut themselves some slack when confronted
with personal failings; they are kind and understanding.
They strive to be the best they can be given situations
beyond their control. They try to balance their self-view
with positives, instead of
being self-absorbed, narcispsychological health The
sistic, or overly critical of
mental, emotional, social, and
spiritual dimensions of health.
themselves.1
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 37
They control tension and anxiety. They recognize the
underlying causes and symptoms of stress and anxiety
in their lives and consciously avoid irrational thoughts,
hostility, excessive excuse making, and blaming others
for their problems. They use resources and learn skills
to control reactions to stressful situations. They recover
from painful events with resiliency, often with the help
of resources and skills developed over a lifetime of coping
with stress.
■■ They meet the demands of life. They try to solve problems
as they arise, accept responsibility, and plan ahead. They
set realistic goals, think for themselves, and make independent decisions. Acknowledging that change is inevitable,
they welcome new experiences.
that things will go well. They look to the future with enthusiasm rather than dread. Having fun and making time for
themselves are integral parts of their lives.
■■
They curb hate and guilt. They acknowledge and combat
tendencies to respond with anger, thoughtlessness, selfishness, vengefulness, or feelings of inadequacy. They do not
try to knock others aside to get ahead, but rather reach out
to help others.
resiliency The ability to
■■ They maintain a positive
adapt to change and stressful
outlook. They approach each
events in healthy and flexible
day with a presumption
ways.
■■
■■
They value diversity. They do not feel threatened by those
of a different gender, religion, sexual orientation, race, ethnicity, age, or political party. They are nonjudgmental and
do not force their beliefs and values on others. They view
self and others in complex, stable, and accurate ways.
■■
They appreciate and respect the world around them. They
take time to enjoy their surroundings, are conscious of
their place in the universe, and act responsibly to preserve
their environment for future generations.
In sum, psychologically healthy people possess emotional,
mental, social, and spiritual resiliency and take a mindful
approach to life. Resilient individuals have the ability to overcome challenges from minor disappointments to major tragedies
and the typical life obstacles we often face. They usually respond
to challenges and frustrations in appropriate ways, despite occasional slips (see FIGURE 2.2). When they do slip, they recognize
it, are kind to themselves rather than engaging in endless selfrecrimination, and take action to rectify the situation.
Psychologically unhealthy
Psychologically healthy
No zest for life;
pessimistic/cynical most of
the time; spiritually down
Shows poorer coping than
most, often overwhelmed by
circumstances
Works to improve in all
areas, recognizes strengths
and weaknesses
Laughs, but usually at others,
has little fun
Has regular relationship
problems, finds that others
often disappoint
Healthy relationships with
family and friends, capable
of giving and receiving love
and affection
Has serious bouts of
depression, “down” and
tired much of time; has
suicidal thoughts
A “challenge” to be around,
socially isolated
Experiences many illnesses,
headaches, aches/pains, gets
colds/infections easily
FIGURE 2.2
Tends to be cynical/critical of
others; tends to have
negative/critical friends
Lacks focus much of the time,
hard to keep intellectual
acuity sharp
Quick to anger, sense of
humor and fun evident less
often
Has strong social support,
may need to work on
improving social skills but
usually no major problems
Has occasional emotional
“dips,” but overall good
mental/emotional adaptors
Possesses zest for life;
spiritually healthy and
intellectually thriving; is
mindful
High energy, resilient, enjoys
challenges, focused
Realistic sense of self and
others, sound coping skills,
open-minded
Adapts to change easily,
sensitive to others and
environment
Has strong social support and
healthy relationships with
family and friends
Characteristics of Psychologically Healthy and Unhealthy People Where do you fall on this continuum?
38 | PART ONE | Finding the Right Balance
SelfActualization
creativity, spirituality,
fulfillment of potential
use information effectively, to engage in creative and mentally
stimulating activities, to think critically, to be open-minded,
to share knowledge, and to strive for continued growth. This
is often referred to as intellectual health, a subset of mental
health.3
Emotional Health
The term emotional health refers to the feeling, or subjective, side of psychological health. Emotions are intensified
feelings or complex patterns of feelings that we experience
on a regular basis, including love, hate, frustration, anxiety, and joy, among others. Typically, emotions are
described as the interplay of four components: physSocial Needs
belonging, affection, acceptance
iological arousal, feelings, cognitive (thought)
processes, and behavioral reactions. As rational beings, we are responsible for evaluating
our individual emotional responses, their
Security Needs
causes, and the appropriateness of our
shelter, safety, protection
actions.
Emotionally healthy people usuSurvival Needs
ally respond appropriately to upsetfood, water, sleep, exercise, sexual expression
ting events. Rather than reacting in an
extreme fashion or behaving inconsistently or offensively, they can express
FIGURE 2.3 Maslow’s Hierarchy of Needs
their feelings, communicate with othWatch Video Tutor:
Maslow’s Hierarchy of
ers, and show emotions in appropriSource: From A. H. Maslow, Motivation and Personality, 3rd
ed., eds. R. D. Frager and J. Fadiman (Upper Saddle River,
Needs
ate ways. In contrast, emotionally
NJ: Pearson Education, 1987). Reprinted with permission.
unhealthy people are much more likely
to let their feelings overpower them.
Psychologists have long argued that before we can achieve
Emotional health also affects social and intellectual health.
any of the above characteristics of psychological health, we
People who are angry, volatile, or moody may become socially
must meet certain basic human needs. In the 1960s, human
isolated. Because they aren’t fun to be around, others may
theorist Abraham Maslow developed a hierarchy of needs to
avoid them at the very time they are most in need of emodescribe this idea (FIGURE 2.3): At the bottom of his hierarchy
tional support. For students, a more immediate concern is the
are basic survival needs, such as food, sleep, and water; at the
impact of emotional upset on academic performance. Have
next level are security needs, such as shelter and safety; at the
you ever tried to study for an exam after a fight with a friend or
third level—social needs—is a sense of belonging and affection;
family member? Emotional turmoil can seriously affect your
at the fourth level are esteem needs, self-respect and respect
ability to think, reason, and act rationally.
for others; and at the top are needs for self-actualization and
self-transcendence.
According to Maslow’s theory, a person’s needs must be met
Social health includes interactions with others, ability to
at each of these levels before he or she can be truly healthy.
use social resources and support in times of need, and
Failure to meet needs at a lower level will interfere with a perability to adapt to a variety
son’s ability to address higher-level needs. For example, someof social situations. Typically,
mental health The thinking
one who is homeless or worried about threats from violence
part of psychological health;
socially healthy individuals
will be unable to focus on fulfilling social, esteem, or actualizaincludes your values, attitudes,
can listen, express themselves,
2
tion needs.
and beliefs.
form healthy attachments,
emotional health The feeling
act in socially acceptable and
part of psychological health;
responsible ways, and adapt
includes your emotional reactions to life.
to an ever-changing society.
emotions Intensified feelings
The term mental health is used to describe the “thinking” or
Numerous studies document
or complex patterns of feelings.
“rational” dimension of our health. A mentally healthy perthe importance of positive
social
health Aspect of psyson perceives life in realistic ways, can adapt to change, can
rela­
t ionships and support
chological health that includes
develop rational strategies to solve problems, and can carry out
from family members, friends,
interactions with others, ability
personal and professional responsibilities. In addition, a mencoworkers, community gro­
to use social supports, and ability to adapt to various situations.
tally healthy person has the intellectual ability to learn and
ups, and significant others to
Esteem Needs
self-respect, respect for others,
accomplishment
Social Health
Mental Health
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 39
dysfunctional families
Families in which there is violence; physical, emotional,
or sexual abuse; significant
parental discord; or other
negative family interactions.
social support Network
of people and services
with whom you share ties
and from whom you get
support.
overall well-being. In addition,
social support has been shown
to moderate the effects of stress,
reduce risks of depression, and
improve overall longevity.4
Numerous studies have shown
that feeling socially connected
to the people in one’s life is
associated with decreased risk
for all-cause mortality as well as
a range of illnesses.5
The Family
Families have a significant influence on psychological development. Healthy families model and help
develop the cognitive and social skills necessary to solve problems, express emotions in socially acceptable ways, manage
stress, and develop a sense of self-worth and purpose. According to the Harvard Study on Adult Development, people who
fare the best in terms of happiness and life satisfaction are
those who have positive relationships with family, friends, and
the greater community. According to the study’s lead author,
“good social connections are good for us, and loneliness kills.”6
Children brought up in dysfunctional families—in which
there is violence, distrust, anger, dietary deprivation, drug
abuse, significant parental discord, or abuse, or where parents
have been incarcerated—may run an increased risk of psychological problems.7 Youth raised in these homes may be more
likely to be involved in bullying, drug abuse, and violence,
and have a greater risk of incarceration themselves.8 Yet not
all people raised in dysfunctional families become psychologically unhealthy, and not all people from healthy environments become well adjusted. The difference may lie in their
support system, community, self-esteem, and personality.
Social Supports
Social support may include our families, social connections, and resources that supply us with aid in
times of need; give us advice; and provide approval, comfort, and
assistance. While our initial social support may come from family members, as we grow and develop, the support of peers and
friends becomes more and more important. We rely on friends
to help us figure out who we are and what we want to do with
our lives. We often bounce ideas off friends to see if they think
we are being logical, smart, or fair or if our reactions are reasonable. Relationships in life provide the social capital that helps us
maintain psychological health in the face of life’s challenges.
The concept of social support refers to the people and services with which we interact and share social connections. (See
Chapter 8 for more information on the importance of social
networks and social bonds.) These people and services can provide tangible support, such as babysitting services or money to
help pay the bills, or intangible support, such as encouraging
you to share your concerns. Research shows that college students with adequate social support have higher GPAs, higher
perceived ability in math and science courses, less stress and
depression, less peer pressure for binge drinking, lower rates of
suicide, and higher overall life satisfaction.9, 10
Community
The communities we live in can provide
social support and have a positive impact on our psychological
health through collective actions. For example, neighbors may
join together to get rid of trash on the street, participate in a
neighborhood watch to keep
WHAT DO
children and homes safe,
help each other with home
THINK?
repairs, or organize community social events. Religious
What are some ways
institutions, schools, clinics,
in which people in
and local businesses can also
your community work together
engage in efforts that demtoward a common goal?
onstrate support and caring
■■ What type of groundwork
for community members.
must be established before
Likewise, you are a part of a
this type of working together
campus community. That
can occur?
community can create a safe
■■ What factors can get in the
environment to explore and
way of collaboration and
cooperation?
develop your mental, intellectual, emotional, social,
and spiritual dimensions.
YOU
Your family members play an important role in your
psychological health. As you were growing up, they
modeled behaviors and skills that helped you develop
cognitively and socially. Their love and support can give
you a sense of self-worth and encourage you to treat
others with compassion and care.
40 | PART ONE | Finding the Right Balance
Loneliness
Happiness is most closely connected to having friends and family. Even so, you could have people around
you constantly and still experience a deep, pervasive loneliness.
Today, a wide range of experts point to the fact that many of us
are lonelier than ever before. A social media–driven society has
made us more connected and yet, surprisingly, more disconnected. Ten thousand online “friends” may not make up for four
or five close, present friends. Social psychologist Sherry Turkle
writes that we are “alone, together” and that our consummate
addiction to social media may not convince us that we are loved,
worthwhile, or valued as an individual.11 Just over 63 percent of
college students reported feeling very lonely in the past year.12
Several factors may contribute to increased reports of loneliness in modern society. These factors include divorce and
death; living longer and losing most of our close friends; connecting with more people on social media but having fewer
close, face-to-face social relationships; a more mobile workforce, in which people may telecommute or change jobs and
locations frequently; and many other causes of social isolation.13 Recent research indicates that social isolation and feelings of vulnerability and loneliness may trigger physiological,
cognitive, and behavioral responses closely tied to depression.
Although depression has been linked to genetic risk, discovering the links between loneliness and actual depressed states
is only in its preliminary stages. More research is necessary to
examine the complex interactions between environmental
and genetic risks, depression, and loneliness.14
Social isolation often results in a person being less trusting, more pessimistic, defensive, and negative, which in turn
increases the likelihood that others may not want to be around
him or her, leading to more loneliness. Some of the health risks of
loneliness are depression and suicide, increased stress levels, antisocial behavior, and alcohol and drug abuse.15 Finding ways to
help individuals who are socially isolated become more engaged
is key. The first step is to recognize the feelings of loneliness in self
and others; tune in and notice your behaviors and those of others
who seem to be left out of social interactions. Think about ways
to include others, and if you aren’t comfortable in social interactions yourself, look for other activities in which you can engage,
such as those provided by clubs, small group social events with
people who have similar interests, or volunteering.
(See Focus On: Mindfulness and Spiritual Intelligence on page
61 for more on the role spirituality plays in your overall health.)
Spiritual Health
­eople who continually expep
rience failure may develop a
pattern of response known as
learned helplessness in which
they give up and fail to take
action to help themselves. Seligman ascribes this response in
part to society’s tendency toward
victimology—blaming one’s problems on other people and circumstances.17 Although viewing
ourselves as victims may make us
feel better temporarily, it does not
address the underlying causes
of a problem. Ultimately, it can
erode self-efficacy by making us
feel that we cannot do anything
to improve the situation.
It is possible to be mentally, emotionally, and socially healthy
and still not achieve optimal psychological well-being. For
many people, the difficult-to-describe element that gives life
purpose is the spiritual dimension.
The term spirituality has many different meanings; however, one of the most inclusive descriptions may be “the aspect
of humanity that refers to the way individuals seek and express
meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, or to the
significant or sacred.”16 Spirituality may be practiced in many
ways, including through religion; however, religion does not have
to be part of a spiritual person’s life. Spiritual health refers to the
sense of belonging to something greater than the purely physical or personal dimensions of existence. For some, this unifying
force is nature; for others, it is a feeling of connection to other
people; for still others, it may be a god or other higher power.
LO 2 | KEYS TO ENHANCING
PSYCHOLOGICAL HEALTH
Discuss the roles of self-efficacy and self-esteem, emotional
intelligence, personality, maturity, and happiness in psychological
well-being.
Psychological health is the product of many influences
throughout life, including family, social supports, and the
community in which you live. Your psychological health is
also shaped by your sense of self-efficacy and self-esteem, your
personality, and your maturity.
Self-Efficacy and Self-Esteem
During our formative years, successes and failures in every
aspect of life subtly shape our beliefs about our personal worth
and abilities. These beliefs in turn become internal influences
on our psychological health.
Self-efficacy describes a person’s belief about whether he
or she can successfully engage in and execute a specific behavior. Self-esteem refers to one’s realistic sense of self-respect
or self-worth. People with high levels of self-efficacy and selfesteem tend to express a positive outlook on life.
Self-esteem results from the relationships we have with our
parents and family growing up; with friends as we grow older;
with our significant others as we form intimate relationships;
and with our teachers, coworkers, and others throughout our
lives. While we tend to think of self-esteem as a positive thing,
the HEALTH HEADLINES box on page 42 discusses the possible
downside of having too much self-esteem.
Learned Helplessn­
ess versus Learned
Optimism Psychologist Martin Seligman proposed that
spiritual health Aspect of
psychological health that
relates to having a sense
of meaning and purpose to
one’s life, as well as a feeling
of connection with others
and with nature.
self-efficacy Describes
a person’s belief about
whether he or she can
successfully engage in and
execute a specific behavior.
self-esteem One’s realistic
sense of self-respect or
self-worth.
learned helplessness
Pattern of responding to
situations by giving up
because of repeated failure
in the past.
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 41
HEALTH
HEADLINES
F
ostering self-esteem in children has
been seen as key to keeping them
away from drugs and violence and to
ensuring well-adjusted lives. While it’s
true people tend to thrive when praised
for hard work and accomplishments,
society is now seeing a possible
downside to handing out trophies just
for showing up. There is a fine line
between healthy self-esteem and vanity
or narcissism, leading some to have
an exaggerated self-image, a need for
constant compliments, and a sense of
feeling entitled to special treatment. In a
study conducted on Facebook updates, it
was found that extraverts more frequently
post about their social activities, those
with lower self-esteem tend to relay
updates about romantic partners, and
Overdosing on Self-Esteem?
narcissists tend to share content about
their achievements, diet, and exercise.
Call it the “soccer trophy effect” if you
will, but it appears to have serious downsides. First, preliminary research indicates
people who have been protected from
failure (perhaps by well-meaning parents
and teachers) and have extremely high
levels of self-esteem might be more prone
to anger, aggression, and other negative
behaviors when others don’t praise them
or meet their needs for instant gratification. Second, learning to lose may teach
us valuable lessons. Carol Dweck, a psychology professor at Stanford University,
found that after a steady diet of praise,
kids collapsed at the first experience of
difficulty. Failure can teach us to keep
trying—and that just showing up is not
Today, many self-help programs use elements of Seligman’s
principle of learned optimism. The basis for these programs
is the idea that we can teach ourselves to be optimistic. By
changing our self-talk, examining our reactions, and blocking negative thoughts, we can “unlearn” habitual negative
thought processes. Some programs practice positive affirmations with clients, teaching them the habit of acknowledging
positive things about themselves.
Defense Mechanisms
Freud proposed that, in
order to deflect negative emotions and stress, we develop
defense mechanisms, strategies we unconsciously use to distort our present reality to help avoid anxiety. While defense
mechanisms can be pathological if taken to an extreme, fantasizing about a vacation to cope with work stress or rationalizing why you weren’t selected for the lead role in a play can help
relieve stress and disappointment.18
■■
Emotional Intelligence
42 | PART ONE | Finding the Right Balance
Sources: T. Marshall, K. Lefringhausen, and N.
Ferenczi, “The Big Five, Self-Esteem, Narcissism as
Predictors of the Topics People Write about in Facebook Status Updates,” Personality and Individual
Differences 85 (2015): 35–40; S. Kaufman, “Narcissism and Self Esteem are Very Different.” Scientific
American Blog. October 29, 2107. https://blogs.
scientificamerican.com/beautiful-minds/narcissismand-self-esteem-are-very-different/; A. Diddaway
and E. Rafestesder, “Agenda for Conceptualizing
and Researching Praise and Criticism,” Journal of
Paediatrics and Child Health 52, no.1 (2016): 99.
In other words, people with high levels of emotional intelligence have a real knowledge of themselves, as well as an ability
to tune in to the emotions of other people.20
Essentially, Salovey and Mayer said that just because you
are intelligent doesn’t mean you “get it” when it comes to
daily interactions with others. If you know how to avoid,
manage, and deflect negative emotions and respond to emotionally charged situations in appropriate, rational ways,
the end result is more likely to be positive—and to improve
well-being.21 Your emotional intelligence quotient (EQ) is an
indicator of social and interpersonal skills—your ability to
successfully maneuver in sometimes emotionally charged
settings. Emotional intelligence typically consists of the
following:
■■
Intelligence has long been regarded as key to a successful career
and healthy social life. In the 1990s, two leading psychologists,
Peter Salovey and John Mayer,
championed a more comprelearned optimism Teaching
hensive view of intelligence,
oneself to think positively.
known as emotional intelliemotional intelligence (EI)
gence (EI).19 Emotional intelThe ability to anticipate, idenligence describes “the ability,
tify, understand, and manage
emotions in positive ways
capacity, skill, or self-perceived
(yours and others’); to commuability to identify, assess, and
nicate effectively with others;
manage the emotions of one’s
and to empathize and avoid/
self, of others, and of groups.”
diffuse potential conflicts.
enough to excel in college or the subsequent work world; in real life, there are no
participation ribbons.
Psychologists continue to support
the idea that self-esteem is important for
positive growth and development. More
research is needed to examine potential
risks of too much self-esteem and the
best ways to deal with it once it occurs.
■■
■■
■■
Self-Awareness. The ability to recognize your own emotions, moods, and reactions, as well as have an awareness of
how others perceive or react to you.
Self-Regulation/Self-Management. The ability to control
your emotional impulses, think before responding, and
express yourself appropriately.
Internal Motivation. A drive for learning about things, being
able to take initiative and follow through, as well as being
trustworthy, stable, and consistent.
Empathy. An awareness of what others might be going
through, rather than being so engrossed in yourself that
you are oblivious to others. Not being judgmental and
rigid in thinking and reacting appropriately to others’ little
“mental moments” are part of this element.
Social Skills. Involves identifying social cues, being able
to listen and respond appropriately, and knowing how to
work with others for the common good and to avoid conflicts with others.
Proponents of EI suggest that developing or increasing your
emotional intelligence can help you build stronger relationships, succeed at work, and achieve your goals.22
Personality
Your personality is the unique mix of characteristics that distinguishes you from others. Heredity, environment, culture,
and experience influence how each person develops. Personality determines how we react to the challenges of life, interpret our feelings, and resolve conflicts. A leading personality
theory called the five-factor model distills personality into five
traits, often called the “Big Five”:23
■■
■■
■■
■■
■■
Agreeableness. People who score high are trusting, likable,
and demonstrate friendly compliance and love; low scorers
are critical and suspicious.
Openness. People who score high demonstrate curiosity,
independence, and imagination, whereas low scorers are
more conventional and down-to-earth.
Neuroticism. People who score high in neuroticism are
anxious and insecure, whereas those who score low show
the ability to maintain emotional control.
Conscientiousness. People who score high are dependable
and demonstrate self-control, discipline, and a need to
achieve, whereas low scorers are disorganized and impulsive.
Extroversion. People who score high on extroversion adapt
well to social situations, demonstrate assertiveness, and
draw enjoyment from the company of others, whereas low
scorers are more reserved and passive.
Scoring high on agreeableness, openness, conscientiousness, and extroversion, while scoring low on neuroticism, is
often related to psychological well-being.
Most recent schools of psychological theory indicate that
we have the power to understand our behavior and change
it, thus molding our own personalities, even as adults.24
Although inhospitable social
environments make it more
difficult, there are opportunities for making changes and
improving our long-term psychological well-being.
psychoneuroimmunology
(PNI) The study of the interactions of behavioral, neural,
and endocrine functions and
the functioning of the body’s
immune system.
positive psychology The
scientific study of human
strengths and virtues.
Lifespan and Maturity
Although our temperaments are largely determined by genetics, we learn to channel our feelings in acceptable ways as we
age. For example, as children we might have screamed or hit
people when upset, but most people have learned that it’s
not okay to throw tantrums as adults. People raised in homes
where life is chaotic and traumatizing and who have poor role
models in their youth may find that they have learned behaviors that cause problems for them as adults.
Transition periods—such as the college years—are easier
for people who have successfully accomplished earlier developmental tasks, such as learning how to solve problems, control their emotions, define and adhere to personal values, and
establish relationships. Graduating from college can also be
another transition for many into adulthood and further independence. Anticipating an adjustment period and exploring
campus resources for new graduates can help in developing
autonomy after graduation.
Happiness and the Mind–Body
Connection
Can negative emotions make a person physically ill? Can positive emotions help us stay well? Researchers are exploring the
interaction between emotions and health,
especially in conditions of uncontrolled, persistent stress, anxiety, and sleep difficulties.
At the core of the mind–body connection
research is psychoneuroimmunology (PNI),
the study of the interactions of behavioral,
neural, and endocrine functions and the
functioning of the body’s immune system.
One area of study that appears to be particularly promising in enhancing health is positive psychology. According to psychologist
Martin Seligman, who is seen as its founder,
positive psychology is the scientific study of
human strengths and virtues.25 Practitioners
of positive psychology believe that science
has focused disproportionally on pathology
and repair of mental health and has paid
very little attention to factors that make life
worth living. Positive psychology is based
Research suggests that laughter can increase blood flow, boost the immune
on the beliefs that people want to nurture
response, lower blood sugar levels, and facilitate better sleep. Additionally,
their best qualities; find meaning and fulfillsharing laughter and fun with others can strengthen social ties and bring joy
ment in their lives; and enhance the love,
to your everyday life.
work, and play that they experience. People
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 43
happiness A collective term
for several positive states in
which individuals actively embrace the world around them.
who are described as mentally
healthy have certain strengths
and virtues in common:
They have high self-esteem.
They are realistic.
■■ They value close relationships with others.
■■ They approach life with excitement and energy.
■■ They think things through and examine things from all sides.
■
■
Positive psychology interventions have proven effective in
enhancing emotional, cognitive, and physical health; reducing depression; lessening disease and disability; and increasing
longevity.26
Seligman suggests that we can develop well-being by practicing positive psychological actions. He describes five elements of well-being (represented by the acronym PERMA) that
help humans flourish:27
Positive emotion. How happy and satisfied are you?
Engagement. Can you get completely absorbed in a task?
■■ Relationships. Are there people in life who really care
about you?
■■ Meaning. Are you working toward something bigger than
yourself?
■■ Accomplishment. How hard will you work for something?
■■
■■
The MAKING CHANGES TODAY box provides some suggestions for things you can do to incorporate PERMA principles
into your own life.
The study of happiness—a collective term for several positive
states in which individuals actively embrace the world around
them—is part of the study of positive psychology. While no differences have been found between men and women in feelings of
happiness, happiness does decrease as we age. Happy people share
four characteristics: health (knowing and partaking in healthy
habits); intimacy (being able to enjoy the company of friends and
family, as well as practice empathy); resources (possessing a certain
agency over one’s conditions in life); and competence (the knowledge of and ability to learn new skills).28 For university students,
happiness has been positively related to friendship, altruism, social
skills, cooperation, and academic success.29 People who experience more feelings of happiness have fewer mental health issues
(depression, anxiety, and obsessive–compulsive disorders), behavioral health issues, and physical health issues (e.g., cardiovascular
disease, obesity, cancer).30 However, some of the newest research
has indicated that being happy or unhappy has no direct effect on
mortality and has suggested that earlier studies had not adequately
adjusted for differences among participants and other variables.31
LO 3 | WHEN PSYCHOLOGICAL
HEALTH DETERIORATES
Describe and differentiate among psychological disorders,
including mood disorders, anxiety disorders, obsessive–compulsive
disorders, posttraumatic stress disorder, personality disorders, and
schizophrenia, and explain their causes and treatments.
Mental illnesses are disorders that disrupt thinking, feeling,
moods, and behaviors and cause varying degrees of impaired
44 | PART ONE | Finding the Right Balance
Spending time in the fresh air with your best friend is a
simple thing you can do to improve psychological health.
functioning in daily living. They are believed to be caused
by a variety of biochemical, genetic, and environmental
factors.32 Among the most common risk factors are a genetic
or familial predisposition and excessive, unresolved stress, particularly that resulting from trauma or war or devastating natural or human-caused disaster. Changes in biochemistry due
to illness, drug use, or other imbalances may trigger unusual
mental disturbances. Car accidents or occupational injuries
that cause physical brain trauma are among common threats
to brain health. In addition, a mother’s exposure to viruses or
toxic chemicals while pregnant may play a part, as can having
a history of child abuse or neglect.33 Mental illnesses can range
from mild to severe and can exact a heavy toll on quality of
life, for people with the illnesses as well as their family, friends,
and colleagues.
Mental disorders are common in the United States and
worldwide. The basis for diagnosing mental disorders in the
United States is the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5). An estimated 18.3 percent
of Americans age 18 years and older—just slightly under 1 in
5 adults—suffer from a diagnosable mental disorder in a given
year, and nearly half of them have more than one mental illness at the same time. Rates of these disorders are increasing,
particularly among young adults, and are often combined with
increasing rates of substance use disorders.34 About 4 percent,
MAKING CHANGES TODAY
Using PERMA to Enhance Your Happiness
Implement the following strategies to enhance well-being
and maintain a more positive outlook:
“P”—Positive Emotions
Consider what brings you the most happiness, and
engage in that behavior often.
Be open to new experiences, be curious, and be kind.
“E”—Engagement
Offer social support to other people, and accept support
that is offered to you.
“M”—Meaning
Consider: What is your legacy?
Invest time in activities that bring you peace: Pray, meditate, or care for other people.
“A”—Accomplishment
Adopt mindfulness and appreciation for being in the present moment.
Set realistic goals, and pursue them.
Consider what activities completely absorb you, and
invest more time in those activities.
If accomplishment equals skills plus effort, put forth the
effort to build strong skills.
“R”—Relationships
Open yourself to building new relationships and deepen
existing ones.
or approximately 1 in 20, suffer from a serious mental illness
requiring close monitoring, residential care in many instances,
and medication, yet fewer than half of these receive mental
health and/or substance use treatment.35
Mental Health Threats to College
Students
Mental health problems among college students are increasing in both number and severity, with visits to university counseling centers up by 30 to 40 percent in the past 5
years.36 The most recent National College Health Assessment
survey found that just over 39 percent of undergraduates
reported “feeling so depressed it was difficult to function”
at least once in the past year, and 12.1 percent of students
reported “seriously considering attempting suicide” in the
past year.37 In all, more than 1 in 4 college students are diagnosed or treated by a professional for a mental health issue
each year.38 Anxiety is the most common (21.6 percent), with
depression (17.8 percent) not far behind.39 FIGURE 2.4 on
page 46 shows the mental health concerns reported by American college students.
Although there are many types of mental illnesses, we
focus here on the disorders that are most common among
college students: mood disorders, anxiety disorders, obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), personality disorders, and schizophrenia. See
the HEALTH HEADLINES box on page 47 for information on
other brain-based disorders in young adults. (Other mental
Sources: Adapted from E. Terantin-O’Brien, IDEA Health and Fitness
Association, “Applying the PERMA Model,” June 2013, Available at www.
ideafit.com/fitness-library/applying-the-perma-model; M. Seligman, Flourish: A Visionary New Understanding of Happiness and Well-Being (New
York: Free Press, 2011).
APPROXIMATELY
9.3
MILLION
adults seriously CONSIDERED SUICIDE
in the past year.
disorders of particular concern for young adults, such as eating
disorders and addiction, are covered in more detail in Focus
On: Enhancing Your Body Image on page 172 and Focus On:
Recognizing and Avoiding Addiction on page 290.)
Mood Disorders
Chronic mood disorders are disorders that affect how you
feel, such as persistent sadness or feelings of euphoria. They
include major depression, persistent depressive disorder, bipolar disorder, and seasonal affective disorder. In any given year,
approximately 10 percent of
Americans age 18 or older sufmental illnesses Disorders
fer from a mood disorder.40
that disrupt thinking, feeling,
Major Depression
We’ve all had days when life’s
challenges push us over the
proverbial edge, but short
periods of feeling down are
moods, and behaviors and
that impair daily functioning.
chronic mood disorder
Experience of persistent
emotional states, such as
sadness, despair, hopelessness, or euphoria.
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 45
Felt overwhelmed by all they needed to do: 86.5%
Felt overwhelming exhaustion (not for physical activity): 83.4%
Felt overwhelming anxiety: 60.9%
Felt so depressed that it was difficult to function: 39.3%
Seriously considered suicide: 12.1%
Intentionally injured themselves: 7%
Attempted suicide: 1.9%
FIGURE 2.4
Mental Health Concerns of American College Students, Past
12 Months
Source: Data from American College Health Association, American College Health Association—National
College Health Assessment II (ACHA-NCHA II): Reference Group Data Report, Fall 2017 (Hanover, MD:
American College Health Association, 2018).
not the same as major depression. Major depression or clinical depression is a common mood disorder, affecting approximately 6.7 percent of the
adult U.S. population in
major depression
a given year, with highest
Severe depressive disorder with
rates (nearly 11 percent) in
physical effects such as sleep
disturbance and ­exhaustion
the 18- to 25-year-old group.
and mental effects such as the
These numbers are likely to
inability to concentrate; also
underestimate the prevacalled clinical depression.
lence of depression. Overattention-deficit (hyperac­
all, nearly 60 percent of U.S.
tivity) disorder (ADD/
adults with major depresADHD) A learning disability
usually associated with schoolsion are not being treated.41
aged children, often involvMajor depression is charing difficulty concentrating,
acterized
by a combination of
organizing things, listening to
symptoms that interfere with
instructions, and remembering
details.
work, study, sleep, appetite,
46 | PART ONE | Finding the Right Balance
relationships, and enjoyment of life. Symptoms can last for weeks,
months, or years and vary in intensity.42 Sadness and despair
are the main symptoms of depression.43 Other common signs
include:
■■
■■
■■
■■
■■
■■
■■
■■
Loss of motivation or interest in pleasurable activities.
Preoccupation with failures and inadequacies; concern
over what others are thinking or saying about you.
Difficulty concentrating; indecisiveness; memory lapses.
Loss of sex drive or interest in close interactions with
others.
Fatigue, oversleeping, insomnia, and loss of energy.
Feeling agitated, emotional volatility, feeling worthless, or
hopeless.
Significant weight loss or gain due to appetite changes.
Recurring thoughts that life isn’t worth living; thoughts of
death or suicide.
HEALTH
HEADLINES
S
ome brain-based disorders are not
mental illnesses. Just as people living
with mental illness can be successful
in college with appropriate counseling,
medication, and/or accommodations,
people living with learning disabilities
(LDs) and neurodevelopmental disorders
can also be successful in college when
the proper supports are in place.
Attention-deficit (hyperactivity) disorder (ADD/ADHD) is a learning disability
usually associated with school-aged
children, but for many people, symptoms
persist into adulthood. People with ADD/
ADHD are distracted much of the time.
Even when they try to concentrate, they
find it hard to pay attention. Organizing
things, listening to instructions, and remembering details are especially difficult.
About 4 percent of the adult population,
or slightly over 12 million adults, are living with ADHD. Recent studies indicate
that ADHD affects somewhere between
2 and 8 percent of college students. Left
untreated, ADHD can disrupt everything
from careers to relationships to financial
stability. Key areas of disruption might
include:
Health. Alcohol and drug abuse,
compulsive eating, and forgetting to
take important medications are all
ways ADHD can impact health.
■■ Work and finances. Difficulty concentrating, completing tasks, listening,
and relating to other people can lead
to trouble at work and at school. A
person with ADHD may also struggle to
pay bills on time, lose paperwork, miss
deadlines, or spend impulsively, resulting in debt.
■■ Relationships. If you have ADHD, it
might feel as though your friends and
loved ones regularly prod you to get
■■
Depression
College Success with Learning
Disabilities and Neurodevelopmental
Disorders
Disorder and chaos can be headaches
for us all, but ADHD sufferers may find
them insurmountable obstacles.
your things organized, to be tidy, and
to get things done. If your romantic
partner has ADHD, you might be hurt
that your loved one doesn’t seem to
listen to you, blurts out hurtful things,
and leaves you with the bulk of organizing and planning.
Dyslexia is a language-based learning
disorder that can pose problems for reading, writing, and spelling. Lesser known,
but equally challenging, are dyscalculia
(a learning disability involving math) and
dysgraphia (a learning disability involving
writing). People with dysgraphia may have
difficulty putting letters, numbers, and
words on a page in order.
Autism spectrum disorder (ASD) is
not a learning disability, but a neurode-
in College Students Mental
health problems, particularly depression, have gained increased
recognition as major obstacles to healthy adjustment and success in college. Students with weak communication skills, who
find that college isn’t what they expected, or who lack motivation often have difficulties. Stressors such as anxiety over
velopmental disorder (an impairment in
brain development). People with an ASD
will continue to learn and grow intellectually, but struggle to master communication
and social behavior skills, which impacts
their performance in school and work.
Some adults with an ASD (especially those
with high-functioning autism or Asperger
syndrome) attend college and go on to
succeed in the workforce.
Universities regularly offer a variety of
support services to help students with
learning disabilities. These may include
testing and diagnosis for LDs, including
prescribing medication for ADD/ADHD;
reading and writing supports; exam accommodations, such as extra time or a
quiet location; and coaching on study skills
and test anxiety. These supports are generally offered at no cost through an office of
disability services or health center. Some
campuses have developed programs specifically targeted toward students on the
autism spectrum. Students with ASD usually need a significant amount of support to
be successful in college. In addition to the
free services offered to students with LDs,
some schools offer additional fee-based
assistance including tutoring, help with
financial management, and support groups
for social interaction and leisure activities.
Sources: Centers for Disease Control and Prevention, “Attention-Deficit Hyperactivity Disorder,”
January 2016, www.cdc.gov/ncbddd/adhd/facts.html;
M. Gormley et al., “First-Year GPA and Academic
Service Use among College Students with and without ADHD,” Journal of Attention Disorders (2016),
DOI: 10.1177/1087054715623046; D. Singley,
“College Students with Learning Disability or
Attention-Deficit Hyperactivity Disorder.” Proquest
Dissertation Pub. 2017. 10278516; A. Fleming et al.,
“Pilot Randomized Controlled Trial of Dialectical
Behavior Therapy Group Skills Training for ADHD
among College Students,” Journal of Attention
Disorders 19, no. 3 (2015): 260–71.
relationships, pressure to get
good grades and win social
acceptance, abuse of alcohol
and other drugs, poor diet,
and lack of sleep can overwhelm even the most resilient
dyslexia Language-based
learning disorder that can pose
problems for reading, writing,
and spelling.
dyscalculia A learning disability involving math.
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 47
SEE IT! VIDEOS
students. In a recent survey
by the American College
Are actors and comedians at
Health Association, 17.8
a higher risk for depression?
percent of college students
Watch What Are the Causes
reported having been diagfor Depression, available on
nosed with or treated for
Mastering Health.
depression in the past 12
months.44
Being far from home without the security of family and
friends can exacerbate problems. International students and
those from different minority groups are particularly vulnerable. Most campuses have counseling centers and other services
available; however, many students do not use them because of
persistent stigma about seeing a counselor.
Persistent Depressive Disorder
Persistent
depressive disorder (PDD), formerly called dysthymic disorder or
dysthymia, is a less severe syndrome of chronic mild depression
and can be harder to recognize than major depression. Individuals with PDD may appear to function well, but they may lack
energy or may fatigue easily; be short-tempered, overly pessimistic, and ornery; or just not feel quite up to par but not have any
significant, overt symptoms.
People with PDD may cycle
dysgraphia A learning disability involving writing; individuals
into major depression over
may have difficulty putting
time. For a diagnosis, sympletters, numbers, and words on
toms must persist for at least 2
a page into order.
years in adults (1 year in chilautism spectrum disorder
dren). This disorder affects
(ASD) A neurodevelopmental
approximately 1.5 percent of
disorder (an impairment in brain
development) where individuthe adult population in the
als learn and grow intellectuUnited States in a given year.45
ally throughout their lives, but
struggle to master communication and social behavior skills,
impacting school and work
performance.
Asperger syndrome A form
of high-functioning autism.
persistent depressive
disorder (PDD) Type of
depression that is milder and
harder to recognize than major
depression; chronic; and often
characterized by fatigue, pessimism, or a short temper. Also
called dysthymic disorder or
dysthymia.
bipolar disorder Form of
mood disorder characterized by
alternating mania and depression; also called manic-depressive illness.
seasonal affective disorder
(SAD) Type of depression that
occurs in the winter months,
when sunlight levels are low.
neurotransmitters Chemicals
that relay messages between
nerve cells or from nerve cells
to other body cells.
Bipolar
Disorder
People with bipolar disorder
(also known as manic-depressive illness) often have severe
mood swings, ranging from
extreme highs (mania) to
extreme lows (depression).
Sometimes these swings are
dramatic and rapid; other
times they are slow and gradual. When in the manic phase,
people may be overactive
and talkative, and have tons
of energy; in the depressed
phase, they may experience
some or all of the symptoms
of major depression. Bipolar
disorder affects approximately
2.8 percent of the adult population in the United States,
and 1.8 percent of college students were treated for bipolar
disorder last year.46
48 | PART ONE | Finding the Right Balance
Although
the
cause of bipolar disorder is unknown,
biological, genetic,
and environmental
factors, such as drug
abuse and stressful or
psychologically traumatic events, seem
to be involved in
triggering episodes.
Once
diagnosed,
persons with bipolar
disorder have several
counseling and pharmaceutical options,
and most will be
able to live a healthy,
functional life while
being treated.
Seasonal
Affective Disorder Seasonal
There is more to depression
than simply feeling blue. When a
person is clinically depressed, he
or she finds it difficult to function,
sometimes struggling just to get
out of bed in the morning or to
follow a conversation.
affective disorder
(SAD) often strikes
during the fall and
winter months and is associated with reduced exposure to
sunlight. People with SAD suffer from extreme fatigue, irritability, apathy, carbohydrate craving and weight gain, increased
sleep time, and general sadness. Several factors are implicated
in SAD development, including disruption in the body’s circadian rhythms and changes in levels of the hormone melatonin and the brain chemical serotonin.47 Over 500,000 people
in the United States suffer from SAD. Nearly three-fourths of
those with SAD are women in early adulthood, particularly
those living at high latitudes with long winter nights.48
The most beneficial treatment for SAD is light therapy,
which exposes patients to lamps that simulate sunlight. Other
treatments for SAD include diet change (such as eating more
complex carbohydrates), increased exercise, stress-management techniques, sleep restriction (limiting the number of
hours slept in a 24-hour period), psychotherapy, and prescription medications.
What Causes Mood Disorders?
Mood disorders are major fluctuations in your emotional state or mood,
typically ranging from depressive symptoms to manic symptoms. The majority of mood disorders fit into two broad
groups: depressive disorders and manic disorders.
Mood disorders are caused by the interaction between
multiple factors, including biological differences, hormones, inherited traits, life events, and early childhood
trauma.49 The biology of mood disorders is related to individual levels of brain chemicals called neurotransmitters.
Several types of depression, including bipolar disorder,
appear to have a genetic component. Depression can also be
triggered by a serious loss, difficult relationships, financial
problems, and pressure to succeed. Early childhood trauma,
such as loss of a parent, may cause permanent changes in
the brain, making one more prone to depression. Changes
in the body’s physical health can be accompanied by mental changes, particularly depression. Stroke, heart attack,
cancer, Parkinson’s disease, chronic pain, type 2 diabetes,
certain medications, alcohol, hormonal disorders, and a
wide range of other afflictions can cause a person to become
depressed, frustrated, or angry. When this happens, recovery
is often more difficult, as a person who feels exhausted and
defeated may lack the will to fight illness and do what is necessary to optimize recovery.
Although researchers aren’t
sure what causes panic attacks,
heredity, stress, and certain biochemical factors may play a role.
Your chances of having a panic
attack increase if a close relative has them. Some researchers
believe that people who suffer
panic attacks are experiencing
an overreactive fight-or-flight
physical response. (See Chapter
3 for more on the fight-or-flight
response.)
Anxiety Disorders
Phobic Disorders
Anxiety disorders, characterized by persistent feelings of
threat and worry, are the most common mental health problems in the United States. They include generalized anxiety
disorder, panic disorders, PTSD, and phobic disorders. Anxiety
disorders affect more than 40 million people in any given
year. Anxiety disorders are most prevalent among 13- to
17-year-olds, with a median age of onset of 6 years.50 Approximately 20.7 percent of U.S. undergraduates report having
been diagnosed with or treated for anxiety in the past year.51
Generalized Anxiety Disorder
One common
form of anxiety disorder, generalized anxiety disorder
(GAD), is severe enough to interfere significantly
with daily life. To be diagnosed with GAD,
one must exhibit at least three of the
following symptoms for more
days than not during a 6-month
period: restlessness or feeling
keyed up or on edge, being easily
fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and/or
sleep disturbances.52
Panic Disorder Panic disorder is
characterized by the occurrence of panic
attacks, an acute anxiety reaction that
brings on an intense physical reaction.
Approximately 10.7 percent of college students report having been diagnosed or treated
for panic attacks in the past year.53 Panic
attacks and disorders are increasing in incidence, particularly among young women.
Although highly treatable, panic attacks may become debilitating and destructive, particularly if they happen often and
cause the person to avoid going out in public or interacting with
others. A panic attack typically starts abruptly, peaks within 10
minutes, lasts about 30 minutes, and leaves the person tired and
drained. Symptoms include increased respiration, chills, hot
flashes, shortness of breath, stomach cramps, chest pain, difficulty swallowing, and a sense of doom or impending death.54
anxiety disorders Mental
illness characterized by
persistent feelings of threat
and worry in coping with
everyday problems.
generalized anxiety
disorder (GAD) A constant
sense of worry that may
cause restlessness, difficulty
in concentrating, tension,
and other symptoms.
panic attack Severe anxiety
reaction in which a particular
situation, often for unknown
reasons, causes terror.
phobia Deep and persistent
fear of a specific object, activity, or situation that results
in a compelling desire to
avoid the source of the fear.
Phobias, or phobic disorders,
involve a persistent and irrational fear of a specific object,
activity, or situation, often
social anxiety disorder
Phobia characterized by
out of proportion to the cirfear and avoidance of social
cumstances. Phobias result in
situations; also called social
a compelling desire to avoid
phobia.
the source of the fear. Between
5 and 12 percent of American
adults suffer from specific phobias, such as fear of spiders,
snakes, or riding in elevators.55
Another 7.4 percent of American adults suffer from social
anxiety disorder, also called social phobia.56 Social anxiety
disorder is characterized by the persistent fear and avoidance of social situations. Essentially, the person dreads
these situations for fear of being humiliated,
embarrassed, or even looked at. These
disorders vary in scope. Some cause
difficulty only in specific situations, such as getting up in front
of the class to give a presentation, while in extreme cases,
a person avoids all contact
with others.
Many
people are
Obsessive–Compulsive
uneasy around
spiders, but if
Disorder A chronic disorder in
your fear of them
which a person has uncontrollable,
is debilitating,
reoccurring thoughts (obsessions) and
it may be a
behaviors (compulsions) that lead to
phobia.
repeating behaviors over and over; has
obsessive fears of things like germs or bugs;
has an unnatural concern about order, symmetry, and exactness; or has persistent intrusive thoughts,
impulses, or images that cause intense anxiety or distress may
be suffering from obsessive–compulsive disorder (OCD). Just
over 1 percent of Americans age 18 and over have OCD.58
Not to be confused with being a perfectionist, a person
with OCD often knows the behaviors are irrational, yet is
powerless to stop them. According to the DSM-5, a diagnosis
of OCD applies when obsessions consume more than 1 hour
per day and interfere with normal social or life activities.
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 49
DID YOU
KNOW?
About 1 in 3 people with panic disorder
develops agoraphobia, a condition in
which the person becomes afraid of
being in any place or situation—such
as a crowd or a wide-open space—
where escape might be difficult in the
event of a panic attack.
actually cause chemical changes in the brain, leading to PTSD.62
Symptoms of PTSD include:
■■
■■
■■
■■
■■
Dissociation, or perceived detachment of the mind from
the emotional state or even the body.
Intrusive recollections of the traumatic event, such as
flashbacks, nightmares, and recurrent thoughts or images.
Acute anxiety or nervousness, in which the person is
hyper-aroused, may cry easily, or experiences mood swings.
Insomnia and difficulty concentrating.
Intense physiological reactions, such as shaking or nausea,
when something reminds the person of the traumatic event.
PTSD may be diagnosed if a person experiences symptoms
for at least 1 month following a traumatic event. However, in
some cases, symptoms don’t appear until months or even years
later. Treatment for PTSD may involve psychotherapy, as well
as medications to help with depression, anxiety, and sleep.
Group therapy and individual talk therapy are also often recommended, depending on the nature and severity of PTSD.
What Causes Anxiety Disorders?
Source: Anxiety and Depression Association of America, “Panic
­Disorder and Agoraphobia,” Accessed February 2016, www.adaa.org/
understanding-anxiety/panic-disorder-agoraphobia.
Although the exact cause is unknown, genetics, biological
abnormalities, learned behaviors, and environmental factors
have all been considered. OCD usually begins in childhood
or the teen years; in most people the disorder is diagnosed
before age 20.59
Although OCD is highly treatable, only one-third of individuals with the disorder receive treatment. Treatments vary
by disorder type, severity, and other factors. The most effective
treatments tend to be a combination of psychotherapy and
medications designed to treat symptoms, such as antidepressants or antianxiety medication.60
Posttraumatic Stress Disorder People who
have experienced or witnessed a traumatic event may develop
posttraumatic stress disorder (PTSD). Between 7 and 8 percent
of U.S. adults will have PTSD in their lifetime. About 50 percent of
women experience at least one traumatic event in their lifetime,
often as a result of sexual assault or child sexual assault. Nearly
60 percent of men will have
obsessive–compulsive
at least one traumatic event;
disorder (OCD) Form of anxihowever, their trauma is often
ety disorder characterized by
the result of accidents, physical
recurrent, unwanted thoughts
assaults, and military conduct,
and repetitive behaviors.
or witnessing death, serious
posttraumatic stress
injury, sexual assault, or other
disorder (PTSD) Collection of
events. Both men and women
symptoms that may occur as
a delayed response to a trauare traumatized by natural
matic event or series of events.
disasters and terrorism.61 It
personality disorder Mental
is important to understand
disorder characterized by
that PTSD is not rooted in
inflexible patterns of thoughts
weakness or an inability to
and beliefs that lead to socially
distressing behavior.
cope; traumatic events can
50 | PART ONE | Finding the Right Balance
Because
anxiety dis­orders vary in complexity and degree, scientists
have yet to find clear r­ easons why one person develops them
and another doesn’t. The following factors are often cited as
possible causes:57
Biology. Some scientists trace the origin of anxiety to the
brain and its functioning. Using sophisticated positron
emission tomography (PET) scans, scientists can analyze
areas of the brain that react during anxiety-producing
events. Families appear to display similar brain and physiological reactivity, so we may inherit tendencies toward
anxiety disorders.
■■ Environment. Anxiety can be a learned response. Experiencing a repeated pattern of reaction to certain situations
can program the brain to respond in a certain way. For
example, if your sibling had a fear of spiders and screamed
whenever one crept into view during your childhood, you
might develop similar anxieties.
■■ Social and cultural roles. Because men and women have
historically been taught to assume specific roles, women may
find it more acceptable to talk about their illnesses and seek
care, while men may talk less about their mental health issues
as a sign of strength. Explaining why women experience
more mental health issues and seek care more frequently is a
complex discussion—one that involves historical precedent,
stigma, and long-established gender role beliefs, as well as
unique social and environmental factors affecting individual
mental health risks, reporting, health care–seeking behaviors, provider diagnosis, and treatment behaviors. For more
on these factors, see Focus On: Difference, Disparity, and
Health: Achieving Health Equity on page 23.
■■
Personality Disorders
According to the DSM-5, a personality disorder is an “enduring pattern of inner experience and behavior that deviates
Schizophrenia
Normal brain
Schizophrenic
brain
These brain images reveal the difference in brain activity in
persons with and without schizophrenia. The yellow and red
correspond to areas with greatest activity, and blue signifies
reduced activity.
markedly from the expectation of the individual’s culture and
is pervasive and inflexible.”63 It is estimated that at least 9.1
percent of adults in the United States have some form of personality disorder as defined by the DSM-5.64 People who live,
work, or are in relationships with individuals suffering from
personality disorders often find interactions with them to be
challenging and destructive.
One common type of personality disorder is paranoid personality disorder, which involves pervasive, unfounded suspicion and mistrust of other people, irrational jealousy, and
secretiveness. Persons with this illness have delusions of being
persecuted by everyone, from family members and loved ones
to the government.
Narcissistic personality disorder involves an exaggerated sense
of self-importance and self-absorption. Persons with narcissistic personalities are preoccupied with fantasies of how wonderful they are. Typically, they are overly needy and demanding
and believe that they are “entitled” to nothing but the best.
Persons with antisocial personality disorder display a long-term
pattern of manipulation and taking advantage of others, often
in a criminal manner. Symptoms include disregard for the safety
of others and lack of remorse, arrogance, and anger. Men with
antisocial personality disorder far outnumber women, and it
remains one of the hardest to treat of all personality disorders.65
Borderline personality disorder (BPD) is characterized by severe
emotional instability, impulsiveness, mood swings, and poor
self-image.66 High suicide rates, unpredictable mood swings,
and erratic and risky behaviors, including gambling, unsafe sex,
illicit drug use, daredevil driving, and self-mutilation, are typical.67 (For more about self-mutilation, see STUDENT HEALTH
TODAY on page 52.) Although causation is not clear, genetics
and environment appear to converge to increase risks. It is estimated that 1.5 percent of adults in the United States have BPD
in a given year; however, that number may be much higher.
BPD usually begins during adolescence or early adulthood.68
For treating personality disorders, individual and group
psychotherapy, skill development, family education, support
from peers, and medications can lead to a good long-term
prognosis.69
schizophrenia Mental
illness with biological origins
Schizophrenia is a severe psycharacterized by irrational
chological disorder that affects
behavior, severe alterations
about 1 percent of the U.S.
of the senses, and often an
inability to function in society.
population.70 Schizophrenia is
characterized by alterations of
the senses (including auditory and visual hallucinations); the
inability to sort and process incoming stimuli and make appropriate responses; an altered sense of self; and radical changes
in emotions, movements, and behaviors. Typical symptoms
of schizophrenia include fluctuating courses of delusional
behavior, hallucinations, incoherent and rambling speech,
inability to think logically, erratic movement, odd gesturing,
and difficulty with normal activities of daily living.71 Symptoms usually appear in men in their late teens and 20s and in
women in their late 20s and early 30s.72 Such individuals are
often regarded as odd or dangerous, and viewed that way, they
have difficulties in social interactions and may withdraw.
For decades, scientists believed that schizophrenia was
a form of madness provoked by the environment in which a
child lived. In the mid-1980s, magnetic resonance imaging
(MRI) and PET scans began allowing scientists to study brain
function more closely; that knowledge indicated that schizophrenia is a biological disease of the brain. The brain damage
occurs early in life, possibly as early as the second trimester of
fetal development. Fetal exposure to toxic substances, infections, and medications have been studied as a possible risk,
and hereditary links are being explored.
Even though theories that blame abnormal family life or
childhood trauma for schizophrenia have been discarded in
favor of biological theories, a stigma remains. Families of people with schizophrenia frequently experience anger and guilt.
They often need counseling on how to meet the schizophrenic
person’s needs for shelter, medical care, vocational training,
and social interaction.
At present, schizophrenia is treatable but not curable. Treatments usually include some combination of hospitalization,
medication, and psychotherapy. With proper medication,
public understanding, support of loved ones, and access to
therapy, many people with schizophrenia lead normal lives.
LO 4 | SUICIDE: GIVING UP
ON LIFE
Discuss risk factors and possible warning signs of suicide, as well
as actions that can be taken to help a person contemplating suicide.
Over 45,000 people die each year of suicide in the U.S. For 15-34
year olds, suicide is the 2nd leading cause of death and rates are
increasing at almost every age and stage of life.73 For every completed suicide globally, it is estimated that there are 20 more
attempts.74 In some of the richest countries, more than three
times as many men die of suicide as women. However, in lowand middle-income countries, the male-to-female suicide ratio
is only 1.5 men to every woman. Globally, suicides make up
50 percent of all violent deaths for men and over 71 percent for
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 51
STUDENT
HEALTH TODAY
W
hen some people are unable to deal
with the pain, pressure, or stress
they experience in everyday life, they may
resort to self-harm in an effort to cope.
Self-injury, also termed self-mutilation,
self-harm, or nonsuicidal self-injury (NSI), is
the act of deliberately harming one’s body
tissue without suicidal attempt and for purposes that are not socially supported.
The most common method of selfharm is cutting (with razors, glass, knives,
or other sharp objects). Other methods
include burning, bruising, excessive nail
biting, breaking bones, pulling out hair, and
embedding sharp objects under the skin.
Approximately 4–6 percent of adults in
the United States have engaged in NSI at
least once in their lifetime. However, the
occurrence of NSI is much higher in young
adults and adolescents. The prevalence of
NSI in college students is estimated to be
approximately 6 percent. NSI more commonly occurs in female college students,
approximately 7 percent in the past 12
months, versus approximately 4 percent
in males. Estimates are higher in the high
school population, with the majority of studies reporting between 14 and 18 percent
of adolescents and young adults engaging
in self-injury at least once in their lifetime.
Many people who harm themselves suffer
from other mental health conditions and
have experienced sexual, physical, or emotional abuse as children or adults. Self-harm
is also commonly associated with mental
illnesses such as borderline personality
Cutting Through the Pain
disorder, depression, anxiety disorders,
substance abuse disorders, posttraumatic
stress disorder, and eating disorders.
Signs of self-injury include multiple
scars, current cuts and abrasions, and
implausible explanations for wounds
and ongoing injuries. A self-injurer may
attempt to conceal scars and injuries by
wearing long sleeves and pants. Other
symptoms can include difficulty handling
anger, social withdrawal, sensitivity to
rejection, or body alienation. If you or
someone you know is engaging in selfinjury, seek professional help. Treatment is
challenging; not only must the self-injurious behavior be stopped, but the sufferer
must also learn to recognize and manage
the feelings that trigger the behavior.
If you are a recovering self-injurer,
some of the following steps may be part
of your treatment:
1. Start by being aware of feelings and
situations that trigger your urge to
hurt yourself.
2. Identify a plan of what you can do
instead when you feel the urge.
3. Create a list of alternatives, including:
Things that might distract you
■■ Things that might soothe and calm
you
■■ Things that might help you
express the pain and deep
emotion
■■ Things that might help release
physical tension and distress
■■
women. The highest rates of suicide are among individuals age
70 years and older.75
Surprisingly, in 54 percent of all suicide deaths, the person has no known mental health condition.76 The pressures,
disappointments, challenges, and changes of the college
years may contribute to the emotional turmoil that can lead
a young person to contemplate suicide. According to the 2017
National College Health Assessment, 12.1 percent of students
had seriously considered suiself-injury Intentionally
causing injury to one’s own
cide in the last 12 months,
body in an attempt to cope
and 1.9 percent had attempted
with overwhelming negato kill themselves in the past
tive emotions; also called
year.77 However, young adults
self-mutilation, self-harm, or
nonsuicidal self-injury (NSSI).
who do not attend college are
52 | PART ONE | Finding the Right Balance
Cutting and scratching behaviors
are more common in females,
while burning and hitting behaviors are more common in males.
■■ Things that might help you feel
supported and connected
■■ Things that might substitute for
the cutting sensation
For more information, visit these
resources: S.A.F.E. Alternatives,
www.selfinjury.com, and Help Guide,
www.helpguide.org/mental/self_injury.htm.
also at risk; in fact, suicide rates are higher for young adults in
the general population than for college students.78
Risk Factors for Suicide
Risk factors include a family history of suicide, previous suicide
attempts, excessive drug and alcohol use, prolonged depression,
financial difficulties, serious illness in oneself or a loved one, and
loss of a loved one through death or rejection. Recent research
indicates that 30 percent of transgender youths have made at
least one attempt at suicide, and around 42 percent of transgender youths have engaged in self-injury, such as cutting—­
significantly higher rates than in other groups.79
Whether they are more likely to attempt suicide or are
more often successful, nearly four times as many men die by
suicide as women.80 The most commonly used method of suicide among males is firearms; for women, the most common
method is poisoning.81
■■
■■
■■
Warning Signs of Suicide
People who die of suicide usually indicate their intentions,
although others do not always recognize their warnings.82
Anyone who expresses a desire to kill him- or herself or who
has made an attempt is at risk. Common signs that a person
may be contemplating suicide include:83
Recent loss and a seeming inability to let go of grief.
History of depression.
■■ Change in personality, such as sadness, withdrawal, irritability, anxiety, tiredness, indecisiveness, apathy.
■■ Change in behavior, such as inability to concentrate, loss
of interest in classes or work, unexplained demonstration
of happiness following a period of depression, or risktaking behavior.
■■
■■
■■
■■
■■
■■
Change in sexual interest.
Change in sleep patterns and/or eating habits.
A direct statement (including statements posted on social
media) indicating they are thinking about suicide, such as
“I might as well end it all.”
An indirect statement (including statements posted on
social media), such as “You won’t have to worry about me
anymore.”
Final preparations such as writing a will, giving away
prized possessions, or writing revealing letters or social
media posts.
Preoccupation with themes of death.
Marked changes in personal appearance.
Preventing Suicide
Most people who attempt suicide really want to live but see
death as the only way out of an intolerable situation. Crisis
counselors and suicide hotlines may help temporarily, but
the best way to prevent suicide is to get rid of conditions and
substances that may precipitate attempts, including alcohol,
drugs, loneliness, isolation, and access to guns.
If someone you know threatens suicide or displays warning signs, get involved. Ask questions and seek help. Specific
actions you can take include:84
■■
■■
■■
■■
■■
■■
■■
Monitor the warning signals. Keep an eye on the person or
see that someone else is present. Don’t leave the person alone.
Take threats seriously. Don’t brush them off as “cries for
attention.” Act now.
Let the person know how much you care. State that you are
there to help.
Ask directly. “Are you thinking of hurting or killing yourself?”
Don’t be judgmental. Let them share their thoughts.
Take action. Remove from the area any firearms or objects
that could be used for suicide.
Help the person think about alternatives to suicide. Offer
to go for help along with the person. Call your local suicide hotline, and use all available community and campus
resources.
Tell the person’s spouse, partner, parents, siblings, or
counselor. Do not keep your suspicions to yourself. Don’t
let a suicidal friend talk you into keeping your discussions
confidential. If your friend succeeds in a suicide attempt,
you may blame yourself.
LO 5 | SEEKING
PROFESSIONAL HELP
In June 2018, highly successful fashion designer and
businesswoman, Kate Spade shocked everyone with
her apparent death by suicide. Sources indicate that
she suffered from anxiety and depression. However, few
realized that she was having difficulties when she took her
life by hanging.
Explain the different types of treatment options and professional
services available to those experiencing mental health
problems.
A physical ailment will readily send most of us to the nearest
health professional, but many view seeking professional help for
psychological problems as an admission of personal failure. In
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 53
2016, only 35 percent of young
adults aged 18–25 with mental
health problems received treatment as compared to 43 percent
of those 26–49 and 47 percent of those over age 50.85
Researchers view breakdowns in support systems, high
societal expectations, and dysfunctional families as three
major reasons why people need more assistance than ever
before. Consider seeking help if:
stigma Negative perception
about a group of people or a
certain situation or condition.
■■
■■
■■
■■
■■
■■
■■
■■
■■
You feel out of control.
You experience wild mood swings or inappropriate
emotional responses to normal stimuli.
Your fears or feelings of guilt frequently distract your
attention.
You begin to withdraw from others.
You have hallucinations.
You feel inadequate or worthless or that life is not worth
living.
Your daily life seems to be nothing but a series of repeated
crises.
You are considering suicide.
You turn to drugs or alcohol to escape your problems.
Low-cost or free counseling sessions or support groups are
often available on college campuses to help students deal with
all types of issues, including mental illness; recovery from eating disorders, substance abuse, and other addictions; dealing
with health conditions such as diabetes or cancer; and addressing other challenges, such as managing stress, overcoming fear
of public speaking, becoming more physically fit, or changing
eating habits.
Mental Illness Stigma
A stigma is a negative perception about groups of people or
certain situations or conditions. Common stigmas about
people with mental illness are that they are dangerous or
irresponsible, require constant care, or “just need to get over
it.” In truth, only about 3 to 5 percent of all violent acts are
attributed to people with serious mental illness. It is no more
likely for most people with mental health problems to be violent than it is for anyone else, even though the mentally ill
are ten times more likely to become victims of violence. Most
hold regular jobs, are productive members of society, and lead
­normal lives.86
54%
OF SUICIDE
deaths occur in people with NO
KNOWN mental health condition.
54 | PART ONE | Finding the Right Balance
The stigma of mental
illness often leads to feelings of shame and guilt,
loss of self-esteem, and
a sense of isolation and
hopelessness. Many people who have successfully
managed their mental illness report that the stigma
they faced was more disabling at times than the
illness itself.87 This stigma
may cause people who are
struggling with a mental
illness to delay seeking
treatment or avoid care
that could dramatically
improve their symptoms
and quality of life.
WHAT DO
YOU THINK?
Do you notice a
stigma associated with
mental illness in your campus?
If yes, describe the way(s)
stigma appears on campus.
■■ How often do you hear terms
such as “crazy” or “whacko”
used to describe people who
appear to have a mental
health problem? Why are
those words harmful?
■■ What could you do to
combat the stigma of mental
illness?
Getting Evaluated for Treatment
If you are considering treatment for a psychological problem,
schedule a complete evaluation first. Consult a credentialed
health professional for a thorough examination, which should
include three parts:
1. A physical checkup, which will rule out thyroid disorders,
viral infections, and anemia—all of which can result in
depression-like symptoms—and a neurological check
of coordination, reflexes, and balance to rule out brain
disorders.
2. A psychiatric history, which will trace the course of the
apparent disorder, genetic or family factors, and any past
treatments.
3. A mental status examination, which will assess thoughts,
speaking processes, and memory, and will include
an in-depth interview with tests for other psychiatric
­symptoms.
Once physical factors have been ruled out, you may decide to
consult a professional who specializes in psychological health.
Mental Health Professionals
Several types of mental health professionals are available;
TABLE 2.1 provides information on the most common types
of practitioners. When choosing a therapist, it is important to
verify that he or she has the appropriate training and certification. The most important factor is whether you feel that you
can work with the therapist. A qualified mental health professional should be willing to answer all your questions during an
initial consultation. Questions to ask the therapist or yourself
include:
■■
Can you interview the therapist before starting treatment?
An initial meeting will help you determine whether this
person will be a good fit for you.
Do you like the therapist as a
person? Can you talk to him or her
comfortably?
■■ Is the therapist watching the clock or
easily distracted? You should be the
main focus of the session.
■■ Does the therapist demonstrate
­professionalism? Be concerned if your
therapist is frequently late or breaks
appointments, suggests social interactions outside therapy sessions, talks
inappropriately about him- or herself,
has questionable billing practices, or
resists releasing you from therapy.
■■ Will the therapist help you set your own
goals and timetables? A good professional should evaluate your general
situation and help you set small goals to
work on between sessions.
■■
When you begin seeing a mental health professional, you enter into a relationship
with that person, and just as with any person, you will connect better with some
therapists than others. If one doesn’t “feel right,” trust your instincts and look for
someone else.
Note that the use of the title therapist or
counselor is not nationally regulated. Check
credentials and make your choice carefully.
TABLE 2.1 | Mental Health Professionals
What Are They
Called?
What Kind of Training Do
They Have?
What Kind of Therapy Do
They Do?
Professional Association
Psychiatrist
Medical doctor degree (MD),
followed by 4 years of mental
health training
Can prescribe medications and
may have admitting privileges at
a local hospital
American Psychiatric Association
www.psych.org
Psychologist
Doctoral degree in counseling
or clinical psychology (PhD),
plus several years of supervised
practice to earn license
Various types, such as
cognitive-behavioral therapy and
specialties including family or
sexual counseling
American Psychological
Association
www.apa.org
Clinical/psychiatric social
worker
Master’s degree in social work
(MSW), followed by 2 years of
experience in a clinical setting to
earn license
May be trained in certain
specialties, such as substance
abuse counseling or child
counseling
National Association of Social
Workers
www.socialworkers.org
Counselor
Master’s degree in counseling,
psychology, educational
psychology, or related human
service; generally must complete
at least 2 years of supervised
practice to obtain a license
Many are trained to provide
individual and group therapy;
may specialize in one type of
counseling, such as family,
marital, relationship, children, or
substance abuse
American Counseling Association
www.counseling.org
Psychoanalyst
Postgraduate degree in
psychology or psychiatry (PhD or
MD), followed by 8–10 years of
training in psychoanalysis, which
includes undergoing analysis
themselves
Based on the theories of Freud
and others, focuses on patterns
of thinking and behavior and
recalling early traumas that block
personal growth; treatment lasts
5–10 years, with three to four
sessions per week
American Psychoanalytic
Association
www.apsa.org
Licensed marriage and
family therapist (LMFT)
Master’s or doctoral degree
in psychology, social work, or
counseling, specializing in family
and interpersonal dynamics;
generally must complete at least
2 years of supervised practice to
obtain a license
Treats individuals or families who
want relationship counseling;
treatment is often brief and
focused on finding solutions to
specific relational problems
American Association for
Marriage and Family Therapy
www.aamft.org
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 55
What to Expect in Therapy
Before making an appointment, call for information and
briefly explain your needs. Ask about office hours, policies and
procedures, fees, and insurance participation. The first trip to
a therapist can be unsettling. Most of us have misconceptions
about what therapy is and what it can do. The first visit serves
as a sizing-up between you and the therapist.
Dress however you feel most comfortable, arrive on time,
and expect your visit to last about an hour. The therapist will
record your history and details about the problem that has
brought you to therapy. Answer honestly and do not be embarrassed to acknowledge your feelings. It is critical to the success
of your treatment that you trust the therapist enough to be
open and honest.
Do not expect the therapist to tell you what to do or how
to behave. The responsibility for improved behavior lies with
you. If after your first visit (or even after several visits), you feel
you cannot work with this person, say so. You have the right to
find a therapist with whom you feel comfortable.
concepts of stimulus, response, and reinforcement to alter
behavior patterns. With cognitive-behavioral therapy, you
work with a mental health professional in a structured way,
attending a limited number of sessions to become aware of
inaccurate or negative thinking. Cognitive-behavioral therapy
enables you to view challenging situations more clearly and
respond to them more effectively. It can be very helpful for
treating anxiety or depression.90
Current research also shows that mindfulness may have
positive effects on treating mental health problems. See the
MINDFULNESS AND YOU box on page 58 for more.
Pharmacological Treatment
Treatment for some conditions combines cognitive-behavioral
therapies with psychoactive medication. TABLE 2.2 includes
information about the major classes of medications used to
treat the most common mental illnesses. Psychoactive drugs
require a doctor’s prescription and carry approval from the
U.S. Food and Drug Administration (FDA). Side effects of psychoactive drugs commonly include dry mouth, headaches,
Treatment Models Many different types of coun- nausea, sexual dysfunction, and weight gain. Additionally, the
FDA requires warnings for antidepressant medications, includseling exist, including psychodynamic therapy, interpersonal
ing a black box labeling (black box warnings are the FDA’s
therapy, and cognitive-behavioral therapy.
most stringent a drug can carry) that warns of increased risks
Psychodynamic therapy focuses on the psychological
of suicidal thinking and behavior during initial treatment in
roots of emotional suffering. This type of therapy has roots
young adults ages 18 to 24.91
in Freud’s theories and involves self-reflection, self-examPotency, dosage, and side effects of drugs can vary greatly.
ination, and the use of the relationship between therapist
It is vital to talk to your health care provider and completely
and patient as a window into problematic relationship patunderstand the risks and benefits of any prescribed medicaterns in the patient’s life. Its goal is not only to alleviate
tion. Likewise, your doctor needs to be notified as soon as
the most obvious symptoms, but also to help people lead
possible of any adverse effects you may experience. With
healthier lives.88
some drug therapies, such as antidepressants, you may not
Interpersonal therapy is a variafeel the therapeutic effects for several weeks, so patience is
tion of psychodynamic therapy
important. Finally, be sure to follow your doctor’s recommenand focuses on social roles and
dations for beginning or ending a course of any medication.
relationships. The patient
To avoid the side effects of psychoactive drugs, some
works with a therapist to evalpatients choose complementary or alternative therapies
uate specific problem areas
such as St. John’s wort or omega-3 fatty acids for depression
in the patient’s life, such
and kava or acupuncture for anxiety. Although the effias conflicts with family
cacy of these therapies has not yet been determined, the
and friends or significant
National Center for Complementary and Integrative
life changes or transitions.
Health continues to invest in research to explore
While past experiences help
alternatives to prescription drugs. Some therainform the process, interperpies, such as St. John’s wort, can be life
sonal therapy focuses mainly
threatening when combined with
on improving relationships in the
traditional depression medicapresent.89
Many
tions. Much research is still
Treatment for mental disorders can
people with
needed on both tradiinclude various cognitive-behavioral
mental illnesses
tional and alternative
therapies. Cognitive therapy focuses on
live normal lives
therapies for mental
the impact of thoughts and ideas on feelings and
with help from drugs
illness, so it is essential
behavior. It helps a person to look at life rationally
that keep their
to
talk to a medical profesand correct habitually pessimistic or faulty thinkillnesses under
sional when you are considering any new treating patterns. Behavioral therapy, as the name implies,
control.
ment or change in treatment.
focuses on what we do. Behavioral therapy uses the
56 | PART ONE | Finding the Right Balance
TABLE 2.2 | Examples of Medications Used to Treat Mental Illness
Antidepressants
Used to Treat Depression, Panic Disorders, and Anxiety Disorders
Selective serotonin-reuptake
inhibitors (SSRIs)
Examples: fluoxetine (Prozac), paroxetine
(Paxil), escitalopram (Lexapro, Esipram),
citalopram (Celexa)
The current standard drug treatment for depression;
also frequently prescribed for anxiety disorders
Noradrenergic and specific
serotonergic antidepressants
(NaSSAs)
Examples: mirtazapine (Remeron)
Reportedly has fewer sexual dysfunction side
effects than do SSRIs
Serotonin-norepinephrine
reuptake inhibitors (SNRIs)
Examples: venlafaxine (Effexor), duloxetine
(Cymbalta)
Also sometimes prescribed for ADHD
Norepinephrine-dopamine
reuptake inhibitors (NDRIs)
Examples: bupropion (Wellbutrin)
Also used in smoking cessation; fewer weight gain
or sexual dysfunction side effects than with SSRIs
Tricyclic antidepressants (TCAs)
Examples: imipramine (Tofranil),
amitriptyline, nortriptyline (Pamelor), and
desipramine (Norpramin)
Negative side effects; usually used as a second or
third line of treatment when other medications prove
ineffective
Monoamine oxidase inhibitors
(MAOIs)
Examples: phenelzine (Nardil),
tranylcypromine (Parnate), and
isocarboxazid (Marplan)
Dangerous interactions with many other drugs and
substances in food; generally no longer prescribed
Anxiolytics (Antianxiety
Drugs)
Used to Treat GAD, Panic Disorders, Phobias, OCD, and PTSD
Benzodiazepines
Examples: lorazepam (Ativan), clonazepam
(Klonopin), alprazolam (Xanax), diazepam
(Valium)
Short-term relief, sometimes taken on an as-needed
basis; dangerous interactions with alcohol; possible
to develop tolerance or dependence
Serotonin 1A agonists
Examples: buspirone (BuSpar)
Longer-term relief; must be taken for at least 2
weeks to achieve antianxiety effects
Mood Stabilizers
Used to Treat Bipolar Disorder and Schizophrenia
Lithium
Examples: lithium carbonate (Eskalith)
Drug most commonly used to treat bipolar disorder;
blood levels must be closely monitored to determine
proper dosage and avoid toxic effects
Anticonvulsants
Examples: valproic acid/divalproex sodium
(Depakote)
Used more frequently for acute mania than for longterm maintenance of bipolar disorder
Antipsychotics
(Neuroleptics)
Used to Treat Schizophrenia, Mania, and Bipolar Disorder
Atypical antipsychotics
Examples: olanzapine, risperidone
(Risperdal)
First line of treatment for schizophrenia; fewer
adverse effects than with earlier antipsychotics
First-generation antipsychotics
Examples: haloperidol (Haldol),
chlorpromazine (Thorazine)
Earliest forms of antipsychotics; unpleasant side
effects such as tremor and muscle stiffness
Stimulants
Used to Treat ADHD
Methylphenidate
Examples: Ritalin, Metadate CD, Concerta
Can lead to tolerance and dependence; frequently
abused for both performance enhancement and
recreational use
Amphetamines
Examples: amphetamine (Adderall),
dextroamphetamine (Dexedrine, Dextrostat)
Can lead to tolerance and dependence; frequently
abused for both performance enhancement and
recreational use
Sources: National Institute of Mental Health, “Mental Health Medications,” October, 2016, www.nimh.nih.gov/health/publications/mental-health-medications/
nimh-mental-health-medications.pdf; National Institute of Mental Health, “Attention Deficit Hyperactivity Disorder,” Accessed April, 2018, www.nimh.nih.gov/
health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml; Mayo Clinic, “Depression: Monoamine Oxidase Inhibitors,” Accessed April, 2016,
www.mayoclinic.org/diseases-conditions/depression/in-depth/maois/art-20043992; Mayo Clinic, “Depression: Tricyclic Antidepressants and Tetracyclic
Antidepressants,” Accessed April, 2018, www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20046983.
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 57
MINDFULNESS
AND YOU
Mindfulness as Mental Health
Treatment
I
magine going to the doctor’s office
and being prescribed mindfulness
instead of medication. This may happen in the future, as research shows
that mindfulness practices have
positive effects on treating mental
health problems.
Millions of Americans have
mental health issues, anxiety and
depression being among the most
common. Today, some mindfulness
training, such as mindfulnessbased stress reduction (MBSR)
and mindfulness-based
cognitive therapy (MBCT), show
promising results as therapies
to treat anxiety and depression.
Mindfulness therapies emphasize an
acceptance of the present moment
without ruminating over past events or
catastrophizing over future events.
In a recent study comparing the
efficacy of mindfulness-based therapy
to that of the standard cognitive-based
therapy for individuals with depression
and anxiety, mindfulness-based therapy
was determined to be as effective as
traditional therapy in reducing depression
and anxiety. The authors of that study
concluded that mindfulness-based
therapy is a viable alternative to more
traditional therapies and may be less
emotional events. Recent research
indicates that health related positive
benefits of mindfulness-based
interventions in community settings
lasts over 12 months post intervention
if individuals continue to practice
MBSR at least 3 times per week!
If you’re interested in mindfulnessbased therapy, contact your school’s
counseling center. Some centers
have their own mindfulness group
sessions; other centers can refer you
to a counselor that specializes in
mindfulness-based therapy.
expensive and easier to implement. It may
also be very helpful for individuals who do
not respond to medications.
Mindfulness practice shows lasting
changes in the brain. After an 8-week
MBSR course, participants showed
increased gray matter volume in
some parts of the brain (such as the
hippocampus) and decreased gray
matter volume in other areas (such as
the amygdala), supporting the idea that
mindfulness increases the encoding
of current experiences and decreases
automatic responses to immediate
STUDY PLAN
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
ASSESS YOURSELF
CHAPTER REVIEW
How is your psychological
health? Want to find out?
LO 1 What Is Psychological
Health?
Take the How Psychologically
Healthy Are You? assessment
available on Mastering Health.
58 | PART ONE | Finding the Right Balance
|
■■
Sources: National Institute of Mental Health,
“Major Depression among Adults,” Accessed
April 2017, www.nimh.nih.gov/health/
statistics/prevalence/major-depressionamong-adults.shtml; National Institute of
Mental Health, “Any Anxiety Disorder among
Adults,” Accessed April 2017, www.nimh.nih.gov/
health/statistics/prevalence/any-anxiety-disorderamong-adults.shtml; National Institute of Mental
Health, “Any Anxiety Disorder among Children,”
Accessed April 2017, www.nimh.nih.gov/health/
statistics/prevalence/any-anxiety-disorder-amongchildren.shtml; J. Sundquist et al., “Mindfulness
Group Therapy in Primary Care Patients with
Depression, Anxiety and Stress and Adjustment
Disorders: Randomised Controlled Trial,” British
Journal of Psychiatry 206, no. 2 (2015): 128–35; L.
Juilliard, et.al. “Effectiveness of Mindfulness-based
Stress Reduction in a Self-selecting and Selfpaying community setting.” Mindfulness,
2017, 1-11.
Psychological health is a complex
phenomenon involving mental,
emotional, social, and spiritual
dimensions.
|
LO 2 Keys to Enhancing
Psychological Health
■■
Many factors influence
psychological health, including
life experiences, family, the
environment, other people,
self-esteem, self-efficacy, and
personality.
■■
The mind–body connection is an
important link in overall health
and well-being. Positive psychology
emphasizes well-being as a key factor
in determining overall reactions to
life’s challenges. Psychoneuroimmunology indicates that mental health
and physical health are linked.
|
LO 3 When Psychological
Health Deteriorates
■■
■■
■■
■■
■■
■■
■■
College is a time when disorders
such as depression or anxiety, often
related to high stress levels that
result from pressures for grades and
financial problems, occur.
Mood disorders include major
depression, persistent depressive disorder, bipolar disorder, and seasonal
affective disorder.
Anxiety disorders include generalized anxiety disorder, panic disorders, and phobic disorders.
People with OCD often have irrational concern about order, symmetry,
or exactness, or have persistent
intrusive thoughts.
PTSD is caused by experiencing or
witnessing a traumatic event, such
as those that occur in war, natural
disasters, or the loss of a loved one.
Personality disorders include paranoid, narcissistic, antisocial, and
borderline personality disorders.
Schizophrenia is often characterized
by visual and auditory hallucinations,
an altered sense of self, and radical
changes in emotions, among others.
|
LO 4 Suicide: Giving Up
on Life
■■
Suicide is a result of negative psychological reactions to life. People
intending to commit suicide often
give warning signs of their intentions
and can often be helped. Suicide
prevention involves eliminating the
conditions that may lead to attempts.
|
LO 5 Seeking Professional
Help
■■
Mental health professionals
include psychiatrists, psychoanalysts, psychologists, social workers,
and counselors/therapists. Many
therapy methods exist, including
psychodynamic, interpersonal, and
cognitive-behavioral therapy.
■■ Treatment of mental disorders can
combine talk therapy and drug therapy using psychoactive drugs.
POP QUIZ
|
LO 1 W
hat Is Psychological
Health?
1. All of the following traits have
been identified as characterizing
psychologically healthy people except
a. conscientiousness.
b. understanding.
c. openness.
d. agreeableness.
|
LO 2 Keys to Enhancing
Psychological Health
2. A person with high self-esteem
a. possesses feelings of self-respect
and self-worth.
b. believes he or she can
successfully engage in a specific
behavior.
c. believes external influences
shape one’s psychological health.
d. has a high altruistic capacity.
3. The initial “A” in the PERMA
acronym represents which
concept?
a. Activity
b. Advocacy
c. Acceptance
d. Accomplishments
4. Which of the following is not part
of a good strategy for building
self-esteem?
a. Develop a support system
b. Concentrate more on mental
health than physical health
c. Make time for you
d. Form realistic expectations
|
LO 3 When Psychological
Health Deteriorates
5. Which statement below is false?
a. One in five adults in the
United States suffers from a
diagnosable mental disorder in
a given year.
b. Mental disorders are the leading
cause of disability in the United
States.
c. Dysthymia is an example of an
anxiety disorder.
d. Bipolar disorder can also be
referred to as manic-depressive
illness.
6. Sarah has a compulsion to wash
her hands over and over again and
she’s extremely fearful of dirt. She
most likely has
a. generalized anxiety disorder.
b. panic disorder.
c. obsessive–compulsive disorder.
d. dysthymic disorder.
7. This disorder is characterized by
a need to perform rituals over
and over again; fear of dirt or
contamination; or an unnatural
concern with order, symmetry, and
exactness.
a. Personality disorder
b. Obsessive–compulsive disorder
c. Phobic disorder
d. Posttraumatic stress disorder
8. How many Americans will
experience posttraumatic stress
disorder in their lifetime?
a. 1 percent
b. 8 percent
c. 16 percent
d. 32 percent
9. This type of disorder is
characterized by an exaggerated
sense of self-importance and
self-absorption.
a. Borderline personality disorder
b. Narcissistic personality
disorder
c. Antisocial personality disorder
d. Paranoid personality disorder
10. What percentage of the
United States population has
schizophrenia?
a. 1 percent
b. 5 percent
c. 10 percent
d. 20 percent
|
LO 4 Suicide: Giving Up
on Life
11. For 15- to 34-year-olds in the
United States, suicide is the ___
leading cause of death.
a. first
b. second
c. third
d. fourth
CHAPTER 2 | Promoting and Preserving Your Psychological Health | 59
|
LO 5 Seeking Professional
Help
12. A person with a PhD in counseling
psychology and training in various
types of therapy is a
a. psychiatrist.
b. psychologist.
c. social worker.
d. psychoanalyst.
Answers to the Pop Quiz can be found on page
A-1. If you answered a question incorrectly,
review the section identified by the Learning Outcome. For even more study tools, visit
Mastering Health.
THINK ABOUT IT!
|
LO 1 What Is Psychological
Health?
1. What is psychological health?
What indicates that you are
or are not psychologically
healthy? Why might the college
environment provide a challenge
to psychological health?
|
LO 2 Keys to Enhancing
Psychological Health
2. Consider the factors that influence
your overall level of psychological
health. Which factors can you
change? Which ones may be more
difficult to change?
3. What connections can you
make between physical and
psychological health?
|
LO 3 When Psychological
Health Deteriorates
4. What proportion of the student
population suffers from some type
of mental illness? What types of
support networks exist on your
campus?
5. What are the symptoms of
major depression? How is major
60 | PART ONE | Finding the Right Balance
depression different from other
mood disorders?
6. What are the symptoms of an
anxiety disorder? How is feeling
anxious different from having an
anxiety disorder or having a panic
attack?
7. How common is obsessive–
compulsive disorder? How is
having OCD different from being a
perfectionist?
