What Is Health?

Consistent with the tenets of Hippocrates to which all health care professions aspire—“rst do no harm” and “the function of protecting and developing health must rank even above that of restoring it when it is impaired”—the primary objective of health care is to promote health and wellness, to prevent illness and disability and, in the event that these occur, to exploit the least invasive interventions.

The World Health Organization (WHO) defines health as “a complete state of physical, emotional and social well-being”—not merely the absence of disease and impairment.³ Although physical well-being contributes to health in the other dimensions, it does not ensure health. Thus emotional and social well-being should be assessed as systematically as is physical well-being in a model of care based on health. Collectively, these domains of health translate into an individual’s capacity to perform activities that enable him or her to participate fully in life.⁴ The WHO’s definition of health has not been amended since 1948. Although having withstood time, this definition has failed to be incorporated as the primary goal of contemporary health care.

Over the past century, the primary determinants of improved health have been the provision of clean water, sanitation, basic nutrition, shelter, and security, rather than biomedical advances (other than mass vaccination programs). In addition, education and socioeconomic and employment status are independent determinants of health. Biomedical care has had particular success in controlling infection, providing symptomatic relief of acute problems, and providing emergency care. Such care, however, has not had the impact on health that the primary determinants of health have had overall, nor has biomedical care achieved major success in preventing, reversing, and managing chronic lifestyle-related conditions.

By the time an individual has entered the biomedical system, health care in its truest sense has failed. Without question, the need exists for invasive care (drugs and surgery), well-equipped hospitals, and highly qualified health care professionals. On the other hand, as practitioners committed to noninvasive care, physical therapists have the capacity to promote health and well-being in their practices, with the global goals of reducing the number of patients and minimizing the need for invasive care. The role of physical therapists in preventing and managing chronic lifestyle-related conditions is essential.

Because of widespread immigration, the cultural and ethnic demographic profiles of high-income countries such as those in North America and Europe are changing rapidly. Beliefs, attitudes, values, cultures, ethnicity, and traditions affect health, ill health, and their interactions, including how often individuals seek health care. For example, Asian immigrants to the United States report fewer stress-related and psychological problems than do non-Hispanic Caucasians.⁵ With increasing time in the United States, however, reports of stress increase for Asian Americans. This may reflect a number of factors: cultural differences in the acceptability of reporting psychological distress (leading to underreporting by members of some cultural groups), sensitization to the definition and the awareness of stress with increasing duration of residence, or the compounding effect of increasing stress in the new culture. How best to reduce racial and ethnic disparities through culturally competent health care is a matter of debate and requires such outcomes as client satisfaction, improved health status, and culturally appropriate management and delivery across racial and ethnic groups.^6,7

Since the psychobiological adaptation model was posited over 25 years ago,⁸ the few models of physical therapy practice that have been reported have included psychosocial and other nonphysiological components.^9–11 Psychosocial components include health belief, self-efficacy, and perceived control. The Health Belief Model is useful in appreciating the ways in which belief may affect health, illness, and the responses and reactions to them (Table 1-1).¹² Assessment of self-efficacy provides an index of an individual’s sense of mastery over his or her health and well-being. These concepts can be used in a clinician’s practice setting. A few questions can help assess a patient’s perception of susceptibility to risk or a condition. These concepts can provide a basis for health education that includes increasing the patient’s awareness of the effects of lifestyle factors on health and of their consequences. The action necessary to avoid the condition or minimize its risk can be selectively targeted for each individual when the individual’s context is known.

The International Classification of Functioning, Disability and Health advocated by the WHO interrelates body functions and structures, activity, and participation in life.⁴ The biomedical model focuses on impairment (i.e., body functions and structures), with less attention to health and wellness, sickness impact, life satisfaction, and quality of life, which reflects an individual’s participation in life and associated activities. One problem that occurs when the primary focus is on the remediation of limitations of function and structure in managing the leading health care priorities of our day (i.e., chronic lifestyle-related conditions) is that such limitations do not necessarily affect activity and participation—the essence of a meaningful life. These relationships need to be evaluated in each case rather than assumed.

