Chapter 3: Health Promotion and Preventive Care

CONCEPTS IN PROMOTION AND PREVENTION

PRINCIPLES OF HEALTH PROMOTION

Health promotion is defined as the actions taken to develop a high level of wellness and is accomplished by influencing individual behavior and the environment in which people live.

Levels of Prevention

• Disease prevention is aimed at avoidance of problems or minimizing problems once they occur.
  • Primary prevention is the total prevention of a condition.
  • Secondary prevention is the early recognition of a condition and the measures taken to speed recovery.
  • Tertiary prevention is the care given to minimize the effects of the condition and prevent long-term complications.
• Preventive care should involve assessment for people at risk for specific disorders.

Healthy People 2000 and 2010

• Health promotion goes beyond prevention to help people manage their health and live longer and feel better.
• Health promotion has become a priority since the U.S. Department of Health and Human Services initiated its Healthy People 2000 campaign in 1990. The campaign focused on 21 key areas, such as reducing tobacco use, reducing alcohol abuse, improving nutrition, improving environmental public health, preventing and controlling human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), and improving maternal and infant health.
  • Overall, 21% of the campaign's stated objectives were reached or exceeded, whereas 41% of the stated objectives were approached. Most notably, deaths from coronary heart disease and cancer were reduced beyond targeted reduction rates.
  • Conditions worsened, rather than improved, for 15% of the targeted objectives, including an increase in asthma and asthma hospitalizations among young people, and an increase in obesity and inactivity in all ages.
• The two major goals of Healthy People 2010 are to enhance life expectancy while improving quality of life, and to reduce health disparities due to gender, race and ethnicity, income and education, disabilities, and other factors.
• Healthy People 2010 is divided into four main categories (focus areas are listed in Box 3-1):
  • Promote healthy behaviors
  • Promote healthy and safe communities
  • Improve systems for personal and public health
  • Prevent and reduce diseases and disorders
• For more information see http://www.healthypeople.gov.

Nursing Role in Health Promotion

• Nurses have played key roles in prevention in such areas as prenatal care, immunization programs, occupational health and safety, cardiac rehabilitation and education, and public health care and early intervention.
• Nurses in all settings can meet health promotion needs of patients, whether their practice is in a hospital, clinic, patient's home, health maintenance organization, private office, or community setting.
• Health promotion is primarily accomplished through patient education, an independent function of nursing.
• Health promotion should occur through the life cycle, with topics focused on infancy, childhood, adolescence, adulthood, and older adults (see Table 3-1, page 24, and Table 3-2, page 25).

  TABLE 3-1 Child Preventive Care Time Line: Recommendations by Major Authorities

  TABLE 3-2 Adult Preventive Care Time Line: Recommendations by Major Authorities

  • For infancy, teach parents about the importance of prenatal care, basic care of infants, breast-feeding, nutrition, and infant safety (see Chapter 42).
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  • For childhood, stress the importance of immunizations; proper nutrition to enhance growth and development; and safety practices such as use of car seats and seat belts, fire prevention, and poison proofing the home (see Chapter 42).
  • For adolescence, focus on motor vehicle safety; avoidance of drug, alcohol, and tobacco use; sexual decision making and contraception; and prevention of suicide.
  • For adulthood, teach patients about nutrition, exercise, and stress management to help them feel better; also teach cancer-screening techniques, such as breast and testicular self-examination, and risk factor reduction for the leading causes of death—heart disease, stroke, cancer, and chronic lung disease.
  • For older adults, stress the topics of nutrition and exercise to help people live longer and stay fit, safety measures to help them compensate for decreasing mobility and sensory function, and ways to stay active and independent (see Chapter 9).

THEORIES OF BEHAVIOR CHANGE

Lifestyle changes that promote wellness and reduce or prevent illness are often difficult to accomplish. Education and support by nurses are key, but lifestyle changes are ultimately up to the patient. Nurses should understand the concepts and processes related to behavior change in order to help direct interventions for successful outcomes at individual patients or groups.

Health Belief Model

The health belief model identifies perceptions that influence an individual's behavior. Nurses can inquire about a patient's perceptions in three areas in order to individualize education and interventions.