8. What are the causes of
posttraumatic stress disorder? Why
do some go less reported than
others?
9. What are the characteristics of
borderline personality disorder?
How is it different from other
personality disorders?
10. How has our understanding of
schizophrenia evolved? What
is responsible for this shift in
understanding? Why might
it be difficult for people with
schizophrenia to lead normal
lives without support and other
treatment?
|
LO 4 Suicide: Giving Up on
Life
11. What are the warning signs of
suicide? Why are some people
more vulnerable to suicide than
others? What could you do if you
heard a classmate say to no one in
particular that he was going to “do
the world a favor and end it all”?
|
LO 5 Seeking Professional
Help
12. Describe the various types of mental
health professionals and types
of therapies. If you felt depressed
about breaking off a long-term
relationship, which professional
and which therapy do you think
would be most beneficial to you?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics related to psychological health.
Active Minds. A campus education
and advocacy/volunteer organization
that was formed to combat the stigma
of mental illness, educate the campus
community, encourage students who
need help to seek it early, and prevent
tragedies related to untreated mental illness.
www.activeminds.org
American Foundation for Suicide
Prevention. Provides resources for suicide
prevention and support for family and friends
of people who die of Includes information
on the National Suicide Prevention Hotline,
1-800-273-TALK (8255). www.afsp.org
American Psychological Association
Help Center. Includes information on
psychology at work, the mind–body
connection, understanding depression,
psychological responses to war, and other
topics. www.apa.org/helpcenter/wellness
National Alliance on Mental Illness.
Support and advocacy organization of
families and friends of people with severe
mental illnesses. www.nami.org
National Institute of Mental Health
(NIMH). Provides an overview of mental
health information and new research.
www.nimh.nih.gov
Helpguide. Resources for improving mental
and emotional health as well as specific
information on topics such as self-injury,
sleep, depressive disorders, and anxiety
disorders. www.helpguide.org
For more on what communities and States
can do to prevent suicide, go to Preventing
Suicide: A Technical Package of Policy,
Programs, and Practices, https://go.usa.
gov/xQBGc
FOCUS ON
MINDFULNESS, SPIRITUAL HEALTH,
AND SPIRITUAL INTELLIGENCE
LEARNING OUTCOMES
LO1
Define and identify the key components of mindfulness.
LO2
Distinguish spirituality and spiritual intelligence from religiosity and explain
their role in cultivating a meaningful life.
LO3
Discuss the evidence that mindfulness and spirituality contribute to health.
LO4
Describe skills you can develop and actions you can take to integrate
mindfulness and spirituality into your life.
WHY
SHOULD I CARE?
Cultivating
mindfulness and
spirituality can increase your sense
of meaning, connection, and vitality.
It can also boost your physical and
psychological health—for example, by
reducing blood pressure, stress, depression, and anxiety. Contemplation,
mindfulness, and other spiritual practices can also improve your concentration, increase your ability to process
information, and enhance your ability
to cope with the daily demands of life.
61
A
sk yourself: Is your mind a
jumble of demands and tasks
that seem to be exhausting
your energies? Do you wish
that you could turn off the constant
intrusive chatter of your digital world and
rest your mind? Do you ever wonder why
you’re so overwhelmed by information
and activity—what it all means, and
whether you’ll ever experience tranquility . . . or joy?
If you answered yes to any of the
above questions, you’re not alone.
According to national surveys, 87 percent of U.S. college students report
that, within the past 12 months, they
have felt overwhelmed by all they had
to do.1 At the same time, nearly 47 percent of college freshmen feel it is very
important or even essential to develop
a meaningful philosophy of life, and
almost 43 percent say it’s important or
essential to integrate spirituality into
their life.2
People of all ages and stages of life
appear to be searching for more: more
“down time” with nothing pressing on
them, more peace in their thoughts and
their relationships, more meaning in
their work and goals, more gratitude,
more joy—in short, more “life” in their
lives. But how do they get there?
Today many people are turning to
mindfulness. Closely intertwined with
the concept of spirituality, mindfulness has become the new “darling” of
twenty-first-century America, with a
flood of health care organizations and
health-related media outlets promising that the practice can transform
our lives. But what is “mindfulness”
and how is it linked to spirituality? Is
there research supporting its benefits,
and, if so, how can you use it to boost
your physical, emotional, and spiritual
health?
WHAT DO
YOU THINK?
Consider the components
of mindfulness.
■■ How would you rate yourself on each?
■■ Which components would you like to
cultivate more deeply? Why?
62 | PART ONE | Finding the Right Balance
Acceptance of things
as they are
Non-judgment
Present-moment
awareness
Non-attachment
Openness to
experience
Compassion
Connection
Intention
Gratitude
Peace and Equanimity
FIGURE 1
Typical Components of Mindfulness
LO 1 | WHAT IS
MINDFULNESS?
Define and identify the key components of
mindfulness.
other mindfulness experts have contributed to a deeper understanding of the
essential components of mindfulness
(FIGURE 1). These include the following:
Acceptance of things as they are.
Cultivating mindfulness means
cultivating an acceptance of yourself, others, and external situations,
events, and environments as they
actually are, not as you would wish
them to be. From this place of acceptance of what is, you can work more
effectively toward positive change.
■■ Nonjudgment. Think about what you
say to yourself when sitting in the
student union, watching people walk
by. Perhaps you think, “Wow, they’re
really attractive!” Or, “Wow, that person needs a haircut!” And how often
in a given day do you spend time
judging yourself? “I shouldn’t have
done that or said that!” Mindfulness
involves nonjudgment. Rather than
labeling a person, an experience, a
thought, or a feeling as good or bad,
mindfulness allows you to observe,
accept, and let go.
■■ Present-moment awareness. When
the “static” in your mind clears, you
begin to see and hear what is happening around you, and feel your
body’s responses. Can you feel your
■■
As we mentioned in Chapter 1, many
people describe mindfulness as an
awareness of the present moment, a
focused, thoughtful, and attentive way of
perceiving the world with all of its flaws
and beauty, and refraining from judgment. This tuning in to the world around
you heightens your understanding,
kindness, and compassion toward yourself and others. People who are mindful
are less judgmental, controlling, and
negative. As they “keep their feet in
the now,” they are freed from dwelling
on past pain or worrying about future
challenges.
In Chapter 1 we introduced Jon
Kabat-Zinn, professor emeritus of medicine and founder of the Stress Reduction Clinic and Mindfulness Center at
the University of Massachusetts. For
Kabat-Zinn, mindfulness is a simple
approach to living your life, moment
by moment, as if it really mattered.3
Another mindfulness expert is clinical
psychologist Melanie Greenberg, author
of The Stress-Proof Brain.4 Together,
Kabat-Zinn, Greenberg, and many
Living with intention requires us to ask ourselves, “Is the life I’m living the life I want?”
heart beat? Are there birds singing?
What does that fresh orange you
are eating really taste like? Smell
like? What does the sun or rain
feel like on your skin? By engaging
your awareness fully in the present
moment, mindfulness effortlessly
blocks memories of the past and
worries about the future. It releases
the debris floating around in your
mind, causing you anxiety and
stress. Meditation and deep breathing can help you focus on the here
and now.
■■ Nonattachment. Many of us are
attached to a certain idea of
ourselves—as good, smart, successful, athletic, artistic, and so on. Or
we may be attached to certain people,
or a certain career, location, or state
of health. Mindfulness challenges us
to recognize these attachments and
let them go, to accept that life is constantly changing and trust in our ability to change with it.
■■ Openness to experience. Being open
to all thoughts, feelings, and other
experiences, even those you might
not like or understand, is a key
component of mindfulness. When
you’re open to experience, you
simply watch what arises without
attempting to block it, judge it, or
deny it.
Compassion. Perhaps one of the most
important components of mindfulness is compassion, a word derived
from the Latin phrase, “to suffer
with.” Compassion requires that you
treat yourself and others with kindness, gentleness, and respect; that
you have patience with your own and
others’ imperfections. In addition,
you actively listen to others, tuning in
to them rather than merely waiting to
advance your own views.
■■ Connection. Closely linked to
spirituality, connection means recognizing that you are a part of the
universe and that you have
connections to all living and nonliving things. For example, you
recognize that food and water,
security, safety, and love are important to people from all parts of the
world. This recognition may move
you to act in preserving and protecting the environment and the
global population.
■■ Intention. The word intention comes
from a Latin noun indicating a
“stretching out” or “leaning toward.”
What goals require you to leave
your comfort zone and “stretch
outward”? These are your intentions. Whether you value caring
for others, finding love, achieving
financial security, making the world
■■
a better place, or simply improving
your grades or being a better listener,
living with intention is a powerful
component of mindfulness.
■■ Gratitude. Much more than an
occasional expression of thanks,
gratitude is a stance we take in life.
Buddhist practitioner and best-selling author Jack Kornfield reminds us
of how privileged we are to exist on
this planet—possibly the only lifesustaining planet in our universe.
As sentient beings, we experience
almost unbearable beauty as well as
deep pain.5 Our response can be fear
and suffering, which blinds us to the
beauty of life, or gratitude, which
reveals the beauty present even
within the pain.
■■ Peace and equanimity. An ability
to stay calm in spite of challenges is
an important element of mindfulness. The heightened awareness that
mindfulness brings helps you to
avoid being swept up in the drama
of your interactions with others or
engaging in behaviors that escalate
conflict. Mindfulness is characterized
by a sense of peace, a readiness to
compromise, and a willingness to do
your part to make life better for others while living your own best life.
As you can see, being mindful involves
much more than meditating, concentrating, or having a burst of inspiration
that is soon lost. Rather, mindfulness is a
way to acknowledge your thoughts, emotions, and experiences without allowing
them to define you. As such, it is a total
approach to life.
10
hours
and 39 minutes
is the amount of TIME WE
SPEND using media each day.
How could you spend at least
part of that time being mindful?
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 63
LO 2 | WHAT ARE
SPIRITUALITY
AND SPIRITUAL
INTELLIGENCE?
Distinguish spirituality and spiritual
intelligence from religiosity and explain
their role in cultivating a meaningful life.
From one day to the next, many of us
attempt to satisfy our needs for belonging and self-esteem by acquiring material possessions, achieving success, or
hanging with the “in crowd.” But eventually we realize that these external factors don’t necessarily bring us happiness
or improve our sense of self-worth, nor
do they protect us from life’s ups and
downs. That’s when many of us begin to
seek more meaningful answers. With this
seeking, our quest for spirituality begins.
Spirituality and
Religion
Spirituality and religion are not the same
thing. The root of the word spirituality
is spirit, which in many cultures refers
to breath, or the force that animates
life. When you’re “inspired,” you are
filled with energy. You’re not held back
by doubts about the meaning of your
existence. Many definitions of spirituality incorporate this sense of meaningmaking; for example, spirituality has
been defined as an internal, or personal,
search for meaning and answers about
life, the sacred, or the transcendent.6
The sacred or transcendent could be
thought of as a higher power or being,
or it could refer to the essential goodness
of life or our relationship with nature
or forces we cannot explain. Another
aspect of spirituality is connection:
Spirituality typically includes a belief in
the interconnectedness between all living creatures, our environment, and, for
some, forces greater than ourselves.
In contrast, religion is a set of rituals,
beliefs, symbols, and practices intended
to establish or maintain a relationship
with a divine power or presence, often
spirituality An individual’s sense of peace,
purpose, and connection to other people and
beliefs about the meaning of life.
64 | PART ONE | Finding the Right Balance
Spirituality and religion are not the same. Many people find that religious practices,
for example, attending services or making offerings—such as the small lamp this
Hindu woman is placing in the sacred Ganges River—help them to focus on their
spirituality. However, religion does not have to be part of a spiritual person’s life.
represented by one or more specific deities
(such as God, Allah, or Vishnu, among
many others). People who identify as
religious may or may not attend services
or belong to a religious community, but
typically engage in some type of religious
practice such as contemplation or prayer.
In the United States, nearly 71 percent
of the population identifies as Christian.7
It may surprise you to learn that the
second-largest group is the unaffiliated—
that is, atheists, agnostics, and those who
identify as “nothing in particular.” This
group represents nearly 23 percent of the
total population, but the percentage is significantly higher among Americans ages
18 to 29 than among older Americans.8
In a recent survey of first-year college
students, for example, nearly 31 percent
identified as atheist, agnostic, or “none.”9
Although younger Americans are
less likely to be religious, they are just
as likely as older Americans to report
that spirituality is important.10 How
can this be? Although we may think of
spirituality and religion as occurring
together, it is possible to be spiritual and
not religious, or to be religious and not
spiritual. This is because spirituality is
not bound by affiliation with a religious
denomination, ceremony, building,
doctrine, or set of practices; individuals have the option to choose whatever path or paths allow them to find
meaning and a sense of purpose in life.
TABLE 1 identifies some characteristics
|
TABLE 1 Characteristics Distinguishing Religion and
Spirituality
Religion
Spirituality
Observable, measurable, objective
Less measurable, more subjective
Formal, orthodox, organized
Less formal, less orthodox, less systematic
Behavior-oriented, outward practices
Emotionally oriented, inwardly directed
Authoritarian in terms of behaviors
Not authoritarian, little accountability
Doctrine separating good from evil
Unifying, not doctrine-oriented
Sources: R. F. Paloutzian and C. L. Park, Handbook of the Psychology of Religion and Spirituality, 2nd ed.
(New York: Guilford Press, 2015); National Center for Complementary and Integrative Health, “Prayer and
Spirituality in Health: Ancient Practices, Modern Science,” CAM at the NIH 12, no. 1 (2005): 1–4.
Relationships,
Values, and
Purpose
Brian Luke Seaward, an internationally known expert on mind-bodyspirit healing, identifies three facets of
spirituality: relationships, values, and
purpose in life (FIGURE 2).11 Questions arising in these three domains
prompt many of us to look for spiritual
answers.
Relationships
Have you ever
wondered whether someone you were
attracted to is right for you? Conversely,
have you wondered whether you should
break off a long-term relationship? Have
you ever wished that you had more
friends or that you were a better friend
to yourself? For many people, such questions and yearnings are natural triggers
for spiritual growth: As we contemplate
whom we should choose as a life partner or how to mend a quarrel with a
friend, we begin to foster our own inner
sense of what is right for us as individuals and to understand how to reflect on
our choices mindfully. At the same time,
healthy relationships are a sign of spiritual well-being. When we think well of
ourselves and treat other people with
respect, honesty, integrity, and love, we
are manifesting our spiritual health.
Values Our personal values are
our principles—the set of fundamental rules by which we conduct our
lives. Our values are what we stand for.
When we attempt to clarify our values
and then live according to those values, we’re moving closer to a spiritually
healthy life. Spiritual health is characterized by a personal understanding of
one’s own values, as well as a respect
and curiosity about the values of others
in our community.
Purpose in Life
What things
make you feel complete? How do you
hope to find meaning in your life? Is
there some wrong in the world that you
would like to help
make right? How
do these choices
reflect what you
hold as your purpose in life? How
will the way you
live your life contribute to your
community
and
society? Spiritual
growth is fostered
by contemplating
questions like these
Pu
questions
about
rp
ips
our place in the
h
os
s
n
ei
o
world rather than
i
t
nL
a
l
our
individual
ife
Re
gains and material
possessions. People
who are spiritually
healthy are able
to articulate their
search for ­purpose
and
to
make FIGURE 2 Three Facets of
Watch Video Tutor:
Spirituality Most of us are
choices that maniFacets of Spirituality
prompted to explore our
fest that purpose.
spirituality because of questions
Picture in your relating to our relationships, values, and purpose in life. At the same
mind
someone time, these three facets together constitute spiritual well-being.
you think has
made the world a better place, perhaps
by volunteering in the community,
Our relationships, values, and sense of
working with youth, or finding other
purpose together contribute to our overways of improving the quality of life
all spiritual intelligence. This term was
for people. You may focus on someintroduced by physicist and philosoone close to you or someone famous
pher Danah Zohar, who defined it as
you admire, like Martin Luther King,
“an ability to access higher meanings,
Jr., or Malala Yousafzai—people whose
values, abiding purposes, and unconlife’s work has helped make the world
scious aspects of the self.”12 Spiritual
a better place for others. Think about
intelligence is, Zohar explains, “the
something you would like to do that
intelligence of the deep self.” Humilwould make a difference in the lives of
ity, the capacity to consider ideas that
other people or in the world more genfall outside the box, to hope, to dream,
erally. Besides family, friendships, and
and to tap into energies outside the ego
career, what would make your life more
are part of Zohar’s definition. Spiritual
meaningful? Allow yourself to see your
intelligence allows us to utilize values,
life as having its own mission and
meanings, and purposes to enrich our
purpose.
lives.
Essentially, spirituality is about
actively paying attention to our relationships, our community, and our
purpose, emphasizing respect and
values Principles that influence our thoughts
awareness while considering the impact
and emotions and guide the choices we
our actions have on our communimake in our lives.
ties. Later in this chapter, we discuss
spiritual intelligence The ability to access
strategies for bringing spirituality into
higher meanings, values, abiding purposes,
and unconscious aspects of the self.
your life.
Values
that can help to distinguish between
religion and spirituality.
Spiritual Intelligence
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 65
Since Zohar introduced the idea
of spiritual intelligence, a number of
psychologists, clerics, and even business consultants have taken the liberty of expanding the definition of the
term. For example, psychologist Robert
Emmons has identified four components of spiritual intelligence:13
The capacity to transcend the
material world, such as by experiencing a sense of oneness with all
things.
■■ The ability to experience heightened states of consciousness, such
as increased intuition and mental
clarity.
■■ The ability to sanctify everyday
experience, such as by recognizing
the higher purpose in one’s day-today activities.
■■ The ability to utilize spiritual
resources to solve problems and cope
with life’s challenges.
■■
LO 3 | HEALTH
BENEFITS OF
MINDFULNESS
AND SPIRITUALITY:
WHAT DOES THE
RESEARCH SAY?
Discuss the evidence that mindfulness and
spirituality contribute to health.
Research into the potential health benefits of mindfulness and spirituality
has increased dramatically in recent
years. Do the findings of this research
justify America’s current enthusiasm
for a mindful and spiritual lifestyle?
This question is the subject of some
controversy.
Although the potential benefits are
now supported by a growing body of
evidence from randomized controlled
trials published in top-tier journals,
critics argue that these quality studies
are being outpaced by inferior research
funded and promoted by entities that
stand to benefit from the mindfulness
movement. They argue that such studies are often poorly designed, fail to
consistently define what mindfulness
is, and fail to precisely measure health
66 | PART ONE | Finding the Right Balance
outcomes. In addition, they maintain that many oft-cited studies, especially early ones, rely on self-reported
results without a control group that
could have helped to rule out the placebo effect. Although these are all
fairly typical criticisms of research
in emerging fields, they are certainly
concerning.14–16
Fortunately, a number of quality studies using more rigorous methodology
have yielded valid and reliable evidence
supporting the benefits of mindfulness
and spirituality in health promotion.
A brief overview of this research is provided here. For more research evidence
supporting the benefits of mindfulness,
check out the Mindfulness and You features throughout this text.
Physical Benefits
Four intriguing areas of research into
the physical benefits of mindfulness
and spirituality include their capacity to alter our perceptions and control
of chronic pain; to promote weight
loss; to increase cancer coping; and to
help patients manage the symptoms of
chronic disease.
Chronic Pain
Two meta-­analyses
of clinical studies on the effects of
mindfulness on chronic pain found
that mindfulness-based interventions
showed a limited ability to reduce
participants’ perception of their pain
intensity, but significantly reduced
participants’ perception of their pain’s
interference with sleep, activities, or
social roles, and significantly increased
their perceived ability to control their
pain.17,18 More narrow studies have
revealed mindfulness interventions to
be beneficial for patients with parti­
cular pain syndromes. For example, a
2018 study of chronic pain in patients
with multiple sclerosis found that the
greater the patient’s mindfulness, the
lower the report of pain interference.19
Similarly, a 2017 randomized controlled
trial involving patients with nerve damage due to diabetes found that mindfulness interventions significantly reduced
pain intensity and pain catastrophizing, and improved health-related quality of life.20 And a study of patients
with chronic low back pain found a
therapeutic mindfulness intervention
significantly more effective at reducing
pain and increasing functioning than
usual care.21
Weight Loss
A meta-analysis of
12 randomized controlled trials assessing the effects of mindfulness training on weight loss and health-related
behaviors among overweight and obese
adults found significant reductions in
impulsive eating behaviors and significant increases in physical activity. Longer interventions were more likely to
result in more significant weight loss.22
Another meta-analysis of randomized
controlled trials showed similar benefits
of mindfulness-based interventions for
overweight and obese individuals, particularly improvements in eating behaviors and eating attitudes.23
Cancer Coping Several studies
show an association between spirituality and a person’s ability to cope with
a variety of physical illnesses, including cancer.24,25 The National Cancer
Institute (NCI) contends that spiritual
well-being may help improve cancer
patients’ quality of life by decreasing
anxiety, despair, and feelings of isolation, and increasing hope, optimism,
and ability to cope.26
Mindfulness interventions may
be particularly beneficial in reducing
cancer patients’ anxiety and improving their quality of life.27–29 Mindfulness may also help cancer patients cope
by improving their sleep quality and
energy levels.30
Markers
of
Chronic
­Disease One recent study of over
33,000 adults found that indicators of
“social capital,” such as visiting friends,
relatives, or neighbors, or attending
church or club meetings, were associated with improved biomarkers like
cholesterol and blood pressure.31
Another recent meta-analysis of seven
clinical trials of mindfulness meditation found significant reductions in
blood pressure among participants over
age 60.32 Mindfulness interventions
have also been shown to improve blood
glucose (blood sugar) control in patients
with diabetes.33
Mindfulness training also appears effective in reducing symptoms of depression in college students.41
Mindfulness is widely acknowledged to have a positive
impact on health. These students are using the meditative
movements of tai chi to improve their health.
Psychological
Benefits
Current research also suggests that spiritual health contributes to psychological
health. Here, we provide a brief overview of recent studies on the effects of
mindfulness and spirituality on anxiety
disorders, depression, and stress.
Anxiety Disorders
Increasing
numbers of studies are examining the
effect that spirituality interventions and
mindfulness training have on anxiety
disorders. One recent study, for example, found that mindfulness training
reduced symptoms of generalized anxiety disorder, leading to fewer missed
work days and fewer health care visits.34
Studies have also supported the effectiveness of mindfulness training for
patients with social anxiety disorder.35
Patients with posttraumatic stress
disorder (PTSD) appear to respond to
spirituality-based interventions and
mindfulness training. Psychologists
at the U.S. Department of Veterans
Affairs, for example, have done extensive clinical work with veterans who are
experiencing PTSD. Research suggests
that, following trauma, powerful emotions such as anger, rage, and wanting
to get even are moderated by actions
such as forgiveness and other spiritual
practices.36 In another study, mindfulness training led to significant reductions in PTSD symptoms, as well as
depression, in veterans.37 Mindfulness
training has also reduced symptoms
of PTSD in children, teens, and adults
who have suffered from adverse childhood events such as physical and sexual
abuse.38
Depression
A meta-analysis of
142 randomized controlled trials found
that mindfulness training led to health
benefits that were equal to or better
than benefits from medications and
other evidence-based interventions.
Mind­fulness training was significantly
better at improving depression, as well
as helping with smoking cessation and
other addictions.39 Among patients
diagnosed with and treated for depression, mindfulness training has also
been found to significantly reduce
relapse even after a year of follow-up.40
Stress Mindfulness-based stress re­­
duction (MBSR), which will be discussed
in more detail in Chapter 3, has been
shown to help increase individuals’
ability to cope with daily stressors and
reduce stress-related health problems.42
One study assessed the effect of mindfulness training on neurological and
hormonal changes involved in the stress
response, and found a decrease of more
than 50 percent in stress hormones as
well as an increase in awareness, compassion, and gratitude.43 Studies of
college students have also found that
mindfulness strategies are helpful in
managing stress.44,45 For example, following a 7-week mindfulness training
program, medical and psychology students reported being more “tuned in” to
psychological and body processes; less
reactive; more tolerant, patient, and selfcompassionate; and more in control of
the stressors in their lives.46
LO 4 | HOW CAN
YOU INTEGRATE
MINDFULNESS AND
SPIRITUALITY INTO
YOUR LIFE?
Describe skills you can develop and
actions you can take to integrate
mindfulness and spirituality into your life.
Cultivating your spiritual side takes ­just
as much work as becoming physically
fit. Ways to integrate mindfulness
and spirituality into your life are
explored here.
WHAT DO
YOU THINK?
Why do you think
mindfulness practices are
gaining more recognition?
■■ What are the benefits of mindfulness?
■■ In your fast-paced life, what would
be the most significant challenges to
practicing mindfulness on a daily basis?
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 67
Your Path to
Mindfulness
Contrary to what some people think,
mindfulness doesn’t require you to
empty your mind, or to sit for hours
with crossed legs in a trance-like state,
oblivious to your surroundings and
focused only on a narcissistic pursuit of
self. Instead, the opportunities to practice mindfulness are as plentiful as the
moments of our lives. Pursuing almost
any endeavor that requires close concentration can help you develop mindfulness and, as an added benefit, deepen
your connection to others and to your
environment. Here are a few common
techniques:
Cultivate compassion. Compassion
involves recognition of another’s
pain and a sincere desire to help. You
cultivate compassion for others by
supporting them through difficult
times or by volunteering to help
those less fortunate. You cultivate
compassion for yourself by learning
to recognize critical or judgmental
thoughts—thoughts that tell you
you’re not good enough, smart
enough, or attractive enough—and
then setting them aside. You may
then remind yourself of your positive
qualities, achievements, and loving
relationships. Practicing meditation
(discussed shortly) can help you
to silence your internal critic and
develop self-confidence. You might
also take a vow to avoid engaging in
negative thinking about yourself and
others for a single day. Throughout
that day, replace negativity with
intentions of kindness. Meet other
people’s eyes as you pass, acknowledging that you’re aware of their presence. Smile. When friends criticize
others, try to listen fully to what’s
behind the words, and respond with
gentleness and honesty.
■■ Express gratitude. Gratitude develops in both the heart and the head.
Take time each day to sit quietly
and consider all of the things you
are thankful for—your family members and friends, your abilities,
your place in society, your health,
the chance to attend college and
everything else. Let people know
■■
68 | PART ONE | Finding the Right Balance
“Almost everything will work again if you unplug it for a few minutes, including
you.” Anne Lamott, Author
that you appreciate who they are or
what they have meant in your life.
Take a moment to point out something you admire in them. Another
strategy for developing gratitude is
to awaken your senses: Look around
you. What do you see that you feel
grateful for? Listen: Do you hear a
friend’s voice, music, or laughter?
What about touch, a soft sweater,
warm sunlight, a breeze? Can you
smell soap, incense, flowers, good
food? Increasing your awareness of
the sensory details around you can
in turn increase your gratitude for
the moment-to-moment richness of
your life.
■■ Simplify your day. We live in a society where many regard busyness as
a badge of honor. They brag about
their ability to multitask and complain about going without exercise,
nourishing meals, and sleep because
they’re so engaged in the activities
that seem to fill every minute of
their lives. In contrast, a mindful
approach to life calls on us to do
one thing at a time, giving it our full
attention, and then moving on. To
increase your focus in any activity,
first name it. Are you listening to a
friend, writing an e-mail, driving
home? Whatever the activity, take
a moment to acknowledge it and
resolve to give it your undivided
attention. Breathe. Notice. If your
mind starts to wander, bring it back
to the activity. If your cell phone
rings, turn it off. By simplifying your
tasks, you bring a more gentle quality to your day. It’s also important to
set aside quiet time, for long walks
in a local park or on a nearby hiking
trail, or for observing, sketching, or
photographing your environment.
Alone time is essential for balance,
renewal, and refreshing.
■■ Start each day with intention. What
are your values, goals, and intentions, and how do they guide your
actions? Each morning, jot down
some intentions. During the day, try
to stay mindful of how your actions
align with the intentions you’ve
identified. Then, before bed each
night, take a moment to consider—
without judgment—how well you
lived your intentions that day. Ask
yourself if the way you’ve spent your
day aligns with the life you want.
What might you wish to do differently tomorrow?
■■ Examine the way you deal with life’s
challenges. Perhaps you became
angry with a friend, felt upset about
a critique of your work, or just got
stressed out by an enormous load
of homework. One method for confronting challenges with mindfulness is to acknowledge what you felt,
TECH
&
HEALTH
I
f you’re looking for an easy way to
enhance your mindfulness, a simple
search of the Internet can help. Literally
hundreds of mindfulness apps exist,
and many are free—at least, at their
basic level. Here are two lists to get you
started:
■■
The Best Meditation Apps of
2017 from Healthline identifies ten
apps helpful for mindfulness and
meditation, and eight of these are
free. Some examples include The
Mindfulness App; Headspace;
Calm; and Stop, Breathe, and
Think. Find the full list at www.
healthline.com.
then try to determine why. Was the
event really as negative as you felt it
to be at the time? Could you have
responded differently? In the future,
would you prefer to let go of your
attachment to particular outcomes,
say “It is what it is,” and move on?
One way to do this is to acknowledge
that nothing in life—and no one—is
perfect, including you. For yourself
and for others, seek goodness rather
than perfection.
■■ Try a mindfulness app! Let your
phone, tablet, or laptop help you
develop more mindfulness. For lists
of some common mindfulness apps,
see the nearby TECH & HEALTH box.
The difficult work of continuing on
our path when obstacles (e.g., emotions,
events, people) are in the way is “spirit
work” that builds our resiliency and
helps us to grow. Mindfulness is a way to
acknowledge our thoughts, emotions,
and experiences without allowing them to
define us.47
Meditation Supports
Mindfulness
Meditation is the practice of cultivating a quiet mind. Although the precise
Mindfulness Apps
■■
Free Mindfulness Apps Worthy of
Your Attention from Mindful.org
includes Insight Timer; Aura; Omvana;
and two apps that also made the
Healthline list: Calm; and Stop,
Breathe, and Think. For details, go to
www.mindful.org/free-mindfulnessapps-worthy-of-your-attention/.
Mindful.org warns consumers to
bear in mind that the effectiveness of
many mindfulness apps isn’t backed
by science. That is, although a large
body of research supports the benefits
of mindfulness itself, those benefits are
not necessarily conferred by use of any
particular mindfulness app. The bottom
details vary with different schools of
meditation, the fundamental task is the
same: to quiet the mind’s “chatter.” In
many ways, meditation and mindfulness go hand in hand.
Benefits of Meditation For
thousands of years, humans of different
cultures and traditions have found that
achieving periods of meditative stillness
each day enhances their health. Today,
researchers are beginning to discover
why. Studies suggest that people who
engage in meditation show a significantly increased level of positive emotions such as empathy—the ability to
understand and share another person’s
experience—and compassion toward
other people.48,49 Studies also suggest
that meditation reduces stress, anxiety,
and depression; improves sleep quality
and may reduce insomnia; decreases
symptoms of irritable bowel syndrome
and other gastrointestinal disorders;
and lowers blood pressure (FIGURE 3 on
page 70).50–55 There is also some evidence that meditation may reduce
inflammation and help regulate the
immune system, thereby enhancing our
body’s defenses against infections and
cancer.56 The physiological processes
line? First, Mindful.org suggests that
you look for apps that are highly specific
to your goal, whether it’s stress reduction, increased focus, or something else.
Second, if the app makes any claims
for benefits, study the research. (See
Chapter 1 for more information on
evaluating research claims.) Third, stay
away from mindfulness apps with music
or white noise, as these may actually
reduce your ability to connect with the
present moment.
Source: S. Tlalka, “The Trouble with Mindfulness
Apps,” August 10, 2016, Available at www
.mindful.org/trouble-mindfulness-apps/.
that produce these effects are only
partially understood. One theory suggests mindfulness meditation works
by reducing the body’s stress response.
People who engage in this practice
seem to experience a sense of peacefulness, subjective well-being, and physical
relaxation that in turn affects all body
systems.
Meditation may also change the
functions and structure of the brain
in positive ways, such as by increasing
its ability to process information, and
reducing or even reversing age-related
changes in brain tissue.57 New research
has shown actual differences in the
brain structures of experienced meditators compared to those of people with
no history of meditation.58,59 Some
studies have shown increases in gray
matter density in parts of the brain
involved in feelings of empathy,60,61 or
in regions critical to learning and memory.62 At the same time, experienced
meditation The practice of concentrated
focus on a sound, object, visualization, the
breath, movement, or attention itself in order
to increase awareness of the present moment, reduce stress, promote relaxation, and
enhance personal and spiritual growth.
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 69
Reduces age-related
changes in the brain
Reduces stress,
anxiety, depression,
and promotes
relaxation
Enhances the brain's
ability to process
information
Improves sleep
Reduces blood
pressure
Helps regulate the
immune response and
reduce inflammation
FIGURE 3
Reduces symptoms
of gastrointestinal
disorders
Effects of Meditation on the Mind and Body
meditators may exhibit a decrease in
gray matter areas known to play key
roles in anxiety and stress.63
Meditation Techniques So,
how do you meditate? Detailed instructions are beyond the scope of this text,
but most teachers suggest beginning by
sitting in a quiet place with low lighting
where you won’t be interrupted. Many
advocate assuming a full lotus position,
with legs bent fully at the knees, each
ankle over the opposite knee. If this
is impossible or uncomfortable, you
may assume a modified lotus position,
with your legs simply crossed in front
SEE IT! VIDEOS
Can meditation help reduce your stress
and improve your grades? Watch
Meditation Becoming More Popular
among Teens, available on Mastering
Health.
70 | PART ONE | Finding the Right Balance
of you, or simply sit up straight (but not
stiffly) on a chair. Rest your hands on your
knees, palms upward. Beginners usually
find it easier to meditate with their eyes
closed.
Once you’re in position, it’s time to
start emptying your mind. The various
schools of meditation teach different
methods to achieve this. Some options
include:
Mantra meditation. Focus on a mantra, a single word such as Om, Amen,
Love, or Peace, and repeat this word
silently. When a distracting thought
arises, simply set it aside. It may help
to imagine the thought as a leaf, and
visualize placing it on a gently flowing stream. Do not fault yourself for
becoming distracted. Simply notice
the thought, release it, and return to
your mantra.
■■ Breath meditation. Count each
breath: Pay attention to each inhalation, the brief pause that follows,
■■
and the exhalation. Together, these
equal one breath. When you have
counted ten breaths, start over,
counting from 1. As with mantra
meditation, release distractions as
they arise, and return to following
the breath.
■■ Color meditation. When your eyes
are closed, you may perceive a
field of color, such as a deep, restful blue. Focus on this color. Treat
distractions as in other forms of
meditation.
■■ Candle meditation. With your eyes
open, focus on the flame of a candle.
Allow your eyes to soften as you
meditate on this object. Treat distractions as in the other forms of
meditation.
■■ Loving-kindness meditation. Imagine someone who loves you sending
you that love. Allow yourself to feel
this person’s warmth and caring.
Now imagine yourself surrounded
by all those who have ever loved you.
Feel them sending their love to you.
Next send your own warmth and
caring to someone you love. Now
expand your focus to send your love
to everyone you love, then to everyone you know, then to all people
everywhere, and finally to all living
creatures.
With practice, you may, after several
minutes of meditation, come to experience a sensation sometimes described
as “dropping down,” in which you feel
yourself release into the meditation.
In this state, which can be likened to
a wakeful sleep, distracting thoughts
are far less likely to arise, yet you may
receive surprising insights.
Initially, try meditating for just 10
to 15 minutes once or twice a day. In
time, you can increase your sessions to
30 minutes or more. As you meditate
for longer periods, you will likely find
yourself feeling more rested and less
stressed, and you may begin to experience the increased levels of empathy
that have been recorded among expert
meditators.
Contemplation
and Prayer
Can Contribute to
Spirituality
Distinct from mindfulness or meditation is another ancient practice known
as contemplation. The word contemplation means a study of something—
whether a candle flame or a theory of
quantum mechanics. In the domain
of spirituality, contemplation refers
to concentrating the mind on a spiritual or ethical question or subject, a
perspective, or an image of the natural
world or a representation of something
held sacred. In addition, many religious
and spiritual traditions advocate engaging in the contemplation of gratitude,
forgiveness, and unconditional love.
This engagement can take many forms,
such as imagining yourself sending a
friend unconditional love or thanking
a loving relative who has died. You can
also contemplate through journaling
or blogging, drawing, taking photographs, or writing a poem.
Contemplation doesn’t always have to mean deep study and reflection. It can be
as simple as enjoying an event in the world around you.
Here are some questions you might
contemplate:
How are you connected to others,
and to the world? Do you spend time
outside, respecting and appreciating the way nature can affect your
emotional state? Do you take actions
to protect and preserve the environment and other living things?
Understanding the interconnectedness of humanity, nature, and the
universe can increase your gratitude,
your compassion, and your inner
peace.
■■ How can you nurture more loving
relationships? Do your relationships bring you joy? Are they based
on mutual respect and love? If not,
what’s behind them, and how can
you strengthen them?
■■ What is your philosophy of life? Are
most of your actions and decisions
guided by a belief system about what
is truly right and wrong? If so, what
is that belief system?
■■ What are your limitations as well as
your strengths? How can you use
your strengths to have a positive
impact on your surroundings? How
can you work with other people to
build on the strengths of the group?
What are your limitations, and how
can you overcome them?
■■
In prayer, an individual focuses the
mind in order to communicate with a
transcendent presence. For many people, prayer offers a sense of comfort, a
sense that they are not alone. Through
prayer, they express concern for other
people, admit their transgressions, seek
forgiveness, and experience renewed
hope and purpose. Many people use
prayer to express gratitude for the richness of their lives. Research has shown
that spiritual practices such as prayer
can increase the ability to cope and
decrease stress among patients with
serious illness.64,65
Meditative Movement
Integrates Body and
Spirit
For thousands of years, in regions
throughout the world, spiritual seekers have pursued transcendence
through physical means. One of the
contemplation The practice of concentrating the mind on a spiritual or ethical question
or subject, a perspective, an image of the
natural world, or a representation of something held sacred.
prayer Practice of focusing the mind in
order to communicate with a transcendent
presence.
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 71
Yoga incorporates a variety of poses (asanas), from energetic to restful. This yoga student is
performing a restful asana known as child’s pose.
foremost examples is the practice of
yoga. Although many people in the
West tend to picture yoga as having to
do with a number of physical postures
and some controlled breathing, more
traditional forms tend to also emphasize chanting, meditation, and other
techniques believed to encourage unity
with the Atman, or spiritual life principle of the universe.
If you are interested in exploring
yoga, sign up for a class. Choose a form
that seems right to you: Some, such as
hatha yoga, focus on developing flexibility, deep breathing, and tranquility;
others, such as ashtanga yoga, are fastpaced and demanding and thus more
focused on developing physical fitness.
See Chapter 3 for more information­
on yoga.
The Eastern meditative movement
practices of tai chi can also reduce stress
and increase mental focus. With roots in
Chinese medicine, tai chi has also been
shown to reduce chronic pain, improve
cognitive functioning and physical fitness, and enhance quality of life.66,67
See Chapter 3 for more on tai chi.
Training your body to improve
your spiritual health doesn’t necessarily require you to engage in a formal
yoga A system of physical and mental training involving controlled breathing, physical
postures (asanas), meditation, and other
practices that are believed to cultivate oneness with the universe.
altruism The costly giving of oneself in the
service of others.
72 | PART ONE | Finding the Right Balance
practice. By energizing your body and
sharpening your mental focus, jogging,
biking, aerobics, dance, or any other
regular exercise can help. In particular,
mindfulness while exercising or engaging in physical pursuits can enhance the
physical benefits.
Altruism
Altruism, which may be defined as the
costly giving of oneself in the service
of others, significantly improves psychological and physical well-being.68
Volunteering time, donating money or
other resources to a food bank or other
program, and even spending an afternoon picking up litter in your neighborhood—all are ways to serve other people
and simultaneously enhance your own
spiritual and overall health. Altruism,
in the form of volunteering, can benefit
the individual helper, the people who
receive the help, and the community in
which they live through increased feelings of satisfaction, camaraderie, and
interconnectedness.69,70
For more strategies to cultivate your
spiritual side by reaching out to others,
see the MAKING CHANGES TODAY box.
Many college students contribute their time and skills to volunteer
organizations such as Habitat for Humanity.
MAKING CHANGES TODAY
Finding Your Spiritual Side through Service
Recognizing our connection to other living beings
is a key component of mindfulness and spirituality.
Volunteering your time and energy is a great way to live
that connection. Here are a few ideas:
Offer to help elderly neighbors with lawn care, babysitting
pets, or housework.
Volunteer with Meals on Wheels, a local soup kitchen, a
food pantry, or another program that helps people obtain
adequate food.
Organize or participate in an after-school or summertime
activity for neighborhood children.
Participate in a neighborhood cleanup, restoration of park
trails, or other environmental preservation projects.
Volunteer at the local humane society or animal shelter.
STUDY PLAN
ASSESS YOURSELF
Are you a spiritual
person? Want to find out?
Take the What’s Your Spiritual
IQ? assessment available on
Mastering Health.
CHAPTER REVIEW
LO 1 | What Is Mindfulness?
■■
Mindfulness is an awareness of the
present moment, a way to acknowledge your thoughts, emotions, and
experiences without allowing them
to define you. Components of mindfulness include acceptance of things
as they are, nonjudgment, presentmoment awareness, nonattachment,
openness to experience, compassion, connection, intention, gratitude, and peace and equanimity.
Apply to become a Big Brother or Big Sister, and mentor
a child who may face significant challenges or have poor
role models.
Join an organization working on a cause such as global
warming, hunger, or poverty. Check out these inspiring examples: Students Against Global Apathy (SAGA),
Students for the Environment (S4E), the National Student
Campaign Against Hunger and Homelessness, or your
local Habitat for Humanity.
To find out more information on service, the following are
some online resources:
Locates service opportunities: www.volunteermatch.org.
Lists overseas volunteer opportunities: www
.projects-abroad.org.
Oriented toward students: www.dosomething.org.
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
|
LO 2 What Are Spirituality
and Spiritual
Intelligence?
■■
Although spirituality is hard to
define and can mean different things
to different people, it encompasses
an individual’s sense of peace, purpose, connection to other people,
and beliefs about the meaning of
life. It involves a person’s values and
way of viewing life and behaving in
the world, and may include a sense
of connection to a higher presence.
Spiritual intelligence is an ability
to access higher meanings, values,
abiding purposes, and unconscious
aspects of the self.
|
LO 3 Health Benefits of
Mindfulness and
Spirituality: What Does
the Research Say?
■■
In recent years, numerous quality studies of mindfulness training
and spiritual practices have shown
that they can be helpful in relieving chronic pain; promoting weight
loss; increasing cancer coping; and
reducing blood pressure, blood glucose, and other biomarkers linked
to chronic disease. Mindfulness
training and certain other spiritual
practices are also thought to be effective in reducing anxiety, depression,
and stress.
|
LO 4 How Can You
Integrate Mindfulness
and Spirituality into
Your Life?
■■
Numerous practices can help you
integrate mindfulness and spirituality into your life. Strategies for
increasing your mindfulness include
FOCUS ON | Mindfulness, Spiritual Health, and Spiritual Intelligence | 73
cultivating compassion, expressing
gratitude, simplifying, starting each
day with intention, and examining
the way you deal with life’s challenges. Meditation, the cultivation
of a quiet mind, has numerous
beneficial effects on the mind and
body, as do meditative movement
practices such as yoga and tai chi.
Contemplation is a way of concentrating the mind on a critical question or subject, and prayer offers
many people comfort and a sense
of connection. Altruistic behavior
such as volunteering significantly
improves psychological and physical
well-being.
POP QUIZ
LO 1 | What Is Mindfulness?
1. Mindfulness encompasses all of the
following except
a. connection.
b. resistance.
c. compassion.
d. nonattachment.
74 | PART ONE | Finding the Right Balance
|
LO 2 What Are Spirituality
and Spiritual
Intelligence?
2. Spirituality could be characterized as
a. informal and unorthodox.
b. behavior-oriented.
c. authoritarian.
d. grounded in specific doctrines.
|
LO 3 Health Benefits of
Mindfulness and
Spirituality: What Does
the Research Say?
3. Which of the following statements
about the benefits of mindfulness
is true?
a. A significant body of quality
research evidence supports
a benefit of mindfulness in
preventing cancer.
b. Mindfulness meditation
appears to help older study
participants reduce their blood
pressure.
c. Mindfulness training has been
shown to cure PTSD in combat
veterans.
d. Among college students, a
7-week mindfulness training
program was shown to thicken
the gray matter in regions
of the brain associated with
intelligence.
|
LO 4 How Can You
Integrate Mindfulness
and Spirituality into
Your Life?
4. Which of the following actions can
help you integrate mindfulness
and spirituality into your life?
a. You engage in breath
meditation for 15 minutes each
morning.
b. You volunteer to help build a
Habitat for Humanity home.
c. You take a twice-weekly hatha
yoga class in your campus
fitness center.
d. While driving home from
campus, you imagine
yourself sending your mother
unconditional love.
e. All of the above.
Answers to the Pop Quiz questions can be
found on page A-1. If you answered a question
incorrectly, review the section identified by
the Learning Outcome. For even more study
tools, visit Mastering Health.
3
MANAGING STRESS
AND COPING WITH LIFE’S
CHALLENGES
LEARNING OUTCOMES
LO1
Define stress, examine the types of stress and its sources,
as well as the potential impact stress can have on health,
relationships, and success in college and in life.
LO2
Explain key stress theories as well as the emotional,
mental, and physiological changes that occur during the
stress response.
LO3
Examine the physical, intellectual, and psychological
effects of stress and their impacts on college students.
LO4
Explain key individual factors that may influence whether
or not a person is able to cope with stressors.
LO5
Explore stress-management and stress-reduction
strategies, ways you can cope more effectively with
stress, and mindfulness strategies that can enrich your
life experiences and reduce stress health risks.
75
WHY
Mental health problems on campus are on the rise. If you are like most students,
your stress level may be having a significant effect on your sleep, your relationships,
your immune system, and your ability to perform in your classes to the best of your
abilities. Getting good grades and a great job when you graduate are high priorities
for most students, and the pressure of competition can be high. In the long term, chronic
stress may affect your risks of high blood pressure, heart arrhythmias and other CVDs, cancer, diabetes,
anxiety, depression, and many other health-related problems. It may also lead to problems in your
interpersonal relationships and increase your risk of drug and alcohol abuse. Stress effects are insidious
and cumulative, and you have only one body. To protect that body, you need to know how to reduce
stress now and control stress throughout your life.
SHOULD I CARE?
I
n today’s fast-paced, 24/7-connected world, stress can
cause us to feel overwhelmed and can zap our energy.
Chronic stress inhibits normal functioning for prolonged
periods and is a growing public health crisis among
people of all ages. According to recent American Psychological Association studies, the health care system is not giving
Americans the support they need to cope with stress and build
healthy lifestyles. Here are some key findings:1
Americans consistently report high stress levels ­­
(20 percent report extreme stress), and teenagers report
stress levels on par with those of adults.
■■ Among those likely to report high levels of stress are lowerincome populations, blacks, Latinos, Millennials,
Gen-Xers, persons with disabilities, and women
(see Focus On: Difference, Disparity, and Health:
Achieving Health Equity for more).
■■ Only about half of all teens say they feel confident in
their ability to handle personal problems.
■■
76 | PART ONE | Finding the Right Balance
10
9
8
Reported stress level
What’s more is that major differences exist in how people
experience, report, and cope with stress. Our past experiences, learned coping mechanisms, and other factors all
figure importantly in our perceptions of, and our reactions to, stressful events—real or imaginary. Men and
women often report a variety of stress responses and
methods of coping with stress. Although the exact reasons for these differences are difficult to determine, an
emerging body of research, in both animal and human
studies, shows significant biological differences between
males and females in stress response, information processing, and emotionality, as well as revealing that
genetic influences in various brain regions may cause
different responses to stressful environments in men and
women. New technologies are beginning to shed light on
how women’s and men’s brains are wired and how they
work.2 Some potential differences occur in areas where
stress may be a contributing factor. For example, women
are twice as likely to experience clinical depression and
posttraumatic stress disorder than men. Men are two
times more likely to become alcoholic or drug dependent. Women also retain stronger, more intense, vivid
memories of emotional experiences, which may explain,
in part, their stress reactivity.3
Women are also more likely to report experiencing negative stress symptoms that affect their eating habits and prevent
them from making lifestyle changes.4 Additionally, while men
recognize and report stress, they are much less likely to take
action to reduce it.5 We are only beginning to fully understand
the multiple contributors to individual stress responses and
the role brain biology may play. What is known is that being
“stressed out” can take a major toll on people at all ages and
stages of life (FIGURE 3.1).
Is too much stress always a bad thing? Fortunately, the
answer is no. How we react to real and perceived threats often
is key to whether they are enabling or debilitating. Learning
to be mindful of our perceptions and reactions—to anticipate,
7
6
5.7
5.3
5
All Americans 4.8
3.9
4
3.3
3
2
1
Millennials
Gen Xers
Boomers
Matures
FIGURE 3.1 Stress Levels by Age Stress levels for Gen-Xers
and Millennials are above average, particularly compared to those for
older generations.
Source: American Psychological Association, "Stress in America: The State of Our
Nation," November 2017, Available at https://www.apa.org/news/press/releases/
stress/2017/state-nation.pdf.
Not all stress is bad for you! Although events that cause
prolonged distress, such as a natural disaster, can
undermine your health, events that cause eustress, such as
the birth of a child or waiting anxiously to see how you did
on a test, only to find you got the best grade in the class,
can have positive effects on your growth and well-being.
avoid, and develop skills to reduce or better manage stressors
and refocus our energies—is key. The first step in controlling
or reducing stress is to understand what stress is, how it affects
the body, and why we may be particularly vulnerable.
LO 1 | WHAT IS STRESS?
Define stress and examine the types of stress and their sources,
as well as the potential impact stress can have on health,
relationships, and success in college and in life.
Most current definitions of stress describe it as the mental
and physical response and adaptation by our bodies to real
or perceived change and challenges. A stressor is any real or
perceived physical, social, or psychological event or stimulus
that causes our bodies to react or respond. Several factors influence one’s response to stressors, including characteristics of the
stressor (How traumatic is it? Can you control it? Did it catch
you by surprise? Has anything in your life experience prepared
you for it?); biological factors (e.g., your age, gender, health status, or whether you’ve had enough sleep recently); and past
experiences (e.g., things that have happened to you, their consequences, and how you felt or responded). Stressors may be
tangible, such as a failing grade on a test, or intangible, such
as the angst associated with meeting your significant other’s
parents for the first time. Change can also be a major stressor.
There are several different types of stress.
Common Types of Stress
Eustress is typically referred to as positive stress. Eustress presents the opportunity for personal growth and satisfaction and
can actually improve health. Getting married, the excitement
of a first date, winning a major competition, or finding out
that you got the highest grade on an exam that you had been
worried about can give rise to
stress A series of mental
the pleasurable rush associand physiological responses
ated with eustress.
and adaptations to a real or
Distress, or negative stress,
perceived threat to one’s wellbeing.
is more likely to occur when
stressor A physical, social,
you are tired; under the influor psychological event or
ence of alcohol or other drugs;
condition that upsets homeounder pressure to do well; or
stasis and produces a stress
coping with an illness, finanresponse.
cial trouble, or relationship
eustress Stress that presents
opportunities for personal
problems. There are several
growth; positive stress.
kinds of distress. The most
distress Stress that can have
common type, acute stress,
a detrimental effect on health;
comes from demands and
negative stress.
pressures of the recent past
acute stress The short-term
and near future.6 Usually,
physiological response to an
acute stress is intense, lasts
immediate perceived threat.
for a short time, and disapepisodic acute stress The
pears quickly without permastate of regularly reacting with
wild, acute stress about one
nent damage to your health.
thing or another.
The positive reaction to acute
chronic stress An ongoing
stress is that you rise to the
state of physiological arousal in
occasion and put your most
response to ongoing or numercharming self forward: Seeous perceived threats.
ing someone you have a crush
traumatic stress A physion could cause your heart
ological and mental response
that occurs for a prolonged
to race and your muscles to
period of time after a major
tense while you appear cool,
accident, war, assault, natural
calm, and collected on the
disaster, or an event in which
outside. In contrast, anticipatone may have been seriously
hurt, killed, or witness to horing a class presentation could
rible things.
cause shaking, sweaty hands,
nausea, headache, cramping, or diarrhea, along with a galloping heartbeat, stammering, and forgetfulness. Episodic acute
stress is the state of regularly reacting with wild, acute stress
to various situations. Individuals experiencing episodic acute
stress may complain about all they have to do and focus on
negative events that may or may not occur. These “awfulizers”
are often reactive and anxious, constantly complaining about
their lack of sleep and all they have to do—habits so much a
part of them that they seem normal. Others may respond to
stress with a hyperactive, chirpy, “happy-happy” persona.
Acute stress and episodic acute stress can both cause physical and emotional reactions, but they may or may not result
in negative physical or emotional outcomes. In fact, they may
serve as a form of self-protection.
61%
is the percentage of college students seeking
counseling that report ANXIETY as their main
concern.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 77
In contrast, chronic stress can linger indefinitely and wreak silent havoc
on your body systems. Caregivers are
especially vulnerable to prolonged
emotional and physiological stress as
they watch a loved one struggle with
illness. Upon a loved one’s eventual
death, or the symbolic death of a love
relationship gone south, survivors
may struggle to balance the need to
process emotions with the need to stay
caught up in classes, work, and everyday life.
Another type of stress, traumatic
stress, is often a result of witnessing or experiencing events like major
accidents, war, shootings, sexual violence, assault, or natural disasters.
Effects of traumatic stress may be felt
for years after the event and cause significant disability, potentially leading
to posttraumatic stress disorder, or PTSD.
Affecting roughly 3.5 percent of U.S.
adults, PTSD can affect anyone, at any
age, from any culture, nationality, or
ethnic background (see Chapter 2 for a
discussion of PTSD).7
63%
The future of
our nation
62%
Money
61%
Work
59% Current social
divisiveness
57%
Current political
climate
43%
Health care
51%
Violence, crime,
terrorist threats
What Causes
Stress?
The American Psychological AssociaFIGURE 3.2 What Do We Say Stresses Us? Over the past few years, the annual
tion conducts one of the most comStress
in America survey has indicated that large percentages of American adults
prehensive studies examining sources
reported experiencing concerns over money, work, and the economy as major sources
of stress among various populations
of stress in their lives. In 2017, some of these concerns continued. However, stress over
annually. The 2015 survey found that
the state of our nation, social divisiveness, political climate, and worry over violence
concerns over money, work, family
were our biggest concerns.
responsibilities, personal and family
Source: Data from American Psychological Association, “Stress in America: The State of Our Nation,”
health, and the economy were the
November 2017, Available at https://www.apa.org/news/press/releases/stress/2017/state-nation.pdf.
biggest reported causes of stress for
American adults. However, by 2017,
counseling centers are up over 30 percent in the past 5 years,
Americans reported that they believed we were at one of the
according to a recent survey of over 150 colleges and universilowest points in American history and said that they were
ties in America.10
most stressed by worries involving the future of our nation,
money, work, the social divisiveness/political climate in the
country, and violence/crime. Health care, the economy, govAdjusting to Change: Key Stressors for
ernment trust, hate crimes, and climate change were among
College Students The stressors that college students
the other major stressors (FIGURE 3.2).8 Younger adults and
face come from more than just pressure to get good grades;
women are more likely to struggle with stress. In fact, levels
in fact, they come from a wide range of internal and external
of stress among women have increased while levels of stress
causes. Moving away from home, trying to fit in and make new
among men have declined since the 2015 APA survey.9 The
friends, missing your family and friends from home, adjusting
good news is that increasing numbers of Americans, parto a new schedule, and learning to live with strangers in housticularly college students, recognize the physical and mening that often lacks the comforts of home can all cause sleeptal effects of stress on health and are seeking psychological
lessness and anxiety and may keep your body in a continual
help for problems as well as engaging in mindfulness-related
fight-or-flight mode. The seriousness of the challenges that stuactivities to avoid, prevent, or control stress. Visits to campus
dents face is perhaps best illustrated by the fact that more than
78 | PART ONE | Finding the Right Balance
Although campus parking fees have increased, finding parking can be a
major stressor, as permits often amount to “hunting licenses” rather than
parking permits.
half of undergraduates e­ ntering four-year colleges for the first
time never finish. Those from low-income backgrounds, firstgeneration students, and minority groups are often the most
vulnerable and most likely to drop out. Many of them will leave
with “costly time spent” in the form of a huge personal debt.11
Schools with high percentages of students at risk for dropping
out are able to boost retention rates by anticipating challenges,
listening to student needs, providing necessary resources and
supports, and advising, and counseling to help students stay
in school.
Hassles: Little Things That Bug You
A
growing chorus of psychologists propose that the little
stressors, frustrations, and petty annoyances, known collectively as hassles, can be just as stressful and damaging to
your physical and mental health as major life changes.12
Cumulative hassles add up, increasing allostatic load and
resulting in wear and tear on body systems. Listening to
others monopolize class time, waiting in long lines, hunting for parking, loud music while you are trying to study,
and a host of other irritants can push your buttons, triggering fight-or-flight responses. A lifetime of hassles can
wreak havoc on the body, triggering mental health issues,
high blood pressure, and other chronic health problems.13
In addition to life and work stressors, electronic devices
pose increased stress loads for many. See the MINDFULNESS
AND YOU box on page 80 for tips on beating technostress.
The Toll of Relationships It isn’t any secret that
relationships can trigger some of the biggest fight-or-flight
reactions of all. Although romantic relationships are the ones
we often think of first, relationships with friends, family,
and coworkers can be sources of struggle as easily as support.
In addition, job insecurity, jobs with high demands and low
control, conflict
relative deprivation The inamong coworkability of lower-income groups
ers and between
to sustain the same lifestyle as
workers
and
higher-income groups in the
same community.
management,
and unrelenting performance expectations
increase health risk. New research points to
increased risks for burnout-related health consequences, such as type 2 diabetes, high cholesterol,
coronary heart disease, fatigue and headaches,
severe injuries, gastrointestinal issues, and death
before age 45.14 Psychological risks include
depression and insomnia.15 Negative health consequences are also related to personality characteristics that may exacerbate high-stress health
risks, particularly for people who are driven and
are constantly overcommitting on what they can
accomplish.16 Competition for rewards and systems that favor certain classes of employees or pit
workers against one another are among the most
stressful job situations.
Money Worries: Impact on Academics
and More College and university students face a number of difficulties managing ever-increasing tuition, housing
costs, and general expenses of college life. Many students
must hold jobs to stay afloat, and some incur huge student
loan debt. According to recent estimates, the 2017 graduating class was the most indebted class ever, with over 70 percent of students graduating with staggering debts, averaging
over $37,172. This occurred at a time when the job market had
tightened and the price of housing had skyrocketed. Over 11
percent of these students are likely to default on these loans,
and another 39 percent will move back in with their parents
or already have done so. Statistics are even worse among
private and for-profit online graduate programs.17 Worries
over finding a job after graduation, coupled with the need to
repay student loans, underscore the fact that finances are a
major source of stress for most students.18
What’s more, because money is often seen as an indicator
of status and success, individuals with long-term financial
insecurity may experience increased feelings of inferiority,
low self-esteem, and self-doubt. These feelings are in part
due to relative deprivation—the inability of lower-income
groups to sustain the same lifestyle as higher-income groups in
the same community.
62%
of adults report MONEY as a significant
source of stress.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 79
MINDFULNESS
AND YOU
I
Beating Technostress Through
Mindfulness
Technostress refers to stress created
by a dependence on technology and the
constant state of connection, which can
include a perceived obligation to respond,
chat, or tweet. Some have likened this
obsession to a form of technology
addiction, whereby individuals may check
their phones 35 to 50 times on an average
day, even waking in the night to respond.
The average student reports spending
more than 6 hours per week alone on
social networks (not counting normal
Internet searches, streaming videos,
television time, and other outlets) and
less time than ever in face-to-face social
interactions. Such
obsessive behavior
can sap energy, lead
to insomnia/sleep
disorders, damage
relationships and
normal in-person
interactions,
and hurt grades.
The negative
consequences of
these addictive
behaviors, which
are sometimes
labeled iDisorders,
Technology may keep you in touch, but it can also add
are on the rise. If
to your stress and loneliness and take you away from
you find yourself
real-world interactions.
in an unhealthy
relationship with
f you become anxious when you get to
class and realize that you forgot your
phone, you may need to think about why
even an hour unplugged is more than you
can take. High-frequency cell phone use is
on the rise, and with it comes a variety of
problems. According to a new study, college students who can’t keep their hands
off their mobile devices are reporting
higher levels of anxiety, less satisfaction
with life, and lower grades than peers who
use their devices less often. The average
student surveyed spent nearly 5 hours per
day using his or her cell phone. Are you
surprised?
Frustration and Conflict
Whenever there is a disparity between our goals (what we hope to obtain in life) and our
behaviors (actions that may or may not lead to these goals), frustration can occur. Conflicts occur when we are forced to decide
among competing motives, impulses, desires, and behaviors
(e.g., to party or study) or when we are forced to face pressures or
demands that are incompatible with our own values and sense
of importance (e.g., get good grades or compete in college athletics). College students may face a variety of conflicts involving parental values, their
overload A condition in which
own beliefs, societal views on
a person feels overly pressured
issues versus their own views,
by demands.
and inner struggles as their
burnout A state of physical
own beliefs and values begin
and mental exhaustion resulting from unrelenting stress.
to change over time.
80 | PART ONE | Finding the Right Balance
your smartphone, tablet, or other media
device, it may be time to unplug. Here are
some mindful strategies that may help you
live more in the moment:
■■ Schedule screen time. Set aside time
to check e-mail, text messages, your
Facebook, Twitter, and other streaming
feeds. Resist the urge to check if you’re
outside this set time frame. NO reading
messages in the middle of the night!
■■ Unfriend the annoying and offensive.
Lighten your load by focusing only on
the people who really matter to you
and add to your day in a positive way.
■■ Connect with your friends in real time.
Socialize with friends in person. And
while you’re at it, put your phone away.
■■ Power devices down. Turn off all
your devices completely (not just silent
mode) when you’re driving, in class, at
work, in bed, having dinner with friends,
or on vacation.
Sources: Eagan et al., The American Freshman:
National Norms Fall 2016 (Los Angeles: Higher
Education Research Institute UCLA, 2017), Available at https://www.heri.ucla.edu/monographs/
TheAmericanFreshman2016.pdf; Pew Research
Center, “Social Media Fact Sheet,” February 2018,
www.pewinternet.org/fact-sheet/social-media/;
T. Panova and A. Lleras. “Avoidance or Boredom:
Negative Mental Health Outcomes Associated with
Use of Information and Communication Technologies Depend on Users’ Motivations,” Computers
in Human Behavior 58 (2016): 249, DOI: 10.1016/
j.chb.2015.12.06.
Overload Overload occurs when we are overextended
and, try as we might, there are not enough hours in the day to
do everything. Students suffering from overload may experience
depression, sleeplessness, mood swings, frustration, anxiety, or a
host of other symptoms. Binge drinking and high consumption
of junk food—often coping strategies for stress overload—catch
many in a downward spiral as their negative behaviors actually
add to their stress load. Unrelenting stress and overload can lead
to a state of physical and mental exhaustion known as burnout.
Stressful Environments
For many students, the
living environment causes significant levels of stress. Perhaps you cannot afford safe, healthy housing, a bad roommate ­constantly makes life uncomfortable, or loud neighbors
keep you up at night. Campus shootings, a volatile political
High stress levels may increase cortisol levels in the
bloodstream, increasing hunger and encouraging stress
eating.
climate, social movements that cause conflict, violence in
your community, and other issues in the news may increase
your stress. Noise, pressure of people in crowded living situations, and uncertainties over food and housing can keep even
the most resilient person on edge.
Natural disasters can cause tremendous stress initially and
for years later. Typhoons and hurricanes, earthquakes and tsunamis, killer tornadoes, as well as human disasters such as oil
spills, nuclear disasters, terrorist attacks, and the devastation
of war, have disrupted millions of lives and damaged ecosystems. Even after the initial images of suffering pass and the crisis has subsided, shortages of vital resources such as gasoline,
clean water, food, housing, health care, sewage disposal, and
other necessities, as well as electricity outages and transportation problems, can wreak havoc in local communities and on
campuses and result in epidemics of infectious disease, major
injuries, and death. Survivors often suffer from horrific emotional and mental health reactions.
Background distressors
in the environment, such
WHAT DO
as noise, air, and water pollution, allergy-aggravating
THINK?
pollen and dust, un­
safe
food, obnoxious odors
■■ Which
com­ing from human waste
environmental
disposal and other sanitastressors bug you the most?
tion issues, or environmen■■ When you encounter these
tal tobacco smoke, can also
environmental stressors, what
be incredibly stressful.
actions do you take, if any?
YOU
Bias and Discrimination
Racial and ethnic diversity of students, faculty members, and staff enriches everyone’s educational experience on campus. It also challenges us
to examine our personal attitudes, beliefs, and biases. Today’s
­campuses include a diverse cultural base of vastly different life
experiences, languages, and customs. Bias and discrimination
based on race, ethnicity, relibackground distressors
gious affiliation, age, sexual
Environmental stressors
orientation, or other real or
of which people are often
perceived differences—whether
unaware.
in viewpoints, appearance,
behaviors, or backgrounds—can take the form of bigotry, insensitivity, harassment, hostility, or simply ignoring a person or
group. (See Focus On: Difference, Disparity, and Health:
Achieving Health Equity for more on this topic, and the
­
HEALTH IN A DIVERSE WORLD box on page 82 for info on how
stress can affect international students.)
Evidence of the health effects of excessive stress in
minority groups has increased significantly among all
populations since 2016, with Hispanic and black adults
­
reporting the highest increases in several categories. A key
stress symptom, lying awake at night, was reported by 56
percent of Hispanic, 42 percent of black, and 42 percent of
white and Asian adults.19 Virtually every minority group
reported increases in stress levels. Although poverty and
socioeconomic status are key sources of stress for many, the
chronic, physically debilitating stress among marginalized
groups may also reflect real and perceived effects of institutional racism rather than the stress caused by individual/
interpersonal poverty and perceived racism alone. More
research is necessary to show direct associations between
racism, stress, and hypertension among those who also
experience persistent poverty. It is important to realize that
all types of “isms” may influence stress-related hypertension
and make it more difficult for those affected to engage in
healthy ­lifestyle behaviors.20
LO 2 | THE STRESS RESPONSE:
WHAT REALLY HAPPENS?
Explain key stress theories as well as the emotional, mental,
and physiological changes that occur during the stress
response.
Over the years, several theories have evolved explaining
what happens (physiologically and psychologically) when
a person perceives or experiences a stressor—as well as why
some people thrive in stressful situations and others suffer
debilitating consequences. One of the most well-developed
and respected theories evolved from the idea that the body’s
efforts to protect itself from threats is part of an evolutionary process. Thousands of years ago, if your ancestors didn’t
respond to danger by fighting or fleeing, they might have
been eaten by a saber-toothed tiger or killed by a marauding
enemy clan. Today, when we face real or perceived threats,
these same physiological responses kick into gear, but our
instinctual reactions to fight, scream, or run must be held in
check. While we learn culturally acceptable restraint, our bodies remain charged for battle—sometimes chronically. Over
time, this vigilant, simmering stress response can lead to serious health problems.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 81
HEALTH
IN A DIVERSE WORLD
I
nternational students experience unique
adjustment issues related to language
barriers, cultural barriers, financial issues,
and a lack of social support, among other
challenges. Academic stress may pose a
particular problem for the nearly 1.1 million international students who left their
native countries to study in the United
States in 2016–17.
Accumulating evidence suggests
that emotional support from others, oncampus socialization opportunities, and
strong host networks are particularly
effective ways for students to cope with
stressful acculturation issues. Yet, many
international students refrain from doing
so because of cultural norms, feelings of
shame, and the belief that seeking support
is a sign of weakness that calls inappropriate attention to both the individual and the
respective ethnic group. This reluctance,
coupled with language barriers, cultural
Unique Stressors Facing
International Students
Language barriers, cultural conflicts,
racial prejudices, and a reluctance to
seek social support all contribute to a
significantly higher rate of stress-related
illnesses among international students
studying in the United States.
Physiology/Systems Theory:
General Adaptation Syndrome
When stress levels are low, the body is often in a state of
homeostasis, or balance; all body systems are operating
smoothly to maintain equilibrium. Stressors trigger a crisismode physiolo­gical response, after which the body attempts
to return to homeostasis by means of an adaptive response.
First characterized in 1936 by noted endocrinologist and stress
researcher Dr. Hans Selye,
general adaptation synhomeostasis A balanced
drome (GAS) (FIGURE 3.3)
physiological state in which all
the body’s systems function
provides an explanation of
smoothly.
the body’s internal fight to
adaptive response The
restore homeostasis when
physiological adjustments the
stressed. GAS has three disbody makes in an attempt to
tinct phases: alarm, resistance,
restore homeostasis.
and exhaustion.21
general adaptation syndrome (GAS) The pattern
followed in the physiological
response to stress, consisting
of the alarm, resistance, and
exhaustion phases.
fight-or-flight response
Physiological arousal response
in which the body prepares
to combat or escape a real or
perceived threat.
Alarm Phase: The
Body in “Protect
Mode” Suppose you are
walking home after a night
class on a dimly lit campus.
You hear someone cough
behind you and sense his or
82 | PART ONE | Finding the Right Balance
conflicts, loneliness, and the pressure to
succeed, can lead international students
to suffer significantly more stress-related
illnesses than their American counterparts.
Many universities are responding
to this extra stress by hosting stressmanagement workshops each term that
are geared toward the needs of international students and that encourage them
to share stress-management techniques
from their home countries. Both American
and international students can help each
other reduce stress with simple actions:
share companionship and communication,
and lend a helping hand. To paraphrase a
popular Hindu proverb: “Help thy neighbor’s boat across and thine own boat will
also reach the shore.”
Source: Institute of International Education, “Open
Doors 2017: Report on International Educational
Exchange,” November 2017, www.iie.org.
her rapid approach. You walk faster, only to hear the other
person’s footsteps quicken. Your senses go on high alert, your
breathing quickens, your heart races, and you begin to perspire. In desperation you stop, rip off your backpack, and prepare to fling it at your would-be attacker. You turn around,
arms flailing, and let out a blood-curdling yell. To your surprise, the would-be attacker screeches back. In relief and a bit
of embarrassment, you realize it’s just one of your classmates
trying to stay close out of her own fear of being alone in the
dark! You have just experienced the alarm phase of GAS. Also
known as the fight-or-flight response, this physiological
reaction is one of our most basic, innate survival instincts22
(FIGURE 3.4 on page 84).
When the mind perceives a real or imaginary stressor, the
cerebral cortex, the region of the brain that interprets the
nature of an event, triggers an autonomic nervous system
(ANS) response that prepares the body for action. The ANS is
the portion of the nervous system that regulates body functions normally outside conscious control, such as heart and
glandular functions and breathing.
The ANS has two branches: sympathetic and parasympathetic. The sympathetic nervous system energizes the body
for fight or flight by signaling the release of several key stress
hormones, particularly epinephrine, norepinephrine, and
cortisol. The parasympathetic nervous system slows systems
stimulated by the stress response—in effect, it counteracts the
actions of the sympathetic branch.
2 Resistance stage:
Adaptation resources
are mobilized to combat
stressor, and body
maintains a higher level
of resistance
Resistance to stress
1 Alarm stage:
Stressor disrupts
body’s stability,
temporarily
lowering
resistance
3 Exhaustion
stage: Body
runs out of
adaptation
energy stores
for adjusting
to stressor, and
resistance drops
below normal
Homeostasis
(normal state
of resistance)
Time
FIGURE 3.3 General Adaptation Syndrome (GAS) GAS
describes the body’s method of coping with prolonged stress.
The sympathetic nervous system’s responses to stress
involve a series of biochemical exchanges between different
parts of the body. The hypothalamus, a structure in the brain,
functions as the control center of the sympathetic nervous
system and determines the overall reaction to stressors. When
the hypothalamus perceives that extra energy is needed to
fight a stressor, it stimulates the adrenal glands, located near
the top of the kidneys, to release the hormone epinephrine,
also called adrenaline. Epinephrine “kicks” the body into gear,
causing more blood to be pumped with each beat of the heart;
dilates the airways in the lungs to increase oxygen intake;
increases breathing rate; stimulates the liver to release more
glucose (which fuels muscular exertion); and dilates the pupils
to improve visual sensitivity. In addition to the fight-or-flight
response, the alarm phase can trigger a longer-term reaction
to stress. The hypothalamus uses chemical messages to trigger the pituitary gland within the brain to release a powerful
hormone, adrenocorticotropic hormone (ACTH). ACTH signals
the adrenal glands to release cortisol, a key hormone that
makes stored nutrients more readily available to meet energy
demands. Finally, other parts of the brain and body release
endorphins, which can relieve the pain and anxiety that a
stressor may cause.
Resistance Phase: Mobilizing the Body’s
Resources In the resistance phase of the GAS, the
body tries to return to homeostasis by resisting the alarm
responses. Special hormones such as oxytocin (also known
as the “­cuddle chemical”) begin to circulate in an attempt to
bring ­physiological processes back to homeostasis. However,
because some perceived stressor still exists, the body does not
achieve complete calm or rest. Instead, the body stays activated or “revved up” at a level that causes a higher metabolic
rate in some organ tissues.
Exhaustion Phase:
Body
Resources
Depleted In the exhaus­
autonomic nervous system
(ANS) The portion of the
central nervous system that
regulates body functions that
a person does not normally
consciously control.
tion phase of GAS, the hormones,
chemicals,
and
systems that trigger and mainsympathetic nervous
tain the stress response are
system Branch of the autodepleted by substances such
nomic nervous system responas oxytocin, and the body
sible for stress arousal.
puts on the stress brakes,
parasympathetic nervous
beginning to bring systems
system Branch of the
autonomic nervous system
into balance. You may feel
responsible for slowing systired or drained as your body
tems stimulated by the stress
returns to normal. In situaresponse.
tions of chronic stress, trighypothalamus A structure in
gers may reverberate in the
the brain that controls the sympathetic nervous system and
body, keeping body systems
directs the stress response.
at a heightened arousal state.
epinephrine Also called
The prolonged effort to adapt
adrenaline, a hormone that
to the stress response leads to
stimulates body systems in
allostatic load, or exhaustive
response to stress.
wear and tear on the body. As
cortisol Hormone released
the body adjusts to chronic,
by the adrenal glands that
makes stored nutrients more
unresolved stress, the adrereadily available to meet energy
nal glands continue to release
demands.
cortisol, which remains in the
endorphins Opioid-like
bloodstream for longer perihormones that are manufacods of time as a result of slower
tured in the human body and
metabolic
responsiveness.
contribute to natural feelings of
well-being.
Over time, cortisol can reduce
allostatic load Wear and
immunocompetence—the
tear on the body caused by
ability of the immune system
prolonged or excessive stress
to respond to attack—as well
responses.
as increase the risk of health
immunocompetence The
problems such as depresability of the immune system to
sion, diabetes, heart arrhythrespond to attack.
mias, cancer, inflammatory
responses, cardiovascular disease (CVD), digestive diseases,
weight gain, insomnia, and many other health problems.23
Psychological Theory: The
Transactional Model of Stress
and Coping
In the transactional model of stress and coping, psychologist
Richard Lazarus proposed that our reaction to stress is not so
much about the nature of a stressor as the interaction between
a person’s perception, coping ability, and the environment. In other
words, your history, experience, and beliefs about a stressor
will influence perceptions about whether you should worry or
jump into action, remain calm and unreactive, or utilize coping strategies that have worked in the past. According to Lazarus, the transactional model consists of four stages: (1) appraisal,
in which you size up whether the stressor is a real threat; (2)
secondary appraisal, in which you assess whether your actions
might reduce the threat with the resources you have; (3) coping,
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 83
More blood flows to brain;
senses sharpen
Pupils dilate to bring in more
light and increase visual
perception
Hearing ability increases
Salivation decreases
Perspiration increases
Respiration rate increases
Heart rate and blood pressure
increase
Digestive system slows as
blood supply is diverted to
more critical areas
Liver and fat tissues release
energy-producing substances
(such as glucose) into
bloodstream
Blood-clotting ability increases
More blood flows to muscles;
muscles tense
Immune system activity
decreases
Urine production decreases
FIGURE 3.4 Fight-or-Flight: The Body’s Acute Stress
Response Exposure to stress of any kind causes a complex series of
involuntary physiological responses.
transactional model of
stress and coping Theory
proposed by psychologist
Richard Lazarus, saying
that our reaction to stress is
about the interaction between
perception, coping ability, and
environment.
minority stress perspective Theory positing that
minority stress may be partially
explained by disparities and
the chronic stress inherent in
populations where rejection,
alienation, and hostility persist.
Yerkes-Dodson law of
arousal Theory suggesting
that when arousal or stress
increases, performance goes
up to a point, after which performance declines.
in which you take action to
reduce the threat; and (4) postassessment, in which you examine what happened and decide
whether you need to take more
action. In this model, your perceptions are key to your stress
response. By changing your
perceptions, you can reduce
the stress effect.24
Minority Stress
Perspective
Another theory explaining
the role of negative stressors
relates to the role that stress
plays in the lives of minority
populations. According to the
84 | PART ONE | Finding the Right Balance
Watch Video Tutor:
Body’s Stress Response
minority stress perspective, there are unresolved conflicts
between minority and dominant group members. As such,
minority stress may be explained in large part by disparities
and the chronic stress inherent in populations that experience
persistent rejection, alienation, and hostility. This is especially
true in cases characterized by a long history of harassment,
maltreatment, discrimination, and victimization.25
Yerkes-Dodson Law of Arousal
According to the Yerkes-Dodson law of arousal, when
arousal or stress increases, performance goes up—but only
to a point. Too much stress can drive performance down. For
example, an athlete who does a great job passing the football
in regular-season games might choke during the conference
championship when NFL scouts are on the field. On the other
end, if you are cramming for four exams a mere 2 days before
you have to take them, you may find yourself so wound up that
you do horribly on all of the exams. You may be listless, find
it hard to concentrate, and watch helplessly
as your grade tumbles. This stress response is
often depicted as a bell-shaped curve. As your
stress increases, the performance curve moves
upward; however, once you reach a certain
level of stress, performance levels off. If stress
persists and increases beyond this point, performance can drop precipitously.26
Do Men and Women
Respond Differently to
Stress?
Tension headaches,
migraine, dizziness
Oily skin, skin blemishes,
rashes, blushing, acne
Dry mouth, jaw pain,
grinding teeth, insomnia,
sleep difficulties
Backache, neck stiffness,
muscle cramps, fatigue,
muscle spasms
Ever since Walter Cannon’s landmark studies
Tightness in chest,
hyperventilation, heart
in the 1930s, it has been thought that humans,
pounding, palpitations
as well as many species of animals, respond
similarly to stressful events. However, newer
Stomachache, acid stomach,
research indicates that men and women may
burping, nausea, indigestion,
actually respond very differently to stressors.
stomach “butterflies”
While men may be more prone to fighting or
fleeing, women may be more likely to “tend
Diarrhea, gassiness,
constipation, increased
and befriend” by befriending the enemy or
urge to urinate
obtaining social support from others to ease
stress-related reactions. There is tremendous
Cold hands, sweaty hands
variability in these behaviors, however, based
and feet, trembling
27
on age, social learning, and other factors.
Many believe that oxytocin, believed to play
a role in social interaction, is a key factor in
explaining some gender-based differences. FIGURE 3.5 Common Physical Symptoms of Stress Sometimes you may
Essentially, women under stress appear to not even notice how stressed you are until your body starts sending you signals.
have higher levels of oxytocin than men in Do you frequently experience any of these physical symptoms of stress?
similar circumstances and are more likely to
form tight social alliances, be empathic, and seek out friends
The higher the levels of stress you experience and the lonfor support when stress levels are high. In contrast, men are
ger that stress continues, the greater the likelihood of dammore likely to withdraw when highly stressed. However, it’s
age to your physical health.29 New research indicates that the
important to note that both
more cumulative adversity (total stressor exposure, including
SEE IT! VIDEOS
men and women may react
complex trauma) some groups experience, the greater is their
similarly, particularly in times
Can a test identify your risk
risk of psychopathology and developmental problems as well
of crisis, with evidence that
for stress-related illnesses?
as increased risk for a wide range of social, emotional, and psyboth are often willing to risk
Watch Stress Can Damage
chological problems.30
their lives to help others, or
Women’s Health, available
on Mastering Health.
defend their loved ones when
necessary.28
Stress and Cardiovascular
Disease
LO 3 | STRESS AND YOUR
HEALTH
Examine the physical, intellectual, and psychological effects of
stress and their impacts on college students.
Researchers have only begun to untangle the complex web of
responses that can take a toll on a person’s physical, intellectual, and emotional well-being. Stress is often described as a
disease of prolonged arousal that leads to a cascade of negative
health effects. Some warning symptoms of prolonged stress are
shown in FIGURE 3.5.
Perhaps the most studied and documented health consequence of unresolved stress is cardiovascular disease. Recent
research indicates that chronic stress plays a significant role
in increased risk of heart arrhythmias, inflammation in
blood vessels that increases risks of atherosclerosis, and several other CVD risks.31 Behaviors that seem to increase the
risks of negative stress outcomes such as high blood pressure
and other CVD issues include prolonged anger, worry, hostility, and chronic rumination
over perceived insults and
cumulative adversity Total
slights during social and work
stressor exposure, including
interactions.32
complex trauma.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 85
Research into the relationship between stress and CVD contributors has also shown direct links between the incidence
and progression of CVD and stressors such as job strain, occupational noise, caregiving, bereavement, and natural disasters.33 (For more on CVD, see Chapter 16.)
Broken Heart Syndrome
Also known as stressinduced cardiomyopathy, broken heart syndrome is the very
real heart damage experienced by some people as a result
of chronic, debilitating stress; depression; loss; a breakup;
betrayal; or another major emotional blow. The resulting overload of stress hormones, such as adrenaline, can lead to shortcircuiting of the heart’s electrical system, including serious
arrhythmias or damage to the heart muscle (cardiomyopathy),
interfering with the heart’s ability to move blood. With symptoms similar to those of a heart attack, this syndrome can lead
to heart failure and even death if untreated.34
Stress and Weight Gain
Are you a “stress eater” or an “emotional eater”? Do you run
for the refrigerator when you are under pressure or feeling
anxious or down? If you think that when you are extremely
stressed, you tend to eat more and gain weight, you probably
aren’t imagining it. Higher stress levels may increase cortisol levels in the bloodstream, which contributes to increased
hunger and seems to activate fat-storing enzymes. Animal and
human studies, including those in which subjects suffer from
posttraumatic stress, seem to support the theory that cortisol
plays a role in laying down extra belly fat and increasing eating
behaviors.35
Stress and Hair Loss
Too much stress can lead to thinning hair, and even baldness,
in men and women—ironically, a problem that can increase
stress even more! The most common type of stress-induced
hair loss is telogen effluvium. Often seen in individuals who
have lost a loved one or experienced severe weight loss or other
trauma, this condition pushes colonies of hair into a resting
phase. Over time, hair begins to fall out. A similar stress-related
condition known as alopecia areata occurs when stress triggers
white blood cells to attack and destroy hair follicles, usually in
patches.36
Stress and Diabetes
Controlling stress levels is critical for preventing development
of type 2 diabetes—and for successful short- and long-term
diabetes management.37 People under a lot of stress often
don’t get enough sleep, don’t eat well, and may drink or take
other drugs to help them get through a stressful time. All of
these behaviors and stress hormones, particularly cortisol, can
affect blood sugar levels and appear to increase the risks of type
2 diabetes.38 (For more, see Focus On: Minimizing Your Risk
for Diabetes on page 434.)
86 | PART ONE | Finding the Right Balance
Prolonged stress can compromise the immune system,
leaving you vulnerable to infection.
Stress and Digestive Problems
Digestive disorders are physical conditions for which causes are
often unknown. It is widely assumed that an underlying illness,
pathogen, injury, or inflammation is already present when stress
triggers nausea, vomiting, stomach cramps and gut pain, or
diarrhea. There is increasing evidence of a brain-gut interaction,
in which chronic stress can influence flare-ups of symptoms, or
even cause symptoms of gastrointestinal problems. Both acute
and chronic stress may increase the severity of symptoms as well
as prolonging them.39 Also, people with depression or anxiety
or who feel tense, angry, or overwhelmed are more susceptible
to dehydration, inflammation, and other digestive problems.40
Stress and Impaired Immunity
A growing area of scientific investigation known as psychoneuroimmunology (PNI) analyzes the intricate relationship
between the mind’s response to stress and the immune system’s ability to function effectively. Several recent research
reviews suggest that too much stress over a long period can negatively affect various aspects of the cellular immune response.
