HCA250 W1 Assignment

Assignment

Psychology of Health in the Workplace Paper

Write a 500- to 700-word paper on health and psychology. Include the following:

· Describe the relationship between health and psychology.

· Identify specific lifestyle choices that affect health and psychology in the workplace.

· Provide examples of lifestyle choices to enhance health and prevent illness.

Format your paper consistent with APA guidelines

Materials attached if needed.

PART I
AN INTRODUCTION: BASI

ISSUES AND PROCESSES

1
AN OVERVIEW OF PSYCHOLOGY
AND HEALTH
What is Health?
An Illness/Wellness Continuum
Illness Today and in the Past

Viewpoints From History: Physiology, Disease
Processes, and the Mind
Early Cultures
Ancient Greece and Rome
The Middle Ages
The Renaissance and After

Seeing A Need: Psychology’s Role in Health
Problems in the Health Care System
‘‘The Person’’ in Health and Illness
How The Role of Psychology Emerged
Health Psychology: The Profession

Current Perspectives on Health and Illness
The Biopsychosocial Perspective
Life-Span and Gender Perspectives

Relating Health Psychology to Other
Science Fields
Related Fields
Health and Psychology Across Cultures

Research Methods
Experiments
Correlational Studies

Quasi-Experimental Studies
Genetics Research

PROLOGUE
‘‘Wide load!’’ the boys shouted as they pressed them-
selves against the walls of the hallway at school. They
were ‘‘making room’’ for a very overweight girl named Ana
to pass through. Lunch time in the cafeteria was even
more degrading for Ana because when she sat down
to eat, her schoolmates would stop eating, stare at her
every move, and make pig noises. ‘‘Kids can be cruel,’’
her parents would say to console her. One of Ana’s aunts
told her that she ‘‘inherited a glandular problem, and
you can’t do anything about it,’’ and another aunt said,
‘‘You’ll lose weight easily in a couple of years when you
start getting interested in boys.’’ Is either aunt right?

Ana’s parents are concerned about her weight
because they know that overweight people often have
social problems and face special health risks, such as for
high blood pressure and heart disease. But her parents
are not sure why she’s so heavy or how to help her.
Although her father is a bit overweight, her mother is
very heavy and was as a child, which could support the
idea of an inherited cause of her being overweight. On
the other hand, they know Ana eats a lot of fattening

2 Part I / An Introduction: Basic Issues and Processes

foods and gets very little exercise, a combination that
often causes weight gain. As part of their effort to change
these two behaviors, they encouraged her to join a
recreation program, where she will be involved in many
physical activities.

This story about Ana illustrates important issues
related to health. For instance, being overweight is
associated with the development of specific health
problems and may affect the individual’s social relations.
Also, weight problems can result from a person’s
inheritance and behavior. In this book, we will examine
the relationships between health and many biological,
psychological, and social factors in people’s lives.

This chapter introduces a relatively new and very
exciting field of study called health psychology. We look at
its scope, its history, its research methods, and how it
draws on and supports other sciences. As we study these
topics, you will begin to see how health psychologists
would answer such questions as: Does the mind affect
our health? What role does the cultural background of
individuals play in their health? Does the age of a person
affect how he or she deals with issues of health and
illness? But first let’s begin with a definition of health.

WHAT IS HEALTH?

You know what health is, don’t you? How would you
define it? You would probably mention something about
health being a state of feeling well and not being sick.
We commonly think about health in terms of an absence

of (1) objective signs that the body is not functioning
properly, such as measured high blood pressure, or
(2) subjective symptoms of disease or injury, such as pain
or nausea (Kazarian & Evans, 2001; Thoresen, 1984).
Dictionaries define health in this way, too. But there is a
problem with this definition of health. Let’s see why.

AN ILLNESS/WELLNESS CONTINUUM
Consider Ana, the overweight girl in the opening story.
You’ve surely heard people say, ‘‘It’s not healthy to
be overweight.’’ Is Ana healthy? What about someone
who feels fine but whose lungs are being damaged
from smoking cigarettes or whose arteries are becoming
clogged from eating foods that are high in saturated
fats? These are all signs of improper body functioning.
Are people with these signs healthy? We probably would
say they are not ‘‘sick’’—they are just less healthy than
they would be without the unhealthful conditions.

This means health and sickness are not entirely
separate concepts—they overlap. There are degrees
of wellness and of illness. Medical sociologist Aaron
Antonovsky (1979, 1987) has suggested that we consider
these concepts as ends of a continuum, noting that ‘‘We
are all terminal cases. And we all are, so long as there is
a breath of life in us, in some measure healthy’’ (1987,
p. 3). He also proposed that we revise our focus, giving
more attention to what enables people to stay well than
to what causes people to become ill. Figure 1-1 presents
a diagram of an illness/wellness continuum, with death
at one end and optimal wellness at the other.

Major disability
from illness

Symptoms and
minor disability

Worse-than-
average signs

Average
signs

Healthful signs
and lifestyle

Very healthful
signs and lifestyle

INCREASING WELLNESS

INCREASING ILLNESS

Death

Neutral
Health Status

Optimal
Wellness

Figure 1-1 An illness/wellness continuum to represent people’s differing health statuses. Starting at the center (neutral
level) of the diagram, a person’s health status is shown as progressively worse to the left and progressively healthful as
it moves to the right. The segments in the central band describe dominant features that usually characterize different
health statuses, based on the person’s physical condition—that is, his or her signs (such as blood pressure), symptoms, and
disability—and lifestyle, such as his or her amount of regular exercise, cholesterol consumption, and cigarette smoking.
Medical treatment typically begins at a health status to the left of the neutral level and intensifies as the physical condition
worsens. Medical treatment can bring the person’s health status back to the mid-range of the continuum, but healthful
lifestyles can help, too. Increasing wellness beyond the mid-range can be achieved through lifestyle improvements. (Based
on information in Antonovsky, 1987; Bradley, 1993; Ryan & Travis, 1981.)

Chapter 1 / An Overview of Psychology and Health 3

We will use the term health to mean a positive
state of physical, mental, and social well-being—not
simply the absence of injury or disease—that varies
over time along a continuum. At the wellness end of the
continuum, health is the dominant state. At the other end
of the continuum, the dominant state is illness or injury,
in which destructive processes produce characteristic
signs, symptoms, or disabilities.

ILLNESS TODAY AND IN THE PAST
People in the United States and other developed, indus-
trialized nations live longer, on the average, than they
did in the past, and they suffer from a different pattern
of illnesses. During the 17th, 18th, and 19th centuries,
people in North America suffered and died chiefly from
two types of illness: dietary and infectious (Grob, 1983).
Dietary diseases result from malnutrition—for example,
beriberi is caused by a lack of vitamin B1 and is character-
ized by anemia, paralysis, and wasting away. Infectious
diseases are acute illnesses caused by harmful matter
or microorganisms, such as bacteria or viruses, in the
body. In most of the world today, infectious diseases
continue to be a main cause of death (WHO, 2009).

A good example of the way illness patterns have
changed in developed nations comes from the history
of diseases in the United States. From the early colonial
days in America through the 18th century, colonists expe-
rienced periodic epidemics of many infectious diseases,
especially smallpox, diphtheria, yellow fever, measles,
and influenza. It was not unusual for hundreds, and some-
times thousands, of people to die in a single epidemic.

Children were particularly hard hit. Two other infectious
diseases, malaria and dysentery, were widespread and
presented an even greater threat. Although these two
diseases generally did not kill people directly, they weak-
ened their victims and reduced the ability to resist other
fatal diseases. Most, if not all, of these diseases did
not exist in North America before the European set-
tlers arrived—the settlers brought the infections with
them—and the death toll among Native Americans sky-
rocketed. This high death rate occurred for two reasons.
First, the native population had never been exposed to
these new microorganisms, and thus lacked the natural
immunity that our bodies develop after lengthy exposure
to most diseases (Grob, 1983). Second, Native Americans’
immune functions were probably limited by a low degree
of genetic variation among these people (Black, 1992).

In the 19th century, infectious diseases were still the
greatest threat to the health of Americans. The illnesses
of the colonial era continued to claim many lives, but
new diseases began to appear. The most significant of
these diseases was tuberculosis, or ‘‘consumption,’’ as it
was often called. In 1842, for example, consumption was
listed as the cause for 22% of all deaths in the state of
Massachusetts (Grob, 1983). But by the end of the 19th
century, deaths from infectious diseases had decreased
sharply. For instance, the death rate from tuberculosis
declined by about 60% in a 25-year period around the
turn of the century.

Did this decrease result mostly from advances in
medical treatment? Although medical advances helped
to some degree, the decrease occurred long before
effective vaccines and medications were introduced.

Epidemics of deadly infectious dis-
eases have occurred throughout the
world. Before the 20th century, there
were no effective methods for preven-
tion or treatment of the plague, for
instance, which is the disease illus-
trated in this engraving.

4 Part I / An Introduction: Basic Issues and Processes

This was the case for most of the major diseases we’ve
discussed, including tuberculosis, diphtheria, measles,
and influenza (Grob, 1983; Leventhal, Prohaska, &
Hirschman, 1985). It appears that the decline resulted
chiefly from preventive measures such as improved
personal hygiene, greater resistance to diseases (owing
to better nutrition), and public health innovations, such
as building water purification and sewage treatment
facilities. Many people had become concerned about
their health and began to heed the advice of health
reformers like William Alcott, an advocate of moderation
in diet and sexual behavior (Leventhal, Prohaska, &
Hirschman, 1985). Fewer deaths occurred from diseases
because fewer people contracted them.

The 20th century witnessed great changes in the
patterns of illness afflicting people. The death rate
from life-threatening infectious diseases declined, and
people’s average life expectancy increased dramatically.
For example, in 1900 in the United States, the life expec-
tancy of babies at birth was about 48 years (USDHHS,
1987); today it is nearly 78 years (USBC, 2010). Figure 1-2
shows this change and an important reason for it: the
death rate among children was very high many years
ago. Babies who survived their first year in 1900 could be
expected to live to about 56 years of age, adding 7 years
to their expected total life span. Moreover, people in
1900 who had reached the age of 20 years could expect

80
At 65 years

At 20 years

At birth

At 1 year

E
xp

ec
te

d
t

ot
al

l
if

e
sp

an
i
n
y

ea
rs

1901 1960
Year

1984 2006

Figure 1-2 Expected total life span for people in the
United States at various years since 1900 who were born
in the specified year or had reached 1 year, 20 years, or 65
years of age. (Data from USDHHS, 1987, p. 2, for years 1900–1902,
1959–1961, and 1984; USBC, 2010, Table 105, for 2006.)

to live to almost 63 years of age. Today the death rate
for American children is much lower, and only a small
difference exists in the expected total life span for
newborns and 20-year-olds. Developed countries around
the world experienced similar histories.

Death is still inevitable, of course, but people die
at later ages now and from different causes. The main
health problems and causes of death in developed coun-
tries today are chronic diseases—that is, degenerative
illnesses, such as heart disease, cancer, and stroke—that
develop or persist over a long period of time. And
worldwide, chronic illnesses account for more than half
of all deaths (WHO, 2009). These diseases are not new,
but they were responsible for a much smaller proportion
of deaths before the 20th century. Why? One reason is
that people’s lives are different today. For example, the
growth of industrialization increased people’s stress
and exposure to harmful chemicals. In addition, more
people today survive to old age, and chronic diseases
are more likely to afflict older than younger individuals.
Thus, another reason for the current prominence of
chronic diseases is that more people are living to the
age when they are at high risk for contracting them.

Are the main causes of death in childhood and
adolescence different from those in adulthood? Yes.
In the United States, for example, the leading cause
of death in children and adolescents, by far, is not an
illness, but accidental injury (USBC, 2010). In the age
range from 1 to 24 years, over 42% of deaths result
from accidents, frequently involving automobiles. In
this age group, the next four most frequent causes of
death are homicide, suicide, cancer, and cardiovascular
diseases. All five of these causes of death are far more
common among 15- to 24-year-olds than for younger
ages. Clearly, the role of disease in death differs greatly
at different points in the life span.

VIEWPOINTS FROM HISTORY:
PHYSIOLOGY, DISEASE PROCESSES,
AND THE MIND

Is illness a purely physical condition? Does a person’s
mind play a role in becoming ill and getting well? People
have wondered about these questions for thousands of
years, and the answers they have arrived at have changed
over time.

EARLY CULTURES
Although we do not know for certain, it appears that the
best educated people thousands of years ago believed

Chapter 1 / An Overview of Psychology and Health 5

A skull with holes probably produced by trephination. This
person probably survived several of these procedures.

physical and mental illness were caused by mystical
forces, such as evil spirits (Stone, 1979). Why do we think
this? Researchers found ancient skulls in several areas
of the world with coin-size circular holes in them that
could not have been battle wounds. These holes were
probably made with sharp stone tools in a procedure
called trephination. This procedure was done presumably
for superstitious reasons—for instance, to allow illness-
causing demons to leave the head. Because there are no
written records from those times, we can only speculate
about the reasons for the holes.

ANCIENT GREECE AND ROME
The philosophers of ancient Greece produced the earliest
written ideas about physiology, disease processes, and
the mind between 500 and 300 B.C. Hippocrates, often
called ‘‘the Father of Medicine,’’ proposed a humoral theory
of illness. According to this theory, the body contains four
fluids called humors (in biology, the term humor refers to
any plant or animal fluid). When the mixture of these
humors is harmonious or balanced, we are in a state of
health. Disease occurs when the mixture is faulty (Stone,
1979). Hippocrates recommended eating a good diet and
avoiding excesses to help achieve humoral balance.

Greek philosophers, especially Plato, were among
the first to propose that the mind and the body are
separate entities (Marx & Hillix, 1963; Schneider &
Tarshis, 1975). The mind was considered to have little or
no relationship to the body and its state of health. This
remained the dominant view of writers and philosophers
for more than a thousand years, and the body and
the mind are conceptually separate today. The body
refers to our physical being, including our skin, muscles,
bones, heart, and brain. The mind refers to an abstract
process that includes our thoughts, perceptions, and
feelings. Although we can separate the mind and body
conceptually, an important issue is whether they function
independently. The question of their relationship is
called the mind/body problem.

Galen was a famous and highly respected physician
and writer of the 2nd century A.D. who was born in Greece
and practiced in Rome. Although he believed generally
in the humoral theory and the mind/body split, he made
many innovations. For example, he ‘‘dissected animals
of many species (but probably never a human), and
made important discoveries about the brain, circulatory
system, and kidneys’’ (Stone, 1979, p. 4). From this work,
he became aware that illnesses can be localized, with
pathology in specific parts of the body, and that different
diseases have different effects. Galen’s ideas became
widely accepted.

THE MIDDLE AGES
After the collapse of the Roman Empire in the 5th century
A.D., much of the Western world was in disarray. The
advancement of knowledge and culture slowed sharply
in Europe and remained stunted during the Middle Ages,
which lasted almost a thousand years. The influence of
the Church in slowing the development of medical knowl-
edge during the Middle Ages was enormous. According
to historians, the Church regarded the human being

as a creature with a soul, possessed of a free will
which set him apart from ordinary natural laws, sub-
ject only to his own willfulness and perhaps the will of
God. Such a creature, being free-willed, could not be
an object of scientific investigation. Even the body of
man was regarded as sacrosanct, and dissection was
dangerous for the dissector. These strictures against
observation hindered the development of anatomy
and medicine for centuries. (Marx & Hillix, 1963, p. 24)

The prohibition against dissection extended to animals
as well, since they were thought to have souls, too.

People’s ideas about the cause of illness took
on pronounced religious overtones, and the belief in
demons became strong again (Sarason & Sarason, 1984).

6 Part I / An Introduction: Basic Issues and Processes

Sickness was seen as God’s punishment for doing evil
things. As a result, the Church came to control the
practice of medicine, and priests became increasingly
involved in treating the ill, often by torturing the body to
drive out evil spirits.

It was not until the 13th century that new ideas
about the mind/body problem began to emerge. The
Italian philosopher St. Thomas Aquinas rejected the
view that the mind and body are separate and saw them
as interrelated (Leahey, 1987). Although his position did
not have as great an impact as others had had, it renewed
interest in the issue and influenced later philosophers.

THE RENAISSANCE AND AFTER
The word renaissance means rebirth—a fitting name for the
14th and 15th centuries. During this period in history,
Europe saw a rebirth of inquiry, culture, and politics.
Scholars became more ‘‘human-centered’’ than ‘‘God-
centered’’ in their search for truth and ‘‘believed that
truth can be seen in many ways, from many individual
perspectives’’ (Leahey, 1987, p. 80). These ideas set the
stage for important changes in philosophy once the
scientific revolution began after 1600.

The 17th-century French philosopher and mathe-
matician René Descartes probably had the greatest
influence on scientific thought of any philosopher in
history (Schneider & Tarshis, 1975). Like the Greeks,
he regarded the mind and body as separate entities,
but he introduced three important innovations. First, he
conceived of the body as a machine and described the
mechanics of how action and sensation occurred. For
example, Figure 1-3 shows his concept of how we experi-
ence pain. Second, he proposed that the mind and body,
although separate, could communicate through the pineal
gland, an organ in the brain (Leahey, 1987). Third, he
believed that animals have no soul and that the soul in
humans leaves the body at death (Marx & Hillix, 1963).
This belief meant that dissection could be an acceptable
method of study—a point the Church was now ready to
concede (Engel, 1977).

In the 18th and 19th centuries, knowledge in science
and medicine grew quickly, helped greatly by improve-
ments in the microscope and the use of dissection
in autopsies. Once scientists learned the basics of
how the body functioned and discovered that micro-
organisms cause certain diseases, they rejected the
humoral theory of illness and proposed new theories.

A
B

C
C

e
d

Figure 1-3 Descartes’ concept of the pain path-
way. Descartes used this drawing to illustrate
the mechanisms by which people experience and
respond to pain: The heat of the fire (at A) sends tiny
particles to the foot (B) that pull on a thread that
courses from the foot to the head. This action opens
a pore (de), releasing spirits from a cavity (F) that
travel to the parts of the body that respond (e.g.,
the leg moves away). (From Descartes, 1664, Figure 7.)

Chapter 1 / An Overview of Psychology and Health 7

The field of surgery flourished after antiseptic techniques
and anesthesia were introduced in the mid-19th century
(Stone, 1979). Before then, hospitals were ‘‘notorious
places, more likely to spread diseases than cure them’’
(Easterbrook, 1987, p. 42). Over time, the reputation of
physicians and hospitals began to improve, and people’s
trust in the ability of doctors to heal increased.

These advances, coupled with the continuing
belief that the mind and body are separate, laid the
foundation for a new approach, or ‘‘model,’’ for con-
ceptualizing health and illness. This approach—called
the biomedical model—proposes that all diseases or
physical disorders can be explained by disturbances
in physiological processes, which result from injury,
biochemical imbalances, bacterial or viral infection, and
the like (Engel, 1977; Leventhal, Prohaska, & Hirschman,
1985). The biomedical model assumes that disease
is an affliction of the body and is separate from the
psychological and social processes of the mind. This
viewpoint became widely accepted during the 19th and
20th centuries and still represents the dominant view in
medicine today.

SEEING A NEED: PSYCHOLOGY’S ROLE
IN HEALTH

The biomedical model has been very useful. Using it as a
guide, researchers have made enormous achievements.
They conquered many infectious diseases, such as polio
and measles, through the development of vaccines. They
also developed antibiotics, which made it possible to
cure illnesses caused by bacterial infection. Despite
these great advances, the biomedical model needs
improvement. Let’s see why.

PROBLEMS IN THE HEALTH CARE SYSTEM
Scarcely a week goes by when we don’t hear through
the mass media that health care costs are rising rapidly,
particularly for prescription drugs and for hospital and
nursing home care. Countries worldwide have been
facing escalating costs in health care. For example,
between 1960 and today the United States saw a 49-fold
increase to over $7,200 in the amount of money spent
per capita on health care, and the economic burden
of health costs increased from about 5% to 16% of
the gross domestic product (NCHS, 2009). In Canada
and most European countries, per capita health costs
are now at about 8% to 10% of their gross domestic
products (WHO, 2009). Because medical costs continue
to rise rapidly, we need to consider new approaches for
improving people’s health.

We’ve seen that the patterns of illness affecting
people have changed, particularly in developed nations
where the main health problems now are chronic
diseases. Consider cancer for example. Although a great
deal of progress is being made in understanding the
causes of cancers, improvements in techniques for
treating them have been modest: gains in cancer survival
rates from the 1950s to the 1980s, for instance, resulted
more from earlier detection of the disease than from
improved treatments (Boffey, 1987). Although detection
occurs earlier today partly because diagnostic methods
have improved, another part of the reason is that people
have changed. Many individuals are more aware of signs
and symptoms of illness, more motivated to take care of
their health, and better able to afford visits to physicians
than they were in the past. These factors are clearly
important and relate to psychological and social aspects
of the person. But the person as a unique individual is not
included in the biomedical model (Engel, 1977, 1980).

‘‘THE PERSON’’ IN HEALTH AND ILLNESS
Have you ever noticed how some people are ‘‘always
sick’’—they get illnesses more frequently than most
people do and get well more slowly? These differences
between people can result from biomedical sources, such
as variations in physiological processes and exposure to
harmful microorganisms. But psychological and social
factors also play a role. Let’s look briefly at two of
these factors: the lifestyle and personality of the person.
(Go to —as described in the Preface, this instruction
prompts you to read the nearby boxed material that has
the same icon.)

Lifestyle and Illness
Earlier we saw that the occurrence of infectious diseases
declined in some nations in the late 19th century chiefly
because of preventive measures, such as improved
nutrition and personal hygiene. These measures involved
changing people’s lifestyles—their everyday patterns of
behavior, such as in washing, preparing, and eating
healthful foods. Changes in people’s lifestyles can also
reduce chronic illnesses. Let’s see how.

Characteristics or conditions that are associated
with the development of a disease or injury are called
risk factors for that health problem. Although some risk
factors are biological, such as having inherited certain
genes, others are behavioral. For example, it is well
known that people who smoke cigarettes face a much
higher risk of developing cancer and other illnesses than
nonsmokers do. Other risk factors for cancer include
eating diets high in saturated fat and having a family

8 Part I / An Introduction: Basic Issues and Processes

ASSESS YOURSELF

What’s Your Lifestyle Like?
At various points in this book, you’ll

find brief self-assessment surveys like this one that you
should try to fill out as accurately as you can. These
surveys relate to the nearby content of the chapter, and
most of them can be completed in less than a minute
or two.

This survey assesses seven aspects of your usual
lifestyle. For each of the listed practices, put a check
mark in the preceding space if it describes your usual
situation.

I sleep 7 or 8 hours a day.

I eat breakfast almost every day.
I rarely eat between meals.
I am at or near the appropriate weight for my height
(see Table 8.3 on page 202)
I never smoke cigarettes.
I drink alcohol rarely or moderately.
I regularly get vigorous physical activity.

Count the check marks—six or seven is quite good.
The more of these situations that describe your lifestyle
now and in the future, the better your health is likely to
be, particularly after the age of 50.

history of the disease. People who ‘‘do more’’ or ‘‘have
more’’ of these characteristics or conditions are more
likely to contract cancer than people who ‘‘do less’’
or ‘‘have less’’ of these factors. Keep in mind that a
risk factor is associated with a health problem—it does
not necessarily cause the problem. For example, being
an African American man is a risk factor for prostate
cancer (ACS, 2009), but that status does not cause the
disease—at least, not directly.

Many risk factors result from the way people live or
behave, such as smoking cigarettes and eating unhealth-
ful diets. Some behavioral risk factors associated with
the five leading causes of death in the United States are:

1. Heart disease—smoking, high dietary cholesterol, obesity,
and lack of exercise.

2. Cancer—smoking, high alcohol use, and diet.

3. Stroke—smoking, high dietary cholesterol, and lack of
exercise.

4. COPD (chronic lung diseases, e.g., emphysema)—
smoking.

5. Accidents (including motor vehicle)—alcohol/drug use
and not using seat belts. (ACS, 2009; AHA, 2010; NCHS,
2009a; USBC, 2010)

Many of the people who are the victims of these
illnesses and accidents live for at least a short while
and either recover or eventually succumb. Part of today’s
high medical costs result from people’s lifestyles that
contribute to their health problems, and society, not
the individual, often bears the burden of medical costs
through public and private health insurance programs.

How influential are lifestyle factors on health?
Researchers studied this question by surveying nearly

7,000 adults who ranged in age from about 20 to over
75, asking them two sets of questions. One set asked
about the health of these people over the previous
12 months—for instance, whether illness had prevented
them from working for a long time, forced them to cut
down on other activities, or reduced their energy level.
The second set of questions asked about seven aspects of
their lifestyles: sleeping, eating breakfast, eating between
meals, maintaining an appropriate weight, smoking
cigarettes, drinking alcohol, and getting physical activity.
The questions you answered above are similar to those
in this research. When the researchers compared the
data for people in different age groups, they found that
at each age health was typically better as the number
of healthful practices increased. In fact, the health of
those who ‘‘reported following all seven good health
practices was consistently about the same as those
30 years younger who followed few or none of these
practices’’ (Belloc & Breslow, 1972, p. 419). And these
health practices were also important in the future health
of these people. Breslow (1983) has described later
studies of the same people, such as to find out which of
them had died in the 9 1/2 years after the original survey.
The data revealed that the percentage dying generally
decreased with increases in the number of healthful
behaviors practiced, and this impact was greater for
older than younger people, especially among males.
These findings suggest that people’s practicing healthful
behaviors can reduce their risk of illness and early death
substantially.

You’ve surely heard someone ask, ‘‘Why don’t
people do what’s good for them?’’ There’s no simple
answer to that question—there are many reasons. One
reason is that less healthful behaviors often bring

Chapter 1 / An Overview of Psychology and Health 9

What risk factors for disease does this photo suggest this boy has developed?

immediate pleasure, as when the person has a ‘‘good-
tasting’’ cigarette or ice cream. Long-range negative
consequences seem remote, both in time and in
likelihood. Keep in mind that pleasurable lifestyles can
benefit health: some evidence suggests that engaging
in enjoyable activities, such as vacationing or attending
concerts, may lead to better health (Bygren et al., 2009;
Pressman et al., 2009). Another reason why people don’t
do what’s good for them is that they may feel social
pressures to engage in unhealthful behavior, as when an
adolescent begins to use cigarettes, alcohol, or drugs.
Also, some behaviors can become very strong habits,
perhaps involving a physical addiction or psychological
dependency, as happens with drugs and cigarettes.
Quitting them becomes very difficult. Lastly, sometimes
people are simply not aware of the dangers involved
or how to change their behavior. These people need
information about ways to protect their health.

Personality and Illness
Do you believe, as many do, that people who suffer
from ulcers tend to be worriers or ‘‘workaholics’’? Or that
people who have migraine headaches are highly anxious?
If you do, then you believe there is a link between

personality and illness. The term personality refers to
a person’s cognitive, affective, or behavioral tendencies
that are fairly stable across time and situations.

Researchers have found evidence linking personality
traits and health. For example, people whose personali-
ties include:

• Low levels of conscientiousness measured in childhood or
adulthood are more likely to die at earlier ages, such as
from cardiovascular diseases, than individuals high in
conscientiousness (Kern & Friedman, 2008; Terracciano
et al., 2008).

• High levels of positive emotions, such as happiness or
enthusiasm, tend to live longer than individuals with
low levels of these emotions (Chida & Steptoe, 2008; Xu
& Roberts, 2010).

• High levels of anxiety, depression, hostility, or pessimism are at
risk for dying early and developing a variety of illnesses,
particularly heart disease (Grossardt et al., 2009; Smith
& Gallo, 2001).

Anxiety, depression, hostility, and pessimism are
reactions that often occur when people experience
stress, such as when they have more work to do than
they think they can finish or when a tragedy happens.
Many people approach these situations with relatively

10 Part I / An Introduction: Basic Issues and Processes

positive emotions. Their outlook is more optimistic than
pessimistic, more hopeful than desperate. These people
are not only less likely to become ill than are people
with less positive personalities, but when they do, they
tend to recover more quickly (Scheier & Carver, 2001;
Smith & Gallo, 2001).

The link between personality and illness is not a one-
way street: illness can affect one’s personality, too (Cohen
& Rodriguez, 1995). People who suffer from serious
illness and disability often experience feelings of anxiety,
depression, anger, and hopelessness. But even minor
health problems, such as the flu or a toothache, produce
temporary negative thoughts and feelings (Sarason &
Sarason, 1984). People who are ill and overcome their
negative thoughts and feelings can speed their recovery.
We will examine this relationship in more detail later in
this book.

Our glimpse at the relationships of the person’s
lifestyle and personality in illness demonstrates why it is
important to consider psychological and social factors in
health and illness. Next we will see how this recognition
came about.

HOW THE ROLE OF PSYCHOLOGY
EMERGED
The idea that medicine and psychology are somehow
connected has a long history, dating back at least to
ancient Greece. It became somewhat more formalized
early in the 20th century in the work of Sigmund Freud,
who was trained as a physician. He noticed that some
patients showed physical symptoms with no detectable
organic disorder. Using his psychoanalytic theory, Freud
proposed that these symptoms were ‘‘converted’’ from
unconscious emotional conflicts (Alexander, 1950). He
called this condition conversion hysteria; one form it can
take is called glove anesthesia because only the hand has no
feeling. Symptoms like these occur less often in urban
than in backwoods areas, perhaps because urbanites
realize that medical tests can generally determine if an
organic disorder exists (Kring et al., 2010). The need
to understand conditions such as conversion hysteria
led to the development of psychosomatic medicine, the
first field dedicated to studying the interplay between
emotional life and bodily processes.

Psychosomatic Medicine
The field called psychosomatic medicine was formed
in the 1930s and began publishing the journal Psy-
chosomatic Medicine (Alexander, 1950). Its founders were
mainly trained in medicine, and their leaders included
psychoanalysts and psychiatrists. The field was soon

organized as a society now called the American Psycho-
somatic Society.

The term psychosomatic does not mean a person’s
symptoms are ‘‘imaginary’’; it means that the mind and
body are both involved. Early research in psychoso-
matic medicine focused on psychoanalytic interpreta-
tions for specific, real health problems, including ulcers,
high blood pressure, asthma, migraine headaches, and
rheumatoid arthritis. For example, Alexander (1950)
described the case of a 23-year-old man with a bleeding
ulcer and proposed that the man’s relationship with his
mother created feelings of insecurity and dependence
that caused the ulcer. The man’s stomach problems
later decreased, presumably because he overcame these
feelings through therapy. Over the years, the field’s
approaches and theories evolved (Duberstein, 2004). It
is currently a broader field concerned with interrelation-
ships among psychological and social factors, biological
and physiological functions, and the development and
course of illness.

Behavioral Medicine and Health
Psychology
Two new fields emerged in the 1970s to study the role of
psychology in illness: one is called behavioral medicine,
and the other is called health psychology.

The field of behavioral medicine formed an organi-
zation called the Society of Behavioral Medicine, which
publishes the Annals of Behavioral Medicine. This field has
two defining characteristics (Gentry, 1984): First, its mem-
bership is interdisciplinary, coming from a wide variety of
fields, including psychology, sociology, and various areas
of medicine. Second, it grew out of the perspective in psy-
chology called behaviorism, which proposed that people’s
behavior results from two types of learning:

• Classical (or respondent) conditioning, in which a stimu-
lus (the conditioned stimulus) gains the ability to
elicit a response through association with a stimulus
(the unconditioned stimulus) that already elicits that
response.

• Operant conditioning, in which behavior is changed because
of its consequences: reinforcement (reward) strengthens
the behavior; punishment suppresses it.

Conditioning methods had shown a good deal of
success as therapeutic approaches in helping people
modify problem behaviors, such as overeating, and emotions,
such as anxiety and fear (Sarafino, 2001). By the 1970s,
physiological psychologists had clearly shown that
psychological events—particularly emotions—influence
bodily functions, such as blood pressure. And researchers
had demonstrated that people can learn to control

Chapter 1 / An Overview of Psychology and Health 11

various physiological systems if they are given feedback as
to what the systems are doing (Miller, 1978).

Why were these findings important? They revealed
that the link between the mind and the body is more
direct and pervasive than was previously thought. Soon
they led to an important therapeutic technique called
biofeedback, whereby a person’s physiological processes,
such as blood pressure, are monitored by the person
so that he or she can gain voluntary control over them.
This process involves operant conditioning: the feedback
serves as reinforcement. As we shall see in later chapters,
biofeedback has proven to be useful in treating a variety
of health problems, such as headaches.

Behaviorism also served as an important foundation
for health psychology, a field that is principally within
the discipline of psychology. The American Psychological
Association has many divisions, or subfields; the Division
of Health Psychology was introduced in 1978 (Sarafino,
2004b) and soon began publishing the journal Health
Psychology. Joseph Matarazzo (1982), the first president of
the Division, outlined four goals of health psychology.
Let’s look at these goals and some ways psychologists
can contribute to them.

• To promote and maintain health. Health psychologists study
such topics as why people do and do not smoke
cigarettes, exercise, drink alcohol, and eat particular
diets. As a result, these professionals can help in
the design of school health education programs and
media campaigns to encourage healthful lifestyles and
behaviors.

• To prevent and treat illness. Psychological principles have
been applied effectively in preventing illness, such as in
reducing high blood pressure. For people who become

seriously ill, psychologists with clinical training can help
them adjust to their current condition, rehabilitation
program, and future prospects, such as reduced work or
sexual activity.

• To identify the causes and diagnostic correlates of health, illness, and
related dysfunction. Health psychologists study the causes
of disease; the research we saw earlier showing the
importance of personality factors in the development
of illness is an example of the work toward this goal.
Psychologists also study physiological and perceptual
processes, which affect people’s experience of physical
symptoms.

• To analyze and improve health care systems and health policy.
Health psychologists contribute toward this goal by
studying and advising medical professionals on ways
by which characteristics or functions of hospitals,
nursing homes, medical personnel, and medical costs
affect patients and their likelihood of following medical
advice.

Psychologists work to achieve these goals in a variety
of ways, some of which involve applying techniques that
were derived from behaviorism. (Go to .)

An Integration
By now you may be wondering, ‘‘Aren’t psychosomatic
medicine, behavioral medicine, and health psychology
basically the same?’’ In a sense they are—they have
very similar goals, study similar topics, and share the
same knowledge. The three fields are separate mainly
in an organizational sense, and many professionals are
members of all three organizations. The main distinc-
tions among the fields are the degree of focus they

CLINICAL METHODS AND ISSUES

Behaviorism’s Legacy: Progress in Health
Psychology’s Goals
The perspective of behaviorism led to

the development of behavior modification techniques, which
use principles of learning and cognition to understand
and change people’s behavior (Sarafino, 2001). These
techniques can be grouped into two categories:
Behavioral methods apply mainly principles of operant
and classical conditioning to change behavior. Cognitive
methods are geared toward changing people’s feelings
and thought processes, such as by helping individuals
identify and alter problematic beliefs; most cognitive
methods were developed after the mid-1960s.

How can professionals use behavioral and cognitive
methods to promote and maintain people’s health and
to prevent and treat illness? Let’s consider two examples.
Using behavioral methods, psychologists reduced work-
related injuries at worksites with high accident rates by
applying a program of reinforcement for safety behaviors
(Fox, Hopkins, & Anger, 1987). In an example that used
cognitive methods with patients suffering from chronic
back pain, a psychologist reduced their degree of pain,
depression, and disability by providing training in ways to
relax and think differently about the pain (Turner, 1982).

12 Part I / An Introduction: Basic Issues and Processes

give to specific topics and viewpoints, and the particu-
lar disciplines and professions involved. Psychosomatic
medicine is closely tied to medical disciplines, including
psychiatry, but works with behavioral scientists to under-
stand and treat physical illness. Behavioral medicine
involves professionals in several disciplines and tends
to focus on studying and applying methods to promote
healthy lifestyles without the use of drugs or surgery.
Health psychology is based in psychology and draws
heavily on other subfields—clinical, social, developmen-
tal, and physiological—to identify and alter lifestyle
and emotional processes that lead to illness and to
improve recovery for people who are sick. Although this
book focuses mainly on health psychology, all three
fields share the view that health and illness result
from the interplay of biological, psychological, and
social forces.

HEALTH PSYCHOLOGY: THE PROFESSION
Because the field of health psychology is so new, the pro-
fession is expanding quickly. Most health psychologists
work in hospitals, clinics, and academic departments of
colleges and universities. In these positions, they either
provide direct help to patients or give indirect help
through research, teaching, and consulting activities.

The direct help health psychologists provide gen-
erally relates to the patient’s psychological adjustment
to and management of health problems. Health psy-
chologists with clinical training can provide therapy for
emotional and social adjustment problems that being
ill or disabled can produce—for example, in reducing
the patient’s feelings of depression. They can also help
patients manage the health problem by, for instance,
teaching them psychological methods, such as biofeed-
back, to control pain.

Health psychologists provide indirect help, too.
Their research provides information about lifestyle and
personality factors in illness and injury. They can
apply this and other knowledge to design programs
that help people practice more healthful lifestyles,
such as by preventing or quitting cigarette smoking.
They can also educate health professionals toward
a fuller understanding of the psychosocial needs of
patients.

The qualifications for becoming a health psychol-
ogist vary across countries, but they usually include
completion of the doctoral degree in psychology (Belar
& McIntyre, 2004). Additional study may be needed if
the doctoral program contained little training in health
psychology. Clinical health psychology is a recognized spe-
cialty of the American Psychological Association. State
licensing is required to practice clinical techniques in the

United States, and board certification is available (Belar
& McIntyre, 2004).

CURRENT PERSPECTIVES ON HEALTH
AND ILLNESS

Once we add the person to the biomedical model, we
have a different and broader picture of how health and
illness come about. This new perspective, called the
biopsychosocial model, expands the biomedical view
by adding to biological factors connections to psychological
and social factors (Engel, 1977, 1980; Kazarian & Evans,
2001). This new model proposes that all three factors
affect and are affected by the person’s health.

THE BIOPSYCHOSOCIAL PERSPECTIVE
We can see elements of the biopsychosocial perspective
in the story about Ana at the beginning of the chapter.
A possible biological contribution to her becoming
overweight might be her inheritance, since her mother
is overweight and was heavy as a child. Psychological
factors are probably important, as shown in Ana’s
behavior—she eats too much fattening food and gets
little exercise. And, although the story did not describe
how social factors play a role in her weight problem,
they are probably there—for example, if she imitates her
mother’s dietary and exercise habits. But we did see social
factors relating to Ana’s condition when her schoolmates
taunted her and her parents expressed concern and
urged her to join a recreation program. Let’s look at the
elements of the biopsychosocial model in more detail.

The Role of Biological Factors
What is included in the term biological factors? This term
includes the genetic materials and processes by which we
inherit characteristics from our parents. It also includes
the function and structure of the person’s physiology.
For example, does the body contain structural defects,
such as a malformed heart valve or damage in the brain,
that impair the operation of these organs? Does the
body respond effectively in protecting itself, such as by
fighting infection? Does the body overreact sometimes
in the protective function, as happens in many allergic
reactions to harmless substances, such as pollen
or dust?

The body is made up of enormously complex physical
systems. For instance, it has organs, bones, and nerves,
and these are composed of tissues, which in turn consist
of cells, molecules, and atoms. The efficient, effective,
and healthful functioning of these systems depends on

Chapter 1 / An Overview of Psychology and Health 13

the way these components operate and interact with
each other.

The Role of Psychological Factors
When we discussed the role of lifestyle and personality
in health and illness earlier, we were describing behavior
and mental processes. Behavior and mental processes
are the focus of psychology, and they involve cognition,
emotion, and motivation.

Cognition is a mental activity that encompasses per-
ceiving, learning, remembering, thinking, interpreting,
believing, and problem solving. How do these cognitive
factors affect health and illness? Suppose, for instance,
you strongly believe, ‘‘Life is not worth living without the
things I enjoy.’’ If you enjoy smoking cigarettes, would
you quit to reduce your risk of getting cancer or heart
disease? Probably not. Or suppose you develop a pain in
your abdomen and you remember having had a similar
symptom in the past that disappeared in a couple of days.
Would you seek treatment? Again, probably not. These
examples are just two of the countless ways cognition
plays a role in health and illness.

Emotion is a subjective feeling that affects and is
affected by our thoughts, behavior, and physiology.
Some emotions are positive or pleasant, such as joy
and affection, and others are negative, such as anger,
fear, and sadness. Emotions relate to health and illness
in many ways. For instance, people whose emotions are
relatively positive are less disease-prone and more likely
to take good care of their health and to recover quickly
from an illness than are people whose emotions are
relatively negative. We considered these relationships

when we discussed the role of personality in illness.
Emotions can also be important in people’s decisions
about seeking treatment. People who are frightened of
doctors and dentists may avoid getting the health care
they need.

Motivation is the process within individuals that gets
them to start some activity, choose its direction, and
persist in it. A person who is motivated to feel and look
better might begin an exercise program, choose the
goals to be reached, and stick with it. Many people are
motivated to do what important people in their lives want
them to do. Parents who quit smoking because their child
pleads with them to protect their health are an example.