• The first perception is susceptibility to and seriousness of disease or threat of illness. This most directly influences whether a person will take action.
• The perceived benefit of taking action also affects behavior change.
• Any perceived barriers to change may prevent or impede action.

Transtheoretical Model

The transtheoretical model of behavior change developed by Prochaska and DiClemente identifies six predictable stages of change. The stages may cycle back and forth several times before change is complete. Education and interventions can be aimed at moving the patient onto the next stage or back into the cycle if a lapse occurs.

• Precontemplation—no intention to change, may deny that there is a problem, may blame others for any problems
• Contemplation—acknowledgement that there is a problem, willing to change but may be ambivalent or anxious about change
• Preparation—explores options, actively plans to change, may go public with intent
• Action—overtly making a change, substituting desired behavior for old behavior
• Maintenance—continuing the change, may devalue old behavior, lapse may occur
• Termination—takes on a new self image, old behavior is no longer a threat

BOX 3-1 Healthy People 2010 Focus Areas

• Access to quality health services
• Arthritis, osteoporosis, and chronic back conditions
• Cancer
• Chronic kidney disease
• Diabetes
• Disability and secondary conditions
• Educational and community based programs
• Environmental health
• Family planning
• Food safety
• Health communication
• Heart disease and stroke
• Human immunodeficiency virus
• Immunization and infectious disease
• Injury and violence prevention
• Maternal, infant, and child health
• Medical product safety
• Mental health and mental disorders
• Nutrition and weight control
• Occupational safety and health
• Oral health
• Physical activity and fitness
• Public health infrastructure
• Respiratory disorders
• Sexually transmitted diseases
• Substance abuse
• Tobacco use
• Vision and hearing

PATIENT TEACHING AND HEALTH EDUCATION

Health education is included in the American Nurses Association Standards of Care and is defined as an essential component of nursing care. It is directed toward promotion, maintenance, and restoration of health and toward adaptation to the residual effects of illness.

Learning Readiness

• Assist the patient in physical readiness to learn by trying to alleviate physical distress that may distract the patient's attention and prevent effective learning.
• Assess and promote the patient's emotional readiness to learn.
  • Motivation to learn depends on acceptance of the illness or that illness is a threat, recognition of the need to learn, values related to social and cultural background, and a therapeutic regimen compatible with the patient's lifestyle.
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  • Promote motivation to learn by creating a warm, accepting, positive atmosphere; encouraging the patient to participate in the establishment of acceptable, realistic, and attainable learning goals; and providing constructive feedback about progress.
• Assess and promote the patient's experiential readiness to learn.
  • Determine what experiences the patient has had with health and illness, what success or failure the patient has had with learning, and what basic knowledge the patient has on related topics.
  • Provide the patient with prerequisite knowledge necessary to begin the learning process.

Teaching Strategies

• Patient education can occur at any time and in any setting; however, you must consider how conducive the environment is to learning, how much time you are able to schedule, and what other family members can attend the teaching session.
• Use a variety of techniques that are appropriate to meet the needs of each individual.
  • Lecture or explanation should include discussion or a question and answer session.
  • Group discussion is effective for individuals with similar needs; participants commonly gain support, assistance, and encouragement from other members.
  • Demonstration and practice should be used when skills need to be learned; ample time should be allowed for practice and return demonstration.
  • Teaching aids include books, pamphlets, pictures, slides, videos, tapes, and models and should be supplemental to verbal teaching. These can be obtained from government agencies, such as the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the National Institutes of Health; not-for-profit groups such as the American Heart Association or the March of Dimes; various Internet health websites, or pharmaceutical and insurance companies.
  • Reinforcement and follow-up sessions offer time for evaluation and additional teaching if necessary and can greatly increase the effectiveness of teaching.
• Document patient teaching, including what was taught and how the patient responded; use standardized patient teaching checklists if available.

SELECTED AREAS OF HEALTH PROMOTION

Counsel patients about proper nutrition, smoking cessation, exercise, relaxation, and sexual health to promote well-being.

