Health and Fitness for Life

By Raschel Larsen

Health and Fitness for Life is an introductory college textbook that shows students how to improve their habits related to physical activity, eating, or stress management. With a focus on real-world activities and practices for increasing overall wellness, this book includes grounded examples of practical health-based situations and healthy choices from diverse perspectives that will give students strategies for identifying and improving areas of their health.
This book covers the basics of exercise and healthy living, as well as more advanced topics, including:
• Cardiorespiratory fitness
• Muscular strength and endurance
• Flexibility training and mobility
• Body composition
• Nutrition planning and guidance
• Stress management
• Chronic and infectious disease
• Substance use and abuse
• Environmental health
This book’s data-driven study of health and fitness is goal-oriented, instructive, and encouraging for students of varying backgrounds and states of wellness. The approach in these pages creates relevant links between guidance from official health organizations and everyday life. There’s something for everyone here, whether you’re looking to improve habits related to physical activity, eating, or stress management, or to better understand your place in the world as a healthy individual.
Written by community college health faculty, Health and Fitness for Life blends down-to-earth instructional text with numerous examples of relevant situations and outcomes for students from all demographics.

• Language: English
• Publisher: Chemeketa Press
• Release date: Sep 1, 2022
• ISBN: 9781955499125

Raschel Larsen

Raschel Larsen has taught Health and Fitness at a community college since 2004. She lives in Salem, Oregon and loves teaching.

Book preview

Health and Fitness for Life

Raschel Larsen

Health and Fitness for Life

© 2022 by Raschel Larsen

ISBN-13: 978-1-955499-00-2

All rights reserved. Edition 2.0 2022. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

Chemeketa Press

Chemeketa Community College

4000 Lancaster Dr NE

Salem, Oregon 97305

[e-mail]

chemeketapress.org

Cover design by Ronald Cox

Interior design by Ronald Cox

References to website URLs were accurate at the time of writing. Neither the author nor Chemeketa Press is responsible for URLs that have changed or expired since the manuscript was prepared.

Printed in the United States of America.

Land Acknowledgment

Chemeketa Press is located on the land of the Kalapuya, who today are represented by the Confederated Tribes of the Grand Ronde and the Confederated Tribes of the Siletz Indians, whose relationship with this land continues to this day. We offer gratitude for the land itself, for those who have stewarded it for generations, and for the opportunity to study, learn, work, and be in community on this land. We acknowledge that our College’s history, like many others, is fundamentally tied to the first colonial developments in the Willamette Valley in Oregon. Finally, we respectfully acknowledge and honor past, present, and future Indigenous students of Chemeketa Community College.

Contents

Chapter 1: Introduction to Health and Wellness

Chapter 2: Fitness and Exercise

Chapter 3: Cardiorespiratory Fitness

Chapter 4: Muscular Strength and Endurance

Chapter 5: Flexibility

Chapter 6: Body Composition Basics

Chapter 7: Nutrition

Chapter 8: Stress Management

Chapter 9: Chronic Disease

Chapter 10: Infectious Disease

Chapter 11: Substances

Chapter 12: Environmental Health

Acknowledgments

Appendix A

Appendix B

Endnotes

Index

This textbook does not provide medical advice.

The information, including but not limited to, text, graphics, images and other material contained in this textbook is for informational purposes only. This material is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read in this textbook.

Key Terms

chronic disease

decisional balance

dimensions of wellness

locus of control

growth mindset theory

health

health disparity

healthy life expectancy

Healthy People 2030

infectious disease

locus of control

life expectancy

morbidity rate

mortality rate

public health

self-efficacy

SMART goal setting

social determinants of health

social support

Stages of Change model

wellness

Introduction

Chuck eats fast food from the comfort of his couch each day. He rationalizes his lifestyle by saying life is short and you have to live life to the fullest. Chuck may be enjoying those onion rings and his couch right now, but what about a year from now, or 10? When friends ask him to hike up to the top of Multnomah Falls to see the view, will he go? Could he even make it to the top?

Your health doesn’t just happen overnight. Like Chuck, the little choices you make each day add up over the course of your lifetime—good or bad. They can make the difference not only in how long you live but also in what you are able to do with that time. Imagine if Chuck, instead of sitting on his couch, had made a series of healthy choices, even small choices, over the course of a year. Instead of munching on onion rings, he might be hiking with his friends or getting a promotion due to his efforts at work. There are short- and long-term payoffs when we make decisions that impact our health and wellness.

This chapter will define and explain health and wellness, show why wellness is so important, and describe a basic goal-setting method for improving individual behaviors associated with wellness. The more we take charge of our health and wellness, the happier and healthier we are as a society. As a whole, our goal should be to spend less of our energy on treating illnesses and more on preventing them by making healthier choices. This book will encourage you to be healthy yourself and to focus on your personal wellness.

Understanding Health and Wellness

The terms health and wellness are often used interchangeably. While one refers to the general condition of our bodies and minds, the other can be considered a deliberate effort to actually be healthy. Health is a person’s physical and mental state. Wellness is a set of multidimensional factors of an individual’s health that can be improved through changes in behavior. Public health refers to the health condition in a group of people and is linked to life expectancy, disease, and general wellness.

These three key terms are interconnected. To improve public health, individuals must make choices that improve their own health and wellness. But it’s not just about individual choice. Public health systems need to be in place to assess a population’s health and to create science-based strategies for improved health. Public health services need to be accessible to everyone in the community in order to support and promote health and wellness.

Thinking back to the opening scenario, it’s easy to say that Chuck just needs to put down the fast food and take a walk. However, the solution is not that simple. It requires us to look at the big picture, including the available community resources. If Chuck cannot find safe places to be physically active outdoors, he might have a harder time being physically active.

Figure 1.1. Academic Performance Challenges. Students report their top ten problems affecting their academic performance in Spring 2021. Source: American College Health Association.

Students report their top ten problems affecting their academic performance in Spring 2021. Source: American College Health Association.