The integration of health belief and motivational models has been a means of incorporating psychosocial dimensions of care, interventions, and outcomes so as to directly focus on an individual’s limitations of activity and participation. As a result of this paradigm shift, an increasing number of measurement tools are available to assess the dimensions of health. These tools can be categorized as generic, as having general application across individuals and conditions, or as having specific application to a cohort of individuals, based on age, condition, or some other variable (see examples in Chapter 17). Many of these scales have been validated on a subset of these cohort groups. Physical therapists need to be able to use these tools knowledgeably and specifically to assess outcomes in their practices, just as they use conventional tools to assess and evaluate anatomic structure and physiological function. One such measure is the Short Form-36, which evaluates health-related quality of life and has become an established tool for general use and has been adapted cross-culturally.^13,14 Such tools can be used to evaluate the individual’s perception of health improvement, which supplements conventional objective clinical measures.

Lifestyle-Related Conditions

Poor nutritional choices and sedentary lifestyles combined with tobacco use, excessive alcohol consumption, and stress underpin chronic lifestyle-related conditions in high-income countries, and they pose the greatest threats to public health.23–25 Eight major risk factors related to lifestyle and their documented impacts on health appear in Table 1-2. This trend has given rise to dramatic increases in a relatively newly defined condition, metabolic syndrome, which includes insulin resistance, high blood pressure, elevated triglycerides and cholesterol, and obesity. With industrialization and technological advances, lifestyle-related conditions are on the rise in low- and middle-income countries as well.^26,27 Despite their prevalence, however, the WHO has long proclaimed that lifestyle-related conditions are largely preventable.²⁸

Atherosclerosis is the major common denominator and contributor to lifestyle-related conditions, including ischemic heart disease (IHD), hypertension, and stroke. Factor analysis supports a two-factor solution for heart disease and possibly for other lifestyle-related conditions: family history (factor 1) and lifestyle factors such as smoking, serum cholesterol, blood pressure, nutrition, exercise, and weight control (factor 2).²⁹ At the population level, choosing health—which includes smoking abstinence along with optimal nutrition and exercise throughout life—can enhance the quality of life, decrease the prevalence of chronic lifestyle-related conditions, and reduce the burden of these conditions on individuals, families, communities, and countries, including suffering and health care costs.^30–32

Life Cycle and Lifestyle-Related Conditions

Lifestyle-related conditions have their foundation in childhood because their associated underlying health behaviors are rooted during this critical period. The latency period before developing significant signs and symptoms can be decades.

IHD secondary to atherosclerosis continues to be the leading cause of premature mortality and disability in industrialized countries. The prevention and management of risk factors of systemic atherosclerosis should be a primary target of contemporary care for children as well as for adults.33–35 Ischemic cerebrovascular, coronary, and peripheral vascular conditions are manifestations of the same underlying pathological process, blood vessel narrowing caused by atherosclerosis and thrombosis. Smoking, a high-fat diet, and inactivity can precipitate damage to the endothelium and fat deposition within arterial walls. This common pathway has been associated with increased fibrinogen and C-reactive protein, markers of inflammation.³⁶ The focus of biomedical research has shifted to the role of inflammatory mediators and the contribution of low-density lipoproteins to atherosclerosis and away from the concept of degenerative vessel disease. Fibrinogen is an inflammation mediator and a clotting factor. People with cardiovascular disease have high fibrinogen levels, which further increase the risk for thrombosis and manifestations of circulatory disease. Inflammation has been implicated in a growing number of chronic conditions, such as IHD, stroke, asthma, gastrointestinal ulcers, cirrhosis of the liver, Alzheimer disease, cancer, and autoimmune conditions.^37,38 Unhealthy lifestyle choices have been thought to contribute to a proinflammatory state, giving rise to low-grade infection in various organ systems and leading to the signs and symptoms associated with various chronic degenerative processes.³⁹ Although this is an important finding, a proinflammatory milieu and inflammation are not the causes of the chronic conditions with which they have been associated but, rather, are precipitating effects of traumas resulting from lifestyle.

Promotion of a healthy lifestyle early in life transfers responsibility to the individual as much as possible and away from some inherent pathophysiological cause. Although conventional invasive biomedical care with medications and surgery may provide symptomatic relief, only fundamental changes in lifestyle can address the root cause in the majority of cases of chronic lifestyle-related conditions. The physical therapist as a contemporary health care provider can serve as an effective health coach in the care of children and adults.