The Role of Social Factors
People live in a social world. We have relationships
with individual people—a family member, a friend, or
an acquaintance—and with groups. As we interact with
people, we affect them, and they affect us. For example,
adolescents often start smoking cigarettes and drinking
alcohol as a result of peer pressure (Murphy & Bennett,
2004). They want very much to be popular and to look
‘‘cool’’ or ‘‘tough’’ to schoolmates and others. These
social processes provide clear and powerful motivational
forces. But our social world is larger than just the people
we know or meet.

On a fairly broad level, our society affects the health
of individuals by promoting certain values of our
culture, such as that being fit and healthy is good. The
mass media—television, newspapers, and so on—often
reflect these values by setting good examples and
urging us to eat well, not to use drugs, and not to drink

Society can help prevent disease or
injury in many ways, such as through
advertisements against smoking.

14 Part I / An Introduction: Basic Issues and Processes

and drive. The media can do much to promote health,
but sometimes they encourage unhealthful behavior,
such as when children see jazzy TV commercials for
sweet, nutrient-poor foods (Harris et al., 2009). Can
individuals affect society’s values? Yes, by writing our
opinions to the mass media and lawmakers, selecting
which television shows and movies to watch, and buying
healthful products, for example.

Our community consists of individuals who live
fairly near one another, such as in the same town
or county, and organizations, such as government.
The influence of communities is suggested in the
research finding that they differ in the extent to which
their members practice certain health-related behaviors,
such as smoking cigarettes or consuming fatty foods
(Diehr et al., 1993). There are many reasons for these
differences. For instance, a community’s environmental
characteristics seem to influence residents’ physical
activity and diets (Sallis et al., 2006; Story et al., 2008).
Residents tend to be more physically active and have
healthier diets in communities that have parks, are safe,
and have stores and restaurants with large selections of
high-quality fruits, vegetables, and low-fat products.

The closest and most continuous social relation-
ships for most people occur within the family, which
can include nonrelatives who live together and share a
strong emotional bond. As individuals grow and develop
in childhood, the family has an especially strong influ-
ence (Murphy & Bennett, 2004). Children learn many
health-related behaviors and ideas from their parents,
brothers, and sisters. Parents can set good examples
for healthful behavior by using seat belts, serving and
eating nutritious meals, exercising, not smoking, and
so on. Families can also encourage children to perform

healthful behaviors and praise them when they do. And
as we have said, an individual can influence the larger
social unit. A family may stop eating certain nutritious
foods, such as broccoli or fish, because one member has
a tantrum when these foods are served.

The role of biological, psychological, and social
factors in health and illness is not hard to see. What is
more difficult to understand is how health is affected by
the interplay of these components, as the biopsychosocial
model proposes. The next section deals with this
interplay.

The Concept of ‘‘Systems’’
‘‘We need to understand the whole person,’’ you’ve
probably heard a professional say. This statement reflects
the recognition that people and the reasons for their
behavior are very complex. Many health professionals
strive to consider all aspects of people’s lives in
understanding health and illness. This approach uses the
biopsychosocial model and is sometimes called holistic, a
term many people use and define to include a wide range
of ‘‘alternative’’ approaches to promote health, such as
treatments that use aromas and herbs to heal.

We can conceptualize the whole person by applying
the biological concept of ‘‘systems’’ (Engel, 1980). A
system is a dynamic entity with components that are
continuously interrelated. By this definition, your body
qualifies as a system, and it includes the immune and
nervous systems, which consist of tissues and cells. Your
family is a system, too, and so are your community and
society. There are levels of systems, as Figure 1-4 depicts.
If we look at levels within the person, illness in one part
of the body can have far-reaching effects: if you fell and

The Person

PSYCHOLOGICAL SYSTEMS
(experience and behavior)

SOCIAL SYSTEMS

The World

BIOLOGICAL SYSTEMS
(genetics and physiology)

Examples of
systems included:

• Cognition• Society

• Community

• Family

Examples of
systems included:

• Organs

• Tissues

• Cells• Motivation

• Emotion

Figure 1-4 A diagram of the interplay of systems in the biopsychosocial model. The person consists of biological and
psychological systems, which interrelate; and each of the systems includes component systems. The person interrelates with
the social systems of his or her world. Each system can affect and be affected by any of the other systems.

Chapter 1 / An Overview of Psychology and Health 15

seriously injured your leg, your internal systems would
be automatically mobilized to help protect the body from
further damage. In addition, the discomfort and disability
you might experience for days or weeks might affect your
social relations with your family and community. As
systems, they are entities that are constantly changing,
and they have components that interrelate, such as by
exchanging energy, substances, and information.

To illustrate how the systems concept can be useful,
let’s use it to speculate how Ana’s weight problem might
have come about. Let’s assume that she did inherit
some factor that affects her weight, such as a liking for
sweet foods. When she was a toddler, Ana’s parents
were not concerned that she was getting heavy because
they believed a popular misconception: ‘‘A chubby baby
is a healthy baby.’’ The meals the family ate usually
contained lots of high-fat, high-calorie foods and a sweet
dessert. Because Ana was heavy, she was less agile,
tired more easily than children who were not overweight,
and preferred to engage in sedentary activities, such as
playing with dolls or watching television, rather than
sports. She and her friends snacked on cookies while
watching television commercials that promoted high-
fat, sweet breakfast and snack foods, which she got
her parents to buy. Thus, interacting biopsychosocial
systems can contribute to a person’s weight problem.

Using the biopsychosocial model as a guide,
researchers have discovered new and important findings
and ways to promote people’s health and recovery from
illness. Here is a sample of discoveries that we will
discuss in later chapters:

• Using psychological methods to reduce anxiety of
patients who are awaiting surgery enables them to
recover more quickly and leave the hospital sooner.

• Programs that teach safer sex practices have dramatically
reduced risky sexual behavior and the spread of HIV
infection.

• People who have a high degree of social support from
family and friends are healthier and live longer than
people who do not.

• Stress impairs the functioning of the immune system.

• Applying psychological and educational programs for
heart disease patients reduces their feelings of depres-
sion and enables them to live longer.

• Biofeedback and other psychological techniques can
reduce the pain of people who suffer from chronic,
severe headaches.

LIFE-SPAN AND GENDER PERSPECTIVES
People change over time through the process called
‘‘development,’’ and each portion of the life span is

affected by happenings in earlier years and affects
the happenings in years that will come. Throughout
people’s lives, health, illness, and the role of different
biopsychosocial systems change. Gender also plays a
role, such as in the health-related behaviors people
perform and the illnesses they develop. This is why it’s
important to keep the life span and gender perspectives
in mind when we examine health psychology.

In the life-span perspective, characteristics of a person
are considered with respect to their prior development,
current level, and likely development in the future
(Hayman, 2007). Health and illness characteristics vary
with development. For instance, the kinds of illnesses
people have tend to change with age. Compared with
older people, children are less likely to experience
activity limitations from chronic diseases (USBC, 2010).
Illnesses that keep children out of school tend to be
short-term infectious diseases, such as colds or the
flu. In contrast, many people in late adulthood and
old age suffer from heart disease, cancer, and stroke,
which often result in disability and death. Pediatrics
and geriatrics are branches of medicine that deal with
the health and illness of children and the elderly,
respectively.

How do the roles of different biopsychosocial
systems change as we develop? Biological systems
change in many ways. Virtually all systems of the body
grow in size, strength, and efficiency during childhood
and decline in old age. The decline can be seen in the
slowing down that older people notice in their physical
abilities. They have less stamina because the heart and
lungs function less efficiently and the muscles are weaker
(Tortora & Derrickson, 2009). They also recover from
illness and injury more slowly.

Changes occur in psychological systems, too—for
example, in cognitive processes. Children’s knowledge
and ability to think are limited during the preschool
years but grow rapidly during later childhood. Before
children can assume responsibility for their health, they
need to understand how their behavior can affect it. As
children get older and their cognitive skills improve, they
are better able to understand the implications of their
own illness when they are sick and the rationales for
behaviors that promote their health and safety (Murphy
& Bennett, 2004).

How do people’s social relationships and systems
change with development? For one thing, there are some
usual progressions: children usually progress through
levels of education, enter a career in adulthood, become
parents and grandparents, and retire in old age. Changes
in social relationships also relate to health and illness.
Children’s health is largely the responsibility of adult
caregivers—parents and teachers. During the teenage

16 Part I / An Introduction: Basic Issues and Processes

years, adolescents take on more and more of these
responsibilities. But age-mates in the community have
a powerful influence, and the need to be accepted by
peers sometimes leads teens toward unhealthful or
unsafe behavior. For example, an adolescent who has
a chronic illness that can be controlled—as diabetes
can—may neglect his or her medical care to avoid
looking and feeling different from other teens (La Greca
& Stone, 1985).

The gender perspective also adds an important dimen-
sion to the biopsychosocial perspective in our effort
to understand how people deal with issues of health
and illness. Males and females differ in their biologi-
cal functioning; their health-related behaviors and social
relationships, such as drinking, dieting, and using safer-
sex practices; and the risk of specific illnesses, such as
breast cancer.

RELATING HEALTH PSYCHOLOGY TO
OTHER SCIENCE FIELDS

Knowledge in health psychology is greatly enriched by
information from many other disciplines, including some
disciplines within psychology, such as the clinical and
social areas; medicine, including psychiatry and pediatrics;
and allied fields, such as nursing, nutrition, pharmacology,
biology, and social work. We will look at four fields that
are very important because they provide information and
a context for health psychology.

RELATED FIELDS
To understand health psychology fully, we need to know
the context in which health and illness exist. The field
of epidemiology—the scientific study of the distribution
and frequency of disease and injury—provides part
of this context. Researchers in this field determine
the occurrence of illness in a given population and
organize these data in terms of when the disease or
injury occurred, where, and to which age, gender, and
racial or cultural groups. Then they attempt to discover
why specific illnesses are distributed as they are. You
have probably seen the results of epidemiologists’ work
in the mass media. For example, news reports have
described areas of the United States where Lyme disease,
a tick-borne illness, occurs at high levels and where
certain forms of cancer are linked to high levels of toxic
substances in the environment.

Epidemiologists use several terms in describing
aspects of their findings (Gerace & Vorp, 1985; Runyan,
1985). We will define five of these terms:

• Mortality means death, generally on a large scale. An
epidemiologist might report a decrease in mortality from
heart disease among women, for instance.

• Morbidity means illness, injury, or disability—basically
any detectable departure from wellness.

• Prevalence refers to the number of cases, such as of
a disease or of persons infected or at risk. It includes
both continuing (previously reported) and new cases at
a given moment in time—for example, the number of
cases of asthma as of the first day of the current year.

• Incidence refers to the number of new cases, such as of
illness, infection, or disability, reported during a period
of time. An example is the number of new tuberculosis
cases in the previous year.

• Epidemic usually refers to the situation in which
the incidence, generally of an infectious disease, has
increased rapidly.

Some of these terms are used with the word rate,
which adds relativity to the meaning. For instance, the
mortality rate gives the number of deaths per number of
people in a given population during a specified period of
time. An example might be a mortality rate of 5 babies
per 1,000 births dying in their first year of life in the
current year in Canada.

Another discipline of importance to health psychol-
ogy is public health, the field concerned with protecting,
maintaining, and improving health through organized
effort in the community. People who work in public
health do research and set up programs to promote
or provide immunizations, sanitation, health education
and awareness, and community health services (Runyan,
1985). This field studies health and illness in the context
of the community as a social system. The success of
public health programs and the way individual people
react to them are of interest to health psychologists.

Two other related fields are sociology and anthro-
pology (Adler & Stone, 1979). Sociology focuses on human
social life; it examines groups or communities of people
and evaluates the impact of various social factors, such as
the mass media, population growth, epidemics, and insti-
tutions. Medical sociology is a subfield that studies a wide
range of issues related to health, including the impact of
social relationships on the distribution of illness, social
reactions to illness, socioeconomic factors of health care
use, and the way hospital services and medical practices
are organized. Anthropology includes the study of human
cultures. Its subfield, medical anthropology, examines differ-
ences in health and health care across cultures: How do
the nature and definition of illness vary across different
cultures? How do people in these cultures react to illness,
and what methods do they use to treat disease or injury?
How do they structure health care systems? Without the

Chapter 1 / An Overview of Psychology and Health 17

knowledge from sociology and anthropology, health psy-
chologists would have a very narrow view. Knowledge
from sociology and anthropology gives us a broad social
and cultural view of medical issues and allows us to
consider different ways to interpret and treat illness.

The combined information health psychologists
obtain from epidemiology, public health, sociology, and
anthropology paints a broad picture for us. It describes
the social systems in which health, illness, and the

person exist and develop. (Go to .)

HIGHLIGHT

Related Nonpsychology Careers
The process of providing care for a

patient who is suffering from a chronic illness, serious
injury, or disability involves a variety of professionals
working together with physicians as a team. Each
professional has specific training for a special role in
the treatment or rehabilitation process. Most of them
have some education in psychology. We’ve already seen
how health psychologists can play a role. Let’s look at
some careers outside of psychology and the training they
require to practice in the United States, as described in
the Occupational Outlook Handbook (USDL, 2010).

Nurses and Physician Assistants

There are two overall categories of nurses: registered nurses
(RNs) and licensed practical nurses (LPNs). RNs work in
hospitals, community health clinics, physicians’ offices,
and industrial settings. They assess and record patients’
symptoms and progress, conduct tests, administer
medications, assist in rehabilitation, provide instructions
for self-treatment, and instruct patients and their families
in ways to improve or maintain their health. RNs
often deal with mental and emotional aspects of the
patient as well. RNs in the United States must be
licensed to practice, have graduated from an approved
training program in nursing, and have passed a national
examination. RN training programs vary in structure and
length; college and university programs take about 4
years and lead to a baccalaureate degree.

LPNs work in hospitals, clinics, physicians’ offices,
and patients’ homes. They perform nursing activities
that require less training than those performed by RNs.
For example, they take and record temperatures and
blood pressures, administer certain medications, change
dressings, assist physicians or RNs, and help patients
with personal hygiene. Like RNs, LPNs must be licensed
to practice and have graduated from an approved
practical nursing program. Training programs for LPNs
take about a year to complete and are offered through
various types of institutions, such as trade and vocational
schools, community and junior colleges, and hospitals.

Physician assistants and nurse practitioners usually work
closely with medical doctors, performing routine tasks

that physicians ordinarily did in the past, such as exam-
ining patients with symptoms that do not appear serious
and explaining treatment details. Training involves a pro-
gram of about 2 years of study; admission often requires
that applicants have had at least 2 years of college and
health care experience.

Dietitians

Dietitians study and apply knowledge about food and its
effect on the body. They do this in a variety of settings,
such as hospitals, clinics, nursing homes, colleges, and
schools. Some dietitians are administrators; other work
directly with patients in assessing nutritional needs,
implementing and evaluating dietary plans, and instruct-
ing patients and their families on ways to adhere to
needed diets after discharge from the hospital. Some
dietitians work for social service agencies in the commu-
nity, where they counsel people on nutritional practices
to help maintain health and speed recovery when they
are ill.

Becoming a dietitian requires a bachelor’s or
master’s degree specializing in nutrition sciences or insti-
tutional management. To become a Registered Dietitian,
the individual must complete a supervised internship
and pass an exam.

Physical Therapists

Many patients need help in restoring functional move-
ment to parts of their body and relieving pain. If they
have suffered a disabling injury or disease, treatment
may be needed to prevent or limit permanent disability.
Physical therapists plan and apply treatment for these goals
in rehabilitation.

To plan the treatment, physical therapists review
the patient’s records and perform tests or measurements
of muscle strength, motor coordination, endurance, and
range of motion of the injured body part. Treatment is
designed to increase the strength and function of the
injured part and aid in the patient’s adaptation to having
reduced physical abilities, which may be quite drastic.
People who have suffered severe strokes are sometimes

(continued)

18 Part I / An Introduction: Basic Issues and Processes

HIGHLIGHT (Continued)

left partially paralyzed, for instance. The most universal
technique used in physical therapy involves exercise,
generally requiring little effort initially and becoming
more and more challenging. Another technique involves
electrical stimulation to move paralyzed muscles or
reduce pain. Physical therapists also give instructions
for carrying out everyday tasks, such as tying shoelaces
or cooking meals. If the patient needs to use adaptive
devices, such as crutches or a prosthesis (replacement
limb), the therapist provides training.

Physical therapists in the United States must have
completed an approved training program and be licensed
by passing an exam. A master’s degree in physical therapy
is now required to enter the profession.

Occupational Therapists

Occupational therapists help physically, mentally, and
emotionally disabled individuals gain skills needed for
daily activities in a work setting, at school, in the
community, and at home. Their patients are often people
who had these skills at one time, but lost them because
of an injury or disease, such as muscular dystrophy.
These professionals usually specialize in working with
a particular age group, such as the elderly, and a
type of disability—physical, for example. They design
and implement educational, vocational, and recreational
activities based on the patient’s age and the type and
degree of disability. The program for a child, for instance,

might involve academic tasks and crafts; for an adult, it
might involve typing, driving a vehicle, and using hand
and power tools.

Occupational therapists in the United States must
be licensed by passing an exam. Training now requires a
master’s degree from an approved occupational therapy
program.

Social Workers

The field of social work is quite broad. Probably most
social workers are employed in mental health programs,
but many others work in hospitals, nursing homes,
rehabilitation centers, and public health programs. When
working with people who are physically ill or disabled,
social workers help patients and their families make
psychological and social adjustments to the illness and
obtain needed community services, including income
maintenance. Thus, social workers may arrange for
needed nursing care at home after a patient leaves the
hospital or refer a patient for vocational counseling and
occupational therapy if the illness or disability requires
a career change.

Social workers in the United States must be licensed
or certified to practice. Training requires a bachelor’s
degree in a social science field, usually social work, but
often a degree in psychology or sociology is sufficient.
Many positions require a master’s degree in social work,
the MSW degree.

HEALTH AND PSYCHOLOGY ACROSS
CULTURES
Health and illness have changed across the history and
cultures of the world, as the following excerpt shows:

Less than a hundred years ago the infant mortality rate
in Europe and North America was as high as it is in
the developing world now. In New York City in the year
1900, for example, the IMR [infant mortality rate] was
approximately 140 per 1,000—about the same as in
Bangladesh today. In the city of Birmingham, England
a survey taken in 1906 revealed an IMR of almost 200
per 1,000—higher than almost any country in the
world in the 1980s. A look behind these statistics also
shows that the main causes of infant death in New
York and Birmingham then were much the same as
in the developing world now—diarrheal disease and
malnutrition, respiratory infections, and whooping
cough. (UNICEF, cited in Skolnick, 1986, p. 20)

The world view we get from historical–cultural
comparisons can be quite dramatic. Each country’s

present culture is different from every other’s and from
the culture it had 200 years ago. Lifestyles have changed
in each culture, and so has the pattern of illnesses that
afflict its citizens.

Sociocultural Differences in Health
The term sociocultural means involving or relating
to social and cultural factors, such as ethnic and
income variations within and across nations. The World
Health Organization collects epidemiological data on
sociocultural differences in health by regions of the
world (WHO, 2008). They reported, for instance, that
the incidence rates (per 100,000 population) for certain
forms of cancer are much higher for some regions than
others. The incidence rates for lung and colon cancers
are low for Eastern Mediterranean nations (21 countries,
including Morocco, Pakistan, and Saudi Arabia) and high
for Western Pacific nations (27, including China, Japan,
New Zealand, and Singapore). Sociocultural health
differences also occur within specific countries. In the

Chapter 1 / An Overview of Psychology and Health 19

United States, for example, Whites and American Indians
have about 2 1/2 times the incidence rate for kidney
cancer as Asian Americans (ACS, 2009). And among
males, African Americans have far higher rates of lung
and prostate cancer than any other ethnic group. The
differences we see in illness patterns between countries,
regions, or ethnic groups result from many factors,
including heredity, environmental pollution, economic
barriers to health care, discrimination-based negative
emotions, and cultural differences in people’s diets,
health-related beliefs, and values (Mays, Cochran, &
Barnes, 2007; Whitfield et al., 2002). Although people
around the world value good health, not all people have
the attitudes, environments, and access to health care
that promote good health.

Sociocultural Differences in Health Beliefs
and Behavior
Differences across history and culture can also be seen in
the ideas people have about the causes of illness. Recall
our discussion of the widespread beliefs in the Middle
Ages that evil spirits caused illness. Today, educated
people in technological societies generally reject such
ideas. But less sophisticated people often do not, as the
following excerpt shows:

I’ve heard of people with snakes in their body, how
they got in there I don’t know. And they take ‘em
someplace to a witch doctor and snakes come out.
My sister, she had somethin’, a snake that was in her
arm. She was a young woman. I can remember her
bein’ sick, very sick … This thing was just runnin’ up
her arm, whatever it was, just runnin’ up her arm. You
could actually see it. (Snow, 1981, p. 86)

A disadvantaged person in the United States gave
this account, which is typical of the level of knowledge
generally found in people in underdeveloped regions
or countries. This is important to recognize because
the large majority of people in the world live in
underdeveloped societies.

The United States has been described as a melt-
ing pot for immigrants from every corner of the world.
Immigrants carry with them health ideas and customs
from their former countries. For example, many Chinese
immigrants have entered their new country with the belief
that illness results from an imbalance of two opposing
forces, yin and yang, within the body (Campbell & Chang,
1981). According to this view, too much yin causes colds
and gastric disorders, for instance, and too much yang
causes fever and dehydration. Practitioners of traditional
Chinese medicine try to correct an imbalance by prescrib-
ing special herbs and foods or by using acupuncture, in

which fine needles are inserted under the skin at special
locations of the body. Immigrants and others with these
beliefs often use these methods when sick instead of,
or as a supplement to, treatment by an American physi-
cian. They may also pressure their family members to do
this, too: a pregnant Chinese woman who was a regis-
tered nurse ‘‘followed her obstetrician’s orders, but at the
same time, under pressure from her mother and mother-
in-law, ate special herbs and foods to insure birth of a
healthy baby’’ (Campbell & Chang, 1981, p. 164).

Religion is an aspect of culture. Many religions
include beliefs that relate to health and illness. For
instance, Jehovah’s Witnesses reject the use of blood and
blood products in medical treatment (Sacks & Koppes,
1986). Christian Scientists reject the use of medicine,
believing that only mental processes in the sick person
can cure the illness. As a result, sick persons need
prayer and counsel as treatment to help these processes
along (Henderson & Primeaux, 1981). These beliefs are
controversial and have led to legal conflicts between
members of these religions and health authorities
in the United States, particularly when parents reject
medical treatments for life-threatening illnesses for their
children. In such cases, the physician and hospital can
move quickly to seek an immediate judicial decision
(Sacks & Koppes, 1986).

Some religions include specific beliefs that promote
healthful lifestyles. Seventh-day Adventists, for example,
believe that the body is the ‘‘temple of the Holy Spirit’’
and cite this belief as the reason people should take care
of their bodies. Adventists abstain from using tobacco,
alcohol, and nonmedically prescribed drugs. In addition,
they promote in fellow members a concern for exercise
and eating a healthful diet (Henderson & Primeaux,
1981). Although it is clear that cultural factors play a role
in health, our knowledge about this role is meager and
needs to be expanded through more research.

RESEARCH METHODS

Contemporary mass media present lots of scientific find-
ings. Diets high in fiber and low in saturated fats are good
for your health. Smoking is not. Dozens of toxic, or poi-
sonous, chemicals can cause cancer. How do scientists
discover these relationships? What methods do they use?

Scientists do research. Often their research is plan-
ned and conducted to test a theory—a tentative explanation
of why and under what circumstances certain events
occur (Michie & Prestwich, 2010). For example, a leading
theory of the cause of heart disease is that excess
cholesterol, a fatty substance in the blood, is deposited
in artery walls. This buildup hardens and narrows the

20 Part I / An Introduction: Basic Issues and Processes

diameter of the artery, thereby causing tissue damage to
the heart if the flow of blood in an artery becomes
blocked. Cholesterol comes from two sources. Most
cholesterol in the blood is manufactured by the body; the
rest of it comes from the foods we eat—especially red
meats, egg yolks, butter and some oils, and most cheeses.

The cholesterol theory is one of several useful
theories of heart disease. By useful we don’t necessarily
mean that it is correct. We mean that it:

• Is clearly stated.

• Brings together or organizes known facts.

• Relates information that previously seemed unrelated.

• Enables us to make predictions, such as what would
happen if cholesterol levels were reduced.

Useful theories play an important role in all sciences.
Because theories offer predictions, they guide research
programs by suggesting a ‘‘road map’’ of relationships to
study.

As you think about the causes of heart disease, you’ll
realize that both the illness and the theoretical cause—in
this case, high levels of cholesterol—can change or vary
from one time to another and from one individual to
another. That is, the condition of the heart and arteries
and the amount of cholesterol in the blood are not
constant. Because these things vary, they are called
variables. A variable is any measurable characteristic of
people, objects, or events that may change. The variables
studied in research are of two types: an independent variable
is studied for its potential or expected influence, as in the
case of cholesterol levels; a dependent variable is assessed
because its value, such as the condition of the heart, is
expected to ‘‘depend’’ on the independent variable.

Researchers use a variety of experimental and nonexper-
imental methods to study health-related variables like the
ones we’ve discussed (Sarafino, 2005).

EXPERIMENTS
An experiment is a controlled study in which researchers
manipulate an independent variable to study its effect on
a dependent variable. In a well-designed experiment—
which is often called a trial in health research—all
other variables are controlled or held constant. The
term manipulate means that the researchers produce or
introduce the levels of the independent variable they are
studying.

The Experimental Method:
A Hypothetical Example
To illustrate the experimental method, let’s see how
researchers might test the cholesterol theory of heart

disease. One prediction, or hypothesis, from the theory is
that people’s incidence of heart disease should decrease
if they reduce their cholesterol levels. We could test this
hypothesis by lowering some people’s cholesterol levels
and seeing if these people develop fewer heart attacks
over a suitable period of time than they otherwise would.
How can we lower their cholesterol levels? There are
two ways to manipulate this independent variable, both
of which would require including medical professionals
in the research team. One way is to alter the people’s
diets, and the other is to have them take a cholesterol-
lowering drug regularly. We will use the latter approach
and assume, for our example, that the drug is new and
the only one available.

We’d start the research by selecting a fairly large sam-
ple of people—preferably at least middle-aged, because
they have a relatively high risk of having a heart attack in
the near future. Then we assign them randomly to the con-
ditions or groups in the experiment. One way to assign
them randomly is to put their names on cards in a bowl,
mix up the cards, and draw the cards out one at a time.
The first name drawn would be assigned to one group, the
second name to another group, and so on. By doing this,
we can equate the groups, distributing the people’s existing
characteristics, such as personality and genetic factors,
fairly equally across groups. As a result, the characteris-
tics will have about the same impact on the dependent
variable (heart attacks) for each of the groups.

To test the hypothesis, we will need two groups of
people. One group receives the experimental treatment,
the cholesterol-lowering pills, and is called the experi-
mental group. The other group receives their usual care
without the drug, and is called the control group (or com-
parison group). By administering the drug to and lowering
the cholesterol level of one group, but not the other,
we are manipulating the independent variable. We then
observe over several years the incidence of heart attacks.
If the experimental group has fewer heart attacks than
the control group, the hypothesis is supported.

You may be wondering, ‘‘Isn’t it possible that a
decrease in heart attacks for the experimental group
could result not from the drug per se, but simply from
taking any substance a medical person prescribes?’’
Sometimes people’s beliefs or expectations can affect
their health (Ader, 1997; Rehm & Nayak, 2004). To control
for this possibility, we would have a third group: they’d
receive an inert, or inactive, substance or procedure—
called a placebo—in the form of pills that look like
medicine. The placebo group would be given the same
instructions as the experimental group, and both would
have equal expectations about the effectiveness of the
pills. Any influence the placebo has on the dependent
variable is called a placebo effect.

Chapter 1 / An Overview of Psychology and Health 21

One other control procedure is needed: the per-
son who distributes the pills should not know which
pills contain the active drug. Why? This person could
inadvertently bias the outcome of the experiment,
such as by giving instructions offhandedly to the
placebo group but emphatically and precisely to the
experimental group. Being unaware of which indi-
viduals are getting which treatment is called being
blind as to the treatment. Since both the individu-
als receiving and distributing the pills are unaware,
the method we are using is called the double-blind
procedure.

Now that we have included these control procedures,
let’s look at the outcome of our hypothetical experiment.
As Figure 1-5 shows, the people in the experimental
group had far fewer heart attacks than those in the other
groups. Thus we can conclude that lowering cholesterol
levels in the blood causes a decrease in heart disease,
as the theory predicts. Notice also in the graph that the
people in the placebo group had somewhat fewer heart
attacks than the controls. This suggests a placebo effect,
with expectancy having some effect on heart disease,
but not nearly as much as the active ingredient in the
cholesterol-lowering drug.

You may have noticed that our conclusion used the
word causes: lowering cholesterol ‘‘causes’’ a decrease in
heart disease. To make a cause-effect conclusion, it must
be clear that three criteria have been met:

• The levels of the independent and dependent variables
corresponded or varied together.

• The cause preceded the effect.

• All other plausible causes have been ruled out.

Well-designed experiments, usually called random-
ized controlled trials, meet these requirements because
the researchers use random assignment to equate the
groups, manipulate the independent variable, and con-
trol variables that are not being studied. Other research
approaches do not use experimental methods and do
not provide the ability to determine what causes what.

Comparing Experimental and
Nonexperimental Methods
Research always involves the study of variables, but
in nonexperimental methods, the researchers either do not
manipulate an independent variable and/or do not equate the
groups. In addition, there is frequently less opportunity
for precise measurement and for control of variables not
being studied. As a result, although nonexperimental
methods may be used to point out relationships between
variables, they do not provide direct and unambiguous
tests of cause-effect relationships.

Nonexperimental methods are nevertheless very
valuable and have some important advantages. Some-
times it is simply not possible or feasible to assign
subjects randomly and manipulate the variable of inter-
est. We cannot manipulate the past lifestyles of people,
for instance; the past has already happened. Nor can
we have individuals in one group of a study do harmful
things they would ordinarily not do simply to test an
important theory. For instance, it would be unethical to
assign people of a sample to a group in which they must
smoke cigarettes for the next 5 years if some of these
people do not smoke or want to quit. Even if it were eth-
ical, nonsmokers might refuse to do it. What if we didn’t

Assess health

Assess health
Assess health

Incidence rate of heart attack

Assign to groups
Subjects
available
for study

Experimental
group
(drug)

Placebo
group

(inert pills)

Control
group

(no pills)

Figure 1-5 The left-hand portion of this diagram shows how the study would be carried out. Subjects (also called
participants) are assigned to groups and, after a suitable period of time, the researcher checks whether they have had
heart attacks. The right-hand portion illustrates how the results might appear on a graph: participants who received the
anticholesterol drug had far fewer heart attacks than subjects in the placebo group, who had somewhat fewer attacks than
those in the control group.

22 Part I / An Introduction: Basic Issues and Processes

randomly assign individuals to groups? If we do not ran-
domly assign them, the groups are not likely to be equal
at the start of the study with respect to characteristics,
such as genetics or past lifestyle, that could affect the
outcome of the research. In situations like this in which
ethical considerations prevent the study of humans in
research, animals are sometimes used.

In many cases, the aim of a research project
requires only that an association between variables be
demonstrated. We may want to know, for instance, which
people are at greatest risk for a disease so that we may
help them avert it. Studies to determine risk factors
are examples, which have revealed that people who are
among the most likely to develop heart disease are
male and/or over 50 years old (AHA, 2010). Researchers
can determine this relationship without manipulating
gender or age, and a nonexperimental method is, in fact,
the most appropriate technique.

The rest of our examination of research methods
will focus on nonexperimental approaches in research
relating to health psychology and continue to use the
cholesterol theory of heart disease as the basis for
research examples. Let’s turn to correlational studies
as the first of these methods.

CORRELATIONAL STUDIES
The term correlation refers to the co or joint relation
that exists between variables—changes in one variable
correspond with changes in another variable. Suppose,
for example, we did a study of two variables: heart
function and people’s diets, particularly the amount of
cholesterol they consume. A measure of heart function
is cardiac output, the amount of blood the heart pumps per
minute. Working with a physician, we recruit a sample of,
say, 200 middle-aged adults and have them keep detailed
records of their diets for the 2 weeks prior to the visit
when the physician measures their cardiac output. We
then calculate the amount of cholesterol consumed on
the basis of their records.

Once we know the cardiac output and cholesterol
intake of each of the subjects, we can assess the degree to
which these variables are related, expressed statistically
as a correlation coefficient, which can range from +1.00
through .00 to −1.00. The sign (+ or −) of the coefficient
indicates the direction of the relationship. A plus sign
means that the association is ‘‘positive’’: for instance,
people with high (or low) scores on one variable, say,
cardiac output, tend to have high (low) scores on the
other variable, such as blood pressure. Conversely, a
minus sign means that the association is ‘‘negative’’: high
scores on one variable tend to be associated with low
scores on the other variable. For example, high cardiac

output is correlated with low concentrations of cells in
the blood, because cells thicken the blood (Rhoades
& Pflanzer, 1996). Thus, there is a negative correlation
between cardiac output and concentration of blood cells.

Disregarding the sign of the correlation coefficient,
the absolute value of the coefficient indicates the
strength of association between variables. The higher the
absolute value (that is, the closer to either +1.0 or
−1.0), the stronger the correlation. As the absolute value
decreases, the strength of the relationship declines. A
coefficient approximating .00 means that the variables
are not related. From the information we have just
covered, we can now state a definition: correlational
studies are nonexperimental investigations of the degree
and direction of statistical association between two
variables.

Let’s suppose that our study revealed a strong
negative correlation—a coefficient of −.72—between
cardiac output and cholesterol intake. This would support
the cholesterol theory, because low cholesterol intake
should produce less fatty buildup to clog the arteries,
thereby allowing the heart to pump more blood per
minute. But we cannot say on the basis of our study
that these events occurred, and we cannot conclude that
low cholesterol intake causes high cardiac output. Why?
Because we did not manipulate any variable—we simply
measured what was there. It may be that some variable
we did not measure was responsible for the correlation.
For example, the people with low cholesterol intake may
also have had low concentrations of blood cells, and it
may have been this latter factor that was responsible
for their high cardiac output. We don’t know. We would
only know for sure that the two variables have a strong
negative relationship.

Although correlational studies typically cannot
determine cause-effect relations, they are useful for
examining existing relationships and variables that can-
not be manipulated, developing hypotheses that may be
tested experimentally, and generating predictive infor-
mation, such as risk factors for health problems.

QUASI-EXPERIMENTAL STUDIES
Quasi-experimental studies look like experiments be-
cause they have separate groups of subjects, but they
are not because the subjects were not randomly assigned
to groups. In some types of quasi-experiments, the
independent variable is manipulated, but in other types,
it is not. A commonly used quasi-experimental approach
is called an ex post facto study, in which subjects are
categorized and placed in groups on the basis of an
existing variable or circumstance. Groups based on
gender (males and females), cholesterol level (high,

Chapter 1 / An Overview of Psychology and Health 23

moderate, and low), or diet (high-fat and low-fat) in
the past year are examples.

We could do a quasi-experimental study relating to
the cholesterol theory of heart disease in the following
way. Suppose we wanted to see if people’s cholesterol
level at the time of a heart attack is associated with
the severity of the attack. For this study, we could just
consult the medical records of heart disease patients,
since it is standard practice to assess both variables. We
could categorize the patients as having a high or low
cholesterol level at the time they were admitted to the
hospital. Then we would determine whether the attacks
were more severe for one group than for the other.

If we found that the high-cholesterol patients had the
more severe heart attacks, could we conclude that higher
levels of cholesterol in the blood cause more severe
attacks? No—for the same reasons we’ve discussed
before. We cannot tell what caused what. In fact, this
particular study could have been turned around. We
could have categorized the patients on the basis of the
severity of their attacks and then compared these groups
for cholesterol levels. We would have found the same
relationship: severe heart attacks are associated with a
high level of cholesterol in the blood.

In general, the conclusions from quasi-experimental
studies are basically correlational. The relationships
they reveal do not become causal simply because we
categorize subjects. There are many variations to the
quasi-experimental method. We will look at a few of the
more important ones, beginning with retrospective and
prospective approaches.

Retrospective and Prospective Approaches
The prefix retro means ‘‘back’’ or ‘‘backward,’’ and spective
comes from the Latin word meaning ‘‘to look.’’ Thus,
the retrospective approach uses procedures that look
back at the histories of subjects, such as individuals who
do or do not have a particular disease. The purpose of
this approach is to find commonalities in the people’s
histories that may suggest why they developed the
disease.

How is the retrospective approach used in a quasi-
experimental study? We might identify two groups of
individuals. One group would consist of people who
have already developed a particular illness, such as
heart disease. They would be compared against a control
group, consisting of similar people without the disease.
We would then examine the two groups for characteristics
of their histories that are common to one group, but
not the other. We might find, for example, that the heart
disease victims reported having eaten higher-cholesterol
diets during the preceding 10 years than the controls

did. Although the retrospective approach is relatively
easy to implement, it has a potential shortcoming: when
the procedures rely on people’s memories, especially
of long-past happenings, the likelihood of inaccurate
reports increases.

The prospective approach uses procedures that
look forward in the lives of individuals, by studying
whether differences in a variable at one point in time are
related to differences in another variable at a later time.
We could do this to see whether certain characteristics
or events in people’s lives are associated with their
eventual development of one or more diseases. In using
the prospective approach, we would start by recruiting a
large group of people—say, 2,000—who did not yet have
the illness in question, heart disease. Periodically over
several years we would interview them, have a physician
examine them, and check their medical records. The
interviews would inquire about various events and
characteristics, such as cholesterol intake. Then we would
categorize the people—for instance, as having or not
having had a heart attack—and determine whether these
groups differed in some earlier aspects of their lives.

What might our study show? We might find that,
compared with people who did not have heart attacks,
those who did had eaten diets that were much higher
in cholesterol. We might also find that changes in
people’s diets, becoming higher or lower in cholesterol
content over the years, corresponded with their suffering
an attack. That is, those who consumed increasing
amounts of cholesterol had more heart attacks than
those whose cholesterol intake decreased. Because this
is a quasi-experimental study, we cannot be certain
that high-cholesterol diets caused the heart disease. But
the prospective approach gives greater plausibility to a
causal link than the retrospective approach would. This is
because the diets, and changes in them, clearly preceded
the heart attacks.

Retrospective and prospective approaches to study
health were developed by epidemiologists. These
approaches have been useful in identifying risk factors
for specific illnesses.

Developmental Approaches
We saw earlier that the life-span perspective adds an
important dimension to the study of health and illness.
An essential research approach in studying life-span
development is to examine and compare subjects at
different ages. Of course, the age of the subjects cannot
be manipulated; we can assign individuals to groups
based on their age, but this assignment is not random.
This approach is quasi-experimental, and, therefore, age
itself cannot be viewed as a cause of health or behavior.

24 Part I / An Introduction: Basic Issues and Processes

Two basic approaches are used for studying the
age variable. In the cross-sectional approach, different
individuals of different ages are observed at about the
same time. The longitudinal approach involves the
repeated observation of the same individuals over a long
period of time. The longitudinal approach is like the
prospective method, but it focuses specifically on age
as a variable. Let’s see how the cross-sectional and
longitudinal approaches are used.

Suppose we were interested in examining age-
related changes in dietary intake of cholesterol among
middle-aged adults. If we use a cross-sectional approach,
we might evaluate the diets of, say, 50 adults at each
of three approximate ages—for example, 35, 45, and 55
years—during the current month. On the other hand, if
we use a longitudinal approach to examine the same age
range, we would evaluate the diets of 50 35-year-olds
during the current month, and again when they are 45
and 55 years of age. This longitudinal study would take
20 years to complete.

Not all longitudinal studies take so long to do.
Often a shorter span of ages—sometimes only a few
months—is appropriate, depending on the question
or issue the researcher wants to resolve. But the
longitudinal approach, and the prospective approach
in general, is typically more costly in time and money
than the cross-sectional approach. Also the longer a
study lasts, the greater the likelihood that subjects in the
sample will be lost. Some will move away, others will lose
interest in participating, and still others may die. Despite
these difficulties, it is a valuable research approach that is
unique in its ability to examine change and stability in the lives
of individuals across time. For example, our longitudinal
study could tell us whether individuals who eat a high-
cholesterol diet at age 35 will generally continue to do so
many years later. In contrast, a cross-sectional approach
loses sight of stability and individual changes.

Now, let’s suppose we did our cross-sectional study
and found that the cholesterol content of adults’ diets
decreased with age. We would then like to know why this
is so. One possible answer is that people change their
diets as they get older because they feel more vulnerable
to heart disease. So we asked the oldest group, using
the retrospective approach, if they feel more vulnerable
and eat less high-cholesterol food today than they used
to. Sure enough, they said yes. But another reason for
the current age differences in diet could be that the
older adults never ate diets as high in cholesterol as
those of the younger adults. So we asked the oldest
group to describe the diets they ate 10 or 20 years
ago. The diets they described contained less cholesterol
than their current diets (which we already knew) and the
current diets of the 35- and 45-year-olds in our study! This

finding reflects the fact that the older subjects grew up
at a different time, when food preferences or availability
may have been different.