The term health has evolved since Hippocrates (circa 460 BCE), one of the most noted medical practitioners in ancient Greece, began teaching people ways to fight diseases and to look at the body as a whole unit. In 1948, the World Health Organization (WHO) was founded as an agency within the United Nations to promote health worldwide. The WHO defines health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, a definition they still use today.¹ What both Hippocrates and the WHO have in common is the idea that health is not only about being free from sickness but also about the holistic nature of the body and its capability to help us thrive.

Wellness is a work in progress in the United States, and its importance comes down to keeping people alive longer and maintaining or improving quality of life. Our population’s average life expectancy, our likelihood of developing disease and disability, and the average amounts of physical activity we perform are all used to measure how healthy we are as a nation. These measurements help determine public policies that can lead to a healthier population.

The United States still struggles with certain health-related issues, but we’ve made monumental progress since Hippocrates. Much of this is the result of medical care and programs that bring awareness to individuals about the importance of health and wellness. As a student, the stresses of life can be overwhelming (figure 1.1).² But even now, you can make changes to help you live a longer, happier life and avoid disease. If enough people pursue improved wellness, the status of our public health can improve with it. Those changes happen within the dimensions of wellness.

Figure 1.2. Illness-Wellness Continuum. Your health is related to where you fall on the illness-wellness continuum.

Your health is related to where you fall on the illness-wellness continuum.

Dimensions of Wellness

Wellness is an active process. Each dimension of wellness factors into individual wellness, and each well person contributes to the public health of their community. All people are somewhere on a continuum with wellness at one end and illness at the other, and every action they take causes them to shift their position on that continuum, either toward illness or wellness (figure 1.2).

The dimensions of wellness encompass seven aspects of an individual’s well-being, including physical, emotional, intellectual, social, spiritual, environmental, and occupational wellness. Each dimension has its own important qualities, but they all should be thought of as an interactive web where each overlaps and intersects with others in different ways. The whole group of seven dimensions makes up overall wellness (figure 1.3). The dimensions all have this in common: they require both recognition of the dimension’s importance and action based on that knowledge.

Physical Wellness

Physical wellness is the complete physical conditioning and functioning of the body. It includes physical fitness, eating habits, sleeping habits, and choices that affect your risk of illness or injury, such as substance use/abuse, sexual habits, safe driving habits, and other self-care practices like getting regular checkups and recognizing symptoms of disease. It gets more complicated to care of yourself as you age (figure 1.4).

Physically well individuals recognize the difference between healthy habits and destructive habits and then make choices that help rather than hurt their longevity. Part of the work is knowing which habits lead to physical wellness. Actions make up the rest.

Figure 1.3. Dimensions of Wellness. Overall wellness is the result of the combination of these seven dimensions of wellness.

Overall wellness is the result of the combination of these seven dimensions of wellness.

Emotional Wellness

Emotional wellness is the ability to cope with the challenges of daily life. An emotionally well person acknowledges that difficulties are normal. They tend to embrace and share the ups and downs in life equally. They handle their emotions with a generally positive outlook. They have control of their behavioral response to strong feelings. They know stress is bound to occur, so they learn to manage and cope with it as it happens.

Students experience high stress levels, and without emotional wellness, they are open to potentially damaging effects (figure 1.5).³ People with emotional wellness often share certain traits, such as optimism, trust, enthusiasm, self-confidence, self-acceptance, resiliency, and self-esteem. You can already begin to see how these dimensions overlap and intersect with each other. A physically well person may achieve emotional wellness easier without health concerns. Someone with a positive outlook, likewise, might not see challenges to physical wellness as difficult to overcome.

Figure 1.4. Physical Wellness. Physical activity is important at all ages.

Physical activity is important at all ages. Photograph by Sasint.

Figure 1.5. Stress Levels of US College Students. In 2021, students reported varying levels of stress over a 30-day period depending on their gender identity. Source: American College Health Association.

Figure 1.6. Social Wellness. Feeling that you are part of a community is an important aspect of social wellness.

Intellectual Wellness

Intellectual wellness describes the ability to use logic and problem-solving to respond to experiences and continue to learn throughout life. An intellectually well person applies this open-mindedness—a willingness to think things through—to their own decisions, their interactions with others, and the improvement of their community. They want to learn about new things. They want to improve their sense of self, build upon their skills, and challenge themselves to see life in new ways.

Social Wellness

Social wellness describes the ability to interact and connect with others in your family, your community, and the world around you, developing and nurturing positive relationships. Social wellness is about more than just spending time with others. It’s about taking an active role in establishing and fostering positive contact with the people in your life (figure 1.6). Socially well people confide in and communicate with others respectfully, support others in different social interactions, and receive love openly and willingly.

Spiritual Wellness

Spiritual wellness may be less concrete than the other dimensions, but it is just as important. A spiritually well person has a sense of meaning and purpose in life. They can identify the values that are important to them, such as compassion, forgiveness, altruism, tolerance, and capacity for love. They can then connect their values with their actions.

There are many ways a person can experience spiritual wellness. Some find it through religion. Others practice it through volunteering, spending time in nature, being creative, meditating, or contributing to a greater cause (figure 1.7).

Environmental Wellness

Environmental wellness describes the ability to take ownership of the quality of our surroundings (figure 1.8). An environmentally well person understands that individual choices have an impact on the safety of the air, water, land, and, by extension, people’s health. They find ways to have a net positive impact on that safety.

This dimension of wellness can be improved by conserving water, walking or riding for transportation, reducing waste, buying reused or recycled products, composting, reducing red meat consumption, shopping locally, growing a garden or purchasing environmentally-friendly/humanely made products. This can also be practiced by voting and making yourself heard to elected officials and others in government agencies.

Occupational Wellness

Occupational wellness describes the ability to take pride in the jobs and career fields that we pursue while balancing the demands of our work and home life. A person who is occupationally well contributes to their career with the desire to have a positive impact on the organization or people they work with.