Lifestyle-related conditions can no longer be considered adult conditions or age-related conditions. Children are exhibiting signs of cardiovascular disease, including arterial atherosclerotic streaking, hypertension, type 2 diabetes mellitus, and obesity.⁴⁰ Forty years ago, these conditions manifested in adults. With sedentary lifestyles, low activity, and poor nutrition, children are showing the results of accumulated injury to blood vessels and larger body frames and weights. As a consequence, children today are manifesting lifestyle-related conditions earlier than previous generations and are thus expected to die prematurely from these conditions and to have shorter life expectancies than their parents. Throughout their lives, these individuals can expect to have prolonged morbidity associated with these conditions, the secondary complications of these conditions, associated adverse responses to other health complaints, and increased iatrogenic problems (secondary to drugs and surgery).^41,42 Health promotion strategies directed toward parents and young children will help to offset the population’s health threat of lifestyle-related conditions.

Life expectancy has almost doubled since 1900. The post–World War II baby-boom generation characterizes the demographics of many industrialized countries. This cohort has lived in prosperous times and up to that time was the longest living generation in history. Despite the prosperity seen by the baby boomers, this era was associated with more sedentary lifestyles and access to food products low in nutritional value. Although the manifestations of lifestyle-related conditions are associated with aging, they are not necessary consequences of aging. This is based on cross-cultural comparison studies. Optimal nutrition, exercise, stress control, smoking abstinence, and moderate alcohol consumption, if any, are central to reducing the probability of chronic lifestyle-related conditions and associated disability and maximizing quality of life as people age.⁴³ In particular, increased quality of life with a higher threshold for chronic lifestyle-related conditions and less morbidity toward the end of life is the objective. Figure 1-1 shows the theoretical increase in the threshold of these conditions with healthy lifestyle choices (i.e., not smoking, optimal nutrition and weight control, regular physical activity and exercise, optimal sleep, and reduced stress) and reduced rate of progression of chronic conditions. Ostensibly, the net result is more “life to years” as well as more “years to life.”

“First Do No Harm”

As primarily a noninvasive health care profession, physical therapy is uniquely positioned to have a primary role in promoting health and wellness, while also preventing, managing, and in some cases, reversing these pandemic lifestyle-related conditions, objectives that commonly coexist because they share a common pathway.⁴⁴ Integrating health promotion into practice would directly address the ultimate knowledge translation gap in health care (with respect to the benefits of healthy living).⁴⁵ Indeed, focusing on health promotion, in addition to directly addressing the risk factors and/or manifestations of secondary lifestyle-related conditions, may result in more favorable outcomes for a patient’s presenting problem. Triage of individuals by both noninvasive practitioners and invasive practitioners would constitute a bold initiative in health care. Such triage could establish whether a patient’s complaint is best managed in the short and long term wholly noninvasively, wholly invasively, or by some combination, with a view to weaning the patient off medications or minimizing the medication. Similarly, every effort should be made to avoid surgical intervention and its risks whenever possible (i.e., surgical intervention as a last resort rather than a first resort) by exploiting noninvasive interventions and strategies to restore health and promote lifelong health. When an individual enters the health care delivery system, her or his receptivity to health information is likely to be high. This is a prime opportunity to evaluate risk factors and prescribe a lifelong health plan.

The effectiveness of nonpharmacological treatments in the management of chronic lifestyle-related conditions has been well documented, but implementation has been poor.46–48 As noninvasive practitioners, physical therapists have a primary role on the health team, which may include physicians and surgeons (i.e., invasive practitioners), nurses, nutritionists, pharmacists, social workers, psychologists, respiratory therapists, spiritual leaders, and others, depending on the requirements of each case. On a broader level, physical therapists can serve in a multisector capacity as consultants and work alongside health care policy makers, corporate business people, urban planners, and architects in developing healthy and safe homes, workplaces, recreational facilities, and communities. The role of the physical therapist clinician is shifting from hospital-based acute care and private practice to the community, schools, industry, home, workplace, and playing field.