The influence of having been born and raised at a
different time is called a cohort effect. The term cohort refers
to a group of people who have a demographic factor in
common, such as age, generation, or social class. As a
result, they share a set of experiences that are distinct
from those of other cohorts. Researchers can examine
cohort effects by combining the two developmental
approaches. Looking back at our study with middle-
aged adults, the combined approach could be carried
out by selecting and testing 35-, 45-, and 55-year-olds
initially. So far the study is cross-sectional, but we would
follow most of these same adults longitudinally and
add younger subjects along the way. By doing this in a
planned and systematic way, we’ll have data on cross-
sectional differences, changes within each cohort, and
differences between cohorts.

Single-Subject Approaches
Sometimes studies are done with just one subject. One
type of research that uses this approach is the case study, in
which a trained researcher constructs a systematic biog-
raphy from records of the person’s history, interviews,
and current observation. This kind of research is useful
in describing, in depth, the development and treatment
of an unusual medical or psychological problem. Other
types of research that use one subject are called single-
subject designs. This approach is often used for demon-
strating the usefulness of a new treatment method for a
specific medical or behavioral problem. In the simplest of
these designs, data on the subject’s problem at the begin-
ning and end of treatment are compared. Often, follow-up
assessments are made weeks or months later to see if the
person’s condition has regressed. Some single-subject
designs have additional phases or features that enable
them to provide evidence for cause-effect relationships.

The principal disadvantage of single-subject app-
roaches is that information on only one subject, no
matter how detailed it is, may not describe what would
be found with other individuals. A major purpose of
psychological research is to collect information that can
be applied or generalized to other people. Nevertheless,
studies using one subject stimulate the development of
new treatment procedures and suggest topics for further
research.

GENETICS RESEARCH
In the 19th century, Charles Darwin speculated that
unseen particles called ‘‘gemmules’’ were present in the

Chapter 1 / An Overview of Psychology and Health 25

sperm and ovum. Darwin’s concept of gemmules formed
the basis for the search for genetic materials. What did
this search yield?

Genetic Materials and Transmission
Researchers discovered threadlike structures called chro-
mosomes and proposed that these structures contained
units called genes. Soon they determined the basic sub-
stance in all genetic material—deoxyribonucleic acid, or DNA
for short—and described its structure. Today we know
that DNA determines our growth patterns and physical
structures (Tortora & Derrickson, 2009). We also know
that genes are discrete particles of DNA that are strung
together in chromosomes and transmitted from parent
to child. Each parent contributes half of the genetic
information we inherit.

Chromosomes have identifying features. Pho-
tographs taken through a microscope can be arranged
according to the size and shape of chromosome pairs.
One pair is called the sex chromosomes because they carry
the genes that will determine whether an individual will
be female or male. The normal sex chromosomes for
males consist of one large chromosome (called an X
chromosome) and one small chromosome (called a Y
chromosome); females have two X chromosomes. As
with chromosomes, genes come in pairs. Although a
single pair of genes may determine some traits a person
inherits, others require many genes. Some traits occur
in the presence of a single dominant gene, with the paired
gene making little or no contribution. But when a trait
occurs only if two identical genes make up the pair,
these genes are called recessive.

Twin and Adoption Studies
How do psychologists and other scientists determine
whether hereditary factors influence people’s health
and illness? The methods are based on a distinction
between two types of twins. Monozygotic (MZ), or identical,
twins are conceived together and have the same
genetic inheritance; dizygotic (DZ), or fraternal, twins are
conceived separately and are no more genetically similar
than singly born siblings and may, of course, be of
different sex.

Much of the research on hereditary factors has
focused on the differences in characteristics shown in
MZ twins as compared with DZ twins. Investigations
using this approach are called twin studies. The ratio-
nale for making these comparisons, although statistically
complex, is logically simple. Because the two individuals
in an MZ pair are genetically identical, we can assume
that differences between them are environmentally deter-
mined. Conversely, the greater the similarity between MZ

twins, the more likely it is that the characteristic is genet-
ically influenced. Differences between DZ twins, on the
other hand, are due to both genetic and environmental
factors, even when they are the same sex. If we could
assume that both members of each MZ and same-sex
DZ pair that we study have had equal environmental
experiences, we could measure genetic influence simply
by subtracting the differences for MZ from the differ-
ences for DZ twins. Even though both members of each
MZ and DZ pair may not have had equal environmental
experiences, researchers can take the differences into
account—and when they do, important genetic forces
are still found (Scarr & Kidd, 1983).

Another way to examine hereditary influences is
to study children adopted at very early ages. Adoption
studies compare traits of adopted children with those
of their natural parents and their adoptive parents.
Why? Adoptive parents contribute greatly to the rearing
environment, but are genetically unrelated to the
children; the natural parents are genetically related to
the children, but play little or no role in rearing them.
So, if adopted children are more similar to their natural
parents than to their adoptive parents, we then have
evidence for heredity’s influence.

Let’s look at a few conclusions relevant to health psy-
chology that have come from twin and adoption studies.
First, heredity affects not only physical characteristics,
such as height and weight, but also physiological func-
tions, including heart rate and blood pressure (Ditto,
1993). Second, genetic disorders can produce very high
levels of cholesterol in the blood, making their victims
susceptible to heart disease at very early ages (AMA,
2003). Third, some evidence indicates that heredity has
its greatest impact on people’s health early in life, and by
old age the role of habits and lifestyle become increas-
ingly important (Harris et al., 1992). Fourth, although
genetic factors affect people’s risk of developing cancer,
environmental factors appear to play a stronger role for
most people (Lichtenstein et al., 2000).

Linking Specific Genes with Diseases
After having identified which disorders have a genetic
basis, researchers began looking for links to specific
genes. We now know that every human cell contains
30,000–40,000 genes, and almost all of the human system
of genes have been identified and mapped (IHGSC, 2001).
Genes influence a vast number of traits, including more
than 3,000 diseases. For some diseases, researchers have
even pinpointed the exact gene locations. We will look
at a few of these traits and diseases.

Sickle-cell anemia is a hereditary disease whose victims
are usually Black people. In the United States, nearly 10%

26 Part I / An Introduction: Basic Issues and Processes

of the African American population carries a recessive
gene for this disease and do not have the disorder
(Raphael, 1999). The body of a person who has two
of these genes manufactures large quantities of sickle-
shaped red blood cells that carry little oxygen and
tend to clump together in the bloodstream—often
they cannot pass through capillaries. As a result, the
vital organs of people with sickle-cell anemia receive
inadequate amounts of oxygen and incur tissue damage.
The condition, which usually develops in childhood,
produces painful episodes, progressive organ failure,
and brain damage.

Another recessive disease is phenylketonuria (PKU). In
this disease, which occurs more frequently among Whites
than other racial groups, the baby’s body fails to produce
a necessary enzyme for metabolizing phenylalanine, a
toxic amino acid present in many common foods (AMA,
2003). If the disease is not treated, the amino acid builds
up and causes brain damage. Placing PKU babies on
special diets as soon as possible after birth can prevent
this. When the brain is more fully developed after about
5 years of age, many PKU children can switch to normal
diets. PKU provides a good example of an inherited
disease that can be controlled by modifying the victim’s
behavior.

Researchers are also closing in on certain oncogenes,
which are genes that can cause cancer. Researchers have,
for example, found oncogenes for certain types of cancers
of the colon (Bodmer et al., 1987), breast (Chen et al.,
1995; Wooster et al., 1995), skin (Hussussian et al., 1994),
lung (Rodenhuis et al., 1987), and prostate (Lee et al.,
1994). Oncogenes can be normal genes or mutations
that may result from exposure to harmful environmental
agents, such as tobacco smoke.

Epigenetic Effects
Epigenetics is a process in which chemical structures
within or around the DNA govern how, when, and how
much a gene acts. These structures typically suppress
the gene’s usual activity, can change, and can be passed
on to one’s offspring (Foley et al., 2009; Zhang & Meaney,
2010). Epigenetics operates in normal development,
such as when cells specialize to become heart or brain
cells. But environmental events can change epigenetic
processes, especially during prenatal, early childhood,
and puberty periods. Environmental factors that can
lead to epigenetic changes include exposure to toxic
chemicals, bacterial and viral infection, dietary elements,
tobacco, alcohol, and drugs.

For both members of an MZ twin pair, gene activity
is highly similar in childhood and becomes less and
less similar as they get older, especially when their

lifestyles differ and the resulting epigenetic changes
accumulate. Evidence today suggests that epigenetic
changes can influence an individual’s response to stress,
ability to learn and remember, and development of health
problems, such as cancer, heart disease, obesity, asthma,
and diabetes. The study of epigenetics is fairly new, and
there’s a lot we don’t yet know about it. Given that most
of the research on epigenetics has been conducted with
animals, to what extent do the same specific effects
occur in humans? What determines the likelihood that
an epigenetic change will be inherited? Can epigenetic
processes that lead to health problems be reversed, such
as by taking medication?

Which Research Method Is Best?
In this chapter, we have discussed a variety of research
methods that are useful in health psychology. Which one
is best? Some scientists might say that randomized
controlled trials are best because they can uncover
cause-effect relationships. But precise control and
manipulation do not always yield results that help us
understand real-life behavior. For example, studying
behavior in experimental settings sometimes involves
artificial conditions, such as precisely occurring events
and special equipment. To the extent that these
conditions are unlike the subjects’ real world, their
behavior may be influenced. As a result, when reading
about an experiment, it is useful to keep two questions
in mind: Does the experimental situation approximate
anything the subjects might experience in real life?
If the experimental situation is highly artificial, what
specific effect might this have on the outcome of the
experiment? New techniques may help avoid these and
other problems. For example, a method called ecological
momentary assessment uses devices, such as pagers, to
cue and collect data on individuals periodically in their
regular day-to-day living (Shiffman & Stone, 1998).

In a sense, all the research methods we discussed
are ‘‘best,’’ since the investigator must select the most
suitable method(s) to answer the specific question(s)
under study. This leads us to a final point: it is possible
and desirable to use experimental and nonexperimental
methods simultaneously in one study. For instance, if we
wanted to find out whether people’s reading information
about the health effects of excessive cholesterol would
induce them to modify their diets we could manipulate
the independent variable by having the experimental
group, but not the control group, read the health infor-
mation. We might also want to test people of different
ages: people who are 50 years of age might be more
easily persuaded to lower their cholesterol levels than
people who are 20. We could examine both variables by

Chapter 1 / An Overview of Psychology and Health 27

randomly assigning people of each of the two age groups
to experimental and control groups and later examining
their diets and blood cholesterol levels. Note, however,

that the kinds of conclusions yielded by each variable
(information and age) will differ; only the manipulated
variable can yield unambiguous causal statements.

SUMMARY

Health and illness are overlapping concepts that exist along
a continuum. One end of the illness/wellness continuum is
dominated by health—a positive state of physical, mental,
and social well-being that varies over time; the other end
is dominated by illness, which produces signs, symptoms,
and disabilities. The patterns of illness affecting people
have changed across history, especially in the 20th century.
Compared with earlier times, today people die at later ages
and from different causes. Infectious diseases are no longer
the principal cause of death in technological societies
around the world. Chronic illnesses now constitute the
main health problem in developed nations.

Ideas about physiology, disease processes, and the
mind have changed since the early cultures thousands of
years ago, when people apparently believed that illness
was caused by evil spirits and the like. Greek philosophers
produced early written ideas about health and illness,
considering how sickness happens and the mind/body
problem. During the Middle Ages, the Church had an
enormous influence on ideas about illness, and the
belief in mystical causes of disease became strong again.
Philosophers and scientists from the 17th to the 20th
centuries provided the foundation for the biomedical model
as a way to conceptualize health and illness.

The biomedical model has been extremely useful,
enabling researchers to make great advances in conquering
many infectious diseases through the development of
vaccines and treatments. But many researchers today have
come to recognize that aspects of individual patients—their
histories, social relationships, lifestyles, personalities,
mental processes, and biological processes—must be
included in a full conceptualization of risk factors for illness.
As a result, the biopsychosocial model has emerged as an

alternative to the biomedical approach and proposed a
constant interplay of biological, psychological, and social
systems—each interrelated with and producing changes in
the others. Psychosomatic medicine, behavioral medicine,
and health psychology have introduced new techniques,
such as behavioral and cognitive methods, to promote
health. Life-span, gender, and sociocultural perspectives
add important dimensions to this model by considering
the role of people’s development, sex, and culture in health
and illness. Health psychology draws on knowledge from a
variety of other psychology fields and nonpsychology fields,
such as medicine, biology, social work, epidemiology,
public health, sociology, and anthropology. Epidemiology
examines the mortality, morbidity, prevalence, incidence,
and epidemic status of illnesses.

The study of important variables in health psychology
involves the use of experimental and nonexperimental
research methods, often testing a theory. A well-designed
experiment can lead to cause-effect conclusions because
it involves rigorous control, such as with placebo and
double-blind methods, and manipulation of variables.
Correlational studies test relationships between variables;
a correlation coefficient describes an association between
variables but does not indicate whether it is a causal
relation. Quasi-experimental studies are useful when
subjects cannot be randomly assigned to groups or
independent variables cannot be manipulated, such as the
subjects’ history, age, and gender; quasi-experiments often
use retrospective and prospective approaches. To study
people at different ages, researchers use cross-sectional
and longitudinal approaches. The role of heredity in health
and illness can be examined through twin and adoption
studies and by examining epigenetics.

KEY TERMS

illness/wellness
continuum

health
infectious diseases
chronic diseases
mind/body problem
biomedical model
risk factors
personality
psychosomatic medicine

behavioral medicine
health psychology
behavioral methods
cognitive methods
biopsychosocial model
system
mortality
morbidity
prevalence
incidence

epidemic
sociocultural
theory
variable
experiment
placebo
double blind
correlation coefficient
correlational studies

quasi-experimental
studies

retrospective approach
prospective approach
cross-sectional approach
longitudinal approach
twin studies
adoption studies
epigenetics

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PART III
LIFESTYLES TO ENHANCE HEALTH
AND PREVENT ILLNESS

6
HEALTH-RELATED BEHAVIOR
AND HEALTH PROMOTION
Health and Behavior
Lifestyles, Risk Factors, and Heal

Interdisciplinary Perspectives on Preventing

Illness
Problems in Promoting Wellness

What Determines People’s Health-Related
Behavior?
General Factors in Health-Related Behavior
The Role of Beliefs and Intentions
The Role of Less Rational Processes

Developmental, Gender, and Sociocultural
Factors in Health
Development and Health
Gender and Health
Sociocultural Factors and Health

Programs for Health Promotion
Methods for Promoting Health
Promoting Health in Schools and Religious

Organizations
Worksite and Community-Based Wellness

Programs
Electronic Interventions For Health

Promotion
Prevention with Specific Targets: Focusing

on AIDS

PROLOGUE
‘‘It’s getting worse—those health nuts are all over th

place these days, telling me how to live my life,’’ said
Joshua between puffs on his cigarette. Things were not
necessarily ‘‘worse,’’ but they had changed. People were
now much more health conscious. They were exercising
more, eating more healthful diets, and using better
hygiene. Does this story describe the contemporary scene
in a technologically advanced country? It could, but it
could also describe the mid-1800s in America. People
of today are not the first to be interested in health and
fitness.

In the 1800s, disease was widespread, epidemics
were common, and physicians had few effective methods
for preventing or treating illness. As a result, health
reformers advocated that people change their lifestyles to
protect their health (Collins, 1987; Leventhal, Prohaska,
& Hirschman, 1985). These reformers were often imbued
with patriotic or religious zeal. Some of them advocated
vegetarian diets. Others proposed that people chew their
food to a watery consistency, or stop smoking cigarettes
and drinking, or get more exercise if they led sedentary
lives. Often people who exercised wore loose-fitting gym
suits and used a variety of apparatuses, such as rowing
machines. It was a lot like today, wasn’t it?

This part of the book contains three chapters con-
cerned with behaviors that can enhance or compromise

131

132 Part III / Lifestyles to Enhance Health and Prevent Illness

health. In the present chapter, we’ll start with the health
habits people practice and how their lifestyles affect their
health. Then we turn to factors that influence the health-
related behaviors individuals adopt and programs to
help people lead more healthful lives. As we study these
topics, you will find answers to questions you may have
about health-related behavior and health promotion. Are
people leading more healthful lives today than they did
in the past? Why is it that some people take better
care of themselves than others do? How effective are
health-promotion programs that try to motivate healthful
behavior through fear?

HEALTH AND BEHAVIOR

The role of behavior in health has been receiving
increased attention in countries around the world
because people’s health habits—that is, their usual
health-related behaviors—influence their likelihood of
developing chronic and fatal diseases, such as heart
disease, cancer, and AIDS (WHO, 2009). Illness and early
death could be substantially reduced if people would
adopt lifestyles that promote wellness, such as by eating
healthful diets and not smoking.

The percentage of deaths resulting from any specific
cause changes over time. Figure 6-1 depicts the pattern
of changes in the United States that occurred since
the late 1960s. These changes resulted partly from the
modifications people made in behavioral risk factors for
major chronic diseases. Cardiovascular disease (heart

disease and stroke) is the most deadly illness worldwide.
In virtually all developed nations, the first and second
leading killers are cardiovascular diseases and cancer
(WHO, 2009). Of course, we can’t live forever, but we
can extend our lives and be healthier in old age by
making several lifestyle changes (Manton, 2008; Yates
et al., 2008). If we made all these changes and researchers
found cures for most major diseases, people’s average life
expectancy in technologically advanced countries would
rise several years to about 85 years, its likely upper limit
(Olshansky, Carnes, & Cassel, 1990).

LIFESTYLES, RISK FACTORS, AND HEALTH
The typical person’s lifestyle includes many behaviors
that are risk factors for illness and injury. For instance,
millions of Americans smoke cigarettes, drink exces-
sively, use drugs, eat high-fat and high-cholesterol diets,
eat too much and become overweight, have too little
physical activity, and behave in unsafe ways, such as by
not using seat belts in automobiles. Many people real-
ize these dangers and adjust their behavior to protect
their health. Adults with healthful lifestyles that include
exercising, eating diets with fruits and vegetables, not
smoking, and not drinking too much, can expect to
live 12 years longer than they would otherwise (Kvaavik
et al., 2010). Each of these four behaviors raises the like-
lihood of a longer life. Table 6.1 shows that the chances
of individuals in their 70s surviving to 90 years of age
decrease substantially with each additional risk factor
they have.

0 10 20

30 4

Percentage of all deaths

M
aj

or
c

au
se

s
of

d
ea

1.51 Liver disease (e.g., cirrhosis)

1.72

COPD (lung diseases, e.g., emphysema)

1.74 Arteriosclerosis

1.99 Diabetes

2.27 Early infancy diseases

Pneumonia and influenza

Accidents

Stroke

Malignancies (cancer)

3.81

5.95

10.95

16.

38.59 Heart disease

0 10 20

Late 1960s Today

30 40

1.41 Septicemia (bacterial infection)

1.87 Kidney disease

2.32 Influenza and Pneumonia

2.98 Alzheimer’s disease

2.98 Diabetes

Accidents

COPD (lung diseases, e.g., emphysema)
Stroke

5.01

5.13

5.65

23.00 Malignancies (cancer)

26.01 Heart disease

Figure 6-1 Percentage of all deaths caused by each of the 10 leading causes of death in the United States in the late 1960s
(1968) and today. Notice that cancer and COPD deaths increased markedly since 1968 (partly due to cigarette smoking); heart
disease and stroke deaths declined (partly due to recent lifestyle changes, such as in diet); deaths from diseases of early
infancy declined markedly and are no longer in the top ten. (Data from USBC, 1971, Table 77; USBC, 2010, Table 116.)

Chapter 6 / Health-Related Behavior and Health Promotion 133

Table 6.1 Likelihood of 70-Year-Old Men with Certain Risk
Factors Living to Age 90

Risk factors present at age 70 Percent living to 90

None of the five risk factors examined 54
Having a sedentary lifestyle 44
Having high blood pressure 42
Being obese 32
Having diabetes 28
Smoking 25
Three of the five risk factors 14
All five of the risk factors 4

Source: Data from Yates et al., 2008.

Health Behavior
Health behavior is any activity people perform to main-
tain or improve their health, regardless of their perceived
health status or whether the behavior actually achieves
that goal. Researchers have noted that people’s health
status influences the type of health behavior they per-
form and their motivation to do it (Kasl & Cobb, 1966a, b;
Parsons 1951). To illustrate these differences, we will
consider examples of behaviors people perform when
they are well, experience symptoms, and are clearly sick.

Well behavior is any activity people undertake to main-
tain or improve current good health and avoid illness.
These activities can include healthy people’s exercising,
eating healthful diets, having regular dental checkups,
and getting vaccinations against diseases. But when
people are well, they may not feel inclined to devote the
effort and sacrifice that healthful behavior entails. Thus,

engaging in healthful behavior depends on motivational
factors, particularly with regard to the individual’s per-
ception of a threat of disease, the value in the behavior
in reducing this threat, and the attractiveness of the
opposite behavior. Some unhealthful behaviors, such
as drinking or smoking, are often seen as pleasurable or
the ‘‘in’’ thing to do. As a result, many individuals do not
resist beginning unhealthful behaviors and may reject
efforts or advice to get them to quit.

Symptom-based behavior is any activity people who
are ill undertake to determine the problem and find
a remedy. These activities usually include complaining
about symptoms, such as stomach pains, and seeking
help or advice from relatives, friends, and medical
practitioners. Some people are more likely than others
to engage in symptom-based behavior when symptoms
appear, and there are many reasons for these differences.
For instance, some individuals may be more afraid than
others of physicians, hospitals, or the serious illness
a diagnosis may reveal. Some people are stoic or
unconcerned about the aches and pains they experience,
and others do not seek medical care because they simply
do not have the money to pay for it. Chapter 9 will
examine these and other reasons why people do and do
not use health care services.

Sick-role behavior refers to any activity people under-
take to get well after deciding that they are ill and what
the illness is. This behavior is based on the idea that sick
people take on a special ‘‘role,’’ making them exempt from
their normal obligations and life tasks, such as going to
work or school. You’d be showing sick-role behaviors if

People engage in health behaviors, such
as using exercise bikes, to maintain or
improve their health and avoid illness.

134 Part III / Lifestyles to Enhance Health and Prevent Illness

you got a prescription filled, used it as the physician
directed, stayed home from work to recover, and had
someone else do your household chores. Although this
status ordinarily obligates patients to try to get well,
many do not follow their recommended treatment, par-
ticularly if it is inconvenient or uncomfortable to do.
Sometimes sick-role behaviors seem to serve emotional
functions, as when patients moan or sigh and receive
sympathy as a result.

How people behave when they are sick depends in
large measure on what they have learned. As an example,
a study of female college students assessed whether they
had been encouraged during adolescence to adopt the
sick role for menstruation or had observed their mothers
exhibit menstrual distress. Compared with students who
did not have these experiences, those who did reported
more menstrual symptoms, disability, and clinic visits for
these symptoms as adults (Whitehead et al., 1986). Other
research has found that there are cultural differences in
the way people respond to their symptoms and go about
trying to get well (Korol & Craig, 2001). For example, stud-
ies in the United States have found differences among
groups of immigrants in their willingness to tolerate pain,
but these differences diminish in succeeding generations

(Chapman & Brena, 1985). (Go to .)

Practicing Health Behaviors
What health behaviors do people actually do? In the
United States, national surveys of men and women
for a limited set of health-related behaviors revealed
the results given in Table 6.2. Although these data
show important shortcomings in the health practices of
American adults, some of these levels of health-related
behaviors are improvements over the levels assessed in
earlier surveys (McGinnis & Lee, 1995).

Who practices healthful behavior and why? We are
far from a complete answer to this question, but there are
gender, sociocultural, and age differences in practicing
health behaviors (Schoenborn, 1993; NCHS, 2009a). For
instance, an international survey of adults in European
countries found that women perform more healthful
behaviors than men (Steptoe et al., 1994). One reason for
such differences is that people seem to perform behaviors
that are salient to them. For example, a study compared
the health behaviors of medical and nonmedical students
and found that the medical students exercised more and
were much less likely to smoke cigarettes, drink alcohol
excessively, and use drugs (Golding & Cornish, 1987).

You probably know some individuals who are highly
health-conscious and others who display little concern

HIGHLIGHT

Two Health Behaviors: Breast and Testicular
Examinations
Breast cancer is a leading cause of

women’s deaths around the world and is the second-
most-frequent type of cancer diagnosed among women
in the United States (ACS, 2009). Compared with breast
cancer, testicular cancer is much less prevalent: several
thousand cases are diagnosed each year in American
men, mainly between the ages of 15 and 35 (ACS, 2009;
Ullrich, 2004). Both cancers have very high cure rates if
treated early.

Individuals can detect cancer of the breast or
testicles in its early stages by self-examination. Breast
and testicular self-examinations are done with the
fingers, searching mainly for abnormal lumps. For breast
self-examination (BSE), the woman lies on her back and
uses the middle three fingertips of her opposite-side
hand to press flatly against the breast tissue and moves
them in a systematic pattern until she examines the
entire breast. The method for testicular self-examination
(TSE) is relatively simple: the man rotates the entire
surface of each testicle between the fingers and thumbs

of both hands. Unfortunately, people don’t perform BSEs
and TSEs very often for such reasons as not knowing how
important early detection can be, being afraid they will
find a malignant lump, or just forgetting and having
no reminders (Aiken, Gerend, & Jackson, 2001; Moore,
Barling, & Hood, 1998; Solomon, 2004; Ullrich, 2004).

One way to encourage the practice of BSE and TSE
is through the mass media, which can note the very high
cure rates (over 90%) and less extensive and disfiguring
treatments for these cancers when detected in early than
in later stages. For example, breast cancer in its early
stages can often be treated without removing the entire
breast. Two other ways to encourage self-examinations
involve health practitioners, such as nurses: they can
provide information and training through individual and
group contacts, such as at worksites and medical offices,
and send reminders to do the examinations (Solomon,
2004). Individuals with family histories or other risk
factors for cancer should devise effective BSE or TSE
reminders, such as by writing them in a calendar.

Chapter 6 / Health-Related Behavior and Health Promotion 135

Table 6.2 Percentages of American Adults with Selected Health-Related
Behaviors or Characteristics

Behavior/characteristics Men (%) Women (%)

Eat breakfast almost every daya 54.6 58.0
Rarely snacka 25.6 25.4
Smoke at least occasionallyb 23.6 18.1
Drink alcohol at least occasionallyb 67.4 54.9
Had 5 or more drinks on at least 12 days past year 14.4 4.3
Get regular leisure time physical activityb, c 33.1 29.0
Overweight or obese (measured directly)b 72.6 61.2

Sources: a USBC, 1995, Table 215 and bNCHS, 2009, Tables 63, 68, 69, 74, and 75.
cVigorous activity for at least 20 min. three times a week or light-to-moderate activity
for at least 30 min. five times a week.

about their health. To some extent individuals who
practice certain behaviors that benefit their health
also practice other healthful behaviors and continue
to perform these behaviors over time (Schoenborn,
1993). But other people show little consistency in
their health habits (Kaczynski et al., 2008; Mechanic,
1979). Research results suggest three conclusions. First,
although people’s health habits are fairly stable, they
often change over time. Second, particular health
behaviors are not strongly tied to each other—that is,
if we know a person practices one specific health habit,
such as using seat belts, we cannot accurately predict
that he or she practices another specific habit, such as
exercising. Third, health behaviors do not seem to be
governed in each person by a single set of attitudes or
response tendencies. Thus, a girl who uses seat belts to
protect herself from injury may watch her weight to be
attractive and not smoke because she is allergic to it.

Why are health behaviors not more stable and
strongly linked to each other? Here are a few reasons
(Leventhal, Prohaska, & Hirschman, 1985). First, various
factors at any given time in people’s lives may differen-
tially affect different behaviors. For instance, a person
may have lots of social encouragement to eat too much
(‘‘You don’t like my cooking?’’), and, at the same time,
to limit drinking and smoking. Second, people change
as a result of experience. For example, many people did
not avoid smoking until they learned that it is harmful.
Third, people’s life circumstances change. Thus, factors,
such as peer pressure, that may have been important in
initiating and maintaining exercising or smoking at one
time may no longer be present, thereby increasing the
likelihood that the habit will change.

INTERDISCIPLINARY PERSPECTIVES ON
PREVENTING ILLNESS
The advances in health that have occurred over the years
have come about through two avenues: efforts to prevent

illness and improvements in medical diagnosis and
treatment. Efforts to prevent illness can be of three types,
which we’ll illustrate with tooth decay as an example:

• Behavioral influence. In this approach, we might promote
tooth brushing and flossing by providing information
and demonstrating the techniques.

• Environmental measures. Public health officials might
support fluoridating water supplies.

• Preventive medical efforts. Dental professionals can remove
tartar from teeth and repair cavities.

In much of the world, behavioral influence approa-
ches may have the greatest impact on health promotion,
such as in reducing cigarette smoking and unhealthful
dietary practices (Breslow, 1983).

We usually think of prevention as occurring before
an illness takes hold. Actually, there are three levels of
prevention, only one of which applies before a disease or
injury occurs (Herndon & Wandersman, 2004; Runyan,
1985). These levels are called primary, secondary, and
tertiary prevention. Each level of prevention can include
the efforts of oneself in our well, symptom-based, and
sick-role behaviors; one’s social network; and health
professionals.

Primary Prevention
Primary prevention consists of actions taken to avoid
disease or injury. In avoiding automobile injuries, for
example, primary prevention activities might include our
well behavior of using seat belts, a friend reminding us to
use them, and public health reminders on TV to buckle
up. Primary prevention can be directed at almost any
health behavior, including dietary practices, exercise,
tooth brushing and flossing, and immunity against a
contagious disease.

Primary prevention for an individual can begin be-
fore he or she is born, or even conceived. For example,
genetic counselors can estimate the risk of a child’s

136 Part III / Lifestyles to Enhance Health and Prevent Illness

inheriting a genetic disorder and, in some cases, to
diagnose genetic abnormalities in the unborn fetus
(AMA, 2003). These estimates are based on the parents’
family histories, biological tests for carriers of specific
genes, and biological tests on the fetus. Prospective and
expectant parents may use this information to help them
make important family planning decisions. Physicians
can help in selecting genetic counselors. Another way
parents can exercise primary prevention is by having their
children immunized against several diseases, including
diphtheria, tetanus, whooping cough, measles, rubella,
mumps, and polio. Although worldwide immunization
rates have increased in recent decades, they remain
lower in poorer than richer societies (WHO, 2009). In
the United States, the percentage of preschool children
with full immunization from controllable diseases has
increased to nearly 80% across all major ethnic groups
(USBC, 2010).

How else can medical professionals promote pri-
mary prevention? One way involves having them give
health-promotion advice to patients. Because physicians
find it hard to incorporate prevention advice in their
practices, nurses or other medical staff might be better
able to do it (Glasgow et al., 2001; Radecki & Brunton,
1992). A system of reminders to provide such advice with
individual patients can improve these activities (Ander-
son, Janes, & Jenkins, 1998). Another approach involves
constructing websites that give health promotion infor-
mation (for example, http://www.hc-sc.gc.ca).

Secondary Prevention
In secondary prevention, actions are taken to identify
and treat an illness or injury early with the aim of
stopping or reversing the problem. In the case of
someone who has developed an ulcer, for example,
secondary prevention activities include the person’s
symptom-based behavior of seeking medical care for
abdominal pain, the physician’s prescribing medication
and dietary changes, and the patient’s sick-role behavior
of following the doctor’s prescriptions. For other health
problems, instances of secondary prevention might
include examination of the mouth and jaw regions
for early cancer detection during dental visits, free
blood pressure measurements at shopping malls, and
assessments of children’s vision and hearing at school.

A common secondary prevention practice is the
complete physical examination, often done each year.
These checkups are costly in time and money because
they include several imaging (such as X-ray) and labo-
ratory tests. Because not all of these tests have proven
useful in prevention, medical experts now recommend
getting specific tests, each with recommended schedules

ranging from 1 to 10 years, depending on the person’s
age (CU, 1998). For instance, the American Cancer Soci-
ety recommends regular schedules after specific ages for
all women to have mammograms (breast X-ray) and for all
adults to have colon inspections, such as a colonoscopy
(ACS, 2009). The schedules depend on risk. Individuals
who are not healthy or are considered to be at high
risk—for example, because of age, past illnesses, fam-
ily history, or hazardous work conditions—should be
examined more often than other people.

These medical examinations are recommended
because they detect the disease earlier and save lives.
In the case of mammograms, women who follow the
recommended schedules after age 50 reduce their
mortality rates by 26% in follow-ups of 10 years or so
after diagnosis (Kerlikowske et al., 1995). A national
survey found that two-thirds of American women over
40 years of age had had a mammogram in the prior 2
years, but the rate was much lower for poor and less
educated women (USBC, 2010). Explicitly describing to
a woman her relatively high risk of breast cancer due
to her family history increases the likelihood that she
will increase her frequency of mammograms (Curry et al.,
1993). Among elderly middle- and upper-middle-class
women, the main reasons for not having mammograms
are fears of pain and radiation (Fullerton et al., 1996).

Tertiary Prevention
When a serious injury occurs or a disease progresses
beyond the early stages, the condition often leads
to lasting or irreversible damage. Tertiary prevention
involves actions to contain or retard this damage,
prevent disability or recurrence, and rehabilitate the
patient. For people with severe arthritis, for instance,
tertiary prevention includes doing exercises for physical
therapy and taking medication to control inflammation
and pain. In the treatment of incurable forms of cancer,
the goal may be simply to keep the patient reasonably
comfortable and the disease in remission as long as
possible. And people who suffer disabling injuries may
undergo intensive long-term physical therapy to regain
the use of their limbs or develop other means for
independent functioning.

PROBLEMS IN PROMOTING WELLNESS
The process of preventing illness and injury can be
thought of as operating as a system, in which the
individual, his or her family, health professionals, and the
community play a role. According to health psychologist
Craig Ewart (1991), many interrelated factors and
problems can impair the influence of each component

Chapter 6 / Health-Related Behavior and Health Promotion 137

in the system, and each component affects each other.
Let’s look at some of these factors, beginning with those
within the individual.

Factors Within the Individual
People who consider ways to promote their own health
often face an uphill battle with themselves. One problem
is that many people perceive some healthful behaviors
as less appealing or convenient than their unhealthful
alternatives. Some people deal with this situation by
maintaining a balance in their lives, setting reasonable
limits on the unhealthful behaviors they perform. But
other people do not, opting too frequently in favor of
pleasure, sometimes vowing to change in the future: ‘‘I’ll
go on a diet next week,’’ for example. They see little
incentive to change immediately, especially if they think
they are healthy. Even when individuals know they have
health problems, many drop out of treatment or fail to
follow some of the recommendations of their physician.

Four other factors within the individual are also
important. First, adopting wellness lifestyles may require
individuals to change longstanding behaviors that have
become habitual and may involve addictions, as in
cigarette smoking. Habitual and addictive behaviors are
very difficult to modify. Second, people need to have
certain cognitive resources, such as the knowledge and
skills, to know what health behaviors to adopt, to make
plans for changing existing behavior, and to overcome
obstacles to change, such as having little time or no place
to exercise. Third, individuals need sufficient self-efficacy
regarding their ability to carry out the change. Without
self-efficacy, their motivation to change will be impaired.
Last, being sick or taking certain drugs can affect people’s
moods and energy levels, which may affect their cognitive
resources and motivation.

Reprinted courtesy of Bunny Hoest.

Interpersonal Factors
Many social factors influence people’s likelihood to
adopt health-related behaviors. For instance, one part-
ner’s exercising or eating unhealthfully before marriage
can lead his or her partner to adopt the same behavior
over time (Homish & Leonard, 2008). The social influence
probably involves individuals giving social support and
encouragement for the other person to change his or her
lifestyle.

People living in a family system may encounter
problems in their efforts to promote wellness. Some
problems come about because the family is composed
of individuals with their own motivations and habits.
Suppose, for instance, that a member of a family
wants to consume less cholesterol, but no one else
is willing to stop eating high-cholesterol foods, such as
butter, eggs, and red meats. Or suppose the person
has begun exercising three times a week, but this
disrupts the daily routine of another family member. The
interpersonal conflicts that circumstances like these can
create in the family may undermine preventive efforts
that the majority of family members support. Similar
interpersonal conflicts can undermine prevention efforts
among friends, classmates at school or college, and
fellow employees at work.

Factors in the Community
People are more likely to adopt healthful behaviors
if these behaviors are promoted or encouraged by
community organizations, such as governmental agen-
cies and the health care system. Health professionals
don’t usually have accurate information regarding their
patients’ health-related behavior, and they have tradi-
tionally focused their attention on treating, rather than
preventing, illness and injury. But this focus began to
change some years ago, and physicians became more
interested in prevention (Radecki & Brunton, 1992).

The larger community faces an enormous array of
problems in trying to prevent illness and injury. These
problems include having insufficient funds for public
health projects and research, needing to adjust to and
communicate with individuals of very different ages and
sociocultural backgrounds, and providing health care
for those who need it most. In some communities,
a lack of safe and convenient places to exercise and
a high number of fast food restaurants can impair
health promotion. Also, people’s health insurance may
not cover preventive medical services. Among the most
difficult problems communities face is trying to balance
public health and economic priorities. For example,
suppose the surrounding community of an industry is

138 Part III / Lifestyles to Enhance Health and Prevent Illness

subjected to potentially unhealthful conditions, such as
toxic substances. But the community depends heavily on
that industry for jobs and tax revenue, and the cost of
reducing the potential for harm would force the company
out of business. What should the community do? Many
such dilemmas exist in most societies throughout the
world.

WHAT DETERMINES PEOPLE’S
HEALTH-RELATED BEHAVIOR?

If people were all like Mr. Spock of the Star Trek TV
show and movies, the answer to the question of what
determines people’s health-related behavior would be
simple: facts and logic, for the most part. These people
would have no conflicting motivations in adopting
wellness lifestyles to become as healthy as they can
be. In this section we examine the complex factors that
affect health-related behavior.

GENERAL FACTORS IN HEALTH-RELATED
BEHAVIOR
The ‘‘average’’ person can describe healthful behaviors
and generate a fairly complete list: ‘‘Don’t smoke,’’ ‘‘Don’t
drink too much, and don’t drive if you do,’’ ‘‘Eat balanced
meals, and don’t overeat,’’ ‘‘Get regular exercise,’’ and
so on. But practicing these acts is another matter.
Several processes affect people’s health habits, and one
factor is heredity. Genetic factors influence some health-
related behaviors—excessive alcohol use provides a
good example. As we’ll see in Chapter 7, twin studies
and adoption studies have confirmed that heredity plays
a role in the development of alcoholism.

Learning
People also learn health-related behavior, particularly
by way of operant conditioning, whereby behavior changes
because of its consequences (Sarafino, 2001). Three types
of consequences are important.

1. Reinforcement. When we do something that
brings a pleasant, wanted, or satisfying consequence,
the tendency to repeat that behavior is increased or
reinforced. A child who receives something she wants,
such as a nickel, for brushing her teeth at bedtime is
more likely to brush again the following night. The nickel
in this example is a positive reinforcer because it was
added to the situation (the word ‘‘positive’’ refers to the
arithmetic term for addition). But reinforcement can also
occur in another way. Suppose you have a headache, you
take aspirin, and the headache goes away. In this case,

your headache was unpleasant, and your behavior of
taking aspirin removed it from the situation. The headache
is called a ‘‘negative’’ reinforcer because it was taken
away (subtracted) from the situation. In both cases of
reinforcement, the end result is a desirable state of
affairs from the person’s point of view.

2. Extinction. If the consequences that maintain a
behavior are eliminated, the response tendency gradually
weakens. The process or procedure of extinction exists
only if no alternative maintaining stimuli (reinforcers)
for the behavior have supplemented or taken the place
of the original consequences. In the above example of
toothbrushing behavior, if the money is no longer given,
the child may continue brushing if another reinforcer
exists, such as praise from her parents or her own
satisfaction with the appearance of her teeth.

3. Punishment. When we do something that brings
an unwanted consequence, the behavior tends to be
suppressed. A child who gets a scolding from his parents
for playing with matches is less likely to repeat that
behavior, especially if his parents might see him. The
influence of punishment on future behavior depends on
whether the person expects the behavior will lead to
punishment again. Take, for example, people who injure
themselves (punishment) jogging—those who think they
could be injured again are less likely to resume jogging
than those who do not.

People can also learn by observing the behavior of
others—a process called modeling (Bandura, 1969, 1986).
In this kind of learning, the consequences the model
receives affect the behavior of the observer. If a teenager
sees people enjoying and receiving social attention
for smoking cigarettes, these people serve as powerful
models and increase the likelihood that the teenager will
begin smoking, too. But if models receive punishment
for smoking, such as being avoided by classmates at
school, the teenager may be less likely to smoke. In
general, people are more likely to perform the behavior
they observe if the model is similar to themselves—that is,
of the same sex, age, or race—and is a high-status person,
such as a physically attractive individual, movie star,
or well-known athlete. Advertisers of products such as
alcoholic beverages know these facts and use them in
their commercials.

