Heart Valve Disorders

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

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

Mitral Valve Prolapse

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

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

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

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

Mitral Valve Regurgitation

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

Mitral Valve Stenosis

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

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

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

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

Aortic Stenosis

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

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

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

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Preventing High Blood Pressure

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

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

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

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

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

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

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

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

• have a health problem such as high blood pressure

• have angina (chest pain)

• tend to feel dizzy or faint

• have difficulty breathing after a mild workout

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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High Blood Pressure

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

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

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

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

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

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

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

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

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Relationships

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

The Changing Male Image

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

• integrity—following a code of moral values

Being a Father

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

Bonding with Your Child

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

Divorce

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


Blended Families 

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

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Physical and Emotional Health: How They Interact

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

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

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

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Addictive Gambling

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

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

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

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

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

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

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

• returning another day to get even after losing money gambling

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

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

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

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

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

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

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

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

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Unsafe Driving Habits

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

Safety with Seat Belts

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

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

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

Road Rage

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

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

• sudden acceleration

• blocking the passing lane

• tailgating

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

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

• making obscene gestures

• failing to dim high beams for oncoming traffic

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

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

• altering your schedule to avoid congestion

• improving the comfort of your vehicle

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

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

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

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How to Quit Alcohol, Drugs and Smoking

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

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

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

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

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

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

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

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

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

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

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

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

• Visit the dentist and have your teeth cleaned.

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

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

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

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

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

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

• Stretch a lot.

• Pay attention to your appearance.

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

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

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

Illegal Drugs

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

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

Cocaine 

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

Club Drugs 

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

Heroin 

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

Marijuana 

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

LSD 

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

• depressed appetite

• loss of sexual desire

• distorted perceptions

• difficulty communicating

• feelings of paralysis

• hyperactivity

• dilated pupils

• increased heart rate and blood pressure

• sleeplessness

• tremors

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

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

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Avoiding Risky Behavior

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

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Developing a Good Relationship with Your Doctor

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

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

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

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

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

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

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

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

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

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

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

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Immunizations

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

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

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

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

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

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Common Screening Tests

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

Blood Test 

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


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


Urinalysis

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


X ray

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


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


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


CT Scan

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

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