Biomedical research that evaluates drugs and surgery often lacks control groups that are otherwise healthy or a comparative group in the research design that includes a potentially superior, noninvasively managed group where feasible. For example, a 12-month exercise program involving selected individuals with stable coronary artery disease has shown superior event-free survival and exercise capacity when compared with individuals who received percutaneous coronary intervention.⁴⁹ In another study, the mortality rate of individuals with heart disease has been estimated to be reduced by 20% to 25% with cardiac rehabilitation, which is comparable to the results of established therapies such as beta blockers.⁵⁰ Cardiac rehabilitation is noninvasive; thus it is cheaper and has few side effects. Management is focused on changing negative health behaviors and maximizing lifelong health rather than on simply altering a sign or a symptom.

Changing one’s lifestyle can be more challenging than taking a drug or undergoing surgery. In both cases, the patient is a passive recipient of treatment. Being an effective agent of change and promoting active participation by clients in their own health are fundamental to the expertise of the physical therapist who specializes in noninvasive, long-term health and care. In societies with open and free marketplaces (such as in North American and European countries), people are presented with seemingly endless choices, many of which can be injurious to lifelong health. Thus physical therapists need superior skills in educating people regarding their lifestyle choices and promotion of health.

In contrast to biomedical advances, progress in these noninvasive yet high-impact interventions receives much less coverage and attention as lead articles in peer-reviewed medical journals or by the popular press. Yet these noninvasive advances show significant promise for having a major impact on the population’s health and well-being, including increased probability of lifelong health at minimal cost, compared with the results of invasive interventions, which frequently do not address the causes or contributing factors. Such findings need to be integrated into contemporary practice to ensure that individuals are not subjected unnecessarily to the risks associated with prolonged courses of medication and invasive procedures, along with the high probability of repeated invasive procedures. Noninvasive interventions have a distinct advantage over drugs and surgery—they empower individuals to manage their own long-term health by learning skills that will change deleterious lifestyle habits and reduce the risks and costs of hospitalization and its recurrence. Considering the risks and costs of an invasive procedure such as revascularization, the advantages of noninvasive interventions are worthy of much greater attention.

Physical therapists treat individuals with chronic lifestyle-related conditions as either primary or secondary diagnoses. Smoking is currently the leading cause and contributor to chronic conditions and premature death in the United States, with poor diet and sedentary lifestyle anticipated soon to overtake tobacco use.⁵¹ Television viewing, an indicator of sedentary living, is associated with obesity and is a marker of cardiovascular disease independent of total reported physical activity.⁵¹ As noninvasive practitioners, physical therapists have a responsibility to manage these conditions and their risk factors in all patients so as to prevent or control their physical, psychosocial, economic, and societal impact and to promote health in their practices. By prioritizing health and addressing suboptimal health behaviors, regardless of a patient’s primary complaint, the complaint may be mitigated, the rate and quality of recovery potentially improved, and the potential for recurrence reduced.

Hypertension and Stroke

Stroke is a preventable tragedy for nearly 750,000 people in the United States annually; hypertension is the most common risk factor.¹¹³ Although lowering blood pressure below 130/85 mm Hg is well accepted across ages, the success of blood pressure control has been reported to be less than 25% in the hypertensive population.¹¹⁴ Stroke risk is far from being well controlled despite considerable understanding of its causes, and it remains a major health threat. Risk factors for stroke include previous stroke, hypertension, IHD, atrial fibrillation, hyperlipidemia, diabetes, abnormal ankle-to-brachial pressure index, reduced exercise endurance, retinopathy, albuminuria, autonomic neuropathy, smoking, alcohol consumption, and lack of exercise.^{113,115–119}

Risk factors for hypertension and stroke can be accentuated by smoking, elevated cholesterol, glucose intolerance, inactivity, and obesity.¹²⁰ In addition to stroke, serious consequences of hypertension include hypertension heart disease and renal disease. Implicated as a cause of stroke is increased sympathetic reactivity.¹²¹