If a behavior becomes firmly established, it tends
to be habitual; that is, the person often performs it
automatically and without awareness, such as when
a smoker catches a glimpse of a pack of cigarettes
and absentmindedly reaches, takes a cigarette from the
pack, and lights up. Even though the behavior may
have been learned because it was reinforced by positive
consequences, it is now less dependent on consequences

Chapter 6 / Health-Related Behavior and Health Promotion 139

and more dependent on antecedent cues (seeing a pack
of cigarettes) with which it has been linked in the
past (Sarafino, 2001). Antecedents are internal or external
stimuli that precede and set the occasion for a behavior. A
smoker who says, ‘‘I must have a cigarette with my coffee
after breakfast,’’ is pointing out an antecedent. Behaviors
that become habitual can be very difficult to change.

Because habitual behaviors are hard to change,
people need to develop well behaviors as early as
possible and eliminate unhealthful activities as soon
as they appear. Families play a major role in children’s
learning of health-related behaviors (Baranowski &
Nader, 1985). Children observe, for example, the dietary,
exercise, and smoking habits of other family members
and may be encouraged to behave in similar ways.
Children who observe and receive encouragement for
healthful behavior at home are more likely than others
to develop good health habits.

Social, Personality, and Emotional Factors
Many health-related behaviors are affected by social
factors (Baranowski & Nader, 1985; Thirlaway & Upton,
2009). Friends and family can encourage or discourage
children’s practice of health-related behaviors, such as
smoking and exercising, by providing consequences,
such as praise or complaints, for a behavior; modeling
it; and conveying a value for good health. These social
processes may also lead to gender differences in
health behavior, such as the greater physical activity
of American boys than girls. Very different patterns of
encouragement may lead boys more than girls toward
healthful physical activity.

Two other factors that are linked to health-related
behavior are the person’s personality and emotional state, par-
ticularly stress. Conscientiousness— the tendency of a per-
son to be dutiful, planful, organized, and industrious—is
a personality characteristic that is associated with prac-
ticing many health behaviors, as Table 6.3 describes.
And the role of emotions can be seen in two ways. First,
among women who have a close relative with breast

cancer and are low in conscientiousness, those who are
very distressed about cancer are especially unlikely to
have a mammogram (Schwartz et al., 1999). A brief cog-
nitive intervention to enhance coping skills can reduce
cancer distress among women who have a close relative
with cancer and substantially improve their preven-
tive behavior (Audrain et al., 1999). Second, we saw
in Chapter 4 that people who experience high levels of
stress engage in less exercise and consume poorer diets
and more alcohol and cigarettes than those who experi-
ence less stress. If you ask people why they smoke, for
example, they often will say, ‘‘To relieve tension.’’ Many
people cite coping with stress as an important reason for
continuing to smoke (Gottlieb, 1983).

Perception and Cognition
The symptoms people experience can influence their
health-related behaviors. The way they react varies
from ignoring the problem to seeking immediate pro-
fessional care. Certainly when the perceived symptoms
are severe—as with excruciating pain, obvious bone frac-
tures, profuse bleeding, or very high fever—almost every-
one who has access to a health care system will try to use
it (Rosenstock & Kirscht, 1979). When symptoms are not
so severe, people often adjust their health habits, such as
by limiting certain foods and drink, to meet the needs of
the health problem as they see it (Harris & Guten, 1979).

Cognitive factors play an important role in the health
behaviors people perform. As we saw earlier, people
must have correct knowledge about the health issue
and the ability to solve problems that arise when
trying to implement healthful behavior, such as how
to fit an exercise routine into their schedules. People
also make many judgments that have an impact on
their health. They assess the general condition of their
health, such as whether it is good or bad, and make
decisions about changing a health-related behavior:
If I begin an exercise program, will I stick to it? But the
judgments they make can be based on misconceptions,
as when hypertensive patients overestimate their ability

Table 6.3 Associations of Conscientiousness with Health-Related
Behaviors or Characteristics

Higher Conscientiousness Higher Conscientiousness
is Linked to Higher is Linked to Lower
Fitness levela Alcohol usea

Healthy food selectiona Drug usea

Mammogram testingb Risky drivinga

Medication taking, as prescribedc Risky sexa

Self-reported healthd Tobacco usea,d

Sources: a Bogg & Roberts, 2004; bSiegler, Feaganes, & Rimer, 1995;
c Christensen & Smith, 1995; dHampson et al., 2006.

140 Part III / Lifestyles to Enhance Health and Prevent Illness

to sense when their blood pressure is high (Baumann
& Leventhal, 1985; Brondolo et al., 1999; Pennebaker
& Watson, 1988). Hypertensive patients often report
that they can tell when their blood pressure is up,
citing symptoms—headache, warmth or flushing face,
dizziness, and nervousness—that are actually poor
estimators of blood pressure. People’s assessments of
their blood pressure often correlate with their symptoms
and moods, but not with their actual blood pressure.
The potential harm in their erroneous beliefs is that
patients often alter their medication-taking behavior or
drop out of treatment on the basis of their subjective
assessments of their blood pressure. Clearly, beliefs are
important determinants of health behavior.

Another important belief that can impair health
behavior is called unrealistic optimism. Neil Weinstein
(1982) studied how optimistically people view their future
health by asking them, ‘‘Compared to other people your
age and sex, are your chances of getting lung cancer
greater than, less than, or about the same as theirs?’’ He
then had students fill out a questionnaire with a long list
of health problems, rating each problem for their own
likelihood of developing it, relative to other students
of the same sex at the university. The results revealed
that the students believed they were less likely than
others to develop three-quarters of the health problems
listed, including alcoholism, diabetes, heart attack, lung
cancer, and venereal disease. They believed they were
more susceptible than other students to only one of
the health problems—ulcers. In a later study, Weinstein
(1987) used similar questions in a mailed survey with 18-
to 65-year-old adults in the general population. He found
that these people were just as unrealistically optimistic
as the students and that this optimism is based on
illogical ideas—for instance, that they are at lower risk
than other people if the health problem occurs rarely
and has not happened to them yet. These factors do not
affect one’s risk relative to that of others.

Do people remain optimistic about their health
when they are sick or when a threat of illness is
clear? Evidently not. Using a procedure similar to
Weinstein’s, a study found that university students who
were waiting for treatment at the student health center
were less optimistic about their future health than were
healthy students in a psychology course (Kulik & Mahler,
1987b). Another study was conducted with students in
Poland, just after the radioactive cloud reached their
community from the explosion of the atomic power plant
at Chernobyl in the Soviet Union (Dolinski, Gromski,
& Zawisza, 1987). Although these people believed they
were less likely than others to have a heart attack or be
injured in an accident, they believed they were equally
likely to develop cancer and more likely than others to

suffer illness effects of the radiation over the next several
years. Thus, in the face of a real threat, they showed
‘‘unrealistic pessimism’’ regarding their health.

Studies of optimistic and pessimistic beliefs are
important for three reasons. First, they have revealed
that feelings of invulnerability are not a unique feature
of adolescence (Cohn et al., 1995). Second, people
who practice health behaviors tend to feel they would
otherwise be at risk for associated health problems
(Becker & Rosenstock, 1984). This means that people
with unrealistically optimistic beliefs about their health
are unlikely to take preventive action. Third, health
professionals may be able to implement programs to
address these beliefs in helping people see their risks
more realistically. The next section examines the role of
people’s health beliefs in more detail.

THE ROLE OF BELIEFS AND INTENTIONS
Suppose your friend believes in reflexology, a ‘‘healing’’
method that involves massaging specific areas of the
feet to treat illnesses. The belief that underlies this
method is that each area of the foot connects to a
specific area of the body—the toes connect to the head,
for instance, and the middle of the arch links to certain
endocrine glands (Livermore, 1991). For a patient with
recurrent headaches, a reflexologist’s treatment might
include massaging the toes. Your friend would probably
try ways to prevent and treat illness that are different
from those most other people would try. Psychologists
are interested in the role of health beliefs in people’s
practice of health behaviors. A widely researched and
accepted theory of why people do and do not practice
these behaviors is called the health belief model (Becker,
1979; Becker & Rosenstock, 1984; Rosenstock, 1966). Let’s
see what this theory proposes.

The Health Belief Model
According to the health belief model, the likelihood that
a person will take preventive action—that is, perform some
health behavior—depends directly on the outcome of
two assessments he or she makes. Figure 6-2 shows that
one assessment pertains to the threat the person feels
regarding a health problem, and the other weighs the
pros and cons of taking the action.

Three factors influence people’s perceived threat—that
is, the degree to which they feel threatened or worried by
the prospect of a particular health problem:

1. Perceived seriousness of the health problem. People con-
sider how severe the organic and social consequences
are likely to be if they develop the problem or leave it
untreated. The more serious they believe its effects will

Chapter 6 / Health-Related Behavior and Health Promotion 141

Perceived threat of an illness or injury without the
associated health behavior, based on:

Perceived benefits and barriers (pros and cons) of
a health behavior (sum = benefits – barriers)

Likelihood of performing
the health behavior

• Perceived seriousness of the health problem
• Perceived susceptibility of the health problem
• Cues to action (reminders of the problem)

Figure 6-2 The health belief model. People’s likeli-
hood of taking preventive action is determined by two
assessments they make: their perceived threat of the
health problem and the sum of pros and cons they
perceive in taking action. Many factors contribute to
these assessments. (Adapted from Becker & Rosenstock,
1984, Figure 2.)

be, the more likely they are to perceive it as a threat and
take preventive action.

2. Perceived susceptibility to the health problem. People
evaluate the likelihood of their developing the problem.
The more risk they perceive for themselves, the more
likely they are to perceive it as a threat and take action.

3. Cues to action. Being reminded or alerted about a
potential health problem increases the likelihood of
perceiving a threat and taking action. Cues to action can
take many forms, such as a billboard about the dangers
of unprotected sex, a friend or relative developing an
illness, an episode about a specific illness and its
symptoms on a TV medical drama, or a reminder phone
call for an upcoming medical appointment.

Figure 6-2 shows that in weighing the pros and cons
of performing a health behavior, people assess the
benefits—such as being healthier or reducing health
risks—and the barriers or costs they perceive in taking
action. What barriers might people see in preventive
action? For the health behavior of getting a physical
checkup, the barriers might include financial consider-
ations (‘‘Can I afford the bills?’’), psychosocial conse-
quences (‘‘People will think I’m getting old if I start
having checkups’’), and physical considerations (‘‘My
doctor’s office is across town, and I don’t have a car’’).
The outcome of weighing the benefits against the barriers
is an assessed sum: the extent to which taking the action
is more beneficial for them than not taking the action.
This assessed sum combines with the perceived threat of
illness or injury to determine the likelihood of preventive
action. Thus, for the health behavior of having a medical
checkup, people who feel threatened by an illness and
believe the benefits of having a checkup outweigh the
barriers are likely to go ahead with it. But people who
do not feel threatened or assess that the barriers are too
strong are unlikely to have the checkup. According to the
health belief model, these processes apply to primary,
secondary, and tertiary prevention activities.

The theory also proposes that characteristics of
individuals can influence their perceptions of benefits,
barriers, and threat. These factors include the person’s

age, sex, race, ethnic background, social class, person-
ality traits, and knowledge about or prior contact with
the health problem. Thus, for example, people who are
poor are likely to see strong barriers to getting medical
treatment. Women, but not men, over 50 are likely to
perceive a substantial risk of breast cancer. And elderly
individuals whose close friends have developed severe
cases of cancer or heart disease are more likely to per-
ceive a personal threat of these illnesses than young
adults whose friends are in good health.

Has research generally supported the health belief
model’s explanation of health-related behavior? The
model has generated hundreds of studies, most of
which have upheld its predictions for a variety of health
behaviors, including getting vaccinations, having regular
dental visits, and taking part in exercise programs (Becker
& Rosenstock, 1984; Conner & McMillan, 2004a; Kirscht,
1983). For instance, compared to people who do not take
prescribed medication as directed or do not stick with
dietary programs, those who do are more likely to believe
they would be susceptible to the associated illness
without the behavior and that the benefits of protective
action exceed the barriers. Perceived risk (susceptibility)
and perceived barriers appear to be critical elements for
predicting health behavior, such as getting vaccinations
and performing BSEs (Brewer et al., 2007; Conner &
McMillan, 2004a), but strong barriers may have more
influence than risk. Research has also supported the role
of cues to action—for instance, individuals are more
likely to perform BSEs or engage in brisk walking if
they receive reminders (Craun & Deffenbacher, 1987;
Prestwich, Perugini, & Hurling, 2010).

Despite the health belief model’s success, it has
some shortcomings. One shortcoming is that it does
not account for health-related behaviors people perform
habitually, such as tooth brushing—behaviors that prob-
ably originated and have continued without the person’s
considering health threats, benefits, and costs. Another
problem is that there is no standard way of measur-
ing its components, such as perceived susceptibility
and seriousness. Different studies have used different

142 Part III / Lifestyles to Enhance Health and Prevent Illness

questionnaires to measure the same factors, thereby
making it difficult to compare the results across studies.
These problems do not mean the theory is wrong, but
that it is incomplete. We now turn to another theory that
focuses on the role of people’s beliefs on their practice
of health-related behavior.

The Theory of Planned Behavior
Suppose you are having dinner at a restaurant with Dan, a
friend who is overweight, and you wonder whether he will
order dessert. How could you predict his behavior? That’s
simple—you could ask what he intends to do. According
to the theory of planned behavior (Ajzen, 1985), an
expanded version of the theory of reasoned action (Ajzen &
Fishbein, 1980), people decide their intention in advance
of most voluntary behaviors, and intentions are the best
predictors of what people will do.

What determines people’s intentions? The theory
indicates that three judgments determine a person’s
intention to perform a behavior, which we’ll illustrate
with a girl named Ellie who has decided to start
exercising:

1. Attitude regarding the behavior, which is basically a
judgment of whether or not the behavior is a good
thing to do. Ellie has decided that exercising ‘‘would
be a good thing for me to do.’’ This judgment is based
on two expectations: the likely outcome of the behavior
(such as, ‘‘If I exercise, I will be healthier and more
attractive’’) and whether the outcome would be rewarding
(for example, ‘‘Being healthy and good looking will be
satisfying and pleasant’’).

2. Subjective norm. This judgment reflects the impact
of social pressure or influence on the behavior’s

acceptability or appropriateness. Ellie has decided that
exercising ‘‘is a socially appropriate thing for me to do.’’
This decision is based on her beliefs about others’ opinions
of the behavior (such as, ‘‘My family and friends think I
should exercise’’) and her motivation to comply with those
opinions (as in, ‘‘I want to do what they want’’).

3. Perceived behavioral control, or the person’s expectation
of success in performing the contemplated behavior
(which is very similar to the concept of self-efficacy).
Ellie thinks she can do the exercises and stick to the
program.

The theory of planned behavior proposes that these
judgments combine to produce an intention that
leads to performance of the behavior. If Ellie had the
opposite beliefs, such as, ‘‘Exercising is a waste of
time,’’ ‘‘I don’t care about my family’s opinion,’’ and
‘‘I’ll never find time to exercise,’’ she probably wouldn’t
generate an intention to exercise, and thus would
not do so. Self-efficacy is an important component.
When deciding whether to practice a health behavior,
people appraise their efficacy on the basis of the effort
required, complexity of the task, and other aspects of
the situation, such as whether they are likely to receive
help from other people (Schunk & Carbonari, 1984).

The theory of planned behavior has generated many
dozens of studies, including a meta-analysis showing
that attitudes toward a behavior, subjective norms,
and perceived behavioral control (self-efficacy) influence
intentions and behavior (Conner & McMillan, 2004b).
Table 6.4 gives a sample of studies on a variety of health-
related behaviors that support the role of the three
factors. Also, a meta-analysis of dozens of experiments
revealed that interventions can change the factors, and
these changes strongly influence intentions, which, to

Table 6.4 A Sample of Research Supporting the Theory of Planned Behavior

The theory proposes that for each of three factors, the higher its level the more likely the intention will be made and the behavior will
be performed. Each study referenced below found this relationship between the factor and the intention or behavior.

Factor Intention/Behavior Reference

Attitude regarding the behavior Donating blood Bagozzi, 1981
Starting smoking Van De Ven et al., 2007
Quitting smoking Norman, Conner, & Bell, 1999
Exercising Wurtele & Maddux, 1987
Eating healthful diet Conner, Norman, & Bell, 2002
Testicular self-exam Moore, Barling, & Hood, 1998

Subjective norm Starting smoking Van De Ven et al., 2007
Cancer screening Sieverding, Matterne, & Ciccarello, 2010
Exercising Latimer & Ginis, 2005

Perceived behavioral control (self-efficacy) Starting smoking Van De Ven et al., 2007
Quitting smoking DiClemente, Prochaska, & Gilbertini, 1985
Exercising Armitage, 2005
Losing weight Schifter & Ajzen, 1985
Rehabilitation exercises Jenkins & Gortner, 1998; Kaplan, Atkins, & Reinsch, 1984

Chapter 6 / Health-Related Behavior and Health Promotion 143

a much lesser extent, improve the targeted health
behaviors (Webb & Sheeran, 2006).

What shortcomings does the theory of planned
behavior have? One problem is that intentions and
behavior are only moderately related—people do not
always do what they plan (or claim they plan) to do. But the
‘‘gap’’ between intention and behavior can be reduced.
Research has found that people are more likely to carry
out their intentions if they make careful plans for doing
so, keep track of their efforts, and recognize that they will
need to continue the behavior on a long-term basis and
are confident they can (Sniehotta, Scholz, & Schwarzer,
2005). Keep in mind that people’s intentions to perform a
health behavior, such as using condoms for safer sex, can
change from one day to the next (Kiene, Tennen, & Armeli,
2008). But if individuals perform preparatory behaviors,
such as buying and carrying condoms, after the intention
is made, the chances of actually using condoms in sex
increases greatly (Bryan, Fisher, & Fisher, 2002).

Another problem is that the theory is incomplete;
it does not include, for example, the important role
of people’s prior experience with the behavior. In the
blood donation study listed in Table 6.4, the subjects
were asked about their past behavior in donating or
not donating blood (Bagozzi, 1981). Of those subjects
who said they intended to give blood, those who had
given before were more likely actually to give than those
who had not donated in the past. Similarly, studies
have found that people’s history of performing a health-
related behavior, such as exercising or using alcohol
or drugs, strongly predicts their future practice of that
behavior (Bentler & Speckart, 1979; Godin, Valois et
al., 1987). Thus, for example, compared to adults who
have engaged in little exercise in the past, those who
have exercised are much more likely to carry out their
promises to exercise in the future.

The health belief model and the theory of planned
behavior provide valid explanations for parts of the
process that determines people’s practice of health-
related behavior. At their core, both theories assume
people weigh perceived benefits and costs and behave
according to the outcome of their analysis. But neither
approach is sufficient, and both have limitations (Janis,
1984; Kirscht, 1983; Weinstein, 1988). One weakness in
these theories is that they assume people think about
risks in a detailed fashion, knowing what diseases are
associated with different behaviors and estimating the
likelihood of becoming seriously ill. In reality, people
may modify their lifestyles, such as reducing coffee
consumption, for very vague reasons, such as, ‘‘My doctor
says coffee is bad for you.’’ People appear to be especially
inaccurate in estimating the degree of increased risk
when the risks of illness, such as cancer, increase beyond

moderate levels—for example, for individuals who smoke
more than 15 cigarettes a day (Sastre, Mullet, & Sorum,
1999; Weinstein, 2000).

The Stages of Change Model
A wife’s letter in a newspaper advice column once
described her worry about her husband, who had
suffered a heart attack but hadn’t tried to lose weight
or exercise as his doctor recommended. This situation
is not uncommon. Although there are probably many
reasons why this man hadn’t changed his behavior, one
may be that he wasn’t ‘‘ready.’’ Readiness to change is
the main focus of a theory called the stages of change
model (also called the transtheoretical model because it
includes factors described in other theories) (DiClemente
et al., 1991; Prochaska & DiClemente, 1984; Prochaska,
DiClemente, & Norcross, 1992). Figure 6-3 defines the
model’s five stages of intentional behavior change and
shows how they spiral toward successful change.

According to the stages of change model, people who
are currently in one stage show different psychosocial
characteristics from people in other stages. For instance,
people in the precontemplation stage regarding an
unhealthy behavior, such as eating a high-cholesterol

Maintenance. People in this stage work to maintain
the successful behavioral changes they achieved.
Although this stage can last indefinitely, resear-
chers often define its length as, say, 6 months, for
follow-up assessment.

Action. This stage spans a period of time, usually 6
months, from the start of people’s successful and
active efforts to change a behavior.

Preparation. At this stage, individuals are ready to
try to change and plan to pursue a behavioral goal,
such as stopping smoking, in the next month. They
may have tried to reach that goal in the past year
without being fully successful. For instance, these
people might have reduced their smoking by half,
but did not yet quit completely.

Contemplation. During this stage people are aware
a problem exists and are seriously considering
changing to a healthier behavior within the next
several months. But they are not yet ready to make
a commitment to take action.

Precontemplation. People in this stage are not con-
sidering changing, at least during the next several
months or so. These people may have decided
against changing or just never thought about it.

Figure 6-3 Five stages of change in the transtheoretical
model advancing as a spiral from precontemplation (bottom),
when the person is not considering change, to maintenance,
when change is complete and stable.

144 Part III / Lifestyles to Enhance Health and Prevent Illness

diet, are likely to have less self-efficacy and see more
barriers than benefits for changing that behavior than
people in the more advanced stages. Efforts to change the
behavior are not likely to succeed until these individuals
advance through the stages. But people’s stages may
regress, too: someone who reached the action stage and
began to change may fail, drop back to a less advanced
stage, and repeat the process of advancing toward
change. People who justify continuing an unhealthy
behavior, such as when smokers say, ‘‘I know heavy
smokers who have lived long, healthy lives,’’ tend to
progress through the stages slowly (Kleinjan et al., 2006).

Is it possible to help people advance through the
stages? Two ways that help are having them:

• Describe in detail how they would carry out the behavior
change, such as the exact foods they would eat to achieve
a low-fat diet (Armitage, 2006).

• Plan for problems that may arise when trying to
implement the behavior change, such as if they crave a
cigarette after quitting smoking (Armitage, 2008).

Another way uses a unique feature of the stages of
change model: it describes important characteristics of
people at each stage, enabling an intervention to match
strategies to the person’s current needs in order to pro-
mote advancement to the next stage (Perz, DiClemente,
& Carbonari, 1996; Prochaska, DiClemente, & Norcross,
1992). Let’s consider an example of matching. Suppose
you are a nurse providing care to an elderly woman with
heart disease who doesn’t exercise, even though her
physician advised her to do so. If she is at the precontem-
plation stage, you might talk with her about why exercise
would help her and not exercising would harm her
physically, for instance, and have her generate ways this
would improve her general functioning. The goal at this
point is just to get the person to consider changing the
behavior. If she is at the contemplation stage, the goal
might be to help her decide to change soon. Discussing
the benefits and barriers she perceives in exercising,
finding ways to overcome barriers, and showing her that
she can do the physical activities would help.

The stages of change model is a very useful theory.
Table 6.5 lists a sample of studies which have confirmed
that people at higher stages are more likely than others

to succeed at adopting healthful behaviors. Research
has also confirmed the processes the model describes as
leading to advancement or regression within the stages
(Schumann et al., 2005) and the value of matching an
intervention to people’s stage of readiness to improve
its success in changing unhealthful behaviors, such as
smoking (Spencer et al., 2002). However, some evidence
suggests that a smaller number of stages with somewhat
different focuses may account better for behavior changes
(Armitage, 2009).

In the preceding sections, we have examined many
aspects of people’s beliefs and intentions that appear
to influence their health-related behavior. These aspects
include people’s perceived susceptibility to illness, per-
ceived barriers and benefits to changing unhealthy
behavior, ideas about what behaviors are socially accept-
able and encouraged by family and friends, self-efficacy
beliefs, and readiness to change. These factors seem
sensible for individuals to consider, but the decisions
they make are often irrational or unwise. The flawed deci-
sions that people make about their health often result
from motivational and emotional processes that are not
addressed in the theories. For instance, these theories do

not provide an adequate explanation for the
widespread tendency of patients who have painful
heart attacks to delay obtaining medical aid … .
Typically, when the afflicted person thinks of the
possibility that it might be a heart attack, he or she
assumes that ‘‘it couldn’t be happening to me.’’ The
patients’ delay of treatment is not attributable to
unavailability of medical aid or transportation delays;
approximately 75% of the delay time elapses before
a patient decides to contact a physician. (Janis, 1984,
pp. 331–332.)

Thus, theories that focus on rational thinking do not
adequately consider the processes we’re about to see
that can override logical decision making.

THE ROLE OF LESS RATIONAL PROCESSES
Although body builders generally know that using
anabolic steroids can harm their health, some may
try to justify using these substances to build muscles

Table 6.5 Sample of Research Supporting the Stages of Change Model
Health Behaviors Reference

Quit cigarette smoking Spencer et al., 2002
Breast cancer screening Spencer, Pagell, & Adams, 2005
Vegetable and fruit consumption Lippke et al., 2009
Using safer sex practices Bowen & Trotter, 1995
Exercising Hellsten et al., 2008; Lippke et al., 2009; Marshall & Biddle, 2001

Chapter 6 / Health-Related Behavior and Health Promotion 145

with statements like, ‘‘Experts have been wrong before.’’
Why do people make decisions regarding health-related
behavior that are not more rational? We’ll look first at
motivational factors that influence people’s decisions.

Motivational Factors
People’s desires and preferences influence the judg-
ments they make of the validity and utility of new infor-
mation through a process called motivated reasoning
(Kunda, 1990). In one form of motivated reasoning, indi-
viduals who prefer to reach a particular conclusion, such
as to continue to eat fatty foods or smoke cigarettes, tend
to use biased cognitive processes: they search for reasons
to accept supportive information and discount discon-
firming information. The reasons they choose seem
‘‘reasonable’’ to them, even if the logic is actually faulty.

Studies have demonstrated nonrational thought
processes in several types of health-related decisions.
First, of people with a chronic illness, such as diabetes,
those who tend to use illogical thought patterns in
health-related situations tend not to follow medical
advice for managing their illness (Christensen, Moran,
& Weibe, 1999). Second, people who use defense
mechanisms a lot to cope with stressful information are
more likely than other individuals to deny that they are
at risk for AIDS, especially if their risk of infection is high
(Gladis et al., 1992). Perhaps their high feeling of threat
motivates their use of denial. Similarly, individuals seem
to use irrelevant information, such as a sexual partner’s
attractiveness, to judge the risks in having sex with that
person (Blanton & Gerrard, 1997; Gold & Skinner, 1996).
Third, people who smoke cigarettes give lower ratings of
risk than nonsmokers do when asked to rate their own
risk of developing smoking-related diseases, such as lung
cancer (Lee, 1989; McCoy et al., 1992). Beliefs like these
appear very resistant to change (Kreuter & Strecher, 1995;
Weinstein & Klein, 1995).

False Hope and Willingness
Here are two features of health-related behaviors the
theories we’ve considered don’t account for well. First,
most people who lose weight gain it back within a year
or so, yet they try again at a later time. Similar patterns
occur for quitting smoking or starting to exercise. Second,
many risky behaviors occur spontaneously, without the
individuals having thought it through.

It’s encouraging to know that people who don’t
maintain a healthier behavior try again, but why do they
decide to retry if they’ve failed previously and are likely
to fail again? The reason may be that they develop false
hopes, believing without rational basis that they will
succeed (Polivy & Herman, 2002). They form false hopes

because they did succeed for a while, which provides
reinforcement for the efforts they made to that point, and
they misinterpret their failures. Probably most changed
behaviors are not maintained because people expect too
large a change in their behavior, too great an effect it
would have for them, and too quick and easy a process
of change. But they often decide instead that they just
didn’t try hard enough for enough time—after all, they
succeeded initially.

What risky behaviors occur without careful thought?
Lots, maybe most. People often find themselves in
situations they didn’t expect to happen in which they
have the opportunity to perform an attractive behavior,
such as drinking a bit too much or having sex, but
there’s some risk. In this type of situation, the critical
issue may not be whether they ‘‘intend’’ to engage in a
risky behavior, but whether they are willing to do it. High
willingness to engage in a risky behavior depends on four
factors (Gibbons et al., 1998). Two factors are positive
subjective norms and attitudes toward the behavior,
which we considered as part of the theory of planned
behavior. The other two factors that heighten willingness
are having engaged in the behavior previously and having
a favorable social image of the type of person who would
perform the behavior.

Emotional Factors
Stress also affects the cognitive processes people use
in making decisions. For example, when given health
promotion information, people under high stress pay
less attention to it and remember less of it than people
under low stress (Millar, 2005). Conflict theory presents a
model to account for both rational and irrational decision
making, and stress is an important factor in this model
(Janis, 1984; Janis & Mann, 1977). According to conflict
theory, the cognitive sequence people use in making
important decisions starts when an event challenges
their current course of action or lifestyle. The challenge
can be either a threat, such as a symptom of illness or a
news story on the dangers of smoking, or an opportunity,
such as the chance to join a free program at work to
quit smoking. This produces an appraisal of risk: if the
person sees no risk, the behavior stays the same, and
the decision-making process ends; but if a risk is seen,
the process continues—for instance, with a survey of
alternatives for dealing with the challenge.

Conflict theory proposes that people experience
stress with all major decisions, particularly those
relating to health, because of the importance of and
conflicts about what to do. People’s coping with
decisional conflict depends on their perceptions of
the presence or absence of three factors: risk, hope,

146 Part III / Lifestyles to Enhance Health and Prevent Illness

and adequate time. These three factors produce different
coping patterns, two of which are:

• Hypervigilance. People sometimes see serious risks in
their current behavior and those alternatives they have
considered. If they believe they may still find a better
solution but think they are fast running out of time,
they experience high stress. These people tend to search
frantically for a solution—and may choose an alternative
hastily, especially if it promises immediate relief.

• Vigilance. When people perceive serious risks in all
possibilities they have considered but believe they may
find a better alternative and have time to search, they
experience only moderate levels of stress. Under these
conditions, people tend to search carefully and make
rational choices.

When the challenge is very serious, such as a physician’s
warning or obvious symptoms of illness, vigilance is
the most adaptive coping pattern. Although the conflict
theory has not been tested sufficiently to know its
strengths and weaknesses, there is little question that
the impact of stress is an important determinant of
preventive action, particularly in people’s symptom-
based and sick-role behavior.

We have examined how each of many different
psychological and social factors can affect people’s
health behavior. But we have not yet considered the
influence of age, sex, and sociocultural background,
which we examine next.

DEVELOPMENTAL, GENDER, AND
SOCIOCULTURAL FACTORS IN HEALTH

It comes as no surprise that people’s health changes
across the life span, that women and men have some
differences in health risks and needs, and that variations
in preventive behavior occur between individuals of
different social classes and ethnic backgrounds.

What are some of these changes and differences,
and why do they exist? Let’s examine these health issues,
starting with the role of development.

DEVELOPMENT AND HEALTH
The biological, psychological, and social factors that
affect people’s health change throughout the life span,
causing individuals to face different health risks and
problems as they develop. For instance, adolescents and
young adults are at relatively high risk for injury from
automobile accidents, but older adults are at relatively
high risk for hypertension and heart disease. As a result,
people’s preventive needs and goals change with age.
Table 6.6 presents main preventive goals for each period
in the life span. Other individuals, such as parents, may

assume responsibility for prevention, especially early
and very late in the life span.

During Gestation and Infancy
Each year millions of babies around the world are
born with birth defects—in the United States alone,
there are over 120,000 cases, or 3 out of every

100

births annually (MD, 2010). These defects range from
relatively minor physical or mental abnormalities to
gross deformities; some are not apparent until months
or years later, and some are fatal. Birth defects result
from genetic abnormalities and harmful factors in the
fetal environment.

A mother can control much of the fetal environment
through her behavior. Early in gestation, a placenta and
umbilical cord develop and begin to transmit substances
to the fetus from the mother’s bloodstream. These
substances typically consist mostly of nourishment,
but they can also include hazardous microorganisms
and chemicals that happen to be in her blood. Many
babies are at risk of low birth weight, which can
result from three prenatal hazards. First, the mother
may be malnourished due to inadequate food supplies
or knowledge of nutritional needs. In addition to low
weights, babies born to malnourished mothers tend
to have poorly developed immune and central nervous
systems and a high risk of mortality in the first weeks
after birth (Chandra, 1991; Huffman & del Carmen, 1990;
Smart, 1991). Second, certain infections the mother may
contract during pregnancy can also attack her gestating
baby, sometimes causing permanent injury or death
(LaBarba, 1984; Tortora & Derrickson, 2009). Vaccinations
can prevent most of these infections.

A pregnant woman receives an ultrasound procedure in
prenatal care to check the development of her baby.
Following medical advice during pregnancy can enhance
the healthfulness of the baby’s prenatal environment.

Chapter 6 / Health-Related Behavior and Health Promotion 147

Table 6.6 Prevention Goals over the Life Span

Health Goals of Gestation and Infancy

• To provide the mother a healthy, full-term pregnancy and rapid recovery after a normal delivery.
• To facilitate the live birth of a normal baby, free of congenital or developmental damage.
• To help both mother and father achieve the knowledge and capacity to provide for the physical, emotional, and social needs of

the baby.
• To establish immunity against specified infectious diseases.
• To detect and prevent certain other diseases and problems before irreparable damage occurs.

Health Goals of Childhood and Adolescence

• To facilitate the child’s optimal physical, emotional, and social growth and development.
• To establish healthy behavioral patterns (in children) for nutrition, exercise, study, recreation, and family life, as a foundation for

a healthy lifetime lifestyle.
• To reinforce healthy behavior patterns (in adolescents), and discourage negative ones, in physical fitness, nutrition, exercise,

study, work, recreation, sex, individual relations, driving, smoking, alcohol, and drugs.

Health Goals of Adulthood

• To prolong the period of maximum physical energy and to develop full mental, emotional, and social potential.
• To anticipate and guard against the onset of chronic disease through good health habits and early detection and treatment where

effective.
• To detect as early as possible any of the major chronic diseases, including hypertension, heart disease, diabetes, and cancer, as

well as vision, hearing, and dental impairments.

Health Goals in Old Age

• To minimize handicapping and discomfort from the onset of chronic conditions.
• To prepare in advance for retirement.
• To prolong the period of effective activity and ability to live independently, and avoid institutionalization so far as possible.
• When illness is terminal, to assure as little physical and mental stress as possible and to provide emotional support to patient

and family.

Source: Based on Breslow & Somers, 1977.

Third, various substances the mother uses may
enter her bloodstream and harm the baby (LaBarba,
1984; Tortora & Derrickson, 2009). Babies exposed
prenatally to addictive drugs, such as cocaine, are far
more likely than others to die in infancy or be born with
very low weights or malformations, such as of the heart
(Lindenberg et al., 1991). Also, cigarette smoke exposure
from the mother’s smoking or from her environment—for
instance, if the father smokes—is associated with
low birth weight and other health problems in babies
(DiFranza & Lew, 1995; Martinez et al., 1994; Tortora &
Derrickson, 2009). And the mother’s drinking alcohol,
especially heavy drinking, can cause fetal alcohol syndrome,
which has several symptoms: (1) slow growth before
and after birth, (2) subnormal intelligence, and (3)
certain facial characteristics, such as small eye openings
(NIAAA, 1993; Tortora & Derrickson, 2009). Ideally,
expectant mothers should use none of these substances.
Health education for pregnant women can help, such
as by getting those who drink or smoke to abstain or
reduce their use (Stade et al., 2009; Windsor et al., 1993).

Table 6.7 gives the percentages of newborns with low
birth weight and the rates of infant mortality for selected
nations around the world. The rate of infant mortality
in some developing countries is extremely high, greater
than 100 per 1,000 live births for the first year of life

(WHO, 2009). In early infancy, the baby’s immunity to
disease depends largely on the white blood cells and
antibodies passed on by the mother prenatally and in
her milk if she breast-feeds (Tortora & Derrickson, 2009).

Table 6.7 Percentage of Newborns with Low Birth Weight
and Infant Mortality Rate (Number per 1,000 Live Births Who
Die in the First Year of Life) in Selected Countries

Percent Low Infant Mortality
Country Birth Weight (per 1,000 births)

Australia 7 5
Brazil 8 20
Canada 6 5
China 2 19
Germany 7a 4
India 30a 54
Italy 6a 3
Netherlands NA 4
Singapore 8 2
South Africa 15a 46
Sweden 4a 2
Turkey 16a 21
United Kingdom 8 5
United States 8 6

Note: NA = data not available.
Sources: WHO, 2009, except a = newest data available from
WHO, 2006.

148 Part III / Lifestyles to Enhance Health and Prevent Illness

Because of the immunity it gives to the baby, breast milk
is sometimes called ‘‘nature’s vaccine.’’ Parents should
arrange for the baby to begin a vaccination program early
in infancy for such diseases as diphtheria, whooping
cough, and polio.

Childhood and Adolescence
In the second year of life, toddlers are walking and begin-
ning to ‘‘get into everything,’’ with the risk for injury, such
as while swimming or from sharp objects and chemicals
around the house. In the United States, accidental injury
is the leading cause of death during childhood and
adolescence (USBC, 2010). Parents, teachers, and other
caregivers can reduce the likelihood of injury by teach-
ing children safety behaviors, supervising them when
possible, and decreasing their access to dangerous sit-
uations, such as by keeping chemicals out of reach. The
role of cognitive processes in the practice of health-
related behavior has important implications here, since
cognitive abilities are immature in early childhood and
become more sophisticated as children get older (Bur-
bach & Peterson, 1986; Murphy & Bennett, 2004). With
these advances, children are more able to make deci-
sions and assume responsibility for promoting their own
health and safety.

Adolescence is a very critical time in the develop-
ment of preventive behavior. Although teenagers have
the cognitive ability to make the logical decisions lead-
ing to healthful behavior, they face many temptations
and forces—especially peer pressure—that lead them
in other directions (La Greca & Stone, 1985; Leffert &
Petersen, 1998). This is the time when they stand the
greatest chance of starting to smoke, drink, use drugs,
and have sexual relations. These risky behaviors are inter-
related: teens who smoke and drink are more likely to
use marijuana and have unsafe sex (Duncan, Strycker, &
Duncan, 1999). Teens also learn to drive, and too often
combine this new skill with drinking and using drugs.
Most teenage deaths in developed countries result from
accidents. In the United States, death rates for accidents
rise sharply during the teenage years and are several
times as high for 15- to 24-year-olds as for younger age
groups (USBC, 2010). All these newly acquired behav-
iors involve substantial health risks, which teenagers are
highly susceptible to taking.

Adulthood and Aging
When people reach adulthood, they become less likely
than they were in adolescence to adopt new behavioral
risks to their health. In general, older adults are more
likely than younger ones to practice various health
behaviors, such as eating healthful diets and getting

medical checkups, even though they have similar beliefs
about the value of these behaviors in preventing serious
illnesses, such as heart attack and cancer (Belloc &
Breslow, 1972; Leventhal, Prohaska, & Hirschman, 1985).
One likely reason for this age difference is that older
adults perceive themselves as more vulnerable to these
illnesses than younger adults, and engage in preventive
acts for that reason.

Old age is not what it used to be. Older people
in industrialized countries live longer and are in better
financial and physical condition than in the past (Horn
& Meer, 1987). One health behavior that generally
declines as adults get older is regular vigorous exercise
(Leventhal, Prohaska, & Hirschman, 1985). Many elderly
people avoid physical exercise because they tend to
exaggerate the danger that exertion poses to their
health, underestimate their physical capabilities, and
feel embarrassed by their performance of these activities
(Woods & Birren, 1984).

GENDER AND HEALTH
In almost all countries of the world, an average female’s
expected life span at birth is at least a few years longer
than a male’s (WHO, 2009). The gap in life expectancy
is about 4 to 6 years in Europe, 5 years in the United
States, and usually somewhat smaller in developing
countries. For people in the United States who survive to
65 years of age, the remaining life expectancy of women
is about 3 years longer than men’s (USBC, 2010). Why do
women live longer? The answer involves both biological
and behavioral factors (Murphy & Bennett, 2004; Reddy,
Fleming, & Adesso, 1992; Williams, 2003). Some of these
factors are:

• Physiological reactivity, such as blood pressure and
stress hormones, when under stress is greater in men
than women, which may make men more likely to
develop cardiovascular disease.

• The female sex hormone estrogen appears to delay heart
disease by reducing blood cholesterol levels and platelet
clotting.

• Men smoke and drink more than women do, thereby
making men more susceptible to cardiovascular and
respiratory diseases, some forms of cancer, and cirrhosis
of the liver.

• Males have higher levels of drug use, unhealthy diets,
and risky driving and sexual activity.

• Males are less likely than females to consult a physician
when they feel ill.

• Work environments of males are more hazardous than
those of females; men account for the large majority of
fatalities on the job.

Chapter 6 / Health-Related Behavior and Health Promotion 149

One of the few behavioral advantages men have is that
they get more strenuous exercise than women do. The
practice of many other health-related behaviors is similar
for men and women.