Nutrition and Diet

• It is projected that 35% of all cancer could be prevented with an improved diet recommended by the National Cancer Institute.
• A low-fat, high-fiber diet is recommended.
  • Fat should account for no more than 30% of calories.
  • Fiber content should be 20 to 30 g daily.
  • Five servings of fruits and vegetables should be included daily, especially those rich in vitamin C and those rich in beta-carotene, such as carrots, sweet potatoes, cantaloupe, broccoli, spinach, and collard greens.
  • Six servings of breads, cereals, and legumes should be included daily.
• Similar guidelines, in addition to calorie restriction and increased energy expenditure, can be used to promote optimal weight, energy, and well-being. More than 60% of American adults are overweight (body-mass index [BMI)] 25 or greater) and 38.8 million American adults meet the criteria for obesity (BMI 30 and greater). Obesity has almost tripled among children in the past 25 years. One of the Healthy People 2010 objectives is to reduce the prevalence of obesity among adults to less than 15%.
• These guidelines—with additional restrictions of substances such as sodium and saturated fat—are also necessary to treat and prevent chronic diseases, such as hypertension, type 2 diabetes mellitus, coronary artery disease (CAD), and hyperlipidemia.
• Educate patients about the five basic food groups and their placement on the food pyramid, optimum weight, calorie requirements, and ways to increase fiber and decrease fat in the diet.
  • Total fat content can be reduced by cutting down on red and fatty cuts of meat; bacon and sausage; cooking oils; whole dairy products; eggs; baked goods; cookies and candy; and sauces, soups, and dressings made with cream, eggs, or oil. Also teach patients to save high-fat foods for a special treat, reduce portion size, use fat substitutes, and prepare dishes at home using low-fat recipes.
  • Teach patients to add fiber to the diet by choosing whole grain breads and cereals; raw or minimally cooked fruits and vegetables (especially citrus fruits, squash, cabbage, lettuce and other greens, beans); and any nuts, skins, and seeds. Fiber can also be increased by adding several teaspoons of whole bran to meals each day or taking an over-the-counter fiber supplement such as psyllium (Metamucil), as directed.
• Encourage patients to keep food diaries and review them periodically to determine if other adjustments should be made.
• If weight loss is desired, have the patient weigh in monthly, and review the diet and give praise or constructive criticism at this visit. Many people, especially women, respond to group therapy that focuses on education, support, and expression of feelings related to overeating.

NURSING ALERT

Encourage all patients to follow-up closely with their health care providers if they are following high-fat, restricted carbohydrate diets. Any diet that is unbalanced may require vitamin supplementation and alter biochemical processes such as cholesterol metabolism and fluid balance.

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Smoking Prevention and Cessation

• It has been estimated that 30% of all cancer is linked to smoking and is preventable.
• Studies show that 60% of all current smokers began smoking by age 14 and that more than 3,000 children each day begin to use tobacco in the United States.
• Smoking is a risk factor for hypertension, heart disease, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and cancer of the lung, colon, larynx, oral cavity, esophagus, bladder, pancreas, and kidney. It also worsens such conditions as respiratory infections, peptic ulcers, hiatal hernia, and gastroesophageal reflux.
• Not smoking promotes health by increasing exercise tolerance; enhancing taste bud function; and avoiding facial wrinkles and bad breath.
• Smoking prevention education should begin during childhood and stressed during adolescence, a time when peer modeling and confusion over self-image may lead to smoking.
• Smoking cessation can be accomplished through an individualized, multidimensional program that includes:
  • Information on the short- and long-term health effects of smoking.
  • Practical behavior modification techniques to help break the habit—gum chewing, snacking on carrot and celery sticks, sucking on mints and hard candy to provide oral stimulation; working modeling clay, knitting, or other ways to provide tactile stimulation; avoiding coffee shops, bars, or other situations that smokers frequent; delaying each cigarette and recording each cigarette in a log before it is smoked; and incentive plans such as saving money for each cigarette not smoked and rewarding oneself when a goal is reached.
  • Use of medications designed to reduce physical dependence and minimize withdrawal symptoms, such as nicotine chewing gum, nasal spray, inhaler system, or transdermal patches as well as oral medication, namely bupropion, that acts on neurotransmitters in the central nervous system.
  • Use of support groups, frequent reinforcement, and follow-up. Encourage additional attempts if relapse occurs.