One study examining the effects of acute and chronic academic stress on college students indicated a marked impact on
various immune defenses, providing further explanation for
increases in infectious diseases during final exams and other
high-stress times each term.41
More prolonged stressors, such as the loss of a loved one, caregiving, living with a disability, and unemployment, have also
been shown to impair the natural immune response over time.42
Stress and Your Mental Health
In a recent national survey of college students, 52 percent of
respondents (41 percent of men and 57 percent of women) said
they felt overwhelmed by all they had to do within the past 2
to depression, dementia, and Alzheimer’s disease as well as an
overactive amygdala (region of the brain associated with emotional responses) that may increase rates of violence.48
LO 4 | INDIVIDUAL FACTORS
THAT AFFECT YOUR STRESS
RESPONSE
Explain key individual factors that may influence whether or not a
person is able to cope with stressors.
Although stress can come from the environment and external
sources, it can also be a result of internal or individual factors: the
“baggage” that we carry with us from a lifetime of real and perceived experiences. Low self-esteem, negative appraisal, lack of
self-compassion, fears and anxiety, narcissistic tendencies, and
other learned behaviors and coping mechanisms can increase
stress levels.
Stress and depression have complicated interconnections
based on emotional, physiological, and biochemical
processes. Prolonged stress can trigger depression in
susceptible people, and prior periods of depression can
leave individuals more susceptible to stress.
weeks, and a similar number reported feeling exhausted.43 Not
surprisingly, these same students rated stress as their number
one impediment to academic achievement.44 Stress can play a
huge role in whether students stay in school, get good grades,
and succeed on their career path. It can also wreak havoc on
students’ ability to concentrate, understand, and retain information. Having a short fuse or being highly reactive can also
cause stress in relationships.
Stress,
Memory,
and
Concentration
Although the exact ways stress affects grades and job performance are complex, new research provides possible clues. Animal studies suggest glucocorticoids—stress hormones released
from the adrenal cortex—may affect cognitive functioning
and overall mental health. In humans, memory is impaired
when acute stress bombards the brain with hormones and neurotransmitters—affecting the way we think, make decisions,
and respond in stressful situations.45 Recent laboratory studies
have linked prolonged exposure to cortisol to actual shrinking
of the hippocampus, the brain’s major memory center.46 Other
research has focused on the role of oxidative stress in synaptic
dysfunction, and as a contributing factor in aging and development of Alzheimer’s disease.47 More research is needed to determine the validity of these theories.
Psychological Effects of Stress
Stress may be
one of the single greatest contributors to mental disability and
emotional dysfunction in industrialized nations. Recent studies have shown that chronic stress may actually cause structural degeneration and impaired function of the brain, leading
Appraisal
Many times, our appraisal of life’s demands, not the demands
themselves, results in experiences of stress. Appraisal is defined
as the interpretation and evaluation of information provided
to the brain by the senses. As new information becomes available, appraisal helps us recognize stressors, evaluate them
based on past experiences and emotions, and decide whether
we can cope. When you feel that the stressors of life are overwhelming and you lack control, you are more likely to feel
strain and distress.
Self-Esteem
Recall that self-esteem refers to your sense of self-worth: how
you judge yourself in comparison to others. Research with
adolescents and young adults indicates that high stress and
low self-esteem significantly predict depression and suicidal
ideation, a desire to die and thoughts about suicide. Fortunately, research has shown that you can improve your ability
to cope with stress by increasing self-esteem.49
While a healthy dose of self-esteem has long been regarded
as necessary for mental health, new research also points to a
potential dark side. Critics of the self-esteem movement point
to the fact that many of today’s college students have some of
the highest levels of narcissism ever recorded, and that the quest
to maintain the persona of
psychoneuroimmunology
being at the top of their game
(PNI) The study of the interwith thousands of friends on
relationship between mind
Facebook or huge Twitter foland body on immune system
lowings can be stressful and
functioning.
appraisal The interpretation
can increase rates of depresand evaluation of information
sion, anxiety, and other
provided to the brain by the
50
Environments
problems.
senses.
in which individuals are
suicidal ideation A desire
always compared to others as
to die and thoughts about
indicators of self-worth may
suicide.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 87
as hard-driving, competitive, time-driven perfectionists. In
contrast, Type B personalities are described as being relaxed,
noncompetitive, and more tolerant of others. Today, most
researchers recognize that none of us are wholly Type A or Type
B; we may exhibit either type in selected situations, sometimes
with varying outcomes.
Thriving Type A: Hardiness, Psychological
Resilience, and Grit In the 1970s, psycholo-
Certain jobs can be especially stressful, particularly
those in which the stakes are high and coworkers have
little control over many outcomes. Individuals such as
firefighters face long work hours and a high-stakes work
environment that make them especially prone to stress,
overload, and burnout.
contribute to more bullying in a quest for power, more prejudice
between groups, and more difficulties in working with other
people after graduation.51
Self-Efficacy
Research has shown that people with high levels of confidence in their skills and ability to cope with life’s challenges
tend to feel more in control of stressful situations and report
fewer stress effects.52 Self-efficacy is considered one of the
most important personality traits that influence psychological
and physiological stress responses.53 Developing self-efficacy
is also vital to coping with and overcoming academic pressures
and worries.54 High test anxiety has been shown to account
for up to 15 percent of the variance in student performance
on exams.55 Research suggests that if you learn to handle test
anxiety, your confidence may increase and your test scores will
improve, leading to improved performance overall.56 Tips on
how to deal with test anxiety and build your testing self-efficacy
can be found in the MAKING CHANGES TODAY box.
Type A and Type B Personalities
It’s no surprise that personality can have an impact on whether
you are happy and socially well-adjusted or sad and socially isolated. But personality may also be a critical factor in stress levels, as well as in your risk for CVD, cancer, and other chronic
and infectious diseases.
In 1974, physicians Meyer Friedman and Ray Rosenman
published a book indicating
that Type A individuals had a
psychological hardiness A
greatly increased risk of heart
personality trait characterized
by control, commitment, and
disease due to increased physithe embrace of challenge.
ological reactivity and propsychological resilience The
longed activation of the stress
capacity to maintain or regain
response, including increased
psychological well-being in
heart rate and blood presthe face of adversity, trauma,
sure.57 Type A personalities
tragedy, threats, or significant
sources of stress.
have historically been defined
88 | PART ONE | Finding the Right Balance
gist Susan Kobasa noted that many people who were superstressed didn’t have the negative health consequences one
might expect. She aptly described the theory of psychological­
hardiness, indicating that hardy individuals were unique
in their control, commitment, and willingness to embrace challenges in life, rather than succumb to them.58 Today, Kobasa’s
work has been expanded and refined to suggest that not only
are certain individuals hardy, but also some seem to thrive on
their supercharged lifestyles, at least in the short term. These
individuals are described as being psychologically resilient—
a dynamic process in which people exposed to sustained
adversity, tragedy, or traumatic challenges adapt positively.59
They pick themselves up when knocked down and recover
quickly from illness, adversity, changes, or challenges. These
high-achieving thrivers often demonstrate (1) a positive and
MAKING CHANGES TODAY
Overcoming Test-Taking
Anxiety
Testing well is a skill needed in college and beyond. Try these
tips on your next exam.
Before the Exam
Don’t wait until the last minute to cram. Keep up with
reading during the term. At least a week before your test,
start studying for a set amount of time each day. Do a
limited review the night before, get a good night’s sleep,
and arrive for the exam early.
Eat a balanced meal before the exam. Avoid sugar and
rich or heavy foods as well as foods that might upset your
stomach. You want to feel your best.
Wear a watch to class on the day of the test in case there
is no clock.
During the Exam
Manage your time during the test. Look at how many
questions there are and what each is worth. Prioritize the
high-point questions, allow a certain amount of time for
each, and make sure that you leave some time for the
rest. Hold to this schedule.
Slow down and pay attention. Focus on one question at a
time. Check off each part of multipart questions to make
sure your answers are complete.
proactive personality; (2) experience and learning history
that contributes to self-efficacy; (3) a sense of control, flexibility, and adaptability—an ability to “go with the flow”; (4)
balance and perspective in their reactions; and (5) a perceived
safety net of social support.60 Newer researchers have focused
their attention on yet another factor contributing to thriving
and resilience despite stress: grit, a combination of passion and
perseverance for a singularly important goal that high achievers demonstrate in all walks of life.61 Studies of youth have
shown that stress management and mindfulness training may
help people develop resilience and grit in the face of PTSD and
other adverse situations, particularly if they have strong social
support, healthy family environments, and community supports during the stress-management programming.62
Type A and a Toxic Core In contrast to those who
thrive, some Type A persons exhibit a “toxic core”; that is, they
demonstrate a disproportionate amount of anger, distrust, and
a cynical, glass-half-empty approach to life—a set of characteristics referred to as hostility. These individuals have an increased
risk for heart disease and a host of other health issues.63
Type C and Type D Personalities
In addition to CVD, an increased risk for a variety of other illnesses has been linked to two other personality types. People
with Type C personality have been described as those who
stuff their emotions, are stoic, deny thoughts/controversy, and
appear calm, even though they may be in turmoil inside. Type D
personality is characterized by being distressed, constantly worried, irritable, and negative, and tends to be socially isolated.
Although these personalities have been linked to increased risks
for a wide range of illnesses in the popular literature, more highquality research is necessary to support these relationships.
Shift and Persist
Some young people who face extreme poverty, abuse, and
unspeakable living conditions as they grow up seem to thrive,
despite bleak conditions. Why? An emerging body of sociological research proposes that in the midst of extreme, persistent
adversity, young people—often with the help of positive role
models in their lives—are able to reframe appraisals of current
stressors more positively (shifting), while persisting in focusing
on the future. This outlook enables people to endure the present by adapting, holding on to meaningful things in their lives,
43%
of adults in America report that they are
"CONSTANT CHECKERS" of their
e-mails, texts, or social media.
DID YOU
Know?
In the most recent National College Health
Assessment, nearly 32 percent of students reported
that stress, 25 percent reported that anxiety, and 21 percent
indicated that sleep difficulties were key negative factors impacting
their grades on exams, major papers, or final course grades.
Source: Data from American College Health Association, American ­College
Health Association–National College Health Assessment II (ACHA-NCHA II):
Reference Group Data Report Fall 2017 (Hanover, MD: American College
Health Association, 2018).
and staying optimistic. These “shift and persist” strategies are
among the most recently identified factors that protect against
the negative effects of stress in our lives.64
LO 5 | MANAGING STRESS IN
COLLEGE: WHEN OVERWHELM
STRIKES
Explore stress-management and stress-reduction strategies, ways
you can cope more effectively with stress, and mindfulness strategies
that can enrich your life experiences and reduce stress health risks.
College students thrive under a certain amount
of stress; however, excessive stress can leave them
overwhelmed and unable to cope. Recent studies of college students indicate that the emotional health self-rating of first-year college students compared
to their peers is at an all-time low. In fact, researchers have
reported that the emotional health of students has dec­lined
­precipitously since sur­veys were first conducted in 1985 and
that increasing numbers of
grit A combination of passion
these students frequently
and perseverance for a singufeel ­overwhelmed, with many
larly important goal.
suffering from anxiety and
hostility The cognitive, affecdepression.65 They spend
tive, and behavioral tendencies
more time studying, more
toward anger, distrust, and
cynicism.
time socializing online, and
less time socializing faceshift and persist A strategy of
reframing appraisals of current
to-face with friends. Nearly
stressors and focusing on a
35 percent felt anxious,
meaningful future that protects
particularly those with disa person from the negative
abilities, chronic illness, or
­effects of too much stress.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 89
other psychological issues,
such as depression.66 In contrast, sophomores and juniors
reported fewer problems with
these issues, and seniors
dispositional mindfulness An acute tuning in and
reported the fewest problems.
awareness of your thoughts,
This may indicate students’
feelings, and reactions, foprogressive emotional growth
cused on finding nonjudgmental views of situations.
through experience, maturity,
increased awareness of support
stress inoculation Stressmanagement technique in
services, and more social conwhich a person consciously
nections.67 It is also possible
anticipates and prepares for
that some of the highly stressed
potential stressors.
first-year students did not conself-compassion Treating yourself with as much
tinue their college education.
understanding and care as you
Although you can’t elimiwould a loved one.
nate all life stressors, you can
cognitive restructuring The
train yourself to recognize the
modification of thoughts, ideas,
events that cause stress and
and beliefs that contribute to
stress.
to anticipate your reactions
to them. Coping is the act of
managing events or conditions to lessen the physical or psychological effects of excess stress (see the STUDENT HEALTH
TODAY box for more on how people try to cope with stress).68
One of the most effective ways to combat stressors is to build
coping strategies and skills, known collectively as stress-management techniques. Training in mindfulness strategies, particularly dispositional mindfulness—an acute “tuning in” to and
awareness of your thoughts, feelings, and reactions, focused
on finding nonjudgmental views of situations—may significantly improve your overall stress responses.69
coping Managing events or
conditions to lessen the physical or psychological effects of
excess stress.
Taking A Mindful Approach to
Stress
Stress management isn’t something that just happens. It calls
for getting a handle on what is going on in your life, taking a
careful look at yourself, and coming up with a personal plan
of action.
One useful way of coping with your stressors is to consciously anticipate and prepare for specific ones, a technique known as stress inoculation. For example, if speaking
in front of a class scares you, practice in front of friends
or a video camera to prevent freezing up on the day of the
presentation.
Because your perceptions are often part of the problem,
assessing your self-talk, beliefs, and actions is a good first step.
The tools in this section will help you.
Assess Your Stressors to Solve Problems Mindfully Before you can prevent or control your
life stressors, you must first analyze them. Several quick mindfulness assessments—which may help you look at your daily
experiences and whether you are tuned in or merely reacting
90 | PART ONE | Finding the Right Balance
College students face a unique set of stressors as
they search for meaning in their lives, try to live up to
expectations, and struggle to find a career path that may
influence the rest of their lives. Social and academic
demands often collide, leading to increased challenges.
to circumstances—are available online. Beyond self-assessments, here are some more suggestions for ways to destress:
■■
■■
■■
■■
■■
Start a journal. Track your worries and the factors that seem
to trigger stress every day for 1 week. Think about when your
stress is greatest, who is around you, and how you respond.
Do you move on, or do you tend to dwell on things?
Examine the causes of your stress. Which are tangible?
Which are intangible?
Think about what is going on with you right now. Are you
wound up and edgy? Tired? A bit ticked at someone?
Focus on your body. Are you tense? Sweating? Exhausted?
Breathe deeply several times, and focus on your breath.
Take a moment that is all about you. Tune in to you, and
tune out whatever is bothering you.
Take a 10-minute break. Go for a walk. Focus on the smells
in the air, the colors of the landscape, or anything that takes
you away from your worries. If you hear yourself being judgmental, either aloud or in your thoughts, stop. Focus on one
good thing about someone near you. Smile at a stranger.
Focus on your stressor. Whether it’s unnecessary clutter,
conflict with friends and family, or chaotic world events
putting you over the edge, jot down three things you will
change, starting now—and then act! Limit your exposure
STUDENT
HEALTH TODAY
P
eople choose a wide range of behaviors to deal with the stress in their
lives. Younger populations, particularly
Millennials, are most likely to choose
“sedentary” or “vegging out” stressmanagement techniques—more so than
any other generation. Not only do they
suffer from the most stress; their strategies to reduce stress may increase their
risk of obesity and related health issues
that can result in major problems down
the road.
How We Cope with Stress
Differences in Stress-Management Strategies by Age (What
They Report Doing)
Actions
Millennials Gen-Xers
Boomers Matures
Listening to music
57%
42%
39%
29%
Watching TV 2+ hr/day
44%
37%
42%
35%
Going online
46%
33%
37%
31%
Eating too much/unhealthy food
35%
35%
29%
21%
Source: American Psychological Association, “Stress in America: Paying with Our Health,” February 4,
2015, Available at https://www.apa.org/news/press/releases/stress/2014/stress-report.pdf.
to unsettling news to no more than 30 minutes a day. Take
care of clutter. Focus on something positive.
A mindful action plan—in which you increase your selfawareness, tune in to your body and surroundings, and assess
your stressors and how to avoid them—can help to reduce stress.
There’s a lot here, but it doesn’t take earth-shattering changes
to help you cope. Making small changes now, and focusing in
on your life and reactions, can really make a difference.
Change Your Inner Voice: Be Compassionate Often we are our own worst enemies—nicer to
strangers than we are to ourselves or to people we care about.
Remember that compassion includes kindness, empathy, tolerance, concern for others, sensitivity, and a desire to help
someone who needs emotional or tangible help. Unfortunately, many of us grieve for hurt animals but walk right past
homeless people without looking at them, treating them as
objects. Likewise, our biases, beliefs, and values can keep us
from being compassionate toward certain groups. We can
also be our own worst critics and show little compassion for
ourselves.
A good place to begin is with self-compassion, treating
yourself with as much caring as understanding as you would
another person. Start each day with two or three things you
are thankful for—the good things in your life or something
you like about yourself—instead of seeing only faults. Practicing mindfulness can help to reduce your stress interactions,
help you become less sensitive to potential criticisms, and let
you look at your day in a more positive light.
Several types of negative self-talk exist. Among the most
common are pessimism, or focusing on the negative; perfectionism, or expecting superhuman standards; “should-ing,” or
reprimanding yourself for things that you should have done;
blaming yourself or others for circumstances and events; and
dichotomous thinking, in which everything is either black or
white (good or bad). To combat negative self-talk, we must
first become aware of it, then stop it, and finally replace
the negative thoughts with positive ones—a process called
­cognitive restructuring. Once you realize that some of your
thoughts may be negative, irrational, or overreactive, or may
reflect a bias, interrupt this self-talk by saying, “Stop” (under
your breath or aloud), and make a conscious effort to think
positively. See the MAKING CHANGES TODAY box for other
suggestions of ways to mindfully rethink your thinking.
Developing a Support Network
If you are stressed out and considering a plan for stress management, remember the importance of social networks and
social bonds. Friendships are important for inoculating yourself against harmful stressors. Studies of college students have
demonstrated the importance of social support, particularly
from trusted friends and family, in buffering individuals from
the effects of adverse childhood stressors.70 Most colleges and
universities offer counseling services at no cost for short-term
crises when the pressures of life seem overwhelming. Clergy,
instructors, and residence hall supervisors also may be excellent
resources.
To have a healthy social support network, you have to
invest time and energy. Cultivate and nurture the relationships that matter: those built on trust, mutual acceptance and
understanding, honesty, and genuine caring. If you want others to be there for you to help you cope with life’s stressors, you
need to be there for them. Spend more time in face-to-face
interactions.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 91
MAKING CHANGES TODAY
A Mindful Rethinking of Your Thinking Habits
Sometimes, our own thinking habits can contribute to stress.
Here are a few ways to rethink those stressful habits:
Reframe a distressing event from a positive perspective.
Change your perspective on the issue to highlight your
strengths.
Remember that nobody is perfect. Tolerate mistakes.
Change your focus and self-talk. Take yourself less seriously, and cut the judgment.
Let things be. Learn to accept what you cannot change,
and remember that you don’t always have to be
in control.
Cultivating Your Spiritual Side
One of the most important factors in reducing stress in your
life is taking the time and making the commitment to cultivate your spiritual side: finding your purpose in life and living
your days more fully. Spiritual health and spiritual practices
can be vital components of your support system, often linking you to a community of like-minded individuals and giving
you perspective on the things that truly matter in your life.
(For more, see Focus On: Mindfulness, Spiritual Health, and
Spiritual Intelligence.)
Managing Emotional Responses
and Perceptions
Have you ever gotten all worked up about something, only to
find that your perceptions were totally wrong? We often get
upset not by realities, but by our faulty perceptions. Social networking sites and e-mails are often perfect places for reading
meaning into things that are said and perceiving issues that
don’t exist. Interactions in which body language, voice intonation, and opportunities for clarification are present are much
better for interpreting true
meanings than are cryptic
WHAT DO
texts or e-mails.
THINK?
Stress
management
requires examining your
emotional responses. With
Who are the biggest
supporters in your life?
any emotional response to
a stressor, you are respon■■ Would you characterize
sible for the emotion and
them as stressed out or well
the resulting behaviors.
adjusted?
■■ Could you follow their lead if
Learning to tell the differthey are more relaxed?
ence between normal emo■■ What tips would you give
tions and emotions that are
them if they’re stressed?
based on irrational beliefs
Break the worry habit. If you are preoccupied with whatifs and worst-case scenarios, the following suggestions
can help to slow the worry drain:
If you must worry, create a 20-minute “worry period”
when you can journal or talk about your worrying
each day. After that, block the worry if it pops up
again.
■■ Try to focus on what is going right rather than what
might go wrong.
■■ Seek help. Talk with a trusted friend or family member,
or make an appointment with a counselor.
■■
or seem ­excessive can help you stop the emotion or express it
in a healthy way.
Fight the Anger Urge Major sources of anger include
(1) perceived threats to self or others we care about; (2) reactions
to injustice, such as unfair actions, policies, or behaviors; (3) fear,
which leads to negative responses (for more on this topic, see
the HEALTH HEADLINES box); (4) faulty emotional reasoning, or
misinterpretation of normal events; (5) low frustration tolerance,
often fueled by stress, drugs, lack of sleep, and other factors; (6)
unreasonable expectations about ourselves and others; and (7)
people rating, or applying derogatory ratings to others.
There are three main approaches to dealing with anger:
expressing it, suppressing it, or calming it. You may be surprised
to find out that expressing anger is probably the healthiest
thing to do in the long run, if you express anger in an assertive
YOU
92 | PART ONE | Finding the Right Balance
Spending time socializing face-to-face can be an important
part of building a support network and reducing your
stress level.
HEALTH
HEADLINES
I
f someone were to ask you what
you were most afraid of—what
your greatest fear was right now—
how would you respond? It may not
surprise you, but when a sample of
Americans were asked to rate their
top 10 fears in 2015 and again in
2017, the areas listed below surfaced
as respondents’ top 10 fears.
Why do you think they are so different
in a relatively short time frame?
Consider the following “selfchecks” whenever your fears seem to
be hindering your behaviors:
2015 Responses
Corruption of government officials
(58.0%)
Cyber-terrorism (44.8%)
Corporate tracking of personal
information (44.6%)
Terrorist attacks (44.4%)
Government tracking of personal
information (41.4%)
Bio-warfare (40.9%)
Identity theft (39.6%)
Economic collapse (39.2%)
Running out of money in the future
(37.4%)
Credit card fraud (36.9%)
An Epidemic of Fear in America
Stressing Ourselves Out Needlessly, Or Real Threat?
1. Are my fears rational or irrational?
What is the threat to me here
and now based on statistics?
What safety nets are in place
to protect me?
2. Can I do anything about it? Are there
things I can do to ­protect myself?
3. Have I thought about what is triggering my fears? Is there anyone I can
talk to about it? Are there any support groups or speakers in my area
where I can go to discuss issues,
vent, and express my concerns?
2017 Reponses
Corruption of government officials
(74%)
Health care/Trumpcare (55%)
Polluted oceans, lakes, rivers (53%)
Pollution/drinking water 50%
Not having enough future money (50%)
High medical bills 48%
Involvement in world war (48%)
Global warming/climate change (48%)
North Korean wars (48%)
Air pollution (48%)
rather than in an aggressive way. There are several strategies
you can use to keep aggressive reactions at bay:71
Identify your anger style. Do you express anger passively
or actively? Do you hold anger in, burning quietly,
or do you suddenly explode when you can’t take it
anymore?
■■ Learn to recognize patterns in your anger responses
and how to de-escalate them. For 1 week, keep track
of everything that angers you or keeps you stewing.
What thoughts or feelings lead up to your boiling point?
Explore ways to interrupt patterns of anger, such as
counting to 10, getting a drink of water, or taking some
deep breaths.
■■ Find the right words to de-escalate conflict. When
conflict arises, be respectful and state your needs or
feelings rather than shooting zingers at the other person. Avoid “you always” or “you never” and instead
■■
Four-legged friends can be great stress
relievers, as they allow you to focus on
something besides yourself and can add
laughter to your life.
Source: “America’s Top Fears, 2017: The Chapman
University Survey of
American Fears,” October 11, 2017, https://blogs.
chapman.edu/wilkinson/
2017/10/11/americas-top-fears-2017/.
say, “I feel_______ when you_______” or “I would really
appreciate it if you could_______.” If you find yourself
continually revved up for battle, consider taking a class
or workshop on assertiveness training or anger management or take some deep breaths and try to calm
yourself.
■■ Plan ahead. Explore options to minimize your
exposure to anger-provoking situations, such as traffic
jams.
■■ Vent to your friends. Find a few close friends you trust and
who can be honest with you. Allow them to listen and give
their perspective, but don’t wear down your supporters
with continual rants.
■■ Develop realistic expectations of yourself and others. Are
your expectations of yourself and others realistic? Try talking about your feelings with those involved at a time when
you are calm.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 93
sympathomimetics Food
substances that can produce stresslike physiological
responses.
■
implementation intentions
A series of goals to accomplish
toward a specific end.
urn complaints into
T
requests. When frustrated
or angry with someone,
try reworking the problem
into a request. Instead of
screaming and pounding
on the wall because your
neighbors are blaring music at 2:00 a.m., talk with them.
Think about the words you will use, and try to reach an
agreement that works for everyone.
■■
Leave past anger in the past. Learn to resolve issues and
not bring them up over and over. Let them go. If you can’t,
seek the counsel of a professional to learn how.
Learn to Laugh, Be Joyful, and Cry
Have
you ever noticed that you feel better after a belly laugh or a good
cry? Adages such as “Laughter is the best medicine” and “Smile
and the world smiles with you” didn’t come from nowhere.
Humans have long recognized that actions such as smiling,
laughing, singing, and dancing can elevate our moods, relieve
stress, calm a tense interaction, and improve our relationships.
Learning to take yourself less seriously and adopting a more
self-compassionate mindful thought process is a good starting
place. Crying can have similar positive physiological effects
in relieving tension. Several preliminary studies indicate that
laughter and joy may increase endorphin levels, raise oxygen
levels in the blood, decrease stress levels, relieve pain, increase
heart rate similar to that produced by a bout of exercise (which
may be beneficial), ease tensions, improve relationships, help
people cope with chronic diseases, and even aid in recovery;
however, the evidence for long-term effects must be validated
through larger, more rigorous studies.72
Taking Physical Action
Are you often feeling sluggish, finding it hard to get out of bed,
or ready to nap? Or, are you feeling wired, restless, and about
to explode? Either could be the result of too much stress.
Get Enough Exercise
Remember that the human
stress response is intended to end in physical activity. Exercise
“burns off” existing stress hormones by directing them toward
their intended metabolic function.73 Exercise can also help
combat stress by raising levels of endorphins—mood-elevating,
painkilling hormones—in the bloodstream, increasing
energy, reducing hostility, and improving mental alertness.
46–48%
of adults say EXERCISING OR WALKING
is their number one stress-management
strategy.
94 | PART ONE | Finding the Right Balance
Research indicates that hugging doesn’t just feel good—it
can also buffer the effects of stress in your life. Hug more,
and pay attention to how hugs make you feel. Hugging may
just be one of the easiest stress reducers in your day!
Source: S. Cohen et al., “Does Hugging Provide Stress-Buffering Social
Support? A Study of Susceptibility to Upper Respiratory Infection and Illness,”
Psychological Science 26, no. 2 (2015): 135–47.
Motivating people, particularly those who are often sedentary
or who are overweight or obese, is a major challenge; however,
the health benefits to be achieved are significant.74 (For more
on the beneficial effects of exercise, see Chapter 7.)
Get Enough Sleep Adequate amounts of sleep allow
you to refresh your vital energy, cope with multiple stressors
more effectively, and be productive when you need to be. In fact,
sleep is one of the biggest stress busters of them all. (These benefits and others are discussed in much more depth in Chapter 4.)
Eat Healthfully
It is clear that eating a balanced,
healthy diet can stress-proof you in ways that are not fully
understood. Research has also shown that undereating, overeating, and eating the wrong kinds of foods can create distress in the body and that stress often leads to eating more
unhealthy foods. In particular, avoid sympathomimetics, substances in foods that produce (or mimic) stress-like
responses, such as caffeine. (For more information about the
benefits of sound nutrition, see Chapter 10.)
Managing Your Time
Ever put off writing a paper until the night before it was due?
We all procrastinate, or voluntarily delay some task despite
expecting to be worse off for the delay. Procrastination can
result in academic difficulties, financial problems, relationship problems, and a multitude of stress-related ailments.
How can you avoid the temptation to procrastinate?
According to recent research focused on university students,
the key is setting clear implementation intentions, a series of
goals to accomplish toward a specific end.75 Having a plan that
includes specific behavioral goals or deadlines (and rewards for
STUDENT
HEALTH TODAY
T
oday, many space designers are trying to create
peaceful “me caves” for reducing the stress of harried lives.
One strategy, known as feng
shui (translation: “wind and
water”), is part of an ancient
Chinese art designed to restore
balance of chi and create peace
and harmony with help from
the built environment. Here are
several tips for reducing stress
in your bedroom area:
Feng Shui for Stress Relief
Keeping your room clear of clutter and well organized using
feng shui techniques can reduce stress.
Declutter. Get rid of any
extra “things” in your space.
Pick up and put things away
each day.
■■ Paint. Use peaceful and
welcoming colors. Coordinate linens and tapestry colors to enhance warmth.
■■ Relocate. Your bed should
never be in line with the
door; nightstands should be
balanced on either side
■■
meeting goals) can help you stay on task. The following time
management tips can help:
■■
■■
■■
■■
■■
Do one thing at a time. Don’t multitask. Instead of watching TV, doing laundry, and writing your term paper all at
once, pick one and stay focused.
Clean off your desk. Sort your desk, tossing unnecessary
paper and mail and filing important papers in labeled folders. (For more on organizing to destress, see the STUDENT
HEALTH TODAY box.)
Prioritize your tasks. Make a daily “to-do” list and stick to
it. Categorize the things you must do today, the things that
must eventually get done, and the things that would be
nice to do. Consider the “nice to do” items only if you finish the others (or if they include something fun).
Work when you’re at your best. If you’re a morning person,
study and write papers in the morning, and take breaks
when you start to slow down.
Remember that time is precious. Many people learn to
value their time only when they face a terminal illness. Try
to value each day. If you have trouble saying no to people
and projects that steal your time, see the MAKING CHANGES
TODAY box on page 96 for some suggestions.
of the bed, and mirrors
should never reflect the bed.
■■ Shut out the world. Use
shades that allow you to
darken or dim the room.
■■ Beautify. Include things that
make you feel peaceful.
■■ Invest. Get a set of soft
sheets, a duvet cover, and
a blanket. Plump and soften
pillows.
■■ Refresh. Open windows
to remove stale odors. If
needed, use relaxing fragrances such as lavender.
■■ Block. If you can’t get rid
of a desk covered in work,
use a curtain to keep things
out of sight. Put your phone
away, and relax.
Source: Feng Shui DeStress, “Using
Feng Shui to Reduce Stress,” Accessed February 2016, www.destress.
com/relax/lifestyle/using-feng-shui-toreduce-stress.htm.
Consider Downshifting
Today’s lifestyles are hectic, and stress often comes from trying to keep up. Many people are questioning whether “having
it all” is worth it, and are working to simplify their lives. This
trend has been labeled downshifting, or voluntary simplicity. The Tiny House movement is one example; others include
giving up high-stress jobs for ones you enjoy, house decluttering, and making other life changes such as cutting down on
“things” while considering the environment.
When you contemplate any form of downshift (or start
your career this way), it’s important to move slowly and consider the following:
Are you spending your money on things you want or things
you need? What can you do without? What things are
necessities?
■■ In your career choices, consider the importance of salary
versus really liking what you do. Can you be happy taking a
lower-paying job if it is less stressful?
■■ Don’t let money and possessions dictate who you are or
rule your life. Save, be prudent, but don’t be excessive in
everything you do. Build a reserve for emergencies.
■■
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 95
TECH
&
HEALTH
L
ooking for a way to relax that you
can carry with you? Selecting the
wrong one can actually cause you stress
by tricking you into subscriptions, sapping your data, and containing malware
and other malicious software that can
disrupt your efforts to find calm. To be
safe, check out the yearly reviews of
apps put out by consumer groups and
others, making sure to note whether
they are affiliated or have conflicts of
Apps for the Relaxation Response
interest with manufacturers. Pay close
attention to the costs, amount of space
used on your device, whether that “free”
subscription asks for a credit card and
hits you with a subscription fee after
a short free period, which devices are
supported, privacy issues, and consumer ratings. Note that these are not
scientific reviews of effectiveness;
rather, they are designed to provide you
with basic information. These change
regularly, and a simple Google search
will get you there. Just search for best
mindfulness, stress-reducing, or meditation apps for your particular devices in
the current year. Use care to determine
who is sponsoring the ratings. These
change regularly, so consider the best
option for what you are looking for. If
you can see an online demo first, check
it out. Ask your friends and take your
time.
Finding Calm: Relaxation
Techniques for Reducing Stress
Focus On: Mindfulness, Spirituality, and Spiritual Intelligence for more.)
Relaxation techniques to reduce stress have been practiced for
centuries and offer opportunities for calming your nervous
energy and coping with life’s challenges. Some common techniques include yoga, qigong, tai chi, deep breathing, meditation, visualization, progressive muscle relaxation, massage
therapy, biofeedback, and hypnosis. Newer forms of relaxation may be found in the latest technology; see the TECH &
HEALTH box for more information.
Qigong and Tai Chi Qigong (pronounced “cheekong”), one of the fastest-growing, most widely accepted
forms of mind–body health exercise, is used by some of the
country’s largest health care organizations, particularly for
people suffering from chronic pain or stress. An ancient Chinese practice, Qigong involves awareness and control of vital
body energy known as qi (or chi, pronounced “chee”). A complex system of internal pathways called meridians is believed
to carry qi throughout your body. If qi becomes stagnant or
Yoga Yoga is an ancient practice that combines meditation, stretching, and breathing exercises designed to relax,
refresh, and rejuvenate. It began about 5,000 years ago in India
and has become increasingly popular among Americans. Over
80 million Americans (34 percent of the population) say that,
over the next year, they are very likely or somewhat likely to
practice yoga as a form of stress release, for balance, flexibility,
and overall health and fitness.76
Classical yoga is the ancestor of nearly all modern forms
of yoga, often consisting of breathing, poses, and verbal
mantras. Of the many branches of classical yoga, Hatha yoga
is the most well known; it is body focused, involving the
practice of breath control and asanas—held postures and
choreographed movements that enhance strength and flexibility. Recent research shows increased evidence of the benefits of Hatha yoga in reducing inflammation, boosting mood,
increasing relaxation, and reducing stress among those who
practice regularly.77 Although studies have shown yoga to have
similar benefits in treating insomnia and PTSD, reducing anxiety, lowering heart rate and
blood pressure, improving
downshifting Taking a step
fitness and flexibility, reducback and simplifying a lifestyle
that is hectic, packed with
ing pain, and other benefits,
pressure and stress, and
much of this research could
focused on trying to keep
benefit from more rigorup; also known as voluntary
ous investigation.78 (See
simplicity.
96 | PART ONE | Finding the Right Balance
MAKING CHANGES TODAY
Learn to Say No and Mean It!
Is your calendar so full you barely have time to breathe?
When you are asked to do something you don’t really want
to do or are overextended, practice the following tips to avoid
overcommitment:
Be sympathetic, but firm. Explain that although you
think it’s a great cause or idea, you can’t participate right
now. Don’t waver if they persist or pressure you.
Don’t say you want to think about it and will get back
to them. This only leads to more forceful requests later.
Don’t give in to guilt. Stick to your guns. Remember
you don’t owe anyone your time.
Even if something sounds good, avoid spontaneous
“yes” responses. Make a rule that you will take at least
a day to think about committing your time.
Schedule time for yourself first. If you don’t have
time for the things you love to do, stop and prioritize your
activities. Don’t let your time be sucked up by things that
you really don’t want to do.
1 Assume a natural, comfortable position either
sitting up straight with your head, neck, and
shoulders relaxed, or lying on your back with
your knees bent and your head supported.
Close your eyes and loosen binding clothes.
2 In order to feel your abdomen moving as you
breathe, place one hand on your upper chest and
the other just below your rib cage.
3 Breathe in slowly and deeply through your
nose. Feel your stomach expanding into your
hand. The hand on your chest should move as
little as possible.
4 Exhale slowly through your mouth. Feel the
fall of your stomach away from your hand.
Again, the hand on your chest should move as
little as possible.
5 Concentrate on the act of breathing. Shut
out external noise. Focus on inhaling and
exhaling, the route the air is following, and the
rise and fall of your stomach.
FIGURE 3.6 Diaphragmatic Breathing This exercise will help you learn to breathe deeply as a way
to relieve stress and enhance mindfulness. Practice this for 5 to 10 minutes several times a day, and soon
diaphragmatic breathing will become natural for you.
blocked, you’ll feel sluggish or powerless. Qigong incorporates
a series of flowing movements, breath techniques, mental
visualization exercises, and vocalizations of healing sounds
that are designed to restore balance and integrate and refresh
the mind and body.
Another popular form of mind–body exercise is tai chi
(pronounced “ty-chee”), often described as “meditation in
motion.” Originally developed in China over 2,000 years ago,
this graceful form of exercise began as a form of self-defense.
Tai chi is noncompetitive and self-paced, and involves a
defined series of postures or movements done in a slow, graceful manner. Each movement or posture flows into the next
without pause. Tai chi has been widely practiced in China for
centuries and is now becoming increasingly popular around
the world, both as a basic exercise program and as a key component of stress reduction and balance and flexibility programs.
Research demonstrating the effectiveness of these benefits is
only in its infancy.
Diaphragmatic or Deep Breathing
Typically, we breathe using only our upper chest and thoracic
region. Simply stated, diaphragmatic breathing is deep breathing that maximally fills the lungs by involving the movement
of the diaphragm and lower abdomen. This technique is commonly used in yoga exercises and in other meditative practices. Try the diaphragmatic breathing exercise in FIGURE 3.6
right now and see whether you feel more relaxed!
Meditation
Emerging evidence suggests that individuals
who meditate may reap significant health rewards. Increasing
numbers of Americans are meditating to relieve stress, improve
their overall health, and aid in relaxation. Meditators are most
likely to be non-Hispanic white women who are physically
active, have a college degree, and use additional complementary health practices. They are also more likely to have one or
more chronic health conditions.79 Although there are many
different forms of meditation, most involve sitting quietly
for 15 to 20 minutes, focusing one’s thoughts, blocking the
“noise” in one’s life, controlling one’s breathing, and ultimately relaxing.
According to a recent review of key randomized controlled
trials (RCTs) by the American Heart Association, transcendental meditation (TM)—in which
one sits in lotus position,
meditation A relaxation
internally chants a mantra,
technique that involves deep
breathing and concentration.
and focuses on rising above
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 97
the negative in one’s life—
appeared to be most effective
in lowering blood pressure,
overall mortality, and CVD
biofeedback A technique
using a machine to self-monitor
events. Other forms of mediphysical responses to stress.
tation appeared to have little
hypnosis A trancelike state
or no effect on these health
that allows people to become
risks.80 More rigorous, conunusually responsive to sugtrolled research must be done
gestion.
to better understand the
potential benefits of meditation. (See Focus On: Mindfulness,
Spirituality, and Spiritual Intelligence.)
visualization The creation
of mental images to promote
relaxation.
Visualization
Often our thoughts and imagination
provoke distress by conjuring up worst-case scenarios. Our
imagination, however, can also be tapped to reduce stress.
In visualization, you use your imagination to create calming mental scenes. The choice of mental images is unlimited,
but natural settings such as ocean beaches, deep forests, and
crystal clear lakes with the haunting sounds of loons, often
conjure up soothing sights, sounds, and smells. These sensory
experiences can replace stressful stimuli with peaceful or pleasurable thoughts. Think of a place that is “quieting” for you.
Try to imagine yourself there, sitting quietly. Breathe deeply
and allow yourself to be in that space/moment.
Progressive Muscle Relaxation
Progressive
muscle relaxation involves teaching awareness of the feeling
of tension and release by systematically focusing on areas of
the body, contracting and relaxing different muscle groups
while breathing in deeply and slowly exhaling. The standard
pattern is to begin with the feet and work your way up your
1 Start with one foot. Inhale, contracting
the muscles of your foot. Hold and notice
the feeling of tension. Exhale, slowly
releasing the muscles. Notice the feeling
of tension flowing away.
3 Follow the same
sequence with your other
foot and leg.
Massage Therapy Massage not only feels great, it is
also an excellent way to relax. Techniques vary from deep-tissue
massage to the gentler acupressure, use of hot rocks on tense
muscle groups, and a wide range of other techniques. Although
a variety of studies have been carried out to assess the health
effects of massage, much of this research is poorly controlled and
lacks sufficient sample size, and results are preliminary or conflicting. However, there is a growing body of evidence indicating
that massage may ease back pain, as well as potentially increase
quality of life for cancer patients and those with HIV/AIDS and
depression.81 Though promising, this research is in its infancy.
Biofeedback
Biofeedback is a technique in which a person learns to use the mind to consciously control bodily functions, such as heart rate, body temperature, and breathing rate.
Using devices from those as simple as stress dots that change
color with body temperature variation to sophisticated electrical
sensors, individuals learn to listen to their bodies and make necessary adjustments, such as relaxing certain muscles, changing
breathing, or concentrating to slow heart rate and relax. Eventually, individuals develop the ability to recognize and lower stress
responses without machines and can practice it anywhere.
Hypnosis
Hypnosis requires a person to focus on one
thought, object, or voice, thereby freeing the right hemisphere
of the brain to become more active. The person then becomes
unusually responsive to suggestion. Whether self- or otherinduced, hypnosis can reduce certain types of stress.
2 Repeat the same steps
contracting and releasing
your foot and lower leg,
then your entire leg.
4 Starting with one hand,
follow the same sequence
for both arms.
FIGURE 3.7
body, contracting and releasing as you go (FIGURE 3.7). With
practice, you can quickly identify tension in your body and
consciously release that tension to calm yourself.
5 Continue these isolations as you progress up your body,
contracting and then relaxing your abdomen, then chest,
followed by neck and shoulders, and ending with your face.
Progressive Muscle Relaxation Sit or lie down in a comfortable position and follow the steps described to
increase your awareness of tension in your body and your ability to release it.
98 | PART ONE | Finding the Right Balance
STUDY PLAN
ASSESS YOURSELF
Is stress negatively affecting
your life? Want to find out?
Take the How Stressed Are
You? assessment available on
Mastering Health.
CHAPTER REVIEW
LO 1 | What Is Stress?
Stress is an inevitable part of our
lives. There are several different
types of stress, some of which are
acute and some that are chronic
in nature. Eustress refers to stress
associated with positive events; distress refers to stress associated with
negative events. All forms of stress
can have a negative impact on your
health.
■■ Key psychosocial and physical
sources of stress include change,
hassles, relationships, academic
and financial pressure, frustrations and conflict, overload, bias/
discrimination, and environmental
stressors.
■■
how health disparities can influence
stress levels.
LO 3 | Stress and Your Health
Undue stress for extended periods of
time can compromise the immune
system and result in serious health
consequences. Stress has been linked
to numerous health problems, including cardiovascular disease, weight
gain, hair loss, diabetes, digestive
problems, and increased susceptibility
to infectious diseases. Psychoneuroimmunology is the science that analyzes
the relationship between the mind’s
reaction to stress and the function of
the immune system.
■■ Stress can have negative impacts on
your intellectual and psychological
health, including impaired memory,
poor concentration, depression,
anxiety, and other disorders.
■■
|
LO 4 Individual Factors That
Affect Your Stress
Response
■■
|
LO 2 Body Responses to
Stress
■■
Several theories attempt to explain
what happens when a person experiences real or perceived stress. The
alarm, resistance, and exhaustion
phases of general adaptation syndrome (GAS) involve physiological
responses to both real and imagined
stressors and cause complex hormonal reactions. The transactional
model, minority stress theory, and
Yerkes-Dodson law of arousal help
explain other factors that influence
how stress is perceived, how people
cope at varying levels of stress, and
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
Some sources of stress are
internal and are related to
appraisal, self-esteem, self-efficacy,
personality types, hardiness and
resilience, grit, shift and persist,
and other factors.
|
LO 5 Managing Stress
in College: When
Overwhelm Strikes
■■
College and the transition to independent adulthood can be especially
stressful. Managing stress begins with
learning coping skills. These include
managing emotional responses, taking
mental or physical action, developing
a support network, practicing selfcompassion, cultivating spirituality,
downshifting, learning time
management, managing finances,
learning relaxation techniques—and
gaining mindfulness skills to deal
with overwhelm and increase calm
in your life.
POP QUIZ
LO 1 | What Is Stress?
1. Even though Andre experienced
stress when he graduated from
college and moved to a new city,
he viewed these changes as an
opportunity for growth. What is
Andre’s stress called?
a. Strain
b. Distress
c. Eustress
d. Adaptive response
2. Losing your keys is an example of
what psychosocial source of
stress?
a. Pressure
b. Inconsistent behaviors
c. Hassles
d. Conflict
3. A state of physical and mental
exhaustion caused by excessive
stress is called
a. conflict.
b. overload.
c. hassles.
d. burnout.
|
LO 2 Body Responses to
Stress
4. In which stage of general
adaptation syndrome does the
fight-or-flight response occur?
a. Exhaustion stage
b. Alarm stage
c. Resistance stage
d. Response stage
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 99
5. The branch of the autonomic
nervous system that is responsible
for energizing the body for either
fight or flight and for triggering
many other stress responses is the
a. central nervous system.
b. parasympathetic nervous system.
c. sympathetic nervous system.
d. endocrine system.
LO 3 | Stress and Your Health
6. The area of scientific investigation
that analyzes the relationship
between the mind’s response to
stress and the immune system’s
ability to function effectively is
called
a. psychoneuroimmunology.
b. immunocompetence.
c. psychoimmunology.
d. psychology.
7. When Jesse encounters a stressful
situation, he adapts well and
tends to bounce back easily, even
though the same situation may
derail others. What protective
factor is Jesse exhibiting to deal
with stress?
a. Cognitive restructuring
b. Type A personality
c. High self-esteem
d. Psychological resilience
|
LO 4 Individual Factors That
Affect Your Stress
Response
8. Which of the following statements
is correct regarding factors that
affect your stress response?
a. Type A individuals are
characterized by anger and toxic
core behaviors that inevitably
lead to negative health
outcomes.
b. Individuals who thrive
under challenges typically
demonstrate qualities of
hardiness and resilience.
c. People with grit are those
who are bull-headed and rigid
and who typically experience
negative health outcomes.
d. People with high self-efficacy
typically have little control
over what happens to them;
100 | PART ONE | Finding the Right Balance
people with high self-esteem
are typically much more in
control of their environment
than those with high
self-efficacy.
|
LO 5 Managing Stress
in College: When
Overwhelm Strikes
9. Which of the following is the
best strategy to avoid test-taking
anxiety on an exam?
a. Do the majority of your
studying the night before the
exam so it is fresh in your
mind.
b. Plan ahead and study over a
period of time for the exam
with a limited, yet thorough,
review the night before.
c. Drink a caffeinated beverage
right before the exam because
sympathomimetics are known
to reduce stress.
d. Go through the exam as quickly
as possible so you don’t dwell
on potential mistakes.
10. Which of the following describes
the stress-management strategy
that focuses on improving your
self-talk?
a. Adaptation
b. Conflict resolution
c. Self-compassion
d. Meditation
Answers to the Pop Quiz questions can be
found on page A-1. If you answered a question
incorrectly, review the section identified by
the Learning Outcome. For even more study
tools, visit Mastering Health.
THINK ABOUT IT!
LO 1 | What Is Stress?
1. Define stress. What are some
examples of scenarios in which you
might feel distress? Eustress?
2. Why are the college years often
highly stressful for many? How do
you think stress may differ between
people your age who go to college
and those who do not? What
factors increase stress risks for both
groups?
|
LO 2 Body Responses to
Stress
3. Describe the alarm, resistance,
and exhaustion phases of general
adaptation syndrome and the
body’s physiological response to
stress. Does stress lead to more
irritability or emotionality, or does
irritability or emotionality lead to
stress? Provide examples from your
own life or from friends or
family.
LO 3 | Stress and Your Health
4. What are some of the health
risks that result from chronic
stress? How does the study of
psychoneuroimmunology link
stress and illness? What are your
biggest stressors right now and do
you think you are experiencing
any physical or mental effects?
What could you do to reduce stressrelated effects?
5. What unique stressors do college
students face that might lead
to increased rates of anxiety,
depression, and feelings of
“overwhelm”? What do you
think can be done to reduce the
prevalence of these mental health
issues?
|
LO 4 Individual Factors That
Affect Your Stress
Response
6. What are the characteristics
of people who thrive by being
resilient and demonstrating grit?
How do you think you measure up
in terms of these characteristics?
|
LO 5 Managing Stress
in College: When
Overwhelm Strikes
7. What are three important actions
you can take right now to help
manage your stressors?
8. How does anger affect the body?
Discuss the steps you can take to
manage your own anger and help
your friends control theirs.
9. How much of a procrastinator
are you? What sorts of situations
make you the most likely to
procrastinate? What could you
do to reduce the likelihood of
procrastinating in these situations?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics and issues related to stress.
American College Counseling
Association. The website of the
professional organization for college
counselors offers useful links and articles.
www.collegecounseling.org
American College Health Association.
This site provides yearly information and
data from the National College Health
Assessment survey, which covers stress,
anxiety, and other health issues for students.
www.acha.org
American Psychological Association.
Here you can find current information and
research on stress and stress-related
conditions as well as an annual survey.
www.apa.org
Higher Education Research Institute.
This organization provides annual surveys
of first-year and senior college students that
cover academic, financial, and health-related
issues and problems. www.heri.ucla.edu
National Institute of Mental Health.
A resource for information on all aspects of
mental health, including the effects of stress.
www.nimh.nih.gov
WHICH PATH WOULD
YOU TAKE?
“Sleep is overrated! I get more
done with less sleep.” Go to
Mastering Health to see how your
actions today affect your future health.
CHAPTER 3 | Managing Stress and Coping with Life’s Challenges | 101
4
IMPROVING YOUR
SLEEP
LEARNING OUTCOMES
LO1
Describe the problem of sleep deprivation in the
United States, including the unique challenges of sleep
deprivation on campus.
LO2
Explain why we need sleep and what happens if we
don’t get enough sleep, including potential physical,
emotional, social, and safety threats to health.
LO3
Explain the processes of sleep, including the two-stage
model, circadian rhythm, and sleep–wake cycle, as well
as how they work and their importance for restful sleep.
102
LO4
Describe some common sleep disorders, including risk
factors and what can be done to prevent or treat them.
LO5
Explore ways to improve your sleep through changing
daily habits, modifying your environment, avoiding sleep
disruptors, adopting mindfulness sleep strategies, and
using other sound sleep hygiene approaches.
WHY
We spend nearly one-third of our lives asleep. Most of us know that getting a
good night’s sleep is important to our health, but too few of us, particularly young
college students, actually make those 7 to 8 hours between the sheets a priority.
Even one night of short sleep (commonly defined as sleep lasting fewer than 7 hours)
can wreak havoc on a mind that is supposed to be focused, able to remember, and
think clearly in classes; a body that should be in its prime but may be sluggish and suffer from
performance declines; and a social being who may be more moody and emotionally reactive.
Short sleep may do more than lower your GPA. Chronic sleep deficits can set the stage for any
of 10 to 15 health consequences (FIGURE 4.1).
SHOULD I CARE?
LO 1 | SLEEPLESS IN
AMERICA
Describe the problem of sleep deprivation
in the United States, including the unique
challenges of sleep deprivation on campus.
Nearly every night, we leave our waking world and slide into a series of
sleep stages, punctuated by changes in
heart rate, respiration rate, blood pressure, and other bodily processes. We
all need sleep—the stages and changes
that allow the body to repair, restore,
and refresh itself. What should healthy
sleep look like? Healthy sleep should
be of sufficient duration (at least 7 hours
in healthy adults) and be of good quality
(punctuated by the various levels of
sleep at regular times). It should also be
without disruptions from outside influences or conditions (such as sleep apnea
or restless legs syndrome).1 However,
more than 35.2 percent of U.S. adults
aged 18 and over don’t get the sleep
they need, with more than 70 million
individuals suffering from an actual
sleep disorder.2
Overall, poor sleep affects quality of
life, productivity, physical and mental
$411
Effects of short-term sleep loss
Effects of chronic sleep loss
• Cravings for fats, carbs increase (grazing)
• Increase in blood pressure
• More moody/emotional/reactive/anxious
• Impaired problem solving, memory, focus
• Trouble with thinking/concentration
• Slowed reaction time, more
accidents (if <4 hours, deficits
in performance)
• Drawn appearance without
”beauty sleep!“
• Loss of some brain cells
(Can you afford this?)
• Changes in metabolism,
weight gain
• Reduced quality of life
• Difficulties in relationships/
interactions
• Skin problems, headaches
• Issues with balance, motor control
• Difficulties in skill development
• Lowered libido
• Circadian rhythm disruptions
• Immune system less effective
• Increase in abnormal blood lipids
• Increased risk for obesity, diabetes, CVD,
and metabolic syndrome
• Increased risk of depression
and anxiety
• Increased risk of
inflammation, pain
• Increased risk of chronic
kidney disease
• Increased mortality from
auto accidents
•Increased rates of arthritis
• Reduced sperm counts,
erectile dysfunction
• Increased risk of volatility/being
violence prone
• Increased risk of smoking, drinking
alcohol
• Prescription drugs don’t work as
effectively
FIGURE 4.1
Effects of Short Term and Chronic Sleep Loss Even 1 or 2 nights
of less than the recommended amount of sleep can have a major effect on your
performance, affect your relations/interactions with others, and have a major impact on
your overall physical and mental health.
Sources: G. Medic et al., “Short- and Long-Term Health Consequences of Sleep Disruption,” Nature and
Science of Sleep 9 (2017): 151; O. Bubu et al., “Sleep, Cognitive Impairment, and Alzheimer’s Disease:
A Systematic Review and Meta-analysis,” Sleep 40, no. 1 (2017); Centers for Disease Control and Prevention, “Short Sleep Duration among U.S. Adults,” May 2, 2017, www.cdc.gov/sleep/data_statistics.html;
C. Dubetz and A. Cripps, “Sleep Deprivation Affecting Athletic Performance,” Journal of Sports Medicine
and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association 3, no. 1 (2017), Article 11,
Available at www.scholarworks.bgsu.edu/jsmahs/vol3/iss1/11.
BILLION
is the estimated ECONOMIC LOSS
from high levels of sleep deprivation in
the U.S. including losses of productivity
and increased risk of mortality.
health, and social interactions of 45 percent of the world’s population, and those numbers are increasing, with the United
States being among the most sleep deprived.3
Sleep deprivation is a condition that occurs when sleep
is insufficient for a given age? What groups are the most sleep
deprived in the United States? Individuals in some states, such
as Kentucky and Hawaii, and in some regions of the southeastern United States, report
being the most sleep deprived.
sleep deprivation A condiIn
contrast,
individuals
tion that occurs when sleep is
insufficient.
from Oregon, Washington,
CHAPTER 4 | Improving Your Sleep | 103
TABLE 4.1 | Percentage of People in Each
Age Group Who Are Sleep Deprived (<7 hours
of sleep per night)
Age Group
% of Sleep Deprivation
18–24
32.2%
25–34
37.9%
35–44
38.3%
45–54
39.0%
55–64
35.6%
65+
26.3%
Source: Centers for Disease Control and Prevention, “Short Sleep Duration
among U.S. Adults,” May 2, 2017.
Colorado, and other Northern Plains States have the lowest
numbers of sleep-deprived individuals.4 Large differences in
sleep deprivation also exist by age, with middle-aged adults
reporting the most sleep deprivation and the 18- to 24-yearold and 65+ groups getting the most sleep.5 (See TABLE 4.1 for
percentages of sleep-deprived people by age group.)
For most of us, sleep isn’t a high priority. When asked to
choose which five things were most important, 35 percent of
a National Sleep Foundation survey respondents said fitness or
nutrition, 27 percent said work, 17 percent said hobbies or other
personal interests, 10 percent said sleep, and 9 percent said their
social life.6 Although sleep and effectiveness are linked, very
few people plan for sleep.7
Somnolence is a lack of mental alertness that can affect
daily performance. While falling asleep in class or studying
for an exam can have serious implications, one of the greatest
potential risks for drowsiness occurs when a tired individual
gets behind the wheel of a motor vehicle. Although many people think drowsy driving means actually falling asleep at the
wheel, significant numbers of drowsy drivers are profoundly
impaired, unable to react quickly, or so sleepy that miles pass
without them even noticing—yet, they don’t actually fall
asleep. This is comparable to a drunk driver who, while awake,
should not be driving.
Drowsy Driving: Sleeper ­Statistics
Although
Federal estimates of drowsy driving have historically relied
on police reports, estimating that approximately 1-2 percent
of crashes are due to drowsy driving, new research indicates
that these estimates may
underestimate actual events.
somnolence Drowsiness,
In fact, new AAA research that
sluggishness, and lack of
mental alertness that can affect
installed cameras in vehicles
your daily performance and
and recorded the driver’s
lead to life-threatening sleepiface 3 minutes before a crash
ness while driving.
revealed that drowsy drivexcessive daytime sleepiing may account for over 10
ness A disorder characterized
percent of all crashes – much
by unusual patterns of falling
higher rates than previasleep during normal waking
hours.
ous reports!8 Of the nearly
104 | PART ONE | Finding the Right Balance
400,000 drowsy driving reports identified by Federal estimates, over 54 percent of crashes were among young adults
aged 15-29. Having trouble keeping your eyes open, drifting
from your lane, and not remembering the last miles you have
driven characterize drowsy driving. Taking breaks every 100
miles, having an alert passenger in the car, and even taking a
20 minute nap along your drive are all part of recommended
strategies. Having lane departure warnings and blind spot
assist on your vehicle and getting a good night’s sleep can also
help you avoid accidents from drowsy driving.9
Sleepless on Campus: Tired
and Dragged-Out Students?
College students seem to be particularly vulnerable to sleep
problems. In a recent survey by the American College Health
Association, only 10.2 percent of students reported getting
enough sleep to feel well rested in the morning 6 or more days
a week.10 Nearly 65 percent of students say they feel tired,
dragged out, or sleepy during the day 3 to 7 days each week.11
Forty-nine percent of college students report that they experienced a problem with sleepiness during their daytime activities. Nearly 22 percent of students report that sleep difficulties
had a serious negative effect on their academic performance.12
Sleep deficiencies have been linked to a host of student issues,
including poor academic performance, weight gain, increased
alcohol abuse, poor physical performance including accidents, daytime drowsiness, relationship issues, anxiety,
depression, and other problems.13 Despite large numbers of
students reporting sleep problems, fewer than 5 percent have
sought treatment for insomnia, and just over 2 percent have
sought treatment for other sleep problems.14 Clearly, there is
room for greater awareness about possible resources and easier
access to sleep resources on America’s campuses.
30%
of students have reported sleep difficulties
have been TRAUMATIC OR DIFFICULT
TO HANDLE in the past 12 months.
Approximately 20 percent of the U.S. population suffers
from a condition known as excessive daytime sleepiness
or excessive sleepiness. This is a major compulsion to sleep,
often when sedentary, along with persistent sluggishness and
fatigue, that can cause individuals to nod off at inopportune
times and interfere with most aspects of life.15 Adults aged 16
to 24 years are twice as likely to be drowsy at the time of auto
crashes as 40- to 59-year-olds and are the most likely to nod off
during the day.16
Increases in high-speed train crashes in recent years have
led to investigations of mental alertness/sleep deficits.
Why So Sleep Deprived?
Several factors can lead to sleep deprivation:
Shift work Work shifts that change regularly or are outside a typical 9-to-5 work schedule can disrupt biological
clocks and lead to sleeplessness, insomnia, and a host
of other problems.17 Work-related accidents are a major
issue; in fact, sleepy workers are 70 percent more likely to
be involved in accidents than are those who get enough
sleep.18 Drowsy driving is a major public health issue, particularly affecting the 9.5 million shift workers who routinely drive without adequate sleep and have a significantly
higher risk of accidents in the 30 minutes after they finish
their shift.19 Short sleepers or drowsy workers are also more
likely to be depressed, miss work, and have increased onthe-job accidents and worker’s compensation claims.20
■■ Long-haul driving Sleep deprivation is common among
truckers, particularly those who drive commercially over
60 hours per week and drive alone.21
■■
17–23
is the age of males at HIGHEST RISK
for drowsy-driving accidents. These
accidents typically occur between the
hours of midnight and 6:00 a.m. and
involve single cars that run off the road
with little evidence of braking.
Drugs and medications As noted on warning labels, prescription, over-the-counter, and illicit drugs can lead to
excessive sleepiness.
■■ Pain Excessive pain can keep a person tossing and turning
through the night, and the enormous amounts of pain
medications given to relieve pain can cause millions of
people to feel sleepy during the day. People who experience
■■
chronic or acute pain along with high stress levels are more
likely to report worse quality of life, more depression, and
more physical and mental health problems.22
■■ Sleep habits Burning the candle at both ends, exercising
before bed, and spending hours on smartphones or tablets
can lead to excess sleepiness. See the TECH & HEALTH box on
page 106 for more on adverse effects of too much screen time.
■■ Gender Women have twice the sleep difficulties of men,
believed to be caused by hormonal factors, pregnancy,
menopause, and psychological issues such as anxiety and
depression.23 Women are more likely to face problems with
insomnia, particularly during midlife and later life as hormones may change dramatically. Estrogen influences how
long it takes to fall asleep, soundness of sleep, and sleep
duration as well as temperature regulation. If estrogen levels
are disrupted, sleep is likely to suffer. Testosterone levels
fluctuate in both men and women, typically rising at night
during REM sleep and falling during the day. Low testosterone levels can affect more than sexual activity; they can lead
to chronic fatigue and disinterest in sex and to increased
risks of sleep apnea and cardiovascular disease (CVD).
■■ Sleep disorders Numerous studies point to sleep disorders
such as sleep apnea and restless legs syndrome as major
risks for excessive daytime sleepiness and subsequent automobile accidents.24
LO 2 | THE IMPORTANCE
OF SLEEP
Explain why we need sleep and what happens if we don’t get
enough sleep, including potential physical, emotional, social, and
safety threats to health.
When there just aren’t enough hours in the day, sleep can get
short-changed. Because Americans are managing to function
with less sleep, you might conclude that sufficient sleep isn’t
all that necessary. In fact, evidence for the importance of adequate sleep to overall health and daily functioning grows daily.
Sleep serves to maintain your physical health; affects your
ability to function effectively; and enhances your intellectual,
social, emotional, and psychological health in several ways:
Sleep restores you both physically and mentally. Certain
reparative chemicals are released while you sleep. There
is also evidence that during sleep, the brain is cleared of
daily minutiae, learning is synthesized, and memories are
consolidated.
■■ Sleep conserves body energy. When you sleep, your core
body temperature and the rate at which you burn calories
drop. This leaves you with more energy to perform activities throughout your waking hours.
■■ Sleep helps you cope with life’s challenges. Sleep
refreshes you; it helps you consolidate cognitive, physiological, and emotional processes and autonomic functions.
Well-rested individuals tend to be happier, have more vigor
in their lives, and have a more positive outlook than do
those who are sleep deprived. People who get enough rest
are also more likely to control their emotions and have
more positive social interactions.25
■■
CHAPTER 4 | Improving Your Sleep | 105
TECH
& HEALTH
T
he average person in the United
States has nearly four connected
devices at any given time. We sleep with
phones a few inches from our heads,
check texts during sleep time, and grab
our phones as soon as we wake up.
Sleep disruptions are one of the major
consequences of our seemingly insatiable need to stay connected.
Why is too much time spent “connected” potentially hazardous to our
sleep, our health, and our academic
success? Numerous studies indicate
that technology can affect our health in
several ways:
Wired and Tired
Technology’s Toll on Our Sleep
■■
■■
■■
■■
The blue light of LED screens can
suppress melatonin, a hormone that
helps you fall asleep and stay asleep.
Long-term melatonin deficiencies can
increase your risk for type 2 diabetes,
heart arrhythmias, migraines, and
many other problems, in addition to
■■
making you feel like a zombie when
you’re awake.
Being connected can make you wired
and stimulate your brain just when it
should be slowing down. Also, using
your laptop or tablet in bed at night
can create a pattern of behavior that
associates bed with work rather than
sleep. Keep work out of the bedroom.
And don’t log in during the night for
any reason.
Here are a few ways to avoid the melatonin-draining effects of blue light on
your sleep and health and to create a
healthy sleep environment:
Have no violent video games or deep
discussions with friends after dusk.
Change your music to soothing classical or new age selections as you
prepare for sleep.
When buying glasses or sunglasses,
purchase protection from blue light
as your glasses are ordered. If you
Sleep and Health
Sleep has beneficial effects on most body systems. That’s why,
when you consistently don’t get a good night’s rest, your body
doesn’t function as well, and you become more vulnerable to
a wide variety of health problems. Researchers are only just
beginning to explore the physical benefits of sleep, summarized briefly here.
■■
Sleep helps maintain your immune system. The common
cold, strep throat, flu, mononucleosis, cold sores, and a
variety of other ailments are more common when your
immune system is depressed. If you aren’t getting enough
sleep, the immune response is weakened. Other studies
have shown that sleep disruption, particularly when circadian rhythms are disturbed repeatedly, disrupts overall
immune function.26 In contrast, oversleeping (more than
9 hours on a regular basis) is associated with a wide range
of health issues.27
■■
Sleep helps reduce your risk for cardiovascular disease.
Several recent studies suggest a link between short sleep
duration and chronic inflammation; increased risk of
coronary artery disease; risk of stroke, hypertension (high
blood pressure), metabolic syndrome, and obesity; and
decreases in high-density lipoprotein (“good cholesterol”)
levels and other disruptions in cholesterol metabolism,
as well as increases in other cardiovascular risks.28 Among
people with untreated or noncompliant sleep apnea and
106 | PART ONE | Finding the Right Balance
can’t afford prescription blue light
blockers, purchase amber-tinted
glasses that block blue light.
■■ Allow yourself only an hour or two of
screen time after dark. Record your
favorite shows and watch them during
the day—and not in the bedroom.
Sources: L. Rosen et al., “Sleeping with
Technology: Cognitive, Affective, and Technology
Usage Predictors of Sleep Problems among
College Students,” Sleep Health 2, no. 1
(2016): 49–56; S. Gokcearslan et al., “Modeling
Smartphone Addiction: The Role of Smartphone
Usage, Self-Regulation, General Self-Efficacy
and Cyberloafing in University Students,” Computers in Human Behavior 63 (2016): 639–49;
C. Czeisler et al., “Problems Associated with
Use of Mobile Devices in the Sleep Environment—Streaming Instead of Dreaming,” JAMA
Pediatrics 170, no. 12 (2016):1146–47; B. McCoy, “Digital Distractions in the Classroom Phase
II: Student Classroom Use of Digital Devices for
Non Class-Related Activity,” Journal of Media
Education 7, no. 11 (2016): 5–11.
nighttime oxygen deprivation, autonomic nervous system
dysfunction, heart arrhythmias, and heart failure risks
increase dramatically in all age groups—even among those
who have otherwise healthy hearts.29 Newer research
points to a strong association between short-duration
sleep and increased risk of developing and/or dying from
cardiovascular disease.30
■■ Sleep contributes to a healthy metabolism. Chemical
reactions in your body’s cells break down food and synthesize
compounds that the body needs. The sum of all these reactions is called metabolism. Several recent studies suggest that
sleep contributes to a healthy metabolism and possibly a
healthy body weight. In fact, youth and adolescents who are
short sleepers have a significantly increased risk of ­obesity.31
Sleeping less is associated with eating more—­particularly highfat foods, which are higher in calories—and exercising less.32
■■ Short sleep increases risk of type 2 diabetes. Evidence
shows that sleep deficiencies, particularly sleep disorders
such as sleep apnea, can increase the risk of type 2 diabetes,
a disorder of glucose metabolism.33
■■ Sleep may be a factor in reproductive health. Although
issues with sexual interest and sexual performance are
common problems for tired people, new research suggests
sleep deprivation may affect males more than they realize.
Young males who suffered from chronic sleep deficits were
shown to have reduced semen concentration, reduced sperm
quality and motility, and smaller testicular size than men
with higher sleep levels. Women have increased issues with
conception and overall fertility.34
More research is necessary to determine the mechanisms contributing
to these problems.
■■ Sleep contributes to neurological/
mental functioning. Restricting
sleep can cause a wide range of
neurological problems, including
lapses of attention, slowed or poor
memory, reduced cognitive ability, difficulty concentrating, and
dementia.”35 Studies of college students consistently reveal that sleep
deprivation is correlated with lower
GPA, delayed sleep–wake time, and
delayed release of melatonin, a key
sleep-­promoting hormone.36 Several studies have shown that:
■■ Sleep improves motor tasks,
particularly driving and athLost that “lovin’ feeling”? If you are sleep deprived, sex drive may diminish
letic performance. Sleep also
dramatically due to decreased testosterone in both men and women, depression,
has a restorative effect on motor
decreases in vaginal lubrication, increases in erectile dysfunction, tiredness, or being
function, and can improve skilljust too ornery, moody, or stressed to want to engage.
based tasks such as playing the
guitar or driving a car. Chronic
sleep deprivation can decrease muscle strength, muscle
“internal clock” is out of sync with the hours of daylight and
power, sprint times, muscle function and overall athdarkness at your destination. Jet lag happens because the new
letic performance. Getting sufficient sleep can improve
day/night pattern disrupts the 24-hour biological clock by which
athletic performance, increase stamina, and reduce
you are accustomed to going to sleep, waking up, and performing
the likelihood of injury.37 Motor function is affected
habitual behaviors. This cycle, known as your circadian rhythm,
by sleep throughout the lifespan among otherwise
is regulated by a master clock that coordinates the activity of
healthy individuals.38 Some researchers contend that
nerve cells, proteins, and genes. The hypothalamus and a tiny
drivers who have had only 4 to 5 hours of sleep or less
gland in your brain called the pineal body, which is responsible for
have vehicle crash rates that are four times the rates for
producing the drowsiness-inducing hormone called melatonin,
drivers who get the recommended 7 hours of sleep—­
are key to these cyclical rhythms.41 See FIGURE 4.2 on page 108
comparable to crash rates of those who are driving
for more on brain structures involved in sleep.
drunk!39
■■ Sleep plays a role in stress management and mental
health. The relationship between sleep and stress is
highly complex: Stress can cause or contribute to sleep
problems and depression, and sleep problems can cause
Sleep researchers generally
circadian rhythm The 24or increase risk of stress and depression. The same is true
distinguish between two prihour cycle by which you are
accustomed to going to sleep,
of clinical psychiatric conditions such as depression
mary sleep stages. During REM
waking up, and performing
and anxiety disorders: Poor-quality sleep seems to be
sleep, rapid eye movement and
habitual behaviors.
key in determining health risks. Individuals who suffer
dreams occur, and brain-wave
melatonin A hormone that
from chronic insomnia have more than twice the risk of
activity appears similar to that
affects sleep cycles, increasing
developing depression.40
when you are awake. Non-REM
Stages and
Cycles of Sleep
LO 3 | THE PROCESSES OF SLEEP
Explain the processes of sleep, including the two-stage model,
circadian rhythm, and sleep–wake cycle, as well as how they work
and their importance for restful sleep.
If you’ve ever taken a flight that crossed two or more time zones,
you’ve probably experienced jet lag, a feeling that your body’s
(NREM) sleep, in contrast, is
the period of restful sleep with
slowed brain activity that does
not include rapid eye movement. During the night, you
alternate between periods
of NREM and REM sleep,
repeating one full cycle about
once every 90 minutes.42
Overall, you spend about
drowsiness.
REM sleep A period of sleep
characterized by brain-wave
activity similar to that seen in
wakefulness in which rapid
eye movement and dreaming
occur.
non-REM (NREM) sleep A
period of restful sleep dominated by slow brain waves;
during non-REM sleep, rapid
eye movement is rare.
CHAPTER 4 | Improving Your Sleep | 107
Pineal Body
Responsible for releasing the drowsiness-inducing
hormone called melatonin as light dims and the
sun goes down. During the day, the pineal body
is inactive and you remain awake.
Hypothalamus
With parts that function as your body’s clock,
regulating your circadian rhythm, the hypothalamus
stimulates the pineal body to secrete melatonin.
Retina
Pons
Light travels through the retina and triggers the
regulation of melatonin, slowing its production
in daylight and encouraging it in darkness,
helping to regulate the sleep cycle.
The pons, one of the smallest areas of the brain,
is a major message transmitter, and is
responsible for much of what happens in our
sleep–wake cycle. Unless disrupted, the pons
helps you enter REM sleep and keeps you down
and out, with muscles essentially immobilized.
Pituitary gland
After being stimulated by the hypothalamus, the
pituitary gland releases human growth hormone,
signaling the body to repair worn tissues.
FIGURE 4.2
Parts of the Brain Involved in Sleep
75 percent of each night in NREM sleep and 25 percent in REM
sleep ­(FIGURE 4.3).
Non-REM Sleep Is Restorative During nonREM sleep, the body rests. Both your body temperature and your
energy use drop; sensation is dulled; and your brain waves, heart
rate, and breathing slow. In contrast, digestive processes speed up,
and your body stores nutrients. In NREM sleep—also called slowwave sleep—you do not typically dream. Four distinct stages of
NREM sleep have been distinguished by their characteristic brainwave patterns as shown on an electroencephalogram (EEG), a test
detecting electrical activity in the brain.
Stage 1 is the lightest stage of sleep, lasts only a few minutes,
and involves the transition between waking and sleep. Your brain
begins to produce theta waves (slow brain waves), and you may
experience sensations of falling with quick, jerky muscle reactions. During stage 2, your eyes close, body movement slows, and
you disengage from your environment. During stages 3 and 4, a
sleeper’s brain generates slow, large-amplitude delta waves. Blood
pressure drops, your heart rate and respiration slow considerably, and you enter deep sleep. The hypothalamus stimulates the
pituitary gland to release human growth hormone, signaling the
body to repair worn tissues. Speech and movement are rare during the final stage (but sometimes people sleepwalk, cook, clean,
or drive during this stage!).
REM Sleep Energizes Dreaming takes place primarily during REM sleep. On an EEG, a REM sleeper’s brainwave activity is almost indistinguishable from that of someone
who is wide awake, and the brain’s energy use is higher than
that of a person who is performing a difficult math problem.43
The pons, one of the smallest areas of the brain, is a major message transmitter, and is responsible for much of what happens
in our sleep–wake cycle. Unless disrupted, the pons helps you
enter REM sleep and keeps you down and out, with muscles
essentially immobilized. You may dream that you’re rock
climbing, but your body is incapable of movement. Almost
108 | PART ONE | Finding the Right Balance
the only exceptions are your respiratory muscles, which allow
you to breathe, and the tiny muscles of your eyes, which move
your eyes rapidly as if you were following the scenario of your
dream. This rapid eye movement gives REM sleep its name.
Research indicates that deep phases of slow-wave sleep consolidate and organize the day’s information, while REM sleep
stabilizes consolidated memory.44 Without adequate slow-wave
sleep and REM sleep, your short-term memory may suffer.
Your Sleep Needs
In 2015, a major U.S. consensus statement was published, providing guidelines for how much sleep a healthy adult should
get each night. Key recommendations are:45
DID YOU
KNOW?
Every night you don’t get 8 hours
of sleep creates a “sleep debt.”
For example, if you only get
5 hours of sleep each night,
by the end of the semester,
that’s a sleep debt of 336 hours,
or 14 days!
Fall
asleep
Wake
up
REM
NREM
1
REM
NREM
2
REM
NREM
3
REM
REM
NREM
4
5
NREM
6
7
Duration of sleep (hours)
FIGURE 4.3 The Nightly Sleep Cycle As the number of
hours you sleep increases, your brain spends more and more time
in REM sleep. Thus, sleeping for too few hours could mean you’re
depriving yourself primarily of essential REM sleep.
Adults should sleep 7 or more hours each night to promote
optimal health.
■■ Getting fewer than 7 hours of sleep per night on a regular
basis increases risks of adverse health outcomes.
■■ Regularly getting more than 9 hours of sleep may be appropriate for young adults, people trying to recover from sleep
debt, and those recovering from illness. For others, concerns are surfacing that oversleeping may increase risk for
several health issues.
■■
Keep in mind that
WHAT DO
sleep needs vary from person to person; your genTHINK?
der, health, and lifestyle
will also affect how much
Do you find it
rest your body demands.
difficult to get 7
or 8 hours of sleep
For example, women need
each night?
more sleep than men,
overall.46
■■ Do you think you are able to
It is worth noting that
catch up on sleep you miss?
sleep patterns change over
■■ Have you noticed any
the lifespan. Newborns
negative consequences in
your own life when you get
need 16 to 18 hours of
too little sleep?
sleep daily, and teens and
younger adults need 8 to 9 hours
per night, slightly more than the adult average. Older adults
may experience sleep difficulties that result in fewer hours of
rest per night, owing to health conditions, pain, and the need to
use the bathroom more frequently.47
Many scientists believe that diabetes, obesity, and other
metabolic disorders may be linked with biological clock activity.48 In general, those who get adequate sleep live longer and
enjoy more quality days than those who don’t.49
YOU
Sleep Debt
In addition to your body’s physiological
need, consider your current sleep debt. That’s the total number of hours of missed sleep you’re carrying around with
you, either because you got up before you were fully rested or
because your sleep was interrupted. Let’s say that last week you
managed just 4 to 5 hours of sleep a night Monday through
Watch Video Tutor:
Sleep Cycle
Thursday while cramming for a Friday exam. Even if you get
7 to 8 hours a night Friday through Sunday, your unresolved
sleep debt of 8 to 12 hours will leave you tired and groggy when
you start the week again. Research has consistently shown that
not only can accruing several days of sleep deprivation make
you sleepy but also it can influence your performance over a
wide range of activities, lead to inflammation, and negatively
affect the immune system.
So, can you make up for lost sleep by sleeping in on the
weekend? Some research shows that you can catch up if
you go about it sensibly. Trying to catch up may make you
feel more wide awake, as well as reduce those dark circles
and eye bags. It also may reduce stress-related cortisol levels that shoot up while you are sleep deprived. On the other
side of the coin, that catch-up sleep is not likely to make
much difference in your performance levels, won’t restore
your functioning, and is likely to disrupt your circadian
rhythm.
Is Napping A Good Idea? Speaking of catching
up, do naps count? Although naps can’t entirely cancel out a
significant sleep debt, they can improve your mood, alertness,
and possibly performance, if your sleep debt is more an occasional deficit than a chronic problem. Regular naps may also
improve immune functioning and help ward off infections, as
well as improve performance and reduce sleepiness.50 It’s best
to nap in the early to mid-afternoon, when the pineal body
in your brain releases a small amount of melatonin and your
body experiences a natural dip
in its circadian rhythm. Never
sleep debt The difference
nap in the late afternoon, as it
between the number of hours
could interfere with your abilof sleep an individual needed
ity to fall asleep that night.
in a given time period and the
Keep your naps short because
number of hours he or she
actually slept.
a nap of more than 30 minutes can leave you in a state of
sleep inertia A state characterized by cognitive impairsleep inertia, characterized by
ment, grogginess, and disoricognitive impairment, nausea,
entation that is experienced
light-headedness, grogginess,
upon rising from short sleep or
an overly long nap.
and a disoriented feeling.
CHAPTER 4 | Improving Your Sleep | 109
The Rare “Short Sleeper”
Although many
people who don’t get enough sleep suffer the consequences, a
small group of people—perhaps fewer than 1 percent—seem to
thrive on less than 6 hours of sleep per night. Recent research
points to a possible gene—the DEC2 gene—that affects circadian rhythms and changing normal day/night cycles. This
gene and other genes may be important factors in determining
wakefulness cycles, NREM and REM sleep, and sleep duration
variability in humans.51
LO 4 | SLEEP DISORDERS
Describe some common sleep disorders, including risk factors and
what can be done to prevent or treat them.
Sleep disorders, also known as somnipathies or dyssomnias,
are any medical disorders with a negative effect on sleep patterns. The American Academy of Sleep Medicine identifies
more than 100 sleep disorders. The most common disorders in
adults are insomnia, sleep apnea, restless legs syndrome, and narcolepsy.52 If you’re still having sleep problems after following
the advice in this chapter, it’s time to visit your health care provider. To aid in diagnosis, you will probably be asked to keep a
sleep diary. You may also be referred to a sleep disorders center
for an overnight clinical sleep study. While you are asleep in
the sleep center, sensors and electrodes record data that will be
reviewed by a sleep specialist who will work with your doctor
to diagnose and treat your sleep problem. The most common
sleep disorders are discussed in the following sections.
Insomnia
Insomnia—difficulty in falling asleep, frequent arousals during
sleep, or early-morning awakening—is the most common sleep
complaint. Young adults aged 18 to 29 experience the most
insomnia, with 68 percent reporting symptoms.53 Somewhat
fewer adults (59 percent) aged
30 to 64 experience regular
sleep disorders (somnipathies or dyssomnias) Any
symptoms, and only 44 permedical disorders that have a
cent of those over age 65 have
negative effect on sleep patregular symptoms.54 Adults
terns.
with children in the household
sleep study A clinical astend to report more insomnia
sessment of sleep in which
symptoms than those withthe patient is monitored while
spending the night in a sleep
out children.55 Approximately
disorders center.
10 to 15 percent of Americans have chronic insominsomnia A disorder
characterized by difficulty in
nia that lasts longer than a
falling asleep quickly, frequent
month.56
arousals during sleep, or earlySymptoms of insomnia
morning awakening.
include difficulty in falling
cognitive-behavioral
asleep, waking up frequently
therapy for insomnia
during the night, difficulty
(CBT-I) A form of therapy that
helps people better understand
in returning to sleep, waking
the thoughts and feelings that
up too early in the morning,
influence their behaviors and
unrefreshing sleep, daytime
focus on changing habits that
sleepiness, and irritability.
disrupt sleep.
110 | PART ONE | Finding the Right Balance
There are more than 100 different sleep disorders affecting
over 70 million Americans. Two of the key disorders are
sleep apnea, which typically requires a sleep study for a
definitive diagnosis, and restless legs syndrome.
Sometimes, insomnia is related to stress and worry. In other
cases, it may be related to disrupted circadian rhythms, which
may occur with travel across time zones, shift work, and other
major schedule changes. Insomnia can also occur as a side
effect from taking certain medications. Left untreated, longterm insomnia may be associated with depression, drug and
alcohol use, and heart disease.57
Sometimes, hormonal changes or issues with the gastrointestinal tract or bladder may be an underlying cause of
insomnia. Excess stress can also be a key factor, and strategies
designed to treat or control the underlying contributors can be
helpful in reducing insomnia.
A major “study of studies” and a follow-up internet-based
study indicate that cognitive-behavioral therapy for insomnia (CBT-I) is one of the best first-line defenses for people who
can’t get to sleep or who wake up during the night and can’t get
back to sleep.58 Essentially, CBT-I helps people better understand the thoughts and feelings that influence their behaviors
and focuses on changing the habits that disrupt sleep. Strategies such as thought blocking, thought refocusing, learning
to meditate, listening to relaxing music,
biofeedback, deep breathing, and other
actions can all help turn an anxiety-prone
bedroom experience into a calm setting for
sleep. Today, increasing numbers of sleep
therapists are helping to coach people on
better sleep hygiene, including examining
the environmental factors that may prevent
deep sleep.
Relaxation strategies, including yoga and
meditation, can be helpful in preparing the
body to sleep. Exercise, done early in the
day, can also help reduce stress and promote
deeper sleep. Talk to a health professional if
you experience insomnia that is unresolved
in spite of your best efforts to make changes.59
Sleep Apnea
Sleep apnea is a disorder in which breathing is briefly and repeatedly interrupted
during sleep.60 Apnea refers to a breathing
pause that lasts at least 10 seconds. Sleep
apnea affects more than 18 million Americans, or 1 in every 15 people, and the numbers are increasing.61
Types of Sleep Apnea
FIGURE 4.4 Continuous Positive Airway Pressure (CPAP) Device People
with sleep apnea can get a better night’s sleep by wearing a CPAP device. A gentle
stream of air flows continuously into the nose through a tube connected to a mask.