Women’s longer lives do not mean that they have
fewer health problems than men. Actually, the opposite
may be true (USBC, 2010; Reddy, Fleming, & Adesso,
1992; Williams, 2003). For example, American women
have much higher rates than men of acute illnesses,
such as respiratory and digestive ailments, and nonfatal
chronic diseases, such as varicose veins, arthritis,
anemia, and headache. They also use medical drugs
and services much more than men, even when pregnancy
and other reproductive conditions are not counted.

SOCIOCULTURAL FACTORS AND HEALTH
‘‘Did a doctor ever tell you that you had [medical condi-
tion]?’’ Researchers asked this question of thousands of
late-middle-age American and British people, inserting
eight serious medical conditions (Banks et al., 2006). The
surveys for this age group revealed that Americans had
far higher prevalence rates for all of the illnesses—for
example, the respective rates for Americans and British
were 12.5% and 6.1% for diabetes, 15.1% and 9.6% for
heart disease, and 9.5% and 5.5% for cancer. Do dif-
ferences in health behaviors account for these results?
Probably not: the British people smoked somewhat more
and drank heavily much more than the Americans, but
the Americans had much higher rates of obesity—and
when obesity was equated statistically, the British were
still healthier. These results point out that health differs
across nations.

Another aspect of the study on American and British
health is that the researchers surveyed only non-Hispanic
White people. Why? Cultural differences also exist within
nations, and the United States has larger percentages of
Hispanic and Black people. A national survey of American
adults of all ages and backgrounds found that fewer than
13% claimed to be in only ‘‘fair’’ to ‘‘poor’’ health (NCHS,
2009b). But this was not uniform across segments of the
population. Compared with the population as a whole,
people were much more likely to rate their health as
‘‘fair’’ or ‘‘poor’’ if they were over 45 years of age, or
from the lower social classes, or of African American
or American Indian background. As it turns out, these
lower assessments reflect real health problems of the
individuals these groups comprise.

Social Class and Minority Group Background
Did you know that when the Titanic sank, passengers
did not all have an equal chance of surviving? Mortality

was far higher for passengers who were from third class
cabins than from first class (Rugulies, Aust, & Syme,
2004). Similarly, the devastation of hurricane Katrina
was greater for poor than for richer people. Social class
and health are linked.

The concept of social class, or socioeconomic status,
describes differences in people’s resources, prestige, and
power within a society (Adler, 2004; Elo, 2009). These
differences are reflected in three main characteristics:
income, occupational prestige, and education. The
lowest social classes in industrialized societies contain
people who live in poverty or are homeless. By almost
any gauge of wellness, health correlates with social class
(Adler, 2004; Anderson & Armstead, 1995; Banks et al,
2006; Gruenewald et al., 2009; Lantz et al., 2005; Lemelin
et al., 2009). For example, individuals from lower classes
are more likely than those from higher classes to:

• Be born with very low birth weight.

• Die in infancy or in childhood.

• Develop early signs of cardiovascular disease, such as
atherosclerosis.

• Have poorer overall health and develop a longstanding
illness in adulthood.

• Experience major stressors, followed in later years
by poorer health and greater limitations in everyday
functioning.

Not coincidentally, individuals from the lower
classes have poorer health habits and attitudes than
those from higher classes. For instance, they smoke more,
participate less in vigorous exercise and have poorer diets
and less knowledge about risk factors for disease (Adler,
2004; Murphy & Bennett, 2004; Myers, 2009). And they
are less likely than individuals from upper classes to get
health information from the mass media (Ribisl et al.,
1998). You probably realize that members of minority
groups usually are disproportionately represented in the
lower social classes.

Minority group background is an important risk
factor for poor health. Today a baby born in Cuba stands a
better chance of reaching the age of one than the average
African American newborn in the United States (USBC,
2010; WHO, 2009). The rate of infant mortality in America
is twice as high for Blacks as it is for Whites. Among
babies who survive the first year, the life expectancy for
an African American baby is about 4 1/2 years shorter than
that for a White baby in America (USBC, 2010). Moreover,
the death rates in the United States for the three most
deadly diseases are far higher for Blacks than Whites, as
Figure 6-4 shows. Although American racial differences
in health were much larger decades ago, they are still
substantial and remain a national disgrace.

150 Part III / Lifestyles to Enhance Health and Prevent Illness

Heart
disease

Cancer Stroke COPD

Fatal illness

0
50
100

150

200

300

250

Blacks

Whites

M
or

ta
li
ty

r
at

Figure 6-4 Death rates (per 100,000 individuals in the
population) for Whites and Blacks in the United States,
resulting from four leading chronic diseases (COPD is
chronic obstructive lung disease). The rates are averaged for
males and females and age-adjusted to take into account
that mortality rates increase with age and that the average
age of Blacks is less than that of Whites. (Data from NCHS,
2009a, Table 28.)

Three minority groups in the United States have
high levels of health problems: in a national survey of
adults, self-ratings of fair or poor health were given by
21.6% of Native Americans, 18.4% of Blacks, and 17.4%
of Hispanics (compared with 12.2% of Whites, NCHS,
2009b). Many individuals in these minority groups live
in environments that do not encourage the practice
of health behavior (Johnson et al., 1995; Whitfield et
al., 2002). African Americans and Hispanics also share
a vulnerability to four health-related problems: stress
from discrimination, substance abuse, AIDS, and injury
or death from violence (Myers, 2009; Whitfield et al.,
2002). These individuals are more likely than whites to
smoke, use drugs, and practice unsafe sex. And African
Americans and Hispanics—especially young males—are

several times more likely than their White counterparts
to become victims of homicide. These problems are
disturbing, and correcting them will take a great deal of
time, effort, and social change.

Promoting Health with Diverse Populations
Immigrants tend to adopt the health behaviors of
their new culture through the process of accultur-
ation (Corral & Landrine, 2008). How can societies
help their diverse populations lead healthful lives?
Long-term approaches involve reducing poverty, increas-
ing literacy, and providing illness prevention services.
A more immediate approach would be to present health
information at low literacy levels (Pignone et al., 2005).
And because communities contain people of different
ages, genders, and sociocultural backgrounds, profes-
sionals who are trying to prevent and treat illness need
to take a biopsychosocial perspective (Flack et al., 1995;
Johnson et al., 1995; Landrine & Klonoff, 2001). You
can see what this means in Table 6.8, which presents
three factors professionals can address to make health-
promotion services culturally sensitive. Ideally, programs
to promote minority health would use a grassroot, cul-
turally relevant approach with trained health leaders
from the community (Castro, Cota, & Vega, 1999). An
example program, called Por La Vita, increased breast
and cervical cancer testing in Hispanic women by identi-
fying and training respected women of their community
to provide weekly educational sessions on cancer pre-
vention (Navarro et al., 1998). The remainder of this
chapter focuses on techniques and program designs for
enhancing health and preventing illness.

PROGRAMS FOR HEALTH PROMOTION

Hoping to save money on the costs of health care and
lost productivity, some employers have begun offering
incentives for healthy behavior—for example, for meeting

Table 6.8 Cultural Diversity Issues for Professionals in Promoting Health

• Biological factors. Sociocultural groups can differ in their physiological processes, as reflected in African Americans’ high risk of
developing the genetic blood disease of sickle-cell anemia. For instance, we saw in Chapter 4 that Black people show relatively
high reactivity to stress, which may result from heredity or environmental factors, such as living under relatively high stress.

• Cognitive and linguistic factors. People of different sociocultural groups seem to have different ideas about the causes of illness, give
different degrees of attention to their body sensations, such as pain, and interpret symptoms differently. For example, Hispanic
Americans often believe in using ‘‘folk healing’’ practices, such as actions to drive away evil spirits. Professionals who try to refute
these beliefs may drive their patients away. Language differences between professionals and the people they serve impair their
ability to communicate with each other.

• Social and emotional factors. Sociocultural groups differ in the amount of stress they experience, their physiological reactivity to it,
and the ways they cope with it. They also differ in their amount and use of social support.

Chapter 6 / Health-Related Behavior and Health Promotion 151

weight loss goals, workers can earn a cash bonus, or days
off work, or even a tropical vacation. Other creative
approaches to promote health have been used to change
other behaviors in other situations. Often programs
for health promotion address several behaviors, which
is efficient: people achieve more changes when more
behaviors are addressed (Young et al., 2009). Let’s look
at some methods these efforts can use.

METHODS FOR PROMOTING HEALTH
Interventions to promote health can encourage the
practice of healthful behavior with dozens of methods
(Abraham & Michie, 2008; Sarafino, 2011). These inter-
ventions usually start by teaching individuals what these
behaviors are and how to perform them, and by persuad-
ing people to change unhealthful habits. An important
step in this effort is motivating individuals to want to
change, and this often requires modifying their health
beliefs and attitudes. What methods do these programs
use to encourage health behavior?

Providing Information
People who want to lead healthful lives need
information—they need to know what to do and when,
where, and how to do it. In reducing dietary cholesterol,
people need to know what cholesterol is and that it can
clog blood vessels, leading to heart disease. They also
need to know where they can have their blood tested
for cholesterol level, what levels are high, how much
cholesterol is in the foods they currently eat, which
foods might be good substitutes for ones they should
eliminate from their diets, and how best to prepare
these foods. There are several sources for information to
promote health.

One source for health information is the mass media:
TV, radio, newspapers, and magazines can promote
health by presenting warnings and information, such
as advice to help people avoid or stop smoking. For
instance, the mass media sometimes presents in public
service advertisements information about the negative
consequences of an activity, such as smoking. This approach
has had limited success in changing behavior (Flay, 1987;
Maes & Boersma, 2004). One reason for the limited
success may be that many people just don’t want
to change the behavior at issue: a noted newspaper
columnist who did not want to change his diet railed
against warnings, writing,

Cholesterol, shmolesterol! … Almost everything
[experts] say is good for you will turn out bad for
you if you hang around long enough, and almost
everything they say is bad for you will turn out not to

matter. (Baker, 1989, p. A31; note that this quote is a
good example of motivated reasoning!)

But when people already want to change an unhealthful
habit, programs conducted on TV can be more effective,
especially if they are combined with other methods
(Freels et al., 1999; Maes & Boersma, 2004). For example,
a program on TV, called Cable Quit, was successful in
helping people stop smoking by showing them how to
prepare to quit, helping them through the day they quit,
describing ways to maintain their success, and giving
them opportunities to call for advice (Valois, Adams, &
Kammermann, 1996). Of those who started the program,
17% continued to abstain from smoking a year later.

Another source of health promotion information
is the computer, particularly via the Internet. People
anywhere in the world who are already interested in
promoting their health and have access to the Internet
can contact a wide variety of websites. Some are huge
databases with information on all aspects of health
promotion, while others provide detailed information
on specific illnesses, such as cancer and arthritis, or
support groups for health problems. People can learn
how to avoid health problems and, if they become ill,
what the illness is and how it can be treated.

A third source of health promotion information is
medical settings, particularly physicians’ offices, which offer
some advantages and disadvantages. Two advantages
are that many individuals visit a physician at least once
a year, and they respect health care workers as experts.
Three disadvantages are that medical personnel have
tight schedules, feel a lack of expertise to help, and
worry that they may be intruding in patients’ personal
lives (Schroeder, 2005). For reasons like these, medical
staff don’t provide enough health promotion advice.
A study found that American physicians checked the
smoking status in a bit more than two-thirds of adult
patients and counseled only about one-fifth of smokers
on ways to quit (Thorndike, Regan, & Rigotti, 2007).
Because of the problem of tight schedules, researchers
have developed 5- to 10-minute counseling programs
that medical staff can be trained to give in person or
by telephone; having a system that cues the staff to
give the program increases its delivery (Adams et al.,
1998). These programs enhance many types of health
behaviors, such as eating low-fat diets, curbing alcohol
intake, and getting cancer screening (Ockene et al., 1999;
Ockene, Reed, & Reiff-Hekking, 2009; Rimer, 1998). Just
asking patients if they smoke, advising them to quit,
and suggesting that they contact a telephone ‘‘quit line’’
takes less than a minute and can help (Schroeder, 2005).

Medical professionals now have another avenue for
providing health promotion information. They can offer

152 Part III / Lifestyles to Enhance Health and Prevent Illness

individuals who are at risk for inherited illnesses, such
as some forms of cancer, estimates of their chances of
getting the disease and opportunities to undergo tests,
such as periodic examinations and genetic testing. But
even when genetic testing is offered at no cost, less
than half of individuals request the testing and results
(Lerman et al., 1996; Lerman, Hughes et al., 1999). Are
there psychological risks for people who receive this
advice and undergo the tests? Making the decision to
have genetic testing can be agonizing because of the
possibility that it will reveal a genetic risk and conflicts
that arise among family members who do and do not want
the information. In breast and ovarian cancer testing, for
example, women who learn that they are carriers of the
gene experience some distress in the subsequent weeks
that declines markedly in the next few months (Hamilton,
Lobel, & Moyer, 2009). (Go to .)

Features of Information to Enhance
Motivation
Individuals do not necessarily follow advice and warnings
on ways to promote their health. How can the information

they receive enhance their motivation to adopt health
behaviors?

One approach to enhance people’s motivation
to follow health promotion advice is to use tailored
content—that is, the advice delivered in person, in print,
or on the telephone is designed for a specific individual,
based on characteristics of that person. For example,
the message would refer to the person by name and
might include personal or behavioral details, such as the
person’s age or smoking history, and a message geared
to the person’s readiness to adopt the proposed health
behavior, such as stopping smoking, scheduling a mam-
mogram, or losing weight. Tailoring the content appears
to enhance the success of health promotion information
(Noar, Benac, & Harris, 2007; Skinner et al., 1999).

Another approach to enhance motivation is based on
a concept called message framing, which refers to whether
the information emphasizes the benefits (gains) or costs
(losses) associated with a behavior or decision. For a
health behavior, a gain-framed message would focus on
attaining desirable consequences or avoiding negative
ones; it might state, for example, ‘‘If you exercise, you
will become more fit and less likely to develop heart
disease.’’ A loss-framed message would focus on getting

CLINICAL METHODS AND ISSUES

Dialogues to Help People Stop Smoking
Patients who smoke tend to express

many common rationalizations for not quitting that their
medical or psychological practitioner can discuss with
them. Each of the following rationalizations has a reply
the practitioner can give (Adapted from USDHHS, 1986a).

PATIENT: I am under a lot of stress, and smoking relaxes me.

STAFF (Practitioner): Your body has become accustomed
to nicotine, so you naturally feel more relaxed when
you get the nicotine you have come to depend on.
But nicotine is actually a stimulant that temporarily
raises heart rate, blood pressure, and adrenaline
level. After a few weeks of not smoking, most ex-
smokers feel less nervous.

PATIENT: Smoking stimulates me and helps me to be more effective
in my work.

STAFF: Difficulty in concentrating can be a symptom of
nicotine withdrawal, but it is a short-term effect.
Over time, the body and brain function more
efficiently when you don’t smoke, because carbon
monoxide from cigarettes is displaced by oxygen in
the bloodstream.

PATIENT: I have already cut down to a safe level.

STAFF: Cutting down is a good step toward quitting.
But smoking at any level increases the risk of
illness. And some smokers who cut back inhale more
often and more deeply, thus maintaining nicotine
dependence. It is best to quit smoking completely.

PATIENT: I only smoke safe, low-tar/low-nicotine cigarettes.

STAFF: Low-tar cigarettes still contain harmful sub-
stances. Many smokers inhale more often or more
deeply and thus maintain their nicotine levels. Car-
bon monoxide intake often increases with a switch
to low-tar cigarettes.

PATIENT: I don’t have the willpower to give up smoking.

STAFF: It can be hard for some people to give up smoking,
but for others it is much easier than they expect.
Millions of people quit every year. It may take more
than one attempt for you to succeed, and you may
need to try different methods of quitting. I will give
you all the support I can.

Similar dialogues can help people change other health-
related behaviors, too.

Chapter 6 / Health-Related Behavior and Health Promotion 153

undesirable consequences and avoiding positive ones;
for instance, ‘‘If you do not get your blood pressure
checked, you could increase your chances of having
a heart attack or stroke, and you will not know that
your blood pressure is good.’’ A large body of evidence
indicates that the best type of framing to use depends on
the type of health behavior (Rothman & Salovey, 1997,
2004). Gain-framed messages work best for motivating
behaviors that serve to prevent or recover from illness
or injury; two such behaviors are using condoms and
performing physical therapy. Loss-framed messages work
best for behaviors that occur infrequently and serve to
detect a health problem early, as getting a mammogram
can do (Gerend, Shepherd, & Monday, 2008).

A special case of loss-framed messages is when infor-
mation is a fear appeal—it arouses fear. According to the
health belief model, people are likely to practice health-
ful behavior if they believe that by not doing so they are
susceptible to serious health problems. In other words,
they are motivated by fear to protect their health. Stud-
ies have found that fear appeals can motivate people to
adopt a variety of more healthful attitudes and behavior
(Diefenbach, 2004). But the effects tend to be transient,
sometimes not lasting long enough to carry a changed
intention into a behavior. What can be done to make
fear appeals more effective? Fear messages for changing
unhealthful behavior are most persuasive if they:

• Emphasize the organic and social consequences—that
is, the perceived seriousness—of developing the health
problem (Banks et al., 1995; Kalichman & Coley, 1995).

• Are presented as a personal testimonial, rather than
statistical chances (de Wit, Das, & Vet, 2008).

• Provide specific instructions or training for performing
the behavior (Albarracı́n et al., 2003; Diefenbach, 2004).

• Help bolster people’s self-confidence, or self-efficacy,
for performing the behavior before urging them to begin
the plan (Self & Rogers, 1990).

Motivational Interviewing
A one-on-one technique called motivational interview-
ing, a counseling style designed to help individuals
explore and resolve their ambivalence in changing a
behavior, was originally developed to help people over-
come addictions, such as to alcohol and drugs (Miller &
Rollnick, 1991; Miller & Rose, 2009). The counselor uses
a style that leads the client, rather than the counselor,
to voice arguments for behavior change. Two important
features of the process are decisional balance and person-
alized feedback. In decisional balance, clients list their
reasons for and against changing their behavior so that
these can be discussed and weighed. In personalized

feedback, clients receive information on their pattern of
the problem behavior, comparisons to national norms
for the behavior, and risk factors and other consequences
of the behavior.

Motivational interviewing has been extended for use
in health care settings to promote healthful behavior,
such as to help a girl named Latisha to get her boyfriend
to use condoms when they had sex. The following
exchange ensued after she pointed out that he had
used condoms in the past ‘‘when he got ’em.’’

INTERVIEWER: So if you had them around, would you be
able to use them with him?

LATISHA: If I really wanted him to. He’d probably use it.

INTERVIEWER: All you’d have to do is ask him to use a
condom, and he’d do it?

LATISHA: Well, I’d have to be nice about it, so he don’t
think I’m sayin’ he’s dirty or go around anymore. I’d
have to be nice.

INTERVIEWER: It sounds like you know what he would be
sensitive about. What could you say to make it sound
nice? (Brown & Lourie, 2001, P. 262)

An interview like this one would then discuss the
things she could say, the problems that could arise, and
how she would deal with them.

The course of motivational interviewing can take
one session or several and typically leads the client to
identify many of the elements of theories we’ve previously
discussed, such as the benefits and barriers (decisional
balance) to the behavior change. They then work through
identified problems that have made the behavior hard to
change in the past. Research has revealed promising
outcomes of motivational interviewing, such as in
helping patients follow the medication directions their
physician prescribed and getting sexually active people
to use condoms (Resnicow et al., 2002). Decisional
balance and feedback are critical components of the
process, particularly in helping college students reduce
heavy drinking (LaBrie et al., 2006; Walters et al., 2009).

Behavioral and Cognitive Methods
Behavioral methods focus directly on enhancing people’s
performance of the preventive act by managing its
antecedents and consequences. The antecedents for
health-related behavior can be managed in many ways,
such as by using calendars to indicate when to perform
infrequent preventive actions and reminders not to eat
high-calorie foods or drink too much.

The consequences for health-related behavior can
be managed by providing reinforcers when the person
practices healthful behaviors, such as flossing teeth or

154 Part III / Lifestyles to Enhance Health and Prevent Illness

not smoking. But the effectiveness of reinforcement
depends on the types of reward used and the age of
the individual (Sarafino, 2001). People differ in their
reward preferences; one person might like to receive
a CD of rock music, but someone else might prefer
classical. The consequences need to be matched to the
person, which can be done by having the person fill
out a questionnaire (Sarafino & Graham, 2006). Some
evidence suggests that reward preferences change with
age: kindergarten children tend to prefer material rewards
(a charm, money, candy) over social rewards such as
praise, but this preference seems to reverse by third
grade (Witryol, 1971). For adults, monetary rewards seem
to be very effective in encouraging health behaviors,
such as stopping smoking in pregnancy and breast self-
examination (Lumley et al., 2009; Solomon et al., 1998).

Cognitive methods can be applied to change
people’s thought processes, such as to enhance their
self-efficacy for quitting smoking. Therapists often teach
behavioral and cognitive methods to clients so they
can apply them themselves—an approach called self-
management (Sarafino, 2011). Although each behavioral
and cognitive method helps in changing a behavior,
such as eating more healthfully, they appear to be most
effective when combined and used together, particularly
when the individuals monitor their own behavior and
keep records of it (Michie et al., 2009).

Maintaining Healthy Behaviors
When people change a long-standing behavior, their
success usually has some setbacks, or lapses (Sarafino,
2001). A lapse is an instance of backsliding—for instance,
a person who quits smoking might have an occasional
cigarette. Lapses should be expected; they do not
indicate failure. A more serious setback is a relapse, or
falling back to one’s original pattern of the undesirable
behavior. Relapses are very common when people try
to change long-term habits, such as their eating and
smoking behaviors.

Psychologists G. Alan Marlatt and Judith Gordon
(1980) have proposed that for many individuals who
quit a behavior, such as smoking, experiencing a lapse
can destroy their confidence in remaining abstinent and
precipitate a full relapse. This is called the abstinence-
violation effect. Because these people are committed to
total abstinence, they tend to see a lapse as a sign of a
personal failure. They might think, for instance, ‘‘I don’t
have any willpower at all and I cannot change.’’ Programs
to change behavior can reduce relapses by training
individuals to cope with lapses and maintain self-efficacy
about the behavior and by providing ‘‘booster’’ sessions
or contacts (Curry & McBride, 1994; Irvin et al., 1999).

Contacts, even by phone, can reduce relapses substan-
tially by providing counseling on dealing with difficult
situations that could lead to lapses (Zhu et al., 1996).

Interventions to promote health have been carried
out in many settings and with a variety of goals, methods,
and populations. We will examine different types of
programs, beginning with health education efforts in
schools and religious organizations.

PROMOTING HEALTH IN SCHOOLS AND
RELIGIOUS ORGANIZATIONS
Schools and religious organizations have unique oppor-
tunities to promote health for two reasons. First, they
have access to virtually all children and adolescents
in developed nations during the years that are proba-
bly most critical in the development of health-related
behaviors. Second, they can reach many minority and
immigrant adults who are at high risk of serious illnesses,
such as heart disease and cancer.

Are health promotion programs in schools and reli-
gious organizations effective? Many have been (Campbell
et al., 2007; Katz, 2009). Some programs in schools
have been designed to promote a broad range of health

Schools can encourage fitness by providing exercise equip-
ment and showing children how to use it, as in this Project
Fit America program.

Chapter 6 / Health-Related Behavior and Health Promotion 155

behaviors—for example, nutrition, exercise, tobacco and
alcohol use, and sexual activity—which improved the
children’s health behavior and physical condition (Katz,
2009; Maes & Boersma, 2004). The most effective pro-
grams for promoting health in schools are comprehen-
sive and involve the children’s family and community
over a long period.

WORKSITE AND COMMUNITY-BASED
WELLNESS PROGRAMS
Wellness programs are spreading rapidly in workplaces
in industrialized countries. A national survey of American
worksites with 50 or more employees found that over
90% offered some form of health promotion activity,
such as for fitness or diet (USDHHS, 2004). One-third of
small worksites and 50% of large worksites offered com-
prehensive programs, which focus on lifestyle change
and screen employees for health promotion needs.
Workers with poor health habits in the United States
cost employers substantially more in health benefits and
other costs of absenteeism than those with good habits.
These savings offset and often exceed the expense of run-
ning a wellness program (Goetzel & Ozminkowski, 2008).
Psychologists who study or administer such programs
are called occupational health psychologists (Quick, 1999).

Worksite wellness programs vary in their aims, but
often apply self-management methods and address some
or all of several risk factors: hypertension, cigarette
smoking, unhealthful diets and overweight, poor physical
fitness, alcohol abuse, and high levels of stress. These
risk factors do not seem to be equally changeable. For
example, although self-management can be sufficient for
dietary and exercise behaviors, smoking often requires
counseling and pharmacological treatment to overcome
nicotine dependence, too (Cahill, Moher, & Lancaster,
2008; Emmons et al., 1999). Housing these interventions
in workplaces has several advantages. Worksite programs
are convenient to attend, are fairly inexpensive for
employees, can provide participants with reinforcement
from the employer and coworkers, and can structure
the environment to encourage healthful behavior, such
as by making healthy food available in the cafeteria
(Cohen, 1985). Although the number of employees who
participate in worksite programs is not as high as one
would hope, over 60% of American workers do (USDHHS,
2004). And the number of workers who participate
and stick with the programs increases markedly if the
employer actively recruits them (Linnan et al., 2002).

Let’s look at a model worksite intervention. Johnson
& Johnson, America’s largest producer of health care
products, began the Live for Life program in 1978. The
program covers thousands of employees and is highly

effective (Maes & Boersma, 2004; Nathan, 1984). The
program is designed to improve employees’ health
knowledge, stress management, and efforts to exercise,
stop smoking, and control their weight. For each
participating employee, Live for Life provides a health
screen—a detailed assessment of the person’s current
health and health-related behavior, which is shared with
the person later—and professionally led action groups
for specific areas of improvement, such as quitting
smoking or controlling weight, focusing on how people
can alter their lifestyle and maintain improvements
permanently. Follow-up contacts are made with each
participant during the subsequent year. The company
also provides a work environment that supports and
encourages healthful behavior: it has designated no-
smoking areas, established exercise facilities, and made
nutritious foods available in the cafeteria, for example.

Community-based programs for health promotion
are designed to reach large numbers of people and
improve their knowledge and performance of preventive
behavior (Thompson et al., 2003). These interventions
may address a set of behaviors or just one and use
any of the methods we have considered. They may,
for instance, use the media and social organizations to
provide information and advice regarding the risks factors
for cancer, the dangers of drinking and driving, or the
availability of free blood pressure testing or vaccinations.
Community-based programs may also provide incentives
for performing a health behavior or reaching a goal, such
as losing a certain amount of weight. An early example
of a community-based program is the Three Community
Study, which was carried out in California to spur
people to change their behavior and reduce their risk of
cardiovascular disease (Farquhar et al., 1977; Meyer et al.,
1980). The program delivered an extensive 2-year mass-
media campaign, consisting of warnings and information
concerning diet, exercise, and smoking. Research has
revealed that the long-term success of the program was
greatest with older people and least with individuals
who were much younger, had little education, and
were from the lower socioeconomic classes (Winkleby,
Flora, & Kraemer, 1994). Although the success of this
program and similar ones was modest—for instance,
reducing blood pressure by a few points—small changes
across thousands of people can affect disease greatly
(Thompson et al., 2003).

ELECTRONIC INTERVENTIONS FOR HEALTH
PROMOTION
Electronically-delivered psychosocial interventions are
being developed to promote health. Internet-based programs
use the World Wide Web to deliver interventions, and

156 Part III / Lifestyles to Enhance Health and Prevent Illness

computer-based programs use software that is loaded on
individual computers (Tate, 2008). Table 6.9 presents
some examples of electronic interventions with evidence
of success in changing several health-related behaviors.
Internet-based programs are particularly useful because
they are easily accessed by enormous numbers of
people around the world, but nearly 50% of people
who begin using them drop out (Bennett & Glasgow,
2009). Providing personal contact and incentives and
reminders to use the programs can reduce drop out
rates. (Go to .)

PREVENTION WITH SPECIFIC TARGETS:
FOCUSING ON AIDS
Sometimes prevention programs focus on reducing
people’s risk of developing a specific health problem
and center these efforts on specific segments of the
population. One example of this approach is the Multiple
Risk Factor Intervention Trial (MRFIT), a project that
recruited and provided health promotion programs for
thousands of men across the United States who were at
substantial risk for heart disease (Caggiula et al., 1981).
Another example involves efforts to reduce the spread

of infection with the human immunodeficiency virus (HIV),
which causes acquired immune deficiency syndrome (AIDS).
We’ll focus on efforts to reduce HIV infection.

HIV Infection
The magnitude of the AIDS threat is astounding (UNAIDS,
2009): tens of millions of its victims have died around
the world, over 33 million people are currently infected
with HIV, and millions are newly infected each year.
Over 160 countries have reported cases of AIDS, but
the infection is unevenly distributed worldwide. The
largest concentration of infections continues to be in
sub-Saharan Africa, which has two-thirds of all people
currently living with HIV/AIDS. Although the incidence of
infection is high in Asian and Latin American regions,
it has declined worldwide since the mid-1990s. New
medical treatments can extend the lives of victims, are
widely used in industrialized nations, and are being used
increasingly in developing nations (UNAIDS, 2009). There
is no vaccine against HIV, and complications from AIDS
kill most people who develop it.

HIV spreads to an uninfected person only through
contact of his or her body fluids with those of an
infected person, generally either through sexual practices

Table 6.9 Examples of Electronic Health Promotion Interventions with Research Evidence of Success
Purpose Population and Program Description (Reference) Related Evidence

Decrease drinking Heavy drinkers. Motivational interview methods to help
them commit to change; and if they do, negotiate goals
and plan for change (Squires & Hester, 2004).

Carey et al., 2009

Decrease smoking Smokers who purchased a nicotine patch. Cognitive-
behavioral program, including methods to manage
antecedents and enhance self-efficacy and coping
(Strecher, Shiffman, & West, 2005).

Myung et al., 2009; Seidman et al.,
2010; Shahab & McEwen, 2009

Decrease chronic pain Headache sufferers. Stress management, including
relaxation training and some biofeedback (Devineni
& Blanchard, 2005).

Bennett & Glasgow, 2009

Decrease insomnia Adults with insomnia. Cognitive-behavioral methods,
such as going to bed only when sleepy and changing
counterproductive beliefs (Ritterband et al., 2009).

Reduce risk of eating disorder Females at high risk of eating disorders. Cognitive–
behavioral program to change beliefs about their
bodies and societal standards that put them at risk
(Taylor et al., 2006).

Reduce risk of substance use Girls, 11 to 13 years old, and their mothers. Each pair
worked together on a computerized program, which
taught them ways to manage their moods and stress,
to reduce the girls’ risk of using tobacco, alcohol, and
illicit drugs (Schinke, Fang, & Cole, 2009).

Hustad et al., 2010; Norman et al.,
2008

Reduce dietary fat; increase exercise Adults in general population. An Internet intervention
had participants provide information about their fat
intake and physical activity. Tailored feedback and
suggestions were given on the healthfulness of their
behaviors and ways to improve them (Oenema et al.,
2008).

Winett et al., 2007

Chapter 6 / Health-Related Behavior and Health Promotion 157

ASSESS YOURSELF

Your Knowledge about AIDS
Answer the following true-false items

by circling the T or F for each one.

T F 1. Most people who develop AIDS die from its
complications.

T F 2. Blood tests can usually tell within a
week after infection whether someone has
received the AIDS virus.

T F 3. People do not get AIDS from using swim-
ming pools or rest rooms after someone
with AIDS does.

T F 4. Some people have contracted AIDS from
insects, such as mosquitoes, that have
previously bitten someone with AIDS.

T F 5. AIDS can now be prevented with a vaccine
and cured if treated early.

T F 6. People who have the AIDS virus can look
and feel well.

T F 7. Gay women (lesbians) get AIDS much more
often than heterosexual women, but not as
often as gay men.

T F 8. Health workers have a high risk of getting AIDS
from or spreading the virus to their patients.

T F 9. Kissing or touching someone who has AIDS
can give you the disease.

T F 10. AIDS is less contagious than measles.
Check your answers against the key below that is

printed upside down—a score of 8 items correct is good,
9 is very good, and 10 is excellent. (Carey, Morrison-Beedy,
& Johnson, 1998; DiClemente, Zorn, & Temoshok, 1987; Vener &

Krupka, 1990).

Answers:

1. T, 2. F, 3. T, 4. F, 5. F, 6. T, 7. F, 8. F, 9. F, 10. T

or when intravenous drug users share needles. The
likelihood of infection increases if the person has
wounds or inflammation from other sexually transmitted
diseases, such as syphilis or herpes, and from rough
sex (Klimas, Koneru, & Fletcher, 2008). Infected mothers
sometimes transmit the virus to their babies during
gestation, delivery, and later during breast-feeding (Carey
& Vanable, 2004; Klimas, Koneru, & Fletcher, 2008).

Who is at high risk of HIV infection? Table 6.10
shows that the modes of exposure to HIV for people
newly infected vary greatly across areas of the world.
In the United States, unprotected male-to-male anal
intercourse is still a major mode of exposure, but the
rate of infection from male-to-male sex was much higher
in the early 1980s and declined sharply in the next
several years (Catania et al., 1991; Coates, 1990). And
the risk of infection has increased among American low-
income and minority groups over the years. In other
parts of the world, the main exposure modes are injection
drug use (sharing needles) and unprotected heterosexual
vaginal intercourse, often with paid sex workers. And the
percentage of people living with HIV who are female has
increased worldwide—today 50% are female (UNAIDS,
2009). Men who are circumcised have a much lower risk
of infection from vaginal sex than uncircumcised men
(Klimas, Koneru, & Fletcher, 2008). But unsafe behavior
is still the main risk, and global prevention efforts
have concentrated on using fear arousing warnings and
providing information to promote safer-sex behavior.

These efforts also try to correct misconceptions
about HIV transmission—for instance, that AIDS can
only happen to homosexuals and drug users, that all
gay men are infected, that mosquitoes can spread the
virus, or that the virus can be transmitted through
casual contact, such as by touching or hugging infected
individuals or by sharing office equipment they have
used (DiClemente, Zorn, & Temoshok, 1987). Many
people also believe that health care personnel are
usually at high risk of becoming infected when working
with AIDS patients, but research has disconfirmed this.
It is rare for health care workers to become infected,
even when they are accidentally stuck with a needle that
had been used on an AIDS patient (Clever & LeGuyader,
1995; Klimas, Koneru, & Fletcher, 2008).

Why do people continue to engage in unsafe sex?
Although ignorance and a lack of availability of protection
are the main reasons in many developing countries, other
factors are more influential in other cultures. Let’s look
at some of these factors:

• People are much more likely to have unsafe sex if they
are promiscuous or have sex while under the influence
of alcohol or drugs (Lowry et al., 1994; Norris et al.,
2009; O’Hare, 2005). In men, intoxication seems to
increase negative attitudes and decrease self-efficacy
about using condoms and to increase the willingness
to have unsafe sex when they are sexually aroused
(Gordon & Carey, 1996; MacDonald et al., 2000). Women

158 Part III / Lifestyles to Enhance Health and Prevent Illness

Table 6.10 Percent of New HIV Infections by Exposure Mode for the United States and Some Regions of the World Where
the Incidence Is High

Country or Region (annual number of new cases)

United States Eastern Europe and Central Latin America Southb and South-East
Exposure Modea (56,300) Asia (110,000) (170,000) Asia (280,000)

Male-to-male sex 41.7% 4% 26% 5%
Injection drug use 21.6% 67% 19% 22%
Heterosexual sex 30.9% NA NA NA
Sex workers/clients NA 5%/7% 4%/13% 8%/41%
Other (see note) 5.9% 17% 38% 24%

aData on exposure modes were available from the sources (below) only in 2006 reports and only for the country and regions
included in the table. Regions for which exposure data were not available include sub-Saharan Africa, which at 1.9 million
new cases has the highest incidence, but exposure there is mainly via heterosexual sex.
bData for India were included in the number of new cases, but not exposure mode, which is mainly heterosexual sex, including
with commercial sex workers.
Notes: NA = data not available; cases for this mode are included in one or more other exposure categories; ‘‘other’’ includes
cases with more than one mode, making the actual exposure unclear, and cases of exposure at or soon after birth and via
blood transfusion.
Sources: New cases data from CDC, 2009; UNAIDS, 2009. Exposure mode data from CDC, 2006; UNAIDS, 2006.

are less likely to request condom use when they’ve been
drinking (Norris et al., 2009).

• Young adults are much more likely to engage in risky sex
if their parents reject them for their sexual orientation
(Ryan et al., 2009).

• Unmarried partners are less likely to use condoms if they
perceive their relationship to be close or serious (Cooper
& Orcutt, 2000; Misovich, Fisher, & Fisher, 1997).

• Decision making in sexual situations is often subject
to nonrational processes, such as denial or wishful
thinking (Blanton & Gerrard, 1997; Gold, Skinner, &
Hinchy, 1999; Thompson et al., 1999). Sexual arousal
and having an attractive partner decrease rationality in
sexual decisions (Shuper & Fisher, 2008).

• Many individuals have maladaptive beliefs about their
own low self-efficacy to use condoms and the effect that
doing so would have on sexual pleasure and spontaneity
(Kelly et al., 1991, 1995; Wulfert, Wan, & Backus, 1996).

• Many people, especially young women, are embarrassed
to buy condoms and make errors putting them on
a penis, such as not leaving a space at the tip and
squeezing air out (Brackett, 2004; Grimley et al., 2005).

• The advent of medical treatments that lower viral load
and prolong life has led to over-optimism in many
individuals, leading them to think that protection is not
so necessary anymore (Kalichman et al., 2007; Lightfoot
et al., 2005).

People’s maladaptive beliefs are often clear when
they recognize their behavior contradicts what experts
say, so they add qualifiers, such as, ‘‘I know that’s
what they say but … ’’ or, ‘‘but in my case … ’’ (Maticka-
Tyndale, 1991).

Basic Messages to Prevent HIV Infection
Major efforts have been introduced in most countries
around the world to prevent HIV infection by hav-
ing the mass media and health organizations provide
information about several basic behaviors (Carey, 1999;
Kalichman, 1998). First, people should avoid or reduce
having sex outside of long-term monogamous relation-
ships or, otherwise, to use ‘‘safer sex’’ practices with new
partners. Safer sex involves selecting partners carefully,
avoiding practices that may injure body tissues, and
using condoms in vaginal and anal intercourse. Second,
not all people who have the virus know they do, and not
all of those who know they do tell their sexual partners
(Ciccarone et al., 2003; Simoni et al., 1995). Third, drug
users should not share a needle or syringe; if they do,
they should be sure it is sterile. Fourth, women who could
have been exposed to the virus should have their blood
tested for the HIV antibody before becoming pregnant
and, if the test is positive, avoid pregnancy. Much of this
information has been designed to arouse fear, and it has
in many people.

Do informational efforts change people’s HIV
knowledge and behavior? In the United States, public
health programs have been directed toward adolescents
and young adults in the general population, intravenous
drug users and their sexual partners, and gays and
bisexuals. Although providing information to youth in
the general population increases their knowledge about
HIV (Yankah & Aggleton, 2008), most sexually experi-
enced teenagers and young adults do not seem follow
recommended precautions (Leigh et al., 1994). Other
approaches try to convince teenagers to abstain from
sex until marriage—often having them take ‘‘virginity

Chapter 6 / Health-Related Behavior and Health Promotion 159

pledges’’—or just reduce sexual risk, but these
approaches are not effective in reducing sexual activity
or risk (Rosenbaum, 2009; Underhill, Montgomery, &
Operario, 2008). Although programs that focus on getting
adolescents to abstain from or reduce their sexual activ-
ity can help for some people, efforts to promote condom
use are more effective for teens who are sexually experi-
enced (Jemmott, Jemmott, & Fong, 1999). A study found
that men who had received school-based condom educa-
tion in adolescence were less likely to contract sexually
transmitted diseases (Dodge, Reece, & Herbenick, 2009).

Providing information about HIV has been more
effective in reducing risky behaviors of intravenous drug
users and gay men. Drug users have learned that sharing
needles can transmit HIV and that there are ways to
protect themselves (Des Jarlais & Semaan, 2008). In the
United States, most of these people have begun to use
sterile needles, reduce their drug use, or use drugs in
other ways, such as by inhaling. The risk of HIV infection
among drug users decreases if they can buy needles
legally or exchange used needles for new ones (Des
Jarlais & Semaan, 2008; Ksobiech, 2003). Although drug
users’ caution may not extend readily to their sexual
behavior, interventions that have addressed both issues
have reduced their injection and sexual risk behaviors
(Meader et al., 2010). Most drug users are heterosexual
men, and their sexual partners often are women who
know about the risks but feel powerless and are willing
to go along with having unprotected sex (Logan, Cole, &
Leukefeld, 2002).

Perhaps the best-organized efforts to change sex-
ual practices have been directed at gay men, particu-
larly in gay communities in large cities. This is partly
because many gay social, political, and religious orga-
nizations existed before the AIDS epidemic began, and
these groups became actively involved in public health

campaigns to prevent the spread of the disease. These
efforts have had a substantial impact: AIDS educa-
tion and prevention campaigns with gay and bisexual
men have reduced their sexual risk behavior markedly
(Johnson et al., 2008), producing ‘‘the most profound
modifications of personal health-related behaviors ever
recorded’’ (Stall, Coates, & Hoff, 1988, p. 878).