A person who demonstrates this dimension of wellness maintains a healthy work-life balance and does not work too much or too little. The ability to recognize what this balance looks like for you is critical to your occupational wellness. Recognizing this dimension of wellness and taking action to make a positive change enables you to grow at work and continue to feel satisfied.

Overall Wellness

Each dimension of wellness needs attention, and many dimensions overlap with one another and can be improved with a single action. For example, some types of exercise, like biking instead of driving to work, can positively impact your physical, emotional, social, and environmental wellness. But some areas of wellness require attention before you can address others.

Figure 1.7. Spiritual Wellness. Finding a sense of peace and purpose is an important aspect of social wellness.

Finding a sense of peace and purpose is an important aspect of social wellness. Photograph by Maxlkt.

Figure 1.8. Environmental Wellness. Interacting with nature is an important aspect of environmental wellness.

According to psychologist Abraham Maslow’s theory on human needs, we have to have our basic needs met—like food, water, and sleep—before we can pay attention to higher-level needs like intellectual satisfaction. Wellness works the same way. Focusing on your emotional wellness by improving your relationships isn’t really possible if you haven’t met your physiological need to feel safe at home (figure 1.9). When proper attention is paid to each dimension of wellness, your life can be more fulfilling and even extended by the habits you build.

Health Challenges in the United States

Medical and technological advancements have improved areas of health in the United States such as life expectancy, but we still have improvements to make. Let’s look at how some of the measurable factors of health—including causes of death and health care costs—have changed over the last 100 years.

Figure 1.9. Maslow’s Hierarchy of Needs. The needs at the bottom of Maslow’s hierarchy must be met before you can give attention to needs closer to the top.

Figure 1.10. Leading Causes of Death in US. In 2020, the leading causes of death in the US were heart disease, cancer, COVID-19, unintentional injuries, and stroke. Source: Centers for Disease Control and Prevention.

In 2019, the leading causes of death in the US were heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, and stroke. Source: Centers for Disease Control and Prevention.

Causes of Death

The leading causes of death have shifted over the years due to advances in science, medical technology, and public health initiatives. In 1900, the leading cause of death was infectious diseases, illnesses caused by an organism that is spread either directly through person-to-person contact or indirectly through contaminated air, water, or food. The most common infectious diseases during the early 20th century included pneumonia, influenza, and tuberculosis.⁴

We have lower rates of death due to infectious disease, despite new, and emerging infectious diseases. The creation of vaccines and antibiotics, as well as improvements in food safety and environmental conditions, are some of the major factors that have reduced the death rate in the United States (figure 1.10).⁵ Infectious diseases and injuries are still a public health concern, however, and you can find more information about infectious diseases in Chapter 10.

Currently, many of the leading causes of death are chronic disease, conditions that last one year or more and require ongoing medical attention or limit daily activities.⁶ Common chronic diseases include heart disease, cancer, accidents (unintentional injuries), chronic lower respiratory disease, and cerebrovascular disease (stroke). In fact, over half of Americans have at least one chronic disease.⁷ Approximately 70% of all deaths in the United States are caused by chronic diseases (figure 1.11).⁸ Other common serious health concerns among Americans today include obesity and unintentional injuries related to drug and alcohol use. You will learn more about chronic diseases, nutrition, and substance use in later chapters of this book.

The leading causes of death vary by age and biological sex. Adults in the United States ages 15–24 are more likely to die from unintentional injuries, homicide, and suicide, while those ages 25–44 have higher death rates from cancer and heart disease. In fact, heart disease is the leading cause of death for both males and females in the United States, followed by cancer. Males, however, are at higher risk for prostate cancer, while females have higher rates of breast cancer. Males experience higher rates of death from unintentional injury, suicide, and chronic liver disease. Females experience higher death rates from stroke, Alzheimer’s disease, and septicemia (bloodstream infections).⁹

This information might seem a bit scary, but knowledge is power. You can avoid many chronic diseases, prevent obesity, and lessen your risk of injuries and infections with healthy lifestyle behaviors. It’s possible to stop or slow their development with regular physical activity, healthy nutrition, and low tobacco and alcohol use. You will learn more about chronic diseases, nutrition, and substance use in later chapters of this book.

Figure 1.11. Rates of Chronic Conditions in Males and Females. This chart shows the distribution of mortality and hospitalizations rates for chronic diseases in 2018 for US adults. Source: International Journal of Environmental Research and Public Health.

This chart shows the distribution of mortality and hospitalizations rates for chronic diseases in 2018 for US adults. Source: International Journal of Environmental Research and Public Health.

Life Expectancy

Life expectancy is the average number of years infants born today can expect to live. This number has risen significantly during the last century. In 1901, the average American could expect to live 49.3 years. In other words, most Americans died before their fiftieth birthday. In 2020, the average life expectancy in the United States was 77.3 years, an increase of almost 30 years.¹⁰ That’s a huge difference.

Healthy living isn’t just about how long we live, however; it’s about how many of those years are lived in good health. This is our healthy life expectancy, our expected years of life free of disability or chronic disease. Chuck, for example, might live to be 70. But he could spend the last 20 of those 70 years with a chronic illness like heart disease, cancer, or diabetes related to his lack of physical activity and poor nutrition. The WHO indicated in 2019 that the healthy life expectancy for an average person in the United States was 66.1 years of age.¹¹

Life expectancy in the United States varies based on biological sex, ethnicity, and geography. For example, females have a life expectancy of 80.2 years, and males have a life expectancy of 74.5 years, according to the Centers for Disease Control and Prevention (CDC). The average life expectancy for White Americans is 77.6 years, while the average life expectancy of Black Americans is 71.8 years and the average life expectancy of Latino Americans is 78.8 years (figure 1.12).¹² Overall life expectancy declined by 1.5 years between 2019 and 2020. This decrease was experienced differently by different ethnicities. Life expectancy declined by 3.0 years for Hispanic Americans, 2.9 years for Black Americans and 1.2 years for White Americans.