Exercise and Fitness

• Regular exercise as part of a fitness program helps achieve optimal weight, control blood pressure, increase high-density lipoprotein, lower risk of CAD, increase endurance, and improve the sense of well-being.
• Long-term goals of regular exercise include decreased absenteeism from work, improved balance and reduced disability among the elderly, decreased osteoporosis and fracture risk, and reduced health care costs.
• Studies have shown that both high-intensity exercise and low- to moderate-intensity exercise performed at least three times per week have positive effects.
  • High-intensity exercise achieving 70% to 90% of maximum heart rate produces lactic acid in the muscles, which inhibits fat burning; however, calories will be burned at a higher rate because carbohydrates are used for energy.
  • Low- to moderate-intensity exercise achieving 50% to 70% of maximum heart rate begins to access fat stores for fuel after 30 minutes of exercise; with longer duration of exercise fewer calories but more fat will be burned.
• Individual tolerance, time allotment, interests, and physical impairment must be figured into exercise planning.
• Suggest walking, jogging, bicycling, swimming, water aerobics, and low-impact aerobic dancing as good low- to moderate-intensity exercise, performed three to five times per week for 45 minutes. Walking can be done safely and comfortably by most patients if the pace is adjusted to the individual's physical condition. Use of weights is important for muscle strengthening throughout the lifespan.
  • Exercise programs should include 5- to 10-minute warm-up and cool-down periods with stretching activities to prevent injuries.
  • Full intensity and duration of exercise should be worked up to gradually over a period of several weeks to months.
• Advise patients to stop if pain, shortness of breath, dizziness, palpitations, or excessive sweating is experienced.
• Advise patients with cardiovascular, respiratory, and musculoskeletal disorders to check with their health care provider about specific guidelines or limitations for exercise.

GERONTOLOGIC ALERT

Due to physiologic limitations of old age, maximum effective exercise for the elderly is 20 to 40 minutes at 50% to 60% of maximum heart rate.

NURSING ALERT

Severe cases of COPD, osteoarthritis, and coronary disease are contraindications for unsupervised exercise; check with the patient's health care provider to see if a physical therapy or occupational therapy referral would be helpful.

Relaxation and Stress Management

• Stress is a change in the environment that is perceived as a threat, challenge, or harm to the person's dynamic equilibrium. In times of stress, the sympathetic nervous system is activated to produce immediate changes of increased heart rate, peripheral vasoconstriction, and increased blood pressure. This response is prolonged by adrenal stimulation and secretion of epinephrine and norepinephrine, and is known as the “fight-or-flight” reaction.
• A limited amount of stress can be a positive motivator to take action; however, excessive or prolonged stress can cause emotional discomfort, anxiety, possible panic, and illness.
• Prolonged sympathetic-adrenal stimulation may lead to high blood pressure, arteriosclerotic changes, and cardiovascular disease; stress has also been implicated in acute asthma attack, peptic ulcer disease, irritable bowel syndrome, migraine headaches, and other illnesses.
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• Stress management can help patients control illnesses, improve self-esteem, gain control, and enjoy life more fully.
• Stress management involves the identification of physiologic and psychosocial stressors through assessment of the patient's education, finances, job, family, habits, activities, personal and family health history, and responsibilities. Positive and negative coping methods should also be identified.
• Relaxation therapy is one of the first steps in stress management; it can be used to reduce anxiety brought on by stress. Relaxation techniques include:
  • Relaxation breathing—the simplest technique that can be performed at any time. The patient breathes slowly and deeply until relaxation is achieved; however, it can lead to hyperventilation if done incorrectly.
  • Progressive muscle relaxation—relieves muscle tension related to stress. The patient alternately tenses, then relaxes muscle groups until the entire body feels relaxed.
  • Autogenic training—can help relieve pain and induce sleep. The patient replaces painful or unpleasant sensations with pleasant ones through self-suggestions; may require extensive coaching at first.
  • Imagery—uses imagination and concentration to take a “mental vacation.” The patient imagines a peaceful, pleasant scene involving multiple senses. It can last as long as patient decides.
  • Distraction—uses the patient's own interests and activities to divert attention from pain or anxiety and includes listening to music, watching television, reading a book, singing, knitting, doing crafts or projects, or physical activities.
• To assist patients with relaxation therapy, follow these steps:
  • Review the techniques and encourage a trial with several techniques of the patient's choice.
  • Teach the chosen technique and coach the patient until effective use of the technique is demonstrated.
  • Suggest that the patient practice relaxation techniques for 20 minutes per day to feel more relaxed and to be prepared to use them confidently when stress increases.
  • Encourage the patient to combine techniques such as relaxation breathing before and after imagery or progressive muscle relaxation along with autogenic training to achieve better results.
• Additional steps in stress management include dealing with the stressors or problem areas and increasing coping behaviors.
  • Help the patient to recognize specific stressors and determine if they can be altered. Then develop a plan for managing that stressor, such as changing jobs, postponing taking an extra class, hiring a babysitter once per week, talking to the neighbor about a problem, or getting up 1 hour earlier to exercise.
  • Teach the patient to avoid negative coping behaviors, such as smoking, drinking, using drugs, overeating, cursing, and using abusive behavior toward others. Teach positive coping mechanisms, such as continued use of relaxation techniques, fostering of support systems—family, friends, church groups, social groups, or professional support groups.