Focusing on Sociocultural
Groups and Women
Although more needs to be done to reduce HIV risk in
urban gay men and intravenous drug users around the
world, efforts must be intensified among heterosexual
women and disadvantaged sociocultural groups (Alvarez
et al., 2009; Logan, Cole, & Leukefeld, 2002; Raj, Amaro,
& Reed, 2001). For minority groups in the United States,
particularly African Americans and Hispanics, there can
be added problems of lesser knowledge about risky
behavior and suspicions concerning information from
health care systems they believe have treated them
badly (Boulware et al., 2003; Raj, Amaro, & Reed, 2001).
Women are often vulnerable to HIV infection when they
are with a male partner who resists using condoms, are
socially or economically dependent on the man, and
have less power in their relationships (Sikkema, 1998).
A woman’s ability to protect herself from infection
by asking for condom use under these circumstances
is especially difficult if she lacks self-efficacy and the
man interprets such requests negatively—for example,
that she doesn’t care about him or thinks he’s been
unfaithful (Neighbors, O’Leary, & Labouvie, 1999;
O’Leary, Jemmott, & Jemmott, 2008).

Interventions have been tested with large numbers
of Hispanic and African American women who met
in small group sessions to enhance their motivation

Efforts to prevent the spread of AIDS include
using billboards to reach teenagers.

160 Part III / Lifestyles to Enhance Health and Prevent Illness

and interpersonal skills for adopting safer sex practices.
Comparisons with women in control groups were made
during subsequent months. Women who received the
interventions were more likely to report using safer sex
practices and to use coupons to redeem free condoms
(Carey et al., 2000; Sikkema, Kelly et al., 2000); they were
also less likely to develop STDs (chlamydia or gonorrhea)
over the next year (Shain et al., 1999).

Making HIV Prevention More Effective
Many interventions provide individual counseling, such
as motivational interviewing, to prevent HIV infection
(Carey, 1999; Kelly & Kalichman, 2002). Although these
methods are moderately effective in decreasing risky
behavior, their success is mainly with men and women
who are already infected (Weinhardt et al., 1999). Unin-
fected people who should reduce their risky sexual
behavior often do not, and the reasons they don’t seem to
be similar for homosexual and heterosexual individuals.
We need to keep in mind that the vast majority of today’s
new infections worldwide are in individuals who are
neither gay nor intravenous drug users (UNAIDS, 2009).

How can programs to reduce the spread of HIV infec-
tion be made more effective? Prevention programs must
provide information about HIV transmission and pre-
vention, use techniques to increase people’s motivation
to avoid unsafe sex, and teach behavioral and cognitive
skills needed to perform preventive acts (Albarracı́n et
al., 2005; Carey & Vanable, 2004). Some ways to enhance
these features include:

• Tailoring the program to meet the needs of the
sociocultural group being addressed (Raj, Amaro, &
Reed, 2001).

• Involving the person’s family in the intervention (Dilorio
et al., 2007; Prado et al., 2007).

• Giving strong emphasis to training in the actual
skills individuals will need to resist having unsafe sex
(Fisher et al., 1996; Kalichman, Rompa, & Coley, 1996;
St. Lawrence et al., 2002).

• Using methods to reduce behaviors, such as alcohol
and drug use, that increase the risk of unsafe sex
(Morgenstern et al., 2009; Naar-King et al., 2006; Patrick
& Maggs, 2009).

• Making sure the training is geared toward bolstering
self-efficacy and advancing the individuals through the
stages of change (Galavotti et al., 1995).

• Making use of experts who are like the program recip-
ients—such as in ethnicity and gender—and respected
or popular individuals as leaders to endorse the program
and promote its acceptance by the recipients (Durantini
et al., 2006; Kelly et al., 1997).

• Encouraging infected individuals to disclose their HIV
status to prospective sexual partners (Kalichman &
Nachimson, 1999).

• Using techniques to reduce nonrational influences in
sexual decisions. For example, having people give advice
publicly that contradicts their own behavior can reduce
their future use of denial (Eitel & Friend, 1999).

SUMMARY

People’s behavior has an important impact on their
health. Mortality from today’s leading causes of death
could be markedly reduced if people would adopt a
few health behaviors, such as not smoking, not drinking
excessively, eating healthful diets, and exercising regularly.
Although some individuals are fairly consistent in their
practice of health-related behaviors, these behaviors can
be quite changeable over time. Health-related behaviors
that become well established often become habitual.

Health problems can be averted through three lev-
els of prevention and can involve efforts by the individual
and by his or her social network, physician, and other
health professionals. Primary prevention consists of actions
taken to avoid illness or injury. It can include public ser-
vice announcements, genetic counseling, and a variety of
health behaviors, such as using seat belts and performing
breast or testicular self-examinations. Secondary preven-
tion involves actions taken to identify and stop or reverse

a health problem. It includes tests and treatments health
professionals may conduct, as well as people’s visiting a
physician when ill and taking medication as prescribed.
Tertiary prevention consists of actions taken to contain or
retard damage from a serious injury or advanced disease,
prevent disability, and rehabilitate the patient.

People acquire health-related behaviors through mod-
eling and through operant conditioning, whereby behavior
changes because of its consequences: reinforcement,
extinction, and punishment. Other determinants of these
behaviors include genetic, social, emotional, and cognitive
factors. Errors in symptom perception and ideas people
have about illnesses can lead to health problems. People’s
thinking about health and illness is not always logical—it
often includes motivated reasoning, unrealistic optimism,
and false hopes about their health. Unhealthful behaviors
are not always planned and often depend on the person’s
willingness to be drawn into an attractive situation.

Chapter 6 / Health-Related Behavior and Health Promotion 161

Some theories focus on the role of health beliefs to
account for people’s health-related behavior. The health
belief model proposes that people take preventive action
on the basis of their assessments of the threat of a health
problem and the pros and cons of taking the action.
Threat perceptions are based mainly on the person’s
perceived seriousness of and susceptibility to the health
problem. Assessing the pros and cons of the action
involves weighing its perceived benefits and barriers.
These assessments combine to determine the likelihood
of preventive action. The theory of planned behavior
proposes that health-related behaviors are determined
by people’s intentions, which are a function of their
attitudes regarding the behaviors, subjective norms, and
self-efficacy. The stages of change model focuses on
people’s readiness to modify their behavior; conflict
theory focuses on the role of stress in decisions.

People’s age, sex, and sociocultural background
also affect health-related behavior and need to be con-
sidered in programs for health promotion. Efforts to
promote healthy behavior use information, fear appeals,
motivational interviewing, and behavioral and cognitive
methods, which can be applied with self-management
procedures. But changes in behavior can be temporary;
relapses can occur, partly via the abstinence-violation
effect. Programs for health promotion can be effective in
the schools and in worksites. Community-based wellness
programs are designed to reach large numbers of people
and improve their knowledge and practice of preventive
behavior. The Three Community Study demonstrated that
media campaigns can promote health, and subsequent
research has also integrated extensive efforts by commu-
nity organizations toward improving people’s preventive
actions, such as in stemming the spread of AIDS.

KEY TERMS

health behavior
primary prevention
secondary prevention
tertiary prevention
reinforcement

extinction
punishment
health belief model
theory of planned behavior
stages of change model

motivated reasoning
false hopes
willingness
conflict theory
motivational interviewing

self-management
relapse
abstinence-violation effect

8
NUTRITION, WEIGHT CONTROL AND DIET,
EXERCISE, AND

SAFETY

Nutrition
Components of Food
What People Ea

Nutrition and Health

Weight Control and Diet
Desirable and Undesirable Weight

Becoming Overly Fat
Dieting and Treatments to

Lose Weight
Anorexia and Bulimia

Exercise
The Health Effects of Physical Activity
Who Gets Enough Exercise, Who Does

Not—and Why?
Promoting Exercise Behavior

Safety
Accidents
Environmental Hazards

PROLOGUE
‘‘Let’s share something with each other,’’ said the health
expert to the members of a community workshop. ‘‘What
excuses do we find ourselves using for not eating more
healthfully, not exercising regularly, and not behaving
in other ways that promote health, such as using seat
belts? I’ll start it off,’’ she continued, ‘‘by confessing that

I sometimes skip exercising because I run out of time.
What excuses do you use?’’ The answers came quickly:

‘‘I never seem to have the energy to exercise.’’

‘‘My wife sprained her ankle jogging, and I know lots of
other people who injured themselves exercising.’’

‘‘I don’t have the time to prepare healthful meals.’’

‘‘My grandparents ate high-fat diets and lived past 85.’’

‘‘My kids hate vegetables, and my husband insists on
having meat for dinner.’’

‘‘Seat belts are uncomfortable to use and wrinkle my
clothes.’’

‘‘I’ve had my habits for so long—it’s hard to change.’’

People cite many reasons for not leading more healthful
lifestyles. Some of the obstacles they describe can be
overcome fairly easily, but others are more difficult.
In most cases, people could find ways to overcome
obstacles to healthful behavior if they believed it was
important and were motivated to do so.

In this chapter, we discuss how nutrition, weight
control, exercise, and safety habits are important to
people’s health. We also examine what people do and
do not do in these areas of their lifestyles, as well as
why they behave as they do and how they can change
unhealthful behaviors. As we study these topics, we will
consider important questions and problems people have
in leading healthy lives. Which foods are healthful, and
which are not? What determines people’s preferences

194

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 19

for different foods, such as sweets? Why do overweight
individuals have such a hard time losing weight and
keeping it off? What kinds of exercise benefit health?
What hazards exist in our environments, and how can we
protect ourselves from them?

NUTRITION

‘‘You are what you eat,’’ as the saying goes. This saying
has at least two meanings. Most commonly, it means
that the quality of your diet can determine how you look,
act, and feel. Another meaning is that the same five
types of chemicals—water, carbohydrates, fats, proteins,
vitamins, and minerals—that make up food also make up
the human body and contribute to the cells’ metabolic
processes (Holum, 1994; Peckenpaugh, 2007). In this
section, we will examine both meanings, beginning
with the components of food and their importance in
metabolic processes.

COMPONENTS OF FOOD
Healthful diets provide optimal amounts of all essential
nutrients for the body’s metabolic needs. Let’s consider
the five types of chemical components, besides water, of
food that provide specific nutrients for body functioning.

1. Carbohydrates include simple and complex sugars
that are major sources of energy for the body. Simple
sugars include glucose, which is found in foods made of
animal products, and fructose, which is found in fruits
and honey. Diets may also provide more complex sugars,

such as sucrose (table sugar), lactose in milk products, and
starch in many plants.

2. Lipids or ‘‘fats’’ also provide energy for the body.
Lipids include saturated and polyunsaturated fats, as
well as cholesterol. Nutritionists recommend that diets
contain not more than 30% of calories (nor less than 10%

)

from fat. To calculate food’s percent of calories from fat,
you need to know its number of calories and grams of
fat. Multiply the grams of fat by 9 (because a gram of fat
has 9 calories), and divide that value by the number of
calories in the food.

3. Proteins are important mainly in the body’s syn-
thesis of new cell material. They are composed of organic
molecules called amino acids; about half of the 20 or so
known amino acids are essential for body development
and functioning, and must be provided by our diet.

4. Vitamins are organic chemicals that regulate
metabolism and functions of the body. They are used
in converting nutrients to energy, producing hormones,
and breaking down waste products and toxins. Some
vitamins (A, D, E, and K) are fat-soluble—they dissolve
in fats and are stored in the body’s fatty tissue. The
remaining vitamins (B and C) are water-soluble—the body
stores very little of these vitamins and excretes excess
quantities as waste.

5. Minerals are inorganic substances, such as
calcium, phosphorus, potassium, sodium, iron, iodine,
and zinc, each of which is important in body development
and functioning. For example, calcium and phosphorus
are components of bones and teeth, potassium and
sodium are involved in nerve transmission, and iron
helps transport oxygen in the blood.

Reading labels informs the consumer of
the food’s content. Guidelines adopted
in the 1990s for labeling packaged foods
in the United States make nutritious
choices easier for consumers.

196 Part III / Lifestyles to Enhance Health and Prevent Illness

Food also contains fiber, which is not considered a
nutrient because it is not used in metabolism but is still
needed in the process of digestion. People can get all the
nutrients and fiber they need by eating diets that consist
of a variety of foods from several basic groups, and you
can see the relative amounts of foods from these groups
to make a healthful diet in Figure 8-1. The way food is
prepared is also important. Consider the potato: A baked
or boiled potato by itself has few calories and almost
no fat, but when french-fried or made into potato chips,
its calorie and fat content skyrockets. People’s increased
use of processed and fast foods has made their diets
less healthful.

Most people who eat healthfully do not need
to supplement their diets with vitamins and other
nutrients—one carrot, for instance, provides enough
vitamin A to last 4 days. A class of vitamins called antioxi-
dants—including vitamins A (carotene), C, and E—reduce
damage to cells from a process in metabolism called oxi-
dation. Early evidence suggested that antioxidants may

Milk Productsa (3 cups) Mainly low-fat or fat-free milk,
cheese, or yogurt.

Vegetables (2–3 cups) Include dark green and orange
vegetables, and beans and peas.

Oils and Sweets Use sparingly; oils (including fats)
should be vegetable, especially from olives, canola,
or corn.

Meats and Fish (Beans and Nuts)b
(5–6½ ounces) Choose poultry without skin, fish, or
lean meats and prepare by broiling, baking, or grilling.

Fruits (1½–2 cups) Include a variety of fresh, frozen,
canned, or dried fruits; limit juice and don’t include
in the amount.

Grains (5–8 ounces) Including bread, cereals, rice, and
pasta; at least half of these should be made of whole
grains, not refined.

0 5 10 15 20 25

Percent of diet (by quantity)
aPeople who cannot consume milk products, or prefer not to, may choose
other calcium sources, such as lactose-free products made from rice or
soy beans.
bPeople who eat little or no animal products substitute beans and nuts.

Figure 8-1 Proportions of six food groups in a healthful
diet. The colored bars reflect the portions of the diet
recommended for each food group for adults; ranges in
daily amounts in parentheses reflect that males and younger
adults need higher quantities. The shaded jogger represents
the importance of physical activity. Diagram based mainly
on the latest food-guide pyramid of the United States
Department of Agriculture, which can be accessed online
(www.mypyramid.gov) for detailed information.

reduce the risk of several diseases, such as cancers and
cardiovascular and eye diseases (Johnson, Meacham,
& Kruskall, 2003). Newer research has found that taking
vitamins C and E does not prevent cardiovascular disease
(Sesso et al., 2008; Vivekananthan et al., 2003).

Some people who take supplements have an attitude
of ‘‘the more the better.’’ But one can overdo taking some
nutrients, leading to a ‘‘poisoning’’ if they accumulate
in the body. For example, although vitamin D seems to
protect against cancer (Garland et al., 2006), too much of
vitamins A and D can pose serious health hazards to the
liver and kidneys, respectively. Women who are pregnant
have greater needs of all nutrients; although most of
their extra nutrients can come from dietary adjustments,
they should also take recommended supplements, such
as of iron (Insel & Roth, 1998; Peckenpaugh, 2007).
Pregnant women with a specific, detectable gene may
need to take folic acid, a B vitamin, to prevent a severe
birth defect called spina bifida, in which the baby’s spinal
column doesn’t close and may protrude through the back
(AMA, 2003).

Unprocessed foods are generally more healthful
than processed foods, which often contain additives
that benefit the food industry more than the consumer.
Some additives lengthen the shelf life of the food,
improve or maintain the texture of foods, or enhance
the taste of foods, for example (Insel & Roth, 1998).
Although most additives are not harmful, some cause
allergic reactions or may be carcinogenic. For instance,
some people are sensitive to monosodium glutamate
(MSG, a flavor enhancer), experiencing heightened blood
pressure and sweating when they consume it. Children
may be very vulnerable to the effects of additives because
their body systems are still forming and maturing rapidly
and, pound-for-pound, they eat more than adults. Many
people buy foods labeled ‘‘organic,’’ believing that they
have less of harmful chemicals, which may be true, but
organic foods do not appear to be more nutritious than
conventional foods (Dangour et al., 2009).

WHAT PEOPLE EAT
Diets vary by gender and culture. A survey of nearly
20,000 university students in 23 countries showed that
women report eating healthier diets—less fat and more
fruit and fiber—than men in almost all countries, but
there are marked national differences in dietary practices
(Wardle et al., 2004). Table 8.1 lists countries with the
most and least healthful practices. For most of the 20th
century, American diets had a fairly consistent trend:
people consumed more and more sugar, animal fats,
and animal proteins, while consuming less and less fiber
(Winikoff, 1983). Since the mid-1980s, dietary trends in

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 19

Table 8.1 Two Countries among the Highest and the Lowest in Percentage of Individuals with
Healthful Practices for Each of Three Dietary Components (Fat, Fruit, and Fiber)∗

Countries with High Practice Countries with Low Practice
Healthful Practices (% of males, females) (% of males, females)

Dietary fat, avoid eating Colombia (36.3, 55.7) France (16.6, 38.2)
Thailand (34.5, 59.2) Korea (11.3, 13.2)

Dietary fruit, eat daily Italy (57.9, 63.8) Japan (11.9, 12.1)
Spain (57.1, 64.0) Korea (16.0, 33.3)

Dietary fiber, eat daily Korea (38.7, 58.8) Bulgaria (12.5, 25.4)
Thailand (64.6, 78.6) France (10.9, 28.7)

∗The percentages were intermediate for the United States (33.1, 50.4 for fat; 31.7, 35.5 for fruit; 21.2,
20.4 for fiber) and England (29.8, 49.5 for fat; 35.8, 44.1 for fruit; 26.0, 38.7 for fiber).
Source: Wardle et al., 2004, abstracted from Table 2.

the United States have shown some good news and bad
news (USBC, 2010):

• Healthful changes. Consumption of red meat and whole
milk has decreased, and poultry, rice, skim milk, and
vegetables increased.

• Unhealthful changes. Intake of sugars, soft drinks, cheese,
cream, and fats and oils has increased.

Table 8.2 compares the diets available for consumption
in the United States and several countries in Europe and
suggests that Americans consume much more calories
and fats than Europeans do.

Why do people eat what they eat? The answer
involves biopsychosocial factors (Peckenpaugh, 2007).
One factor is inborn processes: for instance, newborn babies
like sweet tastes and avoid bitter tastes. Brain chemicals
can bias people to eat fatty foods and activate their brain
pleasure centers when they do (Azar, 1994). Another
factor is the person’s skills—for example, the ability
to regulate or manage one’s food buying or eating
(Anderson, Winett, & Wojcik, 2007). The more able people
are in setting goals, planning, and monitoring the foods
they consume, the healthier their diets are likely to
be. Another factor is one’s environment or experience with
foods; we’ll look at five environmental influences. First,

newborns can learn to like foods they might otherwise
avoid: a study tested newborns’ liking of pureed green
beans, then had their breastfeeding mothers eat green
beans daily for 8 days, and retested the babies’ liking
of pureed green beans (Forestell & Mennella, 2007). At
retesting, the infants ate more of the beans than they had
originally, but infants in a control group that was formula
fed showed no change in the amount they ate. Second,
some foods are more available than others at home,
work, or school, depending on cultural and economic
conditions—and simply being exposed to a food may
increase one’s liking of it (Hearn et al., 1998; Larson
& Story, 2009). Third, the more fast-food restaurants in a
neighborhood, the more fast-food people eat (Moore et
al., 2009). Fourth, people observe in person and through
TV commercials how others respond to a food and tend
to become more attracted to it if they see others eat it
and like it. Sweet, high-fat snack and convenience foods
dominate the ads in popular American children’s TV
shows and are available almost everywhere we go (Farley
et al., 2010; Harrison & Marske, 2005). Fifth, portion sizes
are often ‘‘supersized’’—the larger the portions, the more
people eat (Rolls, Morris, & Roe, 2002).

Enormous numbers of children around the world
simply do not have nutritious diets available to them for
proper growth and development. About half of children
are stunted in growth from malnutrition in several
countries, such as Ethiopia, Guatemala, and Angola
(WHO, 2009). Children are much shorter if they live
in very impoverished areas than in wealthier regions,
even in the same countries (Meredith, 1978). Regional
and social class differences in bodily growth result from
many factors, including genetics, nutrition, and disease.

NUTRITION AND HEALTH
The mass media announce almost daily that many
individuals eat diets that are not as healthful as they
should be. Some people react by using foods and

Table 8.2 Average Quantities of Calories, Fat, and Protein
Available for Consumption per Person per Day in the United States
and Several European Countries

Calories Fat Protein
Country (in kilocalories) (in grams) (in grams)

United States 3900 178 111
Germany 3484 142 100
Italy 3675 156 113
Netherlands 3495 140 105
Sweden 3208 127 108
Turkey 3328 91 96
United Kingdom 3450 135 105

Sources: USBC, 2010, Table 211; WHO/Europe, 2010.

198 Part III / Lifestyles to Enhance Health and Prevent Illness

Reprinted by permission: Tribune Media Services.

substances sold at health food stores. Although some
of these products—such as whole grains—are clearly
beneficial, many supplements and other products are
of dubious worth (Peckenpaugh, 2007). Some people
attempt to improve their diets by becoming vegetarians.
There are degrees of vegetarianism, ranging from simply
avoiding red meats to strictly using only plant foods
and no animal products whatsoever. When people avoid
all animal products, they must plan very carefully to
assure that their diets, and especially their children’s,
contain a balance of proteins and a sufficient amount of
essential vitamins and minerals (Peckenpaugh, 2007).
In many nations of the world, dietary excesses are
the main nutritional problem, especially in developing
atherosclerosis, hypertension, and cancer.

Diet and Atherosclerosis
Cholesterol is the main dietary culprit in atherosclerosis,
the deposit of fatty plaques in our blood vessels,
illustrated in Figure 8-2. As we saw in Chapter 2,
cholesterol is a fatty substance. Our bodies produce
most of the cholesterol in blood, and our diets provide
the remainder. Whether cholesterol forms plaques in
our blood vessels depends on the presence of different
types of lipoproteins, which consist of fat and proteins.
There are several types of lipoproteins, but two are
most important: low-density lipoprotein (LDL) is related
to increased plaque deposits; high-density lipoprotein
(HDL) is linked to decreased likelihood of plaque buildup
(AHA, 2010; AMA, 2003).

Cholesterol carried by LDL is called ‘‘bad choles-
terol’’ because it mixes with other substances to form
plaques, whereas cholesterol carried by HDL is called
‘‘good cholesterol’’ because it seems to carry LDL away

to be processed or removed by the liver. There are many
other types of dietary fat, three of which are clearly linked
to health. Triglycerides are in most fats people consume
and increase the risk of heart disease; omega-3 fatty acids,
which occur at high levels in fish, reduce serum triglyc-
erides and raise HDL; and trans-fatty acids are in certain
oils, such as margarine, increase LDL and lower HDL
(Mozaffarian et al., 2006; Peckenpaugh, 2007). Because of
the role of dietary fats in cardiovascular disease, commu-
nities have begun passing laws against the use of certain
fats in preparing foods sold commercially.

How much cholesterol in the blood is too much?
Normal levels of cholesterol increase with age in adult-
hood; they are measured in milligrams of cholesterol per
100 milliliters of blood serum. Experts once thought that
long-term total serum cholesterol levels above 240 mg
put people at high risk for heart disease or stroke, but
they have refined this view (EPDET, 2001). ‘‘Bad’’ cholesterol
(LDL) is the real culprit, and its risk depends on five other
risk factors:

• Age (over 45 years for men, 55 for women)

• Cigarette smoking

• High blood pressure

• Low ‘‘good’’ cholesterol (HDL less than 40 mg)

• Family history of early cardiovascular disease

To determine one’s heart attack or stroke risk, count up
the person’s risk factors and subtract 1 if his or her HDL is
high (60 mg or higher). People with scores of 0 or 1 are at
low risk and should keep LDL levels below 160 mg. People
with higher scores should maintain much lower LDL
levels, and those who already have heart disease should
strive to keep LDL levels below 100 mg (AHA, 2010).

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 199

(a) Normal artery (b) Obstructed artery

Partially
obstructed
lumen (space
through which
blood flows)

Atherosclerotic
plaque

Lumen

Figure 8-2 Magnified cross-sectional views of two arteries, (a) normal and (b) obstructed from atherosclerosis. As the
plaque (shaded in color) builds up, the lumen becomes smaller, limiting blood flow.

People’s cholesterol levels are determined partly
by heredity and partly by their lifestyles (AHA, 2010;
McCaffery et al., 2001). For instance, smoking cigarettes
appears to increase LDL and decrease HDL levels
(Muscat et al., 1991). Diet is an important factor: some
foods, such as eggs, many milk products, and fatty
meats, contain very high concentrations of cholesterol.
Daily intake of cholesterol should not exceed 300 mg
(Peckenpaugh, 2007); it should be much lower for people
at moderate or high risk for cardiovascular disease.
Children older than 5 years should follow diets like those
recommended for adults; those whose parents or grand-
parents had heart disease at early ages should have their
cholesterol levels and diets assessed because atheroscle-
rosis can begin in childhood (DISC, 1995). If dietary
changes do not lower adults’ cholesterol levels enough,
physicians may prescribe medication. Statin drugs (some
brand names: Crestor, Lipitor, Zocor) greatly reduce LDL
and raise HDL levels (AMA, 2003; Nissen et al., 2006).

Does lowering LDL reduce cardiovascular illness?
Yes. Studies have shown that large reductions in LDL,
produced with combined dietary and drug treatment,
retard and slowly reverse atherosclerosis and reduce the
risk of heart attacks (Karnik, 2001; Nissen et al., 2006).
Dietary patterns, such as the ‘‘Mediterranean diet,’’ that
conform to the recommendations in Figure 8-1 appear to
reduce the risk of heart disease and metabolic syndrome
(Buckland et al., 2009; Salas-Salvado et al., 2008). Most
people can lower their cholesterol intake markedly if they
will modify their eating habits, sometimes by making very
simple changes, such as by substituting low-cholesterol
foods, such as cereals, for just four eggs per week—an
egg contains over 200 mg of cholesterol. Most cereals,
breads, fruits, nuts, and vegetables contain little or
no cholesterol. Other ways include switching to fish
or poultry in place of red meats, broiling or baking foods
instead of frying, using low-fat dairy products, and using

low-cholesterol vegetable fats for cooking. But people
should be wary of processed foods that don’t specify
the type of vegetable oil they use—these products often
contain saturated fats (coconut or palm oils) instead of
the more expensive polyunsaturated fats, such as corn or
soybean oils. Oils that derive from certain plants, such
as olives, consist of monounsaturated fats that contain no
cholesterol and appear to lower serum LDL, but not HDL
(Insel & Roth, 1998; Peckenpaugh, 2007).

There is a curious caution on the health effects
of lowering people’s cholesterol: although the evi-
dence is inconsistent and inconclusive, some studies
have found that markedly reduced serum cholesterol is
associated with nonillness deaths, such as from acci-
dents, suicide, and violence (Muldoon & Manuck, 1992;
Muldoon, Manuck, & Matthews, 1990). But we don’t know
why. Prospective studies have tested whether lowering
cholesterol might, perhaps, increase people’s negative
moods in the following months or years and found
that it does not (Bovbjerg et al., 1999; Coutu, Dupuis,
& D’Antono, 2001).

Diet and Hypertension
People with blood pressures exceeding 140 systolic/90
diastolic are classified as hypertensive. About one billion
people around the world and 30% of American adults are
hypertensive (Hajjar, Kochen, & Kochen, 2006; NCHS,
2009a). Although medication can lower blood pressure,
the first methods doctors advise usually involve lifestyle
changes, especially losing weight and restricting certain
foods in the patient’s diet. People who are at risk for
developing hypertension can effectively reduce their
risk by making such changes (Blumenthal, Sherwood
et al., 2002).

Of all the substances in people’s diets that could
affect blood pressure, sodium—such as in salt (sodium

200 Part III / Lifestyles to Enhance Health and Prevent Illness

chloride)—may play the strongest role. Consuming high
levels of sodium can increase people’s blood pressure
and reactivity when stressed (Blumenthal, Sherwood
et al., 2002; Falkner & Light, 1986). The body needs
about 500 mg of sodium a day, and health experts
recommend consuming less than 2,300 mg, the amount
in 1 teaspoon of salt (Peckenpaugh, 2007). Individuals
who frequently eat processed meats, snacks, and other
convenience foods probably consume more than the
recommended amount. Because sodium can elevate
blood pressure, physicians often place hypertensive
patients on low-sodium diets. Although some people
are more sensitive to the effects of sodium than
others, the evidence is now clear that reducing dietary
sodium lowers blood pressure in hypertensive people.
Salt-sensitive individuals can lower their blood pressure
by reducing sodium intake and by increasing potassium
intake, which counteracts sodium effects (Blumenthal,
Sherwood et al., 2002; West et al., 1999). Reducing
dietary salt also decreases the risk of developing heart
disease (Bibbins-Domingo et al., 2010).

Caffeine is another dietary substance that can affect
blood pressure. Most of the caffeine people consume
comes from drinking caffeinated coffee, tea, and cola.
Caffeine increases people’s reactivity to stress and raises
their blood pressure during the days that it is consumed
(James, 2004; Lane et al., 2002). Does consuming caffeine
lead to high blood pressure and coronary heart disease?
Reviews of research have revealed no link between
caffeine consumption and hypertension and heart
disease (Riksen, Rongen, & Smits, 2009; Wu et al., 2009).

Diet and Cancer
The role of diet in cancer is becoming clear: diets high in
saturated fat and low in fiber and fish are associated with
the development of cancer, particularly of the colon
and prostate gland (ACS, 2009; Norat et al., 2005).
Cancer experts advise people to maintain a healthy
weight, consume little of fatty meats, and eat much
fish, vegetables, fruits, and high-fiber breads and cereals
to reduce their risk of cancer.

Do vitamins protect people from cancer? Many fruits
and vegetables are rich in beta-carotene, which the body
converts to vitamin A; these foods are also good sources
of vitamin C. Early studies yielded results suggesting that
these vitamins may protect people from cancers, but the
current evidence is not definitive (Johnson, Meacham,
& Kruskall, 2003). On the basis of the early findings,
some people began to take high doses of vitamin A and
C supplements. Nutritionists recommend against this,
especially with vitamin A because it builds up in the
body, and it is easy to overdose.

Interventions to Improve Diet
Dietary interventions take many forms. They can focus
on a single nutritional component, such as cholesterol,
or promote a healthy overall diet of low fat and high
vegetable and fruit content. And they can be provided
as counseling sessions with individuals who have a
known dietary or health problem and as large-scale
programs for members of a group or community, such as
employees or school students, using written or computer
materials and group meetings. The most effective dietary
interventions today incorporate or address elements of
the theories of health-related behavior we considered
in Chapter 6—for example, the person’s perceived
barriers and benefits of change (health belief model),
self-efficacy (social-cognitive theory), and readiness to
change (stages of change model) (Glanz, 2001). To
maximize success, interventions can use behavioral
and educational methods for the person, training and
cooperation by members of the person’s household,
support groups, and a long-term follow-up program
(Carmody et al., 1982). They should also address the
person’s strong preferences for high-fat, low-fiber foods
and difficulties having healthful foods when not eating
at home (Terry, Oakland, & Ankeny, 1991).

Let’s look at a couple of examples of dietary
interventions, one that focused on reducing cholesterol
and another that addressed the overall diet. The program
to reduce cholesterol was part of the Multiple Risk
Factor Intervention Trial (MRFIT) and was designed to
modify the diets of thousands of men over a period of
6 years (Caggiula et al., 1981; Dolecek et al., 1986). The
men were at risk of coronary heart disease because of
high serum cholesterol levels, high blood pressure, and
cigarette smoking. The intervention provided counseling
and information each year about the benefits of and
methods for modifying diets when the men and ‘‘their
homemakers’’ attended group meetings. Compared with
a control group with ‘‘usual care’’ from their physicians,
the MRFIT program markedly modified the men’s diets
and lowered their serum cholesterol levels. The men who
most needed to modify their diets tended to do so and
achieved the greatest gains. A meta-analysis of many
similar interventions found that programs to reduce high
serum cholesterol help people improve their diets and
reduce cardiovascular risk (Brunner et al., 1997).

The intervention to modify overall diets recruited
over 600 adult females from a large medical practice
who were not already eating a low-fat diet and assigned
them randomly to an intervention or control condition
(Stevens et al., 2002). The intervention applied elements
of the stages of change model, motivational interviewing,
and social-cognitive theory to decrease fat and increase

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 201

vegetable and fruit consumption. The women in the
intervention received two individual counseling sessions
that included a 20-minute computer program to assess
and give feedback on their dietary habits. They also
received two counseling phone calls and healthful
recipes and hints on shopping, snacking, and eating
in restaurants. Assessments after a few months revealed
that the diets had improved—that is, contained much
less fat and more vegetables and fruit—for women in the
intervention but had gotten a little worse for those in the
control condition.

What people include in their diets is clearly related
to their risk of developing several major chronic diseases.

Do people who receive an intervention and improve their
intake of fat, vegetables, and fruit dislike their new diets?
No, and across years they report greater life satisfaction
and confidence that they can promote their health
than similar people without the intervention (Corle et
al., 2001). Other dietary problems that affect health
arise from consuming too many calories. Research with
animals has shown that reducing calorie intake by 30%
from standard nutritious diets decreases metabolism,
slows the aging process, and increases longevity (Lane
et al., 1996). Eating too much food can be unhealthful,
as we are about to see.

If you have not read Chapter 2, The Body’s Physical
Systems, and your course has you read the modules

from that chapter distributed to later chapters, read
Module 3 (The Digestive System) now.

WEIGHT CONTROL AND DIET

People in many cultures around the world are ‘‘weight
conscious.’’ In the United States, individuals often start
being concerned about their weight in childhood and
adolescence, particularly if they are overweight and
are teased and excluded from social groups (Rosen,
2002; Zeller & Modi, 2008). Many teens become greatly
preoccupied with their physical appearance and would
like to change how they look. They frequently express
concerns about skin problems and wanting to have a
better figure or more athletic body, to be taller or shorter,
and to be the ‘‘right’’ weight. People with less-than-ideal
bodies are often thought of as lazy and self-indulgent,
and many of them wish or strive for bodies they are
biologically unable to achieve (Brownell, 1991). Being
very overweight puts teens—especially girls—at risk for
developing depression and anxiety disorders (Anderson
et al., 2007; Petry et al., 2008).

DESIRABLE AND UNDESIRABLE WEIGHTS
We judge the desirability of our weight with two criteria.
One is attractiveness. Being the ‘‘wrong’’ weight often
affects people’s self-esteem, and American females
provide a clear example. A study of overweight 10-
to 16-year-old Caucasians found that girls’ self-esteem
declined sharply and consistently through those years,
but boys’ self-esteem declined only during the early
years (Mendelson & White, 1985). Perhaps as overweight
boys get older, some degree of bulk is considered
‘‘manly.’’ And a survey of teenagers found that most
of the girls and few boys were trying to lose weight,

and many boys were trying to gain weight (Rosen
& Gross, 1987). The greater concern among females
than males about their weight—especially about being
overweight—continues in adulthood (Forman et al.,
1986). But cultural differences exist. Among overweight
women in the United States, African Americans are
more satisfied with their bodies than Whites are (Flynn
& Fitzgibbon, 1998).

The other criterion for judging weight is health-
fulness, based on data from studies of morbidity and
mortality rates of men and women. Individuals who stay
within certain weight ranges for their height have far
lower rates of chronic illness and longer life spans than
others do. Whether individuals do anything about their
weight and what they do can have important implications
for their health.

Overweight and Obesity
No matter how fit we are, our bodies have some fat—and
they should. Having fat is a problem only when we have
too much. The question is, how much is too much?
Determining how much fat a person’s body has is not
as easy as it may seem. Bulk or stockiness alone can
be misleading since some stocky people simply have
larger skeletal frames than others, or their bodies are
more muscular. Until the mid-1990s, overweight was
evaluated by the degree of excess over ideal weights
given in tables. Today, these judgments are based on
the body mass index (BMI): people are classified as
overweight if their BMI is 25 or higher, and obese if their
BMI equals or exceeds 30 (NCHS, 2009a). You can find
your approximate BMI in Table 8.3 or calculate it exactly:
for American measurements, multiply your weight in

202 Part III / Lifestyles to Enhance Health and Prevent Illness

Table 8.3 Values of the Body Mass Index Calculated from Height and Weight, with Shading for Health-Related Categories:
Underweight, Healthy Weight, Overweight, and

Obese

Under-
weight

6’6’’

6’4’’

6’2’’

6’0’’

5’10’’

5’8’’

5’6’’

5’4’’

5’2’’

5’0’’

4’10’’

4’8’’
4’6’’

Healthy-
weight

Over-
weight

Obese*

31 34 36 39 41 43 46 48 51 53 56 58

29 31 34 36 38 40 43 45 47 49 52 54

27 29 31 34 36 38 40 42 44 46 48 50

25 27 29 31 33 35 37 39 41 43 45 47

24 26 27 29 31 33 35 37 38 40 42 44

22 24 26 28 29 31 33 34 36 38 40 41

21 23 24 26 27 29 31 32 34 36 37 39

20 21 23 24 26 27 29 30 32 34 35 37

19 20 22 23 24 26 27 29 30 32 33

18 19 20 22 23 24 26 27 28 30 31 33

17 18 19 21 22 23 24 26 27 28 30 31

16 17 18 20 21 22 23 24 26 27 28 29

15 16 17 19 20 21 22 23 24 25 27 28

Height in
ft. & in. 130 140 150 160 170 180 190 200 210 220 230 2

Weight in Pounds

BMI � below 18.5 BMI � 30 or moreBMI � below 18.5�24.9 BMI � 25.0�29.9

∗People with BMIs of 40 or more are described as extremely or morbidly obese.

pounds by 704.5 and divide twice by your height in inches
(for metric measurements, simply divide your weight
in kilograms twice by your height in meters). Although
the BMI doesn’t measure the amount of body fat an
individual has, professionals can use complex methods
that do (Perri, Nezu, & Viegener, 1992).

Sociocultural, Gender, and Age Differences
in Weight Control
The prevalence of overly fat people varies with national-
ity, sociocultural factors, gender, and age. Some national
differences can be seen in Table 8.4, which gives the per-
centages of men and women who are obese in a variety
of countries—obesity rates are high in the United States
and low in Asian nations. And in most countries, obesity
rates are higher among women than men.

Research has revealed a disturbing trend: among
children and the population as a whole in the United
States and other developed nations, the percentage
who are overly fat has increased substantially during
the last few decades (NCHS, 2009a; Wadden, Brownell,
& Foster, 2002). As Table 8.5 shows, the prevalence rates
of overweight for Americans has increased dramatically
for men and women and more than quadrupled for
children since the early 1970s. The reason is simple:
people are consuming more calories and engaging in
less physical activity than in the past. For instance,
in the three decades preceding 2000, Americans’ daily

consumption increased by 168 calories (7%) for men and
335 (22%) for women (CDC, 2004). Americans get heavier
throughout the early- and middle-adulthood years, with
the prevalence of overweight reaching and staying at
their highest levels from 50 to 75 years of age (NCHS,
2009a).

Table 8.4 Percentages of Adulta Men and Women Who Are
Obese (BMI = 30 or Higher) in Various Nations Around the World

Country Men Women

Australia 20.5 25.5
Brazil 8.9 13.1
Canada 22.9 23.2
China 2.4 3.4
Germany 20.5 21.1
Italy 7.4 8.9
India 1.3 2.8
Netherlands 10.2 11.9
Singapore 6.4 7.3
South Africa 8.8 27.4
Sweden 11.0 14.0
Turkey na 22.7
United Kingdom 22.3 23.0
United States 33.1 35.2

aAdults were usually defined as 15 and older; some countries used
different lower age limits or applied upper limits. Although the data
were collected recently, some are a few years older than others;
na = data not available.
Sources: NCHS, 2009a, Table 75 (for the United States); WHO, 2009.

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 203

Table 8.5 Percentages of American Adult and Child Population
Who Were Overweight (BMI = 25 or higher) in the Early 1970s
and Today

Ages 6 to 11 Years Ages 20 to 74 Years
Years Both Sexes Men Women

1971–1974 4.0 54.7 41.1
2003–2006 17.0 72.6 61.2

Source: NCHS, 2009a, Tables 75 and 76.

Table 8.6 Percentage of White, Black, and Mexican American
Men and Women Age 20 and Over Who Are Overweight (BMI =
25 or more) and Obese (BMI = 30 or more)

Weight White Black Mexican
Status Male Female Male Female Male Female
Overweight 72.1 57.4 72.0 80.5 77.3 74.4
Obese 33.0 32.5 36.3 54.3 30.4 42.6

Source: NCHS, 2009a, Table 75.

Table 8.6 illustrates two important points about
the body weights of American adults. First, the rates of
overweight and obesity are extremely high across the
three largest ethnic groups. Second, ethnic differences
in overweight and obesity are clear and vary with gender.
African American women have the highest rates of
overweight and obesity; Mexican American women have
the second-highest rate of obesity. The rates of obesity
are similar for White men and women, Black men, and
Mexican American men; White women have the lowest
rates of overweight.