Figure 1.12. Death Rates by Race, Ethnicity, and Biological Sex. This chart shows death rates for 2019 with age-adjusted death rates to control for the effects of differences in population age distributions. Source: National Center for Health Statistics, Centers for Disease Control and Prevention.

Figure 1.13. Life Expectancy in 2019 by Region. Where you are born can affect your quality of life and longevity. Source: World Health Organization.

Life Expectancy in 2019 by Region.

The dramatic increase in life expectancy from 1901 to today can be attributed to changes in public health policy, such as community education, immunization programs, and the availability of health care, as well as advances in science and technology. Essentially, the new ideas in the late 1800s and early 1900s about germ theory and disease led to better health infrastructure and personal behavior. This led to major life-saving scientific innovations, like vaccines, and medical procedures, like surgery and transplants. All of these factors have contributed to the rising life expectancy not just in the United States but also in developed countries around the world (figure 1.13).

Health Care Costs

Public health experts also use the cost of health care to measure health in a given population. The total dollar amount spent on treating health problems indicates two things: the frequency and seriousness of health conditions in that population throughout their lives and the relative cost of treatment in their area (figure 1.14). This isn’t the best way to determine health, though, because it doesn’t give a complete picture of health. If the cost of health care in one population is high and the number of health problems is low, the amount spent on health care might still be the same as a population where costs are lower but problems are higher.

However, as a tool for measuring health, cost is an example of how health and wellness intersect. Take the previous example. If costs are high and health problems are low, the relative burden on an individual’s expenses for health care causes greater stress in other areas of their lives. They may even have to choose between paying for health care and, say, paying their college tuition. In this scenario, the population’s health status (ill or healthy) is relatively positive, but the cost of care negatively impacts the population’s wellness. On the other hand, many individuals may choose to put their other expenses before their health, increasing costs to themselves or the community later on or even spreading illness as a result.

Health Disparities and Inequalities

Life expectancy may have increased over time, but there are still too many people who die at a younger-than-average age because of factors beyond their control (figure 1.15). When describing public health challenges, we must consider the unequal way those challenges affect different groups of people. These inequalities are described as a health disparity, differences in health status that are closely connected with social, economic or environmental disadvantages. Health disparities tend to occur within groups of people that have systematically faced greater obstacles to their health based on race/ethnicity, religion, socioeconomic status, gender, age, mental health, disability, sexual orientation and gender identity, geographic location or other characteristics historically linked to discrimination and exclusion.¹³

Health disparities and inequalities can be seen, for example, in the differences in contracting chronic disease rates by age, receipt of preventive vaccinations by socioeconomic status, or occurrence of risky behaviors by ethnicity are all examples of health disparities (figure 1.16). According to the WHO, the social determinants of health—the conditions in which people are born, grow, live, work, and age—are mostly responsible for health inequalities.¹⁴ For more on this topic, see Addressing Health Disparities later in the chapter.

Consider, for example, how the differences play out between two cousins who both have asthma: Steve and Maya. Steve has health insurance and lives in a quiet, suburban neighborhood. He visits his healthcare provider once each year, and his asthma is well controlled. He almost never visits the emergency room. Maya lives in a congested, urban neighborhood of Pittsburgh, Pennsylvania. Her apartment is in a smoggy area on a busy street not far from an industrial plant. She has been forced to make eight trips to the emergency room in the past year. Her asthma is not well controlled, but she can’t afford to move to an area with better air quality. Maya also can’t afford health insurance that covers medications and better preventive care. If the air quality were better (something Maya has no control over) and better insurance was less expensive (another thing Maya has no control over), her need for care would decrease, and she would spend less.

Figure 1.14. Public Health Costs. Vaccination programs help lower health costs around the world.

Vaccination programs help lower health costs around the world. Photograph by CDC Global.

Figure 1.15. Health Disparities in Newborn Care. Health care for preterm and newborn babies can be complex and costly.

Health care for preterm and newborn babies can be complex and costly. Photograph by Travis McHenry.

Figure 1.16. Health Disparities by Geographic Region. Health outcomes and health-care options often differ by geographic location.

Health outcomes and health-care options often differ by geographic location. Photographs by Jens Lelie and Pawel Nolbert.

Let’s look at some examples of health disparities from a CDC report published in 2013 based on two tools of measurement: mortality and morbidity.¹⁵ The mortality rate is the statistical odds for when a person will die. When a person dies, basic identifying information about them—age, ethnicity, biological sex, geographic location, cause of death—is collected in a database. The total numbers of deaths sorted into these categories form mortality rates for those population segments.

Basic data is widely available on the rates of different causes of death (figure 1.17),¹⁶ but you may find more specific details quite surprising. For example, most people would be surprised to learn the following statistics based on past data:

Figure 1.17. Mortality Rates by Cause of Death. This chart shows the age-adjusted death rates for the ten leading causes of death in the US in 2019. Source: National Center for Health Statistics, Centers for Disease Control and Prevention.

Black Americans are 50% more likely to have a stroke, 40% more likely to have high blood pressure and 30% more likely to have heart disease than White Americans.¹⁷

Black infants are 2.3 times more likely to die before their first birthday than White infants.¹⁸

Males are over 200% more likely to be homicide victims than females.

Black, Latino, and Native American people are far more likely than White people to be homicide victims (figure 1.18).¹⁹

Males are more likely to die in an automobile accident than females, with Native Americans having a higher rate of death in this category than other ethnicities.

Suicide rates are higher for White people and Native Americans than other ethnicities (figure 1.19).²⁰

The morbidity rate is the rate at which people contract infectious or chronic diseases. It is measured like mortality, by tracking categories of information when people are sick. The information can be used to determine an individual’s statistical odds of contracting a disease if they are a member of a given population. For example, based on prior data, the following population segments experience higher rates of infectious or chronic diseases:

Females and White people have significantly greater life expectancies and healthy life expectancies than males or Black people.

Asthma attacks are more common for children than adults, people below the federal poverty level, and people in the United States who live in the South and the West.

Approximately 50% of people under 30 years old have some form of gum disease, especially those with lower household incomes, those who did not finish high school, and current smokers.

