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8.2: Health Concerns

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  • Heart Disease: According to the most recent National Vital Statistics Reports (Xu, Murphy, Kochanek, & Bastian, 2016) heart disease continues to be the number one cause of death for Americans as it claimed 23.5% of those who died in 2013. It is also the number one cause of death worldwide (World Health Organization, 2013). Heart disease develops slowly over time and typically appears in midlife (Hooker & Pressman, 2016).

    Heart disease can include heart defects and heart rhythm problems, as well as narrowed, blocked, or stiffened blood vessels referred to as cardiovascular disease. The blocked blood vessels prevent the body and heart from receiving adequate blood. Atherosclerosis, or a buildup of fatty plaque in the arteries, is the most common cause of cardiovascular disease. The plaque buildup thickens the artery walls and restricts the blood flow to organs and tissues. Cardiovascular disease can lead to a heart attack, chest pain (angina), or stroke (Mayo Clinic, 2014a). Figure 8.5 illustrates atherosclerosis.

    Screen Shot 2019-01-18 at 11.25.40 AM.png

    Figure 8.5: Atherosclerosis. Source.

    Symptoms of cardiovascular disease differ for men and women. Males are more likely to suffer chest pain, while women are more likely to demonstrate shortness of breath, nausea, and extreme fatigue. Symptoms can also include pain in the arms, legs, neck, jaw, throat, abdomen or back (Mayo Clinic, 2014a).

    According to the Mayo Clinic (2014a) there are many risk factors for developing heart disease, including medical conditions, such as high blood pressure, high cholesterol, diabetes, and obesity. Other risk factors include:

    • Advanced Age-increased risk for narrowed arteries and weakened or thickened heart muscle.
    • Sex-males are at greater risk, but a female’s risk increases after menopause.
    • Family History-increased risk, especially if male parent or brother developed heart disease before age 55 or female parent or sister developed heart disease before age 65.
    • Smoking-nicotine constricts blood vessels and carbon monoxide damages the inner lining.
    • Poor Diet-a diet high in fat, salt, sugar, and cholesterol.
    • Stress-unrelieved stress can damage arteries and worsen other risk factors.
    • Poor Hygiene-establishing good hygiene habits can prevent viral or bacterial infections that can affect the heart. Poor dental care can also contribute to heart disease.

    Complications of heart disease can include heart failure, when the heart cannot pump enough blood to the meet the body’s needs, and a heart attack, when a blood clot blocks the blood flow to the heart. This blockage can damage or destroy a part of the heart muscle, and atherosclerosis is a factor in a heart attack. Treatment for heart disease includes medication, surgery, and lifestyle changes including exercise, healthy diet, and refraining from smoking.

    Sudden cardiac arrest is the unexpected loss of heart functioning, breathing, and consciousness, often caused by an arrhythmia or abnormal heartbeat. The heart beat may be too quick, too slow, or irregular. With a healthy heart, it is unlikely for a fatal arrhythmia to develop without an outside factor, such as an electric shock or illegal drugs. If not treated immediately, sudden cardiac arrest can be fatal and result in sudden cardiac death.

    Hypertension, or high blood pressure, is a serious health problem that occurs when the blood flows with a greater force than normal. One in three American adults (70 million people) have hypertension and only half have it under control (Nwankwo, Yoon, Burt, & Gu, 2013). It can strain the heart, increase the risk of heart attack and stroke, or damage the kidneys (CDC, 2014a). Uncontrolled high blood pressure in early and middle adulthood can also damage the brain’s white matter (axons), and may be linked to cognitive problems later in life (Maillard et al., 2012). Normal blood pressure is under 120/80 (Table 8.1). The first number is the systolic pressure, which is the pressure in the blood vessels when the heart beats. The second number is the diastolic pressure, which is the pressure in the blood vessels when the heart is at rest. High blood pressure is sometimes referred to as the silent killer, as most people with hypertension experience no symptoms.

    Table 8.1 Blood Pressure Levels
      Systolic Pressure Diastolic Pressure
    Normal Under 120 Under 80
    Prehypertension (at risk) 20-139 80-89
    Hypertension 140 or high 90 or higher

    Source: adapted from CDC (2014c).

    Risk factors for high blood pressure include:

    • Family history of hypertension
    • Diet that is too high in sodium, often found in processed foods, and too low in potassium
    • Sedentary lifestyle
    • Obesity
    • Too much alcohol consumption
    • Tobacco use, as nicotine raises blood pressure (CDC, 2014b).

    Making lifestyle changes can often reduce blood pressure in many people.