BECOMING OVERLY FAT
People add fat to their bodies by consuming more
calories than they burn up through metabolism. Children
who put on a lot of weight also eat much more
fatty foods than others do (Robertson et al., 1999).
The body stores excess calories as fat in adipose tissue,
which consists of cells that vary in number and
size (Logue, 1991). According to researcher Margaret
Straw, the

growth of adipose tissue throughout childhood and
adolescence involves both an increase in cell size and
in cell number. Thereafter, it appears that growth in
adipose tissue is initially associated with an increase
in cell size; if cell size becomes excessive, new adipose
tissue is generated through an increase in the number
of cells. (1983, p. 223)

There are two main reasons why adults tend to gain
weight as they get older. First, people often put on
weight at certain times, such as during pregnancy or
around holidays, without taking it all off; the balance

A good way to control weight and promote health is to eat
foods that are low in calories and fat, such as salads with
low fat dressings.

accumulates across years (Amorim Adegboye, Linne, &
Lourenco, 2008; Phelan et al., 2008). Second, physical
activity and metabolism decline with age (Smith, 1984).
To maintain earlier weight levels, people need to take
in fewer calories and exercise more after weight gains
and as they get older. Both biological and psychosocial
factors affect weight control.

Biological Factors in Weight Control
Because the metabolic rates of individuals can differ
greatly, some thin people consume many more calories
than some heavy people do and still stay slim. Fat
tissue is less metabolically active than lean tissue,
‘‘so fatness itself can directly lower metabolic rate if
fat tissue begins to replace lean tissue’’ (Rodin, 1981,
p. 362). This means that people who are obese may
continue to gain weight even if they don’t increase
caloric intake. Do heavy people eat more than normal-
weight people? Yes, on average they do, and their
diets contain more fats (Wing & Polley, 2001). Keep in
mind that people’s self-reports of dietary intake without
corroboration can be misleading. Underreporting dietary
intake is very common and occurs more among heavy
than normal-weight individuals, females than males, and
people with little education (Klesges, Eck, & Ray, 1995;
Lichtman et al., 1992).

204 Part III / Lifestyles to Enhance Health and Prevent Illness

Is heredity important in the development of obesity?
Yes—for one thing, fatness of parents and their offspring
are related (Whitaker et al., 1997). The chances of normal-
weight children becoming obese by 30 years of age
are low if their parents are of normal weight rather
than obese. For obese children, the risk of being obese
in adulthood is high even if they have normal-weight
parents, and that risk doubles if their parents are obese.
Of course, parent–child similarities may not be the result
only of genetic factors: children learn many of their eating
habits and physical activity patterns from their parents.
But there is clearer evidence for the role of genetics:

• Twin and adoption studies have consistently found a
genetic link in obesity (Wardle & Carnell, 2009; Wing
& Polley, 2001).

• Evidence is mounting for a role of epigenetic processes
in obesity (Waterland & Michels, 2007). Recall from
Chapter 1 that environmental factors at critical times in
the lifespan can produce chemical structures at DNA that
can suppress a gene’s usual activity and be transmitted
to one’s offspring.

• Researchers have identified specific genes in humans
and animals that are linked to obesity (de Krom et al.,
2009; Frayling et al., 2007; Wardle & Carnell, 2009). Two
such genes are FTO, which affects the feeling of satiation
and is linked to developing adipose tissue, and MC4R,
which is associated with preferring and consuming high
amounts of dietary fat.

But keep in mind three points about genetics and
obesity. First, heredity is not destiny: a study found
that people with the FTO gene who were very physically
active were no heavier than others who did not have the
gene (Rampersaud et al., 2008). This suggests that being
physically active may overcome a genetic predisposition
to be overweight. Second, we don’t know how many
people have genes that promote weight gain or how much
of their excess weight results from these genes. Third, the
recent surge in obesity around the world could not have
resulted only from changes in genes—environmental
factors are important, too.

Part of the way heredity affects our weight seems
to be described in set-point theory, which proposes
that each person’s body has a certain or ‘‘set’’ weight
that it strives to maintain (Keesey, 1986; Wonderlich &
Freiburger, 2004). The body tries to maintain its weight
near the set-point by means of a thermostat-like mech-
anism that involves the hypothalamus. When a person’s
weight departs from the set-point, the body takes cor-
rective measures, increasing or decreasing eating and
metabolism. According to the theory, people whose
caloric intake is either drastically reduced or increased for
a few months should show rapid corresponding weight
changes initially, but the weight should then show slower

changes and reach a limit. Studies have found that these
predictions are correct and that people soon return to
their original weight when they can eat what they want
again (Leibel, Rosenbaum, & Hirsch, 1995; Sims, 1976;
Wonderlich & Freiburger, 2004). But set-point theory is
incomplete: it doesn’t explain, for instance, why some
people who lose a lot of weight manage to keep it off.

How is the hypothalamus involved in regulating
body weight? One way is by monitoring the blood for
levels of two hormones, leptin and insulin, that increase
or decrease in proportion to the amount of body fat
the person has (Tortora & Derrickson, 2009). Leptin
regulates circuits in the hypothalamus that stimulate
and inhibit eating and metabolism. Insulin is produced
by the pancreas and has a similar, smaller effect on
the hypothalamus, but it also regulates the amount of
sugar (glucose) in the blood, glucose’s conversion to
fat, and the storage of fat in adipose tissue (Rodin,
1981, 1985). Obese people tend to have high serum
levels of insulin—a condition called hyperinsulinemia—
which increase one’s sensations of hunger, perceived
pleasantness of sweet tastes, and food consumption.
Taken together, these findings indicate that weight
gain results from a biopsychosocial process in which
physiological factors interact with psychological and
environmental factors (Rodin, 1985).

It seems likely that the setting and function of the
set-point in regulating weight depend on the number and
size of fat cells in the body. Because the number of fat
cells increases mainly in childhood and adolescence, the
diets of individuals during that time in the life span are
likely to be very important. Obese children have fat cells
that are as large as those of adults (Knittle et al., 1981). As
these children gain weight, they do so mainly by adding
fat cells, which normal-weight children don’t do. Also, it
appears that the number of fat cells can increase, but not
decrease (Brownell, 1982). Individuals who develop too
many fat cells—a condition called fat-cell hyperplasia—may
be doomed to struggle against a high set-point for the
rest of their lives. When fat-cell-hyperplastic adults try to
lose weight, their fat cells shrink and

send out metabolic signals similar to those during
food deprivation. As a result, bodily mechanisms
respond as though the person were starving, resulting
in, among other things, an increase in hunger and a
decrease in basal metabolism so that energy stores
(i.e., fat) are maintained more efficiently. (Buck,
1988, p. 467)

This suggests that children’s dietary and exercise pat-
terns may be critical in determining whether they become
overly fat. Once a person’s set-point becomes estab-

lished, changing it appears to be difficult.

(Go to .)

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 205

HIGHLIGHT

Do ‘‘Fat-Bugs’’ Lead to Overweight?
Obese people’s intestines are teeming

with a type of bacteria, called Firmicutes, that lean people
have in much smaller numbers (Bajzer & Seeley, 2006).
Laboratory mice have the same pattern: obese mice
have more of these bacteria than lean mice do. These
bacteria are extremely efficient at drawing calories out
of food, allowing the calories to be absorbed into the
bloodstream. What happens to obese people’s Firmicute
levels when they lose weight? Researchers tested this
and found that the levels decline. What would happen
if researchers were to transfer large numbers of bacteria
from the guts of obese mice to normal-weight mice that

have none of these bacteria? Researchers tested this,
too, and found that the mice that received bacteria from
obese mice gained more weight than a control group
that received bacteria from lean mice.

These findings are intriguing, but there’s a lot we
don’t know yet about the role of these ‘‘fat-bugs’’ in
overweight. How much of one’s weight gain results from
high levels of Firmicutes? Do set-point mechanisms,
especially the role of leptin, influence the levels or
functioning of these bacteria? Would removing or
disabling Firmicutes in obese people help them lose
weight?

Psychosocial Factors in Weight Control
Psychosocial factors are also involved in weight control.
For one thing, negative emotion affects eating and weight
gain. Many people claim to eat more when they are
anxious or upset, and evidence indicates that stress can
induce eating (Logue, 1991). What’s more, the foods
people and animals eat when stressed tend to be
sweet and high in fat—that is, ‘‘comfort foods’’ (Dallman
et al., 2003; Oliver, Wardle, & Gibson, 2000). Prospective
research found that experiencing chronic stress and
negative emotion, such as depression, puts people at risk
for binge eating and becoming obese (Block et al., 2009;
Stice, Presnell, & Spangler, 2002; Vogelzangs et al., 2008).
Binge eating refers to episodes in which the person eats
far more than most people would in a fairly short period,
such as a couple of hours, and feels unable to control
that behavior during that time (Garfinkel, 2002). Frequent
binge eating is a common feature of individuals who seek
treatment for obesity (Stice et al., 1999).

Another factor is the person’s social network. A study
found that individuals with a spouse or a same-sex sibling
or friend who is obese are more likely in the next few years
to become obese themselves than people without close
social ties to obese people (Christakis & Fowler, 2007).
And people with a close person in their social network
who lost weight tended to lose weight. These links do not
seem to result simply from people with shared eating
and exercise patterns gravitating toward one another.
Other research found that youths ate more at a meal if
their eating partner ate a lot and was a friend rather than
an unfamiliar peer, and those who were overweight ate
more if the partner was overweight (Salvy et al., 2009).
Perhaps models in our social network affect our concept

of desirable body size, and we tend to adopt their eating
patterns. If this is so, we’re generally unaware of these
influences (Vartanian, Herman, & Wansink, 2008).

Other lifestyle factors are also important. For
example, regularly drinking a lot of alcohol adds calories
to the diet and reduces the body’s disposal of fat (Suter,
Schutz, & Jequier, 1992; Tremblay et al., 1995). Being
physically inactive lowers the rate at which the body
burns calories. In adulthood, having a sedentary job
may lead to overweight (Mummery et al., 2005). At all
ages, watching TV can lead to weight gain by decreasing
physical activity and by presenting mainly low-nutrient,
sweet foods in shows and ads (Andersen, Crespo et al.,
1998; Harris, Bargh, & Brownell, 2009; Story et al, 2008).
In fact, watching some TV shows can reduce metabolic
rates to below the person’s resting rate: a study compared
obese and normal-weight children while they simply
rested and while they watched a show (The Wonder Years).
During the show, their metabolic rates dropped to 12%
below resting rates for the normal-weight and 16% below
for the obese children (Klesges et al., 1992).

Another psychosocial factor in weight control is
the person’s sensitivity to food-related cues in the
environment: obese people are more sensitive than
nonobese people to certain cues (Schachter, 1971).
For example, compared with the amount normal-weight
people eat, obese individuals eat more when food tastes
good, but eat less when it tastes bad. This stronger
responsiveness to food cues may explain why obese
restaurant diners are more susceptible than nonobese
diners to the influence of a waitress’s description or
display of desserts (Herman, Olmstead, & Polivy, 1983).
Because of this susceptibility to food-related cues, obese
children may have difficulty controlling their eating at

206 Part III / Lifestyles to Enhance Health and Prevent Illness

home. Studies examining family behaviors at mealtimes
have shown that parents give more encouragement for
eating and offer food more often to heavier children than
to slimmer ones (Baranowski & Nader, 1985). Another
food-related cue that affects eating is the size of the
dish and serving utensil the person uses: people serve
themselves larger portions if the dish or utensil is larger
(Wansink, van Ittersum, & Painter, 2006).

Immigrants to a new land encounter many changes in
their lifestyles and food availability. How does this affect
their weight? Researchers studied this issue in the United
States longitudinally with about 4,500 immigrants. When
these people arrived in the country, their rate of obesity
was very low. But their weights increased over time, and
after about 15 years, their prevalence of obesity almost
equaled the high levels of people born and raised in
America (Goel et al., 2004). Surely, a major reason for
their increase in obesity is that they adopted their new
culture’s unhealthy dietary and activity patterns.

Overweight and Health
In a study of overweight and normal-weight men and
women, people were asked to rate their own health on a
10-point scale, where 1 equaled the ‘‘worst health’’ and
10 equaled the ‘‘best health’’ they could imagine (Laffrey,
1986). The ratings of the overweight and normal-weight
individuals were about the same, averaging in the mid-
7s. Are overweight and normal-weight people equally
healthy?

To answer this question, we need to consider three
factors, one of which is the degree of overweight. Research
has clearly demonstrated that obesity is associated with
high cholesterol levels and developing hypertension,
heart disease, stroke, diabetes, and cancer (AHA, 2010;
Bjørge et al., 2008; Calle et al., 2003; Kurth et al., 2003).
This risk even applies to obese adolescents dying by the
time they reach middle age. In general, the more severe
the obesity, the greater the person’s risk of developing
and dying from one of these diseases. Thus, a person

Given what we know about the development of obesity,
this boy is likely to become an overweight adult and be at
heightened risk of developing heart disease and diabetes.
And the treat he is eating won’t help matters.

whose BMI is over 32 has a much greater risk of morbidity
and mortality from, say, heart disease than someone
whose BMI is 26, whose risk may not be elevated very
much. What’s more, the greater the BMI of overweight
people, the more years they lose from their life span, as
shown in Figure 8-3 (Fontaine et al., 2003). And adults’
medical costs are related to BMI: compared with costs for
healthy-weight individuals, annual costs are 69% higher
for severely obese and 43% higher for underweight people
(Wang et al., 2003). Add to all of this the role of smoking:
obese smokers have many times the risk of dying of
cardiovascular disease before age 65 than normal-weight
nonsmokers (Freedman et al., 2006).

The two other factors in the health risks of being
heavy are people’s fitness and distribution of fat on the body.
Among heavy people, those who are physically active and
fit have much lower rates of death and of heart disease
and diabetes than those who are sedentary (Blair &
Brodney, 1999; Sui et al., 2007). Regarding body fat
distribution, men’s fat tends to collect in the abdominal

Body mass index (BMI)

1
2
3
4
5
6

8
9

11
12
13
14

Males

Females

35 40 45 or higher

Y
ea

rs
o

f
li
fe

l
os

Figure 8-3 Years of life lost for obese Caucasian
men and women in the United States as a function
of their BMI in early adulthood. The number of years
lost is the difference between the death ages for each
BMI category and the life expectancies for same-age
normal-weight people. Similar trends were found for
African Americans, but the impact of BMI was less for
the women and far greater for the men—for instance,
among Blacks with BMIs at or above 45, the women lost
about 5 years of life, and the men lost 20. (Abstracted
from Fontaine et al., 2003, Figure 1.)

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 207

region, but heavy women have more of their fat on the
thighs, hips, and buttocks. Research has found higher
rates of hypertension, diabetes, coronary heart disease,
and mortality among people with higher, rather than
lower, ratios of waist to hip girth—that is, their waist
measurements compared to their hip measurements
(Wing & Polley, 2001). The heightened health risks
when bodies are ‘‘rounded in the middle’’ may result
from the unfavorable lipid levels and cardiovascular
reactivity to stress these people show (Daniels et al.,
1999; Goldbacher, Matthews, & Salomon, 2005).

Preventing Overweight
Each weekday morning, Amy and her son ride bikes to
his school instead of taking a bus as part of a program to
improve children’s fitness and weight control. Becoming
obese presents disadvantages to health and social
relationships in childhood and adulthood (Wadden,
Brownell, & Foster, 2002). Is it true, as many people
believe, that children tend to outgrow weight problems,
or that they will find it easy to lose weight when they
are interested in dating? Probably neither belief is true
for most children (Brownell, 1986; Jeffery, 1998). Losing
weight after becoming obese is not easy at any age, and
this is one reason why it is important to try to prevent
overweight.

Preventing overweight should begin early. Infant
obesity and unusually fast weight increases are related to
obesity in later childhood, adolescence, and adulthood
(Baird et al., 2005). And obesity in childhood is likely
to continue into adult life (Serdula et al., 1993). As
Figure 8-4 depicts, the risk depends on the child’s age: the
relationship to adult obesity is much stronger for obese
10- to 13-year-olds than infants. Normal-weight children
don’t usually become obese adults. Another reason to
begin early is to prevent the excess development of fat
cells, which occurs in childhood and adolescence. Obese
adults who were fat in childhood have the double burden
of dealing with bigger fat cells and more of them. Parents
who exercise control over the feeding process do in
fact prevent weight gain in infants (Farrow & Blissett,
2006). Still, there’s a problem in preventing obesity
in childhood: over one-third of parents of overweight
children claim their child is ‘‘at about the right weight’’
(Jeffery et al., 2005; Maynard et al., 2003).

Most school nutrition programs have not been very
successful at reducing future obesity, and those that
have been tended to focus their efforts on females and
students who volunteered to participate (Stice, Shaw, &
Marti, 2006). Schools that simply provide menus with
healthy alternative foods do not reduce the percentage
of their students who are overweight (Veugelers &
Fitzgerald, 2005). Children who are likely to need special

Infant 7 years 10–13 years

Obese

Nonobese

Age

P
er

ce
n
ta

ge
b

ec
om

in
g

ob
es

e
ad

u
lt

Figure 8-4 Percentage of obese and nonobese children
who eventually become obese adults, as a function of age
when weight status is assessed. (Data of Epstein, reported in
Brownell, 1986, p. 313.)

preventive efforts to control their weight have a family
history of obesity or have become overweight already
(Jeffery, 1998). Efforts to help children control their weight
need to focus on improving their diets and physical
activity, involve cafeteria and educational facilities
and staff, and enlist the cooperation of the parents
(Baranowski & Hearn, 1997; Jeffery, 1998; Striegel-Moore
& Rodin, 1985). Some researchers propose that societal
law and policies should prevent obesity (Fabricatore &
Wadden, 2006). For instance, laws in some communities
now require labeling calories for foods in restaurant
menus; when calories are labeled, patrons order fewer
calories (Roberto et al., 2010).

Parents provide almost all the food that comes
into the house and most of the food their children
eat. They also model and encourage eating and physical
activity patterns. Nutritionists and other researchers have
identified several ways parents can help their children
avoid becoming overly fat (Peckenpaugh, 2007; Striegel-
Moore & Rodin, 1985). These recommendations include:

• Encourage regular physical activity and restrict TV
watching.

• Don’t use unhealthful food rewards for eating a
nonpreferred food (e.g., ‘‘You may have dessert if you
eat your peas’’); use praise as the reward instead.

• Decrease buying high-cholesterol and sugary foods of
all kinds, including soft drinks, for use in the home or
elsewhere; avoid fast food restaurants.

• Use fruits, nuts, and other healthful foods as regular
desserts, and reserve rich cakes and other less healthful
desserts for special occasions or once-a-week treats.

• Make sure the child eats a healthful breakfast (with few
eggs) each day and does not have high-calorie snacks at

208 Part III / Lifestyles to Enhance Health and Prevent Illness

night. Metabolism generally decreases later in the day,
so calories consumed at night tend to become fat.

• Monitor the child’s BMI on a regular basis.

Childhood is probably the ideal time to establish activity
and dietary habits to prevent individuals from becoming
overly fat. A potentially useful survey has been developed
to assess modifiable nutrition and physical activity
practices in families and predict a child’s risk for obesity
(Ihmels et al., 2009). Nurses at schools or pediatric clinics
may be able to administer the survey and counsel parents

on ways to lower the risk. (Go to .)

DIETING AND TREATMENTS TO
LOSE WEIGHT
Many millions of people around the world are dieting on
any given day of the year, especially in the spring when
they are getting ready to bare their bodies in the summer.
In the United States alone, about 48% of the women and
34% of the men try to lose weight in a given year (Weiss
et al., 2006). Some individuals try to lose weight because
they are concerned about the health risks of being overly
fat: losing weight does in fact improve blood pressure
and levels of lipids and lipoproteins (Reinehr et al., 2006;
Linden & Chambers, 1994). But attractiveness motivates
many people.

By American tastes, fatness is considered unattrac-
tive, particularly for females—and this confers important
disadvantages for heavy people in social situations, such

as dating. There is also a social stigma to being fat
because many people blame heavy individuals for their
condition, believing they simply lack willpower. Experi-
ments have had high school and college girls rate the
likeability and characteristics of girls they did not know
(DeJong, 1980;Puhl & Latner, 2007). The ratings were less
favorable for obese girls than for normal-weight girls and
were especially low if the subjects thought the obese girl
was to blame for her weight and was not trying to change
it. The social aspects of overweight can be distressing to
those who see themselves as being too heavy, and this
often motivates them to try to lose weight. But many
overweight individuals adopt these weight biases—and
when they do, they are less likely to carry out self-
management acts in a treatment program that could
reduce their weight (Carels et al., 2009).

Most people try to reduce their weight on their own
by ‘‘going on a diet.’’ In the United States, only about one-
third of people who try to lose weight follow minimum
guidelines to reduce calories and get 2 1/2 hours of
exercise a week; many use poor dieting strategies, such as
skipping meals and taking nonprescription supplements
(Weiss et al., 2006). Using ineffective methods may
account for a paradoxical finding: the more that teenage
girls and boys try control their weight, the greater their
increases in weight in the long run (Field et al., 2003;
Stice et al., 1999). Losing weight and keeping it off are
difficult. The best approach for losing weight is to do it
gradually and make lifestyle changes that the dieter and
his or her family can accept and maintain permanently.

HIGHLIGHT

Which ‘‘Carbs’’ to Avoid
The turn of the century brought a diet

craze: avoid carbohydrates (‘‘carbs’’). In the process of
digestion, carbs increase glycemia, or level of sugar in
the blood. Avoiding carbs as a general diet strategy
ignores the fact that carbohydrates differ in the speed and
intensity of conversion to sugar. The physical effect on the
body of an amount of carbs in a serving combined with
the speed and intensity of conversion can be expressed
with a measure called the glycemic load (Brand-Miller
et al., 2003). Foods that contain a lot of carbs per
serving and raise blood sugar quickly and markedly have
high glycemic loads; these foods require strong insulin
responses and are digested quickly. In contrast, foods
with low glycemic loads make lower insulin demands
and spread them out, are digested slowly, and delay
feelings of hunger. A study randomly assigned children

to receive low or high glycemic-load breakfasts and found
that those in the former condition ate less at lunch, where
they could choose their diets freely (Warren, Henry, &
Simonite, 2003).

Thus, not all carbs are equal in their effects, and we
should try to avoid foods with high glycemic loads. Foods
with low glycemic loads include most fruits, vegetables,
nuts, and whole grains; foods with high glycemic loads
include candies, russet potatoes (not new potatoes), and
items containing refined grains, such as instant rice, corn
flakes, and most cakes and pasta. Meats and most dairy
products have low glycemic loads, but often contain high
levels of cholesterol and saturated fats. Eating high-
glycemic-load diets has been linked to the development
of coronary heart disease, diabetes, and cancer (Mente
et al., 2009; Miller & Gutschall, 2009; Peckenpaugh, 2007).

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 209

Losing weight is an important goal in many people’s lives
that brings great joy when it is clear that the effort worked.

People are more likely to succeed at losing weight if they
have constructive social support from their families and
others in their social network and if they have a high
degree of self-efficacy or confidence that they can do it
(Edell et al., 1987; Wing & Polley, 2001).

Although many overweight people succeed in mak-
ing and sticking with the lifestyle changes needed to lose
weight on their own, most do not (Rzewnicki & Forgays,
1987; Schachter, 1982). Many who do not succeed on
their own feel they need help, and probably all people
who seek help to lose weight have failed numerous times
either to reduce or to maintain the new weight. What
kinds of help do people seek, and what works?

Crash ‘‘Fad Diet’’ Plans
One kind of help millions of people try is the latest
‘‘crash’’ fad diet, which is often ‘‘guaranteed’’ to work in
a short time. Some fad diets prescribe a strict dietary
regimen with virtually no deviations permitted, and
others have people eat certain types of food, such as
only fruit, as in the ‘‘Beverly Hills diet,’’ or foods that
are high in protein and fat and low in carbohydrates
and sugar, as in the ‘‘Atkins Diet.’’ Some plans sell low-
calorie liquid or solid replacements for part or all of the

person’s diet, but provide little or no help in maintaining
weight loss. To the extent that people stick to these
diets, they lose similar amounts of weight with each
diet across several months because they consume fewer
calories (Dansinger et al., 2005; Sacks et al., 2009). No
crash diet is a substitute for adopting a healthful lifestyle
of exercise and moderately sized, balanced meals.

Exercise
Physical activity is an important component in con-
trolling weight. One of its benefits is that it increases
metabolism, thereby helping the body to burn calo-
ries. Unfortunately, dieters often fail to exercise as part
of reducing because they notice that it takes a lot of
exercise to use up a few hundred calories—for instance,
they would have to jog about half an hour to burn off the
400 or so calories in a milkshake. But studies of dieting
obese individuals have revealed a variety of benefits of
exercise in weight control. One benefit of exercise occurs
in the first few months: it focuses weight reduction mostly
on body fat, while preserving lean tissue (Andersen
et al., 1999). When overweight people combine exercise
with reduced caloric intake, they lose more weight than
with dieting alone; and the greater the exercise intensity,
the greater the loss (Goldberg & King, 2007). After losing
weight, continued physical activity helps maintain the
reduced weight, especially if the activity is vigorous.

Lifestyle Interventions Using Behavioral
and Cognitive Methods
People who try to lose weight usually find that changing
their eating patterns is very hard to do. Why? A major
reason is that they don’t know how to control antecedents
and consequences in their environments that maintain
their eating patterns. Behavioral methods have been
developed to help dieters gain the control they need.
Richard Stuart (1967) conducted a pioneering study of the
utility of behavioral techniques, such as self-monitoring
and stimulus control, in helping several obese women
lose weight over a 12-month period. The results were
impressive: each of the eight women who stayed with the
program lost weight fairly consistently throughout the
year, losing from 26 to 47 pounds.

The dramatic success of Stuart’s program led to
the incorporation of behavioral methods in programs
called lifestyle interventions, which are designed to modify
diet and exercise in overweight people (Fabricatore &
Wadden, 2006). Meta-analyses have shown that lifestyle
interventions are very effective in helping overweight
and obese adolescents lose weight (Epstein et al., 2007;
Kitzmann et al., 2010). Research findings suggest three
conclusions about lifestyle interventions (Fabricatore

210 Part III / Lifestyles to Enhance Health and Prevent Illness

& Wadden, 2006). First, these programs decrease initial
body weight by 7% to 10% in 4 to 6 months. Second,
lifestyle interventions are most effective in lowering
weight and maintaining the loss when they provide meal
replacements or structured meal plans, such as with
menus and shopping lists. Third, although on average
obese people who complete a behavioral program for
weight control gain much of it back in the first year, many
maintain their lower weight.

What techniques do lifestyle interventions for
weight loss use? They are typically given in a group
format with weekly meetings when participants submit
records of their eating, are weighed, and receive
information and feedback (Fabricatore & Wadden, 2006;
Wing & Polley, 2001). And they usually include the
following components:

• Nutrition and exercise counseling.

• Self-monitoring by having the person keep careful records
of the foods eaten, when, where, with whom, and under
what circumstances.

• Stimulus control techniques, such as shopping for food
with a list, storing food out of sight, and eating at home
in only one room.

• Altering the act of eating, for example, by chewing the food
very thoroughly before swallowing and putting utensils
down on the table between mouthfuls.

• Behavioral contracting, or setting up a system of rewards
for sticking to the diet.

Two other features are important in lifestyle inter-
ventions for weight loss. First, having family or friends
working as a team in the program enhances its success
(Kitzmann et al., 2010; Wing & Jeffery, 1999). Having
these people as weight-loss support partners is most
successful if the partners lose weight, too (Gorin et
al., 2005). Second, rewarding overweight individuals for
not engaging in sedentary activities, such as watching TV or
playing computer games, and unplugging the TV and
computer are very helpful in promoting weight loss
(Epstein et al., 2004).

Cognitive methods have also been used in weight
loss programs. Motivational interviewing, which we’ve dis-
cussed in earlier chapters, is applied to increase the
person’s commitment to and self-efficacy for change; it
is helpful in promoting weight loss (Burke, Arkowitz, &
Menchola, 2003). Another method, called problem-solving
training, is designed to teach people strategies to help
them deal with everyday difficulties they encounter in
sticking to their diets (Perri, Nezu, & Viegener, 1992).
Individuals often have difficulty sticking to a diet at fam-
ily celebrations, when eating at restaurants, and when
under stress, for instance. The skills learned in problem-
solving training enable people to find solutions to these
difficulties. Overweight people who can generate these
kinds of solutions tend to lose more weight and have
fewer lapses than do others (Drapkin, Wing, & Shiffman,
1995. (Go to .)

CLINICAL METHODS AND ISSUES

Problem-Solving Training to Control Weight
The cognitive method called problem-

solving training can help people deal with a variety
of behavioral and emotional difficulties by teaching
them how to generate solutions to specific problems
in their lives (Sarafino, 2001). For example, when
people try to follow a low calorie diet, they often
have trouble eating healthfully when they eat outside
their own households, such as at restaurants, work,
or sporting events. Here are some common problems
these dieters face and examples of solutions they might
produce.

PROBLEM: I eat vending machine and restaurant food too much.
How can I curb this?

SOLUTIONS: Prepare lunch and take it to work; eat with
others who do the same. Take low calorie snacks
with you to work, movies, sporting events, shopping
malls, etc.

PROBLEM: When I know I will be eating out, how can I choose a
restaurant that will make it easier to stick to my diet?

SOLUTIONS: Identify restaurants in advance that have
healthy selections. Avoid going to all-you-can-eat
buffet restaurants that have tempting high calorie
selections.

PROBLEM: When faced with a restaurant menu that includes high
calorie foods, how can I restrict the calories I eat?

SOLUTIONS: Learn about high and low calorie ingredients
and preparation methods, such as frying versus
grilling, and ask the waiter questions. Skim the menu
to reject high calorie selections; read only low calorie
options. If ordering a salad, ask for the dressing on
the side; use only a little. If others are having dessert,
either share one with another person or order fruit or
sherbet. Ask about portion size; if too large, ask for
smaller.

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 211

Self-Help and Worksite Weight-Loss
Programs
There are dozens of commercial self-help organizations
for weight control, and most of the largest ones provide
group or individual support sessions; some of them,
such as Jenny Craig and Optifast, require members to buy
their meal replacement products (Tsai & Wadden, 2005).
Different self-help organizations have their own mix of
methods to help people lose weight. Weight Watchers has
members use behavioral methods, prepare their own
meals, and attend group meetings for information and
social support. Although little research has been done
on the success of self-help groups, the evidence for
Weight Watchers is the strongest so far, showing that this
program produces moderate weight losses for those who
complete them (Heshka et al., 2003; Tsai & Wadden,
2005). But dropout rates for self-help groups may be
high, sometimes over 50% in the first 6 weeks alone
(Stunkard, 1987).

Worksite weight-loss programs have been introduced and
evaluated in a variety of businesses and industries.
These programs generally used behavioral techniques,
but were not very successful (Foreyt & Leavesley, 1991).
High dropout rates and small weight losses have been
common, suggesting that inadequate motivation is a
major flaw. These problems can be reduced in two ways:
gearing the program to the workers’ stages of readiness to
change and providing incentives for participation (Gomel
et al., 1993). Using teams in weight-loss competitions at
worksites provides incentives and increases the amount
of weight lost (Brownell et al., 1984; Wing & Polley, 2001).
Also, a company might offer a prize for the team achieving
the greatest percentage of a weight loss goal. To help the
teams do well, the company could provide information
about nutrition, exercise, and behavioral methods, such
as self-monitoring, stimulus control, and rewards.

Medically Supervised Approaches
Some approaches for losing weight involve medical
procedures or require supervision by a physician.
Because of the risks and side effects, these methods
are recommended only for people who are obese and
have failed to control their weight with diet and exercise.
One medical approach uses prescribed drugs, two of
which are sibutramine, which suppresses appetite, and
orlistat, which decreases intestinal absorption of ingested
fat. Each of these drugs produces moderate weight
loss, and combining pharmacological and behavioral
treatments is more effective than either alone (Han
& Yanovski, 2008; Phelan & Wadden, 2002; Snow et
al., 2005). Another medical approach for losing weight

involves placing the patient on a protein-sparing modified
fast regimen that contains fewer than 800 calories per day
(Han & Yanovski, 2008). Although this approach is safe, it
requires vigilant medical supervision and promotes only
short-term weight loss.

The most drastic medical approaches for losing
weight involve bariatric surgery, procedures that change
the structure of the stomach or intestines (AMA, 2003).
The two most common forms of bariatric surgery alter
the stomach. One form simply installs a band around the
upper part of the stomach to create a little chamber
with a small opening to the rest of the stomach.
Because the chamber holds only an ounce or so,
the person feels full after ingesting a small amount.
The second form reduces the size of the stomach
by literally stapling part of it up. Although bariatric
surgery markedly reduces weight, it entails some surgical
risk and possible side effects (Han & Yanovski, 2008;
Snow et al., 2005). As a result, these methods are
recommended only for patients who are extremely obese
(BMI of 40 or more). Most bariatric surgery programs
require psychological screening, and they may reject the
procedure for patients with certain characteristics, such
as current mental illness or heavy drinking (Bauchowitz
et al., 2005). Another surgical procedure called liposuction
sucks adipose tissue from the body with a tube, but is
not a weight reduction method—its function is strictly
cosmetic, ‘‘body sculpting.’’ It is used for removing fat
from specific regions of the body, such as the thighs
or abdomen. Although the procedure is usually safe,
complications can include blood clots or even death
(AMA, 2003).

We have considered methods for losing weight that
range from adjusting one’s diet and exercising to using
surgical procedures. When overweight people decide
which approaches to use, they should first try to alter
their diets and exercise conscientiously on their own,
perhaps with behavioral methods and a support partner.
If that doesn’t work, the next steps might be to join a
reputable self-help group and then to get psychological
or medical help.

Relapse after Weight Loss
The problem of relapse after completing treatment
to lose weight is similar to that which many people
experience after quitting smoking, drinking, or using
drugs. The situations in which people who have lost
weight overeat usually involve food cues, such as being at
a restaurant or having a special meal, negative emotions,
such as stress or depression, and boredom (Wing & Polley,
2001). Individuals who maintain their reduced weight for
a few years stand a very good chance of maintaining that

212 Part III / Lifestyles to Enhance Health and Prevent Illness

Reprinted courtesy of Bunny Hoest.

weight in subsequent years (McGuire et al., 1999). When
considering weight gain in the years after losing weight,
keep in mind that people generally gain weight as they get
older—1 or 2 pounds a year in middle-aged Americans,
on average. A fair assessment of weight loss success
should also take into account the weight dieters didn’t gain
that other people do (Perri, Nezu, & Viegener, 1992).

Can we prevent relapse after weight loss? Michael
Perri and his colleagues (1988) demonstrated that follow-
up treatment programs can diminish the relapse problem
after people lose weight, allowing them to maintain most
of their loss. The treatment had two critical components:
frequent therapist meetings to deal with problems
individuals were having in maintaining their weight and
social influences of other members who met as a group.
Most lifestyle interventions today continue contact after
people lose weight (Fabricatore & Wadden, 2006). Perri
and colleagues (2001) later found that problem-solving
training after weight loss with behavioral methods was
also effective in helping clients maintain the loss.

Most people who lose weight do not use effective
ways to maintain the loss. If you wanted to lose weight
and keep it off, what methods could you use? Here are
some:

• When losing the weight, use behavioral techniques—
such as self-monitoring and stimulus control—to help
you diet and increase exercise. Choose a reasonable
final weight goal, and plan to lose weight gradually, such
as a pound a week or less.

• After reaching your weight goal, permanently eat a low-
calorie-and-fat diet. Pay attention to calories and use
structured meal plans (Fabricatore & Wadden, 2006;

Phelan et al., 2009). For carbohydrates, choose ones
that have low glycemic loads. Stick to this diet fairly
consistently throughout the week, including weekends
(Gorin et al., 2004).

• Continue to exercise—it’s a strong predictor of long-
term weight maintenance (Phelan et al., 2009; Wing &
Polley, 2001). Weigh yourself each time you exercise.

• Avoid situations that prompt lapses, and reward good
behavior. Occasional lapses are not a problem as long
as you get back on track as soon as possible.

• Get social support from family and friends for maintain-
ing your weight loss. Join a self-help or support group if
you find that you have too many lapses.

(Go to .)

ANOREXIA AND BULIMIA
Although gaining weight by overeating is a very com-
mon problem with psychosocial impacts, it is not a
psychiatric disorder. In contrast, two less common eat-
ing problems—anorexia nervosa and bulimia nervosa—are
included as psychiatric disorders in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) of the Amer-
ican Psychiatric Association (2000). People with these
disorders use extreme ways to keep their weight down.
Anorexia is illustrated in the following case study of a
19-year-old, 5′3′′ tall coed named Frances who had been
20 pounds overweight 6 years earlier. She

weighed 83 lbs upon admission [to therapy]. She
reported eating very little food each day (estimated
to be less than 500 kcal). She exercised for at least
3 hours each day by attending aerobics classes and
running. When she did consume a normal meal, she
purged it via self-induced vomiting … . She never
binged (i.e., ate large quantities of food). She was
obsessed with fears of weight gain. (Williamson,
Cubic, & Fuller, 1992, p. 367)

When she was younger, she had been teased by
peers and repeatedly criticized by her mother for being
overweight. As Frances’s case shows, anorexia nervosa
is an eating disorder that involves a drastic reduction
in food intake and an unhealthy loss of weight. People
with this disorder are characterized by a weight at least
15% below normal (BMI at or less than 17.5), an intense
fear of gaining weight, and a distorted idea of their body
shape (Keel, 2010; Kring et al., 2010). The starvation in
anorexia may be so extreme as to cause or contribute
to the person’s death—for instance, by causing kidney
failure, cardiac arrest, extremely low blood pressure, or
cardiac arrhythmias (due to low levels of electrolytes,
such as potassium) (Kring et al., 2010).

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 213

ASSESS YOURSELF

Your Weight Control Patterns
For each of the following questions,

put a check mark in the preceding space if your answer is
‘‘yes.’’

Do you watch your calorie intake more carefully
than anyone else you know?
Is your BMI less than 19?
Do you think gaining a few pounds during a
holiday season would be a terrible thing?
Have you ever eaten so much so quickly that you
felt as though you had lost control of your eating?
If yes, has this happened more than about 10
times in the past year?
Have you ever eaten a lot and then tried to
‘‘purge’’ the food by using laxatives, diuretics, or
self-induced vomiting?
If yes, has this happened more than about 10
times in the past year?

Have you felt a lot of emotional distress in recent
months?

Do you often eat fewer than two meals a day?

Do you regularly exercise more than 10 hours a
week to lose weight?

How many ‘‘yes’’ answers did you give? A high number
suggests that you may have an eating disorder. If your
number is: from 3 to 5, you may want to consider getting
professional help, especially if your situation seems to be
getting worse; 6 or more, you should seek help right away.
You can find help through your college’s counseling office
or by contacting professional organizations, such as the
American Psychological Association and the American
Psychiatric Association, which are in Washington, DC.
(Based on material in Brownell, 1989; Kring et al., 2010; Logue,

1991.)

Bulimia nervosa is characterized by recurrent
episodes of binge eating, generally followed by purging
by self-induced vomiting, laxative use, or other means
to prevent gaining weight, such as excessive exercise
(Becker, 2010; Kring et al., 2010). These episodes often
occur when feelings of positive affect are low and stress
and negative emotions are high (Smyth et al., 2007).
People with bulimia nervosa appear to experience
chronic high stress levels (Ludescher et al., 2009). This
disorder can cause a wide range of medical problems,
including inflammation of the digestive tract and cardiac
problems, such as arrhythmias. Bulimic individuals are
aware that their eating pattern is abnormal, are fearful
of having lost control of their eating, and tend to be
depressed and self-critical after a bulimic episode. Many
people exhibit some bulimic behaviors, such as purging,
but are not classified as bulimic because they engage in
these behaviors infrequently.

It is difficult to know how prevalent eating disorders
are. A study that compared women’s medical records with
returned surveys on eating disorders to the researchers
found that many of those who did not return the survey
did in fact have eating disorders (Beglin & Fairburn,
1992). Thus, existing data are likely to be underestimates.
Estimates of prevalence for the general population in
Western cultures are 0.5–1.0% for anorexia and 1–2% for
bulimia, with more than 90% of diagnosed cases being
females, and these disorders are becoming increasingly
common in other cultures (Becker, 2010; Keel, 2010;

Kring et al., 2010). Anorexia is especially common among
dance students, models, and athletes who feel pressured
to control their weight (French & Jeffery, 1994).

Why People Become Anorexic and Bulimic
What causes the eccentric eating habits of anorexia and
bulimia? The answer is still unclear, and researchers
have suggested biological, psychological, and cultural
factors that may be involved. There is evidence for genetic
and physiological links to these disorders (Becker, 2010;
Keel, 2010; Kring et al., 2010). For example, studies have
examined the occurrence of anorexia and bulimia in
twins and found that these disorders are far more likely
to appear in both twin members if they are identical
twins rather than fraternal twins. Other research findings
indicate that the functioning of neuroendocrine and
neurotransmitter processes may be abnormal in eating-
disordered individuals.