Since 1960, obesity rates have tripled increased among adults, and disparities continue to exist based upon race/ethnicity, sex, and education.

Diabetes occurs more often among males, senior citizens, Black people, mixed-race people, Latino people, people who did not finish high school, people who are poor, and people with disabilities.²¹

Healthcare Access and Preventive Health Services

Many Americans do not have access to proper healthcare to treat and prevent illness. This disparity may be linked to morbidity rates. When people don’t have easy access to health care, they’re less likely to seek care when they need it or ask for advice to avoid illnesses.

For example, in 2019, 67% of the US population ages 50-75 met the US Preventive Services Task Force’s criteria for up-to-date colon cancer screening. Screening rates increased with age, education level, and household income but varied by insurance status and race/ethnicity.

Likewise, influenza vaccination coverage for children decreased from the 2019-2020 flu season to the 2020-2021 flu season. Among adults, coverage increased most for Latino, Asian, and Native American populations, as well as for non-Hispanic White people. It decreased slightly for Black people. However, White people still had the highest vaccination rates.²²

Behavioral Risk Factors

Your own actions might be the biggest challenge when it comes to health and wellness. Some behaviors put you at greater risk for morbidity and mortality. The likelihood that certain behaviors lead to higher risk can be tracked as well. If more people in a given population engage in risky behaviors, that population is said to be at risk for those behaviors and the consequences that potentially accompany them. Consider how the following risky behaviors affect certain groups:

Figure 1.18. Homicide Rates in the U.S. This chart shows the age-adjusted rates of death by homicide among racial and ethnic groups in the US in 2017. Source: HealthyPeople.gov.

Figure 1.19. Suicide Rates in US. This chart shows the age-adjusted rates of death by suicide among racial and ethnic groups in the US in 2017. Source: Centers for Disease Control and Prevention.

Binge drinking—This risky activity is more common among people ages 18–34, males, White people, and people with higher household incomes. Binge drinkers ages 65 and older report the highest binge drinking frequency, and those ages 18–24, along with Native Americans, report the highest binge drinking intensity.

Unprotected sex—Teen pregnancy rates among Black and Latino populations remain approximately double those of White and Asian/Pacific Islander populations. This is despite a continual decrease in overall rates over the past few years.²³

Cigarette smoking—Little progress has been made in reducing cigarette smoking among people of low socioeconomic status despite improvements among racial/ethnic groups in recent years (figure 1.20).²⁴

Figure 1.20. Tobacco Use by Annual Household Income in 2019. This table shows the percentage of US adults who reported tobacco product use every day or some days by income level. Source: National Health Interview Survey.

Environmental Hazards

Chuck may never have to worry about whether his environment is posing a direct risk to his health, unless his couch becomes infested by bugs. But many people experience health challenges because of where they work or live. We mentioned environmental pollutants a bit earlier in this chapter, and they will be covered again at other points in the book. It’s easy to imagine how smog, poor water quality, and toxins are an environmental hazard, but there are others as well. Police officers and firefighters have obvious dangers in their professions, and many other risks exist in jobs and neighborhoods that we may not realize.

Government agencies track risks associated with hazardous living, working, and air quality conditions. These agencies use the number of deaths and injuries that result from those conditions and compare them to the categories of people in those environments. For example, racial and ethnic minorities, people born outside of the United States, and people who speak a language other than English at home were more likely to live near major highways, suggesting increased exposure to traffic-related air pollution and an elevated risk for adverse health outcomes.²⁵ The likelihood of working in a high-risk occupation—an occupation with an elevated injury and illness rate—is greatest for those who are Latino, are low wage earners, were born outside of the United States, have no education beyond high school, or are male (figure 1.21).²⁶ Work-related death rates are highest for those who are Latino, born outside of the United States, or male while work-related homicide rates are highest for Black, Native American, and Asian/Pacific Islander populations.²⁷

Social Determinants of Health

By now, you can likely see a link between health disparity and inequalities and many of the other health challenges we face in the United States. Social determinants are a significant reason for this. Some disparities result from social factors, such as unemployment, poor or incomplete education, and living area. The following factors increase morbidity and mortality based on the social impact they have on individual health:

Figure 1.21. High-Risk Occupations. Firefighting has increased risks for health.

Firefighting has increased risks for health.

Unemployment—The prevalence of unemployment was higher among Black and Latino people than among White people in 2019.²⁸ Unemployed adults are much less likely than employed adults to report their health as excellent or good.

Education—Latino people, people with income less than 1.9% of the federal poverty level, those with a disability, or those who were born outside of the United States are less likely to complete high school.

Living area—Many people live in areas that lack access to services, such as those living in rural census tracts or those living in areas with a higher percentage of senior citizens. Data shows that these populations more often lacked at least one healthy food retailer nearby (within a half-mile of the tracked boundary) compared with people living in other census tracts (figure 1.22).²⁹

Figure 1.22. Social Determinants of Health. Healthy food retailers aren’t always available.

Addressing Health Disparities

The goal of public health initiatives—and of looking at health challenges and disparities in general—is to achieve health equity and improve the health of all Americans. The future health of the nation will be determined, to a large extent, by how effectively government, private agencies, and organizations work to eliminate disparities that cause disease, disability, and death. The CDC and its partners can use the information they collect to stimulate action to reduce disparities in the United States (figure 1.23). The multiple complex causes of health disparities can be fully addressed only with the involvement of many people and organizations in fields that influence health such as housing, transportation, education, and business.

Recognize Our Role

It’s important to understand the barriers and challenges many face in the United States and do our best to be part of the solution. Sometimes that begins at home. Some barriers to healthy behaviors that come from social disparities can also occur among any group of people, even those without the socioeconomic risk factors listed previously.

We are all products of our environment, to some extent. Chuck may have been raised by parents who valued the relative safety of their couch, just as he does. Fast food may have been a main staple in his diet as a child. If we have unhealthy behaviors keeping us from pursuing wellness, the behavioral change we need might take some hard work.