    Cancer: After heart disease, cancer was the second leading cause of death for Americans in 2013 as it accounted for 22.5% of all deaths (Xu et al., 2016). According to the National Institutes of Health (2015),  cancer is the name given to a collection of related diseases in which the body’s cells begin to divide without stopping and spread into surrounding tissues. These extra cells can divide and form growths called tumors, which are typically masses of tissue. Cancerous tumors are malignant, which means they can invade nearby tissues. When removed malignant tumors may grow back. Unlike malignant tumors, benign tumors do not invade nearby tissues. Benign tumors can sometimes be quite large, and when removed usually do not grow back. Although benign tumors in the body are not cancerous, benign brain tumors can be life threatening.

    Cancer cells can prompt nearby normal cells to form blood vessels that supply the tumors with oxygen and nutrients, which allows them to grow. These blood vessels also remove waste products from the tumors. Cancer cells can also hide from the immune system, a network of organs, tissues, and specialized cells that protects the body from infections and other conditions. Lastly, cancer cells can metastasize, which means they can break from where they first formed, called the primary cancer, and travel through the lymph system or blood to form new tumors in other parts of the body. This new metastatic tumor is the same type as the primary tumor (National Institutes of Health, 2015). Figure 8.6 illustrates how cancers can metastasize.

    Cancer can start almost anywhere in the human body. While normal cells mature into very distinct cell types with specific functions, cancer cells do not and continue to divide without stopping. Further, cancer cells are able to ignore the signals that normally tell cells to stop dividing or to begin a process known as programmed cell death which the body uses to get rid of unneeded cells. With the growth of cancer cells, normal cells are crowded out and the body is unable to work the way it is supposed to. For example, the cancer cells in lung cancer form tumors which interfere with the functioning of the lungs and how oxygen is transported to the rest of the body.


    Figure 8.6. Source.

    There are more than 100 types of cancer. The American Cancer Society assemblies a list of the most common types of cancers in the United States. To qualify for the 2016 list, the estimated annual incidence had to be 40, 000 cases or more. The most common type of cancer on the list is breast cancer, with more than 249,000 new cases expected in 2016. The next most common cancers are lung cancer and prostate cancer. Table 8.2 lists the estimated number of new cases and deaths for each common cancer type (American Cancer Society, 2016).

    Table 8.2 2016 Estimates of Cancer Types
    Cancer Type Estimated New Cases Estimated Deaths
    Bladder 76,960 16,390
    Breast (Female - Male) 246,660 - 2,600 40,450 - 440
    Colon and rectal (combined) 134,490 49,190
    Endometrial 60,050 10,470
    Kidney (renal cell and renal pelvis) cancer 62,700 14,420
    Leukemia (all types) 60,140 24,400
    Lung (including bronchus) 224,390 158,080
    Melanoma 76,380 10,130
    Non-Hodgkin Lymphoma 72,580 20,150
    Pancreatic 53,070 41,780
    Prostate 180,890 26,120
    Thyroid 64,300 1,980


    Cholesterol is a waxy fatty substance carried by lipoprotein molecules in the blood. It is created by the body to create hormones and digest fatty foods, and is also found in many foods. Your body needs cholesterol, but too much can cause heart disease and stroke. Two important kinds of cholesterol are low-density lipoprotein (LDL) and high-density lipoprotein (HDL). A third type of fat is called triglycerides. Your total cholesterol score is based on all three types of lipids (Table 8.3). Total cholesterol is calculated by adding HDL plus LDL plus 20% of the Triglycerides. 

    Table 8.3: Normal Levels of Cholesterol
    Total Cholesterol Less than 200 mg/dl*
    LDL Less than 100 mg/dl
    HDL 40 mg/dl or higher
    Triglycerides Less than 150 mg/dl
    *Cholesterol levels are measured in miligrams (mg) of cholesterol per deciliter (dL) in blood

    Source: Adapted from CDC (2015).

    LDL cholesterol makes up the majority of the body’s cholesterol, however, it is often referred to as “bad” cholesterol because at high levels it can form plaque in the arteries leading to heart attack and stroke. HDL cholesterol, often referred to as “good” cholesterol, absorbs cholesterol and carries it back to the liver, where it is then flushed from the body. Higher levels of HDL can reduce the risk of heart attack and stroke. Triglycerides are a type of fat in the blood used for energy. High levels of triglycerides can also increase your risk for heart disease and stroke when coupled with high LDL and low HDL. All adults 20 or older should have their cholesterol checked. In early adulthood, doctors may check every few years if the numbers have previously been normal, and there are no other signs of heart disease. In middle adulthood, this may become part of the annual check-up (CDC, 2015).

    Risk factors for high cholesterol include: A family history for high cholesterol, diabetes, a diet high in saturated fats, trans fat, and cholesterol, physical inactivity, and obesity. Almost 32% of American adults have high LDL cholesterol levels, and the majority do not have it under control, nor have they made lifestyle changes (CDC, 2015).