Cultural factors may provide the answer to two
obvious questions about these eating disorders: Why
is the prevalence of anorexia and bulimia particularly
high among White females, and why has it increased in
recent years? In the United States, Black girls have lower
prevalence rates of eating disorders than White girls,
partly because they tend to be less concerned about
their weight even when they are heavy (Abrams, Allen,
& Gray, 1993). Beauty plays a central role in the sex-
role stereotype of women in many cultures, and Western

214 Part III / Lifestyles to Enhance Health and Prevent Illness

This anorexic girl probably sees herself as ‘‘too fat’’ despite
her thinness.

cultures have witnessed recent changes in their ideals
about female beauty (Striegel-Moore, 1997). Years ago,
the ‘‘ideally beautiful woman’’ had a figure that was more
rounded, with larger bust and hip measurements. After
1960 or so, the ideal figure of a woman became much
thinner, and the social pressures on women to be slender
increased. Caucasian females are more likely than males
to wish they were thinner and to diet, and these gender
differences begin to show up by age 11 or so (Cohen,
Brownell, & Felix, 1990). In social interactions with other
children, parents, and teachers, girls more than boys are
given the message: thin is better (Attie & Brooks-Gunn,
1987). And once the message is clear, they reach puberty,
when girls add an average of over 20 pounds of fat to their
bodies while boys add muscle. This is a no-win situation
for adolescent girls. How do they deal with it?

When adolescents—especially females—start trying
to control their weight, they typically adjust their diets
in a normal manner, but for many teens the methods
they use become more extreme, involving occasional
fasting or purging. A study found that about 13% of

15-year-olds engaged in some form of purging behavior,
mainly on a monthly basis or less, with the rate for
females being twice as high as that for males (Killen et
al., 1986). Prospective evidence indicates that individuals
who become anorexic and bulimic typically start out
dieting normally but have relatively strong concerns
about their weight, and then begin using more extreme
methods (French & Jeffery, 1994; Killen et al., 1994).
Dieters with strong weight concerns may come to rely
more and more on fasting and purging because these
methods keep weight off, and this pattern becomes
entrenched in those who become bulimic, especially
if they were overweight in childhood (Fairburn et al.,
2003). The development of eating disorders has been
linked to the prior experience of chronic stress and other
psychiatric difficulties, often with a major life event in
the weeks before the disorder’s onset (Rojo et al., 2006).

Why does disordered eating become so compulsive?
People who are extremely concerned about their weight
tend to see themselves as round-faced and pudgy,
even when others do not. Studies using ingenious
apparatuses, such as special projectors, have shown
that the great majority of women overestimate their
size and generally perceive themselves to be one-fourth
larger than they really are (Thompson, 1986). Although
men make similar errors, they do so to a much lesser
degree—and, unlike women, many of these men may
want to be larger. Body size overestimation is very
pronounced among anorexic individuals, and the idea
that they are overweight persists long after they have
become slim. When they are reduced to skin and bones,
anorexic individuals still claim to be ‘‘too fat’’ and greatly
overestimate their size (Askevold, 1975; Crisp & Kalucy,
1974). Another factor that ties in here is the relatively high
levels of the personality trait of perfectionism that people
with anorexia and bulimia tend to have (Becker, 2010;
Keel, 2010). That is, no matter how hard these individuals
strive to achieve their ‘‘perfect’’ body, they are never
satisfied. Interventions delivered on computers or in
person can reduce the risk of developing eating disorders
in people who are very dissatisfied with their body shapes
(Franko et al., 2005; Stice, Shaw, & Marti, 2007).

Treatments for Anorexia and Bulimia
Because anorexia nervosa involves a severe and health-
threatening underweight condition, the first priority in
treating this disorder is to restore the person’s body
weight and nutrition to as near normal as possible.
This is often done in a hospital setting. Treatment with
behavioral techniques is effective for putting weight on
(Kring et al., 2010). But keeping the weight on is difficult;
about half of previously treated anorexics continue to

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 2

have eating problems and often show other social and
emotional difficulties, such as depression. The main
form of psychological therapy for anorexia involves the
patient’s family and often focuses on the dynamics of
mealtime interactions; drugs to treat depression or other
disorders are also used (Keel, 2010; Kring et al., 2010).

Psychotherapy is more effective for bulimia than
anorexia, particularly when it includes behavioral and
cognitive methods (Becker, 2010; Hay et al., 2009; Kring
et al., 2010). These methods—such as self-monitoring,
reinforcement, and cognitive restructuring—focus on
reducing bingeing and purging behaviors; sometimes
drugs are added to these approaches to decrease
depression. Treatment is less effective for clients with
bulimia who have very high initial rates of bingeing and
purging and a history of substance abuse (Wilson, Loeb
et al., 1999).

We have discussed the problems people have in
controlling their weight through adjustments in their
diets. We have also seen that exercise can play an
important role in reducing body fat and, thereby, can
enhance people’s health. The next section examines
exercise as a means of becoming fit and keeping well.

EXERCISE

Sometimes it seems like a fitness boom has occurred in
many nations. For instance, the proportion of Americans
who exercise doubled in the 20 years after the early 1960s
(Serfass & Gerberich, 1984). Joggers and bicyclists today
can be seen on roads and paths in cities and out in the
country, and fitness clubs have sprung up everywhere.
But in the United States and most other industrialized
countries, adults’ lifestyles still include very little or
irregular physical activity (Brownson, Boehmer, & Luke,
2005; Sallis & Owen, 1999). We’ve all heard that exercise

is healthy. We’ll see why in this section. (Go to .)

THE HEALTH EFFECTS OF PHYSICAL ACTIVITY
If you asked fitness-conscious people why they exercise,
they’d probably give a variety of reasons: ‘‘Exercising
helps me keep my weight down,’’ ‘‘I like it when I’m in
shape—and so does my boyfriend,’’ ‘‘It helps me unwind
and relieves my tension,’’ ‘‘Being in shape keeps me sharp
on my job,’’ ‘‘I don’t get sick as often when I’m fit,’’ and
‘‘It makes people’s hearts stronger, so they live longer.’’
These answers describe psychosocial and physical health
benefits of exercising and are, for the most part, correct.

Psychosocial Benefits of Exercise
Three psychosocial benefits of exercise have been shown
in many studies. First, engaging in regular vigorous
exercise is associated with lower feelings of stress and
anxiety, as we discussed in Chapter 5. Second, people
who engage in a fitness program with aerobic exercise
show improved cognitive processes, such as in making
fewer errors and having better memory (Quick et al., 1997;
Smith et al., 2010). Third, participating in regular exercise
is linked to enhanced self-concepts of individuals, especially
children (Dishman, 1986; Sallis & Owen, 1999). Self-
concept enhancements may occur because these people
are able to maintain an attractive appearance and engage
successfully in sports activities; as a result, they receive
many social advantages that accrue with being fit.

But keep in mind two issues about psychosocial
benefits from exercise. First, most studies on stress
and self-concept used correlational or retrospective
methods, making it difficult to determine cause-effect
relationships. Some evidence suggests that part of the
self-reported benefits may have resulted from a placebo
effect of the subjects’ expecting that psychosocial
benefits would occur (Desharnais et al., 1993). Second,
the extent to which individuals experience these benefits
appears to depend on their genetic makeup (Mata,
Thompson, & Gotlib, 2010).

HIGHLIGHT

Types and Amounts of Healthful Exercise
All physical activities—even just

fidgeting—use energy and burn calories. Exercise is a
special class of physical activity in which people exert
their bodies in a structured and repetitive way for
the sake of health or body development. There are
several types of exercise, each with its own form of
activity, physical goals, and effects.

Isotonics, Isometrics, and Isokinetics
Isotonic exercise builds strength and endurance by the
person’s moving a heavy object, exerting most of the
muscle force in one direction. This type of exercise
includes weight lifting and many calisthenics. In doing
push-ups, for example, most of the exertion occurs in
raising the body.

(continued)

216 Part III / Lifestyles to Enhance Health and Prevent Illness

HIGHLIGHT (Continued)

Isometric exercise builds mainly strength rather than
endurance—the person exerts muscle force against an
immovable object. For example, in the ‘‘chair lift’’ the
person sits in a standard unupholstered chair, grasps the
sides of the seat with both hands, and pulls upward,
straining the arm muscles. The seat doesn’t move.
Isokinetic exercise builds strength and endurance—the
person exerts muscle force to move an object in more
than one direction, such as forward and back. Isokinetic
exercise usually requires special equipment, such as
Nautilus machines.

Aerobics

The word aerobic literally means ‘‘with oxygen.’’ What
does oxygen have to do with exercise? When we exert
ourselves physically, the energy for it comes from the
metabolic process of burning fatty acids and glucose
in the presence of oxygen. Continuous exertion at high
intensity over many minutes requires a great deal of
oxygen. Being ‘‘fit’’ means the person consumes a high
volume of oxygen (VO2) per heartbeat during exertion.

The term aerobic exercise refers to energetic
physical activity that requires high levels of oxygen over
an extended time, say, 20 minutes. Aerobic activities
generally involve rhythmical actions that move the
body over a distance or against gravity—as occurs in
fast dancing, jogging, bicycling, swimming, or certain
calisthenics. Performing aerobic activity with sufficient
intensity and duration on a regular basis increases the
body’s ability to extract oxygen from the blood and burn
fatty acids and glucose.

An Ideal Exercise Program for Health

How much and what kinds of exercise are best for
fitness? The answer depends on the individual’s age,
current health and physical capacity, goals, interests, and
opportunities, such as whether facilities or partners are
available (Insel & Roth, 1998). Almost all individuals need
to begin with a moderate starter program and progress in
a gradual manner toward fitness; people who are elderly
or less fit should progress more slowly than others.
Starting gradually avoids muscle soreness and injury
and allows the body to adapt to increasing physical
demands.

Americans spend an average of 6 hours a day
performing physical activities (Matthews et al., 2008).
An ideal exercise program would add the equivalent of
30 minutes a day of moderate-intensity physical activity,

such as walking briskly (USDA, 2005). This translates to
about 3 hours of exercise a week, which can be divided
into three to six sessions, each having three phases (Blair
et al., 1992; Insel & Roth, 1998):

1. Warmup. Each session should include two types
of warmup activities: (1) stretching and flexibility
exercises, for various major muscle groups, such as
of the neck, back, shoulders, abdomen, and legs;
and (2) strength and endurance exercises, such as
push-ups, pull-ups, and lifting.

2. Aerobics. The next 20 minutes or more involves rhyth-
mical exercise of large muscle groups, performed
vigorously, raising the heart (pulse) rate to a mod-
erately high target range. One way to estimate
the target range for an adult is to use a formula
based on the person’s age: the minimum heart rate
equals 160 pulse beats per minute minus the per-
son’s age; the maximum is 200 minus age (La Place,
1984). Thus, 30-year-olds would maintain their heart
rate between 130 and 170 beats per minute during
aerobics.

3. Cool-down. The last few minutes of exercise should
taper off in intensity to return the body to its normal
state. These exercises can include calisthenics or
walking.

Although this ideal seems fairly rigid, there is room
for variation. For instance, individuals who exercise at
the upper end of their target range can use fewer or
shorter exercise periods each week. People can also
tailor the program to their goals and interests by
varying the exercises they perform during each phase
and across sessions, such as by varying the aerobics
they do: jogging on one day, skipping rope on another,
swimming on another, and so on. If they want to firm
their abdomens, they can focus on appropriate activities
during the warmup and cool-down phases.

Is the Ideal Necessary to Benefit Health?

Not all people can or will get the ideal amount and
type of physical activity. Can they benefit from less?
Absolutely, and the activity needn’t be ‘‘exercise’’—it can
be riding a bike or gardening, for instance—and it can
occur in, say, 10-minute periods rather than all at once
(Phillips, Kiernan, & King, 2001). Although the greatest
health benefits accrue with vigorous activity, avoiding an
almost completely sedentary lifestyle is critical.

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 217

Physical Benefits of Exercise
Of the many physiological effects that physical activity
produces, one effect is especially intriguing: vigorous
exercise seems to increase the body’s production of
endorphins, which are morphinelike chemical substances.
Studies have shown that endorphin levels in the blood
are higher after exercise than before (Carr et al., 1981).
Some researchers claim that the euphoric ‘‘runner’s high’’
that many individuals feel after a very vigorous aerobic
workout results from high levels of endorphins reaching
the brain, which then decreases stress and sensations
of pain. But evidence for these possibilities is unclear
(Phillips, Kiernan, & King, 2001).

Exercise can enhance many aspects of people’s
physical fitness throughout the life span. In childhood,
aerobic exercise improves agility and cardiovascular
function (Alpert et al., 1990). What about much later
in the life span, when people generally show a gradual
decline in their flexibility, strength, and endurance? This
decline occurs partly because many individuals get less
exercise as they get older. Compared with people who
are sedentary in mid-life, individuals who have physically
active lifestyles have higher physical function years later
(Hillsdon et al., 2005). And an 18-year longitudinal
study of men who were over 50 years of age at the
start of the study and who engaged in aerobic exercise
regularly found that their work capacity decreased only
slightly across the 18 years, whereas men in the general
population tend to show a 1–2% decrease per year (Kasch,
Wallace, & Van Camp, 1985). Also, the resting blood
pressure and percentage of body fat of these men did not
show the increases that usually occur during these years.
The evidence clearly indicates that engaging in aerobic
exercise curbs the usual decline in fitness that people
experience as they get older (Buchner et al., 1992).

The physical benefits from regular exercise are ref-
lected also in people’s health and longevity, even if they
are overweight (Carlsson et al., 2007; Koster et al., 2009;
Leitzmann et al., 2007). Vigorous exercise produces the
greatest gains, but even taking brisk walks or expending
energy in everyday activities, such as climbing stairs, can
benefit longevity (Kujala et al., 1998; Manini et al., 2006).
The main health benefits of exercise relate to preventing
cardiovascular problems and some forms of cancer
(Phillips, Kiernan, & King, 2001; Sallis & Owen, 1999).
Many studies have found that people who regularly
engage in vigorous physical activity are less likely to
develop and die from coronary heart disease (CHD) than
those who lead relatively sedentary lives (Powell et al.,
1987; Weinstein et al., 2008). Although no experimental
research has been done in which humans were randomly
assigned to exercise and nonexercise conditions, res-

Table 8.7 How Physical Activity/Fitness Protects Cardiovascular
Health

Benefit Description

Blood pressure People who are active and fit have lower
systolic and diastolic blood pressure
than those who are not, and they are
less likely to develop hypertension
(Blair et al., 1992; Haskell, 1984).
Exercise lowers blood pressure in
people with and without
hypertension (Braith et al., 1994;
Kokkinos et al., 1995;
Martinez-Gomez et al., 2009).

Lipids Physical activity improves serum lipid
levels—it raises HDL and lowers
LDL and triglycerides (Szapary,
Bloedon, & Foster, 2003).

Reactivity to stress Fit individuals show lower heart rate
and blood pressure reactivity to
stress than unfit people do (Forcier
et al., 2006).

earch with animals and prospective studies with humans
indicate that the link between physical activity and
reduced risk of CHD is probably causal. Table 8.7
describes ways by which fitness and physical activity
protect individuals against cardiovascular disease.

The risk of developing cancer has been linked to
low physical activity; the evidence is fairly strong for
colon cancer and more modest for other cancers, such
as of the breast and prostate (Sallis & Owen, 1999).
Although the reason for this link is unclear, part of it
may involve the beneficial effect of both immediate and
long-term exercise on the immune system. One study
tested healthy, physically active adults and found that
vigorous exercise sessions increased their natural killer
cell number and function (Fiatarone et al., 1989).

Are There Health Liabilities to Exercise?
Not all effects of exercise are beneficial—there can be
hazards as well. One hazard occurs when people jog
or bicycle in traffic, of course, risking a collision. But
the most common problems that arise involve injury
to bones or muscles from other kinds of accidents and
from overstraining the body (Sallis & Owen, 1999). For
instance, high impact exercises, such as jogging and
tennis, can injure joints and lead to arthritis. Many
injuries happen to people who do not exercise regularly
or are beginners, mainly from overtaxing their bodies and
from unsafe exercise conditions, such as having improper
shoes. Exercising too long in very hot weather can lead to
heat exhaustion—with symptoms of dizziness, rapid and

218 Part III / Lifestyles to Enhance Health and Prevent Illness

weak pulse, and headache—or a more severe condition
called heat stroke, which can be fatal.

Sudden cardiac death can occur when exercising.
Autopsy reports for individuals who had died in asso-
ciation with exercising typically reveal that the cause
was cardiac arrest, and most of them had cardiovascu-
lar problems that existed prior to the attack (Northcote,
Flannigan, & Ballantyne, 1986). Most of these problems
could have been detected by medical screening, which
does in fact reduce the risk of sudden death (Corrado et
al., 2006). Cardiac arrest from exercising is unlikely—one
case per 1.5 million sessions of physical exertion—and
occurs much less frequently in people who exercise five
times rather than once a week (Albert et al., 2004).
Physicians and physical therapists can prescribe exercise
programs for people with specific health problems, such
as diabetes and CHD.

Another health hazard that relates to exercise is
people’s use of anabolic steroids—male hormones that
build tissue—to increase muscle size and strength. Many
more males than females use steroids, and most users
are athletes (AMA, 2003; Strauss & Yesalis, 1991). Using
steroids for an extended period has several negative
health effects. It raises LDL and lowers HDL serum
cholesterol and is related to liver and kidney tumors and
to heart attacks and strokes. It also has a permanent
masculinizing effect in women, increasing facial hair and
lowering the voice, for instance. In males, it increases
acne and balding and decreases the size and firmness
of testes, at least temporarily. Some who use steroids
share needles with others, putting each other at risk for
HIV infection (DuRant et al., 1993).

Conclusions regarding the health effects of exercise
are fairly clear. Frequent physical activity, especially
vigorous exercise, is psychologically and physically
healthful, particularly for preventing heart disease.
People who begin exercise programs should guard
against overtaxing their bodies, exercise under safe
conditions with proper skills, and have periodic medical
examinations to determine whether any underlying risks
exist. Although more people exercise today than was the
case decades ago, most adults in industrialized countries
do not get enough regular and energetic physical activity.

WHO GETS ENOUGH EXERCISE, WHO DOES
NOT—AND WHY?
Most people in the United States and other developed
nations do not get enough exercise. Many individuals
who could be physically active in their normal lifestyles
choose not to be—they may take rest breaks rather than
sustaining an activity or opt to use a machine instead
of doing a task manually. The high physical activity of

early childhood declines sharply during adolescence: for
instance, only half of American teenagers are vigorously
active on a regular basis (Duncan et al., 2007; Marcus
et al., 2000). Teens with high levels of physical activity
tend to have high activity levels in adulthood, too
(Telama et al., 2005). Because little is known about
people’s everyday physical activities, we will emphasize
factors associated with doing and not doing exercises.

Gender, Age, and Sociocultural Differences
in Exercise
Physical activity varies across cultures. Probably most
people around the world have lifestyles that provide reg-
ular, vigorous, and sustained activity naturally, without
actually doing exercises. They commute to work by bicy-
cle, for instance, or have jobs that involve energetic work,
as farmers, laborers, and homemakers often do.

Demographic patterns give a portrait of who
exercises in the United States. Adults who exercise tend
to have more income and education than those who don’t
exercise and are more likely to be men than women and
White than Black or Hispanic (NCHS, 2009a). Also, adults
who exercise tend to have exercised regularly in the past
(Dishman, 1991). Similar patterns exist in other industri-
alized countries, such as Australia (Sallis & Owen, 1999).
Another factor is age—as adults get older, most tend to
engage less and less in physical activity, not so much
because of declining physical functioning but because of
changes in their beliefs and attitudes (Sarkasian et al.,
2005; Vertinsky & Auman, 1988). They often have exag-
gerated expectations of decreased physical ability, risk
of injury, fear of failure, and others’ disapproval regard-
ing exercise in old age, and these ideas are particularly
strong among many of today’s elderly women.

Women seem to learn from past sex-role experiences
that men are more socially and physically suited to
vigorous activity than females. Although both male
and female older people tend to underrate their
physical capabilities and exaggerate their health risks in
performing energetic exercise after middle age, women
are especially prone to these beliefs (Vertinsky & Auman,
1988; Woods & Birren, 1984). Health care workers and
organizations for the elderly have many opportunities
to dispel incorrect beliefs about health risks, change
sex-role stereotypes regarding exercise, and encourage
active lifestyles.

Reasons for Not Exercising
When individuals are asked why they don’t exercise, the
most common reason they give is that they cannot find
the time (Dishman, 1991; Godin et al., 1992). Actually,
of course, most people could have the time but choose

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 219

to use it in other ways. People also report not exercising
because they have no convenient place to do it or because
the weather or other environmental conditions make it
unpleasant or impossible.

Whether people exercise is also related to the
amount of stress in their lives, social influences, and
their beliefs. People who exercise regularly tend to skip
sessions when they experience high levels of stress
(Stetson et al., 1997). Social influences on exercise
involve modeling, encouragement, and reinforcement
by peers and family. Adults who exercise tend to have
spouses who encourage them to do so, and children and
adolescents who exercise or engage in sports tend to
have friends or family who also do so (Dishman, Sallis,
& Orenstein, 1985; Gottlieb & Baker, 1986; Sallis et al.,
1988). People’s beliefs can influence exercising in at least
four ways:

• People with high self-efficacy for their ability to perform
and maintain exercise are more likely to do it and
stick with it than those with low self-efficacy (Anderson
et al., 2006; Armitage, 2005; Sniehotta, Scholz, &
Schwarzer, 2005).

• Perceived susceptibility to illness can spur people to
exercise. People who received information describing
their level of fitness or indicating they might be
susceptible to health problems that could be prevented
through exercise were more likely to start exercising
than others who did not get such information (Godin,
Desharnais et al., 1987; Wurtele & Maddux, 1987).

• Perceived barriers reduce exercise; enjoying exercise
increases it (Rhodes, Fiala, & Conner, 2009; Sallis et al.,
2007; Salmon et al., 2003). The barriers can be personal,
such as feeling tired or having work commitments, or
environmental, such as cost, weather, or safety. But keep
in mind that people who are overweight and sedentary
tend to perceive barriers to physical activity when there
are none (Gebel, Bauman, & Owen, 2009).

• Compared to people who believe they failed to stick with
an exercise program, those who believe they succeeded
are more likely to resume exercising in the future, even if
they had dropped out of the program (Shields, Brawley,
& Lindover, 2005).

A study found evidence of a biopsychosocial
sequence that influences whether people will continue
to exercise after starting: genetic factors influence the
amount of exertion individuals perceive as they exercise,
which affects the mood they feel after exercising, which
influences their intention to exercise in the future (Bryan
et al., 2007). Individuals who experience positive moods
after exercising tend to stick with it.

People who do not exercise tend to have other risk
factors for developing serious illnesses, such as by being

overweight or smoking cigarettes. From the standpoint
of performing health-protective behavior, people whose
health would benefit most from physical activity seem
to be the most resistant to starting or maintaining
an exercise program. Quitting smoking may help: a
study of smokers found that those who quit were more
likely to start exercising than those who didn’t (Perkins
et al., 1993).

PROMOTING EXERCISE BEHAVIOR
A person who spends time watching youngsters play is
likely to have the impression that children are innately
very active—running, jumping, and climbing—and that
they do not need to be encouraged to exercise, as older
individuals do. Some children seem to find physical
activity naturally reinforcing (Epstein et al., 1999).
Although most children and adolescents are more active
than adults, many children are not active enough (Marcus
et al., 2000). School-based programs are effective at
increasing the amount of time children spend in physical
activity and fitness, but are less successful in increasing
the percentage of children who are active in leisure time
(Dobbins et al., 2009). People of all ages could benefit
from school, park, and worksite recreation programs and
facilities, such as parks and trails, to promote exercise
(Giles-Corti et al., 2005; Sallis et al., 2006).

To obtain the full health benefits of physical
activity, people need to exercise or be very active as a
permanent part of their normal lifestyles. Few people in
industrialized societies achieve this ideal. Of individuals
who are already exercising regularly at any given time,
about half will quit in the coming year (Dishman, Sallis,
& Orenstein, 1985). Table 8.8 presents several strategies
that help people start and continue exercising. These
strategies can be applied by individuals who decide
on their own to start or by organized interventions to
promote exercise in target populations, such as school
children, workers, or the elderly.

Note five additional points. First, we can promote
physical activity by giving rewards for increased exercis-
ing and for decreased sedentary behavior (Epstein, Sae-
lens, & O’Brien, 1995). Second, physicians can increase
physical activity in sedentary patients by giving verbal
advice and written plans for specific behaviors and goals
(Grandes et al., 2009). Third, sedentary people who are
willing to increase their activity are more likely to stick
with an exercise routine that requires a high frequency
(5 or more days per week) than a high intensity (Perri
et al., 2002). Fourth, individuals in an exercise program
who are more likely than others to reach and maintain
moderately high exercise levels have higher incomes and
exercise self-efficacy, are more fit, and are more likely to

220 Part III / Lifestyles to Enhance Health and Prevent Illness

People of all ages can benefit from
exercise programs. These children are
in a physical education class.

see neighbors being physically active (King et al., 2006).
Fifth, people are more likely to stick with an exercise
program if they can deal with lapses or setbacks con-
structively, such as by expecting them and attributing
them to temporary factors (Schwarzer et al., 2008)

Interventions can promote exercise with various
populations, particularly if they include behavioral meth-
ods to modify the antecedents and consequences of
physical activity (Sallis & Owen, 1999). Interventions

since the late 1980s that have included strategies like
those in Table 8.8 have reported higher rates of exercise
adherence and fewer dropouts than earlier programs
(Marcus et al., 2000). Two other strategies appear to
increase success. First, providing contact by telephone to
assess progress and give advice when there are problems
improves interventions’ success (Marcus et al., 2000).
Second, an important factor in people’s starting and
sticking with an exercise routine is their readiness to do so,

Table 8.8 Strategies to Promote Exercising

• Preassessment. Before people begin an exercise program, they need to determine their purposes for exercising and the
benefits they can expect. They should also assess their health status, preferably through a medical checkup.

• Exercise selection. The exercises included in the program should be tailored to meet the health needs of the individual
and his or her interests and purposes, such as firming up certain parts of the body. People are more likely to stick
with the program if it includes exercises that they enjoy doing.

• Exercise conditions. Before people start an exercise program, they should determine when and where they will exercise
and arrange to get any equipment they will need. Some people seem to adhere to a program if they pick a fixed time
for exercising and refuse to schedule anything else at that time; others can be more flexible and still make sure to
exercise about every other day. The exercise conditions should be safe and convenient.

• Goals. Most people adhere to a program more closely if they write out a specific sequence of goals and consequences
for exercise behavior in a behavioral contract. The goals should be graduated, beginning at a modest level. They
should also be measurable—as body weight or number of push-ups would be—rather than vague, such as ‘‘to feel
good.’’

• Consequences. Exercise should lead to reinforcement. Some individuals may need tangible reinforcers to maintain
their exercise behavior in the early stages of the program. After these people get in shape, many will find that the
enjoyment of exercise and the physical benefits are sufficient rewards.

• Social influence. People are more likely to start and stick with an exercise program if these efforts have the support and
encouragement of family and friends. Exercising with a partner or in groups sometimes enhances people’s motivation
to continue in a program.

• Record keeping. People can enhance their motivation to exercise by keeping records of their weight and performance.
Seeing on paper how far they have progressed can be very reinforcing.

Sources: Dishman, Sallis, & Orenstein, 1985; Oldridge, 1984; Sallis & Owen, 1999; Serfass & Gerberich, 1984.

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 221

Reprinted courtesy of Bunny Hoest.

in terms of the stages of change model (see Chapter 6).
People who are at the contemplation stage—that is,
they’re already considering the change—are more likely
to start exercising and to exercise vigorously once
they do than are people at the precontemplation stage
(Armstrong et al., 1992). Interventions that provide tele-
phone and print information tailored to the motivational
readiness of individuals to exercise are more effective
than nontailored programs (Marcus et al., 1998).

SAFETY

Unsafe conditions threaten people’s health in virtually
all environments—in traffic, at home, on the job, and
at the beach—producing huge numbers of illnesses,
injuries, and deaths each year. In most cases, these
health problems could have been avoided if the victim
or other people had used reasonable safety precautions.
Sometimes people don’t know how to prevent injury,
as is often the case for elderly individuals who become
injured when they fall, but safety training can reduce
these injuries (Tinetti et al., 1994). Let’s see what is
known about the hazards people face and how to help
people live safer lives.

ACCIDENTS
Each year in the United States, over 34 million injuries or
poisonings occur that require medical attention (USBC,
2010). Some of these events are serious enough to
cause long-term disability or death. More than 121,000
Americans die each year from unintentional injuries in
accidents (USBC, 2010). By far the most frequent of these
accidental fatalities involve traffic mishaps. Nearly 5,800
people die in accidents at their jobs each year, and
thousands of other workers are seriously injured (NCHS,
2009a). The industries with the highest mortality and
injury rates include transportation and warehousing,
manufacturing, construction, and mining. Government
data reveal that accidental injury is:

• The fifth most frequent cause of death in the American
population as a whole.

• The leading cause of death of individuals under age 45.

• Responsible for over 30% of all deaths of children 1 to
14 years of age (USBC, 2010).

Accidents are a global health problem: for instance,
thousands of people die in traffic accidents in the
European Union each year (WHO/Europe, 2010).

Another way to see the relative impact of injury
versus disease is to estimate the years of life lost by
the victims of these causes of death. Using age 65 as a
standard, we’d subtract the age of death of each person
who dies earlier and then sum the years lost for injuries
and disease separately. Calculations like these reveal
that the total number of years lost from unintentional
and intentional (that is, homicide or suicide) injuries in
the United States is about the same as from the total
of the three most frequent causes of death in America:
heart disease, cancer, and stroke (USDHHS, 1995). Over
60% of all injury deaths are unintentional.

How can accidental injuries be prevented? We
will focus on injuries in traffic mishaps because they
account for about half of all accidental deaths and
researchers have done many studies on methods to
prevent traffic injuries. One approach to reduce traffic
accidents capitalizes on perception research on reducing
drivers’ errors and reaction time: mounting an extra
brake light above the trunk of vehicles reduced rear-end
collisions by 50% (Robertson, 1986). Another approach
addresses the role of cell phones in accidents: the
risk of traffic mishaps is four times as likely during or
shortly after the driver uses a phone, even a hands-free
phone (McEvoy et al., 2005). As a result, laws against
drivers using cell phones are being enacted. Other
ways to reduce traffic accidents focus on the driver’s
age: traffic-accident death rates in the United States
increase dramatically during adolescence, as depicted

222 Part III / Lifestyles to Enhance Health and Prevent Illness

0
5
10
15
20

30
35

1–4 5–14 15–24 25–34 35–44
Age (years)

45–64 65–74 75–84

In
ju

ry
d

ea
th

r
at

es
(

p
er

1
0

0
,0

0
0

p
op

u
la

ti
on

)

Figure 8-5 The relationship between age and motor-
vehicle-injury death rates in the United States. (Data from
NCHS, 2009a, Table 43.) Note, however, that the dramatic
increase during adolescence primarily reflects the deaths of
individuals who are occupants of motor vehicles; much of the
upswing in old age reflects deaths of individuals who are
pedestrians. (Cataldo et al., 1986.)

in Figure 8-5. Safe-driving programs have been used
for teens learning to drive, but they seem to have
little effect on accidents (Robertson, 1986). Two other
approaches that effectively promote safe driving and
reduce traffic deaths are not very popular with teenagers;
one involves raising the legal driving age, and the other
has parents restrict their teenager’s driving (Robertson,
1986; Simons-Morton et al., 2005).

Traffic injuries and deaths can also be prevented if
drivers and passengers will use protective equipment,
such as seat belts in cars and helmets when riding
motorcycles or bicycles (Lee et al., 2010; Macpherson
& Spinks, 2009; NHTSA, 2006). After seat belts were
installed as standard equipment in cars, few Americans
opted to use them; today over 80% use them (NHTSA,
2006). Safety programs have targeted parents and
children, and laws requiring seat belt use have been
enacted. A successful educational program provided
computer-assisted video instruction on using an infant
safety seat to mothers before leaving the hospital after
giving birth (Hletko et al., 1987). Observation by a parking
lot attendant at the hospital 4 months later when
mothers brought their babies for a checkup revealed
that many more trained than untrained mothers had
their infants correctly restrained. As you might expect,
parents often fail to follow the safety rules they convey to
their children (Morrongiello, Corbett, & Bellisimo, 2008).
These children tend to follow the stated rules, but they
also plan not to do so when they become adults.

A program to increase seat belt use was presented
to children in preschools, using a theme character called
‘‘Bucklebear’’ (Chang et al., 1985). The children in several
other preschools served as a control group who were
matched to the experimental subjects for their prior
seat belt use. Observations in the preschool parking
lots 3 weeks after the program ended found that over
44% of the ‘‘Bucklebear’’ children and only about 22%
of the control children were using seat belts. Other
programs have addressed the use of bicycle helmets or
car safety restraints; some included incentives for the
parents, such as discounts to buy helmets (Tremblay &
Peterson, 1999). After one of these programs, children in
the community increased helmet use markedly and had
fewer head injuries over the next several years.

ENVIRONMENTAL HAZARDS
A 1987 newspaper poll in New Jersey asked people, ‘‘Do
you use sunscreen in the summer?’’ One young man
answered, ‘‘No. I don’t use anything—never have, never
will,’’ and a young woman said, ‘‘Never, because the sun’s
not too hot in New Jersey.’’ Another young woman said
she uses only the weakest sunscreen because, ‘‘I want
to have a gorgeous tan.’’ Ever since the French fashion
designer Coco Chanel made tanning fashionable, people
in many parts of the world have come to believe tans

Parents can teach their children to use sunscreen.

Chapter 8 / Nutrition, Weight Control and Diet, Exercise, and Safety 223

are attractive and healthful. This belief develops by early
adolescence (Broadstock, Borland, & Gason, 1992).

Today we know that excessive exposure to the sun’s
ultraviolet rays makes the skin age and can cause skin
cancers, particularly in people who are fair skinned and
burn easily (AMA, 2003; Harrison et al., 1994). Keep in
mind that sunlamps and sunbeds have the same effect,
and the more exposure to them, the greater the chance of
getting cancer (Westerdahl et al., 1994). Although most
cases of skin cancer can be easily treated and cured,
others cannot, especially if they are discovered late (ACS,
2009). Dermatologists and other health care practitioners
recommend that most people use sunscreens (SPF of 15
or more) when exposed to the sun for more than, say, an
hour or so. But only about a third of American children
and adolescents use sunscreen, and over 80% report
having had a sunburn in the past year (Geller et al.,
2002). Girls use sunscreen more than boys do, but they
also use tanning beds more. Because skin appearance
is a main motivator for tanning, researchers have tested
interventions with appearance information to promote
sunscreen use. One approach used message framing
and found that information has a greater influence on
the likelihood of sunscreen use if it has gain-framed
messages (‘‘Using sunscreen increases your chances of
maintaining healthy, young looking skin’’) than loss-
framed messages, which might state that not using
sunscreen can cause cancer and prematurely aged skin
(Detweiler et al., 1999). Another approach showed college
students ultraviolet photographs of their skin, which
reveal normally invisible damage from sun radiation,
and found that these students later used tanning beds
less than others who did not see such photographs
(Gibbons et al., 2005).

Ultraviolet radiation is only one of many environ-
mental hazards people need to guard against. Many
harmful chemicals and gases exist in households, work-
sites, and general communities. Some of these hazards
and their effects are (AMA, 2003):

• Lead poisoning, which can damage children’s nervous
system and impair intelligence if they ingest it, such
as by mouthing objects painted with lead-based paints,
drinking water from a plumbing system with poorly

soldered lead joints, or drinking acidic beverages from
lead-glazed ceramics.

• Radon, a radioactive odorless gas that can cause lung
cancer with long-term exposure, enters dwellings from
the ground; ventilating a basement can reduce radon
pollution.

• Asbestos is a substance that was used in buildings and
equipment as a fire retardant. People who have regular
contact with it risk developing lung cancer.

• Radiation poisoning, which can occur with one very high-
level exposure or long-term lower exposure, causes
cancer. It can be released into the environment from
many sources, such as nuclear testing sites and power
plants, hospitals, and military facilities. A massive
radiation release occurred in 1986 at the Soviet nuclear
power plant in Chernobyl.

People who work with hazardous materials need to
know what the substances are, what dangers they pose,
and how to use them safely. Some states in America have
enacted ‘‘Right to Know’’ laws that require (1) employers
to notify and train employees regarding the safe use
of hazardous materials and (2) community agencies to
provide information about the exposure of residents to
hazardous materials. If people know a danger exists, they
can try to take protective action (for example, by drinking
bottled water), become involved in community change,
and notify their physician so that appropriate tests can
be done (Winett, King, & Altman, 1989).

People are becoming increasingly concerned about
the chemicals and gases that pervade our lives. They
should be vigilant—but they should also be aware of
three things. First, not every chemical or gas is harmful.
Second, exposure to toxic or carcinogenic substances
poses little risk when the contact is infrequent and
the dosage is small (Ames & Gold, 1990; Cohen &
Ellwein, 1990). Third, some harmful substances may
have benefits that outweigh their dangers. For example,
chlorinating water has all but erased many of the
waterborne infections that once threatened enormous
numbers of lives. But chlorinated water often has very
small amounts of the carcinogen chloroform in it. Given
these circumstances, the benefits of chlorinating appear
to outweigh the risks.

SUMMARY

In addition to water, food contains five types of chemical
components: carbohydrates, lipids or ‘‘fats,’’ proteins,
vitamins, and minerals. People can get all the nutrients
and fiber they need from diets that include grains,
fruits, vegetables, milk products, and meats and fish.

People’s food preferences are determined by biological
and psychosocial factors.

Diet is associated with the development of atheroscle-
rosis, hypertension, and cancer. Cholesterol leads to
atherosclerosis. Whether plaques form in our blood vessels

224 Part III / Lifestyles to Enhance Health and Prevent Illness

depends on the presence of two types of cholesterol-
carrying proteins: low-density lipoprotein and high-
density lipoprotein. Low-density lipoprotein is often
called ‘‘bad cholesterol’’ because it is the main culprit in
plaque buildup. Genetic factors and the foods people eat
determine serum cholesterol levels. Interventions can be
effective in helping people reduce dietary cholesterol
substantially. High blood pressure can result from
consuming too much sodium.

Many people are very conscious of and concerned
about their weight. Most concerns among Americans
are with being too fat, rather than too thin, particularly
among females. If people’s body mass index (BMI) is 25
or more, they are overweight; if their BMI is 30 or more,
they are considered obese. People become fat because
they consume more calories than they burn up through
metabolism. Heredity plays a role in weight control,
probably by affecting the set-point for body weight. The
set-point mechanism involves the hypothalamus and
serum leptin and insulin levels. Psychosocial factors also
affect weight control, especially in the role of emotions
in binge eating.

Obesity is associated with the development of many
illnesses, such as hypertension, coronary heart disease,
and diabetes. These health risks decrease with fitness
and increase as the degree of obesity increases and when
fat is concentrated in the abdominal region. Prevention
of overweight should begin in childhood to avoid fat-
cell hyperplasia. People can control their weight by
exercising and eating diets that are low in calories, fat,
and carbohydrates with high glycemic loads.

Most heavy people try to reduce their weight on
their own by going on a diet. Those who are not able

to lose weight on their own often seek help, such as
through self-help groups and weight-loss programs.
Behavioral and cognitive methods are more effective
than other approaches. Relatively extreme cases may
warrant drastic procedures with medical supervision,
including placing the patient on a very-low-calorie diet,
using appetite-suppressing drugs, or performing surgery.
Although many people who lose weight keep most of that
weight off, others do not; relapse can be reduced with
follow-up programs.

Anorexia nervosa is an eating disorder that results
in an unhealthy and extreme loss of weight. Bulimia
nervosa is an eating disorder that involves recurrent
episodes of binge eating and purging. Both of these
disorders occur mainly in adolescence and early
adulthood, and are much more prevalent in females
than in males. Treatment is more difficult and less
successful for anorexia than for bulimia.

Isotonic, isometric, and isokinetic exercises have
different procedures and effects. Aerobic exercise refers
to energetic physical activity that involves rhythmical
movement of large muscle groups and requires high
levels of oxygen over a period of half an hour or
so. Engaging regularly in vigorous exercise increases
people’s life span and protects them against coronary
heart disease, by improving lipid levels and reducing
blood pressure and stress reactivity.

Tens of thousands of Americans die each year in
accidents, especially traffic mishaps. Death rates for traf-
fic accidents increase dramatically during adolescence.
People also need to guard against many environmental
hazards, including excessive exposure to sunlight and
harmful chemicals and gases.

KEY TERMS

lipoproteins
low-density lipoprotein
high-density lipoprotein
body mass index
overweight

obese
set-point theory
leptin
insulin
binge eating

glycemic load
anorexia nervosa
bulimia nervosa
isotonic exercise
isometric exercise

isokinetic exercise
aerobic exercise

Note: If you read Module 3 (from Chapter 2) with the
current chapter, you should include the key terms for

those modules.