Lack of motivation, knowledge, resources, willpower, energy, and support often originate within our homes, families, neighborhoods. A tendency to procrastinate or have a negative attitude toward change can be hard-wired into us from an early age. Experiences with public health programs, such as health education in public schools, can give us knowledge and a desire to improve wellness. But without support at home or in your community, people can relapse into poor behaviors even after making a positive change. We must consider how our behaviors are reinforced and enabled by the people around us, how we reinforce and enable the behavior of others, and how we can use that knowledge to break the cycle of unhealthy behavior.

Figure 1.23. Health Disparities Factors. These five factors impact individual and group health.

Reinforce Positive Behaviors

If you’ve ever spent time training a pet, then you know what it means to reinforce actions. When a puppy learns to sit on command, you give him a dog treat or ask him, Who’s a good boy? in that silly, high-pitched voice we all use, motivating him to want to follow instructions. The treat reinforces his positive behavior.

Adult humans are more complex, of course, and our behaviors can be harder to reinforce. Why? First, we know when reinforcing is happening. Unlike puppies, we are not so easy to please. Second, we have more control over our situation. If we don’t perform to get our treat, we can often get it ourselves, even if we didn’t earn it. Third, our learned behaviors may have become habits after years of bad choices. It may take the right kind of reinforcement to change them. That doesn’t mean we can’t do it. It just means that we need to remind ourselves who is in control and choose reinforcements that make sense for us.

Chuck once spent three months trying to lose weight. He got up from his couch, took walks, and ate a fairly healthy diet. Each time he lost a few pounds, he treated himself to an abundance of his old favorite foods. It took him a few days to get back on track after these episodes, and he never really lost weight. Instead, he reinforced the same behavior that caused him to gain weight in the first place.

For Chuck, a reward like a new pair of jeans might have done more to reinforce his positive changes in a healthy way. Chuck could have called some friends to go hiking or shoot pool. They would probably have noticed and praised his efforts. Both the time spent with friends and their encouraging words would have reinforced his positive behavior change.

Enable Positive Behaviors

Certain factors in our environment enable us to slip backward into old habits. Say, for example, that your partner has been instructed by their healthcare provider to cut sugar out of their diet. It has been your habit to bake homemade cookies each week. It’s really hard for you to give that up, so you continue to do so because you’re proud of your baking skills.

You tell them that one little cookie won’t hurt them—after all, they’ve had a hard day and they’ve earned it. As if on cue, they can’t seem to turn it down. This makes you an enabler of the negative behavior they need to change.

Enabling can be positive, too. Maybe you and a friend have both decided to hit the gym together, but you’re really struggling to get motivated. Each time you make an excuse not to go to the gym, your friend shows up in your driveway. She is enabling your success. We can set ourselves up for success when we surround ourselves with positive enablers. This is called social support. You may not always be in a supportive environment that offers positive reinforcement or enables your success, but forming new support systems to offset unhelpful ones can make a huge difference. It doesn’t mean you have to stop baking for your significant other. How about finding a whole grain cookie recipe instead?

Improving Health and Wellness

Part of the reason textbooks like this one exist is to help solve challenges to public health. If public health is seen as a problem worth solving, then working toward better public health is everyone’s responsibility. The rest of this chapter first looks at what communities are doing to address public health challenges, then provides guidance for how individuals can assess their health status, create a plan for improvement, and effectively take action to improve their health and wellness.

Public Health Initiatives and Programs

The Centers for Disease Control and Prevention (CDC), one of the major operating components of the US Department of Health and Human Services (DHHS), leads multiple initiatives that address each of the challenges to public health listed previously and more. These initiatives range from action plans to strategies, and they offer road maps to eliminate targeted problems. These initiatives represent the majority of public health programming at the federal governmental level.

One major initiative is Healthy People 2030. This nationwide set of goals and objectives brings together the efforts of many individuals and organizations. This program is updated every 10 years with objectives that align with measurable improvements to health across the country.

The Healthy People initiative strives to accomplish the following objectives:

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

Achieve health equity, eliminate disparities, and improve the health of all groups.

Create social and physical environments that promote good health for all.

Promote quality of life, healthy development, and healthy behaviors across all life stages.³⁰

The Healthy People initiative began in 1979 when CDC data revealed that chronic diseases, such as heart disease, cancer, and diabetes, were responsible for 75% of all deaths in the United States each year.³¹ Since then, the United States has seen improvements in health outcomes even as it faces new and ongoing challenges to public health.

Figure 1.24. Healthy People 2030 Goals. This initiative targets all these public health areas as objectives to improve. Source: Office of Disease Prevention and Health Promotion.

Healthy People 2030 includes an updated list of objectives that target specific areas of public health. Each area has its own set of goals that must be met for the initiative to claim improvements in that area (figure 1.24).³² Expanding on four decades’ worth of study, Healthy People 2030 gives increased attention to health equity, social determinants of health, and health literacy, as well as a new focus on well-being.

Assessments of Health and Determinants of Wellness

Many factors contribute to public health and individual wellness. You can assess your own health and wellness by investigating the aspects of your life that impact health. The following influences on health and wellness can help you make incremental improvements and cement long-term habits that can help you maintain a healthy lifestyle.

Be Physically Active

The amount and intensity of recommended physical activity varies for adults and children based on a variety of factors, but the basic guidelines from the DHHS recommend moderate-intensity physical activity and strength training for all individuals. At least 150 minutes of moderate activity or 75 minutes of vigorous activity per week is recommended for adults, spread out over several days during a given week. Additional benefits occur with higher levels of activity. Adults should also perform strengthening exercises of moderate or high intensity at least twice a week with all major muscle groups. Training for a 5k or participating in a fundraising walk-a-thon is a fun way to stay active (figure 1.25).³³

Figure 1.25. Physical Activity. Staying active can improve wellness and overall quality of life.

You can find more information on physical activity in Chapters 2, 3, 4, and 5.