    Diabetes (Diabetes Mellitus) is a disease in which the body does not control the amount of glucose in the blood. This disease occurs when the body does not make enough insulin or does not use it the way it should (NIH, 2016a). Insulin is a type of hormone that helps glucose in the blood enter cells to give them energy. In adults, 90% to 95% of all diagnosed cases of diabetes are type 2 (American Diabetes Association (ADA), 2016). Type 2 diabetes usually begins with insulin resistance, a disorder in which the cells in the muscles, liver, and fat tissue do not use insulin properly (CDC, 2014d). As the need for insulin increases, cells in the pancreas gradually lose the ability to produce enough insulin. In some Type 2 diabetics, pancreatic beta cells will cease functioning, and the need for insulin injections will become necessary. Some people with diabetes experience insulin resistance with only minor dysfunction of the beta cell secretion of insulin. Other diabetics experience only slight insulin resistance, with the primary cause being a lack of insulin secretion (CDC, 2014d).

    Screen Shot 2019-01-18 at 11.41.59 AM.png

    Figure 8.7. Source (CDC, 2014d).

    One in three adults are estimated to have prediabetes, and 9 in 10 of them do not know. According to the CDC (2014d) without intervention, 15% to 30% of those with prediabetes will develop diabetes within 5 years. In 2012, 29 million people (over 9% of the population) were living with diabetes in America, mostly adults age 20 and up.

    Table 8.4: Estimated Number and Percentage of Adults age 20 and over Living with Diabetes in 2012
      Number with Diabetes (millions) Percentage with Diabetes (unadjusted)
    20 years or older 28.9 12.3
    By age
    20-44 4.3 4.1
    45-64 13.4 16.2
    65 years or older 11.2 25.9
    By sex
    Men 15.5 13.6
    Women 13.4 11.2
    Source: 2009-2012 National Health and Nutrition Examination Survey estimates applied to 2012 U.S. Census data.

    Table 8.4 shows the numbers in millions and percentage of adults, by age and gender, living with diabetes. The median age of diagnosis is 54 (CDC, 2014d). During middle adulthood, the number of people with diabetes dramatically increases; with 4.3 million living with diabetes prior to age 45, to over 13 million between the ages of 45 to 64; a four-fold increase. Men are slightly more likely to experience diabetes than are women.

    Diabetes also affects ethnic and racial groups differently. Non-Hispanic Whites (7.6%) are less likely to be diagnosed with diabetes than are Asian Americans (9%), Hispanics (12.8%), non- Hispanic Blacks (13.2%), and American Indians/Alaskan Natives (15.9%). However, these general figures hide the variations within these groups. For instance the rate of diabetes was less for Central, South, and Cuban Americans than for Mexican Americans and Puerto Ricans, and four times less for Alaskan Natives than the American Indians of southern Arizona (CDC, 2014d).

    The risk factors for diabetes include:

    • Those over age 45
    • Obesity
    • Family history of diabetes
    • History of gestational diabetes (Chapter 2)
    • Race and ethnicity
    • Physical inactivity
    • Diet

    Diabetes has been linked to numerous health complications. Adults with diabetes are 1.7 times more likely to have cardiovascular disease, 1.8 times more likely to experience a heart attack, and 1.5 times more likely to experience stroke than adults without diabetes. Diabetes can cause blindness and other eye problems. In diabetics age 40 or older, 28.5% showed signs of diabetic retinopathy, damage to the small blood vessels in the retina that may lead to loss of vision. More than 4% showed advanced diabetic retinopathy. Diabetes is linked as the primary cause of almost half (44%) of new cases of kidney failure each year. About 60% of non-traumatic limb amputations occur in people with diabetes. Diabetes has been linked to hearing loss, tinnitus (ringing in the ears), gum disease, and neuropathy (nerve disease) (CDC, 2014d).

    Typical tests for diabetes include a fasting glucose test and the A1C (Table 8.5). Fasting glucose levels should be under 100mg/dl (ADA, 2016). The A1C provides information about the average levels of blood glucose over the last 3 months (NIH, 2014a). The A1C should be under 5.7, where a 5.0 = 97mg/dl and a 6.0 = 126 mg/dl (ADA, 2016).

    Table 8.5 Diagnostic Blood Tests for Diabetes
      Normal Prediabetes Diabetes
    Fasting Glucose Below 100 mg/dl 100-125 mg/dl 126+ mg/dl
    A1C Under 5.7 5.7 - 6.9 7+

    Adapted from the American Diabetes Association (2016).