This steady stream of air helps keep the sleeper’s airway open.
There are two major types
of sleep apnea: central and obstructive. Central sleep apnea
occurs when the brain fails to tell the respiratory muscles to
initiate breathing. Consumption of alcohol, certain illegal
drugs, and certain medications can contribute to central sleep
apnea.
Obstructive sleep apnea (OSA) is more common and occurs
when air cannot move in and out of a person’s nose or mouth,
even though the body tries to breathe. Typically, OSA occurs
when a person’s throat muscles and tongue relax during sleep
and block the airways, causing snorting, snoring, and gagging.
These sounds occur because falling oxygen saturation levels
in the blood stimulate the body’s autonomic nervous system
to trigger inhalation, often via a sudden gasp of breath. This
response may wake the person, preventing deep sleep and
causing the person to wake in the morning feeling as though
he or she hasn’t slept.
People who are overweight often have sagging internal
throat tissue, which puts them at higher risk for sleep apnea.
In addition to overweight, other risk factors include smoking
and alcohol use, being age 40 or older, and ethnicity—sleep
apnea occurs at higher rates in African Americans, Pacific
Islanders, and Hispanics.62 Anatomical risk factors for OSA
can include a small upper airway (or large tongue, tonsils, or
uvula), a recessed chin, small jaw or a large overbite, and a large
neck size. Because OSA runs in some families, genetics may
also play a role.63 OSA is associated with higher risk for chronic
high blood pressure, irregular heartbeats, heart attack, and
stroke. Apnea-associated sleeplessness may also increase the
risk of type 2 diabetes, immune system deficiencies, and a host
of other problems.64
Treatment for Sleep Apnea The most effective method for preventing and treating sleep apnea is to lose
weight, along with avoiding factors that appear to increase
risk. The most commonly prescribed therapy for OSA is continuous positive airway pressure (CPAP), which consists of an airflow device, long tube, and mask (see FIGURE 4.4). The mask
is worn during sleep, and air is forced into the nose to keep
the airway open. Newer treatment options are continually
being developed. Most recent options include hypoglossus nerve
stimulation, in which a small device is surgically implanted
in the chest; this device monitors breathing and stimulates
a nerve that keeps the airway open. It can be turned on and
off by the patient. Another option, the expiratory positive airway pressure (EPAP) system, uses disposable adhesive valves
that are placed over the nose during sleep and that open upon
inhalation, creating pressure that helps the airway stay unobstructed. Both have had promising results.65
Other methods for treating OSA include dental appliances,
which reposition the lower jaw and tongue, and surgery to
remove tissue in the upper airway. In general, these approaches
are most helpful for mild disease or heavy snoring.
Restless Legs Syndrome
Restless
legs
syndrome
(RLS), also known as WillisEkbom disease, is a neurological disorder characterized
by unpleasant sensations in
the legs when at rest, combined with an uncontrollable urge to move in an effort
to alleviate these feelings.
sleep apnea A disorder in
which breathing is briefly and
repeatedly interrupted during
sleep.
restless legs syndrome
(RLS) A neurological disorder
characterized by an overwhelming urge to move the
legs when they are at rest.
CHAPTER 4 | Improving Your Sleep | 111
The sensations range in severity from mildly uncomfortable
to painful. Some researchers estimate that RLS affects over
10 percent of the U.S. population, with increasing diagnosis in
all age groups.66 RLS sensations are often described as burning,
creeping, or tugging, or like insects crawling inside the legs. In
general, the symptoms are more pronounced at night. Lying
down or trying to relax activates the symptoms, and moving
the legs relieves the discomfort, so people with RLS often have
difficulty falling and staying asleep.
In most cases, the cause of RLS is unknown. A family history
of the condition is seen in approximately 50 percent of cases,
suggesting some genetic link. In other cases, RLS appears to
be related to other conditions, including Parkinson’s disease,
kidney failure, diabetes, peripheral neuropathy, and anemia.
Pregnancy or hormonal changes can worsen symptoms.67
If there is an underlying condition, treatment of that condition may provide relief. Treatment options include prescribed
medications, decreasing tobacco and alcohol use, applying heat
to the legs, relaxation techniques, and/or stretching exercises.
Narcolepsy
Narcolepsy is a neurological disorder caused by the brain’s
inability to properly regulate sleep–wake cycles. The result is
excessive, intrusive sleepiness and daytime sleep attacks. Narcolepsy occurs in about 1 of every 2,000 people in the United
States; however, only about 25 percent of those who have it
have had their disorder diagnosed and treated.68 Narcolepsy
is not rare, but it is an underrecognized and underdiagnosed
condition.
Narcolepsy is characterized by overwhelming and uncontrollable sleepiness during the day. Narcoleptics are prone to
falling asleep at inappropriate times and places—in class, at
work, while driving or eating, or even mid-conversation. These
sleep attacks can last from a few seconds to several minutes.
Other symptoms include cataplexy (the sudden loss of voluntary muscle tone, often triggered by emotional stimuli), hallucinations during sleep onset or upon awakening, and brief
episodes of paralysis during sleep–wake transitions.
In most cases, narcolepsy appears to be caused by a deficiency of chemicals in the brain that regulate sleep. Genetics
may also play a role.69 Other possible factors include having
another sleep disorder, using
narcolepsy A neurological
certain medications, or havdisorder that causes people to
ing a mental disorder or subfall asleep involuntarily during
stance abuse disorder.
the day.
Narcolepsy is commonly
parasomnias All of the
treated
with medication.
abnormal things that disrupt
Behavioral
therapy can also
sleep, not including some of
the major problems such as
help narcoleptics cope with
sleep apnea.
their condition. Some lifestyle changes, such as schedsleep hygiene The wide
range of practices that can
uling brief naps during the
help you manage and create a
day or eating smaller meals
systematic approach leading to
on a regular schedule, may be
normal, quality nighttime sleep
and full daytime alertness.
helpful.
112 | PART ONE | Finding the Right Balance
Other Parasomnias
Parasomnias include all of the abnormal things that disrupt
sleep outside the major disorders. Among the most common
parasomnias are circadian rhythm disorder, in which there are
abnormalities in the sleep–wake cycle due to jet lag and adjustments to shift work; sleep phase disorder, in which a person
either wakes up or goes to sleep too early; sleep-related eating
disorder, in which people may be found munching away in the
kitchen with no memory of eating an entire cake or bucket
of ice cream; sleepwalking, in which individuals may wander
around the house, or even go for a drive and not remember
it; night terrors, in which a person wakes up frightened and
screaming, often without knowing why (probably because
night terrors often occur in non-REM sleep cycles); sexsomnia,
in which a person may have sex while asleep and have no recollection of the event; bedwetting, or enuresis, in which a person wets the bed without knowing it; and snoring, in which
inhaled air passes over loose tissue in the back of the throat
or nasal passages and causes a rattling sound. Snoring, by
itself, is not a problem unless the loose tissue interferes with
breathing. In many cases, medications (such as some prescription sleep aids) and other drugs contribute to some of these
parasomnias. Trauma, underlying illnesses, or other neurological conditions may also be factors. For others, the causes
are unknown. With many sleep disorders, the family or person
living or sleeping with the sufferer is often the sleep-deprived
person—and isn’t tabulated in our overall sleep deficiency
statistics!
LO 5 | GETTING A GOOD NIGHT’S
SLEEP
Explore ways to improve your sleep through changing daily habits,
modifying your environment, avoiding sleep disruptors, adopting
mindfulness sleep strategies, and using other sound sleep hygiene
approaches.
Many of us struggle with getting a good night’s sleep on a
regular basis. The good news is that you can do many things
to improve sleep quality and duration. Sleep hygiene refers
to the wide range of practices that can help you create and
maintain normal, quality nighttime sleep and full daytime
alertness.70 The following sections provide proven strategies
for improving your daily sleep patterns and getting the most
out of your time spent sleeping. See FIGURE 4.5 for additional
information on key research that provides guidance for strategies designed to improve your sleep.
Create a Sleep-Promoting
Environment
Where you sleep has much to do with how well you sleep.
Making your bedroom into a calming, wind-down retreat is
essential to setting the stage for restful and restorative sleep.
Here are a few ways:
Pre-planning
How much sleep do YOU need to function at
your best? If you need 7 hours, when do you
have to get to bed and fall asleep to get that
many hours of quality sleep?
1-2 hours before bed
Create a bedtime ritual. Straighten up your
room. Designate a “last call” for checks of
texts, email, and social media. Let your friends
know that after a certain time, you are “checked
out.” Put your papers and assigned readings
away for the night. If you need to do something,
meditate, read a book, turn on some soft music
and “quiet” your body. No alcohol or caffeine!
BEDTIME
Dim the lights. Put on soft music.
Practice mindfulness meditation. Focus on
your surroundings, your breathing. Block out
thoughts of work to be done, relationship issues,
finances, or other worries. Relax...
Sleeeeeeeep... ZZZZZZ
The afternoon and 2-3 hours before sleep
Plan to eat dinner at least 3-4 hours before
bed. New research indicates that the best
time to exercise is in the late afternoon for
most; however, many younger adults can
exercise until an hour or so before bed without
any apparent problems. If in doubt, try a quiet
walk or yoga.
0-1 hours before bed
Decompress. Take a warm shower or bath.
Read a chapter or two from a favorite book.
Listen to a meditation tape or an app like
Headspace, Calm, Relax Melodies (the only
exception to not using your phone, tablet or
laptop!!). Nestle in. Make this YOUR time!
15-20 minutes later
Don’t lie in bed awake. If you can’t get to
sleep, do something else, like read or listen to
music, until you feel tired. When you start to
feel sleepy, get back into bed. Remember
that your bed is for sleeping, not doing
homework or watching TV.
If you continue to have issues with insomnia or sleep deprivation:
• Get one of the many sleep apps that are available on smartphones, bedside
monitors and wearable watches and devices. (Beddit, Sleepmatic, Autosleep, SleepBetter, Pillow, Sleep as Android etc.). Assess your sleep quality.
• If you need help, see someone who specializes in sleep issues or ask for a
referral at your counseling or student health center.
FIGURE 4.5
Proven Strategies For a Good Night’s Sleep. Unfortunately, getting a good night’s sleep isn’t
always easy. These strategies will increase the likelihood that you will get the sleep you need!
1. Chill. Literally. Turn down the thermostat. According to
experts, the best sleep occurs around 65 degrees. Normally, as you get sleepy, your body temperature starts to
drop and conserve energy through most of the sleeping
hours, gradually increasing your temperature just before
dawn. As light hits your room, body temperature goes
up, along with your energy levels. A higher temperature
may actually interfere with your natural body rhythms,
making it harder to enter or remain in deep sleep, with
resultant insomnia and other problems.71 Everyone has
an ideal sleep temperature based on percentage of body
fat and other metabolic differences; finding out what
works best for you is key to the environmental regulation
of sleep.
2. Create a Sleep “Cave.” As bedtime approaches, keep
your bedroom quiet, calm, and dark, with sensory
stimuli at a minimum.
3. Associate bed with sleep. Make your bed a place for
comfort and relaxation—a place for you to get the sleep
you need to be productive and healthy; it shouldn’t
serve as your office or social media center. Invest in a
good mattress. Buy sheets that are smooth and relaxing and pillows that are right for you. Wash bedding
weekly and keep your bedroom clean. Get rid of clutter
CHAPTER 4 | Improving Your Sleep | 113
and keep things organized. Turn off the ringer on your
phone, and charge your cell phone or tablet in a place
that is out of reach—so you aren’t tempted to look at it
during sleep time.
4. Only go to bed when you are tired. If you get in bed
and can’t sleep within 20 to 30 minutes, get up, keep
the lights dim, and listen to relaxing music or meditate.
Don’t get into heavy studying on your computer or try
to memorize complex details for an exam; this will keep
you awake.
5. Establish bedtime and waking rituals. Go to bed
and get up at the same time each day. Establishing
a bedtime ritual signals to your body that it’s time
for sleep. Listen to a quiet song, practice meditation
and deep breathing exercises, take a warm shower,
or read something that lets you quietly wind down.
Cool sheets and bedding and a lavender-scented
room have been shown to be calming and help you
sleep better.72 See the MINDFULNESS AND YOU box
for more on how mindfulness strategies can improve
your sleep. On awakening, make your bed and air out
your room.
Adjust Your Daytime Habits
What we do during the day can have a significant impact on
sleep quality and duration.
Get Adequate Daytime Light Exposure
Light is the best tool for controlling your internal clock. Light
travels through the retina and regulates melatonin, slowing its
production in daylight and encouraging it in darkness, helping to regulate the sleep cycle.73 If you want to stay awake in
the daytime and sleep at night, get as much exposure to natural light outdoors, or light therapy lights during the day, as
you can.
Exercise in the Morning or Afternoon
Exercise may be the great elixir when it comes to sleep.74 However, it appears best to exercise no later than 3 to 4 hours before
you go to bed. Why? Because exercise revs up your metabolism, makes you more alert, and depletes energy stores, while
raising body temperature. It takes hours to bring physiological changes down. Get in an earlier workout, and you will be
awake for studying or writing that term paper. However, set a
cutoff time for relaxing and cooling off the body for optimum
sleep.
Watch Your Diet, Particularly in the
Hours before Bed Avoid eating heavy meals within 2
to 3 hours of bedtime. Foods containing tryptophan, an amino
acid (found in nut butters, bananas, tuna, eggs, chicken, turkey, yogurt and milk, and pork, as well as in high-carbohydrate
foods such as bread and pastries) may encourages sleepiness,
particularly if you eat foods containing it on an empty stomach. However, foods high in protein and containing tyramine
(such as sausage, eggplant, bacon, raspberries, chocolate,
114 | PART ONE | Finding the Right Balance
After-dinner coffee? Not unless it’s decaf. Caffeine
promotes alertness by blocking the neurotransmitter
adenosine in your brain—a useful thing when you are
studying, but a potential problem when you are trying to
sleep.
avocado, nuts, soy, and red wine) and greasy or spicy foods
may keep you awake.75
Avoid Common Sleep Disruptors
Several factors play major roles in whether or not you can fall
asleep and stay asleep. Some of the biggest sleep disruptors are
common and you’ll recognize them right away. Other, lesserknown disruptors may be among the factors that hit you when
you least expect them, leaving you staring at the ceiling when
you should be sawing logs. See the STUDENT HEALTH TODAY
box on page 116 on medicines that disrupt sleep. Avoid some
of these behaviors and sleep on.
1. Go easy on the caffeine. Long recognized for its ability to increase vigilance and alertness and decrease
­sleepiness when you need to stay awake, caffeine can be
bad news for your sleep, decreasing sleep quality, sleep
time, and sleep efficiency. particularly when consumed
in the late afternoon or evening.
MINDFULNESS
AND YOU
A
s scientists look for solutions to what
appears to be an epidemic of sleeplessness, mindfulness-based interventions
are receiving increasing clinical, community, individual, and research attention. In
particular, research has focused on mindfulness-based stress reduction (MBSR),
which is designed to help people focus on
the moment in a calming, nonjudgmental
way. MBSR is touted as a promising and
effective program to help individuals learn
to calm their mind and body as a means of
helping them cope with challenges such as
illness, pain, high stress, and anxiety. Key
studies on the use of MBSR for insomnia
over the course of an 8-week controlled
intervention focused on sleep restrictions,
stimulus control, and sleep hygiene along
with mindfulness meditation have shown
very promising results. Over 70 percent of
participants in the treatment group experienced significant relief from insomnia up to
6 months after the intervention.
Together, MBSR, mindfulness
meditation (a form of meditation that
employs meditation using mindfulness
calming techniques), and other mindfulness
strategies have shown effectiveness in
evoking the relaxation response—a shift in
physiological activity that is the opposite
of the stress response. A growing body
of evidence indicates that taking simple
actions to calm stressors may bring on
a relaxation response that can help with
Evoking The Relaxation
Response
insomnia and other sleep disturbances.
Steps that you can take to evoke the
relaxation response as you prepare
yourself for sleep include the following:
■■ Choosing a calming focus. Listening
to your breathing and using positive
words (such as relax, listen to the quiet,
or I am slowing down/relaxing) are just
some examples. Some people focus on a
beautiful, peaceful setting, such as walking through the woods as snow gently
falls on the trees or hearing loons over the
lake at sunset. Allow yourself 10 minutes
of calming focus several times a day.
■■ Letting go, feeling your body parts
relax. Slowly soften the muscles in
your brow, face, neck, arms, and jaw,
one by one until your body relaxes.
Release tension, and let each part of
your body sink into your mattress. Feel
the coolness of your sheets against
your skin or the cozy warmth of your
comforter. If outside noises or thoughts
intrude, take a deep breath and focus
on how your body is beginning to drift.
Some people find that meditative music
or nature sounds can help to produce a
peaceful, calming environment.
■■ Holding a nonjudgmental world view.
As you mindfully consider what you
find around you and life in general,
discard labeling thoughts, feelings, and
sensations as being black or white,
A recent study indicated that the effects of caffeine
can last 5.5 to 7.7 hours or more—depending on how
“stiff” your coffee or energy drink really is. An everincreasing body of research points to the risks of cardiac
irregularities, psychological problems, and neurological
side effects, including headaches and migraines, from
high-caffeine drinks, particularly energy drinks.76
2. Avoid nicotine, alcohol, and liquids before bed. Like
caffeine, these will also increase the likelihood of sleep
disturbances. Although alcohol may make you sleepy
initially, it disturbs your circadian rhythm, blocks REM
sleep, and can increase your wake-up time for bathroom trips.77 Heavy consumption of any liquids late
in the day can lead to nocturia, or overactive bladder,
meaning you have to get up several times during
the night (pregnant women often suffer from this,
particularly in the first trimester).
good or bad, right or wrong. Observe,
but stop yourself from making judgments. Be open to things, experiences,
people, and feelings.
■■ Non-striving. Live in the moment
and accept the moment as valuable.
Instead of pushing ahead, take time
out to just experience the now. Relax,
observe, and feel.
■■ Letting be. As you observe, don’t
try to change or fix people or things
around you. Let things be as they are.
Instead of viewing change as good or
bad, try to observe, be more compassionate, and go with it.
■■ Having self-reliance. Observe, trust
yourself, and take actions that are based
on truth and wisdom rather than emotions or spur-of-the moment decisions.
Sources: J.Ong, et al. “A Randomized Controlled Trial of Mindfulness Meditation for Chronic
Insomnia: Effects on Daytime Symptoms and
Cognitive-Emotional Arousal.” Mindfulness (2018).
1-11. https://doi.org/10.1007/s12671-018-0911-6.
S. Kim et al., “Effects of Mindfulness-Based Stress
Reduction for Adults with Sleep Disturbance: A
Protocol for an Update of a Systematic Review and
Meta-analysis,” Systematic Reviews 5, no. 1 (2016):
51; M. Bamber and J. Schneider, “MindfulnessBased Meditation to Decrease Stress and Anxiety
in College Students,” Educational Research Review
18 (2016): 1–32; S. Garland et al., “The Quest for
Mindful Sleep: A Critical Synthesis of the Impact
of Mindfulness-Based Interventions for Insomnia,”
Current Sleep Medicine Reports 2, no. 3 (2016):
142–53.
3. Turn off screens. Watching TV, hanging out on
Facebook, working on your latest paper on your
blue-screen laptop or tablet into the wee hours of the
morning—all of these things can wreak havoc on a
good night’s sleep. Blue light is a key factor in our
secretion of the sleep hormone melatonin. If you get
too much blue-light exposure, melatonin production
will drop and you may find it hard to fall or stay
asleep.
4. Tune out on conflict. Avoid late-night phone calls,
texts, or e-mails that can end up in arguments,
­disappointments, and other emotional stressors. If something does rile you up before bed, journal about it briefly,
then promise yourself
that you’ll make time the
nocturia Frequent urination at
next day to explore your
night caused by an overactive
feelings more deeply.
bladder.
CHAPTER 4 | Improving Your Sleep | 115
STUDENT
HEALTH TODAY
J
ust as caffeine, alcohol, nicotine, and
other substances can wreak havoc on
sleep, so can other medications—even
those you may not think of as sleep disruptors. Some of the most common ones that
can negatively affect sleep cycles include:
■■
Medications As Sleep Disruptors
Antidepressants, particularly the
SSRIs (selective serotonin reuptake
inhibitors), such as Prozac, Lexapro,
and Celexa.
■■ Corticosteroids, such as Cortizone and
prednisone.
■■
Alpha and beta blockers, used for
hypertension, benign prostatic hyperplasia (BPH), and Raynaud’s disease.
■■ Glucosamine/chondroitin dietary
supplements, used to relieve joint
inflammation and pain.
■■
Statins and fibrates, such as Crestor,
Lipitor, and Zocor, used to decrease
cholesterol levels.
Sleep Aids: What Works and What
Doesn’t?
In spite of reports of risks associated with prescription and
over-the-counter sleeping pills and other aids, Americans
spent an estimated $41 billion on them in 2015—and that
number is expected to increase to over $52 billion by 2020.78
The problem is, according to a recent review, the benefits of
these sleep remedies may be less than expected. And the risks,
such as sleepy driving, may be greater than reported.79
Prescription Pills for Sleep
Although exact
numbers are difficult to obtain, it is clear that people at all
ages and stages of life are popping pills designed to put them
to sleep, keep them asleep, or keep them awake when they
should be sleeping. Concerns over the limited effectiveness
of many sleep drugs and their potential risks have raised questions over when and if people should use them. A recent study
of one of the newer prescription sleep meds marketed widely
on television ads showed that people using the drug every
night for 3 months fell asleep only 6 minutes faster—and slept
only 16 minutes longer—than those on a placebo. People on
the sleep meds actually felt more tired the next day than those
using a placebo. Similar results were noted with other wellknown sleep aids. While benefits were minimal, risks were
elevated for daytime drowsiness, headache, dizziness, falls,
fractures, auto accidents, constipation, dry mouth, and other
issues.80 (See the STUDENT HEALTH TODAY box for information on a common non-prescription aid, Melatonin.)
White Noise Machines or White Noise
Apps Tools that provide soothing nature sounds and block
out disrupting noise are being used by increasing numbers of
people. These machines are portable, and apps are increasingly
116 | PART ONE | Finding the Right Balance
available on smartphones. However, these machines and
apps vary in cost and may not be the ticket to sleep for you.
The advantage of phone apps is that there are many available
on iOS and Android devices and you can take them with you
anywhere.
Sleep Trackers Consumers now have many choices
for tracking their sleep besides just looking in the mirror or
feeling tired. These range from mobile phone apps that can sync
with your computer to assess movement patterns (tossing and
turning), wearable devices (fitness bands, watches, or devices
that can be attached to shoes or clothing), embedded devices
(integrated into mattresses, furniture, or other fixtures in the
bedroom), and conventional desktop/website resources. Many
help you get a better sense of the quality and quantity of your
sleep, and some actually provide educational messages about
sleep and increase your awareness of the sleep disruptors that
affect you. The downside is that many are costly. Some questions you might ask are: Do I really need this and what will it
do to help me? Is there a simpler device that I can purchase to
find out similar information? Be sure to check online reviews
by unbiased consumer groups for notes on reliability, function,
and ease of use. Also consider privacy concerns to determine
who might access your data.
New Blue-Light Glasses
Recent newcomers in the
sleep technology area are blue-light glasses designed to protect
you from the risks of the blue-light wavelengths believed to
affect sleep and vision. Check reviews on these glasses before
investing. Not only do they vary significantly in price, but
some also work better than others in their blue light–blocking
capacity. The impact of these on actual sleep has not been fully
investigated. Stay tuned.
Melatonin
STUDENT
HEALTH TODAY
A
lthough choices for over-the-counter
(OTC) drugs for sleep are abundant,
melatonin is America’s OTC sleep aid of
choice—with nearly 4 million Americans
spending more than $437 million on melatonin supplements in 2017. What is it?
Melatonin is a natural hormone produced
by the body’s pineal body. Most pills you
buy OTC are synthetic versions of the natural hormone and claim to work in much
the same way. During the day, or when
there is bright light, the pineal body is
inactive and you remain awake. However,
as lights dim and the sun goes down, the
pineal body turns on, producing melatonin, which enters the bloodstream just as
One Popular OTC Sleep Medication
your prime-time TV shows are ending—
and you start feeling drowsy and ready to
sleep. As you drift off, elevated melatonin
levels keep you there for a good night’s
sleep, for some people.
While melatonin can work for those
who have real disruptions in their sleep
due to shift work or jet lag, it doesn’t
appear to significantly increase sleep
among others; in fact, it may only help
you fall asleep a few minutes faster, and
stay asleep less than 15 minutes longer,
according to recent research. Side effects
can include grogginess, headache, and
interference with the effectiveness of
some blood pressure, diabetes, birth
STUDY PLAN
ASSESS YOURSELF
Take the Are You Sleeping
Well? assessment available on
Mastering Health.
CHAPTER REVIEW
LO 1 | Sleepless in America
■■
Sleep deprivation, or insufficient sleep, is a major problem in
­America, affecting as many as 70
million adults, resulting in major
problems with excessive daytime
sleepiness and increased risks of
drowsy-­driving accidents.
|
LO 2 The Importance of
Sleep
■■
Sleep serves as a mental and physical restorer, helps conserve energy,
LO 3
Sources: Consumer Reports, “Does Melatonin
Really Help You Sleep?” January 5, 2016, www
.consumerreports.org/vitamins-supplements/
does-melatonin-really-help-you-sleep/; L. Marshall,
“Melatonin Benefits, Risks: What You Need to
Know,” October 2015, www.webmd.com/sleepdisorders/news/20171004/is-natural-sleep-aidmelatonin-safe.
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
reduces risks of CVD and other
chronic ailments, enhances immune
functioning, aids in healthy metabolism and neurological functioning,
improves motor tasks, helps calm
emotional responses, and helps
manage stress.
Are you getting enough
sleep? Want to find out?
control, and other medications. Since it is
considered to be a supplement, it is not
regulated by the FDA and labs that produce it are not regulated, leading to great
variability in dosage. If you are considering
it, talk with your doctor and do your homework about dosage, possible drug interactions, and the reputation of the maker.
LO 4 | Sleep Disorders
■■
Processes of
| The
Sleep
The sleep cycle, known as the circadian rhythm, is regulated by a
biological clock that coordinates
the activity of nerve cells, proteins, and genes. Melatonin is the
hormone that regulates the sleep
cycle.
■■ REM and NREM sleep occur
throughout the night. NREM sleep
is slow-wave, restful sleep; REM sleep
mimics waking states.
■■ How much sleep you need varies by
age throughout the lifespan.
Sleep disorders, also known as
somnipathies or dyssomnias, are
any medical disorders that have a
negative effect on sleep patterns.
Although there are many sleep disorders, insomnia, sleep apnea, restless legs syndrome, and narcolepsy
are among the most prevalent, with
varying symptoms, causes, prevention, and treatment options.
■■
|
LO 5 Getting a Good Night’s
Sleep
■■
Staying active, paying attention to
your sleep environment, improving
your sleep hygiene, and avoiding
emotional upset as well as food and
drink before going to bed are all
important to getting a good night’s
sleep. Practicing mindfulness meditation, and other mindfulness strategies can help to ensure restful sleep.
CHAPTER 4 | Improving Your Sleep | 117
POP QUIZ
LO 1 | Sleepless in America
1. Which of the following statements
is not correct?
a. Over 70 million Americans are
sleep deprived.
b. Young adults (under age 24)
are the most sleep-deprived
population in America.
c. Over 45 percent of the world’s
population suffer from some
form of sleep deprivation.
d. The highest risk for drowsydriving accidents is among
males aged 17 to 23.
|
LO 2 The Importance of
Sleep
2. Which of the following statements
is NOT correct?
a. Young adults aged 18 to 29 are
the most likely to suffer from
insomnia.
b. Elderly people aged 65+ need
the most sleep each day.
c. Light exposure has little to do
with your biological clock.
d. Short sleepers have increased
risk for depression, anxiety, and
other mental health issues.
|
LO 3 The Processes of
Sleep
3. Which of the following occurs
when your body’s circadian
rhythm becomes out of sync with
daylight hours?
a. Jet lag
b. REM sleep
c. NREM sleep
d. Somnolence
LO 4 | Sleep Disorders
4. Which sleep disorder involves
difficulty falling asleep, waking up
during the night, and/or difficulty
falling back asleep?
a. Obstructive sleep apnea
b. Narcolepsy
c. Restless legs syndrome
d. Insomnia
118 | PART ONE | Finding the Right Balance
|
|
LO 5 Getting a Good Night’s
Sleep
LO 5 Getting a Good Night’s
Sleep
5. Which of the following is not
recommended if you want to get a
good night’s sleep?
a. Getting adequate exposure
to light, particularly sunlight
during the day
b. Exercising each day
c. Paying careful attention to
your sleep environment,
including clean scents and cool
temperatures
d. Consuming lots of fluids and
foods that make you feel sleepy/
full just prior to sleeping
5. What actions can you take to help
get a good night’s sleep? From what
you have learned in this chapter,
what are five things you might
tell your sleep-deprived mother or
father to do to promote improved
sleep?
Answers to the Pop Quiz questions can be
found on page A-1. If you answered a question
incorrectly, review the section identified by
the Learning Outcome. For even more study
tools, visit Mastering Health.
THINK ABOUT IT!
LO 1 | Sleepless in America
1. Why do you think America has
the dubious distinction of being
one of the most sleep-deprived
nations in the world? Although
college students have high rates of
sleeplessness, few seek help. Why
do you think this is the case?
|
LO 2 The Importance of
Sleep
2. Why is sleep so important to you
right now? In the future?
|
LO 3 The Processes of
Sleep
3. What factors interfere with or
disrupt the normal sleep cycles
and cause sleep processes to be
challenged?
LO 4 | Sleep Disorders
4. If you were diagnosed with a sleep
disorder, what behavior changes
might you make to help you with a
specific problem?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics related to sleep.
National Sleep Foundation. Information
source for national and international sleep
statistics, conducts National Sleep in
America survey each year, and provides
general sleep information for consumers.
Covers a variety of sleep topics by experts in
the field. www.sleepfoundation.org
CDC Sleep and Sleep Disorders.
Provides national data/information about
sleep, vetted by experts in the field. www
.cdc.gov/sleep/index.html
National Center on Sleep Disorders
Research. Information and research on
major sleep disorders. www.nhlbi.nih.gov/
about/org/ncsdr/
Annual reviews of sleep apps.
Includes overviews and costs. Updated
each year with details of the newest
apps and consumer ratings. www.
healthline.com/health/healthy-sleep/
top-insomnia-iphone-android-apps
5
NUTRITION: EATING
FOR A HEALTHIER YOU
LEARNING OUTCOMES
LO1
List the six classes of nutrients, and explain the primary
functions of each.
LO2
Explain how the Dietary Guidelines for Americans and
the MyPlate food guidance system can help you follow
a healthy eating pattern.
LO3
Discuss strategies for healthful eating, including how to
read food labels, the role of vegetarian diets and dietary
supplements, how to eat mindfully, and how to choose
healthful foods on and off campus.
LO4
Explain food safety concerns and how to reduce your
risk for foodborne illness.
119
WHY
SHOULD I CARE?
A poor-quality diet is a major risk factor for three of the top five causes of death:
heart disease, cancer, and stroke. The food and beverage choices you make now
can have both immediate and long-term effects on your health.
W
hen was the last time you ate because you felt
truly hungry? True hunger occurs when our
brains initiate a physiological response that
prompts us to seek food for the energy and
nutrients that our bodies require to maintain proper functioning. Often, people in wealthy nations don’t eat in
response to hunger—instead, we eat because of appetite, a
learned psychological desire to consume food. The sight and
smell of food, food advertising, cultural factors, our social
interactions, emotions, finances, and even the time of day
can influence the choices we make to satisfy our appetites.
Given all these influences, how can we make more healthful
choices more often?
Nutrition is the science that studies the relationship
between physiological function and the essential elements of
foods. With an understanding of nutrition, you will be able to
make more informed choices about your diet. What you eat,
how much you eat, and the amount of exercise you engage in
are key determinants of your health. This chapter focuses on
fundamental principles of nutrition—or how you can eat for a
healthier you.
hunger The physiological
impulse to seek food.
nutrients The constituents
of food that sustain humans
physiologically: water, proteins,
carbohydrates, fats, vitamins,
and minerals.
appetite The learned desire
to eat; normally accompanies
hunger but is more psychological than physiological.
nutrition The science that
studies the relationship between physiological function
and the essential elements of
foods.
digestive process The
process by which the body
breaks down foods into smaller
components; it is followed by
absorption of nutrients and
elimination of wastes.
Dietary Reference Intakes
(DRIs) Set of recommended
intakes for each nutrient
published by the Institute of
Medicine.
LO 1 |
ESSENTIAL
NUTRIENTS
FOR HEALTH
List the six classes of nutrients,
and explain the primary
functions of each.
Foods and beverages provide the chemicals needed to
maintain the body’s tissues
and perform its functions.
Essential nutrients are those
the body cannot synthesize (or cannot synthesize in
adequate amounts); we must
obtain them from our diet.
Of the six groups of essential
nutrients, the four we need in
the largest amounts—water,
proteins, carbohydrates, and
fats—are called macronutrients.
120 | PART TWO | Building Healthy Lifestyles
The other two groups—vitamins and minerals—are needed in
smaller amounts, so they are called micronutrients.
Before the body can use food, the digestive system must
break it down into smaller molecules that can cross from the
small intestine into the bloodstream. The digestive process is
the sequence of functions by which the body breaks down
foods chemically and mechanically; this is followed by absorption of nutrients and elimination of wastes. (See F
­ IGURE 5.1.)
Recommended Intakes for
Nutrients
In the next sections, we discuss each nutrient group and
identify how much of each you need. These national intake
guidelines, known as the Dietary Reference Intakes (DRIs),
identify the amount of each nutrient most Americans in a
specified population group need to prevent deficiencies or
reduce the risk of chronic disease. They also identify maximum safe intake levels for healthy people. The DRIs include
the following categories:
Recommended Dietary Allowances (RDAs) are daily
nutrient intake levels meeting the nutritional needs of 97
to 98 percent of healthy individuals.
■■ Adequate Intakes (AIs) are daily intake levels assumed to
be adequate for most healthy people. AIs are used when
there isn’t enough research to support establishing an RDA.
■■ Tolerable Upper Intake Levels (ULs) are the highest
amounts of a nutrient that an individual can consume
daily without risking adverse health effects.
■■ Acceptable Macronutrient Distribution Ranges
(AMDRs) are ranges of protein, carbohydrate, and fat
intake that provide adequate nutrition and are associated
with a reduced risk for chronic disease.
■■
Whereas the RDAs, AIs, and ULs are expressed as amounts—usually grams, milligrams (mg), or micrograms (μg)—AMDRs are
expressed as percentages. The AMDR for protein, for example,
is 10 to 35 percent, meaning that no less than 10 percent and
no more than 35 percent of the calories you consume should
come from proteins. But that raises a new question: What are
calories?
Calories
A kilocalorie is a unit of measure used to quantify the amount
of energy in food. On nutrition labels and in consumer publications, the term is shortened to calorie. Energy is defined as
the capacity to do work. We derive energy from the
Mouth
Salivary glands
1 Your mouth prepares for the food
by increasing production of saliva,
which aids in chewing and swallowing
and contains an enzyme that begins
breaking down some carbohydrates.
2 From the mouth, the food passes
down the esophagus, a tube that
connects the mouth and stomach.
Esophagus
3 In the stomach, food is mixed by
muscular contractions and is broken
down with enzymes and stomach
acids.
Liver
4 Further digestive activity and
Pancreas
absorption of nutrients take place in
the small intestine, aided by enzymes
from the small intestine and pancreas,
and bile from the liver.
Small intestine
5 Water and salts are reabsorbed
Stomach
into the system by the large intestine.
Large intestine
Rectum
Anus
6 Solid waste moves into the
rectum and is passed out through the
anus.
FIGURE 5.1 The Digestive Process It takes approximately 24 hours for the food you eat
to be broken down, the nutrients absorbed, and the wastes eliminated.
energy-containing nutrients in the foods we eat. These
energy-containing nutrients—proteins, carbohydrates, and
fats—provide calories. Vitamins, minerals, and water do not.
TABLE 5.1 on page 122 shows the average caloric needs for
individuals of various ages.
Water: A Crucial Nutrient
The human body consists of 50 to 70 percent water by weight.
This water is contained within cells, as well as in the blood
and tissue fluids in which cells are bathed. It is essential for
the chemical reactions upon which life depends; aids in fluid,
electrolyte, and acid–base balance; helps regulate body temperature; and, as the primary component of blood and lymph,
carries oxygen, nutrients, and hormones and other substances
to body cells and removes metabolic wastes. For all these reasons, humans can survive for several weeks without food, but
only for several days without water.
Individual needs for water vary drastically according to
dietary factors, age, size, overall health, environmental temperature and humidity levels, and exercise. The general recommendations are approximately 9 cups of total water from
all beverages and foods each day for women and an average
of 13 cups for men.1 However, the recommendations also
acknowledge that most healthy Americans can adequately meet
their fluid needs “by letting thirst be their guide.”2 Notice that
the intake recommendations include foods: Fruits and vegetables are 80 to 95 percent water, meats are more than 50 ­percent
water, and even dry bread and cheese are about 35 percent
water!
Contrary to popular opinion, caffeinated drinks, including
coffee, tea, and soda, also count toward total fluid intake. Consumed in moderation (e.g., two cups of brewed coffee), caffeinated beverages have not been found to dehydrate people whose
bodies are used to caffeine.3 High consumption, however (e.g.,
four cups of brewed coffee), does have an acute diuretic effect;
that is, it increases excretion of body fluids.
There are situations in which a person needs additional fluids to avoid dehydration, a state of abnormal depletion of
body fluids. Dehydration can develop within a single day,
especially when you engage in strenuous physical activity in a
hot climate. When you sweat profusely, you need extra water
to keep your body’s core temperature within a normal range
and to remain mentally alert.
Dehydration is also a risk
calorie A unit of measure that
when you have a fever or an illindicates the amount of energy
ness involving vomiting or
obtained from a particular
food.
diarrhea, and in people with
CHAPTER 5 | Nutrition: Eating for a Healthier You | 121
TABLE 5.1 | Estimated Daily Calorie Needs
Calorie Range
a
Sedentary
Activeb
1,000
1,400
4–13 years old
1,200–1,600
1,400–2,200
14–18
1,800
2,400
19–25
2,000
2,400
26–50
1,800
2,200–2,400
51+
1,600
2,000–2,200
4–12 years old
1,200–1,800
1,600–2,400
13–18
2,000–2,400
2,600–3,200
19–20
2,600
3,000
21–40
2,400
2,800–3,000
41–60
2,200
2,800
61+
2,000
2,400–2,600
Children
2–3 years old
Females
Males
a
A lifestyle that includes only the light physical activity associated with
­typical day-to-day life.
b
A lifestyle that includes physical activity equivalent to walking more than
3 miles per day at 3–4 miles per hour, in addition to the light physical activity
associated with typical day-to-day life.
Source: U.S. Department of Agriculture and U.S. Department of Health
and Human Services, 2015–2020 Dietary Guidelines for Americans, 8th ed.,
­Appendix 2, Table A2-1. (Washington, DC: U.S. Government Printing Office.)
kidney disease, diabetes, or cystic fibrosis. Older adults and the
very young are also at increased risk for dehydration.
Excessive water intake can also pose a serious health risk
if it prompts hyponatremia, a condition characterized by low
blood levels of the mineral sodium. Sodium is essential for
the transmission of nerve impulses; sodium in the fluid outside of cells balances potassium in the fluid inside of cells to
keep cells properly hydrated. When the level of sodium in the
bloodstream and tissue spaces
is excessively diluted, water
dehydration Abnormal depletion of body fluids.
flows into cells, which swell.
This can cause a potentially
proteins Large molecules
fatal swelling of the brain and
made up of chains of amino
acids; essential constituents of
other tissues. If you are an athall body cells.
lete and wonder about water
consumption, consult the
amino acids The nitrogencontaining building blocks of
American College of Sports
protein.
Medicine’s current hydration
guidelines at www.acsm.org.
complete proteins Proteins
that contain all nine of the essential amino acids.
incomplete proteins Proteins
that lack one or more of the
essential amino acids.
Proteins
Next to water, proteins are the
most abundant compounds in
122 | PART TWO | Building Healthy Lifestyles
the human body. In fact, proteins are major components of all
living cells. They are called the “body builders” because of their
role in developing and repairing bone, muscle, skin, and blood
cells. They are the key elements of antibodies that protect us
from disease, enzymes that control chemical activities in the
body, and many hormones that regulate body functions. Proteins also supply an alternative source of energy to cells when
fats and carbohydrates are not available. Specifically, every
gram of protein you eat provides 4 calories. (There are about
28 grams in an ounce by weight.) Adequate protein in the diet
is vital to many body functions and ultimately to survival.
Your body breaks down proteins into their nitrogen-­
containing building blocks, known as amino acids. Of the 20
amino acids needed by the body, 9 are essential amino acids,
which means the body cannot make them and they must be
consumed in the diet; the other 11 amino acids are considered
nonessential because the body can make them. Dietary proteins
that supply all the essential amino acids are called complete
proteins. Typically, protein from animal products is complete,
and soy and quinoa (a seed that is cooked and used like rice)
are complete plant proteins. Other proteins from plant sources
are incomplete proteins that lack one or more of the essential
amino acids. However, it is easy to combine plant foods to produce a complete protein meal (FIGURE 5.2). Plant foods rich in
incomplete proteins include legumes (beans, lentils, peas, and
peanuts); grains (e.g., wheat, corn, rice, and oats); and nuts and
seeds. Certain vegetables, such as leafy green vegetables and
broccoli, also contribute valuable plant proteins. Consuming a
variety of foods from these categories will provide all the essential amino acids.
The AMDR for protein is 10 to 35 percent of calories.
The RDA is 0.8 gram (g) per kilogram (kg) of body weight.4
Although protein deficiency poses a threat to the global
population, few Americans suffer from protein deficiencies.
On average, American men age 20 and over have a protein
requirement of about 60 grams per day, but consume about 88
grams. Women need about 52 grams of protein but consume
about 65 grams.5 To calculate your protein needs, divide your
body weight in pounds by 2.2 to get your weight in k
­ ilograms,
then multiply by 0.8. The result is your recommended protein intake per day. For example, a woman who weighs
130 pounds should consume about 47 grams of protein each
day. A 6-ounce steak provides 53 grams of protein—more than
she needs!
People who have a higher RDA for protein include pregnant
women and patients fighting a serious infection, recovering
from surgery or blood loss, or recovering from burns. In these
instances, proteins that are lost to cellular repair and development need to be replaced. Athletes also have a higher need for
protein, requiring from 1.2 to 2.0 g per kg of body weight to
build and repair muscle fibers.6 In addition, a sedentary person may find it easier
DO IT! NUTRITOOLS
to avoid weight gain
Complete the Know
when consuming a
Your Protein Sources activity,
diet with a higher peravailable on Mastering Health.
centage of protein and
a lower percentage of
+
+
Legumes and grains
Green leafy vegetables and grains and legumes
+
Legumes and nuts and seeds
+
+
+
Green leafy vegetables and nuts and seeds and legumes
FIGURE 5.2
Foods Providing Complementary Amino Acids Complementary combinations of plant-based foods
can provide all essential amino acids. In some cases, you might need to combine three sources of protein to supply all nine;
however, the foods do not necessarily have to be eaten in the same meal. Here, two of the limited amino acids in leafy green
vegetables are supplied by either grains or nuts and seeds, and the third is found in legumes.
carbohydrate. Why? Proteins make a person feel full for a longer period of time because protein takes longer to digest than
carbohydrates. Protein intake also increases the secretion of
certain hormones that contribute to feelings of fullness and
suppress feelings of hunger.
Carbohydrates
Carbohydrates supply us with the energy we need to sustain
normal daily activity. In comparison to proteins or fats, carbohydrates are broken down more quickly and efficiently, yielding a fuel called glucose. All body cells can burn glucose for fuel;
moreover, glucose is the only fuel that red blood cells can use
and is the primary fuel for the brain. Carbohydrates are the
best fuel for moderate to intense exercise because they can be
readily broken down to glucose even when we’re breathing
hard and our muscle cells are getting less oxygen.
Like proteins, carbohydrates provide 4 calories per gram.
The RDA for adults is 130 grams of carbohydrate per day.7
There are two major types: simple and complex.
Simple Carbohydrates
Simple carbohydrates
or simple sugars are found naturally in fruits, many vegetables, and dairy. The most common form of simple carbohydrates is glucose. Fruits and berries contain fructose (commonly
called fruit sugar). Glucose and fructose are m
­ onosaccharides.
Combinations of two monosaccharides yield disaccharides.
The most common examples are sucrose (granulated table
sugar); lactose (milk sugar), found in milk and milk products;
and maltose (malt sugar). Eventually, the human body
converts all types of simple sugars to glucose to provide
­
energy to cells.
Sugar is also added to a wide range of processed foods and
beverages. A classic example is soda: There are more than 10
teaspoons per can! Moreover, such diverse items as breakfast cereals, yogurts, and even some peanut butters can be
high in added sugars. Research is increasingly linking high
consumption of added
DO IT! NUTRITOOLS
sugars not only to obeComplete the Know Your
sity but also to chronic
Carbohydrate Sources activity,
diseases such as diabeavailable on Mastering Health.
8
tes and heart ­disease.
Read food labels carefully before purchasing. If sugar or one of its aliases (including high-­fructose corn
syrup) appears near the top of the ingredients list, then
that product is high in added sugars and is not your best
­nutritional bet.
Complex Carbohydrates:
Starches
and Glycogen Also
called polysaccharides, ­complex
carbohydrates are formed
by long chains of glucose.
Starches, glycogen, and fiber are
the main types of complex
carbohydrates.
Starches make up the
majority of the complex carbohydrate group and come
from cereals, breads, pasta,
rice, corn, oats, barley, potatoes, legumes, starchy vegetables, and related foods. The
body breaks down starches
into glucose, which can be
easily absorbed by cells and
used as energy or stored in the
muscles and the liver as
­glycogen. When the body
requires a sudden burst of
energy, the liver converts glycogen into glucose and releases
it into the bloodstream.
carbohydrates Basic nutrients that supply the body with
glucose, the energy molecule
most readily used by cells.
simple carbohydrates A
carbohydrate made up of only
one or two sugar molecules;
also called simple sugars.
monosaccharides One-molecule sugars; include fructose
and glucose.
disaccharides Sugars combining two monosaccharides;
include lactose, maltose, and
sucrose.
complex carbohydrates
Polysaccharides composed of
long chains of glucose.
starches Polysaccharides
that are the storage forms of
glucose in plants.
glycogen The polysaccharide
form in which glucose is stored
in the liver and, to a lesser
extent, in muscles.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 123
A kernel of wheat
Bran
• High fiber
• B vitamins
• Phytochemicals
• Minerals
Germ
• Vitamin E
• Healthy unsaturated fats
• Antioxidants
• Phytochemicals
• Minerals
• B vitamins
Endosperm
• Starch
• Protein
• B vitamins
FIGURE 5.3 Anatomy of a Whole Grain Whole grains
are more nutritious than refined grains because they contain
the bran, germ, and endosperm of the seed—sources of fiber,
vitamins, minerals, and beneficial phytochemicals (chemical
compounds that occur naturally in plants).
Source: Adapted from Joan Salge Blake, Kathy D. Munoz, and Stella Volpe,
Nutrition: From Science to You, 4th ed. © 2019, page 131. Printed and electronically reproduced by permission of Pearson Education, Inc., Upper Saddle
River, New Jersey.
Complex Carbohydrates: Fiber
Sometimes
referred to as “bulk” or “roughage,” fiber is the indigestible
portion of plant foods that helps move foods through the
intestines, reduces absorption of cholesterol and surges in
blood glucose, and softens stools by absorbing water. Dietary
fiber is found only in plant foods, such as fruits, vegetables,
nuts and seeds, and grains.
Fiber is either soluble or insoluble. Soluble fibers, such as pectins, gums, and mucilages, dissolve in water, form gel-like substances, and can be digested easily by bacteria in the colon.
Major food sources of soluble fiber include citrus fruits, berries,
oat bran, and legumes and some other vegetables. Insoluble
fibers, such as lignins and cellulose, typically do not dissolve in
water and cannot be fermented by bacteria in the colon. They
are found in most fruits and vegetables and in whole grains,
such as brown rice and whole-grain breads, pastas, and cereals
(see FIGURE 5.3). The AMDR for carbohydrates is 45 to
65 ­percent of total calories, and health experts recommend
that the majority of this intake be fiber-rich carbohydrates.
Fiber is associated with a
reduced risk for obesity, heart
fiber The indigestible portion
disease, constipation, and posof plant foods that helps move
sibly even diabetes and colon
food through the digestive
system and softens stools by
and rectal cancers. The DRI for
absorbing water.
dietary fiber is 25 grams per day
for women and 38 grams per
whole grains Grains that
retain the bran, germ, and
day for men.9 What’s the best
endosperm, with only the husk
way to increase your intake?
removed.
Eat fewer refined carbohycholesterol A type of
drates in favor of more fiberlipid classified as a sterol and
rich carbohydrates, including
found in animal-based foods;
whole-grain breads and cereals,
it is also synthesized by the
fresh fruits, legumes and other
body.
124 | PART TWO | Building Healthy Lifestyles
A recent analysis of 45 studies from Europe, Asia, and
the United States involving hundreds of thousands of
participants found that the higher the consumption of whole
grains, the lower the risk for death from cardiovascular
disease, diabetes, cancer, and all causes. The risk of
death from heart disease, for example, was reduced by
21 percent. Unfortunately, nearly 100 percent of Americans
fail to meet their recommended intakes for whole grains.
Sources: D. Aune et al., “Whole Grain Consumption and Risk of Cardiovascular Disease, Cancer, and All Cause and Cause Specific Mortality:
Systematic Review and Dose-Response Meta-analysis of Prospective
Studies,” BMJ (June 14, 2016): 353: i2716; U.S. Department of Health and
Human Services and U.S. Department of Agriculture. 2015–2020 Dietary
Guidelines for Americans. 8th Edition. December 2015.
Available at https://health.gov/dietaryguidelines/2015/guidelines/.
vegetables, nuts, and seeds. As with most nutritional advice,
however, too much of a good thing can pose problems. A sudden
increase in dietary fiber may cause flatulence (intestinal gas),
cramping, or bloating. Consume plenty of water or other (sugarfree!) liquids to reduce such side effects. Find out more about the
benefits of fiber in the MAKING CHANGES TODAY box.
Fats
Cholesterol and triglycerides (commonly called fats) are two
forms of a large group of biological compounds known as
­lipids, which are not soluble in water.
Cholesterol
Although commonly referred to as a fat,
cholesterol is technically a sterol, an oily substance found in
both plant and animal cells. Plant sterols are present in small
amounts in plant oils, whole grains, corn, and soy, whereas
cholesterol is obtained from animal-based foods such as meats,
cheese, and egg yolks. In the body, cholesterol is an essential
component of the cell membrane and of many important
functional chemicals, including certain hormones. Although
we can’t live without cholesterol, we don’t have to consume it
in our diet because the liver synthesizes it from other food substances. Thus, it’s not an essential nutrient.
Many people believe that all cholesterol circulating in the
bloodstream is “bad” and increases the risk for cardiovascular
disease (which can lead to a heart attack or stroke). This isn’t
MAKING CHANGES TODAY
Bulk Up Your Fiber Intake!
You can increase your fiber intake by improving your skills
at finding and choosing foods that are high in fiber. Try the
following:
Whenever possible, select whole-grain breads, especially those made without added sugars. Choose breads
with 3 or more grams of fiber per serving. Look for the
word whole on the label. Many breads are called “wheat
bread” and colored brown by adding molasses. This
doesn’t mean they are whole-wheat breads.
Eat whole, unpeeled fruits and vegetables rather than
drinking their juices. The fiber in the whole fruit tends to
slow the release of glucose into your bloodstream and
helps you feel full longer.
Substitute whole-grain pastas, bagels, and pizza crust for
the refined, white flour versions.
Add whole-grain bread crumbs, brown rice, or ground
seeds to meatloaf and burgers to increase fiber intake.
Enhance your fiber intake with quinoa, an edible seed that
is also a complete protein.
Toast grains to bring out their nutty flavor and make foods
more appealing.
Sprinkle ground flaxseed on cereals, yogurt, and s­ alads,
or add to casseroles, burgers, and baked goods.
­Flaxseeds have a mild flavor and are also high in ­beneficial
fatty acids.
strictly true. Cholesterol is transported in the bloodstream in
compounds called lipoproteins that contain, as their name suggests, a variety of lipids as well as protein. Among several types,
two are clinically important:
High-density lipoproteins (HDLs) are about 50 percent
protein. The rest of the compound is made up of lipids,
including cholesterol. HDLs are “high density” because
their high protein content makes these compounds more
dense than other lipoproteins, which have less protein.
HDLs are produced in the liver and circulate in the bloodstream, picking up cholesterol and transporting it back to
the liver for recycling or excretion. Cholesterol removed
from the bloodstream cannot collect in, and damage, the
lining of blood vessels. Thus, a high level of HDLs reduces
an individual’s risk for the blood-vessel damage (called
­atherosclerosis) that leads to cardiovascular disease.
■■ Low-density lipoproteins (LDLs) are about 22 percent
protein, 50 percent cholesterol, and 28 percent other
­lipids. LDLs transport cholesterol to the body cells that
require it. LDLs not taken up by cells are degraded by the
liver, which releases their cholesterol load into the bloodstream. There, this cholesterol can accumulate in the lining
of blood vessels, eventually leading to atherosclerosis and
cardiovascular disease.
■■
A high level of HDL-cholesterol in the blood is desirable, as is
a low level of LDL-cholesterol. However, for most people, cholesterol consumption is not correlated with the levels of cholesterol
circulating in the bloodstream. Surprisingly, fiber intake is! A
diet high in fiber reduces blood cholesterol, mainly because fiber
increases the body’s excretion of bile, a c­ holesterol-containing
compound synthesized by the liver. As bile is lost in feces, the liver
must remove cholesterol from the bloodstream to make more.
(See Chapter 16 for information about recent research on cholesterol, inflammation, and other risks for cardiovascular disease.)
Triglycerides
DO IT! NUTRITOOLS
The term dietary fats
technically
refers
to
Complete the Know Your Fat
­tri­­­­glycerides. At 9 caloSources activity, available on
ries per gram, they are our
Mastering Health.
most significant source of
fuel for low-to-moderate
levels of activity, and during rest and sleep. They also play a vital
role in insulating body organs against cold and shock, as well as
maintaining healthy skin and hair. When we consume too many
calories from any source, the liver converts the excess into triglycerides, which are stored in fat cells throughout the body. Dietary
fats are also broken down into components that contribute to cell
structures and many important body chemicals. Finally, you
need to consume dietary fat for your body to absorb the fat-soluble vitamins A, D, E, and K.
Triglycerides are compounds made up of a molecule called
glycerol attached to three fatty acids, chains of oxygen, carbon,
and hydrogen atoms. Fatty acid chains that cannot hold
any more hydrogen in their c­hemical structure are called
­saturated fats. They generally come from animal sources, such as
meat, dairy, and poultry prodhigh-density lipoproteins
ucts, and are solid at room tem(HDLs) Compounds that faciliperature. Saturated fats have
tate the transport of cholesterol
from the blood to the liver for
long been associated with an
metabolism and elimination
increased risk for heart disease
from the body.
and stroke, largely because they
low-density lipoproteins
appear to decrease the removal
(LDLs) Compounds that faciliof LDL-cholesterol from the
tate the transport of cholesterol
blood. Recent research has
in the blood to body cells.
begun to question the strength
of this association;10,11 howtriglycerides The most comever, the findings of these studmon lipids in our food supply
and in the body; made up of
ies have been challenged, and
glycerol and three fatty acid
the 2015–2020 Dietary Guidechains; commonly referred to
lines for Americans still suggest
as fats.
limiting your intake of satusaturated fats Fats that
rated fat to less than 10 percent
are unable to hold any more
12
of your daily calories.
hydrogen in their chemical
Unsaturated fats have
structure; derived mostly from
animal sources; solid at room
regions where carbon atoms
temperature.
are double-bonded together
instead of to hydrogen. Thus,
unsaturated fats Fats that
have regions not saturated
they are not “saturated” with
with hydrogen; derived mostly
hydrogen. They generally come
from plants; liquid at room
from plants, are liquid at room
temperature.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 125
Percentage of total
100
80
29
60
40
20
0
3
4
5
6
74
66
4
7
8
32
60
58
1
5
11
44
72
23
24
6
5
37
24
13
13
15
17
Olive
oil
Soybean
oil
Peanut
oil
5
2
6
87
39
Corn
oil
5
3
10
46
58
20
12
10
9
7
Canola Safflower Sunflower
oil
oil
oil
5
Lard
50
Palm
oil
60
Butter
Coconut
oil
Key:
FIGURE 5.4
Saturated fatty acids
Polyunsaturated fatty acids (PUFAs)
Monounsaturated fatty acids (MUFAs)
Other fatty substances
Trans fats
Percentages of Saturated, Polyunsaturated, Monounsaturated, and Trans Fats in Common
Vegetable Oils
temperature, and include most vegetable oils. Monounsaturated
fatty acids (MUFAs) have one double-carbon bond in their chain,
and polyunsaturated fatty acids (PUFAs) have more than one double bond. Although most animal and plant-based foods provide a
combination of fats, in general, peanut, canola, and olive oils are
higher in monounsaturated fats, and corn, sunflower, and safflower oils are higher in polyunsaturated fats. All unsaturated fats
are considered more healthful than saturated fats. Replacing saturated fats with unsaturated fats, especially PUFAs, is associated
with reduced blood levels of LDL-cholesterol.13 For a breakdown
of the types of fats in common vegetable oils, see FIGURE 5.4.
Two specific types of polyunsaturated fatty acids essential
to a healthful diet are omega-3 fatty acids (found in many types
of fatty fish; dark green, leafy vegetables; walnuts; and flaxseeds) and omega-6 fatty acids (found in corn, soybean, peanut,
sunflower, and cottonseed oils). Both are classified as essential
fatty acids—that is, those we must receive from our diets—
because the body cannot synthesize them, yet requires them
for functioning. The most important fats within these groups
are linoleic acid, an omega-6 fatty acid, and alpha-­linolenic acid,
an omega-3 fatty acid. The body needs these to make hormone-like ­compounds that control immune function, pain
perception, and inflammation, to name a few key benefits.
You may also have heard of EPA (eicosapentaenoic) and DHA
(docosahexaenoic acid). These are derivatives of alpha-linolenic acid that are found abundantly in oily fish such as salmon
and tuna and are associated with a reduced risk for heart
disease.14
Trans Fatty Acids
For decades, Americans shunned
butter, lard, and other foods high in saturated fats, and used
margarine and solid shortenings instead. What they didn’t
know is that these products were high in trans fats,
trans fats Fats typically prowhich increase the risk for
duced from the hydrogenation
of polyunsaturated oils.
cardiovascular disease even
126 | PART TWO | Building Healthy Lifestyles
more than saturated fats. Research during the past two decades
has shown that consuming trans fats decreases levels of HDLcholesterol and increases levels of LDL-cholesterol, thereby
raising the risk for heart disease. A recent review of 20 studies,
for example, found that trans fat consumption increases the
risk for heart disease and for mortality from heart disease, as
well as mortality from breast and colon cancer.15
Although a small amount of trans fats do occur in some animal products, the great majority have occurred in processed
foods made with partially hydrogenated oils (PHOs).16 PHOs
are produced when food manufacturers add hydrogen to a
plant oil, solidifying it, helping it to resist rancidity, and giving the food in which it is used a longer shelf-life. In 2015, the
U.S. Food and Drug Administration (FDA) ruled that PHOs are
no longer “generally recognized as safe” for consumption, and
gave food companies until July 2018 to remove PHOs from their
products.17
Fat Intake Recommendations The AMDR for
fats is 20 to 35 percent of total calories. Saturated fat should
make up less than 10 percent of your total calories, and you
should keep trans fat intake to an absolute minimum.18 Instead
of trying to eat a low-fat diet, choose healthful unsaturated fats
from plants and fish. Many studies have shown that balanced
higher-fat diets such as the Mediterranean diet, which is rich in
plant oils and fish, produce significant improvements in body
weight and risk factors for cardiovascular disease and diabetes.19
Follow these guidelines to add more healthful fats to your diet:
Eat fatty fish (herring, mackerel, salmon, sardines, or tuna)
at least twice weekly.
■■ Use olive, peanut, soy, and canola oils instead of butter or
lard. See HEALTH HEADLINES on page 128 for more information on coconut oil.
■■ Add green leafy vegetables, walnuts, walnut oil, and
ground flaxseed to your diet.
■■
are fat soluble; B-complex vitamins and vitamin C are water soluble. Fat-soluble vitamins can be stored in the body’s fat tissues,
and toxic levels can accumulate if people regularly consume
more than the UL. Excesses of water-soluble vitamins are generally excreted in the urine and rarely cause toxicity problems.
See TABLE 5.2 on page 129 for functions, recommended intake
amounts, and food sources of specific vitamins.
All fats are not the same, and your body needs some fat to
function. Try to reduce saturated fats, which are in meat,
full-fat dairy, and poultry products, and avoid trans fats,
which may be present in commercially baked goods and
deep-fried foods. Replace these with unsaturated fats, such
as those in plant oils, fatty fish, and nuts and seeds.
Follow these guidelines to reduce your intake of saturated fats:
■■
■■
■■
■■
■■
■■
Chill meat-based soups and stews, scrape off any fat that
hardens on top, and then reheat to serve.
Fill up on fruits and vegetables.
Hold the creams and sauces.
Choose lean meats, fish, or skinless poultry. Broil or bake
whenever possible.
Choose fewer cold cuts, bacon, sausages, hot dogs, and
organ meats.
Select nonfat and low-fat dairy products.
Vitamins
Vitamins are organic (carbon-containing) compounds that
promote growth and are essential to life and health. Every
minute of every day, vitamins help maintain nerves, skin,
blood, and bones; heal wounds; fight metabolic stress; enable
vision; and convert food energy to body energy—and they do
all this without adding any calories to your diet.
Vitamins are classified as either fat soluble, which means they
are absorbed through the intestinal tract with the help of fats, or
water soluble, which means they are absorbed through the intestinal tract directly into the bloodstream. Vitamins A, D, E, and K
Vitamin D Vitamin D, the “sunshine vitamin,” is formed
from a compound in the skin when exposed to the sun’s ultraviolet rays. In most people, an adequate amount of vitamin D
can be synthesized with 5 to 30 minutes of sun on the face,
neck, hands, arms, and legs twice a week, without sunscreen.20
However, the sun is often too low in the sky, the sky is cloudy,
and pollution levels from heating and smog often block the
sun’s rays, particularly in northern winter climates, not allowing for vitamin D synthesis. Skin color, age, and other factors
also affect vitamin D synthesis. For people who cannot rely on
the sun to meet their daily vitamin D needs, consuming vitamin D–fortified milk, yogurt, soy milk, cereals, and fatty fish,
such as salmon, can also supply this vitamin.
Vitamin D promotes the body’s absorption of calcium, the
primary mineral component of bone. It also assists in the processes of bone growth, repair, and remodeling. For these reasons,
a deficiency of vitamin D can promote loss of bone density and
strength, a condition called osteoporosis. The risk of fractures (broken bones) is greatly increased in people with osteoporosis. Two
other bone disorders—rickets in children, and its adult version,
osteomalacia, both of which cause softening and distortion of the
bones—can also be prevented with adequate intake of vitamin
D.21 An adequate level of vitamin D may also reduce the risk for
cardiovascular disease, diabetes, and some forms of cancer.
More is not always better, however.22 As just noted, vitamin
D is stored in the body’s fat tissues, and an excessive intake can
be toxic.
Folate One of the B vitamins, folate is needed for the production of compounds necessary for DNA synthesis in body
cells. It is particularly important for proper cell division during
embryonic development; folate deficiencies during the first
few weeks of pregnancy, typically before a woman even realizes
she is pregnant, can prompt a neural tube defect such as spina
bifida, in which the primitive tube that eventually forms the
brain and spinal cord fails to close properly. The FDA requires
that all bread, cereal, rice, and pasta products sold in the
United States be fortified with folic acid, the synthetic form of
folate, to reduce the incidence of neural tube defects.
Minerals
Minerals are inorganic, indestructible elements that build body
tissues and assist body processes. They are readily absorbed and
excreted. Major minerals are those that the body needs in
fairly large amounts: sodium,
vitamins Essential organic
calcium, phosphorus, magnesium, compounds that promote
potassium, sulfur, and chloride. metabolism, growth, and
Trace minerals include iron, reproduction.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 127
Coconut Oil
HEALTH
HEADLINES Friend or Foe?
I
f you’re a label
reader, you have
probably noticed
coconut oil on the
ingredients list of
milk, spreads, and
yogurt. Or maybe
you’ve seen jars filled
with this semi-solid
milky-white fat on the
grocery store shelves.
Once thought of as
unhealthy, coconut
oil consumption is
now being touted
for several beneficial
effects, including
a reduced risk for
cardiovascular
disease. Let’s see what the science says.
Whereas most plant oils are about 7
to 17 percent saturated fat, 87 percent of
the fatty acids in coconut oil are saturated,
and the majority of these saturated fats
raise levels of LDL cholesterol. Still, they
also raise levels of HDL cholesterol. Moreover, most of the fatty acids in coconut
oil are medium-chain triglycerides, which
are more likely to be burned as energy
and less likely to be stored as body fat.
Coconut oil is also rich in vitamin E and a
variety of phytochemicals.
replacing heart-healthy
polyunsaturated vegetable
oils with coconut oil. There
is a larger body of research
in humans that monounsaturated and polyunsaturated
fatty acids lower LDL cholesterol levels and reduce
the risk of cardiovascular
disease, but only a few
studies support coconut
oil as beneficial for heart
health. At this point, the
American Heart Association
and the American College of Cardiology advise
against adding coconut oil
to your diet.
The original study that sparked interest
in coconut oil was observational. It found
that Polynesian people, who have a low
prevalence of cardiovascular disease,
ingest mostly fat from coconuts. This
association between consumption of coconut oil and reduced rates of cardiovascular disease does not, of course, prove
cause and effect. More recently, however,
some clinical studies have demonstrated
mechanisms by which coconut oil does
appear to exert a cardioprotective effect.
Health professionals are therefore
divided over whether to recommend
zinc, manganese, copper, fluoride, selenium, chromium, and
iodine. Although only very small amounts of trace minerals are
needed, they are just as important as the major minerals. (See
TABLE 5.3 on page 130.)
Sodium
Sodium is necessary for the regulation of blood
volume and blood pressure, fluid balance, transmission of nerve
impulses, heart activity, and certain metabolic functions. It
enhances flavors, acts as a preservative, and tenderizes meats, so
it’s often present in high quantities in the foods we eat. A common misconception is that table salt and sodium are the same
thing: Table salt is a compound containing both sodium and
chloride. It accounts for only 15 percent of our sodium intake.
The majority of sodium in our diet comes from processed foods
that are infused with sodium to enhance flavor and for preservation. Pickles, fast foods, salty
snacks, processed cheeses,
minerals Inorganic, indestruccanned
and
dehydrated
tible elements that aid physisoups, frozen dinners, many
ological processes and build
body structures.
breads and bakery products,
128 | PART TWO | Building Healthy Lifestyles
Sources: K. T. Khaw et al., “Randomised Trial of
Coconut Oil, Olive Oil or Butter on Blood Lipids
and Other Cardiovascular Risk Factors in
Healthy Men and Women,” BMJ Open 8, no. 3
(March 6, 2018): e020167; R. S. Nagashree et
al., “Effect of a Diet Enriched with Fresh Coconut
­Saturated Fats on Plasma Lipids and Erythrocyte
Fatty Acid Composition in Normal Adults,” Journal
of the American College of Nutrition 36, no. 5
(July 2017): 330–4; F. M. Sacks et al., “Dietary
Fats and Cardiovascular Disease. A Presidential
Advisory from the American Heart Association,”
Circulation 136 (2017): e1–e23; D. D. Wang and
F. B. Hu, “Dietary Fat and Risk of Cardiovascular
Disease: Recent Controversies and Advances,”
Annual Review of Nutrition 37 (2017): 423–46, DOI:
10.1146/annurev-nutr-071816-064614.
and smoked meats and sausages often contain several hundred
milligrams of sodium per serving.
The AI for sodium is just 1,500 milligrams, which is about
0.65 teaspoon.23 The 2015–2020 Dietary Guidelines for Americans suggest keeping your sodium intake below 2,300 mg/day.
Unfortunately, 89 percent of Americans exceed this limit.24
Why is high sodium intake a concern? Salt-sensitive individuals respond to a high-sodium diet with an increase in
blood pressure (hypertension), which contributes to heart
disease and stroke. Although the cause of most cases of hypertension is unknown, lowering sodium intake reduces the risk.
See the MAKING CHANGES TODAY box on page 131 for tips on
how to reduce your sodium intake.
Calcium
Calcium is the primary Mineral component
of bones and teeth. It is also essential for muscle contraction, nerve impulse transmission, blood clotting, and acid–
base balance. The issue of calcium consumption has gained
national attention with the rising incidence of osteoporosis
among older adults. Calcium is an underconsumed “nutrient
TABLE 5.2 | A Guide to Vitamins
Vitamin Name
Primary Functions
Recommended Intake
Reliable Food Sources
Thiamin
Carbohydrate and protein
metabolism
Men: 1.2 mg/day
Pork, fortified cereals, enriched
rice and pasta, peas, tuna,
legumes
Carbohydrate and fat
metabolism
Men: 1.3 mg/day
Carbohydrate and fat
metabolism
Men: 16 mg/day
Vitamin B6
Carbohydrate and amino acid
metabolism
Men and women aged 19–50:
1.3 mg/day
Garbanzo beans, meat/fish/
poultry, fortified cereals, white
potatoes
Folate
Amino acid metabolism and
DNA synthesis
Men: 400 μg/day
Fortified cereals, enriched
breads and grains, spinach,
legumes, liver
Formation of blood cells and
nervous system
Men: 2.4 μg/day
Fat metabolism
Men: 5 mg/day
Riboflavin
Niacin
Vitamin B12
Pantothenic acid
Women: 1.1 mg/day
Women: 1.1 mg/day
Women: 14 mg/day
Women: 400 μg/day
Women: 2.4 μg/day
Beef liver, shrimp, dairy foods,
fortified cereals, enriched breads
and grains
Meat/fish/poultry, fortified
cereals, enriched breads and
grains, canned tomato products
Shellfish, all cuts of meat/fish/
poultry, dairy foods, fortified
cereals
Women: 5 mg/day
Meat/fish/poultry, shiitake
mushrooms, fortified cereals,
egg yolks
Carbohydrate, fat, and protein
metabolism
Men: 30 μg/day
Nuts, egg yolks
Collagen synthesis, iron
absorption, and promotes
healing
Men: 90 mg/day
Immune function; maintains
epithelial cells, healthy bones
and vision
Men: 900 μg
Vitamin D
Promotes calcium absorption
and healthy bones
Adults aged 19–70: 15 μg/day
(600 IU/day)
Canned salmon and mackerel,
milk, fortified cereals
Vitamin E
Protects cell membranes and
acts as a powerful antioxidant
Men: 15 mg/day
Sunflower seeds, almonds,
vegetable oils, fortified cereals
Blood coagulation and bone
metabolism
Men: 120 μg/day
Biotin
Vitamin C
Vitamin A
Vitamin K
Women: 30 μg/day
Women: 75 mg/day
Smokers: 35 mg more per day
than RDA
Women: 700 μg
Sweet peppers, citrus fruits and
juices, broccoli, strawberries,
kiwi
Beef and chicken liver, egg
yolks, milk
Carotenoids found in spinach,
carrots, mango, apricots,
cantaloupe, pumpkin, yams
Women: 15 mg/day
Women: 90 μg/day
Kale, spinach, turnip greens,
brussels sprouts
Note: Values are for all adults aged 19 and older, except as noted. Values increase among women who are pregnant or lactating. Data from Food and Nutrition
Board, Institute of Medicine, National Academies, “Dietary Reference Intakes (DRIs): Estimated Average Requirements,” Accessed February 2016, Available at
www.iom.nationalacademies.org/~/media/Files/Activity%20Files/Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf.
of public health concern”; that is, most Americans do not
consume the recommended 1,000–1,300 milligrams of calcium per day.25
Milk is one of the richest sources of dietary calcium.
­Calcium-fortified soy milk is an excellent vegetarian alternative. Many green leafy vegetables are good sources of calcium,
but some contain oxalic acid, which makes their calcium
harder to absorb. Spinach, chard, and beet greens are not particularly good sources, whereas broccoli, cauliflower, kale,
­collard greens, and many peas and beans are rich in absorbable
calcium.
It is generally best to consume calcium-rich foods and
fluids throughout the day, with foods containing protein,
vitamin D, and vitamin C for optimal absorption. Many
dairy products are both excellent sources of calcium and
fortified with vitamin D, which assists in calcium absorption. The question of whether or not taking calcium supplements reduces the risk for osteoporosis or bone fractures is
the subject of debate.26 Moreover, supplements are associated
with a variety of adverse effects, including constipation, an
increased risk for kidney stone formation, and cardiovascular
disease.27
CHAPTER 5 | Nutrition: Eating for a Healthier You | 129
TABLE 5.3 | A Guide to Minerals
Mineral Name
Primary Functions
Recommended
Intake
Reliable Food Sources
Sodium
Fluid and acid–base balance;
nerve impulses and muscle
contraction
Adults: 1.5 g/day
Table salt, pickles, most canned
soups, snack foods, luncheon
meats, canned tomato products
Fluid balance; nerve impulses and
muscle contraction
Adults: 4.7 g/day
Phosphorus
ATP, fluid balance, and bone
formation
Adults: 700 mg/day
Milk/cheese/yogurt, soy milk and
tofu, legumes, nuts, poultry
Selenium
Regulates thyroid hormones and
reduces oxidative stress
Adults: 55 μg/day
Seafood, milk, whole grains, and
eggs
Calcium
Part of bone; muscle contraction,
acid–base balance, and nerve
transmission
Adults: 1,000 mg/day
Milk/yogurt/cheese, sardines,
collard greens and spinach,
calcium-fortified juices
Magnesium
Part of bone; muscle contraction
Men: 400–420 mg/day
Spinach, kale, collard greens,
whole grains, seeds, nuts, legumes
Potassium
(1,500 mg/day)
(4,700 mg/day)
Women: 310–320
mg/day
Most fresh fruits and vegetables:
potato, banana, tomato juice,
orange juice, melon
Iodine
Synthesis of thyroid hormones
Adults: 150 μg/day
Iodized salt, saltwater seafood
Iron
Part of hemoglobin and myoglobin
Men: 8 mg/day
Meat/fish/poultry, fortified cereals,
legumes
Women: 18 mg/day
Zinc
Immune system function; growth
and sexual maturation
Men: 11 mg/day
Women: 8 mg/day
Meat/fish/poultry, fortified cereals,
legumes
Note: Values are for all adults aged 19 and older. Data from Food and Nutrition Board, Institute of Medicine, National Academies, “Dietary Reference Intakes
(DRIs): Estimated Average Requirements,” Accessed February 2016, Available at www.iom.nationalacademies.org/~/media/Files/Activity%20Files/Nutrition/
DRIs/5_Summary%20Table%20Tables%201-4.pdf.
Iron
Worldwide, iron deficiency is the most common nutrient deficiency, affecting more than 2 billion people, about 30
percent of the world’s population.28 In the United States, iron
deficiency is less prevalent; however, because iron is a key component of red blood cells, deficiency can develop with blood
loss and in menstruating women who fail to maintain a balanced diet. Women aged 19 to 50 need about 18 ­milligrams of
iron per day, and men aged 19 to 50 need about 8 milligrams.29
Iron deficiency can lead to iron-deficiency anemia. Anemia
results from the body’s loss of, or insufficient production of,
healthy red blood cells. Iron is the oxygen-carrying component of a protein called hemoglobin in red blood cells.
When iron-deficiency anemia occurs, blood cells pick up
anemia Condition that results
less oxygen from the lungs,
from the body’s loss or insufand transport less oxygen to
ficient production of healthy red
body tissues, including the
blood cells.
brain. As a result, the ironfunctional foods Foods
believed to have specific health
deficient person feels conbenefits beyond their basic
fused, tired, and weak. Iron is
nutrients.
also important for energy
probiotics Living microormetabolism, DNA synthesis,
ganisms that support human
and other body functions.
health.
130 | PART TWO | Building Healthy Lifestyles
Iron toxicity is typically due to consuming iron supplements. Symptoms of toxicity include nausea, vomiting,
diarrhea, rapid heartbeat, weak pulse, dizziness, shock, and
confusion. Excess iron intake has also been associated with an
increased risk for neurological disorders, including dementia,
as well as cardiovascular disease and cancer.30
Beneficial Non-Nutrient
Components of Foods
Increasingly, nutrition research is focusing on components of
foods that are not nutrients themselves, but interact with
nutrients to promote human health. Foods that may confer
health benefits beyond the nutrients they contribute to the
diet—whole foods, fortified foods, enriched foods, or enhanced
foods—are called functional foods. When functional foods
are included as part of a varied diet, they have the potential to
positively impact health.31
Some of the most popular functional foods today are those
containing probiotics, living microorganisms (microscopic
organisms such as bacteria) that enhance human health. Probiotics colonize the large intestine, where they help complete
digestion and synthesize certain vitamins. They’re also
MAKING CHANGES TODAY
Shake Your Salt Habit
Take simple steps today to reduce your sodium intake:
When buying packaged foods, choose low-sodium or
sodium-free products.
At the movies, order popcorn without salt.
Use kosher salt—it has 25 percent less sodium than
regular table salt.
Avoid adding salt to foods during cooking or at the table;
instead, try using fresh or dried herbs and spices to
­season foods.
thought to reduce the risk for diarrhea and irritable bowel syndrome, and some research suggests they may aid in allergies,
infections, and other disorders.32 Fermented milk products
such as yogurt and kefir, and fermented vegetables such as sauerkraut and kimchi, are rich in probiotics.
Many consumers are also choosing foods high in
­antioxidants. These substances appear to protect against
­oxidative stress, a complex process in which free radicals (atoms
with unpaired electrons) destabilize other atoms and molecules, prompting a chain reaction that can damage cell
membranes, cell proteins, or genetic material in the cells.
Free radical formation occurs as a result of normal cell metabolism. Antioxidants combat it by donating their electrons
to stabilize free radicals; activating enzymes that convert free
radicals to less-damaging substances; or reducing or
repairing the damage they cause. Free radical damage is associated with many chronic diseases, including cardiovascular disease, cancer, age-related vision loss, and other diseases of
aging.
Some antioxidants are nutrients. These include vitamins C
and E, as well as the minerals copper, iron, manganese, selenium,
and zinc. Other potent antioxidants are p
­ hytochemicals, compounds that occur naturally in plants (phyto- means plant) and
are thought to protect them against ultraviolet radiation,
pests, and other threats. Common examples include the
following:
Carotenoids are pigments found in red, orange, and dark
green fruits and vegetables. Beta-carotene, the most researched
carotenoid, is a precursor of vitamin A, meaning that vitamin
A can be produced in the body from beta-carotene. Along with
beta-carotene, other carotenoids, such as lutein, lycopene, and
zeaxanthin, are associated in numerous studies with a reduced
risk for inflammation and oxidative stress linked to chronic
disease.33
Polyphenols, which include a group known as flavonoids,
are the largest class of phytochemicals. They are found in an
Milk is a great source of calcium and other nutrients. If you
don’t like milk or can’t drink it, make sure to get enough
calcium—at least 1,000 milligrams a day—through other
sources.
array of fruits and vegetables as well as soy products, tea, and
chocolate. Like carotenoids, they are thought to have potent
antioxidant properties.34
Although research supporting the health benefits of antioxidant nutrients and phytochemicals is not conclusive,
studies do show that individuals deficient in antioxidant
vitamins and minerals have an increased risk for age-related
diseases, and that antioxidants consumed in whole foods,
mostly fruits and vegetables, may reduce these individuals’
risks.35 In contrast, antioxidants consumed as supplements
do not necessarily confer such a benefit, and multiple studies
suggest they may be harmful, acting as “pro-oxidants” and
increasing the risk of certain cancers and overall mortality
in some populations, such as smokers.36 In contrast, antioxidant nutrient supplements containing a combination of vitamin E, vitamin C, zinc, and beta-carotene have been shown
to reduce the risk of progression of an age-related eye disorder
called macular degeneration.37
LO 2 | NUTRITIONAL GUIDELINES
Explain how the Dietary Guidelines for Americans and the MyPlate
food guidance system can help you follow a healthful eating
pattern.
Americans consume about 900 more calories per day than they
did 50 years ago (see FIGURE 5.5 on page 133).38 When this
trend combines with our increasingly sedentary lifestyle, it is
not surprising that we have seen
a dramatic rise in obesity. Forantioxidants Substances
tunately, the U.S. Department
believed to protect against
oxidative stress and resultant
of Health and Human Services
cell damage.
and the U.S. Department of
phytochemicals
Naturally
Agriculture (USDA) publish two
occurring non-nutrient plant
tools for consumers to make
chemicals believed to have
healthy eating easy: the Dietary
beneficial properties.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 131
Guidelines for Americans and the MyPlate food
guidance system.
Dietary Guidelines
for Americans
The Dietary Guidelines for
Americans (DGAs) are recommendations for eating a
healthy, nutritionally adequate
diet. They are revised every 5 years.
The most recent, the 2015–2020 Dietary Guidelines for Americans, include the following five key guidelines.39
1. Follow a healthy eating pattern across the lifespan. An
eating pattern is the totality of what you habitually eat
and drink. Following a healthful eating pattern requires
you to recognize that every food and beverage choice
you make throughout the day can positively influence
your health, providing nutrients and fiber at an appropriate calorie level to help you achieve and maintain a
healthy body weight, and reduce your risk for chronic
disease. The DGAs identify the following components of
a healthful eating pattern:
A variety of vegetables of different types and colors,
from leafy green to red, orange, and yellow, plus
legumes (beans, peas, and lentils)
■■ Fruits, especially whole fruits
■■ Grains, at least half of which are whole grains
■■ Fat-free or low-fat dairy choices, including milk,
cheese, yogurt, and/or fortified soy milk
■■ A variety of lean-protein foods, including seafood,
lean meats and poultry, eggs, legumes, soy products,
and nuts and seeds
■■ Oils
A healthful eating pattern
SEE IT! VIDEOS
should be accompanied
Cut back on sugar while
by regular physical activity.
satisfying your sweet tooth!
The DGAs advise at least
Watch Ditching Sugar,
150 minutes of physical
available on
activity each week, along
Mastering Health.
with muscle-strengthening
■■
­exercise on 2 or more days each
week. For more information
on improving your physical fitBlueberries are
ness, see Chapter 7.
a great source of
antioxidants.
2. Focus on variety, nutrient
density, and amount. To meet
your nutrient needs, yet stay
within your budget of calories,
choose the most nutrient-dense
versions of foods within all food
groups. Nutrient-dense foods provide
a relatively high level of nutrients and fiber
for a relatively low number of calories. For example, a
slice of whole-grain toast with peanut butter provides
healthful unsaturated fats, protein, and fiber-rich carbohydrates, as well as vitamins and minerals, for about
300 calories, whereas another
breakfast choice, a plain waffle with butter and
maple syrup, provides little more than refined carbohydrates, saturated fats, and added sugars, for about
400 calories. The toast with peanut butter is also more
filling, so you won’t be as likely to feel hungry as
quickly.
3. Limit calories from added sugars and saturated fats,
and reduce sodium intake. Specifically, the DGAs advise
you to:
Consume less than 10 percent of calories per day
from added sugars. This means avoiding sugary
drinks such as soft drinks, energy drinks, flavored
milks, and specialty coffees, and making candy,
cookies, ice cream, and other desserts occasional
treats.
■■ Consume less than 10 percent of calories per day from
saturated fats. Limiting your intake of animal-based
foods such as fatty meats, cheese, and ice cream will
help you meet this goal.
■■ Consume less than 2,300 mg per day of sodium.
Review the MAKING CHANGES TODAY box on
page 131 for tips on how.