Choose a Healthy Diet to Maintain a Healthy Body Weight

A healthy diet gives you the energy and nutrients you need and can help reduce your risk of developing future health problems. Several of the leading causes of disease are connected to nutrition, and choosing healthy foods can help improve your quality of life and overall wellness. According to the Dietary Guidelines for Americans, 2020–2025, a healthy dietary pattern includes the following core elements:

Vegetables of all types—This includes beans, peas, and lentils and dark green, red and orange, and starchy vegetables.

Fruits—The guidelines emphasize eating whole fruit.

Grains—According to the guidelines, half of your grains should be whole grain.

Dairy—This includes fat-free or low-fat milk, yogurt, and cheese, and/or lactose-free versions and fortified soy beverages and yogurt as alternatives.

Protein foods—The guidelines recommend lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products.

Oils—This includes vegetable oils and oils in food, such as seafood and nuts.

The Dietary Guidelines for Americans, 2020–2025 also encourages people to follow a healthy dietary pattern at every life stage. To make a healthy dietary pattern sustainable, the guidelines recommend that people customize and enjoy nutrient-dense food and beverage choices to reflect their personal preferences, cultural traditions, and budgetary considerations. They should focus on meeting food group needs with nutrient-dense foods and beverages and staying within calorie limits. One way to accomplish this is to limit foods and beverages higher in added sugars, saturated fat, and sodium and limit alcoholic beverages.

You can find more information on body composition and nutrition in Chapters 6 and 7.

Manage Stress

Stress is a normal psychological and physical reaction to the ever-increasing demands of life. Some days, by the time we make it to work or school, we’ve already argued with our roommate, spilled coffee on our shirt, been stuck in traffic, and arrived 20 minutes late with the phrase I’m so stressed on the tip of our tongue. And those are only the small stressors, the insignificant ones that only matter because they accumulate. Larger stressors, like job loss, illness, or financial worries, can pose an even stronger reaction. None of us are immune to stress. Surveys show that many Americans experience challenges with stress at some point during the year (figure 1.26).

Figure 1.26. Common Stressors. Stress is normal, but you should learn to manage your stress levels as you experience these common stressors.

That’s why learning how to handle stress is so important. Your body can respond to stress like it’s a fire alarm, and stress management gives you a range of tools to reset your alarm system (figure 1.27). Over time, high levels of stress can lead to serious health problems as your body adapts to being on high alert. Don’t wait until stress has a negative impact on your health, relationships, or quality of life to start practicing a range of stress management techniques. You can start today.

You can find more information about stress management techniques in Chapter 8.

Get Adequate Sleep

This is one piece of advice that most of us would love to follow, though we often struggle to do so. What isn’t commonly known is that insufficient sleep is associated with many chronic diseases and conditions—such as diabetes, cardiovascular disease, obesity, and depression—that threaten our nation’s health.

Inadequate sleep is also responsible for motor vehicle and machinery-related crashes, causing substantial injury and disability each year. In testing done on sleep-deprived individuals using a driving simulator, the participants often performed the same or worse than a person who was intoxicated.³⁴ Some Americans have become so accustomed to functioning while sleep deprived that they don’t even realize the toll it takes on their minds and bodies—it just becomes a new, riskier version of normal.

Figure 1.27. Managing Stress. Meditation is one stress management tool.

Often, this lack of sleep is self-inflicted and well within our control. How many times have you stayed up late bingeing a television series, playing a game on your laptop, or checking social media? How often have you put off writing an essay for a class until 2:00 a.m. the day it is due? You knew you would be tired the next day, but you may not have known how dangerous it could be to you or those around you. That is because many of us have allowed ourselves to accept being tired as a part of life.

Over 25% of the US population reports occasionally not getting enough sleep, while nearly 10% experience chronic insomnia.³⁵ However, new methods for assessing and treating sleep disorders bring hope to the millions suffering from insufficient sleep. For those of us who miss out on adequate sleep due to poor planning or poor choices, it’s time for a wake-up call. Getting sufficient sleep is not a luxury—it is a necessity, and it should be thought of as a vital sign of good health.

Figure 1.28. Risks from Secondhand Smoke. Secondhand smoke affects those around you.

Secondhand smoke affects those around you.

Avoid Tobacco

Tobacco use leads to disease and disability and harms nearly every organ of the body. According to the 2019 National Healthcare Quality and Disparities Report, more than 16 million Americans are living with a disease caused by smoking.³⁶ For every death caused by smoking, at least 30 more people live with a serious smoking-related illness.³⁷ Diseases like cancer, heart disease, stroke, lung disease, diabetes, and chronic obstructive pulmonary diseases, including emphysema and chronic bronchitis, are just a few of the diseases caused by smoking, and the list goes on.

Smoking even causes harm to those who don’t smoke. Secondhand smoke exposure contributes to approximately 41,000 deaths among nonsmoking adults and 400 deaths in infants each year (figure 1.28).³⁸ It also increases the risk of stroke, lung cancer, and coronary heart disease in adults.

Children who are exposed to secondhand smoke are at increased risk for sudden infant death syndrome (SIDS), slowed lung growth, and a host of other medical issues. In fact, there are many risks from secondhand smoke, including the following:

Cognitive impairment—Secondhand smoke impairs a child’s ability to learn, and high levels of exposure are associated with deficits in reading, math, and spatial reasoning.

Infections—Children who breathe secondhand smoke are at an increased risk for ear infections.

Lung diseases—Children who breathe secondhand smoke are more likely to suffer from pneumonia, bronchitis, asthma, and other lung diseases.

Lung cancer—Smoking doesn’t just affect people. Pets in smoking households have a 60% higher risk of developing lung cancer.

The good news is that people who use tobacco can quit, and their body is able to recover from much of the damage, especially if a person stops using tobacco while they are a young adult (figure 1.29).³⁹ You can find more information about the dangers of tobacco and strategies for quitting in Chapter 11.

Figure 1.29. Benefits of Quitting. The benefits of quitting smoking begin almost immediately and continue for several years. Source: Centers for Disease Control and Prevention.