    Metabolic Syndrome is a cluster of several cardiometabolic risk factors, including large waist circumference, high blood pressure, and elevated triglycerides, LDL, and blood glucose levels, which can lead to diabetes and heart disease (Crist et al., 2012). The prevalence of metabolic syndrome in the U.S. is approximately 34% and is especially high among Hispanics and African Americans (Ford, Li, & Zhao, 2010). Prevalence increases with age, peaking in one’s 60s (Ford et al., 2010). Metabolic syndrome increases morbidity from cardiovascular disease and diabetes (Hu et al., 2004; Malik, 2004). Hu and colleagues found that even having one or two of the risk factors for metabolic syndrome increased the risk of mortality. Crist et al. (2012) found that increasing aerobic activity and reducing weight led to a drop in many of the risk factors of metabolic syndrome, including a reduction in waist circumference and blood pressure, and an increase in HDL cholesterol.

    Rheumatoid arthritis (RA) is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints (NIH, 2016b). RA occurs when the immune system attacks the membrane lining the joints (Figure 8.8).

    Screen Shot 2019-01-18 at 11.49.45 AM.png

    Figure 8.8. Source.

    RA is the second most common form of arthritis after osteoarthritis, which is the normal wear and tear on the joints discussed in chapter 9. Unlike osteoarthritis, RA is symmetric in its attack of the body, thus, if one shoulder is affected so is the other. In addition, those with RA may experience fatigue and fever. Below are the common features of RA (NIH, 2016b).

    Features of Rheumatoid Arthritis

    • Tender, warm, swollen joints
    • Symmetrical pattern of affected joints
    • Joint inflammation often affecting the wrist and finger joints closest to the hand
    • Joint inflammation sometimes affecting other joints, including the neck, shoulders, elbows, hips, knees, ankles, and feet
    • Fatigue, occasional fevers, a loss of energy
    • Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest
    • Symptoms that last for many years
    • Variability of symptoms among people with the disease.

    About 1.5 million people (approximately 0.6%) of Americans experience rheumatoid arthritis. It occurs across all races and age groups, although the disease often begins in middle adulthood and occurs with increased frequency in older people. Like some other forms of arthritis, rheumatoid arthritis occurs much more frequently in women than in men. About two to three times as many women as men have the disease (NIH, 2016b). The lifetime risk for RA for women is 3.6% and 1.7% for men (Crowson, et al., 2011).

    Genes play a role in the development of RA. However, individual genes by themselves confer only a small risk of developing the disease, as some people who have these particular genes never develop RA. Scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis. For instance, some scientists also think hormonal factors may be involved. In women who experience RA, the symptoms may improve during pregnancy and flare after pregnancy. Women who use oral contraceptives may increase their likelihood of developing RA. This suggests hormones, or possibly deficiencies or changes in certain hormones, may increase the risk of developing RA in a genetically susceptible person (NIH, 2016b).

    Rheumatoid arthritis can affect virtually every area of a person’s life, and it can interfere with the joys and responsibilities of work and family life. Fortunately, current treatment strategies allow most people with RA to lead active and productive lives. Pain-relieving drugs and medications can slow joint damage, and establishing a balance between rest and exercise can also lessen the symptoms of RA (NIH, 2016b).

    Digestive Issues

    Screen Shot 2019-01-18 at 11.52.29 AM.png

    Figure 8.9: Digestive system. Source.

    Heartburn, also called acid indigestion or pyrosis, is a common digestive problem in adults and is the result of stomach acid backing up into the esophagus. Prolonged contact with the digestive juices injures the lining of the esophagus and causes discomfort. Heartburn that occurs more frequently may be due to gastroesophageal reflux disease, GERD. Normally the lower sphincter muscle in the esophagus keeps the acid in the stomach from entering the esophagus. In GERD this muscle relaxes too frequently and the stomach acid flows into the esophagus. In the U.S. 60 million people experience heartburn at least once a month, and 15 million experience it every day. Prolonged problems with heartburn can lead to more serious complications, including esophageal cancer, one of the most lethal forms of cancer in the U.S. Problems with heartburn can be linked to eating fatty or spicy foods, caffeine, smoking, and eating before bedtime (American College of Gastroenterology, 2016a).

    Gallstones are hard particles, including fatty materials, bile pigments, and calcium deposits, that can develop in the gallbladder. Ranging in size from a grain of sand to a golf ball, they typically take years to develop, but in some people have developed over the course of a few months. About 75% of gallstones do not create any symptoms, but those that do may cause sporadic upper abdominal pain when stones block bile or pancreatic ducts. If stones become lodged in the ducts, it may necessitate surgery or other medical intervention as it could become life-threatening if left untreated (American College of Gastroenterology, 2016b).

    Gallstones are present in about 20% of women and 10% of men over the age of 55 (American College of Gastroenterology, 2016b). Risk factors include a family history of gallstones, diets high in calories and refined carbohydrates (such as, white bread and rice), diabetes, metabolic syndrome, Crohn’s disease, and obesity, which increases the cholesterol in the bile and thus increases the risk of developing gallstones (NIH, 2013).