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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Dealing with End-of-Life Decisions

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

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

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

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

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

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

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

Family Caregiving

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

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

Hospice Care

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

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

Advance Directives

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

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

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

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

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

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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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Stress Management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Get a Good Night’s Sleep

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

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

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

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

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

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

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

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

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

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

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

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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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Emotional Health and Well-being

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

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

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

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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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