Limit Alcohol Consumption

Excessive alcohol use includes underage drinking and binge drinking, which is defined as drinking five or more drinks on occasion for males or four or more drinks on occasion for females. This can lead to an increased risk of health problems such as injuries, violence, liver disease, and cancer.

Excessive alcohol use was responsible for 93,296 deaths and 2.7 million years of potential life lost (the amount of expected life left after early deaths) each year in the United States from 2011 to 2015, shortening the lives of those who died by an average of 30 years. Among the 93,296 deaths, 51,078 (54.7%) were caused by chronic conditions and 42,218 (45.2%) were caused by acute conditions.⁴⁰

In addition to injury and death, excessive alcohol use has immediate effects that increase your risk for many harmful conditions. Alcohol poisoning, violence, sexual assault or risky sex, miscarriages, pregnancy, and other problems can occur while binge drinking.

Over time, excessive alcohol use can lead to the development of chronic diseases and other serious problems, including the following:

High blood pressure, heart disease, stroke, liver disease, and digestive problems

Cancer of the breast, mouth, throat, esophagus, liver, and colon

Learning and memory problems, including dementia and poor school performance

Mental health problems, such as depression and anxiety

Social problems, including lost productivity, family problems, and unemployment

Alcohol dependence or alcoholism

By limiting alcohol consumption, you can reduce the risk of these short- and long-term health risks. You can find more information about alcohol abuse and treatment in Chapter 11.

Protect Yourself from Infectious Diseases

Everyone is exposed to germs on a regular basis. You can’t help it. Even Chuck, with his love of the indoors, will encounter them on the bags of his carry-out goodies. Some can live on surfaces like door handles and ATM buttons for up to 24 hours, making it easy for them to spread from person to person. Some may be the common cold virus, while others, like bacterial meningitis, can be dangerous and cost you a stay in the hospital—or even your life.

While you may have heard that it is good to challenge your immune system on occasion, you can take steps to avoid being constantly bombarded by infectious agents. Stopping the spread of disease can be as simple as regular, effective handwashing.

To wash your hands adequately, follow these steps:

Wet your hands with running water, warm or cold.

Apply liquid, bar, or powder soap.

Lather well.

Rub your hands vigorously for at least 20 seconds.

Remember to scrub all surfaces, including the backs of your hands, your wrists, between your fingers, and under your fingernails.

Rinse well.

Dry your hands with a clean or disposable towel or air dryer.

If possible, use a towel or your elbow to turn off the faucet.

In addition to frequent, thorough handwashing, you can often prevent illness or lessen its effects by taking good care of yourself in general. A healthy diet and adequate sleep can keep your body ready to fight what comes your way. Your body doesn’t have what it takes to do the job when you’re fatigued or malnourished.

Protect Yourself from Injuries

We like to think we should laugh in the face of danger—after all, we can’t predict everything that can happen to us. We want to enjoy our lives. Most of us look at caution or warning signs and think, That won’t happen to me. Right? Instead of considering why certain guidelines exist and being respectful of them, we take that extra step up the ladder or dive headfirst into the shallow end of the pool.

Some injuries are more avoidable than others, of course, but special attention should be paid in many situations. For example, be especially careful concerning poisonous household products, playing in or around water, prescription and over-the-counter drug storage, fire safety, motor vehicle and bicycle safety, pedestrian safety, and caring for older adults and children. And please, listen to the warning labels. If the dosage instructions are to take two tablets of acetaminophen every four to six hours, do that rather than assuming more is better because you’re six feet tall. If the box of cold medicine says not to consume with alcohol, you should follow that rule—every time.

Apply Critical-Thinking Skills as a Health Consumer

Many people avoid a trip to their healthcare provider as if it were a luxury rather than a necessity. However, getting regular preventive care and prompt emergency care should be part of your lifestyle. Know your body’s limits and understand when you need to seek professional medical help rather than waiting too long. This is an essential part of maintaining personal health and striving toward wellness. Schedule regular checkups to find hidden problems before they begin to affect your life.

In the twenty-first century, most people who recognize a problem with their health—maybe an unexpected pain or discomfort—visit one of the many health websites on the internet to seek advice. These websites are a great place to learn introductory information about different conditions. But they can be alarming to naive users who go looking for the cause of the pain in their foot and come away thinking, It could be cancer! This jump to an extreme conclusion seems to happen all the time, and that’s no wonder, as most health information seems so foreign to most readers. And, let’s face it, everyone on the internet has an opinion, informed or not. It’s an easy trap to fall into, so thinking critically about health advice from a website should be your first line of defense against alarmist fears.

Figure 1.30. Social Support. Fostering friendships is key to social wellness.

Fostering friendships is key to social wellness. Photograph by Anna Vander Sel.

You should always apply your critical-thinking skills when researching health information on your own, but this same attitude is helpful when you see advertisements for prescription medication, pick up a health-related brochure, or even when speaking with a healthcare professional. You don’t always need a second opinion, but being equipped with the knowledge that other opinions are out there can be really useful when a serious situation—like high treatment costs or dangers in a procedure—comes up. Some level of critical thinking is essential in all interactions regarding one’s health.

Cultivate Relationships and Social Support

Consider all the songs and movies written about friendship—don’t you get by with a little help from your friends, as the Beatles say? Social interactions are some of the most impactful life experiences you will have. Without overstating it, your relationships help define who you are, what your interests are, how you spend your time, and how much enjoyment you get out of life. Nourishing these relationships is a key ingredient to wellness and represents a significant investment in your health.

Social support consists of the connections you have with friends, family, and peers. Strong social support can improve physical and psychological health. Having the support and encouragement of others can help hold us accountable and maintain motivation when we are trying to make a health-related behavior change. Having strong social connections can increase emotional wellness by improving resilience to stress. Strong social support can improve self-esteem, promote good lifelong mental wellness, and help alleviate the effects of emotional distress. Positive social support can even reduce the risk for certain chronic diseases, improve