In the adult population between 60 and 74 years of age, almost 75% of African Americans and 50% of Caucasians have high blood pressure.¹²² As with IHD, risk factors for high blood pressure consist of nonmodifiable and modifiable risk factors. Nonmodifiable risk factors include age, sex, race, and other genetic factors. Modifiable risk factors include diets high in sodium and low in potassium, alcohol consumption, reduced physical activity, and being overweight.¹²³ Obesity is a strong predictor of hypertension.¹²⁴ Although significant reduction of hypertension has been attributed to low-dose thiazide diuretics and beta blockers, the first line of defense to prevent high blood pressure and normalize blood pressure should be nutritional approaches, weight reduction, and regular physical activity and exercise.¹²⁵ In individuals whose hypertension is controlled, the combination of a Mediterranean diet and physical activity can reduce health risk substantially.¹²⁶ Like other lifestyle-related conditions, hypertension is increasingly common in American children; thus screening should be included in routine pediatric assessments.¹²⁷

With respect to nutrition, high sodium and low potassium have been implicated in hypertension and stroke, as have lipids. The National Academy of Science has recently announced that reducing added salt by as little as one-third would reduce hypertension in the United States by 25% (11 million fewer cases). Low plasma vitamin C is associated with a several-fold increased risk for stroke, particularly in men who are overweight and hypertensive.¹²⁸ A minimal reduction in diastolic blood pressure (5 to 6 mm Hg) reduces the risk for stroke by 35% to 40%.⁸³ Thus weight control; regular exercise; a diet rich in fruits, vegetables, and whole-grain cereals; smoking cessation; and blood pressure control are central to stroke prevention, as well as to the comprehensive management of stroke.

Although weight reduction is an essential component of hypertension prevention and management, the protective effect of physical activity may be unrelated to the degree of obesity.¹²⁹ A 4% to 8% reduction in body weight can reduce blood pressure by 3 mm Hg, and physical activity can reduce blood pressure by 5/3 mm Hg.¹³⁰

In normotensive African American men, aerobic exercise can attenuate an exaggerated blood pressure response.¹³¹ Similarly, normotensive fit African American women have blunted blood pressure responses to experimental stressors.¹³² One study reported no relationship between physical activity and hypertension, flow-mediated dilation of the brachial artery, or an index of angiogenesis assessed with plasma vascular endothelial growth factor (the latter two being indicators of endothelial dysfunction).¹³³ In this study, however, physical activity was based on self-report in a questionnaire rather than on fitness outcomes, so the results of the study are difficult to interpret.

Physical activity and optimal nutrition can reduce the risk for early atherosclerosis, a precursor to stroke, in lifelong nonsmokers.¹³⁴ Smokers benefit less from this protective effect. Physical activity seems not only to reduce the risk for stroke but also to provide a potent prophylactic strategy for increasing blood flow and reducing brain injury during cerebral ischemia.¹³⁵ A possible mechanism is augmented endothelium-dependent vasodilation via up-regulation of endothelial nitric oxide synthase throughout the vasculature. Aerobic exercise three times a week reduces cerebral infarct size and functional deficits in a mouse model and improves endothelium-dependent vasorelaxation.¹³⁵

Assessment of risk for hypertension is an important component of each patient’s assessment. The management strategy should be based on an analysis of the overall risk assessment rather than on blood pressure alone. The prevention of hypertension requires more than normalizing blood pressure if the deadly manifestations of high blood pressure including IHD are to be avoided. Because of the dire consequences of hypertension, the American Heart Association advocates stringent blood pressure limits—specifically, below 130/85 mm Hg, regardless of age.¹³⁶ Recommendations by the American Heart Association concerning physical activity and exercise guidelines for survivors of stroke concur that physical conditioning is a primary goal in these individuals, who must contend with both the pathological effects of stroke and the effects of deconditioning.¹³⁷ Walking as little as 2 hours a week can reduce the risk for stroke by 50%.¹³⁰ Improved conditioning may help to reduce limitations of activity and participation and hence improve quality of life. The burden of disease and disability and their risk factors may be correspondingly reduced.

To affect the health of the population, stroke prevention depends on the dissemination of these well-established and widely available interventions to a large number of people through public health policy. Advice given by a health provider to individuals with stroke for the purpose of prevention of a second stroke can have significant impact. In one study, individuals were simply advised to eat fewer high-fat and high-cholesterol foods and to exercise more.¹³⁸ Compared with a control group that received no advice, those receiving advice reported fewer days with limited activity, fewer days that “were not good physically,” and more “healthy” days. The results of this study are compelling in that even simple advice by a health care provider can have a major impact on important health behaviors and on potential health outcomes.