Sexual Health

• Because sexuality is inherent to every person and sexual functioning is a basic physiologic need of human beings, nurses must provide care in a way that promotes sexual health.
• As a health educator and counselor in the area of sexual health, the nurse helps the patient gain knowledge, validate normalcy, prepare for changes in sexuality throughout the life cycle, and prevent harm gained through sexual activity.
• Education about sexuality should begin with school-age children, increase during adolescence, and continue through adulthood.
• Topics to cover include:
  • Relationships, responsibilities, communication.
  • Normal reproduction—the menstrual cycle, ovulation, fertilization (see page 807).
  • Unwanted pregnancy—approximately 1 million teen pregnancies occur in the United States each year.
  • Contraception—ideally should begin before sexual activity is started; discuss various methods, adverse effects, effectiveness, convenience (see page 814).
  • Sexually transmitted diseases (STDs)—mode of transmission, prevalence, signs and symptoms, methods of prevention (see page 833).
    • More than 50 million people in the United States have genital herpes.
    • With an estimated 3 million cases per year, chlamydia is now the most common sexually transmitted pathogen and is often asymptomatic.
    • Genital warts are highly recurrent and may lead to cervical dysplasia.
    • Approximately 40,000 cases of AIDS, with 16,000 deaths, are reported in the United States each year.
  • Safer sex or abstinence—primarily adopted to prevent HIV transmission, but can also prevent other STDs and pregnancy.
    • Abstinence is the only 100% effective method for HIV prevention related to sexual transmission.
    • Mutual monogamy can also be 100% effective if both partners enter the relationship HIV negative.
    • Use of female or male latex condoms correctly and consistently is also highly effective.
    • For individuals infected with HIV, avoid vaginal, anal, and oral intercourse, deep kissing, and any practices that may injure tissues.
• Other areas in which nurses can help promote healthy sexual functioning:
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  • Discuss with teenagers the value of delaying sexual activity—prevention of pregnancy and STDs, saving money by not having to purchase contraceptives, greater enjoyment of the first sexual encounter can be experienced when they are older, have greater control of relationships and make better decisions if they are not sexually involved.
  • Encourage men to have greater respect for women, to allow women to be equal partners in their relationship, and to not equate sex with power as is commonly depicted in movies and television.
  • Assist women to understand their sexual needs, become comfortable with their bodies, communicate with their sex partners about their satisfaction, and seek medical help for gynecologic problems.
• Use and refer patients to such resources as:
  • American Social Health Association: http://www.ashastd.org
  • Centers for Disease Control and Prevention Health Topics A to Z: http://www.cdc.gov/health/default.htm.

PATIENT TEACHING AIDS

Copy and distribute the following patient teaching aids to enhance your counseling and promote health.

PATIENT EDUCATION GUIDELINES

Exercise Guidelines

Aerobic exercise provides a wide range of benefits including weight loss, muscle toning, endurance building, improved circulation, increased high-density lipoprotein (the “food” cholesterol), lowered risk of a heart attack, better controlled blood pressure, and a sense of reduced tension and feeling better. Aerobic exercise refers to any type of activity that uses oxygen to produce energy. The cardiovascular system is stimulated and fat is burned. Most people can do aerobic exercise of some kind, adjusting the intensity as necessary. Follow these guidelines to develop your own exercise program.