■■ If alcohol is consumed, it should be consumed in
moderation—up to one drink per day for adult
women and two drinks per day for adult men.
For more information, see Chapter 11.
■■
4. Shift to healthier food and beverage choices. Choose
58%
of Americans FAIL TO MEET the DGA
recommendation for added sugar
intake, consuming, on average, 25.1
teaspoons (420 calories) of added
sugars each day.
132 | PART TWO | Building Healthy Lifestyles
nutrient-dense foods and beverages across and within
all food groups in place of less healthy choices. For
example, more than three-fourths of Americans
consume a diet that is low in vegetables, fruits, dairy,
and healthful fish and plant oils. The DGAs recommend you shift your intake of these foods upward, by
replacing snack foods like chips and cheese curls with
raw veggies; meat-based entrées with fish and legumes;
sugary drinks with milk or soy milk; and desserts high
in added sugars, like cookies and brownies, with whole
fruits.
2010
MyPlate Food Guidance System
388 g
474 g
To help consumers understand and implement the Dietary
Guidelines, the USDA has developed an easy-to-follow graphic
and Web-based guidance system called MyPlate, which can
be found at www.choosemyplate.gov and is illustrated in
F
­ IGURE 5.6 on page 134. The MyPlate food guidance system takes
into consideration the dietary and caloric needs for a wide variety
of individuals, such as pregnant or breastfeeding women, those
trying to lose weight, and adults with different activity levels. The
interactive website can create personalized dietary and exercise
recommendations based on the individual information you enter.
MyPlate’s key messages, which support the Dietary Guidelines, include the following:
19 g
25 g
92 g
120 g
53 g
59 g
470 mg
460 mg
1960
Carbohydrates
Dietary fiber
Protein
Saturated fat
Cholesterol
FIGURE 5.5 Trends in Per Capita Nutrient
Consumption Since 1960, Americans have increased
their daily caloric intake from 3,100 to 4,000 and their daily
consumption of carbohydrates, protein, and saturated fat.
Source: Data are from the USDA Center for Nutrition Policy and Promotion,
www.ers.usda.gov/data-products/food-availability-(per-capita)-data-system/
.aspx#26715, Accessed April 5, 2018.
Eat nutrient-dense foods. While eating the recommended
number of servings from MyPlate, make the most nutrientdense choices within a given food group. Again, these are
foods and beverages that have a high nutritional value for
their caloric content.
■■ Eat seafood twice a week. Replace red meat or poultry
with grilled, broiled, or baked seafood twice a week. In addition to salmon, tuna, and other fatty fin fish, clams, mussels, oysters, and calamari are all high in omega-3 fatty acids.
■■ Avoid empty calories. MyPlate refers to calories from added
sugars and saturated fats as empty calories. Here are some
examples of empty-calorie foods:
●● Sausages, hot dogs, bacon, and ribs. Adding a sausage
link to your breakfast adds 96 empty calories.
●● Cheese. Switching from whole-milk to nonfat mozzarella, for example, saves you 76 empty calories per
ounce.
●● Refined grains, including crackers, bagels, and white
rice. Switching to whole-grain versions can save you 25
or more empty calories per serving.
●● Cakes, cookies, pastries, and ice cream. Approximately
75 percent of the calories in a serving of ice cream are
empty calories.
●● Wine, beer, and all alcoholic beverages. A whopping
155 empty calories are consumed with each 12 fluid
ounces of beer.
■■ Engage in physical activity. Any activity that gets your
heart pumping counts, including walking on campus, playing basketball, and dancing. MyPlate offers personalized
recommendations for weekly physical activity. (For more
on physical fitness, see Chapter 7.)
■■
5. Support healthy eating patterns for all. The DGAs
affirm that everyone has a role in helping to create and
support healthy eating patterns wherever we are, from
home to campus to work to within our communities.
Citing the social-ecological model of health, the DGAs
point out that each of your choices—while shopping,
eating out, standing in line at your campus dining hall,
or cooking for friends—can promote the availability of
healthy foods aligned with the Dietary Guidelines.
You can also encourage others to join you in physical
activity.
LO 3 | HOW CAN I EAT MORE
HEALTHFULLY?
Discuss strategies for healthful eating, including how to read food
labels, the role of vegetarian diets and dietary supplements, how to
eat mindfully, and how to choose healthful foods on and off campus.
Whether you follow a vegetarian diet, eat only organic foods,
take dietary supplements, or choose to eat locally grown foods,
CHAPTER 5 | Nutrition: Eating for a Healthier You | 133
Label Claims Sometimes, food labels contain claims
about the product’s content or effects. The FDA allows
three types of claims on the packages of foods and dietary
supplements:40
Health claims describe a relationship between a food and
a health effect, but no food label is allowed to claim that
a food can treat or cure a disease. FDA-approved health
claims are supported by current scientific evidence and
meet the standard for significant scientific agreement (SSA)
among experts. For example, an approved health claim
on a package of whole-grain bread may state, “In a low-fat
diet, whole-grain foods like this bread may reduce the risk
of heart disease.”
■■ Nutrient content claims indicate a specific nutrient is present at a certain level. For example, a product label might
say “High in fiber” or “Low in fat.” Nutrient content claims
can use the following words: more, less, fewer, good source of,
free, light, lean, extra lean, high, low, reduced. The claims are
strictly regulated and reflect the nutrient data on the Nutrition Facts label.
■■ Structure and function claims describe the effect that
a component in the food product has on the body. For
example, the label of a carton of milk is allowed to state,
“Calcium builds strong bones.” Be aware that the FDA does
not regulate structure-function claims.
■■
FIGURE 5.6 The MyPlate System The USDA
MyPlate food guidance system takes a new approach
to dietary and exercise recommendations. Each colored
section of the plate represents a food group, and an
interactive tool at www.choosemyplate.gov helps you
analyze and track your foods and physical activity and
provides helpful tips to personalize your plans.
Source: U.S. Department of Agriculture, 2018, www.choosemyplate.gov.
there are ways to improve the nutrient density of your meals.
Let’s begin with how to read a food label.
Read Food Labels
How do you know what nutrients are in the packaged food
you’re thinking of buying? Or how much of the food is a
serving size, or whether one brand is more nutritious than
another? The answers are on the label.
Nutrition Facts Label To help consumers evaluate
the nutritional values of packaged foods, the FDA and the
USDA developed the Nutrition Facts label that is typically displayed on the side or back of packaged foods. One of the most
helpful items on the label is the % Daily Values (%DVs) list,
which tells you how much of an average adult’s allowance for a
particular substance (protein, fiber, calcium, etc.) is provided
by a serving of the food. The %DV is calculated based on a
2,000-calorie-per-day diet, so your values may be different
from those listed. The label also includes information on the
serving size and calories. In 2016, the FDA released a new label
intended to be more helpful for consumers. Most food companies are required to use it by 2020. It identifies the calories per
serving in much larger type,
and uses a serving size that
% Daily Values (%DVs)
­Percentages on food and
better reflects the amount of
supplement labels ­identifying
the food that people typically
how much of each listed
FIGURE 5.7 walks you
eat. ­
nutrient or other substance a
through the former and new
serving of food contributes to a
2,000 calorie/day diet.
Nutrition Facts labels.
134 | PART TWO | Building Healthy Lifestyles
In addition to food labels, shoppers are increasingly being
guided in their food choices by nutritional rating systems.
What are these systems, and can they help you make smarter
choices? See the ­STUDENT HEALTH TODAY box on page 136
for answers.
Front of Package Labeling
The FDA requires
several types of information on the front of food labels. These
include the name of the food, the manufacturer or distributor, the ingredients, and the
SEE IT! VIDEOS
net weight of the food. Other
Are whole-grain product
aspects of the labeling on the
labels telling the truth?
front of packages are unreguWatch Grain Labels Do
lated and may cause confusion
Not Reflect “Whole”
for consumers.
Truth, available on
The Facts Up Front initiative is
Mastering Health.
a voluntary labeling system that
can be used by manufacturers
to provide quick, accurate information on the front of the food
package. As shown in FIGURE 5.8, Facts Up Front identifies the
calories, saturated fat, sodium, and added sugars per serving. It
also lists the amount and %DV of other “encouraged” micronutrients, such as potassium, that are underconsumed by Americans, if a serving of the food contains more than 10 percent.
Understand Serving Sizes MyPlate presents personalized dietary recommendations based on servings from
the five food groups. But how much is one serving? Is it different from a portion? Although these two terms are often used
interchangeably, they mean very different things. A serving is
Sample Label for Macaroni and Cheese
Start here. Serving sizes
are standardized to make
shopping easier.
Calories per serving and
the number of servings
are listed on the label.
Original Label
New Label
Nutrition Facts
Nutrition Facts
Serving size 2/3 cup (55g)
Servings Per Container About 8
8 servings per container
Serving size
Amount Per Serving
Calories 230
Calories from Fat 40
Total Fat 8g
Saturated Fat 1g
% Daily Value*
12%
5%
Trans Fat 0g
% Daily Values tell you if
the food is high or low in a
nutrient based on a 2,000
calorie diet.
Cholesterol 0mg
0%
7%
12%
16%
Sodium 160mg
Total Carbohydrate 37g
Dietary Fiber 4g
Sugars 1g
Protein 3g
Vitamin A, vitamin C,
calcium, and iron are
required on the label.
Other vitamins and
minerals are voluntary.
Vitamin A
10%
Vitamin C
Calcium
Iron
8%
20%
45%
* Percent Daily Values are based on a 2,000 calorie diet.
Your Daily Values may be higher or lower depending on
your calorie needs:
Calories:
2,000
2,500
Total Fat
Less than
65g
80g
Sat Fat
Less than
20g
25g
Cholesterol
Less than
300mg
300mg
Sodium
Less than
2,400mg 2,400mg
Total Carbohydrate
300g
375g
Dietary Fiber
25g
30g
FIGURE 5.7
2/3 cup (55g)
230
Amount Per serving
Calories
Total Fat 8g
Saturated Fat 1g
New labels have bolder and
larger type for serving sizes.
Calories from fat is removed.
% Daily Value*
10%
5%
Trans Fat 0g
Cholesterol 0mg
Sodium 160mg
Total Carbohydrate 37g
Dietary Fiber 4g
Sugars 12g
Includes 10g Added Sugars
0%
7%
13%
14%
20%
Protein 3g
Vitamin D 2mcg
10%
Calcium 260mg
Iron 8mg
Potassium 235mg
20%
45%
6%
% Daily Values are listed
first and explained in a
new detailed footnote.
Added Sugars are listed
separately.
Vitamin D, calcium, iron, and
potassium are required.
Other vitamins and minerals
are voluntary.
* The % Daily Value (DV) tells you how much a nutrient in
a serving of food contributes to a daily diet. 2,000 calories
a day is used for general nutrition advice.
Reading a Food Label
Source: U.S. Food and Drug Administration, “Changes to the Nutrition Facts Label,” Accessed March 15,
2018, www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Labeling
Nutrition/ucm385663.htm.
PER 1 CUP SERVING
140 SAT1gFAT 410
mg
5g 1000mg VITAMIN
A
SODIUM SUGARS POTASSIUM
CALORIES
5% DV
17% DV
29% DV
20% DV
FIGURE 5.8 Facts Up Front Information is placed on the
front of the package for a quick and accurate nutritional profile
of a serving of the food.
the recommended amount you should consume, and it’s found
on the Nutrition Facts label. A portion is the amount you choose
to eat at any one time. Most of us consume portions that are
much bigger than recommended servings. If a food label says
that a serving size of 1 cup is 250 calories, but you eat a portion of
1.5 cups, you’ve consumed 375 calories. See FIGURE 5.9 on page
137 for a handy pocket guide with tips on recognizing serving
sizes.
Even when we read the label, we don’t always get a clear idea
of what a serving of that product really is. Consider a bottle of
chocolate milk: The label may list one serving size as 8 fluid
ounces and 150 calories. But if the bottle holds 16 ounces, drinking the whole thing will serve up 300 calories.
Vegetarianism:
A Healthy
Diet?
Watch Video Tutor:
Understanding Food Labels
WHAT DO
YOU THINK?
Why are so many
The word vegetarian means
people becoming
different things to different
vegetarians?
people. Strict vegetarians,
■■ How easy is it to be a
or vegans, avoid all foods of
vegetarian on your campus?
animal origin, including
■■ What concerns about
dairy products and eggs.
vegetarianism do you have,
Their diet includes legumes
if any?
and
other
vegetables,
grains, fruits, nuts, and seeds. Far more common are lactovegetarians, who eat dairy products but avoid flesh foods and
eggs. Ovo-vegetarians add eggs to a vegan diet, and lacto-ovovegetarians eat both dairy products and eggs. Pesco-vegetarians
eat fish, dairy products, and eggs, and semi-vegetarians might
eat chicken as well.
According to a poll conducted by the Vegetarian Resource
Group, 3.3 percent of U.S. adults, approximately 8 million adults,
are vegetarians, and about half of these people are vegans.41
Among young adults (ages 18 to 34), 5.3 percent are vegetarian.42
Common reasons for pursuing a vegetarian lifestyle include
concern for animal welfare, the environmental costs of meat
CHAPTER 5 | Nutrition: Eating for a Healthier You | 135
STUDENT
HEALTH TODAY
Nutrition Rating Systems
N
ext time you’re at the
grocery store, take a
close look at the tags on the
store shelves. Do you see
anything different—stars, perhaps, or numbers inside blue
hexagons? If so, you’re looking at a nutrition rating system
designed to help you quickly
locate healthful foods. Four
of the most popular systems
in American markets are the
following:
Guiding Stars. This system rates the nutritional
quality of foods using
zero to three stars, with
three indicating the highest nutritional quality. A
fresh tomato, for example,
gets three stars. What the
system lacks in subtlety it
makes up for in simplicity. Even consumers who haven’t been
introduced to it can quickly understand
the basic message behind it: The product with the most stars “wins.”
■■ NuVal. The NuVal System uses a scale
of 1 to 100. The higher the number, the
higher the nutritional quality. In rating
each food, the system considers more
than 30 dietary components—not just
nutrients, but fiber and phytochemicals, too. In this system, a tomato gets
a top score of 100 points. The 100point rating scale allows consumers to
make more subtle distinctions between
very similar foods. For example, if two
brands of whole-grain bread get scores
of 48 and 29, the bread with the higher
score is lower in calories and sodium
and higher in fiber.
■■ American Heart Association (AHA)
Heart Check. The AHA Heart Check
identifies foods that promote good
heart health. To receive a Heart Check
■■
136 | PART TWO | Building Healthy Lifestyles
rating, the food must meet specific criteria for levels of saturated fat, sodium,
and other nutrients. Each serving must
also contain 10 percent or more of the
daily value for dietary fiber or at least
one of the following nutrients: protein,
vitamin A, vitamin C, iron, or calcium.
■■ Aggregate Nutrient Density
Index (ANDI). This index ranks
foods according to the number of
micronutrients per calorie and takes
into account as many known beneficial
phytochemicals as possible. However,
it does not consider macronutrient
density, such as the amount of highquality protein or essential fatty acids in
the food. A top score is 1,000. How does
this system rate our tomato? It gets just
164 points! In contrast, kale gets a top
score of 1,000. Here’s why: A mediumsized tomato and two-thirds of a cup
of kale have about the same number of
calories, but the kale has more vitamin
C, calcium, and beta-carotene.
Do these ranking systems prompt
shoppers to choose more healthful foods?
Research suggests that they might. A
recent study that followed shoppers in
three supermarkets implementing a ranking system found small but meaningful
changes in the foods purchased, such as
an increase in purchases of foods high
in fiber and low in sugars. Another study
in 150 markets found that the systems
may be most effective in discouraging
unhealthful choices. Sales of less nutritious foods fell by as much as 31 percent,
resulting in an average purchase of more
nutritious foods overall.
Sources: E. Hobin et al., “Consumers’ Response
to an On-Shelf Nutrition Labelling System in Supermarkets: Evidence to Inform Policy and Practice,”
The Milbank Quarterly 95, no. 3 (September 2017):
494–534; E. Finkelstein, et al. “Identifying the effect
of shelf nutrition labels on consumer purchases:
results of a natural experiment and consumer
survey. The American Journal of Clinical Nutrition,
Volume 107, Issue 4, 1 April 2018, Pages 647–651.
1 Serving Looks Like . . .
Grain Products
1 cup of cereal flakes = fist
1 pancake =
flat hand
1 Serving Looks Like . . .
Vegetables and Fruit
2 cups of salad
greens = two fists
1 baked potato = fist
1/2 cup of cooked rice,
pasta, or potato =
handful
1 slice of bread =
flat hand
1 piece of cornbread
= flat hand
1 Serving Looks Like . . .
Dairy and Cheese
1 medium fruit = fist
1 cup of fresh
fruit = fist
1/4 cup of raisins
= two thumbs
1 Serving Looks Like . . .
Meat and Alternatives
11/2 oz cheese =
pointed finger
3 oz meat, fish,
and poultry =
palm
1/2 cup of ice cream =
3 oz grilled or
baked fish =
palm
handful
Fats
1 Tbsp margarine or
spreads = thumb
2 Tbsp peanut
butter = two thumbs
FIGURE 5.9 Serving-Size Card One of the challenges of
following a healthy diet is judging how much food constitutes
a serving. The comparisons on this card can help. For easy
reference, photocopy or cut out the card, fold on the dotted
lines, and keep it in your wallet. You can even laminate it for
long-term use.
Sources: National Heart, Lung and Blood Institute, “Serving Size
Card,” Accessed April 2018, www.nhlbi.nih.gov/health/educational/
wecan/downloads/servingcard7.pdf; National Dairy Council, “ServingSize Chart,” Accessed April 2018, www.healthyeating.org/Portals/0/
Documents/Schools/Parent%20Ed/Portion_Sizes_Serving_Chart.pdf?
ver=2017-08-31-150411-207.
production, food safety, personal health, weight loss, and
weight maintenance. Generally, people who follow a balanced
vegetarian diet weigh less and have better cholesterol levels,
fewer problems with constipation and diarrhea, and a lower
risk of heart disease than do nonvegetarians. A recent study
found that people who follow a vegetarian diet reduce their
risk of diabetes by 50 percent, of heart attack by 40 percent,
and of stroke by nearly 30 percent.43 The Academy of Nutrition and Dietetics supports vegetarian diets as appropriate for
A vegetarian diet can be a very healthy way to eat. Make sure
you get complementary essential amino acids throughout the
day. Meals like this tofu and vegetable stir-fry can be further
enhanced by adding a whole grain, such as brown rice.
people of all ages, including athletes, and cites their benefits in
reducing the risks for obesity, diabetes, heart disease, and some
types of cancer.44
Vegetarianism requires careful meal planning to ensure
proper nutrient intake. Vegan diets are of greater concern than
diets that include dairy products and eggs. Vegans may be deficient in vitamins B2 (riboflavin), B12, and D, as well as calcium,
iron, and zinc; however, many foods are fortified with these
nutrients, or vegans can obtain them from a multivitamin/mineral supplement. Eating a variety of plant foods throughout the
day will provide adequate protein. Seek advice from a registered
dietitian nutritionist (RDN) if you have questions about adopting or maintaining a vegetarian diet.
Supplements: Research on the
Daily Dose
Dietary supplements are products containing one or more
dietary ingredients taken by mouth and intended to supplement
existing diets. Ingredients range from nutrients and herbs to
enzymes and hormones. They can come in tablet, capsule, liquid, powder, and other forms. A majority of Americans—76
percent—take at least one dietary supplement.45 Among supplements users, 96 percent take vitamin/mineral supplements.46
It is important to note that dietary supplements are not
regulated like foods or drugs. The
FDA does not evaluate the safety
vegetarian A person who
and efficacy of supplements prior
follows a diet that excludes
to their marketing, and it can
some or all animal products.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 137
take action to remove a supplement from the market only
after the product has been
proved harmful. Currently,
the United States has no formal guidelines for supplement
mindful eating Eating with
marketing and safety, and
a focused awareness of the
supplement
manufacturers
sensations experienced and
are
responsible
for self-monithe way the food affects your
toring the safety and effectivebody, feelings, and mind.
ness of their products.
Do you really need to take dietary supplements? A recent
consensus statement of international experts agreed that use
of multivitamin/mineral supplements is safe for most adults,
but there is no evidence that they reduce the risk for chronic
disease.47 The U.S. Preventive Services Task Force concluded
that there is insufficient evidence to recommend that healthy
people take multivitamin/mineral supplements to prevent
cardiovascular disease or cancer.48 Those who may benefit
from using multivitamin/mineral supplements include pregnant and breastfeeding women, older adults, vegans, people
on a very-low-calorie weight-loss diet, individuals dependent
on alcohol, and patients with significant health problems.
However, many dietary supplements are unproven. The benefit of fish consumption in reducing the risk for cardiovascular disease is well established, for example, but studies have
yielded conflicting results about fish-oil supplements.49
As noted earlier in this chapter, taking high-dose supplements of the fat-soluble vitamins, especially vitamin A, can be
harmful or even fatal. You should also be aware that supplements can interact with certain medications, including aspirin,
diuretics, and steroids, resulting in potential problems. Moreover, supplements often do not contain the ingredients listed on
the label; for instance, the New York State Office of the Attorney
General required several national supplements retailers to cease
selling a variety of herbal supplements found to entirely lack the
ingredients indicated on the label and to be contaminated with
plant products not identified on the label. Only 4 percent of the
supplements tested from Walmart stores, for example, had DNA
matching the plants identified on the ingredients list.50
If you do decide to take dietary supplements, choose brands
that contain the U.S. Pharmacopeia (USP) Verified Mark or
the Consumer Lab seal. This ensures that the supplement is
free of toxic ingredients and contains the ingredients stated
on the label. Store your supplements in a dark, dry place (not
dietary supplements
Products taken by mouth and
containing dietary ingredients
such as vitamins and minerals
that are intended to supplement existing diets.
4.6%
ONLY
of college students EAT THE
RECOMMENDED five or more
servings of fruits and vegetables a day.
138 | PART TWO | Building Healthy Lifestyles
Meals like this may be convenient, but they are high in
saturated fat, sodium, and calories. Even when you are
short on time and money, it is possible—and worthwhile—
to make healthier choices. If you are ordering fast food, ask
for lean meat, poultry, fish, or a vegetarian option prepared
by grilling, baking, or roasting, not frying.
the bathroom or other damp spots), make sure they are out of
reach of small children, and check the expiration date.
Eating Well in College
Many college students find it hard to fit a well-balanced
breakfast into their
morning routine,
SEE IT! VIDEOS
but breakfast is an
How accurate are restaurant calorie
important meal if
counts? Watch Menu Calorie Counts,
you are to get the
available on Mastering Health.
most out of your
classes.
Choose
fiber-rich carbohydrates, protein, and healthy unsaturated
fat, such as a bowl of oatmeal topped with fruit and nuts, or
a sandwich made with banana, peanut butter, and wholegrain bread. If you’re short on time, bring a container of
plain yogurt and a handful of almonds to your morning
class.
Try to avoid eating mindlessly while studying or catching up on your social network sites. A slower, more thoughtful, and focused way of consuming food, known as mindful
eating, can help you get more pleasure out of eating, avoid
overeating, and make more healthful food and beverage
choices. For more on mindful eating, see the MINDFULNESS
AND YOU box.
If your campus is like many others, your lunchtime options
include a variety of fast-food restaurants. Generally speaking,
you can eat more healthfully and for less money if you bring
food from home or eat at your campus dining hall. If you must
eat fast food, follow the tips below to get more nutritional
bang for your buck:
■■
Ask for nutritional analyses of menu items. The FDA
requires that most restaurants provide calorie and other
nutritional information on menus or menu boards. Read,
compare, and make the most nutrient-dense choices.
MINDFULNESS
AND YOU
Mindful Eating
D
o you ever eat meals while standing
at the counter, sitting in front of your
computer or TV, or parked in your car?
Eating this way interferes with your body’s
ability to feel hunger, stop when full, or
enjoy food. This in turn makes it easy to
eat too fast, not recognize fullness, overeat and gain weight. In contrast, mindful
eating—a slower, more intentional way of
eating without distractions—may reduce
body weight and improve food choices.
Mindful eating isn’t just filling up the gas
tank—something to do as quickly as possible. It’s an opportunity to get to know
yourself, what you enjoy, and what your
body is telling you.
To eat mindfully, follow these simple
steps:
■■ Eat at the table. Food eaten at the
table is often more nutritious and is
■■
■■
■■
■■
eaten more slowly. When you eat food
in the car or between classes, you
tend to eat quickly and often simply
to satisfy hunger.
Make food the main focus. Notice the
colors, smells, flavors, and textures of
your food. Get rid of distractions such
as smartphones, tablets, or television
while eating.
Slow eating down. When you sit down
to eat, set a timer for 20 minutes. Serve
foods that take longer to eat, such as
soups or salads; take small bites; and
chew slowly.
Choose food you enjoy. Plan meals
that are colorful, satisfying, and nourishing, and use all your senses as you eat.
Eat until you are satisfied and then
stop. Become aware of your own cues
for when to begin eating and when
to stop.
Order salads, but be careful about what you add to them.
Taco salads and Cobb salads are often high in fat, calories,
and sodium. Ask for low-fat dressing on the side, and use it
sparingly. Stay away from high-fat add-ons, such as bacon
bits, croutons, and crispy noodles.
■■ If you crave french fries, try baked “fries,” which are
­typically low in saturated fat.
■■ Avoid large portion sizes. At one national chain, a large
burger, fries, and cola add up to 1,320 calories, whereas
a small burger, fries, and water total 470 calories—a
­difference of 850 calories!
■■ At Asian restaurants, avoid meats and vegetables ­swimming
in sauces high in sugar and sodium. Also find out the sodium
content of ramen, miso soup, and other dishes and ask if
lower-sodium versions are available.
■■ At Mexican restaurants, order chicken or bean burritos or
enchiladas, instead of beef, and ask that they be prepared
with less cheese. Or order veggie fajitas with beans and
rice for a meal high in plant protein and low in
saturated fat.
DO IT! NUTRITOOLS
■ Out for pizza? You
Ever wondered how your favorite
guessed it: Order a
meal stacks up, nutrition-wise?
veggie pizza with a
Complete the Build a Meal, Build
whole-grain crust and
a Salad, Build a Pizza, and Build
request that it be prea Sandwich activities, available on
pared with less cheese
Mastering Health.
or low-fat cheese.
■■
Start slowly to begin the practice of
mindful eating and self-compassion.
Begin with just one meal a day or one
per week to eat in a more attentive
manner, as old eating habits may be
difficult to change.
Sources: M. Mantzios et al., “How Does Grazing
Relate to Body Mass Index, Self-Compassion,
Mindfulness and Mindful Eating in a Student
Population?” Health Psychology Open 5, no. 1
(March 8, 2018): 2055102918762701; E. Forman
et al., “Mindful Decision Making and Inhibitory
Control Training as Complementary Means to
Decrease Snack Consumption,” Appetite 103
(2016): 176–83; M. Mantzios and J. C. Wilson,
“Mindfulness, Eating Behaviours, and Obesity:
A Review and Reflection on Current Findings,”
Current Obesity Reports 4, no. 1 (2015): 141–46;
C. Dawn et al., “Impact of Non-Diet Approaches
on Attitudes, Behaviors, and Health Outcomes:
A Systematic Review,” Journal of Nutrition
Education and Behavior 47, no. 2 (2015):
143–55.
Wherever you dine, refrain from ordering extra sauce,
bacon, cheese, and other toppings that add calories, saturated fat, and sodium.
■■ Limit sodas, shakes, and other beverages high in added
sugars.
■■ If you typically order a burger, sandwich, or wrap with
beef, swap for a chicken, turkey, fish, or vegetarian
version.
■■
In the dining hall, try these ideas:
Choose lean meats, grilled chicken, fish, or vegetable
dishes. Avoid fried chicken, fatty cuts of red meat, or meat
dishes smothered in cream sauce.
■■ Hit the salad bar and load up on leafy greens, beans, tuna,
or tofu. Choose items such as avocado or nuts for “good”
fat. Go easy on the dressing.
■ Choose pasta dishes with vegetables (primavera) or with
marinara (tomato) sauce rather than alfredo (cream) sauce
or macaroni and cheese.
■■ Look for beans or lentils over brown rice with a variety of
vegetables. Add a sprinkle of nuts or seeds for extra
protein.
■■ Build yourself a veggie taco or burrito using beans,
­vegetables, and some shredded cheese.
■■ When choosing items from a made-to-order food station,
ask the preparer to hold the butter or oil, mayonnaise, sour
cream, or cheese- or cream-based sauces.
■■
CHAPTER 5 | Nutrition: Eating for a Healthier You | 139
organic Grown without use of
toxic and persistent pesticides,
chemicals, or hormones.
■ Avoid going back for sec-
onds and consuming large
portions.
■ If there is something you’d
locavore A person who
like but don’t see in your
primarily eats food grown or
­dining hall, speak to your
produced locally.
food service manager and
provide suggestions.
■■ Pass on foods high in added sugars and saturated fats,
such as sugary cereals, ice cream, and other sweet treats.
Choose fruit with plain yogurt to satisfy your sweet tooth.
Between classes, avoid vending machines. Reach into your
backpack for an apple, banana, some dried fruit and nuts,
a single serving of unsweetened applesauce, or whole-grain
crackers spread with peanut butter. Energy bars can be a nutritious option if you choose right. Check the Nutrition Facts label
for bars that are below 200 calories and provide at least 3 grams
of dietary fiber. Cereal bars usually provide less protein than
energy bars; however, some are low in added sugars and high in
fiber.
LO 4 | FOOD SAFETY:
A GROWING CONCERN
Explain food safety concerns and how to reduce your risk for
foodborne illness.
Eating unhealthy food is one thing. Eating food that has been
contaminated with bacteria, a toxin, or another harmful substance is quite another. The federal Food Safety Modernization
Act requires food processors to implement multiple procedures
to prevent contamination of foods. The act also gives the FDA
greater authority to inspect food-manufacturing facilities and
to recall contaminated foods.51
Organic and Locally Grown Foods
Concerns about the health effects of chemicals used to grow
and produce food have led many people to turn to foods and
beverages that are organic—produced
without the use of toxic and persistent pesticides or fertilizers, antibiotics, hormones, irradiation, or genetic
modification. Any food sold in the
United States as organic has to meet
criteria set by the USDA under the
National Organic Rule and can carry a
USDA seal verifying products as “certiUSDA label for
fied organic.” Under this rule, a prodorganic foods.
uct that is certified may carry one of
the following terms:
“100 percent Organic” (100% compliance with organic
criteria).
■ “Organic” (must contain at least 95% organic materials).
■ “Made with Organic Ingredients” (must contain at least
70% organic ingredients).
■
“ Some Organic Ingredients”
(contains less than 70% organic
ingredients—usually listed
individually).
SEE IT! VIDEOS
Is organic produce better
for you? Watch Organic
Produce, available on
Mastering Health.
In contrast, the term natural on
food labels is not currently regulated.
However, the FDA is investigating
concerns related to the use of the term and may shortly develop
regulations on its use.52
The market for organic foods has been increasing faster
than food sales in general for many years. Whereas only a small
subset of the population once bought organic, 82 percent of all
U.S. families now buy organic foods at least occasionally, and
sales of organic foods represent nearly 5 percent of total food
sales.53 In 2016, annual organic food sales were estimated to be
over $47 billion.54
Is organic food really more nutritious? That depends on
what aspect of the food is being studied and how the research
is conducted. Two early review studies, both of which examined decades of research into the nutrient quality of organic
versus traditionally grown foods, reached opposite conclusions: One found that organic foods were more nutritious; the
other did not.55 Newer research suggests that organic meats
and dairy provide higher levels of certain nutrients, including
essential fatty acids, vitamin A, and iron.56
Another consideration is safety. These and other studies have
found higher pesticide residues on conventionally grown produce. Pesticide exposure is a health risk because various types
have been associated with significant adverse effects; for example,
the International Agency for Research on Cancer has identified
DID YOU
KNOW?
Even after washing their hands, nearly
58 percent of college students had
“an uncountable number of microbial
colonies” colonizing their hands, and
many of the species were linked to
infectious disease. Wash hands for at
least 20 seconds, backs and fronts,
with soap, under warm, running water.
■
140 | PART TWO | Building Healthy Lifestyles
Source: Data are from K. J. Prater et al., “Poor Hand Hygiene by College
Students Linked to More Occurrences of Infectious Diseases, Medical Visits,
and Absence from Classes,” American Journal of Infection Control 44, no. 1
(2016): 66–70.
TABLE 5.4 | Five Most Common Sources of Foodborne Illnesses
Microbe
Estimated Illnesses
(per year)
Norovirus
5.5 million
Transmitted through contact with the vomit or stool of infected people,
norovirus is the most common cause of foodborne illness in the United States
annually. Symptoms include nausea, vomiting, and diarrhea. Most cases are
self-limiting, but about 800 Americans die of infection each year. There is
no treatment, but washing hands and all kitchen surfaces can help prevent
transmission.
Salmonella
1 million
Commonly found in the intestines of birds, reptiles, and mammals, it can
spread to humans through foods of animal origin. Infection by Salmonella
usually consists of fever, diarrhea, and abdominal cramps. Salmonellosis can
be life-threatening if the bacteria invade the bloodstream, as is more likely in
people with poor health or weakened immune systems.
Clostridium perfringens
966,000
Bacterial species found in the intestinal tracts of humans and animals, as well
as in the environment. Infection causes abdominal cramping and diarrhea.
Campylobacter
845,000
Most raw poultry has Campylobacter in it, and this bacterial infection most
frequently results from eating undercooked chicken, raw eggs, or foods
contaminated with juices from raw chicken. Shellfish and unpasteurized milk
are also sources. Infection causes fever, diarrhea, and abdominal cramps.
Staphylococcus aureus
241,000
Staph lives on human skin, in infected cuts, and in the nose and throat.
Infection causes severe nausea, vomiting, and diarrhea that lasts 1–3 days.
Description
Source: Data are from Centers for Disease Control and Prevention,“Foodborne Illnesses and Germs,” February 18, 2018. https://www.cdc.gov/foodsafety/
foodborne-germs.html.
several pesticides used worldwide as probable carcinogens.57
What can the FDA do to
Other research indicates that
make food safe? Watch
we don’t have enough knowlFDA Proposes New Food
edge to say whether or not the
Safety Rules, available on
higher prices of organic foods
Mastering Health.
are justified for safety reasons
alone.58
The U.S. Environmental Protection Agency regulates pesticide use and, while assuring Americans that only low levels
of pesticide residue remain on conventionally grown foods,
advises consumers to scrub produce under running water and,
if possible, peel it.59
The word locavore has been coined to describe people who
eat mostly food grown or produced locally, usually within close
proximity to their homes. Because these foods are transported
only a few miles from farm to market, they are assumed to use
fewer resources and cause the emission of a lower level of greenhouse gases, as well as to be fresher and to stay fresh longer after
they’re sold. Consumers should not assume, however, that
these foods are organic, or that they are less likely to be contaminated with microorganisms. Toxic pesticides and harmful
bacteria can be found on foods shipped to markets from distant
countries, as well as on foods purchased from a local farm.
SEE IT! VIDEOS
Foodborne Illnesses
The Centers for Disease Control and Prevention (CDC)
estimate that foodborne illnesses cause 48 million illnesses,
128,000 hospitalizations, and 3,000 deaths in the United
States annually.60 Although the incidence of infection with
certain microorganisms has declined, the incidence of infection with others has risen or stayed essentially unchanged;
therefore, the CDC reports that foodborne infections
are an ongoing public health concern requiring improved
prevention.61
Causes of Foodborne Illness
Several common
types of bacteria and viruses, including Salmonella, Staphylococcus, and norovirus, cause most foodborne infections
and illnesses (TABLE 5.4). Foodborne illnesses can also be
caused by a toxin in food that was originally produced by a
bacterium or other microbe in the food. These toxins can
produce illness even if the microorganisms that produced
them have been destroyed. For example, the Staphylococcus
bacterium produces an intestinal toxin that can cause a selflimiting illness characterized by nausea, vomiting, and diarrhea. In contrast, Clostridium botulinum, another bacterium,
produces the botulism toxin, which is the most deadly nerve
toxin known. Botulism is rare, and most cases occur in homecanned vegetables; however, store-bought foods from cans
that are dented, pierced, leaking, or bulging may also harbor
the botulism toxin.62
Several factors contribute to foodborne illnesses, including
inadequate oversight of both foreign and domestic suppliers by
uncoordinated and underfunded federal agencies. Moreover, federal agencies can be slow to identify and respond to outbreaks.63
The task, however, is enormous: Food can become contaminated
in the field by contaminated irrigation water or runoff from
nearby animal feedlots, or during harvesting if farm laborers
have not washed their hands properly after using the toilet. Foodprocessing equipment, facilities, or workers may contaminate
CHAPTER 5 | Nutrition: Eating for a Healthier You | 141
food, or it can become contaminated if not kept clean and cool
during transport or on store shelves.
Signs and Symptoms of Foodborne Illness
Although they vary greatly between individuals and the type
of contamination involved, the signs and symptoms of foodborne illnesses usually include one or more of the following:
diarrhea, cramping, nausea, and vomiting. Depending on the
amount and virulence of the pathogen, symptoms may appear
as early as 30 minutes after eating contaminated food or as
long as several days or weeks later. Most of the time, symptoms
occur within 8 hours of eating and last only a few hours to a
day or two. For certain populations, such as the very young,
older adults, pregnant women, or people with severe illnesses,
foodborne diseases can be serious or even fatal.
Avoiding Risks in the Home
The bacterium
Escherichia coli, species of which produce a dangerous toxin,
is present in some meats; pork and fish may be contaminated
with the larvae of intestinal worms; and raw produce may harbor any of a variety of harmful microorganisms. So how can
you stay food-safe? Although 75 percent of cases of foodborne
illness are due to foods eaten out, about 9 percent result from
unsafe handling of food at home.64 Four basic steps reduce
the likelihood of contaminating your food (see FIGURE 5.10).
Among the most basic precautions are to wash your hands
and to wash all produce before eating it. Also, avoid cross-contamination in the kitchen by using separate cutting boards,
utensils, and plates for meats, produce, and breads. Temperature control is also important—refrigerators must be set at
40°F or lower. Cook meats to the recommended temperature
to kill contaminants such as bacteria and the larvae
of intestinal worms. Keep hot foods hot and cold
foods cold to avoid unchecked bacterial growth. Eat
leftovers within 3 days, and if you’re unsure how
long something has been sitting in the fridge, don’t
take chances. When in doubt, throw it out. See the
MAKING CHANGES TODAY box for more tips about
reducing risk of foodborne illness.
FIGURE 5.10
The Four Core Practices This logo
reminds consumers how to prevent foodborne illness.
Source: Foodsafety.gov, “Check Your Steps,” Accessed April 2018,
www.foodsafety.gov/keep/basics/.
used safely in the United States for over 30 years.66 Foods that
have been irradiated are marked with the “radura” logo.
Food Sensitivities, Allergies, and
Intolerances
Although many people today think they have a food allergy, it
is estimated that only 5 percent of children and 4 percent of
adults actually do.67 A food allergy, or hypersensitivity, is an
abnormal response to a component—usually a protein—in
food that is triggered by the immune system. Symptoms of an
allergic reaction vary in severity and may include a tingling
sensation in the mouth; swelling of the lips, tongue, and
throat; difficulty breathing; skin hives; vomiting; abdominal
cramps; and diarrhea. A severe reaction called anaphylaxis
can cause widespread inflammation, difficulty breathing,
and cardiovascular problems such as a sudden drop in blood
pressure. It can be fatal.68 Anaphylaxis may occur within seconds to hours after eating a food to which one is allergic.
The Food Allergen Labeling and Consumer Protection Act
(FALCPA) requires food manufacturers to label foods clearly to
indicate the presence of (or possible contamination by) any of the eight major food allergens: milk, eggs, peanuts, wheat, soy, tree nuts
(walnuts, pecans, cashews, pistachios, etc.),
fish, and shellfish. Although over 160 foods
have been identified as allergy triggers, these
8 foods account for 90 percent of all food allergies in the United States.69
Celiac disease is an immune disorder
USDA “radura” label for that causes malabsorption of nutrients from
irradiated foods.
the small intestine in genetically susceptiFood irradiation is a process that exposes foods to low
ble people. It is thought to affect as many as
doses of radiation, or ionizing energy, to break down the DNA
1 in every 141 Americans, most of whom are undiagnosed.70
of harmful bacteria, destroying them or keeping them from
When a person with celiac disease consumes gluten—a proreproducing. Essentially, the rays pass through the food withtein found in wheat, rye, and barley—the person’s immune
out leaving any radioactive residue.65
system responds with inflammation. This degrades the lining
Irradiation lengthens food products’ shelf-life and prevents
of the small intestine and reduces nutrient absorption. Pain,
the spread of harmful microorganisms, particularly in highabdominal cramping, diarrhea, constipation, nausea, vomrisk foods such as ground beef and pork. It also lowers food
iting, and other symptoms are common. Untreated, celiac
costs to consumers by reducing the need for chemicals to predisease can lead to long-term health problems, such as malserve foods. Use of food irradiation is limited because of connutrition, tissue wasting, osteoporosis, seizures, and certain
sumer concerns about safety
cancers. Blood tests and intestinal biopsies are used to diagand because irradiation facilifood allergy Immune hypernose celiac disease. Individuals who have been diagnosed
sensitivity response to normally
ties are expensive to build.
are encouraged to consult a registered dietitian nutritionist
harmless proteins in foods.
Still, food irradiation has been
(RDN) for help designing a gluten-free diet.
Food Irradiation
142 | PART TWO | Building Healthy Lifestyles
MAKING CHANGES TODAY
Reduce Your Risk for Foodborne Illness
When shopping, put perishable foods in your cart last.
Check for cleanliness throughout the store, especially
at the salad bar and at the meat and fish counters.
Never buy dented cans of food; report them to the
store manager. Check the “sell by” or “use by” date
on foods.
Wash your hands with soap and warm water before
preparing food. Wash fruits and vegetables before
peeling, slicing, cooking, or eating them—but not meat,
poultry, fish, or eggs! Wash cutting boards, countertops,
and other utensils and surfaces with detergent and hot
water after food preparation.
Once you get home, put perishable foods in the refrigerator immediately. If you don’t plan to eat meats within
2 days, freeze them. You can keep an unopened package of hot dogs or luncheon meats for about 2 weeks.
Once the package is opened, use hot dogs within
1 week and luncheon meats within 5 days.
Don’t cross-contaminate. Dedicate one cutting board for
meats, another for breads, and another for produce. Wash
each after use in hot, soapy water. After a plate has held
raw meat, wash it. Do not use it to carry any other food.
When refrigerating or freezing raw meats, make sure
their juices can’t spill onto other foods.
Use a meat thermometer to ensure that meats are completely cooked. To find out proper cooking temperatures
for different types of meat, visit www.foodsafety.gov/
keep/charts/mintemp.html.
Never thaw frozen foods at room temperature. Put them
in the refrigerator to thaw or thaw in the microwave,
following manufacturer’s instructions.
Refrigeration slows the secretion of bacterial toxins into
foods. Never leave leftovers out for more than 2 hours.
On hot days, don’t leave foods out for longer than 1 hour.
The mechanisms behind another disorder related to gluten are less clearly understood. Called nonceliac gluten sensitivity, it is diagnosed when an individual who has tested
negative for celiac disease experiences any of a wide variety of
symptoms, from abdominal bloating to diarrhea to joint pain,
upon consumption of gluten—yet symptoms improve or resolve
on a gluten-free diet.71 See the HEALTH HEADLINES box
on page 144 for more on glutenfree diets.
Peanuts are an
Food intolerance can
excellent source
cause symptoms of digesof plant proteins and
tive upset, but the upset
beneficial unsaturated
is not the result of an
fats, but they are among
immune system response.
the eight most common
The most common examfood allergens.
ple is lactose intolerance, an
inability to adequately digest
the disaccharide lactose, which
is in dairy products. Lactase is an
enzyme produced by the small
intestine that helps break the
bonds in the lactose molecule.
If you don’t have enough lactase,
undigested lactose draws water into
the small intestine, resulting in diarrhea.
When the undigested lactose reaches the large intestine, it is
fermented by gut bacteria. Gas is formed, and the person experiences bloating and abdominal pain.
If you suspect that you have a food allergy, celiac disease, or a food intolerance, see your doctor. Because these
diseases can have some common symptoms, as well as share
symptoms with other gastrointestinal disorders, clinical
diagnosis is essential.
Genetically Modified Food Crops
Cultivation of genetically modified crops is expanding rapidly around the world. Genetic modification involves the
insertion of genes into, or deletion of
genes from, the DNA of an organism.
In the case of genetically modified (GM) foods, usually this
genetic cutting and pasting
is done to enhance production—for
example,
by increasing a crop’s
tolerance to common
herbicides (weed killers),
making disease- or insectresistant plants, or improving yield. On average, GM
crops grow faster and have
yields 22 percent higher than
those of traditional crops,
and thus are credited with
contributing to the global
decline in hunger prevalence since their widespread
adoption in the 1990s.72 GM
foods are sometimes created
celiac disease An inherited
immune disorder causing malabsorption of nutrients from the
small intestine and triggered by
the consumption of gluten.
food intolerance Disorder
occurring in people who lack
the digestive enzymes needed
to break down certain substances in foods.
CHAPTER 5 | Nutrition: Eating for a Healthier You | 143
HEALTH
HEADLINES
Gluten-Free Diets
G
luten-free diets
have become a
fad. By the year 2020,
the sales of gluten-free
foods are estimated to
reach nearly 7.6 billion
dollars, double the sales
in 2013. According to a
2015 national poll, 1 in
5 Americans purchases
gluten-free foods, and
1 in 6 actively avoids
foods with gluten. This
is far more people than
the number who have
been clinically diagnosed
with celiac disease
or nonceliac gluten
sensitivity (NCGS). Is this wise?
A gluten-free diet entirely excludes
gluten, which is found in breads, cereals, and other grain products made with
wheat, barley, and rye, as well as in many
processed foods. The diet is highly restrictive, but for people with celiac disease, it
is essential to survival.
In contrast, for people who do not
have celiac disease or NCGS, a glutenfree diet reduces overall diet quality and
does not provide any health benefits. In
fact, many whole-grain foods that contain
gluten provide more dietary fiber, vitamins,
minerals, and phytochemicals than glutenfree versions, which are typically made
with refined, unenriched sorghum and rice
flours. Thus, people who choose glutenfree foods may have inadequate intakes of
fiber and several micronutrients, including
iron and the B vitamins riboflavin, thiamin,
folate, and niacin. Gluten-free foods also
tend to be higher in calories and more
expensive.
If you have been diagnosed with celiac
disease or NCGS, consult a registered
dietitian nutritionist (RDN) for advice on
avoiding gluten while still following a
healthy eating pattern. Many nutritious
to boost the level of specific nutrients or reduce the level of
potential toxins. For example, currently under development
is a GM variety of rice high in vitamin A and iron. Another
use under development is the production and delivery of vaccines through GM foods.
The long-term safety of GM foods—for humans,
other species, and the environment—is still in question.
Although the genetic engineering of insect-resistant crops
has reduced the use of insecticides, it has simultaneously
increased the use of herbicides, leading to the evolution
of so-called “superweeds,” while also killing off beneficial
weeds such as milkweed.73
As a result of increased
genetically modified (GM)
use of herbicides as well as
foods Foods derived from
loss of habitat to agricul­organisms whose DNA has
ture, butterfly populations
been altered using genetic
that depend on milkweed,
engineering techniques.
144 | PART TWO | Building Healthy Lifestyles
foods are naturally free of
gluten, including legumes
and other vegetables, fruits,
nuts, seeds, all animalbased foods, and even
several grains such as oats,
cornmeal, brown rice, and
quinoa. In buying foods for
a gluten-free diet, fresh, unprocessed foods are the best
choice. When you are buying
packaged foods, look for the
words “certified gluten-free.”
The FDA requires that, to
have a gluten-free label, the
product must contain less
than 20 parts per million of
gluten. For all other packaged foods, carefully study the ingredients
list before buying, as many unfamiliar food
ingredients contain gluten.
Sources: Statista, “Global Gluten-Free Food
Market Size from 2013 to 2020 (in Million U.S.
­Dollars),” 2018, Available from www.statista
.com/­statistics/248467/global-gluten-free-foodmarket-size/; R. Riffkin, “One in Five Americans
Include Gluten-Free Foods in Diet,” Gallup, Inc.,
July 23, 2015, www.gallup.com/poll/184307/onefive-­americans-include-gluten-free-foods-diet.
aspx; H. M. Staudacher, M. Kurien, and K. Whelan,
­“Nutritional Implications of Dietary ­Interventions
for Managing Gastrointestinal ­Disorders,” Current
Opinions in Gastroenterology 34, no.2 (March 2018):
105–11.
particularly the monarch butterfly, have declined in the
past two decades by an estimated 90 percent.74 Loss of
crop diversity is another potential threat, as GM varieties
of certain plants have been found several miles from their
origin. Moreover, monocultures—genetically identical
­
crops—are far more vulnerable to c­ limate events and plant
diseases than diverse crops; thus, populations that depend
on monocultures for food are at increased risk for food
shortages.
In contrast, although the unintentional transfer of potentially allergy-provoking proteins has occurred, a recent
review of 83 relevant studies concluded that GM foods
themselves are no more likely to provoke allergies than
other foods.75 Moreover, the American Association for the
Advancement of Science, the American Medical Association,
and the World Health Organization report that GM foods are
safe to eat.76
STUDY PLAN
ASSESS YOURSELF
function. Probiotics in fermented
milk and vegetable products help
maintain a healthy population of
intestinal microorganisms, whereas
antioxidant nutrients and phytochemicals help protect the body
from oxidative stress.
Do you eat healthfully? Want
to find out? Take the How
Healthy Are Your Eating
Habits? assessment available on
Mastering Health.
CHAPTER REVIEW
LO 2 | Nutritional Guidelines
■■
|
LO 1 Essential Nutrients for
Health
Nutrition is the science of the relationship between physiological
function and the essential elements
of the foods we eat. The Dietary
Reference Intakes (DRIs) are recommended nutrient intakes for healthy
people. A calorie is a measure of the
energy in food.
■■ The essential nutrients include
water, proteins, carbohydrates,
fats, vitamins, and minerals. Water
makes up 50–60 percent of our body
weight and is necessary for nearly
all life processes. Proteins are major
components of our cells, tissues,
and functional compounds such
as antibodies, enzymes, and hormones. Carbohydrates are broken
down to glucose, our most readily
available source of energy. Fiber
is a non-digestible carbohydrate
that enhances bowel function and
reduces the risk for obesity, heart disease, and constipation. Fats provide
energy for long-term activity and
rest; help maintain body temperature; cushion and protect organs,
and promote healthy cell function.
Unsaturated fats, including the
essential fatty acids, are critical to
health. Vitamins are organic compounds, and minerals are inorganic
elements. We need these micronutrients in small amounts to maintain healthy body structure and
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
■■
The 2015–2020 Dietary Guidelines for
Americans and the MyPlate graphic
and website are tools developed by
the U.S. Department of Health and
Human Services and the U.S. Department of Agriculture to help Americans
maintain a healthy diet and reduce
their risk for obesity and chronic
disease. The Guidelines emphasize
following a healthy eating pattern
across the lifespan; focusing on variety, nutrient density, and amount;
limiting calories from added sugars
and saturated fats; reducing sodium;
shifting to healthier choices; and supporting healthy eating patterns
for all.
|
LO 3 How Can I Eat More
Healthfully?
The Nutrition Facts label on packaged foods identifies the serving size,
number of calories per serving, and
amounts of various nutrients, as well
as the %DV, which is the percentage
of recommended daily values those
amounts represent.
■■ With a little menu planning, vegetarianism can be a healthful lifestyle
choice, providing plenty of nutrients, plus fiber and phytochemicals,
typically with less saturated fat and
fewer calories.
■■ Although some people may benefit
from taking vitamin and mineral
supplements, a healthy diet is the
best way to give your body the nutrients it needs.
■■
■■
College students face unique challenges in eating healthfully. Choosing
more plant-based foods, avoiding
added sugars, limiting saturated fats,
and eating mindfully are strategies for
maintaining a healthy eating pattern.
|
LO 4 Food Safety:
A Growing Concern
Organic foods are grown and produced without the use of toxic and
persistent synthetic pesticides, fertilizers, antibiotics, hormones, or genetic
modification. The USDA offers certification of organic farms and regulates
claims regarding organic ingredients
used on food labels.
■■ Foodborne illnesses sicken over 48
million Americans each year. They
can be traced to contamination
of food at any point from farms to
the consumer’s kitchen. Viruses,
bacteria, and bacterial toxins are
the most common culprits. To keep
food safe at home, follow four steps:
clean, separate, cook, and chill.
■■ A food allergy is an immune hypersensitivity response to a component,
usually a protein, in a food. Celiac
disease is characterized by erosion
of the lining of the small intestine
because of an immune response to
gluten, a protein in wheat, rye, and
barley. Food intolerances such as
lactose intolerance are caused by
an inability to adequately digest a
­component of a food.
■■ Genetically modified (GM) crops
grow faster on average and have
higher yields, factors that have led
to their adoption worldwide. Environmental concerns include generation of superweeds, potential loss of
crop diversity, and negative effects
on other species. Nevertheless, GM
foods are considered as healthful as
foods traditionally grown.
■■
CHAPTER 5 | Nutrition: Eating for a Healthier You | 145
POP QUIZ
|
LO 1 Essential Nutrients for
Health
1. Which of the following nutrients is
most critical for the growth, repair,
and maintenance of body tissues?
a. Carbohydrates
b. Proteins
c. Essential fatty acids
d. Vitamins
2. Which of the following substances
helps move food through the
intestinal tract?
a. Folate
b. Fiber
c. Glycogen
d. Starch
3. What substance provides energy,
insulates body organs, helps
maintain body temperature, and
contributes to healthy cell function?
a. Fats
b. Fibers
c. Proteins
d. Carbohydrates
4. Which of the following fats is the
most healthful?
a. Trans fat
b. Saturated fat
c. Unsaturated fat
d. Partially hydrogenated oils
5. Which vitamin helps maintain
bone health?
a. B12
b. D
c. B6
d. Niacin
LO 2 | Nutritional Guidelines
6. Which of the following foods
or beverages is the most
nutrient-dense?
a. Low-fat milk
b. Cheddar cheese
c. Chocolate milk
d. Fruit-flavored yogurt
7. The 2015–2020 Dietary Guidelines
for Americans recommend that you
a. stop smoking and walk daily.
b. consume one alcoholic beverage
a day.
c. follow an eating pattern low in
total fat and cholesterol.
d. limit your intake of added sugars,
saturated fats, and sodium.
146 | PART TWO | Building Healthy Lifestyles
|
LO 3 How Can I Eat More
Healthfully?
8. The %DV on a Nutrition Facts label
tells you
a. the Dietary Reference Intake for
the particular food component.
b. how much of your daily need for
a particular food component is
met by the food in the package.
c. how much of an average adult’s
allowance for a particular food
component is provided by one
serving of the food.
d. the relative level (high, low, etc.)
of a specific component (fiber,
sodium, etc.) in a food.
9. Carrie eats dairy products and eggs,
but she does not eat fish, poultry,
or meat. Carrie is considered a(n)
a. vegan.
b. lacto-ovo-vegetarian.
c. ovo-vegetarian.
d. pesco-vegetarian.
|
LO 4 Food Safety: A
Growing Concern
10. Lucas’s doctor diagnoses him
with celiac disease. Which of
the following foods must Lucas
avoid?
a. Shellfish
b. Milk
c. Peanut butter
d. Whole-wheat bread
Answers to the Pop Quiz can be found on page
A-1. If you answered a question incorrectly,
review the section tagged by the Learning
Outcome. For even more study tools, visit
Mastering Health.
THINK ABOUT IT!
|
LO 1 Essential Nutrients for
Health
1. Which factors influence a person’s
dietary patterns and behaviors?
What factors have been the
greatest influences on your eating
behaviors?
2. What are the six types of
nutrients that you need to
obtain from your diet? What
are their most important
functions? For each of the six
nutrients, list one particularly
healthful food or beverage high
in that nutrient.
LO 2 | Nutritional Guidelines
3. State the first key guideline from
the 2015–2020 Dietary Guidelines
for Americans. Explain the role of
nutrient density in following this
guideline.
4. Identify the major food groups
in the MyPlate plan. From which
groups do you eat the least number
of servings? What can you do
to increase your intake of these
foods?
|
LO 3 How Can I Eat More
Healthfully?
5. Distinguish among varieties of
vegetarianism. Which types are
most likely to lead to nutrient
deficiencies, and which are the
nutrients of concern? How can a
strict vegetarian consume enough
of these nutrients?
6. What are the major problems
you face when trying to eat
right? List five actions that you
and your classmates could take
immediately to improve your
eating.
|
LO 4 Food Safety:
A Growing Concern
7. Imagine you’re preparing a
barbecue of grilled chicken and
salad for friends. What four steps
should you take to reduce your risk
for foodborne illnesses?
8. How does a food intolerance differ
from a food allergy?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore
further topics and issues related to
nutrition.
Academy of Nutrition and Dietetics.
The academy provides information on a full
range of nutrition topics; the site also links
to scientific publications and information on
scholarships and public meetings.
www.eatright.org
U.S. Food and Drug Administration (FDA).
The FDA provides information about food
labeling, food safety, supplements, and
many other topics. It also provides links to
other sources of nutrition information.
www.fda.gov
Food and Nutrition Information Center.
This site offers a wide variety of information
related to food and nutrition. www.fnic.nal
.usda.gov
National Institutes of Health, Office
of Dietary Supplements. This is the
site of the International Bibliographic
Database of Information on Dietary
Supplements (IBDIDS), updated quarterly.
www.dietary-supplements.info.nih.gov
U. S. Department of Agriculture,
USDA: Choose MyPlate. Use this site
to design a personalized diet and physical
activity plan based on the MyPlate program,
and find sample menus, recipes, and tips for
healthy eating. www.choosemyplate.gov
WHICH PATH WOULD
YOU TAKE?
“Who needs breakfast? I save
those calories for lunch!” Go to
Mastering Health to see how your
actions today affect your future health.
U S. Department of Health and
Human Services: Food Safety. This
is the federal government’s official gateway
to food safety information, including
recalls and alerts, news, and more.
www.foodsafety.gov
CHAPTER 5 | Nutrition: Eating for a Healthier You | 147
6
REACHING AND
MAINTAINING A
HEALTHY WEIGHT
LEARNING OUTCOMES
LO1
Describe the current epidemic of overweight and obesity
in the United States and globally and the health risks
associated with excess weight.
LO2
Describe factors that put people at risk for overweight
and obesity, distinguishing between controllable and
uncontrollable factors.
148
LO3
Discuss reliable options for determining a healthy weight
and body fat percentage.
LO4
Explain the effectiveness and potential pros/cons of
various weight control strategies, including exercise, diet,
lifestyle modification, supplements/diet drugs, surgery,
and other options.
WHY
It may be easy to grab a handful of chips or pick up a medium vanilla latte between
classes, but unless you are physically active and forgo part of your calories at mealtime, those extra calories matter! Eating 500 extra calories a day—less than a latte
and bagel with cream cheese—can lead to a pound of weight gain in just a week’s time.
A 150-pound person would need to walk for about 90 minutes at 4 mph to burn that off. If
you walked more slowly, it would take even longer. At a period in life when young adults should
be at their healthiest, nearly 39 percent of college students are somewhere between being
overweight and having Class III or “morbid” obesity, setting the stage for a lifetime of increased
health risks.1 College students aren’t the only young adults affected. In fact, at 18.5 percent, the
United States has one of the highest percentages in the world of youth and young adults aged
2 through 19 who are obese.2 (See FIGURE 6.1 for an overview of obesity by age group in the
United States.)
SHOULD I CARE?
I
n spite of major efforts to stem the trend toward weight
gain, in the United States and globally, no country’s obesity rates have been successfully reduced in the past 33
years. The prevalence of overweight, obesity, and severe
obesity is increasing worldwide. In fact, the number of people
who are overweight or obese has doubled since 1980 in 73
countries, with no sign of slowing any time soon.3 The obese
population in the United States accounts for the highest number of obese adults at nearly 80 million, followed by China
with just over 57 million. Globally, over 2.2 billion humans
are overweight or obese. The United States also has the greatest
percentage of obese children, at nearly 13 percent.4
Young and old, rich and poor, rural and urban, educated
and uneducated, Americans share one thing in common: They
are heavier than virtually all previous generations.5 The word
obesogenic refers to environmental conditions that promote
obesity, such as the availability and marketing of unhealthy
foods and social and cultural norms that lead to high calorie
consumption and lack of physical activity—an apt descriptor
of American society and a growing list of others.
18.5%
Youth 2–19 years
35.7%
42.8%
20–39 years
40–59 years
39.8%
Overall
41.0%
≥60 years
FIGURE 6.1
Obesity Rates in the United States,
2015–2016
Source: C. Hales et al., “Prevalence of Obesity among Adults and Youth:
United States: 2015–2016,” NCHS Data Brief #288, October 2017.
LO 1 | OVERWEIGHT AND
OBESITY: A GROWING
HEALTH THREAT
Describe the current epidemic of overweight and obesity in the
United States and globally and the health risks associated with
excess weight.
Humans aren’t the only ones to become obese. Often, owners’
own dietary issues are reflected in the way they feed their pets,
who unfortunately can develop many of the same health issues as
humans.
What do we mean when we use the terms overweight and
obesity? Categorized by class (reflecting both severity and
increasing risks based on percent body fat), obesity
refers to a body weight that is more than 20 percent above
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 149
obesogenic Refers to environmental conditions that promote obesity, such as the availability of unhealthy foods, social
and cultural norms that lead to
high calorie consumption, and
lack of physical activity.
obesity Having a body weight
more than 20 percent above
healthy recommended levels; in
an adult, a BMI of 30 or more.
body mass index (BMI) A
number calculated from a
person’s weight and height
that is used to assess risk
for possible present or future
health problems.
overweight Having a body
weight more than 10 percent
above healthy recommended
levels; in an adult, having a BMI
of 25 to 29.9.
recommended
levels
for
health, or a body mass index
(BMI)—a description of body
weight relative to height that
we cover in more depth
later—over 30. Class 1 obesity
refers to those with a BMI of
30 to 34.9, Class II obesity
includes those with a BMI of
35 to 39.9, and Class III obesity
includes those with a BMI of
40 or higher and is often
referred to as morbid or extreme
obesity.6 Less extreme, but still
damaging, is overweight,
which is body weight more
than 10 percent above healthy
levels or a BMI between 25
and 29 (TABLE 6.1).
Overweight and Obesity in the
United States
FIGURE 6.2 illustrates just how prevalent obesity is across the
United States. Indeed, the prevalence of obesity has steadily
increased in recent decades, with disproportionate risks among
some populations.7 Children aged 2 to 5 years appear to have
stabilized in prevalence in recent years; however, rates remain
high, with over 9.4 percent of our youngest children already
obese. Obesity rates are up in almost all other groups, with nearly
19 percent of youth and adolescents aged 2 through 19 classified as obese.8 Children and adolescents living in low-income,
low-education, and higher-unemployment homes are at significantly greater risk of developing obesity, while those from higherincome homes with more educated parents have decreasing risk.9
Research also points to higher rates of obesity among some
adult populations in the United States. Hispanic men (43.1 percent) and non-Hispanic white men (37.9 percent) are more likely
Obesity rates:
<20%
20%–25%
25%–30%
30%–35%
≥35%
Insufficient data
FIGURE 6.2
Obesity in the United States
Source: E. J. Benjamin et al., “Heart Disease and Stroke Statistics—2018
Update: A Report from the American Heart Association,” Circulation 135, no.
10 (2018): e1–442.
to be obese than are nonHispanic black men (36.9 percent).10 Non-Hispanic black
women have the highest percentage of obesity (54.8 percent), followed by Hispanic
women (50.6 percent) and
non-Hispanic white women
(38 percent).11 In sharp contrast, 12.7 percent of Asian
men and 14.8 percent of
Asian women in the United
States are obese.12
An Obesogenic
World
WHAT DO
YOU THINK?
Can you think
of factors in your
particular environment that
are contributing to your own
risks for obesity? Risks of your
family and friends?
■■ What actions could you take
to combat them?
■■ What could be done on your
campus to help make weight
control easier for students?
The United States is not alone in the obesity epidemic. In fact,
obesity has more than doubled globally since 1980, with over
1.9 billion overweight and 650 million obese adults and over
340 million children and adolescents aged 5 through 19 who are
overweight or obese.13 While obesity was once predominantly a
TABLE 6.1 | Weight Classifications Based on BMI, Waist Circumference, and Associated Risks
Disease Risk* Relative to Normal Weight and Waist
Circumference
BMI (kg/m2)
Obesity Class
Men 102 cm (40 in) or less
Women 88 cm (35 in) or less
Men > 102 cm (40 in)
Women > 88 cm (35 in)
Underweight
< 18.5
—
—
Normal
18.5–24.9
—
—
Overweight
25.0–29.9
Increased
High
Obesity
30.0–34.9
I
High
Very high
35.0–39.9
II
Very high
Very high
+
III
Extremely high
Extremely high
Extreme/Morbid Obesity
40.0
* Disease risk for type 2 diabetes, hypertension, and CVD.
+
Increased waist circumference also can be a marker for increased risk, even in persons of normal weight.
Source: National Heart, Lung and Blood Institute, “Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks,”
­Accessed March 2017, www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_dis.htm.
150 | PART TWO | Building Healthy Lifestyles
MENTAL HEALTH
• Increased rates of depression
and anxiety disorders
• Increased risk of Alzheimer's
disease, dementia, and
cognitive decline
IMMUNE SYSTEM
• Tendency toward more
infectious diseases
• Reduced wound healing
CARDIOVASCULAR SYSTEM
• High blood pressure
• Higher triglyceride levels and
decreased HDL levels, both
factors in the development of
cardiovascular disease
HEART
• Dramatically increased risk for all
forms of heart disease
RESPIRATORY SYSTEM
• Increased risk of sleep apnea and
asthma
ENDOCRINE SYSTEM
• A weight gain of 11–18 pounds
doubles a person’s risk of type 2
diabetes
DIGESTIVE SYSTEM
• Increased risks for colon,
gallbladder, and kidney cancers
• Increased risk of gallbladder
disease
REPRODUCTIVE SYSTEM
• Higher rates of sexual
dysfunction
• Increased risks for prostate,
endometrial, and uterine cancer
• Increased risk of breast cancer in
women
• In pregnant women, increased
risks of fetal and maternal death,
labor and delivery complications,
and birth defects
FIGURE 6.3
BONES AND JOINTS
• For every 2-pound increase in
weight, the risk of arthritis
increases 9%–13%
• Increased risk of osteoarthritis,
especially in weight-bearing
joints, such as knees and hips
Potential Negative Health Effects of Overweight and Obesity
concern in high-income countries, today increasing numbers
of low- and middle-income countries have overweight/obesity
issues.14 The global epidemic of high rates of overweight and
obesity in multiple regions of the world has come to be known
as ­globesity. Increases in sedentary lifestyles and occupations;
mass marketing of high-fat, high-sugar, high-salt, micronutrient-poor, high-carbohydrate foods; and an increase in the food
energy supply to the world’s population through international
distribution have each contributed to the rise in obesity.15
Health Risks of Excess Weight
Although smoking is still the leading cause of preventable
death in the United States, obesity is rapidly gaining ground.
Obesity is linked to cardiovascular disease (CVD), stroke, cancer, hypertension, diabetes, depression, digestive problems,
gallstones, sleep apnea, Alzheimer’s, osteoarthritis, decreased
mobility, restrictions on activities of daily living, and other
mental and social health issues.16 FIGURE 6.3 summarizes
these and other potential health consequences of obesity.
Consider the following facts about specific risks for obese
individuals compared to their nonobese counterparts in this
classic study:17
Watch Video Tutor:
Obesity Health Effects
70.7%
of U.S. adults are OVERWEIGHT—
INCLUDING OBESITY.
They have a 104 percent increase in risk of heart failure.
BMI greater than 30 reduces their life expectancy by 2 to 4
years.
■■ BMI greater than 40 costs 8 to 10 years of life expectancy—
similar to what happens to a long-term smoker.
■■ Nearly 55 percent of obese children are still obese in adolescence; 80 percent of obese adolescents will be obese
adults—with 70 percent of those continuing to be obese
after age 30.18
■■
■■
Diabetes, strongly associated with overweight and obesity, is
another major concern. A
woman with a BMI of 30 or
globesity Global rates of
obesity.
greater is 12 times more likely
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 151
58%
OVER
of college students are AT HEALTHY
WEIGHT. Over 23% are overweight,
over 15% are obese, and over 4% are
underweight.
to develop type 2 diabetes, while a man with a similar BMI
increases his type 2 diabetes risk by 7 times.19
In addition, the more fat cells a person has, the greater the
risk of inflammation, a culprit in several different diseases. Fat
cells, particularly those around the waist, secrete hormones
that actually trigger inflammation and other problems. Having too many fat cells leads to too much inflammation, which
not only increases risks of coronary artery disease but also
makes the body less responsive to insulin and changes the
way the body metabolizes fats and carbohydrates. Over time,
the fat–inflammation connection can lead to increased blood
sugar and significantly increased risks for type 2 diabetes.20
The more weight you gain, the greater the risk. Likewise, losing
5 to 10 percent of body weight can lead to significant decreases
in risk for pre-diabetes and diabetes (see Focus On: Minimizing
Your Risk for Diabetes on page 435).
CVD, cancers, and other chronic diseases are not the
only risks associated with overweight and obesity. Others
are pregnancy complications, inflammation, asthma, elevated blood lipids, musculoskeletal issues, increased risks
of falls and disability, fatty liver and gallbladder problems,
polycystic ovary syndrome, depression, reproductive health
problems, sexual dysfunction, and accidents and decreased
productivity at work.21 The costs of social isolation, bullying in school, stigmatization, discrimination, and diminished quality of life due to overweight and obesity can also
be devastating.
LO 2 | FACTORS CONTRIBUTING
TO OVERWEIGHT AND OBESITY
Describe factors that put people at risk for overweight and obesity,
distinguishing between controllable and uncontrollable factors.
The reasons for our soaring rates of overweight and obesity are
complex, and not all of them are within easy individual control. Increasingly, scientists recognize that, rather than being
a problem with willpower or simply a “calories in and calories burned” formula alone, a vast array of factors influence
whether a person becomes overweight or obese or remains
at a healthy weight or fat
level. Among these factors
healthy weight Those with
are genetics, biology, and
BMIs of 18.5 to 24.9, the range
of lowest statistical health risk.
physiology; environments
152 | PART TWO | Building Healthy Lifestyles
that support or inhibit physical activity; social and learned
behavioral factors that influence your exercise predisposition, sleep, and diet; psychological factors such as stress and
depression; societal and community influences; access to
healthy foods versus unhealthy choices; mass media influences; family/cultural influences; and a host of other variables. Newer thinking regarding reducing obesity risk involves
a more ecological approach that seeks to change obesogenic
environmental and contextual factors as well. Learned behaviors in the home; influences at school and in social environments; media influences; and the environments where we
live, work, and play are important to our weight profiles and
may offer promising options for prevention and intervention.22 In addition, new research is focusing on the way the
body defends itself after weight loss, by “re-setting” biological mechanisms that keep weight within a normal range. If
we engage in extreme dieting or fasting, our body responds
by lowering basal metabolic rate, effectively slowing calorie
burning and maintaining weight.23
Physiological, Genetic, and
Hormonal Factors
Are some people born to be fat? In fact, the evidence is increasing that obesity is a multifactorial problem involving complex genetic, hormonal, physiological, and environmental
interactions.24
FTO, Ghrelin, and Leptin: Genes and
Hormones at Work? New research suggests that
there is a genetic basis for our appetite and that some people
inherit a lower sensitivity to satiety, or feeling full.25 These people may be more prone to grazing and food cravings than others.
One gene in particular, the fat mass and obesity-associated
(FTO) gene, may be among the most important. To date, the
FTO gene has been associated with several significant gastrointestinal diseases often related to excess BMI, including
fatty liver disease, colon adenomas, and pancreatic cancer, as
well as being related to successful outcomes from weight loss
surgery.26 Much research has centered on the role of genes such
$150
OVER
Billion
is the amount of money spent on
EXCESS HEALTH CARE COSTS
associated with obesity in America,
not including billions more spent
on lost productivity and other social
and economic costs.
So, if our genes play a key role in obesity tendencies, are we facing a lifelong battle with our
weight? Probably not. A healthy lifestyle and
environment may be able to override “obesity”
genes. More research is necessary to determine
specific mechanisms by which the gene/behavior/environment interaction can be utilized
in tailoring exercise and weight loss programs
most likely to be effective over time.31
Thrifty and Spendthrift: Impact
on Weight Loss New research theorizes that the ease with which one person
loses weight and another hangs on to it may
be influenced by individual biology. One early
controlled lab study that provided fuel for this
theory included 12 obese men and women who
Many factors help determine weight and body type, including heredity and
were asked to fast for 1 day and remain as inpagenetic makeup, hormones, environment, and learned eating patterns,
tients for 6 weeks, consuming 50 percent of
which are often connected to family habits.
their normal calories each day. The individuals
who lost the least during the time period were
those whose metabolism slowed down significantly in
as FTO in regulating ghrelin, a hormone that has been shown
response to caloric restriction.32 Subsequent research focusing
to play a key role in metabolism, specifically in increasing
on the epidemic of obesity in Samoan populations supported
appetite and food intake, suppressing satiety, and regulating,
this theory.33 Individuals in these studies had what researchgastrointestinal motility, gastric acid secretion, endocrine and
ers referred to as a thrifty metabolism. In contrast, those with
exocrine pancreatic secretions, glucose and lipid metabolism,
a spendthrift metabolism had metabolisms that kept c­ hugging
and cardiovascular and immunological processes.27
along when caloric in­take decreased, losing significantly more
Another hormone that has gained increased attention and
weight than the thrifty group.
research is leptin, an appetite regulator produced by fat cells
Today, researchers realize that genetics, environment, behavin mammals that appears to suppress food intake and proior, and biological adaptations converge in a complex set of
mote calorie burning. As fat tissue increases, levels of leptin
interactions that appear to predispose individuals to weight gain
in the blood increase, and when levels of leptin in the blood
and obesity or not. In response to fast weight loss and highly
rise, appetite drops. Scientists believe leptin serves as a form of
restrictive low-calorie diets—particularly those that cut carbo“adipostat” that signals you are getting full, slows food intake,
hydrates and fats to extreme levels—the body goes into a form
and promotes energy expenditure. When leptin levels are low,
of biological protection mode, slowing metabolism and energy
researchers believe that people will be more prone to overeatexpenditure and making it harder to lose weight and keep
ing and weight gain. However, it may not be as simple as this.
weight off. This form of metabolic defense may persist long after
Newer research indicates that in many obese individuals,
the diet is finished, making weight regain almost inevitable.34 In
leptin levels may be high and “food finding” behaviors may
fact, the majority of dieters regain weight. Researchers also now
actually increase. Scientists believe that in these individuals,
recognize that there is huge variability in why and when people
bodies may be less sensitive to leptin and it doesn’t work as it
gain weight, based on age, disease state, dietary changes, envishould, perhaps due to some protective defense mechanism
ronment, lifestyle, genetics, and a host of other factors.35
that may sabotage its action and help maintain weight.28
Obese people seem to have excess ghrelin production and
Metabolic Rates Several aspects of your metabofaulty leptin receptors, although the exact reasons why these
lism also help determine whether you gain, maintain, or lose
hormones function improperly are not clear. It may be that
weight. Each of us has an innate energy-burning capacity called
environmental and psychological cues are stronger than biologbasal metabolic rate (BMR)—the minimum rate at which the
ical signals in some individuals.29 Specifically, people with cerbody uses energy to maintain
tain genetic variations may tend to graze for food more often,
basic vital functions. A BMR
eat more meals, and consume more calories every day, as well as
satiety The feeling of fullness
for the average, healthy adult
display patterns of seeking out high-fat food groups. Also, difor satisfaction at the end of a
is usually between 1,200 and
ferent genes may influence weight gain at certain periods of life,
meal.
1,800 calories per day. Techand in different environments.30 Rather than acting individubasal metabolic rate (BMR)
nically, to measure BMR, a
ally, the effects of the genes may be in clusters, influencing the
The rate of energy expenditure
person would be awake, but
regulation of food intake through action in the central nervous
by a body at complete rest in a
all major stimuli (including
system, as well as influencing fat cell synthesis and functioning.
neutral environment.
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 153
Oprah Winfrey, part owner and spokesperson for
Weight Watchers, has been candid about her struggles
with yo-yo dieting. Such a pattern disrupts the body’s
metabolism and makes future weight loss more difficult
and permanent changes even harder to maintain.
stressors to the sympathetic nervous system and digestion)
would be at rest. Usually, the best time to measure BMR is after
8 hours of sleep and after a 12-hour fast.
A more practical way of assessing your energy expenditure
levels is the resting metabolic rate (RMR). Sli­­ghtly higher than
the BMR, the RMR includes the BMR plus any additional energy
expended through daily sedentary activities such as food digestion, sitting, studying, or standing. The exercise metabolic
rate (EMR) accounts for the
remaining percentage of all
resting metabolic rate
daily calorie expenditures and
(RMR) The energy expendirefers to the energy expenture of the body under BMR
conditions plus other daily
diture that occurs during
sedentary activities.
physical activity. For most of
exercise metabolic rate
us, these calories come from
(EMR) The energy expenditure
light daily activities, such as
that occurs during exercise.
walking, climbing stairs, and
adaptive thermogenesis
mowing the lawn.
Theoretical mechanism by
Your BMR and RMR flucwhich the brain regulates
tuate
through life, and are
metabolic activity according to
highest
during
infancy,
caloric intake.
puberty, and pregnancy.
yo-yo diets Cycles in which
Generally, the younger you
people diet and regain weight.
are, the higher your BMR,
set point theory Theory that
partly because cells undergo
a form of internal thermostat
rapid division during periods
controls our weight and fights
of growth, consuming lots of
to maintain this weight around
a narrowly set range.
energy. After age 30, a person’s BMR slows down 1 to 2
hyperplastic obesity A
condition characterized by an
percent a year; older people
excessive number of fat cells.
commonly find an extra
helping of ice cream harder
hypertrophy The act of
to burn off. Slower BMR,
swelling or increasing in size,
as with cells.
coupled with less activity,
154 | PART TWO | Building Healthy Lifestyles
age-related muscle loss, and shifting priorities from fitness to
family and career obligations, contributes to the weight gain of
many middle-aged people.
Anyone who has ever lost weight, only to reach a point at
which, try as he might, he can’t lose another ounce, may be
a victim of adaptive thermogenesis, whereby the body slows
metabolic activity and energy expenditure as a form of defensive protection against possible starvation. With increased
weight loss may come increased hunger sensations, slowed
energy expenditure, and a tendency to regain weight or make
further weight loss more difficult.
A recent study conducted with The Biggest Loser participants
is an excellent example of why extreme diets can be detrimental. Some who engaged in the program’s restricted diet and
intense exercise showed significant short-term weight loss during the show—but had trouble maintaining their weight loss
months and years after the intervention ended.36 As a result
of their intervention, participants experienced significant
reduction in their RMR at the conclusion of the intervention.
Surprisingly, those with initial lowered RMR maintained their
lowered RMR months and even years afterward. These individuals experienced challenges keeping their weight off and/or
losing more weight. Individuals who undergo rapid and highly
restricted regimens for weight loss may find it harder to lose
subsequent weight and maintain losses in the future. Without
sufficient support, they may actually regain weight.37
Yo-yo diets refer to when people cycle between periods of
weight loss and gain. Typically, after weight loss, BMR is lower
because the body has less muscle mass and weight and requires
less energy for basic functioning. When dieters resume eating
after their weight loss, due to the related BMR decrease, calories burn more slowly, and they regain weight. Repeated cycles
of dieting and regaining weight may actually increase the likelihood of getting heavier over time. Increased age and overall
loss of muscle mass through inactivity also tend to result in
lowered BMR.
On the other side of the BMR equation is set point theory,
which suggests that our bodies fight to maintain weight
around a narrow range or set point. If we go on a drastic starvation diet or fast, BMR slows to conserve energy. Set point theory suggests that our own bodies may sabotage our weight loss
efforts by holding on to calories, explaining why people tend
to stay near a certain weight threshold and why moving to a
different level of weight loss is difficult. The good news is that
set points can be changed; however, these changes may take
time to become permanent.
Fat Cells and Predisposition to Obesity
Some obese people may have excessive numbers of fat cells.
Where an average-weight adult has approximately 25 to
35 ­billion fat cells and a moderately obese adult 60 to 100
­billion, an extremely obese adult has as many as 200 billion.38
This condition, hyperplastic obesity, usually appears in early
childhood and perhaps, due to the mother’s dietary habits, even
prior to birth. The most critical periods for the development of
hyperplastic obesity are the last 2 to 3 months of fetal development, the first year of life, and the period between ages 9 and 13.
Central to this theory is the belief that the number of fat cells in
Before body
weight
reduction
Initial
weight
reduction
Second
weight
reduction
Body
weight
328 lb
227 lb
165 lb
Fat cell
size
0.9 μg/cell
0.6 μg/cell
0.2 μg/cell
Fat cell
number
75 billion
75 billion
75 billion
FIGURE 6.4
One Person at Various Stages of Weight
Loss Note that, according to the hyperplasia theory, the
number of fat cells remains constant, but their size decreases
when weight is lost.
a body does not increase appreciably during adulthood. However, the ability of each of these cells to swell ­(hypertrophy)
and shrink does carry over into adulthood. People with large
numbers of fat cells may be able to lose weight by decreasing the
size of each cell in adulthood, but with the next calorie binge,
cells swell and sabotage weight loss efforts. Weight gain may be
tied to both the number of fat cells in the body and the capacity
of individual cells to enlarge (FIGURE 6.4).
Environmental Factors
Environmental factors have come to play a large role in
weight maintenance. Automobiles, remote controls, desk
jobs, too much screen time and sedentary habits contribute to
decreased physical activity and energy expenditure. Coupled
with our culture of eating more, it’s a recipe for weight gain.
Greater Access to High-Calorie Foods
More foods that are high in calories and low in nutrients
exist today compared to the past. Many environmental factors can prompt us to take the high-calorie path:
Because of constant advertising, we are bombarded with
messages to eat, eat, eat, and taste often trumps nutrition.
■■ Super-sized portions are now the norm (see the STUDENT
HEALTH TODAY box on page 156), leading to increased
calorie and fat intake.
■■ Widely available high-calorie coffee and sugary drinks lure
people in for a form of a break or reward between meals,
and these really add up in calories over time.
■■ Misleading food labels confuse consumers about serving sizes.
■■
Today’s consumers have access to an ever-increasing array
of fresh, frozen, canned, and packaged foods. Comparing the
The easy availability of high-calorie foods, such as those
found in most vending machines, is one of the environmental
factors contributing to the obesity problem in the United
States today.
“then” and “now” trends may help us understand why we
have a growing epidemic of obesity in the United States today
(TABLE 6.2 on page 157). 39
Lack of Physical Activity
Although heredity,
metabolism, and environment all have an impact on weight
management, the way we live our lives is also responsible. In
general, Americans are eating more and moving less than ever
before—and becoming overfat as a result.
According to data from the 2017 National Health Interview
Survey, just over 52 percent of all adults and over 62 percent of
those 18 to 24 years of age in the United States met the guidelines for aerobic activity through involvement in leisure-time
activity.40 Nearly 24 percent met the minimum guideli­nes for
both aerobic exercise and muscle strengthening.41
Psychosocial and Socioeconomic
Factors
The relationship of weight problems to emotional insecurities,
needs, and wants remains difficult to assess. What we do know
is eating tends to be a focal point of people’s lives and is in part
a social ritual associated with companionship, celebration, and
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 155
STUDENT
HEALTH TODAY
H
ow many times have you ordered
something at a restaurant and sat wideeyed as the heaping dish is placed in front
of you? For many, that “wow” response is
synonymous with good restaurant ratings.
A quick check on Trip Advisor or Yelp will
clearly show “bigger is better” for many,
with large portions being synonymous with
good food value. But is that really the case?
Many researchers believe that the main
reason Americans are gaining weight is
that people no longer recognize a normal
serving size. The National Heart, Lung,
and Blood Institute has developed a pair
of “Portion Distortion” quizzes that show
how today’s portions compare with those
of 20 years ago. Test your knowledge
of portion size online at www.nhlbi.nih.
gov/health/educational/wecan/eat-right/
portion-distortion.htm.
Of course, you can still get good value
and be wise by flipping your perspective and following these simple strategies
when you sit down for your next meal out:
■■
Check out the menu before you get to
the restaurant. If you have to have a big
portion, cut it in half and take a portion home for the next day. That way,
you’ll get two meals for the same price
and it will really be a good value! Alternatively, split an entrée with a friend
and order a side salad for each of you.
Decide before the food is put in front of
you that you will cut the portion in half
and not touch serving no. 2!
Be Wise About Size
Flip Your Restaurant Priorities
20 years ago
Today
333 kcal
590 kcal
210 kcal
610 kcal
Today’s bloated portions.
Source: National Heart, Lung, and Blood Institute,
“Portion Distortion,” Accessed April 1, 2015, www
.nhlbi.nih.gov/health/educational/wecan/eat-right/
portion-distortion.htm.
■■ Be wise about size. More doesn’t mean
better quality. Much of what you see as
size is you being duped. Remember that
many restaurants use less expensive
filler foods (potatoes, rice, salad, bread)
and cheaper cuts of meat and protein to
make servings look larger and fill you up
faster. That way you may not realize that
your piece of chicken or other protein
is small or tough, or that in the “all-youcan-eat” area, you’re full to the brim way
before the main course is served.
enjoyment. Comfort food is used to help you feel good when
other things in life are not going well. Our friends and loved
ones are often key influences in our eating behaviors. In fact,
according to recent research, young adults who are overweight
and obese tend to befriend and date overweight and obese
people in much the same way that smokers or exercisers tend
to hang out with other smokers or exercisers. Gaining or losing weight may be affected by other people’s support for weight
loss or social undermining of weight loss attempts (“Let’s order
pizza!”). Social influences are widely recognized as influences on
nutrition and weight control. In 2014, researchers suggested that
family, friends, work, and community provide the social settings
and influences that create an
human microbiome The
eating culture that prediscombined microorganisms
poses us to obesity. Accordand their genes residing in
the human body.
ing to these researchers, your
156 | PART TWO | Building Healthy Lifestyles
■■ Think about taste and quality first, not
portion size. Prioritize fresh, proteinrich foods, particularly those with
unique tastes and seasonings. Think
about combining two to three different
appetizers or tapas into a meal, choosing things that are healthy. Happy-hour
menus can allow you to combine some
smaller plates and save money while
eating foods you wouldn’t find on your
meal plan or cook yourself!
■■ Take your time. Go slowly, and taste
your food. Chew more, talk more, set
your fork down more often between
bites, and don’t wash your food down
with a beverage. Savor the flavor.
■■ Order condiments and dressings on the
side and don’t use the entire container!
Lightly dip your food in dressings or gravies rather than pouring on extra calories.
■■ Avoid buffets and all-you-can-eat
establishments. If you go to them, use
small plates and fill them with salads,
vegetables, and other high-protein,
low-calorie, low-fat options.
■■ Pay careful attention to newly required
menu labeling for fast-food restaurants.
These can be helpful in making sure you
choose the best alternative for healthy
dining. Focus on the entrée and avoid
the biggie fries or super-sized drinks.
Source: Data are from National Heart, Lung, and
Blood Institute, “Portion Distortion: Eat Right,” April 1,
2015, www.nhlbi.nih.gov/health/educational/wecan/
eat-right/portion-distortion.htm.
chances of becoming
obese increase by 57
percent if a close friend
is obese, by 40 percent if
a sibling is obese, and by
37 percent if your partner or spouse is obese.42
Today, researchers are
proposing that you may
actually become obese
as a form of social contagion in which obesity
spreads among people
through their interactions and influences in
a given community.43
WHAT DO
YOU THINK?
■■ Why do you
think the United
States has become one of the
most overweight nations on Earth,
even though we have policies and
educational programs in place
to fight our epidemic of obesity/
overweight? What should we do
differently (policies/programs, etc.)
to motivate people to lose weight
and keep it off? What do you
think should be done on campus
to help people reduce risks of
overweight/obesity?
TABLE 6.2
early Food Availability Per Capita/Year in Pounds:
| YUnited
States, 1970 and 2017
1970
2017
Coffee, tea, cocoa, spices
205
321
Vegetables
328
381
Fats and oils
56
83*
Red meat, chicken
40
89
7
11
94
121
Sugar and Sweeteners
119
129
Fruit (Fresh)
137
115
Dairy Products
564
628
Fish and shellfish
Grains
* 2010 represents the most recent data.
Source: United States Department of Agriculture, Food Availability (Per Capita) Data System, January 17, 2018, www.ers.usda.gov/
data-products/food-availability-per-capita-data-system/.
Socioeconomic status can also have a sig­­­
nificant effect
on risk for obesity. When times are tough, people tend to eat
more inexpensive, high-calorie processed foods. People living
in poverty may have less access to fresh, nutrient-dense foods
and have less time to cook nutritious meals due to shift work,
longer commutes, or multiple jobs. Counselors, fitness center
memberships, and other supports for weight loss are often too
expensive or unavailable. Additionally, unsafe neighborhoods
and poor infrastructure, such as lack of sidewalks or parks, can
make it difficult for less-affluent people to exercise.44
Emerging Theories on Obesity
Risks
rhythm and high blood pressure pills, corticosteroids used
for skin conditions and other problems, diabetes drugs, and
cancer medications in increased weight gain and weight fluctuation. Finding the underlying mechanisms for each type of
drug is important for prevention efforts.47
Sleep Deprivation
People who are sleep deprived
tend to have significant drops in leptin, which plays a role
in metabolism, insulin sensitivity, and other weight-related
changes as well as disruptions in circadian rhythms, which
may increase obesity risks.48 (See Chapter 4 for leptin’s role
in sleep.)
There is much emerging research on factors that may increase
obesity risk. The results may offer opportunities for prevention
and control.
LO 3 | ASSESSING BODY WEIGHT
AND BODY COMPOSITION
Pathogens and Environmental Toxins
Discuss reliable options for determining a healthy weight and body
fat percentage.
Several researchers have studied the role of viruses and other
pathogens in a form of infectobesity. Most of this research
focuses on the effect of viruses. bacteria, and, most recently,
antibiotics, in altering intestinal flora, metabolism, hunger
and satiety, and insulin sensitivity. Each of these factors is
believed to influence the human microbiome—the combined microorganisms and their genes that affect our risk for
obesity and other health outcomes.45
Researchers are also examining how over three dozen chemicals may alter bacteria in the gastrointestinal tract and predispose people to obesity. Paints, pesticides, floor coverings, and
other chemical-containing products are among possible culprits in increased obesity risk.46
Drugs
Several studies have examined the role of prescription drugs such as antidepressants, allergy medications, heart
Everyone has his or her own ideal weight, based on individual variables such as body structure, height, and fat
distribution. Traditionally, experts used measurement techniques such as height-weight charts to determine whether
an individual was an ideal weight, overweight, or obese.
These charts can be misleading because they don’t take body
composition—a person’s ratio of fat to lean muscle—or fat
distribution into account. More accurate measures of evaluating healthy weight and disease risk focus on a person’s
percentage of body fat and how that fat is distributed in his
or her body.
It’s important to remember that body fat isn’t all bad.
In fact, some fat is essential for healthy body functioning. Fat regulates body temperature, cushions and insulates
organs and tissues, and is the body’s main source of stored
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 157
energy. Body fat is composed of
two types: essential fat and storage fat. Essential fat is the fat necessary for maintenance of life
and reproductive functions. Sto­rage
fat, the nonessential fat that many
of us try to shed, makes up the
remainder of our fat reserves.
Being underweight, or having extremely low body fat, can
cause a host of problems, including
hair loss, visual disturbances, skin
problems, a tendency to fracture
bones easily, digestive system disturbances, heart irregularities, gastrointestinal problems, difficulties
in maintaining body temperature, and loss of menstrual periods
in women.
4’6” 24 27 29 31 34 36 39 41 43 46 48 51 53 55 58 60 63
4’8” 22 25 27 29 31 34 36 38 40 43 45 47 49 52 54 56 58
4’10” 21 23 25 27 29 31 33 36 38 40 42 44 46 48 50 52 54
5’0” 20 22 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Height (feet and inches)
5’2” 18 20 22 24 26 27 29 31 33 35 37 38 40 42 44 46 48
5’4” 17 19 21 22 24 26 28 29 31 33 34 36 38 40 41 43 45
5’6” 16 18 19 21 23 24 26 27 29 31 32 34 36 37 39 40 42
5’8” 15 17 18 20 21 23 24 26 27 29 30 32 33 35 37 38 40
5’10” 14 16 17 19 20 22 23 24 26 27 29 30 32 33 34 36 37
6’0” 14 15 16 18 19 20 22 23 24 26 27 29 30 31 33 34 35
6’2” 13 14 15 17 18 19 21 22 23 24 26 27 28 30 31 32 33
6’4” 12 13 15 16 17 18 20 21 22 23 24 26 27 28 29 30 32
6’6” 12 13 14 15 16 17 19 20 21 22 23 24 25 27 28 29 30
6’8” 11 12 13 14 15 17 18 19 20 21 22 23 24 25 26 28 29
6’10” 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Body Mass Index
Recall that BMI is a description of body weight relative to
height—numbers that are highly
correlated with your total body
fat. Find your BMI in inches and
pounds in FIGURE 6.5, or calculate your BMI now by dividing your
weight in kilograms by height in
meters squared. The mathematical
formula is
BMI = weight
squared (m2)
(kg)/height
7’0” 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
100
120
140
160
180
200
Weight (pounds)
220
240
260
Key:
Underweight
Overweight
Normal weight
Obese
FIGURE 6.5 Body Mass Index (BMI) Locate your height, read across to find your
weight, and then read up to determine your BMI. Note that BMI values have been rounded
off to the nearest whole number.
A BMI calculator is also available from the National Heart,
Lung, and Blood Institute at www.nhlbi.nih.gov/guidelines/
obesity/BMI/bmicalc.htm, along with their standard classification system.
Limitations of BMI Although BMI is often considered a way to assess body fat, it is actually a surrogate measure
since it measures excess weight, rather than excess fat tissue,
via calculation measures. Because it is highly correlated with
more direct measures of body composition such as underwater
weighing, bod pod, and dual-energy X-ray absorptiometry, it
is often used as a quick indiunderweight Having a body
cator of body fat. Desirable
weight more than 10 percent
BMI levels may vary with age
below healthy recommended
and by sex; however, most
levels; in an adult, having a BMI
below 18.5.
BMI tables for adults do not
account for such variables
morbidly obese Having a
body weight 100 percent or
and, as such, should be viewed
more above healthy recomas a general guide. Water,
mended levels; in an adult,
muscle, and bone mass are not
having a BMI of 40 or more.
158 | PART TWO | Building Healthy Lifestyles
included in BMI calculations, and BMI levels don’t account
for the fact that muscle weighs more than fat. BMI levels can
be inaccurate for people who are under 5 feet tall; who are
highly muscled; who have certain physical disabilities, such
as injuries to the spinal column; or who are older and have
little muscle mass. Although a combination of measures might
be most reliable in assessing fat levels, BMI continues to be a
quick, inexpensive, and useful tool for developing basic health
recommendations.49
Youth and BMI Although BMI levels in youth are
calculated in the same way as BMI levels in adults, they are
interpreted and discussed differently. Today, nearly 19 percent
of American youth aged 2 through 19 are obese.50 Although
the labels obese and morbidly obese have been used for years
for adults, there is growing concern that such labels increase
bias and obesity stigma against youth. According to a recent
study, when subjected to bias and discrimination, the person
who is the recipient of stigma is actually more likely to eat
more and have other negative emotional and psychological
outcomes.51 BMI ranges above a normal weight for children
Underwater (hydrostatic)
weighing:
Measures the amount of water a
person displaces when completely
submerged. Fat tissue is less dense
than muscle or bone, so body fat can
be computed within a 2%–3%
margin of error by comparing weight
underwater and out of water.
Skinfolds:
Involves “pinching” a person’s fold
of skin (with its underlying layer of
fat) at various locations of the
body. The fold is measured using a
specially designed caliper. When
performed by a skilled technician,
it can estimate body fat with an
error of 3%–4%.
Stigmatization of people who are obese can contribute to
depression and loss of self-esteem.
and teens are often labeled differently, as “at risk of overweight”
and “overweight,” to avoid the sense of shame such words may
cause. In addition, BMI ranges for children and teens take into
account normal differences in body fat between boys and girls
and the differences in body fat that occur at various ages.
Specific guidelines for calculating youth BMI are available
at the Centers for Disease Control and Prevention website at
www.cdc.gov.
Waist Circumference and Ratio
Measurements
Knowing where your fat is carried may be more important
than knowing how much you carry. Men and postmenopausal women tend to store fat in the upper regions of the
body, particularly in the abdominal area. Premenopausal
women usually store fat in the lower regions of their bodies, particularly the hips, buttocks, and thighs. Waist circumference measurements, including waist-circumference
only, the waist circumference-to-hip ratio, and the waist
circumference-to-height ratio, have all been used to measure
abdominal fat as an indicator of obesity and health risk.
Both general obesity and central obesity increase risk of
diabetes, cardiovascular disease, hypertension, and stroke;
however, central obesity appears to carry a significantly
higher risk of stroke.52
A waistline greater than 40 inches (102 centimeters) in
men and 35 inches (88 centimeters) in women may be particularly indicative of greater health risk.53 If a person is less
than 5 feet tall or has a BMI of 35 or above, waist circumference standards used for the general population might
not apply.
The waist circumference-to-hip ratio measures regional
fat distribution. The higher your waist-to-hip ratio is, the
greater chance of having increased health risks.54 Newer
Bioelectrical impedance analysis
(BIA):
Involves sending a very low level of
electrical current through a person’s
body. As lean body mass is made up
of mostly water, the rate at which
the electricity is conducted gives an
indication of a person’s lean body
mass and body fat. Under the best
circumstances, BIA can estimate body
fat with an error of 3%–4%.
Dual-energy X-ray absorptiometry
(DXA):
The technology is based on using
very-low-level X-rays to
differentiate between bone tissue,
soft (or lean) tissue, and fat (or
adipose) tissue. The margin of error
for predicting body fat is 2%–4%.
Bod Pod:
Uses air displacement to measure
body composition. This machine is
a large, egg-shaped chamber
made from fiberglass. The person
being measured sits in the
machine wearing a swimsuit. The
door is closed and the machine
measures how much air is
displaced. That value is used to
calculate body fat, with a 2%–3%
margin of error.
FIGURE 6.6 Overview of Various Body Composition
Assessment Methods
Source: Adapted from J. Thompson and M. Manore, Nutrition: An Applied
Approach, 4th ed., © 2015. Printed and electronically reproduced by permission
of Pearson Education, Inc., Upper Saddle River, New Jersey.
research has pointed to waist-to-hip ratio being more effective than waist circumference alone or BMI use when measuring body fat in children and adolescents.55 A waist
circumference-to-height ratio is a simple screening tool that
says your waist should be approximately one-half of your
height; if you are 70 inches tall, your waist shouldn’t be more
than 35 inches.
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 159
STUDENT
HEALTH TODAY
M
illions of Americans start their New
Year with the most popular resolution:
to lose weight and keep it off. Research
indicates that losing even 5 percent of your
total weight can significantly reduce risks
for a variety of health problems, and let’s
face it, most people want to look and feel
better, too, and vow to get rid of those
extra pounds. While many are successful,
the majority who lose some weight ultimately regain it. But what about those few
losers who manage to keep it off?
In general, the literature indicates success rates between 2 and 15 percent,
using a variety of weight and BMI parameters, as well as timelines for defining success. What works for one person won’t
necessarily work for another. However,
based on recent studies, characteristics
of those likely to be successful include the
following.
■■ Those who have strong initial weight
loss in the first month are most likely to
be successful at 1 year; hence, having
supports for change and incentives to
keep going are critical to early and sustained success.
■■ Those who attend group sessions for
support in those first months are more
likely to be successful.
■■ High self-esteem and self-efficacy (success breeds success) are important.
Who Wins at Losing?
Characteristics of Successful Losers
■■ A strong internal locus of control—
being motivated by internal rather than
external factors—is key.
■■ Having awareness of current risks
and reasonable knowledge of healthy
nutrition is helpful. Keep healthy foods
readily available at home.
■■ Knowing how to access and utilize
community resources is important.
■■ People who journal and track calories,
nutrients, and/or portion sizes, as
well as monitor weight regularly, find
success. Contrary to many sources,
weighing daily seems to be the best
way to keep in control and stay motivated. Using electronic tracking/monitoring devices shows great promise in
motivating change.
■■ Making a commitment to follow a
healthy, realistic eating and exercise
pattern and setting specific goals prove
valuable. For example, “I will walk 30
minutes at a moderate intensity, 3 days
this week, and get at least 10,000 total
steps each day” and “I will eat 5 servings of fruits and vegetables on 5 days
this week” are measurable goals.
■■ Staying positive, practicing self-­
compassion, taking a mindful approach
to eating rather than eating mindlessly,
and avoiding becoming discouraged by
setbacks are vital guidelines. When you
Measures of Body Fat
There are numerous ways to assess whether your body fat levels are too high. One low-tech way is simply to look in the mirror or consider how your clothes fit now compared with how
they fit last year. For those who wish to take a more precise
measurement of their percentage of body fat, more accurate
techniques are available, several of which are described and
depicted in FIGURE 6.6 on page 159. These methods usually
involve the help of a skilled professional and typically must
be done in a lab or clinical setting. Before undergoing any procedure, make sure you understand the expense, potential for
accuracy, risks, and training of the tester. Also, consider why
you are seeking this assessment and what you plan to do with
the results.
160 | PART TWO | Building Healthy Lifestyles
have a “miss,” get right back on track
the next day.
■■ Using weight loss programs that
include exercise have greater chances
of success. Find something you like to
do. Try to include meditation or yoga in
your weekly routine.
■■ Sleep as if your life depended on it!
Renew and refresh so you have the
energy to focus on what you need to
do to meet the challenges of your day.
Sources: F. Magkos et al., “Effects of Moderate and Subsequent Progressive Weight Loss on
Metabolic Function and Adipose Tissue Biology
in Humans with Obesity,” Cell Metabolism 23,
no. 4 (2016): 591–601; A. Sifferlin, “The Weight
Loss Trap: Why Your Diet Isn’t Working,” Time,
May 25, 2017, www.time.com/4793832/theweight-loss-trap/; M. Batterham et al., “Using
Data Mining to Predict Success in a Weight Loss
Trial,” Journal of Human Nutrition and Dietetics
30, no. 4 (2017): 471–78; S. Soini et al., “LongTerm Weight Maintenance after Successful Weight
Loss: Motivational Factors, Support, Difficulties,
and Success Factors,” American Journal of Health
Behavior 42, no. 1 (2018): 77–84; S. Guendelman
et al., “Weight Loss Success among Overweight
and Obese Women of Mexican-Origin Living in
Mexico and the United States: A Comparison
of Two National Surveys,” Journal of Immigrant
and Minority Health (2016): 1–9; O. Santos et al.,
“Weight Control Behaviors of Highly Successful
Weight Loss Maintainers: The Portuguese Weight
Control Registry,” Journal of Behavioral Medicine
40, no. 2 (2017): 366–71.
LO 4 | MANAGING YOUR WEIGHT:
INDIVIDUAL ROLES
Explain the effectiveness and potential pros/cons of various weight
control strategies, including exercise, diet, lifestyle modification,
supplements/diet drugs, surgery, and other options.
At some point, almost all of us will decide to lose weight. Many
will have mixed success and others will fail. Failure is often
related to thinking about losing weight in terms of shortterm “dieting” rather than adjusting long-term behaviors.
Drugs and intensive counseling can contribute to positive
weight loss, but even then, many people regain weight after
­treatment. Maintaining a healthy body takes constant attention and nurturing. The STUDENT HEALTH TODAY box looks
at characteristics of successful weight losers.
Understanding Calories and
Energy Balance
A calorie is a unit of measure that indicates the amount of
energy gained from food or expended through activity.
Although many factors affect weight gain, each time you
consume 3,500 calories more than your body needs to maintain weight, you gain about 1 pound of storage fat. Conversely,
each time your body expends an extra 3,500 ­calories, you lose
about 1 pound of fat. If you consume 140 calories (the amount
in one can of regular soda) more than you need every single
day and make no other changes in diet or activity, you would
gain 1 pound in 25 days (3,500 calories ÷ 140 calories per day =
25 days). Conversely, if you walk for 30 minutes each day at a
pace of 15 minutes per mile (172 calories burned) in addition
to your regular activities, you would lose 1 pound in 20 days
(3,500 calories ÷ 172 calories per day = 20.3 days). FIGURE 6.7
illustrates the concept of energy balance.
Diet and Eating Behaviors
Successful weight loss requires shifting energy balance. The
first part of the equation is to reduce calorie intake through
modifying eating habits and daily diet.
Being Mindful of Your Eating Triggers
When you sit down to eat, is your mind actually “out to lunch”?
If you are like the 66 percent of American adults who eat in front
of the TV or computer, it should be no surprise that you are eating faster and eating more, with more awareness of the TV than
of your food.56 Mindless eating, or putting food in your mouth
Energy
expenditure
Energy
intake
Energy expenditure = Energy intake
FIGURE 6.7 The Concept of Energy Balance Although
“calories in and calories burned” has long been the recipe
for weight control, we now know that genetic, biological,
physiological, social, environmental, and other complex
variables interact to make weight loss more challenging for
some individuals than others.
MAKING CHANGES TODAY
Tips for Sensible Snacking
Keep healthy munchies around. Buy 100 percent whole
wheat breads, and if you need something to spice it
up, use low-fat or soy cheese, low-fat cream cheese,
peanut butter, hummus, or other high-protein healthy
favorites. Some baked or popped crackers are low in
fat and calories and high in fiber.
Keep “crunchies” on hand. Apples, pears, green or red
pepper sticks, popcorn, snap peas, and celery all are
good choices. Wash the fruits and vegetables and cut
them up to carry with you; eat them when a snack attack
comes on.
Choose natural beverages. Drink plain water, 100
percent juice in small quantities, or other low-sugar
choices to satisfy your thirst. Hot tea, coffee (black), or
soup broths are also good choices.
Eat nuts instead of candy. Although relatively high in
calories, nuts are also loaded with healthy fats and are
healthy when consumed in moderation.
If you must have a piece of chocolate, keep it small and
dark. Dark chocolate has more antioxidants.
Avoid high-calorie energy bars. Eat these only if you are
exercising hard and don’t have an opportunity to eat a
regular meal. Select ones with a good mixture of fiber
and protein and that are low in fat, sugar, and calories.
that you don’t really taste or notice while consuming more than
you should, may be a key contributor to excess calorie consumption and weight gain. When we eat mindlessly, we may miss feelings of satiety and ignore tendencies that we might have to use
restraint in shoving potato chips into our mouths. Eating mindfully means eating with awareness—awareness of why we are eating (was it a trigger, or are we really hungry?), what we are eating
(should we really be eating this?), and how much we are eating
(stop! put it down!).
Before you can change an unhealthy eating habit, you must
first determine what triggers you to eat. Keeping a log of eating
triggers—when, what, where, and how much you eat—for 2 to 3
days can help you identify what is pushing those “eat everything in sight” buttons for you.
Typically, dietary triggers center on patterns and problems in everyday living rather than real hunger pangs. Many
people eat compulsively when stressed; however, for other
people, the same circumstances diminish their appetite,
causing them to lose weight. When your mind wanders, you
may find yourself grazing in the refrigerator or pulling into
a fast-food drive-through. Ask yourself: Are you really hungry, or are you eating for comfort and distraction? Focus
on why you have your hand on the chips. If you eat while
working or watching TV, limit what you put on your plate, and
put the rest away. Finally, eat slowly. Focus on what you are
putting in your mouth. Taste your food and savor the flavor.
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 161
If your trigger is . . .
then
try this strategy . . .
A stressful situation
Acknowledge and address feelings of anxiety or stress, and develop
stress management techniques to practice daily.
Feeling angry or upset
Analyze your emotions and look for a noneating activity to deal
with them, such as taking a quick walk or calling a friend.
A certain time of day
Change your eating schedule to avoid skipping or delaying meals
and overeating later; make a plan of what you’ll eat ahead of time
to avoid impulse or emotional eating.
Pressure from friends and family
Have a response ready to help you refuse food you do not want, or look for healthy
alternatives you can eat instead when in social settings.
Being in an environment where
food is available
Avoid the environment that causes you to want to eat: Sit far away from the food at
meetings, take a different route to class to avoid passing the vending machines, shop from
a list and only when you aren’t hungry, arrange nonfood outings with your friends.
Feeling bored and tired
Identify the times when you feel low energy and fill them with activities other than eating, such
as exercise breaks; cultivate a new interest or hobby that keeps your mind and hands busy.
The sight and smell of food
Stop buying high-calorie foods that tempt you to snack, or store them in an inconvenient
place, out of sight; avoid walking past or sitting or standing near the table of tempting
treats at a meeting, party, or other gathering.
Eating mindlessly or inattentively
Turn off all distractions, including phones, computers, television, and radio, and eat more
slowly, savoring your food and putting your fork down between bites so you can become
aware of when your hunger is satisfied.
Spending time alone in the car
Get a book on tape to listen to, or tape your class notes and use the time for studying. Keep
your mind off food. Don’t bring money into the gas station where snacks are tempting.
Alcohol use
Drink plenty of water and stay hydrated. Seek out healthy snack choices. After a night out,
brush your teeth immediately upon getting home and stay out of the kitchen.
FIGURE 6.8
Feeling
deprived
Allow yourself to eat ”indulgences” in moderation, so you won’t crave them; focus on
balancing your calorie input to calorie output.
Eating out
of habit
Establish a new routine to circumvent the old, such as taking a new route to class so you
don’t feel compelled to stop at your favorite fast-food restaurant on the way.
Watching
television
Look for something else to occupy your hands and body while your mind is engaged with the
screen: Ride an exercise bike, do stretching exercises, doodle on a pad of paper, or learn to knit.
Avoid Trigger-Happy Eating Learn what triggers your “eat” response—and what stops it—by keeping a daily log.
See the MAKING CHANGES TODAY box on page 161 for tips
on healthy snacking, and see FIGURE 6.8 for ways to adjust
your eating triggers.
Choosing a Diet Plan
Once you have determined
your triggers, begin to devise a plan for improved eating by
doing the following:
■■
Seek assistance from reputable sources such as MyPlate
(www.choosemyplate.gov), a registered dietitian (RD),
some physicians, health educators, or exercise physiologists with nutritional training.
162 | PART TWO | Building Healthy Lifestyles
Be wary of nutritionists or nutritional life coaches, since
there is no formal credential for those titles.
■ Avoid weight loss programs that promise quick, “miracle”
results or that are run by people who offer short courses on
nutrition and exercise that are designed to sell products or
services.
■ Assess the nutrient value of any prescribed diet, verifying
dietary guidelines are consistent with reliable nutrition
research, and analyzing the suitability of the diet to your
tastes, budget, and lifestyle.
■■
STUDENT
HEALTH TODAY
A
lthough the debate has raged for
decades, recent research supports
the idea that calories consumed ultimately
are more important than exercise in a
weight loss regimen. It turns out that if the
experts are right, you really can’t outrun a
bad diet!
According to the above researchers,
by most indicators, diet trumps exercise
when it comes to weight loss and maintenance. If you want to lose weight in the
short term, portion control and healthy
eating habits are both key to success. Eat
fewer calories and you will lose weight. Of
course, there continue to be critics of the
“diet is the key” philosophy. Numerous
studies have shown that the combination
of diet and exercise is the best way to
lose weight. Other studies have found that
Which Is Best for Weight Loss?
Diet, Exercise, or Both?
exercise plus calorie restriction achieves
the same weight loss as calorie restriction alone, and very few people exercise
enough to affect weight in the long term.
Many who increase physical activity
increase their caloric intake, and when
they do, calories win out.
Does that mean you can just starve
yourself, lose weight, and ignore exercise? Of course not. There are numerous
benefits of exercise that are important to
overall health, psychological health, and
well-being. Diet and exercise, when working together in perfect harmony, continue
to be the most powerful long-term strategy for weight control. Combined, they
also are important in reducing blood lipids,
blood pressure, and the risks of cardiovascular disease and type 2 diabetes.
Sources: K. Hall and S. Kahan, “Maintenance
of Lost Weight and Long-Term Management of
Obesity,” Medical Clinics 102, no. 1 (2018): 183–97;
C. Elliot et al., “Combined Diet and Physical Activity
Is Better Than Diet or Physical Activity Alone at
Improving Health Outcomes for Patients in New
Zealand’s Primary Care Intervention,” BMC Public
Health 18, no. 1 (2018): 230; S. Berger et al.,
“Comparison among Criteria to Define Successful Weight-Loss Maintainers and Regainers in the
Action for Health in Diabetes (Look AHEAD) and
Diabetes Prevention Program Trials,” The American
Journal of Clinical Nutrition 106, no. 6 (2017):
1337–46; I. Santos et al., “Weight Control Behaviors
of Highly Successful Weight Loss Maintainers: The
Portuguese Weight Control Registry,” Journal of
Behavioral Medicine 40, no. 2 (2017): 366–71; A.
Myers et al., “Associations among Sedentary and
Active Behaviours, Body Fat and Appetite Dysregulation: Investigating the Myth of Physical Inactivity
and Obesity,” British Journal of Sports Medicine
(2016): DOI: 10.1136/bjsports-2015-095640.
Any diet that requires radical behavior changes or sets
What makes one diet plan
up artificial dietary programs
work better than another?
through prepackaged prodWhat has worked best for you
ucts is likely to fail. The most
in the past? Watch Low-Carb
successful plans allow you to
Diet Trumps Low Fat in
make food choices in realWeight-Loss Study, available
world settings and do not ask
on Mastering Health.
you to sacrifice everything
you enjoy. See TABLE 6.3 on
page 164 for an analysis of
some popular diets marketed today. For information on other
plans, check out the regularly updated list of reviews on the
website of the Academy of Nutrition and Dietetics (formerly
the American Dietetic Association) at www.eatright.org.
SEE IT! VIDEOS
Including Exercise
Although a healthy diet may be the most important factor
in weight loss, diet and exercise combine to help people lose
weight and increase muscle mass and to maintain any weight
loss they have achieved. Because lean (muscle) tissue is more
metabolically active than fat tissue, having more muscle
mass means that you burn more calories. Exact estimates
vary, but experts currently think that 2 to 50 more calories
per day are burned per pound of muscle than per pound of
fat tissue. Thus, the base level of calories needed to maintain
a healthy weight varies greatly from person to person.
Participating in daily physical activity is key to managing
your weight, as well as overall fitness and health.
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 163
TABLE 6.3 | Overall Best Diets in 2018
Good for
Diabetes and
Heart Health?
Weight Loss
Effectiveness
Pros, Cons, and Other
Things to Consider
Yes
Not specifically
designed for
weight loss.
A balanced, safe, and healthy diet,
tied for no. 1 best diet overall by
U.S. News & World Report in 2018.
Although not designed for weight
reduction per se, it is regarded
as very effective in improving
cholesterol levels and other
biomarkers long term.
Developed by National
Institutes of Health (NIH). Focus
on CVD risk reduction with
fruits and veggies, lean protein,
low fat, etc. Balanced and
effective.
Yes
Weight loss likely;
cholesterol key.
Safe, balanced, and healthy diet,
tied for no. 5 best diet by U.S.
News & World Report in 2018.
Particularly good for heart health
and cholesterol reduction.
Mediterranean
A plan that emphasizes fruits,
vegetables, fish, whole grains,
beans, nuts, legumes, olive
oil, and herbs and spices.
Poultry, eggs, cheese, yogurt,
and red wine can be enjoyed
in moderation, whereas sweets
and red meat are saved for
special occasions.
Yes
Effective
Widely considered to be one of the
more healthy, safe, and balanced
diets. Weight loss may not be as
dramatic but long-term health
benefits have been demonstrated.
Tied for no. 1 best diet overall by
U.S. News & World Report in 2018.
Relatively easy to follow.
Weight Watchers
New “Beyond the Scale”
program, which emphasizes
three components: eating
healthier, fitness that fits your
life, and “developing skills and
supportive connections to help
you stay on track.” Involves
tracking food, nutritional values,
and exercise. Total points
allowed depend on activity
level and personal weight
goals. Online membership or
in-person group meetings are
options.
Yes (depending on
individual choices)
Effective
Consistently rated by experts as
one of the top, most effective
weight loss programs. Rated no.
4 best overall diet in U.S. News
& World Report in 2018. Flexible
programs that don’t deny foods,
but rather teach about healthy
choices. Works for both short- and
long-term weight loss. Support
groups are available, but can do
online in privacy of home with
coaches. Planning for indulgences
helps maintain control. Check your
campus or community for meeting
times and watch for specials.
While not as expensive as some
plans, there are membership fees.
Rated number one weight loss
diet by U.S. News & World Report
in 2016.
MIND Diet
Combines best elements of
DASH and Mediterranean diets
into a healthy dietary regimen.
Yes
Effective
Tied for no. 5 best diet overall by
U.S. News & World Report in 2018.
Noteworthy for potential to boost
brain power and reduced risk of
cognitive decline.
FLEXITARIAN
Balanced approach that is
primarily vegetarian with an
occasional meat substitute.
Includes grains, nuts, beans,
seeds, dairy, sugar, and fruits
and vegetables, for around
1,500 calories per day. Healthy
nutritional approach, flexible.
Helps prevent
CVD, type 2
diabetes, and
some cancers.
Steady weight
loss.
Weight loss and scientifically
supported approach with
emphasis on food groups and use
of healthy plant proteins. Rated no.
3 best diet overall by U.S. News &
World Report in 2018.
Diet Name
Basic Principles
DASH (Dietary
Approaches
to Stop
Hypertension)
A balanced plan developed to
fight high blood pressure. Eat
fruits, veggies, whole grains,
lean protein, and low-fat dairy.
Avoid sweets, fats, red meat,
and sodium.
TLC (Therapeutic
Lifestyle Change)
Sources: Opinions on diet pros and cons are based on U.S. News & World Report, “Best Diets Overall,” 2018.
164 | PART TWO | Building Healthy Lifestyles
TECH
& HEALTH
S
tudies consistently report that
people who keep detailed food and
exercise journals lose more weight and
keep it off longer than those who do
not. Want to track what you ate today
in terms of total calories and amount of
nutrients? There’s an app for that. Want
to track your walking, running, swimming, lifting, and sleeping activities?
There are apps for that, too.
The best programs combine food
and physical activity logs, so if you
splurge on dessert, you can figure out
how many miles you’ll need to jog to
burn it off. These apps often feature
calculators for determining daily calorie
intake goals as well as barcode scanners that allow you to quickly add
packaged foods to your log. Check for
WHAT DO
YOU THINK?
If you wanted to lose
weight, what strategies
would you most likely choose?
■■ Which strategies, if any, have
worked for you before?
■■ What factors might serve to
Tracking Your Diet or Weight Loss?
There’s an App for That
pricing and hidden fees and all of these
to determine whether they are truly free
or if there is a hook to get you purchasing more of their products and features.
Here are just a few of the latest apps for
iPhone and Android users:
My Fitness Pal Calorie Counter and
Diet Tracker. Easy-to-use app for
those interested in tracking details of
diet, calories, and exercise. Includes
easy data entry, barcode scanning via
phone to analyze food purchases, and
meal logs to help you assess progress
and set goals.
■■ Lose It. Tracks calorie intake and
exercise; also has incentives and
support forums to help you stay
motivated. Barcode scanners report
■■
The number of calories
spent through physical
activity depends on three
factors:
1. The number and proportion of muscles used
2. The amount of weight
moved
3. The length of time the
activity takes
help or hinder your weight
loss efforts?
An activity involving
both the arms and legs
burns more c­ alories than one involving only the legs. An activity performed by a heavy person burns more calories than the
same activity performed by a lighter person. And, an activity performed for 40 minutes requires twice as much energy
as the same activity performed for only 20 minutes. See the
STUDENT HEALTH TODAY box on page 163 for more on diet
and exercise.
Keeping Weight Control in
Perspective
Weight loss is a struggle for many people, and as discussed
earlier, many factors influence success or failure. To reach
and maintain a healthy weight, develop a program of exercise
and healthy eating behaviors that you can maintain. Avoid
extreme diets that may reset your BMR and make weight loss
weekly calories from packaged foods.
“Snap it” features take a picture of
what you are eating and register portion size and likely calories. Scientifically validated by experts.
■■ Mindful Eating Tracker. Focuses on
inner hunger cues and fullness cues.
What triggers your “need to eat”
response. Tracks calories and works
with decision making around food
cues to help you recognize your own
triggers for eating when you aren’t
hungry or mindless eating.
■■ SparkPeople. Allows you to log
meals and exercise from a huge database. Has a barcode scanner, exercise demo access, and motivational
points for goals achieved.
more difficult. Remember, you didn’t gain your weight in a
week or two, and it is both unrealistic and potentially dangerous to take drastic weight loss measures. Instead, try to lose
a healthy 1 to 2 pounds during the first week, and stay with
this slow and easy regimen. Adding exercise and cutting back
on calories to expend about 500 calories more than you consume each day will help you lose weight at a rate of 1 pound
per week. You may find tracking your intake and activity easier
with one of the apps described in the TECH & HEALTH box.
See the MAKING CHANGES TODAY box on page 166 for strategies to help your weight management program succeed.
Considering Drastic Weight Loss
Measures?
When nothing seems to work, some people become frustrated
and pursue high-risk, unproven methods of weight loss or
seek medical interventions. Dramatic weight loss may be recommended in cases of extreme health risk. Even then, drastic
dietary, pharmacological, or surgical measures should be considered carefully and discussed with several knowledgeable,
licensed health professionals working in accredited facilities.
Very-Low-Calorie Diets
In severe cases of obesity that are not responsive to traditional dietary strategies,
medically supervised, powdered formulas with daily values of
400 to 700 calories plus vitamin and mineral supplements may
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 165
be given to patients. Many of these diets emphasize high levels of protein and very low amounts of carbohydrates. Such
very-low-calorie diets (VLCDs) should never be undertaken
without strict medical supervision. They do not teach healthy
eating, and persons who manage to lose weight on VLCDs
or prolonged fasts may experience significant weight regain.
Problems associated with any form of severe caloric restriction
include blood sugar imbalance, cold intolerance, constipation,
decreased BMR, dehydration, diarrhea, emotional problems,
fatigue, headaches, heart irregularities, kidney infections and
failure, loss of lean body tissue, weakness, and the potential for
coma and death.
One particularly dangerous potential complication of
VLCDs occurs when the person’s brain cells and red blood
cells don’t have enough of the glucose they need for energy.
When this happens, the body begins to burn stored fat for
energy, producing ketones—acidic chemicals that can cause
major risks to health. Over time on VLCDs or starvation diets,
these ketones can increase, the person may not feel hungry
or thirsty, and weight loss may occur. As ketones increase and
ketosis progresses, ketoacidosis or acidic blood levels are likely.
This is a potentially dangerous complication of VLCD diets or
starvation diets.
Weight Loss Supplements and Over-theCounter Drugs Thousands of over-the-counter supplements and drugs that claim to make weight loss fast and
easy are available for purchase. It’s important to note that U.S.
Food and Drug Administration (FDA) approval is not required
for over-the-counter “diet aids” or supplements. The lack of
regular and continuous monitoring of supplements in the
United States leaves consumers vulnerable to fraud and potentially toxic “remedies.” Most dietary supplements contain
stimulants, such as caffeine, or diuretics, and their effectiveness in promoting weight loss has been largely untested and
unproved by any scientific studies. In many cases, the only
thing that users lose is money. In review studies, virtually all
persons who used supplements and diet pills regained their
weight once they stopped taking them.57
Supplements containing Hoodia gordonii, an African
­cactus-like plant, have become popular in recent years; these
supplements may also contain more unproven ingredients such
as bitter orange and other stimulants.
Products containing ephedra can cause rapid heart rate,
tremors, seizures, insomnia, headaches, and raised blood pressure, all without significant effects on long-term weight control. St. John’s wort and other alternative medicines reported
to enhance serotonin, suppress appetite, and reduce the side
effects of depression have not been shown to be effective in
weight loss, either.
Until relatively recently, FDA-approved diet pills were available only by prescription and were closely monitored. This
changed in 2007 when the
FDA approved the first oververy-low-calorie diets
the-counter weight loss pill:
(VLCDs) Diets with a daily
a half-strength version of
caloric value of 400 to 700
calories.
the prescription drug orlistat
166 | PART TWO | Building Healthy Lifestyles
MAKING CHANGES TODAY
Keys to Successful Weight
Management
MAKE A PLAN
Establish short- and long-term plans. What are the diet
and exercise changes you can make this week? Once
you do 1 week, plot a course for 2 weeks, and so on.
Look for balance. Remember, calories taken in and
burned over time are what make the difference.
CHANGE YOUR HABITS
Be adventurous. Expand your usual foods to enjoy a
wider variety.
Eat small portions, less often, and savor the flavor.
Notice whether you are hungry before starting a meal. Eat
slowly, noting when you begin to feel full, and stop before
you are full.
Eat breakfast, especially low-fat foods with whole grains
and protein. This will prevent you from being too hungry
and overeating at lunch.
Keep healthful snacks on hand for when you get hungry.
INCORPORATE EXERCISE
Be active and slowly increase your time, speed, distance,
or resistance levels.
Vary your physical activity. Find activities that you really
love and try things you haven’t tried before.
Find an exercise partner to help you stay motivated.
(brand name Xenical), marketed as Alli. This drug inhibits the
action of lipase, an enzyme that helps the body to digest fats,
causing about 30 percent of fats consumed to pass through the
digestive system undigested, leading to reduced overall caloric
intake. Known side effects of orlistat include gas with watery
fecal discharge; oily stools and spotting; frequent, often unexpected, bowel movements; and possible deficiencies of fat-soluble vitamins.
Prescription Weight Loss Drugs
Several FDAapproved weight loss drugs are now available after more than
10 years of inactivity. Belviq and Qsymia, which were among
the first available, were met with much controversy and carry
several warnings and restrictions. Qsymia is an appetite suppressant and antiseizure drug that reduces the desire for food.
Belviq affects serotonin levels, helping patients feel full. Newer
Staples
Small
stomach
pouch
Esophagus
Stomach
Band
Bypassed
stomach
Small stomach
pouch
New connection
with small intestine
Small
stomach
pouch
Larger
stomach
pouch
Band
Lower
portion
of small
intestine
Unused
portion of
small intestine
Small intestine
a Normal anatomy
b Sleeve gastrectory
c Gastric bypass
d Gastric banding
9
FIGURE 6.9
Weight Loss Surgery Alters the Normal Anatomy of the Stomach
Source: Adapted from J. Thompson and M. Manore, Nutrition: An Applied Approach, 4th ed., ©2015. Printed and electronically reproduced by permission of
Pearson Education, Inc., Upper Saddle River, New Jersey.
drugs, such as Contrave, combine antidepressants with
A new strategy to keep
other approved drugs and
off the weight? Watch
carry warnings specific to
Experiment Shows Portion
both. Today, there are nearly
Control Is the Key to
65 prescription, over-theHealthy Eating, available
counter, alternative, and offon Mastering Health.
label options. When used as
part of a long-term, comprehensive weight loss program, weight loss drugs can potentially
help severely obese individuals to lose weight and keep it off;
however, few of these drugs are without side effects. Investigate side effects and check with your doctor before using any
of these drugs.58
SEE IT! VIDEOS
Surgery When all else fails, particularly for those who are
severely overweight and have weight-related diseases, a person
may be a candidate for weight loss surgery (bariatric surgery).
Generally, these surgeries fall into one of two major categories:
restrictive surgeries, such as gastric banding or lap banding, that
limit food intake; and malabsorption surgeries, such as gastric
bypass, which decrease the absorption of food into the body
(see FIGURE 6.9).
To select the best option, a physician will consider the operation’s benefits and risks and the patient’s age, BMI, eating
behaviors, obesity-related health conditions, mental history,
dietary history, and previous operations. Like drugs prescribed
for weight loss, surgery for obesity also carries risks for consumers. Some health advocates have proposed that obesity be
classified as a disability, which could potentially affect a physician’s decision on recommending surgery.
In gastric banding and other restrictive surgeries, the surgeon uses an inflatable band to partition off part of the stomach. The band is wrapped around that part of the stomach
and is pulled tight, like a belt, leaving only a small opening
between the two parts of the stomach. The upper part of the
stomach is smaller, so the person feels full more quickly, and
food digestion slows so that the person also feels full longer.
Although the bands are designed to stay in place, they can be
removed surgically. They can also be inflated to different levels
to adjust the amount of restriction.
Sleeve gastrectomy is another form of restrictive weight
loss that is often done laparoscopically. In this surgery,
about 75 percent of the stomach is removed, leaving only a
tube (about the size of a banana) or sleeve that is connected
directly to the intestines. This procedure achieves weight loss
and health benefits similar to those seen with gastric bypass.
However, this procedure isn’t reversible and potential risks
may be higher.
Gastric bypass is one of the most common types of weight
loss surgery and it combines restrictive and malabsorption elements. It can be done laparoscopically or via full open surgery.
In this surgery, a major section (as much as 70 percent) of the
stomach is sutured off, restricting the amount of food you can
eat and absorb. The remaining pouch is hooked up directly
to the small intestine. As with sleeve gastrectomy, results are
fast and dramatic, with health issues related to obesity, such as
diabetes, high blood pressure, arthritis, sleep apnea, and other
problems, diminishing in a short time.
While weight loss tends to be maintained and health problems decline after gastric bypass surgery, there are many risks,
including nutritional deficiencies, blood clots in the legs, a
leak in a staple line in the stomach, pneumonia, infection,
and, although rare, even death. Another risk is rapid gastric
emptying, commonly referred to as “dumping,” in which undigested foods rush through the small intestine, causing cramping and problems with uncontrollable diarrhea.59 Because the
stomach pouch that remains after surgery is only the size of
a lime, the person can drink only a few tablespoons of liquid
and consume only a very small amount of food at a time. For
this reason, other possible side effects include nausea, vitamin
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 167
DID YOU
KNOW?
Obesity can affect fertility in men,
leading to impaired sperm counts,
reduced testosterone levels, erectile
dysfunction, and poor libido. Simply
taking a testosterone
supplement or other
drugs does not seem
to be effective treatment. Those who
also smoke appear
to have even greater
risks of problems
in this area. If you
notice issues, see
your doctor.
Source: V. Stokes et al., “How Does Obesity Affect Fertility in Men—and What
Are the Treatment Options?” Clinical Endocrinology 82, no. 5 (2015): 633–38.
and mineral deficiencies, and dehydration. Additional risks
include those from anesthesia, as well as the potential for
excess bleeding, ulcers, and hernia.
A technique gaining in popularity because it is even more
effective than gastric bypass for rapid weight loss is the biliopancreatic diversion or duodenal switch procedure, which combines elements of restrictive and malabsorption surgeries.
The patient receives a partial gastrectomy to reduce the size
of the stomach (less than the reduction with gastric bypass)
while bypassing less of the small intestine. The pyloric valve
remains intact, which helps prevent dumping syndrome,
ulcers, blockages, and other problems that can occur with
other techniques. This surgery is one of the most difficult and
highest-risk surgeries for patients, with the risk of death and
other complications higher than those of other options.60
Considerable research has demonstrated exciting, unexpected results from gastric surgeries: Even prior to weight
loss, patients have shown complete remission of type 2 diabetes in the majority of cases, with drastic reductions in
blood glucose levels in others. Add postsurgical exercise to
the formula and both weight loss and relief of type 2 diabetes occur.61 While extremely promising, newer research indicates that about one-third of those who have gastric surgery
with remission of diabetic s­ ymptoms will relapse and begin
to show diabetic symptoms within 5 years after surgery. For
those at high risk from these diseases, the choice of undergoing surgery may ultimately be similar to the risk of maintaining their current weight.
Bariatric arterial embolization (BAE) is a new nonsurgical
alternative to gastric bypass in which a catheter is inserted
168 | PART TWO | Building Healthy Lifestyles
Former American Idol judge and record producer Randy
Jackson underwent gastric bypass surgery to shed well
over 100 pounds and reduce the risks of serious chronic
diseases such as type 2 diabetes.
through the wrist or groin and targets blood vessels in the
stomach where the “hunger hormone” ghrelin is produced.
Microscopic beads designed to block ghrelin production are
injected in the vessels, causing the patient to be less hungry.
With lifestyle and dietary modifications as well as exercise,
results of limited early trials appear promising.
Thus, other options for weight loss via surgical or nonsurgical treatments are not a panacea for weight loss. All have risks,
with diet and exercise as part of a sound weight control program being the best option for most.
Unlike surgeries that help make weight loss easier, or nonsurgical options such as BAE, liposuction is a surgical procedure
in which fat cells are actually removed from specific areas of
the body. Generally, liposuction is considered cosmetic surgery rather than true weight loss surgery, even though people
who have it lose weight and contour their bodies. Liposuction
is not risk-free. If you are considering this procedure, check the
credentials of the surgeon, the certification of the facility, and
the proximity to emergency care if problems arise.
Things to Consider When Considering
Surgery If you are thinking about surgical remedies for
obesity, it is important to think carefully about your options.
Ask yourself:
1. Have you exhausted all of the nonsurgical strategies for
weight loss? Why are you opting for surgery now?
2. What are your goals (preventing diabetes or other health
risks, getting off diabetes or heart medications, wanting
to improve your overall health, or wanting to feel better
about yourself)?
3. What are the costs? According to a recent study assessing
costs of gastric bypass or adjustable bands procedures,
the costs could easily be over $30,000, with the average
cost of $15,000.62 Does your insurance pay for it? Under
what circumstances, if any?
4. Have you considered where you would have the surgery?
What questions should you ask before opting to have a particular procedure? As with most surgeries, the best results
are likely to occur in accredited facilities, with board-certified surgeons who do large numbers of these procedures
each year and have comprehensive presurgical counsel­ing and follow-up care, as well as support staff. Hospitals
STUDY PLAN
ASSESS YOURSELF
Do you need to lose weight?
CHAPTER REVIEW
|
■■
Overweight, obesity, and weightrelated health problems have reached
epidemic levels globally, termed
globesity, and threatens the health
of many countries, with the United
States having some of the highest
rates of overweight and obesity in
nearly all age groups. Societal costs
from obesity include increased health
Trying to Gain Weight
For some people, trying to gain weight is a challenge. If you
have trouble, the first priority is to determine why you cannot
gain weight. Perhaps you’re an athlete and you burn more calories than you eat. Perhaps you’re stressed out and skip meals
to increase study time. Among older adults, senses of taste and
smell may decline, making food less pleasurable to eat. Visual
problems and other disabilities may make meals more difficult
to prepare, and dental problems may make eating more difficult. People who engage in extreme energy-burning sports
and exercise routines may be at risk for caloric and nutritional
deficiencies, which can lead not only to weight loss, but also to
immune system problems and organ dysfunction; weakness,
which leads to falls and fractures; slower recovery from diseases; and a host of other problems. Underweight individuals
need to examine diet and exercise behaviors and take steps to
achieve and maintain a healthy weight.
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
socioeconomic status, education
level, and lack of access to nutritious
food, and lifestyle factors, including
sedentary lifestyle and high calorie
consumption, all make weight loss
challenging. Significant differences
in obesity risks and resultant health
risks exist by race and ethnicity, geographic location, community
supports/resources, and other
factors.
care costs and lowered worker productivity. Individual health risks
from overweight and obesity include
increased chance of developing cardiovascular diseases, arthritis, stroke,
diabetes, gastrointestinal problems,
and low back pain, among others.
Overweight individuals are also at risk
of struggling with depression, low
self-esteem, and high levels of stress.
Want to find out if you’re ready?
Take the Are You Ready for a WeightLoss Program? assessment available
on Mastering Health.
LO 1 Overweight and
Obesity: A Growing
Health Threat
that have emergency and intensive care facilities for those
who have surgical complications as well as a documented
history of infection control policies and procedures are
among those most likely to have positive outcomes.
|
LO 2 Factors Contributing
to Overweight and
Obesity
■■
It is important to consider biological,
physiological, social, environmental,
cultural, and socioeconomic factors
when working to prevent obesity. In
addition to genetics, metabolism,
hormonal influences, excess fat
cells, and physical risks, key environmental influences, such as poverty,
|
LO 3 Assessing Body Weight
and Body Composition
■■
Percentage of body fat is a fairly
reliable indicator for levels of overweight and obesity. There are many
different methods of assessing body
fat. Body mass index (BMI) is one
of the most commonly accepted
measures of weight based on
height; however, it isn’t as precise
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 169
as underwater weighing and dualenergy X-ray absorptiometry (DXA).
Waist circumference, or the amount
of fat in the belly region, is believed
to be related to the risk for several
chronic diseases, particularly type 2
diabetes.
|
LO 4 Managing Your Weight:
Individual Roles
■■
Increased physical activity, a balanced, healthy diet that controls
caloric intake, and other strategies
are recommended for controlling
your weight. When these options
fail and risks increase, doctorrecommended prescription medications, weight loss surgery, and
other strategies are used to maintain
or lose weight. However, sensible
eating behaviors and aerobic and
muscle-strengthening exercises offer
the best options for weight loss and
maintenance.
POP QUIZ
|
LO 1 Overweight and
Obesity: A Growing
Health Threat
1. All of the following statements are
true except:
a. Hispanic and non-Hispanic
white men are more likely to
be overweight/obese than nonHispanic black or Asian men.
b. Children and adolescents
living in higher-income
homes where parents are
more educated have a greatly
increased risk of obesity over
those living in low-income
homes where parents are less
educated and/or unemployed
in the United States.
c. Non-Hispanic black and
Hispanic women are more
likely to be overweight or obese
than non-Hispanic white
women.
d. The United States has the
distinction of being one
of the most overweight
developed nations on Earth.
170 | PART TWO | Building Healthy Lifestyles
Rates of obesity are increasing
dramatically in low and
medium income countries.
|
LO 2 Factors Contributing
to Overweight and
Obesity
2. The rate at which your body
consumes food energy to sustain
basic functions is your
a. basal metabolic rate.
b. resting metabolic rate.
c. body mass index.
d. set point.
3. All of the following statements are
true except:
a. A slowing basal metabolic rate
may contribute to weight gain
after age 30.
b. Hormones are increasingly
implicated in hunger impulses
and eating behavior.
c. The more muscles you have,
the fewer calories you will
burn.
d. Yo-yo dieting can make weight
loss more difficult.
4. Research suggests there may
be a genetic predisposition
toward fat storage that makes
losing fat more difficult for
individuals who have a
a. thrifty metabolism.
b. low set point.
c. responsive metabolism.
d. spendthrift metabolism.
|
LO 3 Assessing Body
Weight and Body
Composition
5. The proportion of your total
weight that is made up of fat is
called
a. body composition.
b. lean mass.
c. percentage of body fat.
d. BMI.
6. All of the following statements
about BMI are true except:
a. BMI is based on height and
weight measurements.
b. BMI is an actual measure of
body composition and is one of
the most accurate assessments
of fat for all populations.
c. Very low and very high
BMI scores are associated
with greater risk of
mortality.
d. BMI stands for “body mass
index.”
7. Which of the following body
circumferences is most strongly
associated with risk of heart
disease and diabetes?
a. Hip circumference
b. Chest circumference
c. Waist circumference
d. Thigh circumference
|
LO 4 Managing Your Weight:
Individual Roles
8. One pound of additional body fat
is created through consuming how
many extra calories?
a. 1,500 calories
b. 3,500 calories
c. 5,000 calories
d. 7,000 calories
9. Successful weight maintainers
are most likely to do which of the
following?
a. Eat two large meals a day before
1:00 p.m.
b. Skip meals
c. Drink diet sodas
d. Eat high-volume but low-calorie
foods
10. Successful, healthy weight loss is
characterized by
a. a lifelong pattern of healthful
eating and exercise.
b. cutting out all fats and
carbohydrates and eating a lean,
high-protein diet.
c. never eating foods that
are considered bad for you
and rigidly adhering to a
plan.
d. a pattern of repeatedly losing
and regaining weight.
Answers to the Pop Quiz can be found on page
A-1. If you answered a question incorrectly,
review the section tagged by the Learning
Outcome. For even more study tools, visit
Mastering Health.
THINK ABOUT IT!
|
LO 1 Overweight and
Obesity: A Growing
Health Threat
1. Why do you think that obesity
rates are rising in both developed
and less-developed regions of the
world? Why are so many youth
and young adults obese in America
today? What strategies can we take
collectively and individually to
reduce risks of obesity nationally?
Internationally?
|
LO 2 Factors Contributing
to Overweight and
Obesity
2. List the risk factors for your
being overweight or obese right
now. Which seem most likely to
determine whether you will be
obese in middle age? What factors
do you think might help your
weight loss? Which might sabotage
your weight loss?
|
LO 3 Assessing Body
Weight and Body
Composition
3. Which measurement would
you choose to assess your fat
levels? Why? What would be the
“normal” BMI for you right now?
|
LO 4 Managing Your
Weight: Individual
Roles
4. Are you satisfied with your body
weight? If so, what do you do to
maintain a healthy weight? If not,
what are some lifestyle changes
you could make to improve your
weight and overall health?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics and issues related to obesity.
Academy of Nutrition and Dietetics.
This site includes recommended dietary
guidelines and other current information
about weight control. www.eatright.org
Weight Control Information
Network. This is an excellent resource
for diet and weight control information.
www.win.niddk.nih.gov/index.htm
The Rudd Center for Food Policy and
Obesity. This website provides excellent
information on the latest in obesity research,
public policy, and ways we can stop the
obesity epidemic at the community level.
www.uconnruddcenter.org
The Obesity Society. Key site for
information/education about our national
obesity epidemic, including statistics,
research, consumer issues, and fact sheets.
www.obesity.org
CHAPTER 6 | Reaching and Maintaining a Healthy Weight | 171
FOCUS ON
ENHANCING YOUR BODY IMAGE
LEARNING OUTCOMES
LO1
Define body image, list the factors that influence it, and identify the
difference between being dissatisfied with your appearance and having body
dysmorphic disorder.
LO2
Describe disordered eating, anorexia nervosa, bulimia nervosa, and bingeeating disorder, as well as treatment options for each.
LO3
Outline criteria, symptoms, and treatments for exercise disorders and
syndromes such as muscle dysmorphia and female athlete triad.
W
hen you look in the
mirror, do you like
what you see? If you
feel dissatisfied, frustrated, or even angry, you’re not alone.
Many people experience dissatisfaction with their bodies, leading to
more than 45 million Americans on
a diet and over 20 million cosmetic
procedures done in the world annually.1 Body dissatisfaction is defined
172
as a person’s negative thoughts and
feelings about his or her body.2 Concerns about body weight, size, shape,
muscularity, and muscle tone are central to many people’s body dissatisfaction. Females experience higher levels
of body dissatisfaction throughout
their lifespan, especially when coupled
with a higher body weight.3 Sadly,
dissatisfaction with your body can
result in behaviors that disrupt your
WHY
SHOULD I CARE?
Dissatisfaction
with appearance
and shape
can foster unhealthy attitudes
and thought patterns, as well
as disordered eating and
compulsive exercise behaviors.
relationships, undermine your goals,
affect your mental health, and lead to
life-threatening illness. In fact, body
weight dissatisfaction is associated
with depression, regardless of actual
weight, age, or gender.4 The good
news? Being satisfied with your body
and having a healthy body image can
enhance your relationships, reduce
stress, improve your confidence, and
bring increased joy to your life!
LO 1 | BODY IMAGE
Define body image, list the factors that
influence it, and identify the difference
between being dissatisfied with your
appearance and having body dysmorphic
disorder.
Body image refers to what you believe
or emotionally feel about your body’s
shape, weight, and general appearance.
More than what you see in the mirror, it
includes the following:5
How you see yourself in your mind.
What you believe about your own
appearance (including beliefs about
how others view you).
■■ How you feel about your body, including your height, weight, and shape.
■■ How you physically experience or
feel in your own body.
■■
■■
A positive body image is a true perception of your appearance: You see yourself
as you really are. You are comfortable and
confident in your own skin. You understand that everyone is different, and you
celebrate your uniqueness—including
perceived “flaws,” which have nothing
to do with your value as a person. How
you look is not the most important part
of who you are.
Conversely, a negative body image is
either a distorted perception of your
shape or feelings of discomfort, shame,
or anxiety about your body. With a negative body image, you may feel that other
people are ­
attractive and that you are
not. A negative body image is associated with poorer health behaviors, emotional distress, unhealthy eating patterns,
anxiety, depression, eating disorders,
sleep ­
deficits, sexual risk-taking, social
­withdrawal, and a reduced quality of life.6
Is your body image positive, negative, or somewhere in between? To help
you evaluate your body image behaviors, researchers have developed a body
image continuum that identifies behaviors associated with full body acceptance to feeling dissociated from your
body (see FIGURE 1 on page 174).
Many Factors
Influence Body Image
You’re not born with a body image,
but you do begin to develop one at an
Although the “in” look changes from generation to generation, unrealistic celebrity
images are nothing new. Baywatch’s Dwayne Johnson and Kelly Rohrbach both
exhibit physical features difficult for the average person to achieve.
early age. Children can start to express
body dissatisfaction by age 6, and 40
to 60 percent of girls ages 6 to 12 report
having concerns about their weight or
getting too fat.7 Since these negative
perceptions can continue throughout
life, let’s look at the factors involved in
body image development.
The Media and Popular
Culture Media images tend to set
the standard for what we find attractive,
leading some people to go to dangerous
extremes to have bigger biceps or fit into
smaller jeans. Changing our bodies to
better achieve what the current society
identifies as “attractive” has long been
part of American culture. During the
early twentieth century, men idolized
the strong, hearty outdoorsman, while
women pulled their corsets ever tighter
to achieve unrealistically tiny waists.
By the 1960s, tough guys were the male
ideal and rail-thin supermodels were
the standard of female beauty. Today we
seem to have a societal obsession with
celebrity appearance as the ideal—even
when we know many images are “Photoshopped” (i.e., altered) or the person
has had cosmetic surgery.
Today’s college students have additional challenges due to the negative association between using social
networking sites (or social media) and
body image. Spending more time on
social media, particularly on photo
viewing and sharing, is associated with
increased body dissatisfaction, a drive
for thinness (increasing risk of eating
disorders), and thoughts about using
anabolic steroids.8 These feelings may
arise from constantly comparing one’s
appearance to others’ and because the
pictures posted often show idealized
curated images, not real ones. Many
sites warn against posts that glorify
self-harm, but images of unrealistically
thin bodies coupled with catch phrases
telling people to get “thin” or “fit” are
WHAT DO
YOU THINK?
What are the ideals of beauty
for different races, cultures,
and ethnic groups?
■■ Why do you think the differences exist?
■■ Are body image pressures different for
males and females within these groups?
body image How you see yourself in
your mind, what you believe about your
­appearance, and how you feel about
your body.
FOCUS ON | Enhancing Your Body Image | 173
Body hate/
disassociation
Distorted body
image
I often feel separated
and distant from my
body—as if it belonged
to someone else.
I spend a significant
amount of time
exercising and dieting to
change my body.
I hate my body, and I
often isolate myself
from others.
My body shape and size
keeps me from dating
or finding someone
who will treat me the
way I want to be
treated.
I don’t see anything
positive or even neutral
about my body shape
and size.
I don’t believe others
when they tell me I
look okay.
I have considered
changing (or have
changed) my body
shape and size through
surgical means.
I hate the way I look in
the mirror.
I wish I could change the
way I look in the mirror.
Body preoccupied/
obsessed
Body acceptance
Body is not an
issue
I pay attention to my
body and my
appearance because it
is important to me, but
it only occupies a small
part of my day.
I feel fine about my
body.
I would like to change
some things about my
body, but I spend most
of my time highlighting
my positive features.
I never weigh or
measure myself.
I weigh and measure
myself a lot.
I spend a significant
amount of time
viewing myself in the
mirror.
I compare my body to
others.
I have days when I feel
fat.
I accept society’s ideal
body shape and size as
the best body shape
and size.
I’d be more attractive if
I were thinner, more
muscular, etc.
My self-esteem is based
on my personality
traits, achievements,
and relationships—not
just my body image.
I don’t worry about
changing my body
shape or weight.
My feelings about my
body are not influenced
by society’s concept of
an ideal body shape.
I know that the
significant others in my
life will always love me
for who I am, not for
how I look.
FIGURE 1
Body Image Continuum This continuum shows a range of attitudes
and behaviors toward body image, from full acceptance to disassociation.
Source: Adapted from Smiley/King/Avery, “Eating Issues and Body Image Continuum,” Campus Health
Service 1996. Copyright © 1997 Arizona Board of Regents for University of Arizona.
all over social media and the Internet.
Some of these sites even promote eating
disorders, extreme thinness, and bone
protrusion, leading to many negative
consequences.9 See STUDENT HEALTH
TODAY for more on “thinspiration.”
60%
of college females
and 57% of college
males have a HEALTHY BMI
(range = 18.5–24.9).
174 | PART TWO | Building Healthy Lifestyles
With more than two-thirds of
American adults overweight or obese,
a significant disconnect exists between
the media’s idealized images and the
typical American body.10 The images
of “beauty” we are bombarded with
are unrealistic, and these messages
can damage our body image, since
no amount of dieting or exercise
can achieve that ideal “hot” Photoshopped body.
Family, Community, and
Cultural Groups
People we interact with on a regular basis
strongly influence the way we see ourselves. Parents are especially influential
in body image development. Mothers
and fathers who are not comfortable
Watch Video Tutor:
Body Image Continuum in
Mastering Health
with their own bodies can project that
dissatisfaction on to their child.11 ­Par–
ents who have biases about their child’s
weight or body shape and express
those biases can affect their child’s
self-­perception and weight progression
from childhood into adolescence and
adulthood.12 The negative messages
about their body can predispose adolescents to body image disorders13; however, positive parental role models are
associated with greater levels of body
satisfaction.14
Interactions with other relatives,
peers, teachers, coworkers, and other
community members can also influence body image development. Being
overweight is a common cause of peer
harassment (teasing and ­
bullying)
STUDENT
HEALTH TODAY
T
Thinspiration vs. Fitspiration
he pro-anorexia movement has a
host of websites, chatrooms, blogs,
and discussion boards, most of them
created and hosted by girls and women
who are struggling with eating disorders. Along with dangerous and incorrect information about restrictive eating,
metabolism, bingeing, and laxative abuse,
many of these sites feature “thinspiration”—pictures and quotes intended to
inspire visitors to thinness—as well as
tips and tricks to hide and maintain disordered eating. Not surprisingly, visiting
these sites is associated with body image
dissatisfaction.
“Fitspiration” websites aim to inspire
people to get active, get fit, and live
healthy lifestyles. One group of researchers analyzed the content on these sites
and found that many of them focus
on exercise for appearance-motivated
reasons, dietary restrictions, and excessive exercise. While another study found
that these “fitspiration” websites promoted
healthier behaviors than the “thinspiration” sites, there were still many images on
their pages idealizing extremely thin body
shapes. “Thinspiration” and “fitspiration”
websites are not the type of inspiration
girls and women need.
We can be inspired, however, by
some changes in the modeling industry.
To prevent the use of excessively thin
models, the French government passed
a law that models must have a BMI of 18
or over. The bill also requires that Photoshopped images—in particular, those
that make a model’s silhouette narrower
or wider—be labeled as “retouched.” In
the United States, the retailer Modcloth
had its employees of all shapes and sizes
model the site’s new swimsuits; Calvin
at school and online. Weight bullying contributes to a negative body
image and psychological outcomes
for ­
overweight children and adolescents.15 This is a serious concern
for parents, teachers, and school
administrators, which is prompting
some school districts to take actions
for change.16 Associations within one’s
cultural group are also an influence
on body image. For example, women
of color have lower rates of body
dissatisfaction than white females.17
However, body dissatisfaction increases
when those women are acculturated
within and exposed to mainstream
media.18
relative with the ­disorder.20 There is
also a link between distortions in body
image (as in body dysmorphic disorder) and malfunctions in the brain’s
Biology and Your Brain
People diagnosed with a body image
disorder may have brain structure
anomalies or alterations in the brain’s
ability to regulate mood-linked chemicals called neurotransmitters.19 Poor
regulation of neurotransmitters is
involved in depression, anxiety disorders, and obsessive–compulsive disorder. Additional evidence for a genetic
link is that these disorders are more
common in those who have a blood
Klein recently featured a size 10 model in
its “Perfect Body” campaign; and in 2016,
the cover of the Sports Illustrated swimsuit
issue featured a plus-sized model, Ashley
Graham. The tag “real-sized” (instead of
“plus-sized”) is now commonly used for
popular models such as Tocarra Jones
and Robyn Lawley. This acceptance of
beauty of all sizes is the kind of inspiration
we need.
Sources: R. Rodgers et al., “A Meta-analysis
Examining the Influence of Pro-Eating Disorder
Websites on Body Image and Eating Pathology,”
European Eating Disorders Review 24, no. 1 (2016):
3–8; L. Boepple et al., “Strong Is the New Skinny:
A Content Analysis of Fitspiration Websites,” Body
Image 17 (2016): 132–5; C. V. Talbot et al., “A
Content Analysis of Thinspiration, Fitspiration, and
Bonespiration Imagery on Social Media,” Journal of
Eating Disorders 5, no. 1 (2017): 40; V. Friedman, “A
New Age in French Modeling,” The New York Times,
May 8, 2017, www.nytimes.com/2017/05/08/
fashion/france-laws-thin-models.html.
visual processing region.21 All of this
suggests that some people are more
biologically susceptible to developing
body image disorders.
DID YOU
KNOW?
The average “female”
mannequin is 6 feet
tall and has a 23-inch
waist, whereas the
average woman is 5
feet 4 inches tall and
has a 38-inch waist.
In a recent study,
100 percent of female
mannequins were
represented as underweight compared to
only 8 percent of male
mannequins.
Sources: E. Robinson and P. Aveyard, “Emaciated Mannequins: A Study of Mannequin Body Size
in High Street Fashion Stores,” Journal of Eating Disorders 5, no. 1 (2017): 13; Centers for Disease
Control and Prevention, “FASTSTATS: Body Measurements,” May 3, 2017, www.cdc.gov/nchs/fastats/
body-measurements.htm.
FOCUS ON | Enhancing Your Body Image | 175
(See Chapter 2 for more discussion
of anxiety disorders.) This preoccupation causes significant distress
and reduces social and occupational
functioning, often leading to isolation, hospitalization, and risk of
suicide.24
People with BDD may try to fix their
perceived flaws through abuse of steroids, excessive bodybuilding, ­cosm­etic
­surgeries, extreme tattooing, or other
appearance-altering behaviors. About
­
10 percent of people seeking cosmetic
treatments have BDD25; however, seeking cosmetic alteration is considered
one of the diagnostic signs of BDD.
People with BDD should be referred
for psychiatric treatment, including
psychotherapy and/or antidepressant
medications.
It is not easy to spot people who are
highly dissatisfied with their bodies.
People who cover their bodies with
tattoos may have high self-esteem.
On the other hand, extreme tattooing
can be a sign of body dysmorphic
disorder.
Body Dysmorphic
Disorder
Although most Americans report being
dissatisfied with some aspect of their
appearance, very few have a true body
image disorder. The difference lies
in the degree of dissatisfaction and
the actions taken to chase satisfaction. Approximately 1 in 50 people in
the United States suffers from body
dysmorphic disorder (BDD).22 BDD
­
is a complex disorder in which patients
are obsessively concerned about one
or more perceived physical appearance
defects. People with BDD will spend
between 3 and 8 hours per day thinking about their “defects,” and BDD is
often accompanied by an anxiety disorder or obsessive–compulsive disorder.23
body dysmorphic disorder (BDD)
Psychological disorder characterized by an
obsession with one’s appearance and a
distorted view of one’s body or with a minor
or imagined flaw in appearance.
176 | PART TWO | Building Healthy Lifestyles
Building a Positive
Body Image
To develop a more positive body image,
start by challenging some commonly
held myths and attitudes in society
today.26
■■
Myth 1: How you look is more
important than who you are.
Fact: Your appearance does not
determine who you are or what you
are capable of.
■■
Myth 2: Anyone can look like a
celebrity if he or she works hard
enough.
Fact: While exercise and healthy
eating can improve anyone’s health,
not everyone has the genes to be
muscular, tall, or curvy. We can
MAKING CHANGES TODAY
Ten Steps to a Positive Body Image
Turn negative thoughts into positive ones by looking more healthfully and happily at
yourself and the body you naturally have.
Step 1. Appreciate all of the amazing things your body does for you—running,
dancing, breathing, laughing, dreaming.
Step 2. Make a list of things you like about yourself—things that aren’t related
to how much you weigh or how you look. Add to it as you notice new things.
Step 3. Remind yourself that true beauty is not skin deep. When you feel
good about yourself and who you are, you carry yourself with a sense of confidence, self-acceptance, and openness that makes you beautiful.
Step 4. Look at yourself as a whole person. When you see yourself in a mirror
or in your mind, choose not to focus on specific body parts.
Step 5. Surround yourself with positive people. It is easier to feel good about
yourself when you are around those who are supportive and who recognize
the importance of liking yourself as you naturally are.
Step 6. Shut down those voices in your head that tell you that your your body
is not “right” or that you are a “bad” person.
Step 7. Wear comfortable clothes that make you feel good about your body.
Work with your body, not against it.
Step 8. Become a critical viewer of social and media messages. Recognize
images, slogans, and attitudes that make you feel bad about your appearance.
Step 9. Show appreciation for your body. Take a bubble bath, make time for a
nap, walk in nature, or find a peaceful place outside to just relax.
Step 10. Use the time and energy you might have spent worrying about
food, calories, and your weight to do something to help others. Reaching out
to other people can help you feel better about yourself and make a positive
change in our world.
Source: “10 Steps to Positive Body Image,” from National Eating Disorders Association website,
Accessed June 2018. National Eating Disorders Association. Reprinted with permission. For more
information, visit www.NationalEatingDisorders.org or call NEDA’s helpline at 1-800-931-2237.
exercise and eat our way to health,
but not to a particular shape.
■■
Myth 3: Extreme dieting is an
effective weight loss strategy.
Fact: Extreme dieting is dangerous
and quick weight loss is rarely sustainable. (See Chapter 6 for more on
weight loss techniques.)
■■
Myth 4: Things will go better for
me after I achieve the perfect body.
Fact: A certain shape or weight is not
the key to a happy, wonderful life.
Investing in healthy relationships
and working toward life goals can
bring lasting happiness.
Eating disordered
I worry all the time
about what I will eat
or when I will exercise.
I follow a very rigid
eating plan and know
precisely how many
calories, fat grams, or
carbohydrates I eat
every day.
I feel incredible guilt,
shame, and anxiety
when I break my diet.
I regularly stuff myself
and then exercise,
vomit, or use laxatives
to get rid of the food.
My friends and family
tell me I am too thin,
but I feel fat.
I am out of control
when I eat.
I am afraid to eat in
front of others.
I prefer to eat alone.
For ways to build a more positive body
image, check out the MAKING CHANGES
TODAY box.
LO 2 | DISORDERED
EATING AND EATING
DISORDERS
Describe disordered eating, anorexia nervosa,
bulimia nervosa, and binge-eating disorder,
as well as treatment options for each.
People with a negative body image fixate on a wide range of self-perceived
Disruptive eating
patterns
My food and exercise
concerns are starting to
interfere with my school
and social life.
I use food to comfort
myself.
I have tried diet pills,
laxatives, vomiting, or
extra time exercising in
order to lose or maintain
my weight.
I have fasted or avoided
eating for long periods
of time in order to lose
or maintain my weight.
Food preoccupied/
obsessed
I think about food a lot.
I’m obsessed with
reading books and
magazines about
dieting, fitness, and
weight control.
I sometimes miss school,
work, and social events
because of my diet or
exercise schedule.
I divide food into
“good” and “bad”
categories.
If I cannot exercise to
burn off calories, I panic.
I feel guilty when I eat
“bad” foods or when I
eat more than what I
feel I should be eating.
I feel strong when I can
restrict how much I eat.
I am afraid of getting
fat.
I feel out of control when
I eat more than I wanted
to.
I wish I could change
how much I want to eat
and what I am hungry
for.
“flaws,” such as feeling overweight.
Some people channel weight-related
anxiety into self-defeating thoughts
and harmful behaviors. The far left of
the eating issues continuum (FIGURE 2)
identifies a pattern of thoughts and
behaviors associated with disordered
eating, including chronic dieting, rigid
eating patterns, abusing diet pills and
laxatives, self-induced vomiting, and
disordered eating A pattern of atypical
eating behaviors that is used to achieve or
maintain a lower body weight.
Concerned in
a healthy way
Food is not an issue
I pay attention to what I
eat in order to maintain
a healthy body.
I am not concerned
about what or how
much I eat.
Food and exercise are
important parts of my
life, but they only
occupy a small part of
my time.
I feel no guilt or shame
no matter what I eat
or how much I eat.
I enjoy eating, and I
balance my pleasure
with my concern for a
healthy body.
I usually eat three
balanced meals daily,
plus snacks, to fuel my
body with adequate
energy.
I am moderate and
flexible in my goals for
eating well and being
physically active.
Sometimes I eat more
(or less) than I really
need, but most of the
time I listen to my body.
Exercise is not really
important to me. I
choose foods based on
cost, taste, and
convenience, with little
regard to health.
My eating is very
sporadic and irregular.
I don’t worry about
meals; I just eat
whatever I can,
whenever I can.
I enjoy stuffing myself
with lots of tasty food
at restaurants, holiday
meals, and social
events.
FIGURE 2
Eating Issues Continuum This continuum shows progression from eating
disorders to healthy eating, with healthy attention to food as the goal.
Source: Adapted from Smiley/King/Avery, “Eating Issues and Body Image Continuum,” Campus Health Service 1996.
Copyright © 1997 Arizona Board of Regents for University of Arizona.
FOCUS ON | Enhancing Your Body Image | 177
Sociocultural factors
• Family and personal
relationships
• History of being teased
• History of abuse
• Cultural norms
• Media influences
• Economic status
Psychological factors
• Low self-esteem
• Feelings of inadequacy
or lack of control
• Unhealthy body image
• Perfectionism
• Lack of coping skills
FIGURE 3
Biological factors
• Inherited personality traits
• Genes that affect
hunger, satiety, and
body weight
• Depression or anxiety
• Brain chemistry
Factors That Contribute to Eating Disorders
body hatred. People with disordered
eating patterns may take dieting to the
extreme by obsessively counting calories,
lying about the amount of food eaten,
or abstaining from certain types of food.
Disordered eating creates an unhealthy
relationship with food and weight. Avoid
this negative pattern by staying away
from highly restrictive diets, fasting only
for medical reasons, stopping fat talk,
separating food from mood, and focusing on eating mindfully (see Focus On:
Cultivating Your Spiritual Health on
page 61 for more on mindfulness).
A small number of people with
disordered eating patterns progress
to a clinical eating disorder. The
eating disorders defined by the
American
Psychiatric
Association
(APA) in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth
Edition (DSM-5), are anorexia nervosa,
bulimia nervosa, binge-eating disorder,
eating disorder A psychiatric disorder
characterized by severe disturbances in body
image and eating behaviors.
anorexia nervosa Eating disorder characterized by deliberate food restriction, selfstarvation, or extreme exercising to achieve
weight loss, as well as an extremely distorted
body image.
178 | PART TWO | Building Healthy Lifestyles
and a cluster of less-distinct condi­
tions collectively referred to as other
specified feeding or eating disorders
(OSFED).27
Women have a lifetime eating disorder prevalence of 5 percent, and in
men it’s 2 percent, with the highest risk
among obese individuals.28 In 2017, 2.8
percent of college students reported
having been diagnosed or treated
for anorexia or bulimia in the past
12 months.29 Eating disorders are more
common among athletes in aesthetic
sports (ballet, figure skating, bodybuilding, and gymnastics) and weight-based
sports (running, tae kwon do, rowing, and wrestling) than in the general
population.30 Eating disorders are also
on the rise among men, who make up
nearly 25 percent of all anorexia and
bulimia patients.31
What factors put individuals at
risk? Many people with eating disorders feel controlled in other aspects
of their lives and try to gain a sense of
power through food. Many are clinically depressed, suffer from obsessive–
compulsive disorder, or have other
psychiatric problems. In addition, individuals with low self-esteem, negative
body image, and a high tendency for
perfectionism are at risk.32 FIGURE 3
shows how individual and social factors interact to increase the risk of an
eating disorder.
Anorexia Nervosa
Anorexia nervosa is a ­persistent, chronic
eating disorder characterized by deliberate food restriction and self-starvation
motivated by an intense fear of gaining
weight and an extremely distorted body
image. People with anorexia nervosa will
have severe, life-threatening weight loss
that contributes to a six-fold increase in
mortality compared to the general population.33 Initially reducing total food
intake, they progress to restricting their
intake of almost all foods. They may
purge the little they do eat through vomiting or using laxatives. Although they
lose weight, people with anorexia nervosa never feel thin enough. An estimated 0.9 to 2.0 percent of females suffer
from anorexia nervosa in their lifetime.34
The DSM-5 criteria for anorexia nervosa are as follows:35
Refusal to maintain body weight at
or above a minimally normal weight
for age and height.
■■ Intense fear of gaining weight or
becoming fat, even though considered underweight by all medical
criteria.
■■ Disturbance in the way in which
one’s body weight or shape is experienced, undue influence of body
weight or shape on self-evaluation,
or denial of the seriousness of the
current low body weight.
■■
FIGURE 4 illustrates physical symptoms and negative health consequences
associated with anorexia nervosa.
Although the exact causes of anorexia
nervosa are unknown, many people
with anorexia have coexisting psychiatric problems, including low self-esteem,
depression, an anxiety disorder such
as obsessive–compulsive disorder, or
substance abuse.36 Some people have a
history of being physically or sexually
abused, and others have troubled interpersonal relationships. While genes
and hormones may play a role as well,
we know that cultural norms valuing
appearance and glorifying thinness are
■■
Altered levels of
neurotransmitters can
lead to depression,
anxiety, fatigue, poor
sleep, dizziness,
fainting, and impaired
functioning.
FIGURE 5 on page 180 illustrates the
physical symp­toms and negative health
consequences associated with bulimia
nervosa.
A complex interaction of genetic,
social, biological, psychological, and
behavioral factors contributes to bulimia
nervosa.40 One study showed that brain
circuitry involved in regulating impulsive
behavior seems to be less active in women
with bulimia than in healthy women.41
However, it is unknown whether such
differences existed before the bulimia
developed or as a consequence of the disorder. The average age of onset of bulimia
nervosa is 18 years old, so it is important
to identify risk factors early.42 Treatments
include nutritional counseling, group
and individual psychotherapies, and possibly medications for any co-­
occurring
mental health conditions.43
Hair thins and becomes
dry and brittle.
Skin becomes dry,
discolored, easily
bruised; fine, downy
hair may grow.
Blood levels of iron
and electrolytes fall
dangerously low.
Decreased immune
function makes
infections more likely.
Kidney failure can lead
to dehydration and
death.
Heart disturbances
include low blood
pressure, irregular
heartbeats, and
potential sudden death
from cardiac arrest.
Decreased digestive
activity can cause
constipation,
abdominal pain, and
bloating.
Reproductive
hormones decrease
and menstruation
and fertility cease in
women.
Bones lose density and
fracture more easily.
Binge-Eating
Disorder
Muscle tissue is lost.
Nails turn brittle.
FIGURE 4
What Anorexia Nervosa Can Do to the Body
factors, as are weight-based shame, peer
comparisons, and weight bias.37
Bulimia Nervosa
Individuals with bulimia nervosa
binge on huge amounts of food—often
with a feeling of being out of control—
and then engage in some kind of purging or compensatory behavior, such
as vomiting, taking laxatives, or exercising excessively, to lose the calories
they have just consumed. People with
bulimia are obsessed with their bodies, weight gain, and appearance, but
unlike those with anorexia, their problem is often hidden from the public eye
because their weight may fall within
a normal range or they may be overweight. Among American adults, the
lifetime prevalence of bulimia nervosa
is 1 percent; 94.5 percent of those diagnosed also met the criteria for at least
one other mood, anxiety, or substance
use disorder.38
The DSM-5 diagnostic criteria for
bulimia nervosa are as follows:39
Recurrent episodes of binge eating (defined as eating, in a discrete
period of time, an amount of food
that is larger than most people
would eat during a similar period
of time and under similar circumstances, and experiencing a sense of
lack of control over eating during
the episode).