• Choose an activity that you enjoy, is convenient, and you are capable of; consider walking, bicycle riding, jogging, swimming, aerobics or step aerobics, sporting activities, or use of fitness equipment such as the rowing machine, stair stepper, or cross country ski machine.
• Start out exercising 15 to 20 minutes at a time for the first week or two, then gradually increase the intensity and length of exercise time over several weeks to months.
• Include a 5- to 10-minute warm-up and cool-down period with each exercise session, doing stretching of major muscles, deep breathing, and light calisthenics.
• Exercise at least three times per week and be consistent.
• Exercise at 50% to 70% of your maximum heart rate for moderate intensity or 70% to 90% for high intensity, as tolerated.

CALCULATING TARGET HEART RATE

To get the most out of exercise, calculate your heart rate. First, subtract your age from 220. This is your maximum heart rate; do not exceed this rate while exercising to avoid strain on your heart.

If you are 40 years old, your maximum heart rate is 220 minus 40, or 180. Your target heart rate is 40% to 50% of maximum for low-intensity exercise, 50% to 70% of maximum for moderate-intensity exercise, or 70% to 90% of maximum for high-intensity exercise. So, if you want to exercise at moderate intensity, 60% of 180 is 108 (180 × 0.6). Your target heart rate is 108. By taking your pulse several times during exercise, you can adjust your pace to stay close to your target heart rate and exercise optimally but safely.

TAKING YOUR PULSE

First take your resting pulse before you begin exercise, counting for 30 seconds and multiplying by 2.

To take your pulse during exercise, slow down and find the carotid pulse point in your neck. Place two or three fingers on your trachea (windpipe) near the base of your neck and then move them over to the left or right about 2 to 3 inches until you feel the beating of your pulse. Press lightly so you do not cause an irregular heartbeat or interrupt circulation to your brain. Use a watch with a second hand to count the number of beats in 6 seconds. Now, multiply by 10 to get an estimate of your true 60-second pulse

If you counted 10 beats in 6 seconds, your working heart rate is 100 (10 × 10). As you continue to exercise, you can work a little harder to reach your target rate. If your working heart rate is 10 beats or more greater than your target rate, slow down your pace and check your pulse again in 5 to 10 minutes

When you complete your exercise, your pulse should be no more than 15 beats above your resting pulse; if it is, continue your cool-down activity.

WHEN TO STOP

You should usually never stop exercising abruptly; you must allow the heart to slow down and the blood to redistribute appropriately.

You should slow down if you experience muscle cramps, shortness of breath, or fatigue. You should stop, however, if you experience chest pain, a cold sweat, dizziness, nausea or vomiting, heart palpitations, or fainting. Seek help and notify your health care provider immediately.

Stress Management

Stress is a common phenomenon among most individuals today and can be related to job, relationship, financial, and other pressures. Known as the “fight-or-flight” reaction, the physiologic and emotional response to stress can lead to tension, anxiety, and a variety of health threats. Stress can be minimized by better coping with it and adapting to its causes. Follow this guide to better manage stress.

RECOGNIZE STRESS

• First, identify signs that you may be under stress (eg, irritability, tension, fatigue, insomnia, loss of interest in activities, feeling overwhelmed, or fighting with spouse and others).
• Next, try to identify the true cause of stress. For example, you may snap at your children for playing the stereo too loudly, but what is the underlying cause of your irritability?
• Examine areas of your job, family life, financial stability, and other roles and responsibilities that may be demanding or problematic.

DO SOMETHING ABOUT IT

• Try to manage stressful areas better—be assertive, negotiate, and say no if necessary. For example, confront the person with whom you are at odds and work out a mutual agreement, put the plan in writing, and try to stick to it.
• Make more time for yourself and important relationships. Say no to responsibilities that you do not have time for and get help from a family member or friend, or hire a babysitter when necessary.

RELAX

When you enter a stressful situation or you feel tension rising, practice the following relaxation techniques; you will be able to think more clearly and function more effectively.

Relaxation Breathing

Concentrate on breathing slowly and deeply with eyes closed (if possible) for several minutes when you need a quick tension reducer or before beginning one of the other methods.

• Breathe in through your nose and mouth with face relaxed for a count of 1 and 2 and 3 and 4.
• Hold your breath for 4 seconds, without straining.
• Breathe out through your nose and pursed lips for a count of 6.
• Repeat two or three times, breathe naturally for about 30 seconds, then repeat one or more sequences.
• If you feel dizzy or tingling in your fingertips, you may be hyperventilating; slow down your breathing and do not breathe out so forcefully.

Progressive Muscle Relaxation

Because stress may cause you to subconsciously contract your muscles, in this exercise you will alternately tense and relax your muscle groups one by one, until your entire body is in a state of relaxation.

• Assume a comfortable position, either sitting or reclining, and close your eyes.
• Start with your forehead and tense the muscles so you feel tightness or strain; hold this position for 5 to 10 seconds.
• Next, relax your forehead, noting the relief; concentrate on this for 10 to 15 seconds.
• Progress from head to toe with each muscle group, including your jaw, shoulders, arms, hands, abdomen, buttocks, legs, and feet (you can do both sides simultaneously).
• Note the feeling of total relaxation in your body once you have relieved tension from all your muscles.
• Complete the exercise by opening your eyes, taking a few deep breaths, stretching, and arising slowly.

Imagery

Imagery allows you to take a mental vacation by using your imagination and diverting your attention from stressful thoughts.

• Assume a comfortable position, breathe deeply, and close your eyes.
• Count backward from 5 and begin to imagine a pleasant place such as a beach or garden.
• Put yourself in that place by imagining it with all your senses (eg, hear the sound of waves washing up on the beach, feel the warm sun saturating your skin, or taste a tangy drink of lemonade).
• Stay in that place for about 5 minutes, imagining different images.
• Slowly let the images fade, breathe deeply, and count to 5 before opening your eyes.

Distraction

You can use many methods of distraction to block your concentration from anxiety and stressful matters. Using your senses to listen to music, petting your dog, or reading can be relaxing.

• Choose activities that you enjoy—reading, watching television, listening to music, taking a walk, playing an instrument, knitting, doing a craft, or drawing or painting.
• Adjust the distraction method to your mood—if you are extremely tense, do not attempt a complex project or listen to loud, lively music. Rather, listen to quiet, soothing music or sketch a free-form design.
• Use a variety of methods—some reserved for longer periods of time, and others that can be used on the spot when needed (eg, a portable tape player with headphones and your favorite music or a book of poetry).

Eating Healthier

To help maintain optimal weight, feel better, and reduce the risk of heart disease, cancer, and a variety of health problems, the following dietary guidelines are recommended:

• Increase fiber in diet to 20 to 30 g daily.
• Reduce fat content to no more than 30% of total calories each day.
• Eat five servings of fruits and vegetables each day. A serving consists of:
  • One medium piece of fruit, ½ cup of cut-up fruit, or 6 oz of juice
  • One half cup of cooked or raw vegetables, or 1 cup of leafy greens
• Include six or more servings of cereal or bread per day.
• Maintain moderate protein intake of fish, beans, nuts, or no more than 5 to 7 oz of lean meat per day.
• Limit salt and alcohol consumption.

REDUCING FAT

To determine how many grams of fat you should eat in your diet, first identify how many calories you should eat each day. This will vary depending on your body build and activity level, but approximately 2,100 calories is an average amount for an active medium-sized man or woman who is not trying to lose weight. Next, figure that 30% of 2,100 is 630 calories of fat. There are 9 calories per gram of fat, so 630 divided by 9 equals 70 g of fat. Now you are ready to read food labels to see how many grams of fat are in each serving of food you eat. Margarine, for example, contains 11 g of fat per tablespoon, and cheddar cheese contains about 8 g of fat per ounce. You will find that 70 g will add up quickly unless you include a variety of low-fat foods in your diet. Note: If you are trying to lose weight and are on a lower-calorie diet with a lower percentage of fat, this figure will be much lower.