■■ Recurrent inappropriate compensatory behavior to prevent weight
gain, such as self-induced vomiting;
misusing laxatives, diuretics, or
other medications; fasting; or excessive exercise.
■■ Binge eating and inappropriate compensatory behavior occurs on average
at least once a week for 3 months.
■■
Body shape and weight unduly influence self-evaluation.
Individuals with binge-eating ­disorder
gorge themselves by eating large amo­
unts of food rapidly (even when not
hungry), but do not take excessive measures to purge (as in bulimia). Thus, these
individuals are often clinically obese.
Binge-eaters report that they eat to avoid
dealing with problems, but binge-eating
episodes are often followed by feeling
guilty, depressed, powerless, shameful,
and socially isolated.44 The lifetime prevalence of binge-eating disorder among
U.S. adults is 2.8 percent.45
The DSM-5 criteria for binge-eating
disorder are as follows:46
■■
Recurrent episodes of binge ­eating
(defined as eating, in a discrete
period of time, an amount of food
that is larger than most people
bulimia nervosa Eating disorder characterized by binge eating followed by inappropriate purging measures or compensatory
behavior, such as vomiting or excessive
exercise, to prevent weight gain.
binge-eating disorder A type of eating disorder characterized by gorging on food once
a week or more, but not typically followed by
a purge.
FOCUS ON | Enhancing Your Body Image | 179
Altered brain chemistry
can cause depression,
anxiety, dizziness,
impaired functioning,
and seizures; use of
diet pills or stimulant
appetite suppressants
may cause addiction.
Throat can become
inflamed and glands in
the face, neck, and jaw
become swollen and
sore.
Tooth enamel erodes,
leading to pain and
sensitivity; cavities,
gum disease, and tooth
loss can occur.
Esophagus can
become inflamed or
rupture; backflow of
stomach acid causes
heartburn.
Blood levels of
electrolytes fall
dangerously low;
anemia and low blood
pressure can develop.
Electrolyte imbalances
can lead to arrhythmia
and sudden cardiac
arrest and death.
Kidney malfunction
and dehydration can
result from diuretic
abuse and vomiting.
Stomach can enlarge
and even rupture;
ulcers and bleeding
may occur.
Laxative abuse can
cause rebound
constipation.
FIGURE 5
Pain, diarrhea, and
bloating result from
digestive dysfunction.
What Bulimia Nervosa Can Do to the Body
would eat during a similar period
of time and under similar circumstances, and experiencing a sense of
lack of control over eating during
the episode).
■■ Binge-eating episodes are associated
with three (or more) of the following: (1) eating much more rapidly
than normal; (2) eating until feeling
uncomfortably full; (3) eating large
amounts of food when not feeling
physical hunger; (4) eating alone
because of embarrassment over how
other specified feeding or eating disorder
(OSFED) Eating disorders that are a true
psychiatric illness but that do not fit the strict
diagnostic criteria for anorexia nervosa, bulimia nervosa, or binge-eating disorder.
orthorexia nervosa An eating disorder
characterized by fixation on food quality and
purity.
180 | PART TWO | Building Healthy Lifestyles
much one is eating; (5) feeling disgusted with oneself, depressed, or
guilty after overeating.
■■ Experiencing marked distress regarding binge eating.
■■ The binge eating occurs, on average,
at least once a week for 3 months.
■■ The binge eating is not associated with the recurrent use of
­inappropriate compensatory behavior (e.g., purging) and does not occur
exclusively during the course of bulimia nervosa or anorexia nervosa.
Other Disordered
Eating
The APA recognizes that some ­patterns
of disordered eating qualify as a legitimate psychiatric illness but don’t fit
into the strict diagnostic criteria for
anorexia, bulimia, or binge-eating
disorder. Called other specified
­feeding or eating disorders (OSFED),
this group of disorders includes five
specific subtypes: night eating syndrome,
purging disorder, binge-eating disorder
of low frequency/limited duration, bulimia nervosa of low frequency/duration,
and atypical anorexia nervosa. Atypical
anorexia nervosa is defined in this category as displaying anorexic features
without low weight.47 All of these subtypes can cause remarkable distress or
impairment but don’t exhibit the full
criteria of another feeding or eating
disorder; some people may cross over
between types of eating disorders over
time. OSFED affects up to 6 percent of
the population.48
Orthorexia nervosa is an unhealthy
obsession with what would otherwise
be healthy eating. The term orthorexia
means “correct appetite,” but in this disorder, what typically begins as a simple
attempt to eat more healthfully can
become a fixation with food quality and
purity. People with orthorexia nervosa
become hyperfocused on what and how
much to eat and how to deal with eating
mistakes. Although the DSM-5 does not
categorize orthorexia nervosa as an eating disorder, the person’s food choices
eventually become so restricted that his
or her health can suffer. Problems with
social relationships and interactions
might also result because the individual
is obsessed with food.
Treatment for Eating
Disorders
Over 30 million people in the United
States, regardless of age, race/ethnicity, gender, or sexual orientation, suffer from an eating disorder.49 ­Without
treatment, about one person per hour
will die as a result of his or her serious eating disorder; this is the highest
mortality risk of any mental illness.50
Interview data show that 34 percent of
anorexic patients sought treatment for
their disorder, compared with 43 percent of bulimic patients, and 44 percent
of binge-eaters.51
Treatment often focuses first on
reducing the threat to life, and once
the patient’s condition is stabilized,
long-term therapy focuses on the factors that have led to the problem.
Through therapy, the patient works on
adopting new eating behaviors, building self-­
confidence, finding healthy
ways to deal with problems, and getting treatment for underlying anxiety or
depression. Support groups can help the
family and the individual learn positive
actions and interactions.
Helping Someone
with Eating Issues
Although every situation is different,
you have several options if you suspect someone you know is struggling
with disordered eating or an eating
disorder:52
■■
■■
■■
■■
■■
■■
Know the facts about weight, nutrition, exercise, disordered eating, and
eating disorders. Accurate information can help you reason against
excuses used to maintain a disordered eating pattern.
Be honest and talk openly about
your concerns.
Be caring, but be firm because
caring about your friend does
not mean allowing him or her to
manipulate you. Your friend must
be responsible for his or her actions
and the consequences of those
actions. Avoid making threats that
you cannot or will not uphold.
Don’t badger or get angry. Stay calm
and be reassuring.
Compliment your friend’s
personality, successes, and
accomplishments.
Be a good role model for healthy
eating, exercise, and self-acceptance.
Tell someone, and don’t wait
until your friend’s life is in danger.
WHAT DO
YOU THINK?
What do you think can be
done to increase awareness of
eating disorders in the United States?
■■ What resources are available on your
campus for people with food and
exercise issues?
When talking to a friend about disordered eating patterns or a suspected eating
disorder, be a good listener, let the person know that you care, and offer your
support. Avoid blaming, preaching, or offering unsolicited advice.
Addressing disordered eating patterns in their beginning stages offers
your friend the best chance for working through these issues and becoming healthy again.
and syndromes specific to exercise
behaviors.
Compulsive Exercise
Many resources are available for
people who are considering seeking
help or finding out if they are at risk
for developing an eating disorder.
The National Eating Disorders Association has a general online screening
tool that allows individuals to assess
their own patterns to determine if they
should seek professional help (www
.nationaleatingdisorders.org/onlineeating-disorder-screening). They also
have additional information and a
helpline (1-800-931-2237) for guidance,
treatment referrals, and support.53
LO 3 | EXERCISE
DISORDERS
Outline criteria, symptoms, and treatments
for exercise disorders and syndromes such
as muscle dysmorphia and female athlete
triad.
Can you get too much of a good thing,
like exercise? Yes! In addition to being
used to compensate for eating by people with anorexia or bulimia, exercise
can contribute to additional disorders
People who use excessive exercise or
compulsive exercise as a way to control
their body weight, self-worth, anxiety,
and emotions may have anorexia athletica, also called sports anorexia or hypergymnasia.54 Persons with anorexia
athletica will struggle with guilt and
anxiety if they don’t exercise, and workout sessions are characterized by a compulsion to complete them. Compulsive
exercisers define their self-worth externally and overexercise to feel more in
control or to relieve guilt; often, disordered eating or an eating disorder is part
of the picture also.
Compulsive exercise can increase
musculoskeletal injuries, such as sprains,
strains, or stress fractures, and stress the
heart, especially if combined with disordered eating. Signs that exercise has
crossed over to compulsion include feeling anxious or depressed when exercise
compulsive exercise Disorder characterized by a compulsion to engage in excessive
amounts of exercise and feelings of guilt and
anxiety if the level of exercise is perceived as
inadequate.
FOCUS ON | Enhancing Your Body Image | 181
The Female Athlete
Triad
To reach a high level of athleticism,
some women put themselves at risk for
developing a syndrome called the female
athlete triad. Triad means “three,” and
the three interrelated problems are low
energy (food) intake, typically prompted
by disordered eating behaviors; menstrual dysfunction such as amenorrhea;
and poor bone density (FIGURE 6).58
muscle dysmorphia Body image disorder
in which men believe that their bodies are
insufficiently lean or muscular.
female athlete triad A syndrome of three
interrelated health problems seen in some
female athletes: disordered eating, amenorrhea, and poor bone density.
amenorrhea The absence of menstruation.
182 | PART TWO | Building Healthy Lifestyles
ity
ns
de
ne
bo
Muscle dysmorphia is a form of body
image disturbance and exercise disorder
in which a person (most commonly a
male) believes his body is insufficiently
lean or muscled.55 Men who have muscle dysmorphia believe, despite looking normal or even muscular, that they
look “puny.” Social or occupational
activities may fall by the wayside due
to their adherence to a meticulous diet
and time-consuming workout schedule. Other behaviors associated with
muscle dysmorphia include comparing
oneself unfavorably to others, checking one’s appearance in the mirror, and
camouflaging one’s appearance. Men
with muscle dysmorphia are also likely
to abuse anabolic steroids and dietary
supplements, and those with low selfesteem are at greatest risk.56 As a society
that glorifies certain types of bodies,
we will likely see more of this disorder.
To be supportive of your family and
friends, avoid equating worth to size or
musculature and don’t joke with people
about their size or shape.57
w
Lo
Muscle Dysmorphia
Me
ns
tru
al
dy
sfu
nc
tio
n
isn’t possible, skipping other commitments in favor of exercise, and exercising despite injury. People who engage in
compulsive exercise may see their social
and academic life suffer as they fixate
more and more on exercise.
Low energy availability
FIGURE 6
The Female Athlete Triad
This cycle begins when an athlete
restricts her eating, depleting her body
of its essential nutrients and fat stores.
Adequate body fat is vital to maintaining healthy levels of the female reproductive hormone estrogen, so when
an athlete isn’t getting enough food,
estrogen levels will decline. The body
will then shut down nonessential body
functions, such as menstruation, causing amenorrhea and increasing risk for
future infertility. In addition, the depletion of fat-soluble vitamins, calcium,
and estrogen weakens the athlete’s
bones, leaving her with an elevated risk
for early osteoporosis and fractures.
The female athlete triad is particularly prevalent in women who participate in sports or activities that
emphasize leanness and body lightness, and that require body-contouring
clothing. Cross-country runners, gymnasts, figure skaters, ballet dancers, and
weight-class athletes like rowers are
among those at highest risk.
Warning signs of the female
athlete triad include dry skin; light-­
­
headedness/fainting; lanugo (fine,
downy hair covering the body); multiple injuries; and muscle cramps, weakness, and fatigue.59 Behaviors associated
with the female athlete triad include
preoccupation with food and weight,
compulsive exercise, use and abuse of
weight loss products or laxatives, anxiety, and depression. Treatment can be
challenging, and requires a multidisciplinary approach involving the athlete’s
coach and trainer, a sports medicine
team, and a psychologist, as well as family members and friends.
Health at Every Size
Many people struggle with disordered
eating, eating disorders, and unhealthy
exercise patterns; at the same time
Americans who are overweight put on
their extra pounds through high calorie intake and low energy expenditure.
The Health at Every Size (HAES) initiative aims to reframe the public health
approach to obesity to reduce weight
stigma and bias at a population level.60
HAES encourages body acceptance at
any size, intuitive eating, and physical
activity for movement and health.61
The hope is that we can adopt a healthy
lifestyle full of movement, nutritious foods, and mindful eating while
embracing size diversity. We want to
recognize that humans come in a variety of shapes and sizes, all of which are
deserving of love and respect.
STUDY PLAN
ASSESS YOURSELF
Could you be suffering
from an eating or exercise
disorder? Take the Are Your
■■
Efforts to Be Thin Sensible—
Or Spinning Out of Control?
assessment available on
Mastering Health.
■■
CHAPTER REVIEW
LO 1 | Body Image
■■
■■
■■
■■
■■
Body image refers to what you
believe or emotionally feel about
your body’s shape, weight, and
general appearance. Media, family,
community, cultural groups, and
psychological and physiological
­factors all influence body image.
A negative body image is a distorted
perception of your shape or feelings
of discomfort, shame, or anxiety
about your body.
A positive body image is a true perception of your appearance, seeing
yourself as you truly are.
Researchers have developed a body
image continuum that may help you
decide if you have a positive or negative body image.
Persons with body dysmorphic
disorder are obsessively concerned
with their appearance and have a
distorted view of their own body
shape, size, weight, perceived lack
of muscles, facial blemishes, size of
body parts, etc. Although the exact
cause is unknown, BDD is often
accompanied by an anxiety disorder
or obsessive-compulsive disorder.
LO 2 | Disordered Eating and
Eating Disorders
■■
Most Americans report some dissatisfaction with their appearance.
Based on the degree of that dissatisfaction, they may develop a
■■
■■
■■
■■
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
disordered relationship with food.
Disordered eating is the following
of strict food rules, but not to the
degree of an eating disorder.
Anorexia nervosa is a persistent,
chronic eating disorder chara­
cterized by deliberate food restriction and severe, life-threatening
weight loss.
Individuals with bulimia nervosa
rapidly consume large amounts of
food and purge with either vomiting
or laxative abuse or by using nonpurging techniques such as excessive
exercise and/or fasting.
Individuals with binge-eating
­disorder gorge themselves but do
not take excessive measures to lose
weight.
Patterns of disordered eating that
qualify as a legitimate psychiatric
illness but don’t meet the diagnostic criteria for anorexia, bulimia,
or binge-eating disorder are called
other specified feeding or eating disorders (OSFED). This group of disorders includes five specific subtypes:
night eating syndrome, purging disorder, binge-eating disorder of low
frequency/limited duration, bulimia
nervosa of low frequency/duration,
and atypical anorexia nervosa.
Orthorexia nervosa is an unhealthy
obsession with a rigid diet focused
on food quality and purity.
Eating disorders are caused by a
combination of many factors, and
there are no simple solutions. Longterm treatment focuses on the psychological, social, environmental,
and physiological factors that have
led to the problem.
LO 3 | Exercise Disorders
■■
Compulsive exercise, also called
anorexia athletica, is characterized by
a compulsion to exercise, resulting
in guilt and anxiety if the exercise
plan isn’t completed.
Muscle dysmorphia, typically found
in men, is characterized by a distorted
belief that their body isn’t muscular
or lean enough, resulting in an inordinate amount of time working out.
■■ The female athlete triad occurs
when female athletes restrict their
food intake and train intensively,
altering their normal body functions. Three interrelated problems
occur (low energy intake, amenorrhea, and poor bone density) that
require a multidisciplinary treatment approach involving the coach,
­psychologist, and family members.
■■ Health at Every Size is a model that
encourages all people to accept their
size while working toward an active
and healthy life.
■■
POP QUIZ
LO 1 | Body Image
1. All of the statements about body
image are true except which?
a. Posting selfies on social media
and looking at other people’s
images will enhance your
positive body image.
b. Concerns about weight seem
to be central to many people’s
dissatifaction with their body.
c. People who have been
diagnosed with a body image
disorder show differences in
the brain’s ability to regulate
neurotransmitters.
d. Positive body image is
possessing a true perception of
your appearance.
2. A complex disorder where patients
are obsessively concerned about
one or more perceived physical
appearance defects is called:
a. Body dysmorphic disorder
b. Anorexia nervosa
c. Binge eating disorder
d. Bulimia nervosa
FOCUS ON | Enhancing Your Body Image | 183
LO 2 | Disordered Eating and
Eating Disorders
3. Which of the following is NOT
classified under the category of
Other Specified Feeding or Eating
Disorders?
a. Atypical anorexia nervosa
b. Night eating syndrome
c. Purging disorder
d. Anorexia athletica.
4. Orthorexia nervosa is
a. an excessive focus on eating
foods high in calcium and
vitamin D.
184 | PART TWO | Building Healthy Lifestyles
b. characterized by a fixation on
the quality and purity of food.
c. an obsession with bone health.
d. a condition that results from
bingeing and purging.
LO 3 | Exercise Disorders
5. Muscle dysmorphia
a. is a muscular disease that results
from an autoimmune disorder.
b. occurs only in women.
c. results in menstrual
dysfunction.
d. occurs most often in men.
6. Which of the following is NOT one
of the three interrelated problems
that make up the female athlete
triad?
a. Low food intake
b. Menstrual problems
c. Poor self esteem
d. Low bone density
Answers to the Pop Quiz questions can be
found on page A-1. If you answered a question
incorrectly, review the section identified by
the Learning Outcome. For even more study
tools, visit Mastering Health.
7
IMPROVING YOUR
PERSONAL FITNESS
LEARNING OUTCOMES
LO1
Describe the health benefits of being physically active.
LO4
LO2
Outline the key components of fitness for optimal health,
wellness, and physical functioning.
Identify your obstacles to physical activity and ways to
overcome them.
LO5
Create a strategy for optimal food and fluid consumption
for exercise and recovery.
LO6
Explain how to prevent and treat exercise injuries.
LO3
Plan a safe and effective fitness program using the FITT
(frequency, intensity, time, and type) principle of physical
fitness.
185
WHY
You may already know that being physically active reduces your risk for chronic
diseases, but there are immediate benefits, too! Becoming physically fit can
(1) improve your physical appearance and sense of self-esteem, (2) boost your
resistance to diseases such as colds and flus, (3) reduce your stress level, (4) improve
your sleep, and (5) help you concentrate. All that, and it can be fun—especially when you
are realistic and find activities that you really enjoy.
SHOULD I CARE?
M
ost Americans are aware of the wide range of
physical, social, and mental health benefits of
physical activity and know that they should
be more active. The physiological changes in
the body that result from regular physical activity reduce
the likelihood of coronary artery disease, high blood pressure, type 2 diabetes, obesity, and other chronic diseases.
Furthermore, engaging in physical activity regularly helps
to control stress, increases self-esteem, and contributes to a
positive mood.1
Despite knowing the importance of physical activity, most
people are not active enough to get these health benefits.
Recent statistics indicate that 50.9 percent of American adults
met the 2008 Physical Activity Guidelines for Americans for aerobic exercise, and 30.4 percent met the guidelines for strengthening exercise.2 However, only 20.5 percent reported meeting
the guidelines for both aerobic and strengthening exercise, and
25.9 percent reported no leisure-time physical activities.3 These
statistics are based on activity reported during one’s “down”
time in the previous month.4 The growing percentage of Americans who live physically inactive lives has been linked to the
high incidence of type 2 diabetes and an increased risk of dying
from cancer and cardiovascular diseases.5
College students are typically more active than older
adults; however, 54.9 percent of college women and 44.7
percent of college men are still not doing the recommended
3 to 5 days of moderate to vigorous physical activity per week.6
Extracurricular activities, screen time, studying, and social
activities can be physical activity barriers for college students.
LO 1 | PHYSICAL ACTIVITY
FOR HEALTH
Describe the health benefits of being physically active.
physical activity Refers to all
body movements produced by
skeletal muscles, resulting in
substantial increases in energy
expenditure.
exercise Planned, structured,
and repetitive bodily movement
done to improve or maintain
one or more components of
physical fitness.
Physical activity refers to all
body movements produced
by skeletal muscles that result
in substantial increases in
energy expenditure. Physical
activities can vary by intensity: light, moderate, or vigorous. For example, walking on
a flat surface at a casual pace
requires little effort (light),
186 | PART TWO | Building Healthy Lifestyles
Activities such as walking and playing with your dog count
toward your recommended daily physical activity.
whereas walking uphill is more intense and harder to do
(moderate). Jogging and running are examples of vigorousintensity physical activities. Physical activities can also be
defined by their purpose: leisure-time physical activity
WHAT DO
(e.g., exercise, walking the
dog), occupational physiTHINK?
cal activity (e.g., restaurant
server, summer camp counWhy do you think
selor), and lifestyle physimost college students
cal activity (e.g., walking to
aren’t more physically active?
class, housework).
■■ Do you think your college
Exercise is defined as
years are a good time to
planned, repetitive, and struc­
become more physically
tured bodily movement
active? Why or why not?
YOU
150
MINUTES
of moderate physical activity a week—along
with strength exercises 2 days a week—
provides substantial HEALTH BENEFITS.
For most people, more is even better!
undertaken to maintain or better physical fitness components—
cardiorespiratory fitness, body composition, muscular strength
or endurance, or flexibility. Although all exercise is physical
activity, not all physical activity would be considered exercise.
For example, walking from your car to class is physical activity,
whereas going for a brisk 30-minute walk to maintain a healthy
body weight is considered exercise.
Adding more physical activity to your day, such as walking or
cycling to school, is good for health, and we also know that physical inactivity increases your risk of negative health outcomes.
Insufficient physical activity (or physical inactivity) is defined
as not meeting the minimum activity recommendations for
health (see TABLE 7.1), and it
sedentary Activity that
is a worldwide health concern.
expends no more than
A recent analysis of sitting time
1.5 times the resting energy
level while seated or reclined.
across 54 countries indicated
that sitting more than 3 hours per day was responsible for over
400,000 deaths, which is 3.8 percent of all causes of mortality.7
Based on this statistic, the researchers determined that a decrease
in sitting time of just 30 minutes per day could reduce 0.6 percent
of the deaths attributed to excess sitting time.8 When considering major chronic diseases, it is estimated that physical inactivity
is responsible for 30 percent of cases of ischemic heart disease, 27
percent of cases of type 2 diabetes, and 21 to 25 percent of cases of
breast and colon cancer worldwide.9 These concerning numbers
led the World Health Organization (WHO) to launch the WHO
Global action plan on physical activity and health 2018–2030: More
active people for a healthier world in 2018, with the goal of reducing physical inactivity by 15 percent in adults and adolescents by
2030.10
Sedentary time is generally considered time spent while
sitting or reclining in an activity that does not increase energy
expenditure more than 1.5 times the resting level. Sedentary
time, however, should not be confused with inactivity.
Common sedentary activities include screen time, sitting
at a desk, reading, and driving. Keep in mind that someone who gets regular activity might also have many hours
TABLE 7.1 | 2008 Physical Activity Guidelines for Americans
Adults
Key Guidelines for Health*
For Additional Fitness or
Weight Loss Benefits*
150 min/week moderate-intensity
physical activity
300 min/week moderate-intensity
physical activity
OR
75 min/week of vigorous-intensity
physical activity
OR
PLUS
Muscle-strengthening activities for
all the major muscle groups at least
2 days/week
150 min/week of vigorous-intensity
physical activity
OR
OR
Equivalent combination of moderateand vigorous-intensity physical activity
(e.g., 100 min moderate intensity + 25
min vigorous intensity)
Equivalent combination of moderateand vigorous-intensity physical
activity (e.g., 200 min moderate
intensity + 50 min vigorous intensity)
OR
More than the previously described
amounts
Older Adults
If unable to follow above guidelines,
then as much physical activity as their
condition allows
If unable to follow above guidelines,
then as much physical activity as
their condition allows
In addition to muscle-strengthening
activities, those with limited mobility
should add exercises to improve
balance and reduce risk of falling
Add vigorous-intensity physical
activities within the 60 daily minutes
at least 3 days/week
Include muscle and bone
strengthening activities at least 3
days/week
Physician’s clearance is recommended
for older adults with health problems
Children and
Adolescents
60 min or more of moderate- or
vigorous-intensity physical activity
daily
Activities should be ageappropriate, enjoyable, and varied
* Avoid inactivity (some activity is better than none), accumulate physical activity in sessions of 10 minutes or more at one time, and spread activity throughout
the week.
Source: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 2008 Physical Activity Guidelines for Americans: Be
Active, Healthy, and Happy! (Washington, DC: U.S. Department of Health and Human Services, 2008), ODPHP Publication no. U0036, www.health.gov.
CHAPTER 7 | Improving Your Personal Fitness | 187
BRAIN
• Reduces stress and improves
mood
• Decreases risk of depression
• Decreases anxiety
• Improves concentration
• Increases oxygen and nutrients to
the brain
• Improves cognitive function,
reduces fatigue, improves sleep
BREASTS
• Decreases risk of breast cancer
in women
HEART
• Decreases risk of heart disease
• Strengthens the heart
• Increases volume of blood
pumped to the body
IMMUNE SYSTEM
• Reduces inflammation
• Improves immune function
WEIGHT
• Reduces the risk for type 2 diabetes
• Helps maintain healthy body weight
LUNGS
• Improves respiratory capacity
• Improves ability to extract oxygen
from the air
BONES
• Increases bone density
• Strengthens bones
• Decreases risk of osteoporosis
LIVER AND PANCREAS
• Increases rate of metabolism
• Reduces risk of type 2 diabetes
JOINTS
• Increases range of motion
• Reduces the pain and swelling of
arthritis
COLON
• Decreases risk of colon cancer
MUSCLES
• Increases muscle strength and
tone
• Improves muscle endurance and
coordination
BLOOD VESSELS
• Increases levels of good
cholesterol (HDL)
• Lowers resting blood pressure
• Decreases risk of atherosclerosis
• Improves circulation
FIGURE 7.1
Selected Health Benefits of Regular Exercise
of sedentary time each day. Although regular exercise and
physical activity can protect against disease and premature
death, sedentary time has an independent negative effect on
disease and mortality.11 Research shows that risk for cardiovascular disease, cancers, and type 2 diabetes is increased with
high amounts of sitting time.12 So, moving is important! You
can get activity through your lifestyle choices, your job, or
your leisure-time activity and exercise.
Regular participation in physical activity improves more
than 50 different physiological, metabolic, and psychological
aspects of human life. FIGURE 7.1 summarizes some of these
major health-related benefits.
Reduced Risk of
Cardiovascular Diseases
Regularly getting enough physical activity is good for your
cardiovascular system (the heart, lungs, and blood vessels);
it reduces the risk for heart-related diseases and premature
death, and eases the performance of everyday tasks.
Consistent aerobic activity makes the cardiovascular and
respiratory systems more efficient by strengthening the heart
muscle. One change you typically notice a few weeks after the
188 | PART TWO | Building Healthy Lifestyles
Video Tutor:
Health Benefits of Regular Exercise
adoption of a regular aerobic activity program is a decrease in
your resting heart rate. As your heart becomes stronger, it can
pump more blood with each beat (increased stroke volume).
Basically, the heart can beat fewer times per minute and still
get the same amount of blood throughout the body. The number of capillaries (small blood vessels that allow gas exchange
between blood and surrounding tissues) increases with regular
aerobic activity in the trained skeletal muscles. This change
enables more blood and oxygen to reach the working muscles. Aerobic activity also improves the respiratory system by
increasing the amount of oxygen that is inhaled with each
breath and distributed to body tissues. In sum, regular exercise
encourages changes that ultimately contribute to an increased
level of aerobic fitness.13
Physical activity can prevent or improve a number of
cardiovascular conditions. For instance, participating in
moderate-intensity physical activity can reduce hypertension,
a significant risk factor for other coronary heart diseases and
stroke (see Chapter 16).14 Consistent physical activity also
improves the blood lipid profile. Triglycerides (a blood fat)
typically decrease with aerobic activity, while high-density
lipoprotein (HDL, or “good” cholesterol) levels go up.15 HDL
cholesterol is associated with lower risk for coronary artery
disease because of its role in removing plaque in the arteries.16 Low-density lipoproteins (LDLs, or “bad” cholesterol)
and total cholesterol are often improved with exercise due to
weight loss and the improvements in HDL and triglycerides.17
Reduced Risk of Metabolic
Syndrome and Type 2 Diabetes
Regular physical activity reduces the risk of metabolic syndrome,
a combination of risk factors that produces a synergistic
increase in risk of heart disease and diabetes.18 Specifically,
metabolic syndrome includes high blood pressure, abdominal obesity, low levels of HDLs, high levels of triglycerides, and
impaired glucose tolerance.19 Performing moderate-intensity
physical activity regularly reduces risk for each factor individually and for the metabolic syndrome as a whole.20
Having a healthy diet combined with sufficient physical activity could prevent many cases of type 2 diabetes.21 All
intensities of physical activity are associated with improved
glucose tolerance and insulin sensitivity for those at risk of
diabetes, with higher intensities of exercise showing greater
effects.22 It’s also important to focus on accumulating
enough minutes of physical activity (30 min/day and at least
150 min/week) for optimal diabetes risk factor reduction.23
(See Focus On: Minimizing Your Risk for Diabetes for more.)
Reduced Cancer Risk
The American Cancer Society reports that approximately onethird of cancers could be prevented with regular physical activity and healthy diet choices.24 There is an association between
healthy dietary patterns and reduced colon and breast cancer
risk, but this relationship can be mediated by other lifestyle
factors, like physical activity.25 Regular physical activity is
especially important for cancer prevention in individuals who
already have chronic diseases, such as heart disease or diabetes.26 Just sitting less can help! Sitting time is associated with a
higher risk of colorectal cancer and more sitting equals higher
risk.27 Despite this finding, another study did not uncover an
association between sedentary time and breast cancer incidence.28 Aerobic and resistance exercise can improve health
and quality-of-life outcomes in breast cancer survivors.29
Long-term quality of life is also improved for colorectal cancer
survivors with higher levels of physical activity.30
Improved Immunity
Regular moderate-intensity physical activity reduces individual susceptibility to disease through improving the body’s
ability to fight infections.31 Regular exercise also reduces body
inflammation that is associated with chronic conditions such
as cardiovascular disease or cancer.32 With a weaker immune
system, you are more susceptible to diseases and infections.
Susceptibility to disease will decrease with moderate activity
but then increase with extreme levels of exercise.33 Athletes
engaging in intense physical training programs have been
shown to have a suppression of their immune system during
recovery.34 To reduce risk of infections and illness during this
time, adequate rest and dietary strategies (carbohydrate supplementation) should be instituted.35
Reduced Risk of Low Bone Mass
Lifestyle behaviors, such as being active and eating right,
can reduce your risk of developing osteoporosis, a disease of
low bone mass, altered bone structure, and increased fracture risk.36 Higher levels of bone-building physical activities
(weight-bearing and strength-building exercises) are associated
with greater bone densities in young women.37 These same
types of activities are recommended throughout the lifespan
to maintain bone health in women.38 Although both men and
women can be affected by osteoporosis, it is more common in
women. Due to this difference, much of the research focuses
on women; however, support is growing for exercise interventions to improve bone health in men.39 In addition to bonebuilding physical activities, it is important for everyone to
maintain sufficient hormone levels (estrogen in women, testosterone in men) and adequate calcium, vitamin D, and total
caloric intakes.40
Because early intervention for building bone mass during
the growing years is so important, the National Osteoporosis
Foundation published a position statement on peak bone mass
and lifestyle factors that stressed the importance of physical
activity and calcium intake in youth and adolescence for optimal development of bone density and mass.41 Although certain sports build more bone than others, total physical activity
time may be more important for bone density changes in adolescents than time spent in sports activities alone.42 In fact,
total leisure-time physical activity (moderate or high intensity) has been found to significantly reduce the incidence of
osteoporotic fractures in both men and women.43
Better Weight Control
For many people, the desire to lose weight or maintain a
healthy weight is the main reason for physical activity. On
the most basic level, physical activity requires your body
to generate energy through calorie expenditure; if calories
expended exceed calories consumed over a span of time, the
net result will be weight loss. Some activities are more vigorous
than others and result in more calories used. FIGURE 7.2 on
page 190 shows the 1-hour caloric cost of various activities.
Should diet or exercise be the emphasis for weight control? Research supports comprehensive lifestyle changes that
include both exercise and diet changes for weight loss.44
Dietary recommendations for weight loss may need to be individualized (see Chapter 6). Anyone with medical conditions,
diseases, or illnesses should consult his or her physician before
embarking on a new diet. For example, an individual with diabetes will need to consider the glycemic index of food when
planning meals. When it comes to trimming excess pounds,
the amount of exercise recommended is an accumulation of
300 minutes of aerobic exercise per week for weight loss versus
150 minutes per week for general health maintenance.45
CHAPTER 7 | Improving Your Personal Fitness | 189
Calories burned per hour of activity
2500
2000
885kcal
1500
1000
44kcal
36kcal
29kcal
133kcal
109kcal
86kcal
620kcal
531kcal
248kcal
500
203kcal
0
160kcal
Sitting
125 lb
FIGURE 7.2
Yoga
(hatha)
160 lb
620kcal
Walking
(3.5mph;
17 min/mile)
725kcal
508kcal
508kcal
342kcal
399kcal
399kcal
Cycling
(Moderate)
Jogging
(5.0mph;
12 min/mile)
Swimming
(Moderate)
435kcal
570kcal
Running
(6.7 mph;
9 min/mile)
195 lb
Calories Burned in One Hour for Activities of Varying Intensities
Ultimately, when you’re trying to lose weight and keep it
off, it is important to make changes that can be maintained
long term. One strategy is to simply monitor your weight.
Monitoring your weight frequently is a predictor of weight
loss and weight maintenance.46 People who weigh themselves
regularly are more likely to make healthy behavior choices
that support weight maintenance than those who don’t weigh
themselves regularly.47
Physical activity is another key component of weight
maintenance. The National Weight Control Registry (NWCR)
comprises individuals who have lost at least 30 pounds and
have maintained the loss for at least a year.48 Ninety percent
of individuals on the registry report an average of 60 minutes
of daily exercise, and decreased activity levels are associated
with weight regain.49 In addition to the calories expended
during activity, vigorous physical activities (like interval
workouts) will trigger an elevated metabolic rate, enhanced
fat breakdown, and improved disease risk variables for several hours in obese and nonobese individuals.50 The increase
in metabolic rate can lead to an increased number of calories expended throughout the day. If you are currently at a
healthy body weight, regular physical activity can prevent
weight gain and improve overall weight control.
Improved Mental Status
and Reduced Stress
Mental health is an area of growing concern for many
college students. Recent data show that the factors with
the biggest impact on academic performance reported
190 | PART TWO | Building Healthy Lifestyles
by college students include stress, anxiety, sleep difficulties, and depression.51 Fortunately, acute (each session) and
regular exercise (a training program) can help. One comprehensive study showed that regular exercise improved
sleep quality and reduced fatigue in college students; and
those benefits remained at 1 and 3 months later.52 In addition to those benefits, reguSEE IT! VIDEOS
lar physical activity provides
Get moving to benefit
a break from stressors such
your brain in a variety of
as work and everyday worways! Watch New Study
ries. In fact, aerobic activShows Exercise May Build
ity can improve the way
Brain Power, available on
the body handles stress by
Mastering Health.
affecting neurotransmitters
associated with enhancing
mood and reducing depression.53 Physical activity can also
improve mood in those who are experiencing symptoms of
depression, as well as those who are diagnosed with major
depressive or mood disorders.54
People who engage in regular physical activity are likely to
notice psychological benefits, such as feeling better about oneself, feeling less stressed, and feeling an improved sense of wellbeing.55 These intangible benefits are frequently mentioned as
primary reasons for continuing to be active. In addition, both
sticking to a physical activity plan and developing increased
skills and abilities in recreational activities can boost selfesteem.56 It’s a two-way street though, because increased stress
is associated with lower levels of physical activity.57 So, get
active to enhance your mood and lower stress; then, chances
are, you stay more active as a result!
Improved Cognitive Function
and Reduced Dementia Risk
There is increasing evidence that regular physical activity
positively affects cognitive function across the lifespan.58
Consistent physical activity and greater fitness levels (aerobic
and muscular) are associated with improved academic performance in school, and more sedentary time is associated with
poorer academic performances.59 Regular aerobic exercise
reduces study-related fatigue and enhances executive cognitive functions immediately after the intervention and during
follow-ups 1 and 3 months later.60
Although physical activity actually stimulates the stress
response, a physically fit body adapts efficiently to it, and
as a result is better able to tolerate and effectively manage
stresses of all kinds.
Regular physical activity, even when initiated as an adult, is
associated with reduced risk for and improvement of dementia and Alzheimer’s disease in adults.61 There also seems to be a
dose-response relationship: Every 500-kcal increase in exercise
calorie expenditure per week results in an average decrease in
the risk of dementia by 10 percent and Alzheimer’s disease by
13 percent.62 This exciting area of research is expanding and
additional studies are needed to better describe the relationship
between exercise and cognitive decline throughout the lifespan.
Longer Lifespan
If you want to lose weight, you need to move more
and often!
Experts have long debated the relationship between physical
activity and longevity. Greater physical activity levels have
been associated with an increased life expectancy and a greater
number of years lived without cardiovascular disease.63 The
largest benefits to increasing lifespan occur in sedentary individuals who add a little physical activity to their lives, with
additional benefits as physical activity levels increase.64
It is not just structured exercise that is important, but
moving as much as possible and sitting as little as possible.
Even if you sit a lot for work or school, higher amounts of
moderate physical activity (60–75 min/day) may eliminate
the increased risk of death associated with sitting time.65
The exact mechanisms by which being active may increase
your lifespan are not fully understood. There is increasing evidence that regular exercise counteracts the aging-related shortening of telomeres, which are chromosome caps that act as a
cell’s “life clock.”66 Slowing down telomere shortening may
lead to a reduction in age-related diseases and contribute to a
longer and healthier lifespan.67
CHAPTER 7 | Improving Your Personal Fitness | 191
LO 2 | FITNESS COMPONENTS
FOR HEALTH, WELLNESS, AND
PHYSICAL FUNCTION
Outline the key components of fitness for optimal health, wellness,
and physical functioning.
Physical fitness refers to a set of attributes that are either
health or skill related.
Health-Related Components of
Physical Fitness
The health-related attributes—cardiorespiratory fitness, muscular strength and endurance, flexibility, and body composition—allow you to perform moderate- to vigorous-intensity
physical activities on a regular basis without getting too tired
and with energy left over to handle physical or mental emergencies. FIGURE 7.3 identifies the major health-related components of physical fitness.
Cardiorespiratory Fitness
Cardiorespiratory fitness is the ability of the heart, lungs, and blood vessels to supply
the body with oxygen efficiently. The primary category of physical activity known to improve cardiorespiratory fitness is aerobic
exercise. The word aerobic means “with oxygen” and describes
any type of exercise that requires oxygen to make energy for prolonged activity. Aerobic activities, such as swimming, cycling,
and running, are among the best exercises for improving or maintaining cardiorespiratory fitness.
Cardiorespiratory fitness is measured by ­determining aerobic
capacity (power), the volume of oxygen the ­muscles consume
during exercise. Maximal aerobic power (commonly written as
VO2max) is defined as the peak volume of oxygen that the muscles can consume per minute at maximal exercise intensity. The
most common measure of maximal aerobic capacity is a run
test on a treadmill. For greatest accuracy, this is done in a
physical fitness A balance
lab with specialized equipment
of health-related attributes
that allows you to perform
and technicians to measure
moderate to vigorous physical
the precise amount of oxygen
activities on a regular basis and
entering and exiting the body
complete daily physical tasks
during the exercise session. To
without undue fatigue.
get an estimate of cardiorespiracardiorespiratory
tory fitness, submaximal cardio
­fitness The ability of the
heart, lungs, and blood vessels
test results can be used to preto supply oxygen to skeletal
dict maximal aerobic capacity.
muscles during sustained
physical activity.
aerobic exercise Prolonged
exercise that requires oxygen
to make energy for activity.
aerobic capacity
(power) The functional status
of the cardiorespiratory system;
refers specifically to the
volume of oxygen the muscles
consume during exercise.
Muscular
Muscular Endurance
Muscular endurance is the
ability of a muscle or group of muscles to exert force repeatedly without fatigue or the ability to sustain a muscular
contraction. The more repetitions you can perform successfully (e.g., push-ups) or the longer you can hold a certain position (e.g., plank), the greater your muscular endurance.
Flexibility
Flexibility refers to the range of motion, or the
amount of movement possible, at a particular joint or series
of joints. A greater range of motion means better flexibility.
Various tests measure the flexibility of the body’s joints, including range-of-motion tests for specific joints.
Body Composition Body composition describes
the relative proportions and distribution of fat and fat-free
(muscle, bone, water, organs) tissues in the body. (For more
details on body composition, including its measurement, see
Chapter 6.)
Skill-Related Components
of Physical Fitness
In addition to the five health-related components of physical fitness, physical fitness for athletes involves attributes that
improve their ability to perform athletic tasks. These attributes, called the skill-related components of physical fitness,
also help recreational athletes and general exercisers increase
fitness levels and their ability to perform daily tasks. The skillrelated components of physical fitness (also called sport skills)
are agility, balance, coordination, power, speed, and reaction time.
Note that some of the skill-related fitness components can
impact health. For example, consider the importance of balance and coordination for older adults who are at increased
risk for falls.
Strength
Muscular strength refers to
the amount of force a muscle
or group of muscles can generate in one contraction. The
most common way to assess the
strength of a particular muscle
or muscle group is to measure
192 | PART TWO | Building Healthy Lifestyles
the maximum amount of weight you can move one time (and
no more) or your one repetition maximum (1 RM).
It is important for all people, including those with
disabilities, to develop optimal levels of physical fitness
and participate in physical activities they enjoy—including
competitive sports.
Cardiorespiratory
fitness
Ability to sustain
aerobic whole-body
activity for a prolonged
period of time
FIGURE 7.3
Muscular strength
Maximum force able
to be exerted by single
contraction of a
muscle or muscle
group
Muscular endurance
Ability to perform
muscle contractions
repeatedly without
fatiguing
Body composition
The relative proportions of fat mass and
fat-free mass in the
body
Health-Related Components of Physical Fitness
LO 3 | UTILIZING THE FITT
PRINCIPLE TO CREATE YOUR
OWN FITNESS PROGRAM
Plan a safe and effective fitness program using the FITT (frequency,
intensity, time, and type) principle of physical fitness.
The first step in creating a personal physical fitness program
is identifying your goals. Do you want to be better at sports
or feel better about your body? Is your goal to manage stress
or reduce your risk of chronic diseases? Perhaps your most
vital goal will be to establish a realistic schedule of diverse
physical activities that you can maintain and enjoy throughout your life. Your physical fitness goals and objectives
should be both achievable for you and in line with what you
truly want.
Set SMART Goals for Your
Physical Fitness
Goal setting done correctly can provide direction and help you
develop a plan that works. Ideally, goals should be difficult,
so you will work hard. However, they must also be attainable,
so you will not set yourself up for failure and get discouraged.
To set successful goals, try using the SMART system. SMART
goals are specific, measurable, action-oriented, realistic, and
time-oriented.
A vague goal would be “Improve fitness by exercising more.”
A SMART goal would be as follows:
■■
Flexibility
Ability to move joints
freely through their
full range of motion
Specific—“I’ll participate in a resistance-training program
that targets all of the major muscle groups 3 to 5 days
per week.”
Measurable—“I’ll improve my fitness from the average
classification to the above average classification by
increasing the amount of weight I lift by 20 percent.”
■■ Action-oriented—“I’ll meet with a personal trainer to
learn how to safely do resistance exercises and to plan a
workout for the gym and home. The trainer will assess my
fitness level to make sure the goal is realistic.”
■■ Realistic—“I’ll increase the weight I can lift by
20 percent.”
■■ Time-oriented—“I’ll try my new weight program for
8 weeks, then reassess.”
■■
Setting both short- and long-term goals is important. The
short-term goals can help to maintain motivation and help
to determine whether the
long-term goal should be
muscular strength The
amount of force that a muscle
adjusted. If you are a novice
is capable of exerting in one
exerciser, you might need
contraction.
help with setting realisone repetition maximum
tic goals. Getting a fitness
(1 RM) The amount of weight
assessment or consulting
or resistance that can be lifted
with a trainer can help you
or moved only once.
set realistic goals.
Use the FITT
Principle
To improve your healthrelated physical fitness (or
performance-related physical fitness), use the FITT (frequency, intensity, time, and
type)68 principle to define
muscular endurance A
muscle’s ability to exert force
repeatedly without fatiguing or
the ability to sustain a muscular
contraction for a length of time.
flexibility The range of motion,
or the amount of movement
possible, at a particular joint or
series of joints.
body composition The
relative proportions of fat and
fat-free (muscle, bone, water,
organs) tissues in the body.
CHAPTER 7 | Improving Your Personal Fitness | 193
Frequency
The frequency of your program is related
to your intensity. If you choose to do moderate-intensity
exercises, you should aim for a frequency of at least 5 days
(frequency drops to at least 3 days per week with vigorousintensity activities). Newcomers to exercise can still improve
by doing less intense exercise (light to moderate level),
but doing it more days during the week. In this case, follow the recommendations for moderate physical activity in
Table 7.1 on page 187.
Intensity
The most common methods used to determine
the intensity of cardiorespiratory endurance exercises are target heart rate, rating of perceived exertion, and the talk test.
The exercise intensity required to improve cardiorespiratory
endurance is a heart rate between 64 and 95 percent of your
maximum heart rate (moderate to vigorous intensity). Before
calculating your target heart rate, you must first estimate
your maximal heart rate with the formula [207 – 0.7 (age)]. The
example below is based on a 20-year-old. Substitute your age to
determine your target heart rate training range; then multiply
by 0.64 and 0.95 to determine the lower and upper limits of
your target range.
One great way to motivate yourself is to sign up for an
exercise class. The structure, schedule, social interaction,
and challenge of learning a new skill can be the motivation
you need to get moving!
your exercise program. The FITT prescription (FIGURE 7.4)
uses the following criteria:
Frequency refers to the number of times per week you
need to engage in particular exercises to achieve the desired
level of physical fitness in a particular component.
■■ Intensity refers to how hard your workout must be to
achieve the desired level of physical fitness.
■■ Time, or duration, refers to how many minutes or repetitions of an exercise are required at a specified intensity during any one session to attain the desired level of physical
fitness for each component.
■ Type refers to what kind of exercises should be performed
to improve the specific component of physical fitness.
■■
The FITT Principle for
Cardiorespiratory Fitness
The most effective aerobic exercises for building cardiorespiratory fitness are total body activities involving the large muscle
groups. The FITT prescription
for cardiorespiratory fitness
FITT Acronym for frequency,
includes 3 to 5 days per week of
intensity, time, and type;
the terms that describe the
vigorous, rhythmic, continuous
essential components of a
activity at 64 to 95 percent of
program or plan to improve a
your estimated maximal heart
health-related component of
rate for 20 to 60 minutes.69
physical fitness.
194 | PART TWO | Building Healthy Lifestyles
1.
2.
3.
4.
5.
207 − 0.7 (20) = target heart rate for a 20-year-old
207 − 14 = 193 (maximal heart rate)
193 (0.64) = 123.5 (lower target limit)
193.5 (0.95) = 183.8 (upper target limit)
Target range = 124–184 beats per minute
To determine how close you are to your target heart rate,
take your pulse. Lightly place your index and middle fingers
(not your thumb) over the carotid artery in your neck or on
the radial artery on the inside of your wrist (FIGURE 7.5 on
page 196). Count your pulse while exercising, if possible, or
start counting your pulse immediately upon stopping exercise, as your heart rate decreases rapidly when you stop. Using
a watch or a clock, take your pulse for 10 seconds and multiply
this number by 6 to get the number of beats per minute. If you
have a heart rate tracking feature on your cell phone or activity
tracker, you can use that instead of taking your pulse.
Another way to determine the intensity of cardiorespiratory
exercise is to use a perceived exertion scale. Perceived exertion
refers to how hard you feel you are working, which you might
base on your heart rate, breathing rate, sweat, and level of
fatigue. One of these scales is called the OMNI scale, and it uses
a ranking from 1 (no exertion at all) to 10 (maximal exertion)
20.2%
of American adults meet guidelines for
both cardiorespiratory and muscular
FITNESS.
Cardiorespiratory Endurance
Muscular Fitness
Flexibility
Frequency
3–5 days per week
2–3 days per week
Minimally 2–3 days per week
Intensity
64%–96% of maximum
heart rate
60%–80% of 1 RM
To the point of mild tension
Time
20–60 minutes
8–10 exercises, 2–4 sets,
8–12 reps
10–30 seconds per stretch,
2–4 reps
Type
Any rhythmic, continuous,
large muscle group activity
Resistance training (with
body weight and/or external
resistance) for all major
muscle groups
Stretching, dance, or yoga
exercises for all major muscle
groups
FIGURE 7.4
The FITT Principle Applied to Cardiorespiratory Fitness, Muscular Strength and Endurance, and Flexibility
(FIGURE 7.6 on page 196). A perceived exertion between 5 and
8 is generally recommended for training the cardiorespiratory
system.
The easiest method of measuring cardiorespiratory exercise intensity is the “talk test.” A “moderate” level of exercise
(heart rate at 64 to 76 percent of maximum) is a conversational level of exercise. At this level you are able to talk with
a partner while exercising. If you can talk, but only in short
fragments and not sentences, you may be at a “vigorous” level
of exercise (heart rate at 76 to 95 percent of maximum). If you
are breathing so hard that speaking at all is difficult, the intensity of your exercise may be too high. Conversely, if you can
sing or laugh heartily while exercising, the intensity of your
exercise is light.
for moderate intensity and 75 minutes per week for vigorous
intensity). See the STUDENT HEALTH TODAY box on page 198
for information on a few exercise programs that can really give
you a lot of bang for your buck.
Time
The FITT
Principle for
Muscular
Strength and
Endurance
For cardiorespiratory fitness benefits, the American
College of Sports Medicine (ACSM) recommends that vigorous activities be performed for at least 20 minutes at a time,
and moderate activities for at least 30 minutes.70 See also the
HEALTH IN A DIVERSE WORLD box on page 197 for recommendations for individuals with chronic diseases or conditions that require alterations to the FITT prescription.
Free time for exercise can vary from day to day, so you can
also set a time goal for the entire week as long as you keep
your sessions to at least 10 minutes (150 minutes per week
Type
Any sort of rhythmic,
continuous, and moderatelevel physical activity that can
be done for 20 or more minutes
will improve cardiorespiratory
fitness. Examples include walking briskly, cycling, jogging,
fitness classes, and swimming.
The FITT prescription for muscular strength and endurance
includes 2 to 3 days per week
frequency As part of the FITT
prescription, refers to how
many days per week a person
should exercise.
intensity As part of the FITT
prescription, refers to how hard
or how much effort is needed
when a person exercises.
time As part of the FITT
prescription, refers to the
duration of an exercise session.
type As part of the FITT
prescription, refers to what kind of
exercises a person needs to do.
target heart rate The heart
rate range of aerobic exercise
that leads to improved
cardiorespiratory fitness (i.e., 64
to 95% of maximal heart rate).
perceived exertion The
subjective perception of effort
during exercise that can be used
to monitor exercise intensity.
CHAPTER 7 | Improving Your Personal Fitness | 195
a Carotid pulse
intensity recommendations. Muscular strength is improved
when resistance loads are greater than 60 percent of your 1 RM,
whereas muscular endurance is improved using loads less than
50 percent of your 1 RM.
Everyone begins a resistance-training program at an
initial level of strength. To become stronger, you must
overload your muscles; that is, you must regularly create a
degree of tension in your muscles that is greater than what
they are accustomed to. Overloading them forces your muscles to adapt by ­getting larger, stronger, and capable of producing more tension. If you “underload” your muscles, you
will not increase strength. If you create too great an overload, you may experience m
­ uscle injury, muscle fatigue, and
potentially a loss in strength.
b Radial pulse
FIGURE 7.5 Taking a Pulse Palpation of the carotid
(neck) or radial (wrist) artery is a simple way of determining
heart rate. You can also use an activity tracker or cell phone to
take your heart rate.
Time
of exercises that train the major muscle groups, using enough
sets, repetitions, and resistance to maintain or improve muscular strength and endurance.71
Frequency For frequency, training the major muscle
groups 2 to 3 days a week is recommended. It is believed that
overloading the muscles, a normal part of resistance training
described below, causes microscopic tears in muscle fibers,
and the rebuilding process that increases the muscle’s size and
capacity takes about 24 to 48 hours. Thus, resistance-training
exercise programs should include at least 1 day of rest between
workouts before the same muscles are overloaded again. But
don’t wait too long between workouts: One of the important principles of strength training is the idea of reversibility.
Reversibility means that if you stop exercising, the body
responds by deconditioning. Within 2 weeks, muscles begin
to revert to their untrained state.72 The saying “use it or lose
it” applies!
Intensity
To plan the optimal intensity of exercises for
improving muscular strength and muscular endurance, start
by estimating the maximum amount of weight you can lift (or
move) in one contraction. This estimate of your one repetition
maximum (1 RM) is then used as the basis for muscular fitness
0
1
Extremely
easy
2
3
Easy
FIGURE 7.6
4
Somewhat
easy
5
The time recommended for muscular strength and
endurance exercises is measured not in minutes of exercise,
but rather in repetitions and sets.
Repetitions and sets. To increase muscular strength, you
need higher intensity and fewer repetitions and sets: Use a
resistance of at least 60 percent of your 1 RM, performing
8 to 12 repetitions per set, with two to four sets performed
overall. If improving muscular endurance is your goal, use
less resistance and more repetitions: Perform one to two
sets of 15 to 25 repetitions using a resistance that is less
than 50 percent of your 1 RM.
■■ Rest periods. Resting between exercises is crucial to reduce
fatigue and help with performance and safety in subsequent sets. A rest period of 2 to 3 minutes is recommended
when using the guidelines for general health benefits.
However, the rest period when working to develop strength
or endurance will vary. Note that the rest period refers specifically to the muscle group being exercised. For example,
you can alternate a set of push-ups with curl-ups, as the
muscle groups worked in one set can rest while you are
working the other muscle groups.
■■
Type To improve muscular strength or endurance, it is
recommended that resistance training use either the body’s
weight or some form of external resistance (see TABLE 7.2
on page 199 for resistance-type comparisons and TABLE 7.3
6
Somewhat
hard
7
8
Hard
9
10
Extremely
hard
Determine your Perceived Exercise Intensity Use the OMNI 1–10 scale to assess how you feel
while exercising and aim for ratings of 5–8 for most activities.
196 | PART TWO | Building Healthy Lifestyles
HEALTH
IN A DIVERSE WORLD
P
eople with the special considerations mentioned below might
need to make modifications to the
FITT prescription. It is recommended
that all individuals, but particularly
those with health conditions, consult
with a physician before beginning
any exercise program.
Physical Activity and Exercise for
Special Populations
Athletes like Brandon Morrow, a Major League
Baseball pitcher who has type 1 diabetes, are
living proof that chronic conditions needn't
prevent you from achieving your physical
activity goals.
Diabetes
Asthma
Regular physical activity provides
benefits for individuals with asthma.
It strengthens the respiratory
muscles, making it easier to breathe;
improves immune system functioning; and helps maintain weight.
Before engaging in exercise,
ensure that your asthma is under
control. Ask about adjusting your
medications (e.g., your doctor may
recommend you use your inhaler
15 minutes prior to exercise). Keep your
inhaler nearby. Warm up and cool down
properly; it is particularly important that you
allow your lungs and breathing rate to adjust
slowly. Protect yourself from your asthma
triggers when exercising (e.g., pollution or
cold environments). If you have symptoms
while exercising, stop and use your inhaler;
if an asthma attack persists, call 9-1-1.
Obesity
Obese individuals may have limitations
such as heat intolerance, shortness of
breath during physical activity, lack of
flexibility, frequent musculoskeletal injuries, and difficulty with balance. Programs
should emphasize physical activities that
can be sustained for longer periods of
time such as walking, swimming, or bicycling. Use caution when performing these
activities in hot or humid environments.
exercise, individuals who are hypertensive should engage in physical
activity on most, if not all, days of
the week, at a moderate intensity
for 30 minutes or more.
Although it is recommended to start slowly
(5 to 10 minutes of activity) and at a lower
intensity (55 to 65% of maximal heart
rate), aim to eventually perform at least
30 to 60 minutes of exercise per day—150
to 300 minutes per week. Regardless of
weight lost, evidence suggests that obese
individuals will improve health outcomes
with regular cardiorespiratory and resistance-training activities.
Coronary Heart Disease and
Hypertension
Although regular physical activity reduces
risk of coronary heart disease and hypertension, vigorous-intensity activity acutely
increases risk of sudden cardiac death
and myocardial infarction (heart attack).
Individuals with coronary heart disease or
hypertension must consult their physician
and might need to participate in a supervised exercise program. Once cleared for
on page 199 for popular muscular fitness equipment). When
selecting resistance-training exercises, there are three important principles to bear in mind: specificity, exercise selection,
and exercise order. According to the specificity principle, the
effects of resistance training are specific to the muscles exercised; thus, to improve total body muscular fitness, include
exercises for all the major muscle groups.
The second important concept is exercise selection. It is
important to select exercises that will meet your goals. Selecting 8 to 10 exercises targeting all major muscle groups is
Physical activity benefits individuals
with diabetes in many ways. It controls blood glucose (for individuals
with type 2) by improving transport
into the cells, controls body weight,
and reduces risk for heart disease.
Before people with type 1 diabetes engage in physical activity,
they must learn how to manage
their resting blood glucose levels.
Individuals should have an exercise
partner; eat 1 to 3 hours prior to
the activity; eat complex carbohydrates after the activity; avoid late-evening
exercise; and monitor their blood glucose
before, during, and after activity.
One of the most crucial factors for individuals with type 2 diabetes is the length of
their physical activity. A primary goal for the
management of type 2 diabetes is to reduce
body fat (obesity), so the recommendations for exercise time are longer—at least
30 minutes, working up to 60 minutes per
session or 300 minutes per week. Multiple
10-minute sessions can be used to accumulate these totals. For sessions of this length,
it is prudent to reduce the intensity of the
activity to a target heart rate range of 40 to
60 percent of maximal heart rate.
Sources: P. Williamson, Exercise for Special
Populations (Philadelphia: Lippincott Williams
& Wilkins, 2011); American College of Sports
Medicine, ACSM’s Guidelines for Exercise Testing
and Prescription, 10th ed. (Baltimore, MD:
Lippincott Williams & Wilkins, 2018).
generally recommended and will ensure that exercises are balanced for opposing muscle groups.
Finally, for optimal training effects, pay attention to exercise
order. When training all major muscle groups in a single workout, complete large muscle group exercises (e.g., the bench
press or leg press) before small muscle group exercises, multiple-joint exercises before single-joint exercises (e.g., biceps
curls, triceps extension), high-intensity exercises before lowerintensity exercises, and don’t fatigue your core trunk stabilizing muscles until the end of your workout.
CHAPTER 7 | Improving Your Personal Fitness | 197
STUDENT
HEALTH TODAY
H
igh-intensity interval training (HIIT) is a type of training that combines alternating
high-intensity bouts and active
rest bouts within your exercise
session. For example, after the
warm-up phase, you might do
2 minutes of a near-maximalpaced run, and then jog for
2 minutes to rest. Alternately, you
might perform 30 seconds of a
high-intensity full body activity
(repeated squat jump to a pushup) followed by a 60- to 90-second recovery and then repeat
this cycle three to six times. The
intervals can be adjusted to align
with your fitness level and goals.
This type of training can provide
a very efficient workout. The
volume of exercise is generally less than
a continuous bout at a constant pace, but
similar or greater benefits can be gained.
In fact, HIIT workouts are associated with
greater increases in peak oxygen consumption, muscle mitochondria, insulin
sensitivity, and basal metabolic rate in
overweight individuals than are achieved
with continuous endurance training. These
metabolic changes result in similar body
Is High-Intensity Interval Training
Right For You?
High-intensity interval training (HIIT) is a
highly effective method of training. If you're
healthy enough—and up for the challenge—it
might be right for you.
composition changes over time, with less
time investment and similar levels of exercise enjoyment.
How do you know if this type of training is right for you? If you are a beginner, have risk factors for cardiovascular
disease or musculoskeletal disorders,
are obese, or have been sedentary, make
sure you get clearance from your health
care provider. After getting checked out,
The FITT Principle for Flexibility
Although often overshadowed by cardiorespiratory and muscular fitness training, flexibility is important. Inflexible muscles are susceptible to injury, and flexibility training reduces
the incidence and severity of lower back problems and muscle
or tendon injuries.73 Improved flexibility also means less tension and pressure on joints, resulting in less joint pain and
joint deterioration.74 Thus, remaining flexible can help to
prevent the decreased physical function that often occurs with
aging.75
Frequency
The FITT principle calls for a minimum of
2 to 3 days per week for flexibility training.
Intensity
Intensity reco­mmendations for flexibility are
that you perform or hold
static stretching Stretching
stretching positions at an
techniques that slowly and
individually
determined
gradually lengthen a muscle
“point of feeling tightness.”
or group of muscles and their
tendons.
You should be able to feel
198 | PART TWO | Building Healthy Lifestyles
find a fitness professional who
can help you get started and help
you modify exercises to accommodate your personal level of
fitness. HIIT might be a good
option if time is a barrier or you
are trying to improve your performance. With high-intensity activities it is important to allow your
body time to rest and recover
to reduce the risk of injury. HIIT
should be alternated with other
activities throughout the week. If
you want maximal benefits in a
short amount of time, give HIIT
a try!
Sources: D. De Strijcker et al., "High
Intensity Interval Training Is Associated
with Greater Impact on Physical Fitness,
Insulin Sensitivity and Muscle Mitochondrial Content in Males with Overweight/
Obesity, as Opposed to Continuous Endurance
Training: A Randomized Controlled Trial" (2017);
M. R. Wewege et al., "The Effects of High-Intensity
Interval Training vs. Moderate-Intensity Continuous Training on Body Composition in Overweight
and Obese Adults: A Systematic Review and
Meta-analysis," Obesity Reviews 18, no. 6 (2017):
635–46; B. R. R. Oliveira et al., "Affective and
Enjoyment Responses in High Intensity Interval
Training and Continuous Training: A Systematic
Review and Meta-analysis," PloS One 13, no. 6
(2018): e0197124.
slight discomfort in the muscle(s) you are stretching, but the
stretch should not hurt.76
Time
The time recommended to improve flexibility is
based on total time per stretching exercise. The goal is to work
up to a total stretch time per exercise or muscle group of
60 seconds.77 This is achieved by holding your stretching
position for 10 to 30 seconds (one rep) and repeating it two to
four times in close succession.78
Type The most effective exercises for increasing flexibility involve stretching the major muscle groups of your body
when the body is already warm, such as after your cardiorespiratory workout. The safest exercises for improving flexibility involve static stretching. The primary strategy is to
decrease the resistance to lengthening within a tight muscle.79
To do this, repeatedly stretch the muscle and its tendons to
elongate them. With each repetition, your range of motion
improves temporarily; when done regularly, range of motion
increases. FIGURE 7.7 on page 200 illustrates some basic
stretching exercises to increase flexibility.
TABLE 7.2 | Methods of Providing Muscular Resistance
Body Weight
■■ Uses your own body weight to develop
muscular strength and endurance
■■ Improves overall muscular fitness and,
in particular, core body strength and
overall muscle tone
Examples: Push-ups, pull-ups, curl-ups,
dips, planks, chair sits, lunges, etc.
Free Weights/Equipment
■■ Provides a constant resistance
Weight Machines
■■ Resistance altered so that the
throughout the full range of movement
■■ Requires balance and coordination;
promotes development of core body
strength
Examples: Barbells, dumbbells, medicine balls,
kettlebells, resistance bands or tubes, etc.
muscle’s effort is consistent
throughout the full range of motion
■■ Provides more controlled motion and
isolates certain muscle groups
Examples: Leg press, chest press, lat pull
down, seated row, assisted pull-up, etc.
TABLE 7.3 | Popular Muscle Fitness Equipment
Stability Ball
Ball made of
burst-resistant
vinyl that can
be used for
strengthening
core muscles
or to improve
flexibility.
■■ Balls must be
inflated correctly to be
most effective.
Cost: $25–100
Balance Board
Resistance Band
Medicine Ball
A board with a
rounded bottom
that can be used to
improve balance,
core muscle
strength, and
flexibility.
Rubber or elastic
material, sometimes
with handles, that
can be used to build
muscular strength
and endurance.
Can also be used
in yoga or Pilates to
provide assistance in
flexibility training.
A heavy ball,
about 14 inches in
diameter, used in
rehabilitation and
strength training.
Weight varies from
2 to 25 lb. Some
made with handles.
A heavy ball with
a handle used
for full-body
muscular strength
and endurance
exercises. Weight
varies from 5 to
100 lb.
■■ Can be used
■■ Can be used
■■ Great for
improving
agility, coordination, reaction
skills, and ankle
strength.
■■ Can be difficult
initially for new
users. Caution
new users with
weak ankles,
as there is a
risk of straining
ligaments and
tendons.
Cost: $40–80
■■ Improves mus-
cular strength
and endurance,
balance, coordination, and
flexibility.
■■ Lightweight, dura-
ble, and portable.
■■ Breaks down over
time; need to
inspect regularly
to avoid injury if
it breaks during
use.
Cost: $5–35
effectively to
increase explosive power.
■■ Also used to
develop core
body strength.
■■ If used incor-
rectly, there is
potential for
lower back
injuries.
Cost: $10–150
Kettlebell
effectively
to increase
muscular fitness,
core strength,
and explosive
power.
■■ Movements can
be complex,
and if used
incorrectly, there
is potential for
lower back and/
or wrist injuries.
Cost: $10–150
Free Weights
Rubber, plastic, or
metal dumbbells or
barbells, often with
adjustable weight;
can be used with a
weight bench.
■■ Traditional
method for
building muscular strength and
endurance.
■■ A full set allows
you to increase
resistance as
you train, allowing for greater
improvements
in muscular
strength.
■■ Potential for
injury if form is
incorrect; must
concentrate on
body alignment
and ensuring
sufficient core
body strength.
Cost: $10–300
CHAPTER 7 | Improving Your Personal Fitness | 199
a Stretching the inside of the thighs
b Stretching the upper arm and the
c Stretching the triceps
d Stretching the trunk and the hip
e Stretching the hip, back of the
f Stretching the front of the thigh
and the hip flexor
side of the trunk
thigh, and the calf
FIGURE 7.7
Stretching Exercises to Improve Flexibility Use these stretches as part of your cool-down. Hold each stretch for
10 to 30 seconds and repeat two to four times per side.
Implement Your Fitness Program
As your physical fitness im­proves, you need to adjust the frequency, intensity, time, and type of exercise to maintain or
continue to improve your level of physical fitness. Below are a
few suggestions to get started and stay on track.
Develop a Progressive Plan Begin an exercise
regimen by picking something that you enjoy. Keep in mind
that you might have to try a few activities to find one that is
fun for you, so do not get discouraged if you do not enjoy your
first trip to the gym. Once you find activities that you like,
gradually increase the frequency or time of your workouts. For
example, in week 1, you might exercise 2 days for 20 minutes
per day, and then move to 3 days in week 3 or 4. Then, consider
increasing your duration to 30 minutes per session over the
next couple of weeks. Gradual increases in intensity are typically made once the duration and frequency goals are met.
Finding a variety of exercises can reduce the risk of overuse
injuries. Choosing different exercises for your workouts will
also provide for a more complete training program by targeting more muscle groups. Reevaluate your physical fitness goals
and action plan monthly to ensure that they are still working
for you. A mistake many people make when they decide to
become more physically active (or to make any other behavior
change) is putting a lot of effort into getting started, but failing to develop a long-term plan for action and maintenance
phases. The MAKING CHANGES TODAY box offers more tips
on starting and sticking with an exercise plan.
200 | PART TWO | Building Healthy Lifestyles
Because some goals take
WHAT DO
several weeks to achieve, be
mindful of the benefits you
THINK?
are getting in the meantime
to keep yourself motivated.
What does a
Focus on how you feel after
“realistic goal” mean
a brisk walk or run. Is your
to you?
breathing fast and is your
■■ How soon do you expect
face flushed? Do you feel
to see results from your
warm and can you feel your
increased activity levels?
heart beating? Focus on
■■ How do you plan to measure
the warmth of your skin
your results?
and how your muscles feel.
■■ What are you willing and able
Inhale deeply. Exhale. Repeat
to do to reach your goal?
several times. Notice how
your body is relaxing yet you feel more alive, more energized, and
less stressed. Allow yourself to bask in the moment. Make note of
how exercise made you feel. Do you sleep better after exercise? Do
you feel more relaxed after a stressful day? Journaling these simple
benefits can keep you on track as you work toward bigger goals.
YOU
Design Your Exercise Session
A comprehensive workout should include a warm-up, cardiorespiratory
and/or resistance training, and then a cool-down to finish the
session. FIGURE 7.8 on page 202 shows a sample 60-minute
cardiorespiratory workout.
■■
Warm-Up The warm-up prepares the body physically and
mentally for cardiorespiratory and/or resistance training.
MAKING CHANGES TODAY
Plan It, Start It, Stick With It!
The most successful physical activity program is one that
you enjoy, is realistic, and is appropriate for your skill level
and needs.
Make it enjoyable. Pick activities you like to do so you will
make the effort and find the time to do it.
Start slowly. If you have been physically inactive for a
while, any type and amount of physical activity is a step in
the right direction. Letting your body adapt gradually will
reduce soreness later.
Make only one lifestyle change at a time. It is not realistic to change everything at once, and success with one
behavioral change will increase your confidence to make
other changes.
Set reasonable expectations for yourself and your physical fitness program. You will not become “fit” overnight.
Focus on the changes you do see immediately (e.g.,
improved sleep, feeling relaxed, stress management,
A warm-up should involve
large body movements, generCan you use some tips on
ally using light cardiorespirastretching before and after
tory activities, followed by
exercise? Watch The Do’s
range-of-motion exercises of
and Don’ts of Stretching,
the muscle groups to be used
available on Mastering
during the exercise session.
Health.
Usually 5 to 15 minutes long,
a warm-up is shorter when
you are ready to go and longer when you are struggling to
get moving or your muscles are cold or tight. The warmup provides a transition from rest to physical activity
by slowly increasing heart rate, blood pressure, breathing rate, and body temperature. These gradual changes
improve joint lubrication, increase muscle and tendon
elasticity, and enhance blood flow throughout the body,
facilitating performance during the next stage of the workout. Dynamic stretching is a great addition to the warmup phase, but static stretching should only be performed
after light cardiovascular activity. When stretching, make
sure you target the muscles that you are going to use in
your workout.
SEE IT! VIDEOS
■
■
Cardiorespiratory and/or Resistance Training. The next
stage of your workout may involve cardiorespiratory training, resistance training, or a little of both. If completing
aerobic and resistance exercise in the same session, it is
often recommended to perform your aerobic exercise first.
This order will provide additional warm-up for the resistance session, and your muscles will not be fatigued for the
aerobic workout.
ool-Down and Stretching. A cool-down is an essential
C
component of a fitness program; it involves another
feeling good about yourself). These things will help you
stay motivated while working to meet long-term goals. Be
patient and enjoy!
Choose a time to be physically active during your week
and stick with it. Establish priorities and keep a written or
electronic schedule with your exercise sessions added in.
Try different times of the day to learn what works best for
you.
Record your progress. Include the intensity, time, and
type of physical activities; your emotions; and your personal achievements in an activity log. This action will help
you stick to your program and modify it as needed.
Take lapses in stride. Sometimes life gets in the way. Start
again and do not despair; your commitment to physical
fitness has ebbs and flows like almost everything else in
life.
Reward yourself. Find meaningful and healthy ways to
reward yourself when you reach your goals.
10 to 15 minutes of activity time. Start your cool-down
with 5 to 10 minutes of moderate- to low-intensity activity,
and follow it with approximately 5 to 10 minutes of
stretching. Because of the body’s increased temperature,
the cool-down is an excellent time to stretch to improve
flexibility. The purpose and importance of the cool-down
is to gradually reduce your heart rate, blood pressure,
and body temperature to pre-exercise levels. In addition,
the cool-down reduces the risk of blood pooling in the
extremities and facilitates quicker recovery between
exercise sessions.
LO 4 | COMMITTING TO
PHYSICAL ACTIVITY
Identify your obstacles to physical activity and ways to overcome them.
To succeed at incorporating physical fitness into your life,
you need to design a fitness program that takes obstacles into account and is founded on the activities you
enjoy most.
What if I Have Been Inactive
for a While?
If you have been physically inactive for the past few months
or longer, first make sure
dynamic stretching Gradual
that your health care protransitions in movement
vider clears you for exerand body position that
cise. Consider consulting a
progressively increase the
personal trainer or fitness
range of motion through
repeating the movements.
instructor to help you get
CHAPTER 7 | Improving Your Personal Fitness | 201
DID YOU
KNOW?
100
Warm-up
Resting (10 min)
Cardiorespiratory
Workout (40 min)
Cooldown
(10 min) Recovery
90
HR max (%)
80
70
60
50
40
30
Start
exercise
An interval workout using whole-body resistance training, such
as kettlebell exercises, will increase aerobic capacity, as well
as muscular strength and endurance.
10
20
30
40
Minutes of exercise
50
Stop
exercise
Key:
Anaerobic (96–100% HRmax)
Vigorous/high intensity training (76–95% HRmax)
Moderate/medium intensity training
(64–75% HRmax)
Source: J. A. Falatic et al., “Effects of Kettlebell Training on Aerobic Capacity,”
Journal of Strength and Conditioning Research 29, no. 7 (2015): 143–147.
Low/light intensity training (57–63% HRmax)
started. In this phase of a fitness program, known as the initial conditioning stage, you may be starting at levels that are
lower than the recommendations for physical fitness. For
example, you might start your cardiorespiratory program by
simply moving more each day and reducing your sedentary
time. As you make the decision to be more active and reduce
your sedentary time, assess your environment to evaluate how it supports and/or impedes physical activity. Be
mindful of your physical and social environments to determine how you can become more active. You might notice
that you walk past the stairs to get to the elevator in your
dorm or that your friends sit more than they move in their
free time.
Small changes can get you started on a path to increased
activity and improved health. Take the stairs instead of
the elevator, walk farther from your car to the store, and
plan for organized movement each day, such as a 10- to
15-­minute walk. In addition, you can start your muscle f­ itness
program with simple body weight exercises, e­mphasizing
proper technique and body alignment before adding any
resistance.
Overcome Common Obstacles
to Physical Activity
People have real and perceived barriers that prevent regular
physical activity, ranging from personal (“I do not have time”)
to environmental (“I do not have a safe place to be active”) to
social (“I do not have a workout partner”). Some people may
be reluctant to exercise if they are overweight, feel embarrassed
202 | PART TWO | Building Healthy Lifestyles
FIGURE 7.8 A 60-minute Workout Plan This graph
charts a sample 60-minute cardiorespiratory workout, including
warm-up, cardiorespiratory fitness, and cool-down.
to work out with their more “fit” friends, or feel they lack the
knowledge and skills required.
Think about your obstacles to physical activity and write
them down. Consider anything that gets in your way of
exercising, however minor. Some of the barriers reported by
college students include lack of motivation, self-discipline,
or enjoyment coupled with the enjoyment of sedentary
activities, such as screen time and the use of technology.80
“Partying” and social networks that do not support physical activity are also reported as barriers.81 Commute time to
school, studying, school demands, and equipment cost also
get in the way of college students getting enough physical
activity.82 Once you honestly evaluate why you are not as
physically active as you want to be, review TABLE 7.4 for suggestions on overcoming your hurdles. Once you determine
your biggest obstacles, develop and write out specific plans to
address them.
Incorporate Physical Activity into
Your Life
When you design your fitness program, consider several factors. Here are a few ways to incorporate physical activity into
your daily life, mindfully:
■■
Be Mindful of Your Own Preferences. Choose activities
that are appropriate for you, that are convenient, and that
TABLE 7.4 | Overcoming Obstacles to Physical Activity
Obstacle
Possible Solution
Lack of time
■■ Look at your schedule. Where can you find 30-minute time slots? Perhaps you need to focus on shorter times
(10 minutes or more) throughout the day.
■■ Multitask. Read while riding an exercise bike or listen to lectures or podcasts while walking.
■■ Be physically active during your lunch and study breaks as well as between classes. Skip rope or throw a
Frisbee with a friend.
■■ Select activities that require less time, such as brisk walking or jogging.
■■ Ride your bike to class, or park (or get off the bus) farther from your destination.
Social influence
■■ Invite family and friends to be active with you.
■■ Join an exercise class to meet new people.
■■ Explain the importance of exercise and your commitment to physical activity to people who may not support
your efforts.
■■ Find a role model to support your efforts.
■■ Plan for physically active dates—walking, dancing, or bowling.
Lack of motivation,
willpower, or energy
■■ Schedule your workout time just as you would any other important commitment. Prioritize you.
■■ Enlist the help of an exercise partner to make you accountable for working out.
■■ Give yourself an incentive or reward for meeting short-term goals and longer-term goals.
■■ Schedule your workouts when you feel most energetic. If you are too tired to walk a mile, do what you can
do. Every little bit helps—and every small step is a positive achievement. Remind yourself that exercise gives
you more energy.
■■ Get things ready; for example, if you choose to walk in the morning, set out your clothes and shoes the night
before.
Lack of resources
■■ Select an activity that requires minimal equipment, such as walking, jogging, jumping rope, lifting small free
weights, or using resistance bands.
■■ Identify inexpensive resources on campus or in the community.
■■ Whenever possible, walk, bike, or select active transportation rather than riding.
■■ Take advantage of no-cost opportunities, such as playing catch or Frisbee. Get into a pickup game of basket-
ball, volleyball, or soccer in the park or green space on campus.
Environmental
barriers
■■ Develop a plan for inclement or extreme weather, such as an indoor option or home exercise if driving is
hazardous.
■■ Have a workout partner or use a gym if safety is a concern.
■■ Increase lifestyle activity and decrease sedentary time.
Source: Adapted from National Center for Chronic Disease Prevention and Health Promotion, “Overcoming Barriers to Physical Activity,” Updated December
2017, www.cdc.gov/physicalactivity/basics/adding-pa/barriers.html.
you genuinely enjoy. For example, you might choose jogging because you like to run and there are beautiful trails
nearby. Don’t swim if you don’t like the water and the pool
is difficult to get to.
■■ Be Mindful of Your Current Fitness Level. Choose activities that make sense for your current fitness level. If you are
overweight or have not exercised in months, start slowly,
plan fun activities, and progress to more challenging physical activities as your physical fitness improves. You may
choose to simply walk more and keep track of your steps
with an activity tracker to achieve the recommended goal
of 10,000 steps per day.
■■ Be Mindful of Opportunities to Increase Your Activity
Levels. Do you sit all day? Choose the elevator over the
stairs? Park as close as you can to the front door or the store
entrance? All of these instances could be opportunities for
activity. Try to make physical activity a part of your routine
by incorporating it into something you already have to do,
such as getting to class or work. (See the TECH & HEALTH
box on page 204 for more on choosing the right activity
tracker for your needs and lifestyle.)
■ ■ Green Your Routine. Outdoor exercise (sometimes
called green exercise) is a great way to get mental
health benefits on top of the physical ones. 83 Your
campus surroundings may offer many opportunities
to be active—and present. Take a walk through the
campus, purposefully noticing your outdoor spaces.
Open green space is great for a yoga mat or meditating.
Stadium stairs and benches can be incorporated into
an exercise routine, and even trees can become exercise
equipment.
See the HEALTH HEADLINES box on page 205 for more
about using transportation for fitness.
CHAPTER 7 | Improving Your Personal Fitness | 203
TECH
& HEALTH
Activity Trackers
Which One Is Right for You?
A
ctivity trackers and apps are now
commonplace and many people
use them. Now the question is, are
they accurate and do they encourage
behavior change? Research shows that
some features such as heart rate and
step counting can be very accurate,
while measures like caloric expenditure
and sleep variables are less accurate.
The impact on behavior change will
likely depend on the individual. With all
the options, how do you choose one?
What do you want to track? If your
goal is to monitor steps and exercise
time, your phone may be an ideal
option, especially if cost is a concern.
However, for continuous monitoring,
your phone is not the best choice. For
estimates of energy expenditure, sleep,
heart rate, and sedentary time, you
will have to spend a little money to get
accurate information. Fortunately, there
are several affordable monitors.
Cost. There are many free and lowcost apps that can be downloaded
or that come preloaded on your cell
phone. There are also monitors that
cost a couple of hundred dollars. Be
sure to find one that works for your
budget.
Behavior change features. All fitness
trackers and apps have some behavior
change elements. Keeping track of your
activity patterns is helpful for maintaining
a new behavior. Look for monitors that
have features to motivate you. Setting
goals, connecting with friends or social
Explore Activities for
Functional Fitness
Some forms of activity have the potential to improve several
components of physical fitness and thus improve your everyday functioning (“functional” exercises). For example, core
strength training improves posture and can prevent back pain.
In addition, yoga, tai chi, and Pilates improve flexibility, muscular fitness and endurance, balance, coordination, and agility. They also develop the mind–body connection through
concentration on breathing and body position.
Core Strength Training
The body’s core muscles
are the foundation for all movement. These muscles include
the deep back, abdominal, and hip muscles that attach to the
spine and pelvis. The contraction of these muscles provides
the basis of support for movements of the upper and lower
body and powerful movements of the extremities. A weak core
generally results in poor posture, low back pain, and muscle
injuries. A strong core provides a more stable center of gravity and, as a result, a more stable platform for movement, thus
reducing the chance of injury.
You can develop core muscular fitness by doing various exercises, including body weight exercises, yoga, or Pilates. Examples
of exercises that increase core strength include holding yourself
in a plank or doing abdominal curl-ups. However, a structured
routine of exercises is better than one single exercise for enhancing overall core muscle strength and endurance. It is important
to perform a core fitness program that has a balance of all the
key core stabilizing muscles (back, abdominal, and hip muscles).
204 | PART TWO | Building Healthy Lifestyles
media, and reminders to exercise are all
behavior change features to consider.
Trackers that have websites to download
your information are great for tracking progress for long-term goals. Good
tracker websites provide up-to-date
scientific information about fitness and
exercise as a resource. Wrist monitors
wear like a watch, and some even look
more like jewelry than a fitness gadget for
those who do not want to compromise
style for function. Whatever you do, be
sure to search for reviews and compare
devices before you make a purchase.
Source: J. Xie et al., “Evaluating the Validity of
Current Mainstream Wearable Devices in Fitness
Tracking under Various Physical Activities:
Comparative Study,” Journal of Medical Internet
Research mHealth and uHealth 6, no. 4 (2018).
Yoga Yoga, based on ancient Indian practices, blends the
mental and physical aspects of exercise—a union of mind and
body that participants often find relaxing and satisfying. The
practice of yoga focuses attention on controlled breathing as
well as physical exercise and incorporates a complex array of
static stretching and strengthening exercises expressed as postures (asanas). Done regularly, yoga improves flexibility, vitality, posture, agility, balance, coordination, and core muscular
fitness and endurance. Many people report an improved sense
of general well-being, too.
Tai Chi
Tai chi is an ancient Chinese form of exercise that
combines stretching, balance, muscular endurance, coordination, and meditation. It increases range of motion and flexibility while reducing muscular tension. It involves continuously
performing a series of positions called forms. Tai chi is often
described as “meditation in motion” because it promotes serenity through gentle movements that connect the mind and body.
Pilates
Pilates was developed by Joseph Pilates in 1926
as an exercise style that combines stretching with movement against resistance, frequently aided by devices such
as tension springs or heavy rubber bands. It differs from
yoga and tai chi in that it includes a component specifically
designed to increase strength. Some movements are carried
out on specially designed equipment, whereas others can
be performed on mats. It teaches body awareness, good posture, and easy, graceful body movements while improving
flexibility, coordination, core strength, muscle tone, and
economy of motion.
HEALTH
HEADLINES
Pedal or Pedestrian—Embrace Your
Personal Power!
T
here is a movement toward more
active transportation, or using
your own power to get from place to
place—whether walking, riding a bike,
skateboarding, or roller skating. A bicycle
is an excellent and cost-effective way
to get to and around campus. Check to
see whether your city has a bike share
program at http://bikeshare.com. Here
are just a few of the many reasons to
make active transportation a bigger
part of your life:
You will be adding more exercise
into your daily routine. People who
use active forms of transportation to
complete errands are more likely to
meet physical activity guidelines.
■■ Walking or biking can save you money.