Follow this guide to reduce fat:

Breads, cereals, and grains

• Eat whole grain (oat, bran, multigrain), light, wheat, or rye bread rather than pure white bread or other breads that list eggs as a major ingredient.
• Eat pasta or rice rather than egg noodles, serve with light tomato sauce or vegetables as main dish, rather than meat.
• Substitute angel food cake, low-fat cookies, crackers, and home-baked goods made with low-fat ingredients for higher-fat pies, cakes, cookies, doughnuts, biscuits, and muffins.
• Watch portion sizes of starchy products; overeating carbohydrates can increase calories.

Eggs and dairy products

• Use only skim or 1% milk, no cream or half and half.
• Use part skim and reduced-fat cheeses sparingly; substitute low-fat cottage cheese.
• Use low-fat yogurt and frozen yogurt, pudding made from skim milk, and fat-free dessert items.

Fats and oils

• Never use butter, lard, or coconut, palm, or palm kernel oil.
• Use unsaturated vegetable oils sparingly (especially canola, safflower, sesame, soybean, sunflower, and olive).
• Substitute margarine, especially diet or light margarine, for butter, but use sparingly.
• Avoid egg yolks, chocolate, and bacon or beef fat for cooking; substitute two egg whites for one whole egg in recipes.
• Use only low-fat mayonnaise and salad dressings.

Meats, fish, and poultry

• Use lean cuts of beef, lamb, and pork sparingly.
• Eat white meat (chicken and turkey) with skin and fat removed before cooking, if possible.
• Avoid organ meat, ribs, chicken wings, sausage, hot dogs, and bacon.
• Use fillets of sole, salmon, mackerel, tuna, haddock, or canned tuna packed in water; avoid sardines, roe, and shrimp (they are high in cholesterol).
• Eat small portions; bake or broil; blot with a paper towel after cooking; and discard drained fat.

INCREASING FIBER

Fiber is a plant cell wall component that is not broken down by the digestive system. It absorbs fluid and moves through the intestines in a bulky mass with the ability to absorb cholesterol and carcinogens. It decreases intestinal transit time, therefore decreasing constipation and related problems. Increase fiber in your diet gradually to prevent gas. Here are good sources of fiber:

• Cereal containing 4 g or more of fiber per serving (read package label)
• Whole grain breads and muffins
• Fresh or frozen fruits and vegetables, not overcooked, with the skin on
• Nuts, seeds, and popcorn
• Bran; add 1 teaspoon to food three times per day
• Legumes (pods), such as peas or beans

Smoking Cessation

Cigarette smoking is the single most preventable cause of death and disability today. Smoking is related to about 30% of all cancer deaths, is the leading risk factor for coronary artery disease and emphysema, and has many other effects on health and hygiene. People who smoke tend to have more dental problems, premature aging of the skin, increased acid in the stomach, decreased exercise tolerance, loss of taste bud function, problems with pregnancy and fetal growth, more frequent respiratory infections, and bad breath.

Smoking cessation, however, will reverse most of these risks and allow you to breathe more easily and feel better.

PLAN TO QUIT

• Make a list of all the positive things and all the negative things about smoking; consider the short- and long-term health risks on your list.
• Talk to your health care provider about the use of nicotine chewing gum, nasal spray, or skin patch to aid your stop smoking program by reducing withdrawal symptoms and cravings for a cigarette. An oral medication that does not contain nicotine is also available by prescription.
• Talk to family and friends and form a support network of people who have quit smoking.
• Set a date to quit and don't make excuses.
• Stock up on low-calorie treats, such as raw vegetables, sugarless gum, popcorn, and sugar-free soft drinks to enjoy when the urge to smoke hits.
• Remove ashtrays, cigarettes, matches, and lighters from your home, car, and office.

STICK WITH IT

• Avoid smoky environments such as bars and coffee shops and the smoking section of restaurants.
• Restructure your routine to eliminate times you previously enjoyed a cigarette.
• Anticipate feeling irritable for several days to several weeks while quitting, and avoid stressful situations.
• Increase exercise, such as walking, biking, or sporting activities to relieve tension, fill free time, and concentrate on healthy activity.
• Occupy your hands with modeling clay, knitting, doodling, or a craft project.
• Brush your teeth often and enjoy fresher breath.
• Reward yourself for not smoking.

TRY, TRY AGAIN

• If you start smoking again, do not be discouraged; many people are successful the second time around.
• Review and revise your plan and pick a new quit date.