It is significantly less expensive to own
a bike than a car when you consider
gas and maintenance. It is estimated
that it costs 30 times more to maintain
a car than a bike! Also consider that
you will save the cost of a parking permit and any parking tickets.
■■ Walking or biking may save you time!
Short commutes of 3 to 5 miles are
usually as fast or faster via bicycle
rather than via car.
■■ You will enjoy being outdoors.
Research is emerging on the physical
and mental health benefits of nature
and being outdoors. So much of what
we do is inside, with recirculated air
and artificial lighting, that our bodies
are deficient in fresh air and sunlight.
Hop on that bike and join the green
revolution! Active transportation is an
excellent way to protect the environment
and add physical activity to your day,
especially on nonexercise days.
■■
You will contribute to global environmental health. Reducing vehicle trips
will help reduce overall greenhouse gas
emissions and the need to source more
fossil fuel. Swapping walking or cycling
for the car when taking short trips is
estimated to save over 10 billion gallons of fuel per year.
Safety is paramount, so make sure you
consider the following recommendations:
Always wear a bike helmet! Even
for short trips, you should wear a
helmet that fits well and has not been
damaged.
■■ Obey traffic rules. Cycle with the flow
of traffic, obey traffic lights and signs,
and use bike lanes when available.
■■ Be seen. Avoid dark clothing, wear
reflective clothing, have reflectors and
head and tail lights for your bike. Be
aware of your surroundings. Remember
that drivers often do not look for
pedestrians and cyclists.
■■ Use caution when carrying items. Use
a backpack or rack for carrying books,
class materials, and groceries.
■■
■■
You will make a significant contribution to reducing air pollution. Choosing
to walk or bike instead of driving only
2 days a week can reduce greenhouse gas emissions by an average of
4,000 pounds a year.
■■ You will help reduce traffic. More active
commuters means fewer cars on the
roads and less traffic congestion.
■■
Some people set themselves up to succeed in terms of their fitness goals by participating in group activities or exercise classes.
For some guidance on how best to choose the right fitness class
for you, see the MAKING CHANGES TODAY box on page 206.
LO 5 | TAKING IN PROPER
NUTRITION FOR EXERCISE
Create a strategy for optimal food and fluid consumption for
exercise and recovery.
It’s important to evaluate your eating habits in light of your
exercise habits. Whether you’re a seasoned fitness buff or a
beginner, the importance of proper nutrition for exercise can’t
be overstated.
Sources: A. Milne et al., Alliance for Biking and
Walking, Bicycling & Walking in the United States
2016 Benchmarking Report, Copyright © 2016
by Alliance for Biking & Walking, The Library of
Congress, United States Copyright Office, All rights
reserved, http://bikingandwalkingbenchmarks.
org/#; Pedestrian and Bicycle Information Center,
“Be a Role-Model: Personal Safety Tips,” Accessed
June 8, 2018, www.pedbikeinfo.org/community/
tips.cfm.
Foods for Exercise and Recovery
To make the most of your workouts, follow the recommendations of the U.S. Department of Agriculture’s MyPlate plan,
and make sure that you eat sufficient carbohydrates, the body’s
main source of fuel. Your body stores carbohydrates as glycogen
primarily in the muscles and liver and then uses this stored glycogen for energy when you are physically active. Fats are also
an important source of energy, packing more than double the
amount of energy per gram compared to carbohydrates. Protein plays a role in muscle repair and growth but is not normally a source of energy.
When you eat is almost as important as what you eat. Eating a large meal before exercising can cause upset stomach,
cramping, and diarrhea because your muscles have to compete with your digestive system for energy. After a large meal,
CHAPTER 7 | Improving Your Personal Fitness | 205
MAKING CHANGES TODAY
Find the Right Class
There are a lot of options for fitness classes. Which one is
right for you? Here are a few tips to help you narrow it down.
Keep in mind that you may have to try out multiple classes
and instructors before you find a good match.
Check for certification. Is your instructor certified?
If so, check with the National Commission for
Certifying Agencies (www.credentialingexcellence.org/
nccadirectory) to find out if your trainer or instructor has
an accredited fitness certification.
Check for variability. See if you can find a class whose
instructor provides modifications for individual levels of fitness.
Check class difficulty. Is the class appropriate for your fitness level? An advanced Zumba class might not be the
best choice for a beginner. Make sure it’s not too hard—
or too easy—for your current level of fitness.
Assess your fitness goals. Will the class you’d like to
join meet your fitness goals? Yoga is great for stress
management and flexibility, but a spin class will produce
greater increases in cardiorespiratory fitness.
Know what you like. Will you enjoy the class? Odds
are you’re more likely to stick with a class if it’s with an
instructor you like, doing an activity you find enjoyable.
wait 3 to 4 hours before you begin exercising. Smaller meals
(snacks) can be eaten about an hour before activity. Not eating
at all before a workout can cause low blood sugar levels that in
turn cause weakness and slower reaction times.
After your workout, help your muscles recover by eating a
snack or meal that contains plenty of carbohydrates and a little
protein, too.84 Today, there is a burgeoning market for dietary
supplements that claim to deliver the nutrients needed for
muscle recovery, as well as additional “performance-enhancing”
ingredients; one thing to keep in mind is that there are few standards and virtually no Food and Drug Administration (FDA)
approval needed for these products. (See TABLE 7.5 for some of
the most popular performance-enhancing drugs and supplements, their purported benefits, and associated risks.)
Fluids for Exercise and Recovery
In addition to eating well, staying hydrated is also crucial. How
much fluid do you need? Keep in mind that the goal of fluid
replacement is to prevent excessive dehydration (greater than
2% loss of body weight). The ACSM and the National Athletic
Trainers’ Association recommend consuming 5 to 7 milliliters
per kilogram of body weight (approximately 0.7 to 1.07 ounces
per 10 pounds of body weight)
4 hours prior to exercise.85 A
hyponatremia An abnormally
good way to monitor how much
low concentration of sodium in
fluid you need to replace is to
the blood.
water intoxication A potentially weigh yourself before and after
fatal form of hyponatremia.
your workout. The difference in
206 | PART TWO | Building Healthy Lifestyles
The American College of Sports Medicine and the National
Athletic Trainers' Association recommend consuming 14 to
22 ounces of fluid several hours prior to exercise and about
6 to 12 ounces per 15 to 20 minutes during—assuming you
are sweating.
weight is how much you should drink. So, for example, if you
lost 2 pounds during a training session, you should drink 32
ounces of fluid.86
For exercise sessions lasting less than 1 hour, plain water
is sufficient for rehydration. If your exercise session exceeds
1 hour—and you sweat profusely—consider a sports drink
containing electrolytes. The electrolytes in these products are
mineral ions such as sodium and potassium that are needed
for proper functioning of your nervous and muscular systems.
Replacing electrolytes is particularly important for endurance
athletes. In endurance events lasting more than 4 hours, an
athlete’s overconsumption of plain water can dilute the sodium
concentration in the blood, an effect called h
­ yponatremia,
which can lead to potentially fatal water intoxication.
Although water is the best choice in most cases, there are
situations in which you might need to choose something different. Some people are likely to consume more when their
drink is flavored because the taste is more appealing than
water, a point that may be significant in ensuring proper
hydration. For example, low-fat chocolate milk is a r­ecovery
TABLE 7.5 | Performance-Enhancing Dietary Supplements and Drugs—Their Uses and Effects
Supplement/Drug
Primary Uses
Side Effects
Creatine Naturally occurring compound that helps
supply energy to muscle
■■ Improve postworkout
■■ Weight gain, nausea, muscle cramps
recovery
■■ Large doses can impair kidney function
■■ Increase muscle mass
■■ Increase strength
■■ Increase power
Ephedra and ephedrine Stimulant that constricts
blood vessels and increases blood pressure and
heart rate*Illegal; banned by FDA in 2008; banned
by sports organizations
■■ Lose weight
■■ Nausea, vomiting
■■ Increase performance
■■ Anxiety and mood changes
Anabolic steroids Synthetic versions of the
hormone testosterone *Nonmedical use is illegal;
banned by major sports organizations
■■ Improve strength,
■■ Hyperactivity
■■ Rarely seizures, heart attack, stroke, psychotic
episodes
power, and speed
■■ Increase muscle mass
■■ In adolescents, stops bone growth; therefore
reduced adult height
■■ Masculinization of females; feminization of males
■■ Mood swings
■■ Severe acne, particularly on the back
■■ Sexual dysfunction
■■ Aggressive behavior
■■ Potential heart and liver damage
Steroid precursors Substances that the body
converts into anabolic steroids, for example,
androstenedione (andro), dehydroepiandrosterone
(DHEA)*Nonmedical use is illegal; banned by
major sports organizations
■■ Converted in the body
Human growth hormone Naturally occurring
hormone secreted by the pituitary gland that is
essential for body growth*Nonmedical use is
illegal; banned by major sports organizations
■■ Antiaging agent
■■ Structural changes to the face
■■ Improve performance
■■ Increased risk of high blood pressure
■■ Increase muscle mass
■■ Potential for congestive heart failure
to anabolic steroids to
increase muscle mass
■■ In addition to side effects noted with anabolic ste-
roids: body hair growth, increased risk of pancreatic cancer
Sources: National Institutes of Health, Office of Dietary Supplements, “Dietary Supplements for Exercise and Athletic Performance
Fact Sheet for Health Professionals,” Updated June 30, 2017, https://ods.od.nih.gov/factsheets/ExerciseAndAthleticPerformance-HealthProfessional/;
U.S. Anti-Doping Agency, “Effects of PEDs,” Accessed June 8, 2018 www.usada.org/substances/effects-of-performance-enhancing-drugs/.
drink because it not only hydrates, but also is a source of
sodium, potassium, carbohydrates, and protein. Consuming
carbohydrates and protein immediately after exercise will help
replenish muscle and liver glycogen stores and stimulate muscle protein synthesis for better recovery from ­exercise.87 The
protein in milk, whey protein, is ideal because it ­contains all
the essential amino acids and is rapidly absorbed by the body.
LO 6 | PREVENTING AND
TREATING EXERCISE INJURIES
Explain how to prevent and treat common exercise injuries.
Two basic types of injuries stem from fitness-related activities:
traumatic injuries and overuse injuries. Traumatic injuries
occur suddenly and usually by accident. Typical traumatic
injuries are broken bones, torn ligaments and muscles, contusions, and lacerations. If a traumatic injury causes a noticeable
loss of function and immediate pain or pain that does not go
away after 30 minutes, consult a physician.
Overuse injuries result from the cumulative effects of
day-after-day stresses. These injuries occur most often in
repetitive activities such as swimming, running, bicycling,
and step aerobics. The forces that occur normally during
physical activity are not enough to cause a ligament sprain or
muscle strain, as in a traumatic injury, but when these forces
are applied daily for weeks or months, they can result in an
overuse injury. Factors such as being overweight, poor running mechanics, and inappropriate shoes can also contribute
to overuse injury.
The three most common overuse injuries are runner’s knee,
shin splints, and plantar fasciitis. Runner’s knee is a general term
describing a series of problems involving the ­muscles, tendons, and ligaments around the knee. Shin splints is a general
term used for any pain that occurs below the knee and above
the ankle in the shin. Plantar fasciitis is an ­inflammation of
the plantar fascia, a broad band of dense, inelastic tissue in the
foot. Rest, variation of routine, new shoes, and stretching are
the first lines of treatment for any of these overuse injuries. If
pain continues, visit a physician. Orthotics, physical therapy,
or steroid shots are possible treatment options.
CHAPTER 7 | Improving Your Personal Fitness | 207
Preventing Injuries
To reduce your risk of overuse or traumatic injuries, use common sense and the proper gear and equipment. Vary your
physical activities throughout the week, setting appropriate
and realistic short- and long-term goals. Listen to your body
when working out. Warning signs include muscle stiffness and
soreness, bone and joint pain, and whole-body fatigue that
simply does not go away.
Padded collar with
Achilles notch
Heel
counter
(inside shoe)
Upper
Toe box
Appropriate Footwear
Proper footwear, replaced
in a timely manner, can decrease the likelihood of foot, knee,
hip, or back injuries. Running, jumping, and other highimpact activities have a significant impact on your joints.
Consider the impact for a runner who has poor mechanics
or an overweight individual who participates in weight-bearing activities. The force not absorbed by the running shoe is
transmitted upward into the foot, leg, thigh, and back. Our
bodies can absorb forces such as these but may be injured by
the cumulative effect of repetitive impact (such as running
40 miles per week). Thus, the shoes’ ability to absorb shock is
critical—not just for those who run, but for anyone engaged in
weight-bearing activities.
In addition to absorbing shock, an athletic shoe should
provide a good fit for maximal comfort and performance
(see FIGURE 7.9). To get the best fit, shop at a sports or fitness specialty store where there is a large selection and the
salespeople are trained in properly fitting athletic shoes.
Try on shoes later in the day when your feet are largest, and
check to make sure there is a little extra room in the toe and
that the width is appropriate. Because different activities
place different stresses on your feet and joints, you should
choose shoes specifically designed for your sport or activity.
Shoes of any type should be replaced once they lose their
cushioning. A common rule of thumb is that running shoes
ought to be replaced after 300 to 500 miles of use, which
is typically between 3 and 9 months, depending on your
activity level.
Protective Equipment It is essential to use wellfitted protective equipment for your physical activities. For
example, using the correct racquet with the proper tension
helps prevent the general inflammatory condition known
as tennis elbow. As another example, eye injuries can occur
in virtually all physical activities, although some activities
(such as baseball, basketball,
and racquet sports) are riskier
traumatic injuries Injuries
that are accidental and occur
than others.88 As many as 90
suddenly.
percent of eye injuries could be
overuse injuries Injuries that
prevented by wearing approresult from the cumulative
priate eye protection, such as
effects of day-after-day
goggles with polycarbonate
stresses placed on tendons,
lenses.89
muscles, and joints.
208 | PART TWO | Building Healthy Lifestyles
Midsole
Arch support
Outsole Heel wedge
FIGURE 7.9 Anatomy of a Running Shoe A good running
shoe should fit comfortably; allow room for your toes to move;
have a firm, but flexible midsole; and have a firm grip on your
heel to prevent slipping.
Wearing a helmet while
WHAT DO
bicycle riding is an important safety precaution. In a
THINK?
bicycle accident, wearing a
helmet reduces your chance
How do your physical
of traumatic brain injury
activities put you at risk of
by 51 percent and your risk
injury?
90
of dying by 44 percent.
■■ What changes can you make
In a recent study of colto your approach to training,
lege students, 39 percent of
your training program,
students who rode a bicyequipment, or footwear to
cle in the past 12 months
reduce these risks?
reported never wearing a
helmet, and 24 percent said they wore one only sometimes
or rarely.91 Cyclists aren’t the only ones who should be wearing helmets. People who ski, skate, scooter, snowboard, ride a
motorcycle, or play contact sports should also wear helmets.
Look for helmets that meet the established standards and fit
your head properly.92 Be sure to wear your helmet according to
the instructions and replace it after five years or after a crash.93
YOU
Exercising in the Heat Exercising in hot or humid
weather increases your risk of a heat-related illness. In these
conditions, your body’s rate of heat production can exceed its
ability to cool itself. The three different heat stress illnesses,
progressive in their level of severity, are heat cramps, heat
exhaustion, and heatstroke.
Heat cramps (heat-related involuntary and forcible muscle
contractions that cannot be relaxed), the least serious problem, can usually be prevented by adequate fluid replacement
and a dietary intake that includes the electrolytes lost during
sweating.
Heat exhaustion is actually a mild form of shock, in
which the blood pools in the arms and legs away from the
brain and major organs of the body. It is caused by excessive
water loss because of intense or prolonged exercise or work in
a hot and/or humid environment. Symptoms of heat exhaustion include nausea, headache, fatigue, dizziness and faintness, and, paradoxically, goose bumps and chills. When you
are suffering from heat exhaustion, your skin will be cool
and moist.
Heatstroke, often called sunstroke, is a life-threatening
emergency condition with a high morbidity and mortality rate. Heatstroke occurs during vigorous exercise when
the body’s heat production significantly exceeds its cooling capacities. Core body temperature can rise from normal
(98.6°F) to 105 to 110°F within minutes after the body’s cooling mechanism shuts down. A rapid increase in core body
temperature can cause brain damage, permanent disability,
and death. Common signs of heatstroke are dry, hot, and usually red skin; very high body temperature; and rapid heart
rate. If you experience any of the symptoms mentioned here,
stop exercising immediately. Move to the shade or a cool spot
to rest and drink plenty of cool fluids for heat cramps and
exhaustion. If heatstroke is suspected, seek medical attention
immediately.
You can prevent heat stress by following certain precautions. First, acclimatize yourself to hot or humid weather. The
process of heat acclimatization, which increases your body’s
cooling efficiency, requires about 10 to 14 days of gradually
increased physical activity in the hot environment. Second,
reduce your risk of dehydration by replacing fluids before,
during, and after exercise. Third, wear clothing appropriate
for the activity and the environment—for example, light-colored nylon shorts and a tank top. Finally, use common sense.
For example, on a day when the temperature is 85°F and the
humidity is around 80 percent, postpone lunchtime physical
activity until the evening when it is cooler or exercise indoors
where the conditions are controlled.
Exercising in the Cold
When you exercise in
cool weather, especially in windy and damp conditions, your
body’s rate of heat loss is frequently greater than its rate of heat
production. These conditions may lead to hypothermia—a
condition in which the body’s core temperature drops below
95°F.94 Temperatures need not be frigid for hypothermia to
occur; it can also result from prolonged, vigorous exercise in
40 to 50°F temperatures, particularly if there is rain, snow, or
a strong wind.
As body core temperature drops from the normal 98.6°F to
about 93.2°F, shivering begins. Shivering—the involuntary contraction of nearly every muscle in the body—increases body temperature by using the heat given off by muscle activity. You may
also experience cold hands and feet, poor judgment, apathy, and
amnesia. Shivering ceases in most hypothermia victims as body
core temperatures drop to between 87 and 90°F, a sign that the
body has lost its ability to generate heat. Death usually occurs at
body core temperatures between 75 and 80°F.
Reducing risk for exercise injuries requires common sense
and preventative measures, including wearing protective
gear (helmets, knee pads, elbow pads, eyewear).
To prevent hypothermia,
analyze weather conditions
before engaging in outdoor
physical activity. Remember
that wind and humidity are
as significant as temperature.
Have a friend join you for
safety when exercising outdoors in cold weather, and
wear layers of appropriate
clothing to prevent excessive heat loss and frostbite
(synthetic or woolen undergarments, a windproof outer
garment, and a wool hat
and gloves). Keep your head,
hands, and feet warm. Finally,
do not allow yourself to
become dehydrated.95
heat cramps Involuntary and
forcible muscle contractions
that occur during or following
exercise in hot and/or humid
weather.
heat exhaustion A heat
stress illness caused by
significant dehydration resulting
from exercise in hot and/or
humid conditions.
heatstroke A deadly heat
stress illness resulting from
dehydration and overexertion in
hot and/or humid conditions.
hypothermia Potentially fatal
condition caused by abnormally
low body core temperature.
RICE Acronym for the
standard first-aid treatment
for virtually all traumatic and
overuse injuries: rest, ice,
compression, and elevation.
CHAPTER 7 | Improving Your Personal Fitness | 209
Treating Injuries
20 minutes every hour for the first
24 to 72 hours.
■■ Compression of the injured body part can be
accomplished with a 4- or 6-inch-wide elastic bandage;
this applies indirect pressure to damaged blood vessels
to help stop bleeding and reduce inflammation.
Be careful, though, that the compression wrap does
not interfere with normal blood flow. Throbbing or
pain indicates that the compression wrap should
be loosened.
■■
Elevation of an injured extremity above
the
level
of your heart also helps control
Applying
internal or external bleeding and reduce
ice to an injury
such as a sprain
the inflammatory response by making
can help relieve pain
the blood flow upward to reach the
and reduce swelling. To
injured area.
prevent frostbite, never
apply ice directly to
the skin.
First-aid treatment for virtually all fitness
training–related injuries involves RICE:
rest, ice, compression, and elevation.
est is required to avoid further
R
irritation of the injured body
part.
■ ■ Ice is applied to relieve pain
and constrict the blood vessels
to reduce internal or external
bleeding or the inflammatory
response. To prevent frostbite,
wrap the ice or cold pack in a
layer of wet toweling or elastic bandage
before applying it to your skin. A new
injury should be iced for approximately
■■
STUDY PLAN
ASSESS YOURSELF
Want to measure your
muscular strength, flexibility,
and cardiovascular
endurance? Take the How
Physically Fit Are You? assessment
available on Mastering Health.
is independently increased by
high amounts of sitting time.
|
LO 2 Fitness Components
for Health, Wellness,
and Physical
Function
■■
CHAPTER REVIEW
|
LO 1 Physical Activity for
Health
■■
Benefits of regular physical activity include reduced risk of cardiovascular diseases, metabolic
syndrome and type 2 diabetes,
and cancer, as well as improved
blood lipoproteins, bone mass,
weight control, immunity to
disease, mental health, stress
management, and lifespan.
Sedentary activity and the time
spent sitting also increase the
risk of poor health outcomes.
The risk for type 2 diabetes,
cardiovascular disease, some
cancers, and premature death
210 | PART TWO | Building Healthy Lifestyles
Visit the Study Area in Mastering Health to enhance
your study plan with MP3 Tutor Sessions, Practice
Quizzes, Flashcards, and more!
Physical fitness involves
achieving minimal levels in
the health-related components
of fitness: cardiorespiratory,
muscular strength, muscular
endurance, flexibility, and
body composition. Skill-related
components of fitness—such
as agility, balance, reaction
time, speed, coordination, and
power—are essential for elite
and recreational athletes
to increase their performance
in and enjoyment of sport.
|
LO 3 Utilizing the FITT
Principle to Create Your
Own Fitness Program
■■
Set SMART goals to improve your
physical fitness level, then use the
FITT principle to develop a progressive program to meet those goals. For
general health benefits, every adult
should participate in moderateintensity activities for 30 minutes
at least 5 days a week. To improve
cardiorespiratory fitness, you should
engage in vigorous, continuous,
and rhythmic activities 3 to 5 days
per week at an exercise intensity
of 64 to 96 percent of your
maximum heart rate for 20 to
30 minutes.
■■ Muscular strength is improved by
engaging in resistance-training
exercises two to three times per
week, using an intensity of greater
than 60 percent of 1 RM, and completing two to four sets of 8 to 12
repetitions. Muscular endurance is
improved by engaging in resistancetraining exercises two to three times
per week, using an intensity of
less than 50 percent of 1 RM, and
completing one to two sets of 15 to
25 repetitions.
■■ Flexibility is improved by engaging
in two to four repetitions of static
stretching exercises at least 2 to
3 days a week, where each stretch is
held for 10 to 30 seconds.
■■ Implement your physical activity
program so that it includes a warmup, muscle fitness exercises, aerobic
activities, and a cool-down with
stretching exercises. Core strength
training is important for mobility,
stability, and preventing back injury.
The popular exercise forms of yoga,
tai chi, and Pilates all develop your
functional fitness (core strength,
flexibility, muscle endurance).
|
LO 4 Committing to
Physical Activity
■■
Commit to your new lifestyle of
physical activity and increased fitness levels by incorporating fitness
activities into your life. If you are
new to exercise, start slowly, keep
your fitness program simple, and
consider consulting your physician
and/or a fitness instructor for recommendations. Overcome your barriers
or obstacles to exercise by identifying them and then planning specific
strategies to address them. Choose
activities that are fun and convenient to increase your likelihood of
sticking with them.
|
LO 5 Taking in Proper
Nutrition for Exercise
■■
Fueling properly for exercise involves
eating a balance of healthy foods
3 to 4 hours before exercise. In exercise sessions lasting an hour or more,
performance can benefit from some
additional calories ingested during the exercise session. Hydrating
properly for exercise is important for
performance and injury prevention.
Chocolate milk is a source of carbohydrates and protein for postexercise
recovery.
|
LO 6 Preventing and
Treating Exercise
Injuries
■■
Physical activity–related injuries are
generally caused by overuse or trauma.
The most common overuse injuries
are plantar fasciitis, shin splints, and
runner’s knee. Proper footwear and
protective equipment help to prevent
injuries. Exercising in the heat or cold
requires taking special precautions.
Minor exercise injuries should be
treated with RICE (rest, ice, compression, and elevation).
POP QUIZ
|
LO 1 Physical Activity for
Health
1. What is physical fitness?
a. The ability to respond to
routine physical demands
b. Having enough physical reserves
to cope with a sudden challenge
c. A balance of cardiorespiratory,
muscle, and flexibility fitness
d. All of the above
2. Which of the following is not a
health benefit associated with
regular exercise?
a. Reduced risk for some cancers
b. Reduced risk for cardiovascular
diseases
c. Elimination of chronic diseases
d. Improved mental health
|
LO 2 Fitness Components
for Health, Wellness,
and Physical Function
3. The maximum volume of oxygen
consumed by the muscles during
exercise defines
a. target heart rate.
b. muscular strength.
c. aerobic capacity.
d. muscular endurance.
4. Flexibility is the range of motion
around
a. specific bones.
b. a joint or series of joints.
c. the tendons.
d. the muscles.
strength development does this
represent?
a. Reversibility
b. Overload
c. Flexibility
d. Specificity of training
6. The “talk test” measures
a. exercise intensity.
b. exercise time.
c. exercise frequency.
d. exercise type.
7. At the start of an exercise session,
you should always
a. stretch before doing any
activity.
b. do 50 crunches to activate your
core muscles.
c. warm up with light
cardiorespiratory activities.
d. eat a meal to ensure that you are
fueled for the activity.
|
LO 4 Committing to
Physical Activity
8. Miguel is thinking about becoming
more active. Which of the
following is not a good piece of
advice to offer him?
a. Incorporate physical activity
into your daily life.
b. Make multiple changes to
diet and exercise routines
simultaneously.
c. Identify the habits and
environmental elements that
keep him from being active.
d. Set SMART goals.
|
LO 5 Taking in Proper
Nutrition for Exercise
9. Chocolate milk is good for
a. preworkout energy boost.
b. postworkout recovery.
c. slimming down.
d. staying hydrated during exercise.
|
LO 6 Preventing and Treating
Exercise Injuries
|
LO 3 Utilizing the FITT
Principle to Create
Your Own Fitness
Program
5. Janice has been lifting 95 pounds
while doing three sets of six leg
curls. To become stronger, she
began lifting 105 pounds while
doing leg curls. What principle of
10. Overuse injuries can be
prevented by
a. monitoring the quantity and
quality of your workouts.
b. engaging in only one type of
aerobic training.
c. working out daily.
d. working out with a friend.
CHAPTER 7 | Improving Your Personal Fitness | 211
Answers to the Pop Quiz can be found on page
A-1. If you answered a question incorrectly,
review the section identified by the Learning
Outcome. For even more study tools, visit
Mastering Health.
THINK ABOUT IT!
|
LO 1 Physical Activity for
Health
1. How do you define physical fitness?
Identify at least four physiological
and psychological benefits of
physical activity. How would
you promote these benefits to
nonexercisers?
|
LO 2 Fitness Components
for Health, Wellness,
and Physical Function
2. How are muscle strength and
muscle endurance different? What
are some ways you might work
to increase muscle strength and
muscle endurance?
LO 3
|
Utilizing the FITT
Principle to Create Your
Own Fitness Program
3. Describe the FITT prescription for
cardiorespiratory fitness, muscular
strength and endurance, and
flexibility training.
212 | PART TWO | Building Healthy Lifestyles
|
LO 4 Committing to
Physical Activity
4. What do you do to motivate
yourself to engage in physical
activity on a regular basis? What
and who helps you to be physically
active?
|
LO 5 Taking in Proper
Nutrition for Exercise
5. Why is when you eat as important
as what you eat? How might
your exercise preparation and
routine differ in hot and cold
climates?
LO 6
and Treating
| Preventing
Exercise Injuries
6. What precautions do you need to
take when exercising outdoors in
the heat and in the cold?
ACCESS YOUR
HEALTH ON THE
INTERNET
The following websites explore further
topics and issues related to personal
fitness.
American College of Sports Medicine.
This site is the link to the American College
of Sports Medicine and all its resources.
www.acsm.org
American Council on Exercise.
Information is found here on exercise and
disease prevention. www.acefitness.org
Centers for Disease Control and
Prevention, National Center for
Chronic Disease Prevention and
Health Promotion, Division of
Nutrition, Physical Activity, and
Obesity. This site is a great resource for
current information on exercise and health.
www.cdc.gov/nccdphp/dnpao
National Strength and Conditioning
Association. This site is a resource for
personal trainers and others interested in
conditioning and fitness. www.nsca.com
WHICH PATH
WOULD YOU TAKE?
“Are You Going to Hit the Gym or
the Couch After Class?” Go to
Mastering Health to see how your
actions today affect your future health.
8
BUILDING HEALTHY
RELATIONSHIPS AND
COMMUNICATING EFFECTIVELY
LEARNING OUTCOMES
LO1
Describe the types of social support available and the
impact of social networks on health status.
LO2
Discuss the purpose and common forms of intimate
relationships.
LO3
Discuss ways to improve communication skills and
interpersonal interactions, particularly in the digital
environment.
LO4
Identify the characteristics of successful relationships,
including how to overcome common conflicts, and
discuss how to cope when relationships end.
LO5
Compare and contrast the types of committed
relationships and singlehood.
213
WHY
SHOULD I CARE?
Unless you decide to be a hermit, there is hardly a career or life path you might
choose that won’t require communicating and cooperating with others. Develop
good communication skills now, and you’ll be poised for success.
H
umans are social beings—we have a basic need to
belong and to feel loved, accepted, and wanted.
We can’t thrive without relating to and interacting with others. Strong connections to others
reduce depression and anxiety, improve sleep, increase selfesteem, and enhance our capacity to have greater empathy for
others, and be more open and trusting of others.1
In fact, people who have positive, fulfilling relationships
with spouses, family members, friends, and coworkers are
30 percent more likely to survive over time than people who
are socially isolated.2 However, having a healthy social life is
not a given, even for people who regularly interact with many
others. A person can feel lonely, even in a crowd, because loneliness does not result from being physically alone; it is caused
by feeling disconnected from others.3 In this chapter, we
examine the vital role relationships play in our lives and the
communication skills necessary to create and maintain them.
LO 1 | THE VALUE OF
RELATIONSHIPS
Describe the types of social support available and the impact of
social networks on health status.
Historically, research examining the benefits of intimate relationships has focused on marriage; however, recent studies
report that all types of close relationships are good for our
health.4 The benefits range from a decreased likelihood of
catching a cold, to a faster recovery from stressful tasks, to a
longer lifespan. On the flip side, people with poor social connections have decreased immune function, higher blood pressure, and higher rates of depression, pain, and fatigue.5 One
recent study analyzing data from more than 14,000 people over
multiple decades revealed that the effects of social isolation are
long lasting, raising future risks for increased blood pressure,
body mass index, waist circumference, and inflammation (a
risk factor for heart disease and cancer).6
Why do relationships make us healthier? First, they impact
our choices. For example, we eat healthier when our friends eat
healthy foods.7 Second, friends often provide us with social
support—the type of help we
receive from our contact with
social support Help we
receive from people in our
others. Social support is delivsocial network in the form
ered in four forms: emotional,
of emotional, instrumental,
instrumental, informational,
informational, and appraisal
support.
and belonging.8 For a college
214 | PART THREE | Creating Healthy and Caring Relationships
student who breaks her leg playing basketball, social support
might be:
Emotional support. Displays of caring, love, trust, and
empathy; for example, when close friends and family
members provide a listening ear about frustrations
and pain.
■■ Instrumental support. Concrete help and service; for
example, a roommate carrying her backpack to class as she
learns to use her crutches and keeping the apartment tidy
so she doesn’t trip.
■■ Informational support. Advice, suggestions, and information, for example, when an aunt shows her some tricks to
better navigate on crutches.
■■ Belonging support. Sharing activities or a sense of belonging, for example, when her teammates still encourage her
to come to practice while she recovers.
■■
Research shows that it is the quality of our friendships, not
the quantity, that matters when it comes to health. There’s
a lot of wisdom in that quip often attributed to Al Capone,
“I’d rather have 4 quarters than 100 pennies.” He was right;
a few close friends are worth far more to our health than 100
acquaintances—or a thousand Facebook friends. The good
news is that the average number of confidants reported by
Americans is on the rise, averaging a little over two per person;
sadly, 9 percent of Americans report they have no one they can
turn to for discussing important matters.9
Healthy relationships can come in all shapes and sizes, but
they do have some characteristics in common, including
communication, caring, respect, and support.
Besides our closest relationships, we all have a constellation
of neighbors, relatives, classmates, coworkers, and friends of
friends that make up our social network. The collective value
of all the people in your social network—and the likelihood of
those people providing social support when you need it—
determines your social capital. The more social capital we
have, the happier and healthier we are.10
To build social capital, we can both strengthen our existing ties and widen our network. John Cacioppo, a leading
researcher on loneliness, describes these actions as building
relational connectedness and collective connectedness.11
Relational connectedness comes from mutually rewarding face-to-face contact. We deepen our relational connectedness each time we interact positively with people in our social
network, strengthening our ties and increasing the likelihood
of someone coming to our aid when asked.
Collective connectedness, on the other hand, comes from
the feeling that you are part of a group beyond yourself. It
manifests itself in feelings like trust and having a sense of community, as well as in actions like voting and volunteering. The
groups you belong to deepen your collective connectedness
and can expand your social network. People find collective connectedness in many ways: cheering for the same sports team,
volunteering together, or worshipping at the same temple. The
important thing is feeling that you are a part of something,
even when you might not have intimate ties to the group.
LO 2 | INTIMATE RELATIONS:
WHEN CONNECTING GETS
PERSONAL
Discuss the purpose and common forms of intimate relationships.
We all need people in our lives who affirm who we are and provide intimate connectedness.12
These intimate relationships often include four characteristics: behavioral interdependence, need fulfillment, emotional
attachment, and emotional availability. Each of these characteristics may be related to interactions with family, close friends,
and romantic partners.
Behavioral interdependence refers to the mutual impact that
people have on each other as their lives intertwine. What one
person does influences what the other person wants to do and
can do. Behavioral interdependence usually becomes stronger
over time, to the point that each person would feel a great void
if the other were gone.
Intimate relationships are also a means of need fulfillment.
Through relationships with others, we fulfill our needs for:
■■
■■
■■
■■
■■
Intimacy—someone with whom we can share our feelings
freely.
Social integration—someone with whom we can share worries and concerns.
Nurturance—someone we can take care of and who will
take care of us.
Assistance—someone to help us in times of need.
Affirmation—someone who will reassure us of our own worth.
The emotional bonds that characterize intimate relationships
often span generations and help individuals gain insight into
and understanding of each other’s worlds.
In mutually rewarding intimate relationships, partners and
friends meet each other’s needs. They disclose feelings, share
confidences, and provide support and reassurance. Each person comes away feeling better for the interaction and validated
by the other person.
In addition to behavioral interdependence and need fulfillment, intimate relationships involve strong bonds of emotional
attachment, or feelings of love. When we hear the word intimate, we often think of a sexual relationship. Although sex can
play an important role in emotional attachment to a romansocial network People you
know who can provide social
tic partner, relationships can
support when needed.
be intimate without being sexual; for example, two people
social capital Collective value
of all the people in your social
can be emotionally intimate
network and the likelihood of
(share feelings) or spirituthose people providing social
ally intimate (share spiritual
support when you need it.
beliefs and practices) without
relational connectedness
being sexually intimate.
Mutually rewarding face-toEmotional availability, the
face contacts.
ability to give emotionally to
collective connectedness
and receive emotionally from
Feeling that you are part of a
others without fear of being
community or group.
hurt or rejected, is the fourth
intimate connectedness A
characteristic of intimate relarelationship that makes you feel
who you are is affirmed.
tionships. For this to be possible, people need to be in touch
intimate relationships Relawith their own emotions and
tionships with family members,
friends, and romantic partners,
be mindfully aware of the
characterized by behavioral
emotional cues of others. At
interdependence, need fulfilltimes, it is healthy to limit
ment, emotional attachment,
our emotional availability.
and emotional availability.
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 215
For example, after a painful
breakup, we may decide not
to jump into another relationship immediately, or we may
self-nurturance Developing
decide to talk about it only
individual potential through a
with close friends. Holding
balanced and realistic appreciation of self-worth and ability.
back can offer time for introspection, healing, and considfamily of origin People presering lessons learned. Some
ent in the household during a
child’s first years of life—usupeople who have experienced
ally parents and siblings.
intense trauma find it difficult
to ever be fully available emotionally, which can limit their
ability to experience intimate relationships.13
accountability Accepting
responsibility for personal decisions, choices, and actions.
Caring for Yourself
You have probably heard the old saying that you must love
yourself before you can love someone else. What does this
mean, exactly? Learning how you function emotionally and
how to nurture yourself through all life’s situations is a lifelong task. You should certainly not postpone intimate connections with others until you achieve this state. However,
a certain level of individual maturity will help you maintain
relationships.
Two personal qualities that are especially important to
any good relationship are accountability and self-nurturance.
Accountability means that you recognize responsibility for
your own choices and actions. You don’t hold others responsible for positive or negative experiences. Self-nurturance
means developing individual potential through a balanced
and realistic appreciation of self-worth and ability. To make
good choices in life, a person must balance many physical
and emotional needs—sleeping, eating, exercising, working, relaxing, and socializing. When the balance is disrupted,
self-­
nurturing people are patient with themselves as they
put things back on course. Learning to live in a balanced and
healthy way is a lifelong process. Individuals who are on a
path of accountability and self-nurturance have a much better
chance of achieving this balance and maintaining satisfying
relationships with others.
Important factors that affect your ability to nurture yourself
and maintain healthy relationships with others include the
way you define yourself (self-concept) and the way you evaluate
yourself (self-esteem). Your self-concept is like a mental mirror
that reflects how you view your physical features, emotional
states, talents, likes and dislikes, values, and roles. A person
might define herself as an activist, a mother, an honor student,
an athlete, or a musician. As we discuss in other chapters, how
you feel about yourself or evaluate yourself constitutes your
self-esteem.
families have been made up of people related by blood, marriage
or long-term committed relationships, or adoption. Today, however, many groups of people are recognized and function as family units. Although there is no “best” family type, we do know
that a healthy family’s key roles and tasks include nurturance
and support. Healthy families foster a sense of security and feelings of belonging that are central to growth and development.
During the childhood years, families provide our most
significant relationships. It is from our family of origin, the
people present in our household during our first years of life,
that we initially learn about feelings, problem solving, love,
intimacy, and gender roles. We learn to negotiate relationships
and have opportunities to communicate effectively, develop
attitudes and values, and explore spiritual belief systems. It is
not uncommon when we establish relationships outside the
family to rely on these initial experiences and on skills modeled by our family of origin.
Friendships
Friendships are often the first relationships we form outside
our immediate families. Establishing and maintaining strong
friendships may be a good predictor of your success in establishing romantic relationships, as both require shared interests
and values, mutual acceptance, trust, understanding, respect,
and self-confidence.
Developing meaningful friendships is more than merely
“friending” someone on Facebook. Getting to know someone well requires time, effort, and commitment. But the effort
is worth it—a good friend can be a trustworthy companion,
someone who respects your strengths and accepts your weaknesses, someone who can share your joys and your sorrows,
and someone you can count on for support.
Romantic Relationships
At some point, most people choose to enter an intimate
romantic and sexual relationship with another person.
Beyond the characteristics of friendship, romantic relationships typically include the following characteristics related to
passion and caring:
■■
■■
■■
Family Relationships
A family is a recognizable group of people with roles, tasks,
boundaries, and personalities whose central focus is to protect,
care for, love, and socialize with one another. Because the family is a dynamic institution that changes as society changes,
the definition of family changes over time. Historically, most
216 | PART THREE | Creating Healthy and Caring Relationships
■■
■■
Fascination. Lovers tend to pay attention to the other person even when they should be involved in other activities.
They are preoccupied with the other and want to think
about, talk to, and be with the other.
Exclusivity. Lovers have a special relationship that usually
precludes having the same kind of relationship with a third
party. The love relationship often takes priority over all
others.
Sexual desire. Lovers desire physical intimacy and want to
touch, hold, and engage in sexual activities with the other.
Giving the utmost. Lovers care enough to give the utmost
when the other is in need, sometimes to the point of
extreme sacrifice.
Being a champion or advocate. Lovers actively champion
each other’s interests and attempt to ensure that the other
succeeds.
Liking =
Intimacy only
Intimacy
Romantic Love =
Intimacy + Passion
Consummate
Love
Passion
Infatuation =
Passion only
Companionate Love =
Commitment + Intimacy
Commitment
Fatuous Love =
Passion + Commitment
Empty Love =
Commitment only
FIGURE 8.1
Sternberg’s Triangular Theory of Love According to Sternberg’s
model, three elements—intimacy, passion, and commitment—existing alone or in
combination, form different types of love. The most complete, ideal type of love in the
model is consummate love, which combines balanced amounts of all three elements.
Theories of Love There is no single definition of
love, and the word may mean different things to different
people, depending on cultural values, age, gender, and situation. Although we may not know how to put our feelings into
words, we know it when the “lightning bolt” of love strikes.
Several theories related to how and why love develops have
been proposed. In his classic triangular theory of love, psychologist Robert Sternberg proposed the following three key
components to loving relationships (FIGURE 8.1):14
Intimacy. The emotional component, which involves closeness, sharing, and mutual support.
■■ Passion. The motivational component, which includes
lust, attraction, and sexual arousal.
■■ Commitment. The cognitive component, which includes
the decision to be open to love in the short term and commitment to the relationship in the long term. See the
STUDENT HEALTH TODAY box on page 218 for a discussion of hooking up. According to Sternberg, the quality
of a love relationship is related to the level of intimacy,
passion, and commitment each person brings to the relationship over time. He suggests that relationships including two or more of those components are more likely to
endure than those that include only one. He uses the term
­consummate love to describe a combination of intimacy,
passion, and commitment—an ideal and deep form of love
that is, unfortunately, all too rare.15
■■
Quite different from Sternberg’s approach are theories of
love and attraction based on brain circuitry and chemistry.
Anthropologist Helen Fisher, among others, hypothesizes that
attraction and falling in love follow
a fairly predictable pattern based on
(1) imprinting, in which our evolutionary patterns, genetic predispositions,
and past experiences trigger a romantic
reaction; (2) attraction, in which neurochemicals produce feelings of euphoria
and elation; (3) attachment, in which
endorphins (natural opiates) cause lovers to feel peaceful, secure, and calm; and
(4) production of a cuddle chemical—that
is, the brain secretes the hormone oxytocin, which stimulates sensations during
lovemaking and elicits feelings of satisfaction and attachment.16
According to Fisher’s theory, lovers who claim to be swept away by passion may not be far from the truth. A
love-smitten person’s endocrine system
secretes chemical substances such as
dopamine and norepinephrine.17 Attraction may in fact be a “natural high”;
however, this passion “buzz” lessens
over time as the body builds up a tolerance. Fisher speculates that some people
become attraction junkies, seeking out
the intoxication of new love much as a
drug user seeks a chemical high.
Choosing a Romantic Partner Attraction theory
suggests that more than just chemical and psychological processes influence with whom a person falls in love. This theory
proposes that proximity, similarities, reciprocity, and physical attraction also play strong roles.18 Proximity is being in the
same place at the same time. When you are out and about in
the community, it is more likely that an interaction will occur
than if you stay at home. And if you meet a person while at
work, at the dog park, or at a religious event, it is likely that you
may share interests. While physical proximity is important,
with the growth of Internet dating sites, it has become easier
to meet people outside your
geographic proximity.
WHAT DO
You also choose a partner based on similarities (in
THINK?
attitudes, values, intellect,
interests, education, and
What factors do
socioeconomic status); the
you consider most
important in a potential
old adage that “opposites
partner?
attract” usually isn’t true,
at least not in the long run.
■■ Are any absolute musts?
If your potential partner
■■ Does what you believe to be
expresses interest, you may
important in a relationship
react with mutual regard—
differ from what your parents
might feel is important?
reciprocity. The more you
express interest, the safer it is
for someone else to reciproconsummate love A relationcate, continuing the cycle and
ship that combines intimacy,
compassion, and commitment.
strengthening the connection.
YOU
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 217
Hooking Up
STUDENT
HEALTH TODAY
H
ooking up is a vague term often
used to describe sexual encounters,
from kissing to intercourse, without the
expectation of commitment. While the
media often report about the new “hookup
culture” on campus, research tells a
different story. Longitudinal data indicate
that young adults’ sexual behavior hasn’t
changed much in the past few decades.
College students are not having more
sex or a greater number of partners than
their counterparts 20 or 30 years ago.
Today’s college students are more likely
to describe their sex partner as a “friend”
than in the past, but today’s college
students are still twice as likely to have
sex with a romantic partner than with a
hookup.
While hookup behavior may not be as
pervasive as some think, college students
should understand the risks involved:
The New Norm or Nothing New?
Recognize the role of emotions in sex.
Sternberg’s triangular theory of love
would place hooking up in the infatuation category, passion with no commitment or intimacy, far from Sternberg’s
picture of “ideal.” Additionally, according to Fisher, attraction and sex create
a chemical reaction in the brain that
fosters an emotional response even if
we say, “It’s just about the sex.”
■■ Recognize the role of alcohol in hooking up. In a recent study of college
hookups, students reported that they
were more likely to hook up if they
had been drinking alcohol. Among
participants who consumed alcohol
before their last hookup, 31 percent of
females and 28 percent of males indicated that they would likely not have
hooked up with their partners had alcohol not been involved.
■■
A final factor that plays a significant role in selecting a partner
is physical attraction. Attraction is a complex notion, influenced
by social, biological, and cultural factors.19 People seem to seek
out “similarly attractive” partners, meaning more attractive people seek out more attractive partners and vice versa; however, as
relationships evolve, status and personality become more significant, and the importance of personal appearance diminishes.20
LO 3 | BUILDING
COMMUNICATION SKILLS
Discuss ways to improve communication skills and interpersonal
interactions, particularly in the digital environment.
From the moment of birth, we struggle to be understood. We
flail our arms, cry, scream, smile, frown, and make sounds and
gestures to attract attention or to communicate our wants or
needs. By adulthood, each of us has developed a unique way
of communicating through gestures, words, expressions, and
body language. No two people communicate exactly the same
way or have the same need for connecting with others, yet we
all need to connect.
Different cultures have different ways of expressing feelings
and using body language. Members of some cultures gesture
broadly; others maintain a
closed body posture. Some are
self-disclosure Sharing feeloffended by direct eye conings or personal information
with others.
tact; others welcome a steady
218 | PART THREE | Creating Healthy and Caring Relationships
■■ Recognize the risk of unintended
pregnancy and STIs. In one study,
only 70 percent of students reported
condom use during their last hookup.
Reduced inhibitions due to alcohol plus
a lack of communication with a new
partner increase the risk of unprotected
sex and thus the risk for unintended
pregnancy and STIs.
Sources: M.A. Monto and A.G. Carey, “A New
Standard of Sexual Behavior? Are Claims
Associated with the “Hookup Culture” Supported
by General Social Survey Data?,” Journal of
Sex Research 56, no. 6 (2014): 605–15; P.N.E.
Roberson et al., “Hooking Up During College Years:
Is There a Pattern?,” Culture, Health & Sexuality
17, no. 5 (2015): 576–91; J.M. Bearak, “Casual
Contraception in Casual Sex: Life-Cycle Change
in Undergraduates’ Sexual Behavior in Hookups,”
Social Forces 93, no. 2 (2014): 483–513.
gaze. Men and women also tend to have different styles of
communication, largely dictated by culture and socialization
(see the HEALTH IN A DIVERSE WORLD box).
Although people differ in the ways they communicate,
this doesn’t mean that one gender, culture, or group is better at communication than another. We have to be willing to
accept differences and work to keep lines of communication
open and fluid. Remaining interested, actively engaging, and
being open and willing to exchange ideas and thoughts are all
things we can typically learn with practice. By understanding
how to deliver and interpret information, we can enhance our
relationships.
Learning Appropriate
Self-Disclosure
Sharing personal information with others is called selfdisclosure. If you are willing to share personal information
with others, they will likely share personal information with
you. Likewise, if you want to learn more about someone, you
have to be willing to share some of your personal background
and interests with that person. Self-disclosure is not only
storytelling or sharing secrets; it is also sharing emotions about
what you are currently experiencing in life and providing
any information about the past that is relevant to the other
person’s understanding of your current reactions.
Self-disclosure can be a double-edged sword because there
is risk in divulging personal insights and feelings. If you sense
that sharing feelings and personal thoughts will result in a
HEALTH
IN A DIVERSE WORLD
S
ome communication patterns and
behaviors may be gender specific
(see graphic). For example, compared with
women, men tend to use fewer voice tones
and facial expressions while communicating. However, there are also differences in
the driving force behind the ways in which
men and women communicate. Men tend to
talk with a focus on achieving social status
He Says/She Says
and avoiding failure, while women focus on
feeling connected to others. Neither focus
is better than the other. Recognizing these
differences and how they make us unique
is a good first step in avoiding unnecessary
frustrations and miscommunications.
Sources: S. Stewart, “Male and Female
Communication: Differences Worth Noting,”
2017, Achieve Solutions, https://www.
Women (Tendencies)
achievesolutions.net/achievesolutions/en/Content.
do?contentId=10241; S. Lieberman, “Differences
in Male and Female Communication Styles,” 2016,
http://simmalieberman.com/differences-in-male-andfemale-communication-styles/; B. Wu, “The Struggle
between Men and Women to Communicate,” 2018,
https://goodmenproject.com/featured-content/
he-said-she-said-the-struggle-between-men-andwomen-to-communicate-wcz/; J. Wood, Gendered
Lives: Communication, Gender, and Culture, 11th ed.
(Boston: Wadsworth Publishing, 2014).
Men (Tendencies)
FACIAL EXPRESSIONS
• Smile and nod more often
• Maintain better eye contact
FACIAL EXPRESSIONS
• Frown more often
• Often avoid eye contact
SPEECH PATTERNS
• Higher pitched, softer voices
• Use approximately 5 speech tones
• May sound more emotional
• Make more tentative statements
• Interrupt less often
SPEECH PATTERNS
• Lower pitched, louder voices
• Use approximately 3 speech tones
• May sound more abrupt
• Make more direct statements
• More likely to interrupt
BODY LANGUAGE
• Take up less space
• Gesture toward the body
• Lean forward when listening
• More gentle when touching others
• More feedback via body language
BODY LANGUAGE
• Occupy more space
• Gesture away from the body
• Lean back when listening
• More forceful gestures
• Less feedback via body language
BEHAVIORAL DIFFERENCES
• Express intimate feelings more readily
• More likely to ask for help
• Apologize more frequently
• Talk is primarily a means of rapport,
establishing connections, and
negotiating relationships
BEHAVIORAL DIFFERENCES
• Have more difficulty in expressing
intimate feelings
• Less likely to ask for help
• Apologize less often
• Talk is primarily a means of
preserving independence and
negotiating and maintaining status
Women and men may show differences in communication styles. However,
note that styles of communication can vary widely within groups of men and
women.
Watch Video Tutor:
Gender Differences in Communi­ation
Sources: C. B. Torppa, Gender Issues: Communication Differences in Interpersonal Relationships, Retrieved from https://ohioline.osu.edu/factsheet/
FLM-FS-4-02-R10; J. Wood and N. Fixmer-Oraiz, Gendered Lives (Boston: Cengage, 2017); S. Stewart, “Male and Female Communication: Differences Worth
Noting,” 2017, Achieve Solutions, https://www.achievesolutions.net/achievesolutions/en/Content.do?contentId=10241; S. Lieberman, “Differences in Male and
Female Communication Styles,” 2016, http://simmalieberman.com/differences-in-male-and-female-communication-styles/; B. Wu, “The Struggle between
Men and Women to Communicate,” 2018, https://goodmenproject.com/featured-content/he-said-she-said-the-struggle-between-men-and-women-tocommunicate-wcz/; J. Wood, Gendered Lives: Communication, Gender, and Culture, 11th ed. (Boston: Wadsworth Publishing, 2014).
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 219
HEALTH
HEADLINES
Life Is an Open (Face)Book
T
hink of headlines like “No sign of
Caitlyn Jenner in Kylie’s baby video.
No public congratulations either.” Kylie
Jenner announced the birth of her baby
on Twitter, with an 11-minute video
from the hospital room. This confirms
that celebrities have no expectation of
privacy in a world where nearly everyone
has a camera phone and an Internet
connection. The reality is, non-celebrities
are no different. Inappropriate Facebook
and social media postings—by us and/
or our friends—are an all too common
occurrence. We are just one photo tag
away from a family member or potential
employer seeing us in less than flattering
circumstances or knowing information
we’d prefer kept quiet.
“Social media screening,” the practice
of searching out all possible information on
a prospective employee, is done by about
a third of employers. Increasingly, job
applicants are being asked to share their
Facebook pages to see if they are a good
fit for a job! Mostly employers want to see if
job candidates present themselves professionally, are a good fit for company culture,
have good communication skills, or are
lying about their qualifications. Employers
also report looking for inappropriate photos
or evidence of drug or alcohol abuse.
If you are concerned about your
privacy, make sure your publicly available
closer relationship, you will likely take such a risk. But if you
believe that the disclosure may result in rejection or alienation, you may not open up so easily. If the confidentiality of
previously shared information has been violated, you may hesitate to be as open in the future. However, the risk in not disclosing yourself to others is a lack of intimacy in relationships.
If self-disclosure is a key element in creating healthy communication, but fear is a barrier to that process, what can be
done? The following suggestions can help:
■■
■■
■■
■■
■■
Get to know yourself. Remember that your self includes
your feelings, beliefs, thoughts, and concerns. The more
you know about yourself, the more likely you will be able
to share yourself with others.
Become more accepting of yourself. No one is perfect or
has to be.
Choose a safe context for self-disclosure. When and where
you make such disclosures and to whom may greatly influence the response you receive. Choose a setting where you
feel safe to let yourself be heard.
Be willing to talk about sex. The U.S. culture puts many
taboos on discussions of sex, so it’s no wonder we find it
hard to disclose our sexual past to those with whom we
are sexually intimate. However, the threats of unintended
pregnancy and sexually transmitted infections make it
important for partners to discuss sexual history.
Be thoughtful about self-disclosure via social media. Selfdisclosure can be an effective method of building intimacy
with another person, but not with large groups. Sharing
too much information or information that is too personal
220 | PART THREE | Creating Healthy and Caring Relationships
information is what you want prospective employers, family, and other people
to see. Tighten your privacy settings and
untag yourself in photos you don’t want
people to see. Due to cached sites and
reposts, you can’t erase everything, so
you may need to prepare an explanation for past posts, photos, and other
information. As our “private” lives get
more public all the time, we may have to
accept that what we do in private always
has the potential to become public
knowledge.
Sources: J. Oleksinski, “The Honeymoon Is Over
for Celebs and Social Media, New York Post,
February 17, 2018, https://nypost/2018/thehoneymoon-is-over-for-celebs-and-social-media/;
Video: “Five Social Media Mistakes That Will Hurt
Your Job Search,” Forbes, 2017, https://www.
forbes.com/video/5426802245001/#d46374e63ced.
on Facebook or Twitter may cause you to feel vulnerable
or embarrassed later. See the HEALTH HEADLINES box for
more about social media and privacy.
Becoming a Better Listener
Listening is a vital part of interpersonal communication. Good
listening skills enhance our relationships, improve our grasp of
information, and allow us to more effectively interpret what
others say. We listen best when (1) we believe that the message is somehow important and relevant to us; (2) the speaker
holds our attention through humor, dramatic effect, or other
techniques; and (3) we are in the mood to listen (free of distractions and worries). See the MINDFULNESS AND YOU box
on page 222 for information on how mindful listening can
improve your relationships.
The Three Basic Listening Modes
There are
three main ways in which we listen:
Passive listening occurs when we are listening but not providing either verbal or nonverbal feedback to the speaker.
The speaker may feel unsure about whether the message is
being received, and without feedback, it is easy for the listener to be distracted or lose a train of thought.21
■■ Selective listening occurs when we are engaged but listening only for information that supports what we already
believe; otherwise, we are tuned out while thinking of
our rebuttal or waiting for a chance to break into the
conversation.22
■■
■■
Active listening occurs when we not only hear the words,
but also are trying to understand what is really being
said. The listener confirms understanding by restating or
paraphrasing the speaker’s message before responding. By
actively listening, we show genuine interest in and an open
mind to what the other person is thinking and feeling.23
Using Nonverbal Communication
Understanding what someone is saying usually involves more
than listening and speaking. Often, what is not said may speak
louder than any words could. Rolling the eyes, looking at the floor
or ceiling rather than maintaining eye contact, body movements,
and hand gestures—all these nonverbal clues influence the way
we interpret messages. Nonverbal ­communication includes all
unwritten and unspoken messages, both intentional and unintentional, including touch, gestures, interpersonal space, body
language, tone of voice, and facial expressions.24 Ideally, our nonverbal communication matches and supports our verbal communication, but this is not always the case. Research shows that
when verbal and nonverbal communication don't match, we are
more likely to believe the nonverbal cues.25 This is one reason it is
important to be aware of the nonverbal cues we use regularly and
to understand how others might interpret them.
While facial expressions like smiling are believed to have near
universal meaning, other facial expressions and most body language are culturally specific.26 A gesture of agreement or approval
in one culture can be offensive in another. To communicate as
effectively as possible, it is important to recognize and use appropriate nonverbal cues that support and help clarify your verbal
messages. Awareness and practice of your verbal and nonverbal
communication will help you better understand others.
Connecting Digitally: Too Much of
a Good Thing?
You may have noticed a few pages ago that, in the definition of
relational connectedness, Dr. Cacioppo specifically describes the
contact as “face-to-face.” Does Facetime count? Is oxytocin—the
hormone that make us feel happy when we interact with friends
in person—released when we receive a Snap or comment on a
friend’s Facebook post?
The research on technology’s impact on health is far from
definitive. At this point, it appears there can be both benefit
and harm, depending on who the user is and how the technology is used.
On one hand, digital communication allows us to have a
diverse social network and easily keep in touch over long distances. One of the most popular online activities of adult Internet users in the United States is accessing social networking
sites (SNSs).27 Overall, 69 percent of Americans use some type of
social media. Approximately 74 percent of adults 18 to 29 years
old use the Internet for social networking daily. Social connectedness as a result of using Facebook is associated with positive
outcomes such as better psychological health and well-being.28
On the other hand, research shows that some SNS users feel
more depressed, stressed, and disconnected. When people spend
One way to communicate better is to pay attention to your
body language. Much of our message is conveyed by
nonverbal cues.
more time on Facebook, they report higher levels of depression.29
Researchers first thought the depression was related to envy of
the activities and lifestyles of their friends, but newer research
shows that social comparison (paying attention to how one does
things compared with how other people do things) may be what
mediates the depressive symptoms. No matter whether the comparison is upward, downward, or neutral and whether the user is
male or female, constant comparison fuels depression.30
Another concern is stress caused by reading Snaps or Facebook posts. When social media make users aware of stressful
events in other people’s lives about which they otherwise
would not know, their stress levels can increase. Because social
media allow wide dissemination of news about illness, death,
car crashes, or just bad days, we now have details about other
people’s lives that, in the past, we would have known only
about our closest friends. This phenomenon has been dubbed
“the cost of caring” and has been found only in females; males
do not report increased stress in similar circumstances.31
Another group that reports technology-related stress is
what the American Psychological Association refers to as
the “­constant checker”—the 43 percent of Americans who
are always checking their e-mails, texts, and/or social media
accounts. Constant checkers feel more stress than non–­
constant checkers related to political and cultural discussions
on social media and work-related e-mail. Constant checkers report feeling disconnected from family even if they’re in
the same place (44 percent of constant checkers compared
to 25 percent of non–constant checkers). Even among non–­
constant checkers, disconnection is an issue. Almost half of
millennials (45 ­
percent) report feeling disconnected from
­family even when they are together.32 See the TECH & HEALTH
box on page 223 for more on social media and relationships.
A final concern about SNS use relates to the lack of nonverbal
communication in text-based digital communication, which can
lead to confusion and misunderstanding.33 Some experts
nonverbal communication
are concerned that, over time,
Unwritten and unspoken mesreduced exposure to nonverbal
sages, both intentional and
unintentional.
communication may reduce
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 221
MINDFULNESS
AND YOU
G
ood communication starts with good
listening. When we listen mindfully,
we focus on the speaker’s words and
on the speaker’s tone of voice, facial
expressions, and body language. We are
aware, fully listening, and receptive to the
person’s message. We avoid interrupting, except possibly to encourage or ask
for clarification. This allows us to hear the
meta-message—the message underlying
the words that tells the whole story the
speaker is trying to convey. It takes discipline to listen without judging or arguing
or being defensive, but mindful listening
helps to avoid conflict and allows the
Mindful Listening
speaker to feel fully heard, improving our
relationships and connections with others.
To listen more mindfully, practice these
listening skills on a daily basis:
■■ To avoid distractions, turn off the TV, shut
your laptop lid, and put your phone away.
■■ Be present in the moment. Good listeners participate and acknowledge what
the other person is saying through nonverbal cues such as nodding or smiling
and asking questions at appropriate
times.
■■ Ask for clarification. If you aren’t sure
what the speaker means, say that you
27%
of 18- to 24-year-olds have used
ONLINE DATING—triple the rates of just
2 years ago.
people’s ability to read facial expressions, affecting their inperson communication skills and making relationship building
more difficult.34 See the MAKING CHANGES TODAY boxon page
224 for information on how to deal with social media meanness.
Thus, while social media can improve our lives, it may be
wise to limit the time spent on social media and monitor our
emotions related to its use. When using social media, remember that people often show the most flattering image of themselves possible; it is not always an accurate representation of
their lives. Furthermore, the number of likes or followers you
have is not a reflection of your worth as a person.
Managing Conflict through
Communication
A conflict is an emotional state that arises when the behavior
of one person interferes with that of another. Conflict is inevitable whenever people
conflict Emotional state that
live or work together. Not
arises when opinions differ or the
all conflict is bad; in fact,
behavior of one person interferes
airing feelings and comwith the behavior of another.
ing to resolution over difconflict resolution Concertferences can sometimes
ed effort by all parties to constrengthen a relationship.
structively resolve differences
Conflict resolution and
or points of contention.
222 | PART THREE | Creating Healthy and Caring Relationships
don’t completely understand, or paraphrase what you think you heard.
■■ Control the desire to interrupt. Try taking
a deep breath for 2 seconds, then hold
your breath for another second, and
really listen to what is being said as you
slowly exhale.
Sources: F. Hennessey, “The Skill of ­Mindfully
­Listening,” Psych Central, July 2016, https://­
psychcentral.com/lib/the-skill-of-mindful-listening;
M. Hartwell-Walker, “Meta-communication:
What I Said Isn’t What I Meant,” Psych Central,
­February 2017, https://psychcentral.com/lib/meta-­
communication-what-i-said-isnt-what-i-meant.
successful conflict management form a systematic approach
to resolving differences fairly and constructively, rather than
allowing them to fester. The goal of conflict resolution is to
solve differences peacefully and creatively.
Here are some strategies for conflict resolution:
1. Identify the problem or issue. Talk with each other
2.
3.
4.
5.
6.
to clarify exactly what the conflict is. Try to understand
both sides. In this first stage, you must say what you
want and listen to what the other person wants. Focus
on using “I” messages and avoid “you” messages. Be an
active listener: Repeat what the other person has said
and ask questions for clarification.
Generate several possible solutions. Base your
search for solutions on the goals and interests identified
in the first step. Come up with several different alternatives, and avoid evaluating any of them until you have
finished brainstorming.
Evaluate the alternative solutions. Narrow solutions to one or two that seem to work for both parties.
Be honest with each other about a solution that feels
unsatisfactory, but also be open to compromise.
Decide on the best solution. Choose a solution that
is acceptable to both parties. You both need to be committed to the decision for it to be effective.
Implement the solution. Discuss how the decision will be carried out. Establish who is responsible
to do what and when. The solution stands a better
chance of working if you agree on how it will be
implemented.
Follow up. Evaluate whether the solution is working.
Check in with the other person to see how he or she feels
about it. Are you satisfied with the way the solution is
working out? If something is not working as planned, or
if circumstances have changed, discuss revising the plan.
Remember that both parties must agree to any changes
to the plan, as they did with the original idea.
TECH
& HEALTH
Love in the Time of Twitter
T
echnology has revolutionized our access to information and how we communicate.
Couples can meet on Tinder,
keep in constant contact via
texting, and tell the world about
their relationship highs and lows
via Facebook, Twitter, Instagram,
and Snapchat. Nancy Baym,
author of Personal Connections
in the Digital Age, suggests that
we currently lack standard etiquette for the use of new media
in relationships. At its best,
social media can bring people
closer together. At its worst, it
can be used intentionally or unintentionally to embarrass or hurt. Consider
the following suggestions to safeguard
yourself:
When Meeting
If you join a dating site, be honest
about yourself. State your own interests and characteristics fairly, including things you think might be less
attractive than stereotypes and cultural
norms dictate.
■■ If you meet someone online and
want to meet in person, put safety
first. Plan something brief, preferably
during daylight hours. Meet in a public place, such as a coffee shop. Tell
a friend or family member the details
of when and where you are meeting
and any information you have on the
person you are meeting.
■■ Respect
your partner’s privacy. Logging onto his or her
e-mail or Facebook account to
look at private messages is a
breach of trust.
■■ Know that a phone’s GPS can
be used to track your location,
and cell phone spyware can allow
e-mail and texts to be read from
another device. If you think you
may be a victim of cyberstalking, get a new phone or ask the
service provider to reinstall the
phone’s operating system to wipe
out the software.
While Dating
■■
■■
■■
■■
■■
■■
Discuss with your partner limits on the
type of information each of you wants
shared online. Agree to share only
within those limits.
Recognize that constant electronic
updates throughout the day can
leave little to share when you are
together. Save some information for
face-to-face talks.
Sober up before you click “submit.”
Things that seem funny under the
influence might not seem funny the
next morning—and could possibly get
you in trouble.
Remember that the Internet is forever.
Once a picture or a post has been sent,
it can never be completely erased.
Never post anything that would
embarrass someone if it were seen
by a family member or potential
employer.
LO 4 | RELATIONSHIPS: FOR
BETTER AND WORSE
Identify the characteristics of successful relationships, including
how to overcome common conflicts, and discuss how to cope
when relationships end.
Success in intimate relationships is often defined by whether
a couple stays together and remains close over time. Perhaps
this isn’t the best measure, though, as we can still benefit from
relationships that come to an end or lose closeness. Either
way, learning to communicate, respecting each other, and
If Breaking Up
Do not break up with someone via
text, e-mail, tweet, Facebook, or chat.
People deserve the respect of a faceto-face breakup.
■■ When you break up, be sure to
change any passwords you may have
confided to your partner. The temptation to use those for ill might be too
strong to resist.
■■
Source: V. Marin, “How to Navigate Social Media
Boundaries in a Relationship,” New York Times,
2017, https://www.nytimes.com/2017/08/29/
smarter-living/navigating-social-media-­
relationships.html; CareerBuilder.com, “Number
of Employers Using Social Media to Screen Candidates Has Increased 500 Percent over the Last
Decade,” April 28, 2016, http://www.­careerbuilder.
com/share/aboutus/­pressreleasesdetail.aspx?ed
=12%2F31%2F2016&id.=pr945&sd=4%2F28%
2F2016.
sharing a genuine fondness are crucial to relationship success.
Many social scientists agree that the happiest committed relationships are ones flexible enough to allow partners to grow
throughout their lives.
Characteristics of Healthy and
Unhealthy Relationships
Satisfying and stable relationships are based on good communication, intimacy, friendship, and other factors. A key ingredient is trust, the degree to which each partner feels he or she
can rely on the integrity of the other. Without trust, intimacy
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 223
will not develop, and the relationship will likely fail. Trust
includes three fundamental elements:
Predictability—the ability to predict your partner’s behavior based on past actions.
■■ Dependability—the ability to rely on your partner to emotionally support you in all situations, particularly those in
which you feel threatened or hurt.
■■ Faith—belief in your partner having positive intentions
and behavior.
■■
What does a healthy relationship look and feel like?
FIGURE 8.2 contrasts healthy and unhealthy relationships.
Answering some basic questions can also help you determine
if a relationship is working.
Do you love and care for yourself to the same extent that
you did before the relationship? Can you be yourself in the
relationship?
■■ Is there genuine caring and goodwill? Do you share interests,
values, and opinions? Is there mutual respect for differences?
■■ Is there mutual encouragement? Do you support each
other unconditionally?
■■ Do you trust each other?
Are you honest with each
WHAT DO
other? Can you comfortTHINK?
ably express your feelings,
opinions, and needs?
■■ Is there room in your relaWhat has been
your experience
tionship for growth as you
with rudeness in digital
both evolve and mature?
■■
YOU
communication?
Relationships are nurtured
by consistent comfriendship because of rude
munication,
actions, and
online behavior?
self-reflection.
Poor commu■■ What kind of actions would
nication
can
weaken
bonds
lead you to “unfriend”
and create mistrust. We all
someone on Facebook?
■■ What are some examples of
need to reflect periodically
bad behavior you have seen
on how we typically relate
online?
to others through our words
and actions. Have we been honest, direct, and fair in our conversations? Have we listened to others’ thoughts, wants, and needs?
Have we behaved in ways consistent with our words, values, and
beliefs?
Breakdowns in relationships often begin with a change in
communication, however subtle. Either partner may stop listening and cease to be emotionally present for the other. In
turn, the other feels ignored, unappreciated, or unwanted.
Unresolved conflicts increase, and unresolved anger can cause
problems in sexual relations, which can further increase communication difficulties.
College students, particularly those who are socially isolated and far from family and hometown friends, may be particularly vulnerable to staying
in unhealthy relationships.
jealousy Aversive reaction
They may become emotionevoked by a real or imagally dependent on a partner.
ined relationship involving a
Mutual obligations, such as
person’s partner and a third
person.
shared rental, financial, or
MAKING CHANGES TODAY
Social Media Meanness
Why does technology seem to bring out the worst in
people? Psychologists often identify anonymity and
invisibility as the culprits for this lack of restraint. When
people feel anonymous, they are more willing to say
things they normally wouldn’t. Even when people aren’t
anonymous, impulse control is reduced because it’s so
easy to respond or vent immediately. What can you do
when people are rude or are trolling you?
Try not to respond emotionally. Don’t type anything you
wouldn’t say to the person’s face.
When you are angry, press “pause,” not “send.” Take
time to think about your response.
Watch your words. Reread your response, and think
about how your words could be interpreted without the
benefit of tone of voice or other nonverbal cues.
End the conversation. If you want to respond without
continuing the rudeness, you can thank the person for
giving you their thoughts, ask to meet to talk about it in
person, or “agree to disagree.”
Sources: A. G. Zimmerman and G. J. Ybarra, “Online Aggression: The
Influences of Anonymity and Social Modeling,” Psychology of Popular
Media Culture 5, no. 2 (2016): 181–93; C. P. Barlett, “Anonymously
­Hurting Others Online: The Effect of Anonymity on Cyberbullying
­Frequency,” Psychology of Popular Media Culture 4, no. 2 (2015): 70.
■■ Have you ever ended a
224 | PART THREE | Creating Healthy and Caring Relationships
transportation arrangements, and sometimes childcare, can
complicate a decision to end an unhealthy relationship. It’s
also easy to mistake sexual advances for physical attraction
or love. Without a strong social network to validate feelings
or share concerns, a student can feel stuck in an unhealthy
relationship.
Honesty and verbal affection are usually positive aspects of
a relationship. In a troubled relationship, however, they can be
used to cover up irresponsible or hurtful behavior. Saying “at
least I was honest” is not an acceptable substitute for acting in
a trustworthy way, and claiming “but I really do love you” is
not a license for being inconsiderate or hurtful.
Confronting Couples Issues
Couples seeking a long-term relationship must confront a
number of issues that can either enhance or diminish their
chances of success. These issues can involve jealousy, sharing
power and responsibility, and communication about unmet
expectations.
Jealousy Jealousy is a negative reaction evoked by a real
or imagined relationship involving one’s partner and another
person. Contrary to what many people believe, jealousy is not
a sign of intense devotion. Instead, jealousy often indicates
In an unhealthy relationship . . .
In a healthy relationship . . .
You care for and focus on another person only and neglect
yourself or you focus only on yourself and neglect the other
person.
You both love and take care of yourselves before and
while in a relationship.
One of you feels pressure to change to meet the other
person’s standards and is afraid to disagree or voice ideas.
You respect each other’s individuality, embrace your
differences, and allow each other to “be yourselves.”
One of you has to justify what you do, where you go, and
whom you see.
You both do things with friends and family and have
activities independent of each other.
One of you makes all the decisions and controls everything
without listening to the other’s input.
You discuss things with each other, allow for differences
of opinion, and compromise equally.
One of you feels unheard and is unable to communicate
what you want.
You express and listen to each other’s feelings,
needs, and desires.
You lie to each other and find yourself making excuses for
the other person.
You both trust and are honest with yourselves and with
each other.
You don’t have any personal space and have to share
everything with the other person.
You respect each other’s need for privacy.
Your partner keeps his or her sexual history a secret or hides
a sexually transmitted infection from you, or you do not
disclose your history to your partner.
You share sexual histories and information about sexual
health with each other.
One of you is scared of asking the other to use protection or
has refused the other’s requests for safer sex.
You both practice safer sex methods.
One of you has forced or coerced the other to have sex.
You both respect sexual boundaries and are able to say
no to sex.
One of you yells and hits, shoves, or throws things at the
other in an argument.
You resolve conflicts in a rational, peaceful, and mutually
agreed upon way.
You feel stifled, trapped, and stagnant. You are unable to
escape the pressures of the relationship.
You both have room for positive growth, and you both
learn more about each other as you develop and mature.
FIGURE 8.2
Healthy versus Unhealthy Relationships
Source: Advocates for Youth, Washington, DC, 2006, www.advocatesforyouth.org. Copyright © 2000. Used with permission.
Fear of losing control. Some people need to feel in control
of every situation. Feeling that they may be losing control
over a partner can cause
jealousy.
underlying problems, such as insecurity or possessiveness—
significant barriers to a healthy relationship. Often, jealousy is
rooted in past experiences of deception or loss. Other causes of
jealousy typically include:
■■
Overdependence on the relationship. People who have few
social ties and rely exclusively on their partners tend to be
overly fearful of losing them.
■■ Severity of the threat. People may feel uneasy if someone
with good looks or a great personality appears to be interested in their partner.
■■ High value on sexual exclusivity. People who believe that
sexual exclusivity is a crucial indicator of love are more
likely to become jealous.
■■ Low self-esteem. People who think poorly of themselves
are more likely to fear that someone else will gain their
partner’s affection.
Jealousy is a natural part
of love, and it does not have
to destroy a relationship. The
key is to recognize, validate,
and accept these feelings as
normal. Feelings of jealousy
are often embedded in fear.
Talking about it with your
partner can help bring about
a clearer commitment to one
another and bring you and
your partner closer.35
■■
WHAT DO
YOU THINK?
Have you ever
felt jealousy in a
relationship?
■■ Can you identify what
actions or events caused
you to feel this way?
■■ Did you have actual facts
to support your feelings, or
was your response based on
suspicions?
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 225
Sharing Power and Responsibility Power can be defined as the
also contribute to the demise of a relationship. Under stress,
communication and cooperation between partners can break
down. Conflict, negative interactions, and a general lack of
respect between partners can erode even the most
loving relationship.
What behaviors signal trouble? On the basis
of 35 years of research and couples therapy,
therapist John Gottman has identified four
behavior patterns in couples that predict
future divorce with better than 90 percent
accuracy:37
ability to make and implement ­
decisions.
Historically, men have been the ­
primary
wage earners and, consequently, had
decision-making power. Women exerted
­
much influence, but ultimately, they
needed a man’s income for survival. As
increasing numbers of women have
entered the workforce and generated
their own financial resources, the power
dynamics between women and men have
■■ Criticism. Phrasing complaints in
shifted considerably.
terms of a partner’s defect; for examAll couples
While gender roles and tasks were
have conflicts.
ple, “You never talk about anyone but
more rigid in the past, modern society has
Learning to handle
yourself. You are self-centered.”
very few gender-specific roles. Both women
them maturely is
■■ Defensiveness. Righteous indignation
vital to relationship
and men work, care for children, drive, run
as a form of self-protection; for example,
success.
businesses, manage family finances, and per“It’s not my fault we missed the flight.
form equally well in the tasks of daily living.
You always make us late.”
Rather than taking on traditional female and
■■ Stonewalling. Withdrawing emotionally
male roles, many couples find it makes more
from a given interaction; for example, the
sense to divide tasks on the basis of schedule,
listener seems to ignore the speaker, giving
convenience, and preference. However, while
no indication that the speaker was heard.
many women work as many hours outside
■■ Contempt. Talking down to a person;
the home as men, the division of labor at
for example, “How could you be so
home is rarely equal. The Bureau of Labor
stupid?”38
Statistics estimates that on a typical day,
Of these, contempt is the biggest pre50 percent of women do household chores
dictor
of divorce. While these behaviors
such as cleaning or laundry, while the same
do
not
guarantee
that an individual couple
is true of only 21 percent of men; 70 percent of women
will
divorce,
they
are
“red
flags”
for
relationships at high risk
prepare food or clean up afterward, but only 45 percent of
36
for
failure.
men share those tasks. Over time, if couples can’t communicate how they feel about sharing power and responsibility
and arrive at an equitable solution, the relationship is likely
to suffer.
Coping with Failed Relationships
Unmet Expectations
We all have expectations of
ourselves and our partners—how we will spend our time and
our money, how we will express love and intimacy, and how
we will grow together as a couple. Expectations are an extension of our values, beliefs, hopes, and dreams for the future.
When communicated and agreed upon, these expectations
help relationships thrive. If we are unable to communicate our
expectations, we set ourselves up for disappointment and hurt.
Partners in healthy relationships can communicate wants and
needs and have honest discussions when things aren’t going as
expected.
When and Why Relationships End
Relationships end for many reasons, including illness, financial concerns, career problems, and personality conflicts. Many
people enter a relationship with certain expectations about
how they and their partner will behave. Failure to communicate
these beliefs can lead to resentment or disappointment. Difpower Ability to make and
ferences in sexual needs may
implement decisions.
226 | PART THREE | Creating Healthy and Caring Relationships
No relationship comes with a guarantee. Losing love is as
much a part of life as falling in love. That being said, uncoupling can be very painful. Whenever we risk getting close
to another person, we also risk getting hurt if things don’t
work out. Consider the following tips for coping with a failed
relationship:39
Acknowledge that you’ve gone through a rough experience. You may feel grief, loneliness, rejection, anger, guilt,
relief, sadness, or all of these. Seek out trusted friends and,
if needed, professional help.
■■ Let go of negative thought patterns and habits. Engage in
activities that make you happy. Take a walk, read, listen to
music, go to the movies or a concert, spend time with fun
friends, volunteer with a community organization, or write
in a journal. Seek out joy!
■■ Make a promise to yourself: no new relationships until
you have moved past the last one. You need time to
resolve your experience rather than escape from it. It can
be difficult to be trusting and intimate in a new relationship if you are still working on getting over a past relationship. Heal first, before looking for love again.
■■
that emphasizes certain rights and obligations for each spouse.
Marriage is socially sanctioned and highly celebrated in American culture, so there are numerous incentives for couples to
formalize their relationship in this way.
Historically, close to 90 percent of Americans married at
least once during their lifetime; today, however, the percentage
of Americans who are married is at its lowest point since 1920.
Only about half of people aged 18 and over were married in
2016, compared with 72 percent in 1960 (FIGURE 8.3).41 This
decrease is due to a combination of delay of first marriages,
substitution of cohabitation for marriage, and concerns over
finances.42 When people do marry, they do so later than ever
before. In 1960, the median age for first marriage was 22.8 years
for men and 20.3 years for women; today, the median age for
first marriage has risen to 29.5 years for men and 27.4 years
for women.43 Although marriage rates seem to be declining,
remarriage rates are increasing. Men are more likely to remarry
(67 percent) than are women (52 percent), but most people do
opt to give marriage another go.
Divorce rates in the United States have been high for multiple decades. Some estimates indicate that between 40 and
50 percent of marriages end in divorce. The divorce rate in
second and third marriages is even higher.44 However, other
studies suggest that the divorce rate for new marriages is
only 30 ­percent and that it has been declining since the early
1980s.45 This decrease is related to an increase in the number
of couples who cohabit instead of marrying, an increase in the
age at which people first marry, and a higher level of education
Women
It may feel as if there is no end to the sorrow, anger, and
guilt that often accompany a difficult breakup, but time is a
miraculous healer. Acknowledging your feelings and finding
healthful ways to express them will help you deal with the
end of a romantic relationship.
Married 51%
Never married 29%
Divorced 8%
LO 5 | PARTNERING AND
SINGLEHOOD
Widowed 9%
Compare and contrast the types of committed relationships and
singlehood.
Commitment in a relationship means that one intends to act
over time in a way that perpetuates the well-being of the other
person, oneself, and the relationship. Polls show that the
majority of Americans strive to develop a committed relationship whether in the form of marriage, cohabitation, or partnerships, but an increasing number of Americans, particularly
men, choose to remain single.40
Marriage
Men
Married 54%
Never married 35%
Divorced 9%
Widowed 3%
FIGURE 8.3
In many societies, traditional committed relationships take
the form of marriage. In the United States, marriage means
entering into a legal agreement that includes shared finances,
property, and often the responsibility for raising children.
Many Americans also view marriage as a religious sacrament
Marital Status of the U.S. Population by Sex
Note: The figure combines the percentages of people who are married, separated, and married with a spouse absent.
Source: U.S. Census Bureau, “Table MS-1, Marital Status of People 15 Years
and Over, by Sex, Race and Hispanic Origin: 1950 to Present,” America’s
Families and Living Arrangements, 2017, www.census.gov.
CHAPTER 8 | Building Healthy Relationships and Communicating Effectively | 227
among those who do marry.46
The risk of divorce is lower for
college-educated people marserial monogamy Series of
rying for the first time; it is
monogamous sexual relationlower still for people who wait
ships.
to marry until their mid-20s
open relationship A relationand who haven’t cohabited
ship in which partners agree
with multiple partners before
that sexual involvement can
marriage.47
occur outside the relationship.
Many Americans believe
cohabitation Intimate partthat
marriage involves mono­
ners living together without
gamy, or exclusive sexual
being married.
involvement with one partcommon-law marriage
ner. However, the lifetime patCohabitation lasting a desigtern for an increasing number
nated period of time (usually
7 years) that is considered
of young Americans appears
legally binding in some states.
to be serial monogamy, in
which a person has a monogamous sexual relationship with one
partner before moving on to another monogamous relationship.48 A small number of couples choose an open relationship
(or open marriage), in which partners agree that there may be
sexual involvement outside their relationship.
A healthy marriage provides emotional support by combining the benefits of friendship with a loving, committed relationship. It also provides stability both for the couple and for those
involved in their lives. Considerable research indicates that married people live longer, feel happier, maintain healthier lifestyles,
and suffer fewer physical and mental health problems.49 A new
study by the National Bureau of Economic Research confirms the
long-lasting benefits of marriage, indicating that friendship is the
critical element of these benefits.50
Couples in healthy marriages have less stress, which in turn
contributes to better overall health. A recent study found that
happily married people had lower levels of the stress hormone
cortisol than those who had never married, or had been previously married. Risky personal behaviors, including smoking
and heavy alcohol use, are lower in married adults. Married
people are also less likely to experience mental illness and have
lower rates of cardiovascular disease, cancer, and respiratory
diseases.51 While it may be that marriage causes the improved
behaviors, it may also be that people who engage in healthier
behaviors are just more likely to get married.
monogamy Exclusive sexual
involvement with one partner.
For many, weddings or commitment ceremonies serve as
the ultimate symbol of a long-term, exclusive relationship
between two people.
73%
of Americans list “similar ideas about having
and raising children” as the MOST
IMPORTANT TRAIT when choosing a
partner, followed by “a steady job” (63%).
Cohabitation
Cohabitation is a relationship in which two unmarried people with an intimate connection live together in the same
household. For a variety of reasons, more Americans—now
more than 18 million couples, about 7 percent of adults 18 and
older—are choosing cohabitation.52 In some states, cohabitation that lasts a designated number of years (usually 7) legally
constitutes a common-law marriage for purposes of purchasing real estate and sharing other financial obligations.
Cohabitation ca