Type 2 Diabetes Mellitus and Metabolic Syndrome

Type 2 diabetes mellitus is a serious multisystem condition that has rapidly become pandemic in Western countries and some other countries where its incidence was previously minimal. In addition to the serious physical and functional consequences of this condition, perceived health status and quality of life are also compromised.¹³⁹ By 2010, an estimated 250 million people will be affected worldwide.¹⁴⁰ Formerly known as adult-onset diabetes, type 2 diabetes mellitus is now being diagnosed in children, predisposing them to blindness, IHD, stroke, renal disease, peripheral neuropathies, vascular insufficiency, and amputations.^141,142 Inositol acts as a poison on the membranes of cells in the presence of high blood sugar, and it has been implicated in the deadly systemic consequences of diabetes. The primary consequences include pathological changes to the macro- and microvasculature and to the nerve endings. Impaired glucose tolerance is a marker of vascular complications in the large and small blood vessels, independent of an individual’s progression to diabetes. Early detection of glucose intolerance allows intensive dietary and exercise modifications, which have been shown to be more effective than drug therapy in normalizing postprandial glucose and inhibiting progression to diabetes.¹⁴³ Diabetic autonomic neuropathy as an independent risk factor for stroke may reflect increased vascular damage and effect on the regulation of cerebral blood flow in individuals with diabetes.¹¹⁵

Individuals with type 2 diabetes mellitus have increased risk for cardiovascular disease compared with individuals without diabetes, so strict control is essential. Moderate physical activity (such as brisk walking¹⁴⁴) along with weight loss is a powerful combination to reduce the risk for type 2 diabetes mellitus, as well as to reverse it. These interventions combined with a balanced diet can reduce the risk for developing diabetes among those who are at high risk by 50% to 60%.⁸⁶ Cigarette smoking is an independent risk factor for type 2 diabetes mellitus¹⁴⁵ and is particularly dangerous for individuals who already have diabetes.¹⁴¹

Metabolic syndrome refers to a virulent and lethal group of atherosclerotic risk factors, including dyslipidemia, obesity, hypertension, and insulin resistance, and it affects some 47 million people in the United States.¹⁴⁶ The incidence of the syndrome is increasing and warrants aggressive noninvasive management. Insulin sensitivity is predicted primarily by body mass index, smoking, age, and daily physical activity. Weight reduction counters the effects of metabolic syndrome and may counter the associated hypertension and dyslipidemia as well. Diet and exercise are primary components of the multifactorial approach to preventing and managing this lethal condition.

Obesity

Obesity has been increasing exponentially over recent decades; currently, 61% of the American population is overweight.¹⁴⁷ Obesity is becoming a global pandemic that rivals malnutrition as a health priority in some low-income countries,¹⁴⁸ and it contributes to health risks for all lifestyle-related conditions. The complications and risks for which each patient should be assessed include IHD, cardiac myopathy, and chronic heart and lung dysfunction; hypertension and stroke; some cancers; insulin insensitivity and type 2 diabetes mellitus; gallbladder disease; dyslipidemia; osteoarthritis and gout; and pulmonary conditions, including alveolar hypoventilation and sleep apnea.^149–153 With each kilogram of weight above normal, the risk for hypertension, IHD, and type 2 diabetes mellitus increases proportionately. Obesity is commonly linked with insulin resistance and high blood pressure, which may reflect reduced activity and exercise. Reduced physical activity is a predictor of obesity.¹⁵⁴ Insulin resistance associated with lack of exercise in people who are overweight may be further compounded by insulin resistance associated with chronic inflammation observed in fat cells.¹⁵⁵ Abdominal obesity, lipid metabolism, and insulin resistance are interrelated markers for coronary artery disease.¹⁵⁶ In addition to cardiovascular and general health risk, being overweight affects quality of life.^157,158

Comprehensive management of an individual who is overweight and has abnormal blood glucose levels includes normalizing blood glucose (with recommendations for low-glycemic foods and small, frequent snacks rather than infrequent large meals), weight reduction, restricted intake of trans fats and saturated fats, strict blood pressure and lipid control, regular physical activity and exercise, and avoidance of tobacco.¹⁵⁹

Nutritional habits during childhood are associated with lifestyle-related conditions in adulthood.¹⁶⁰ Obesity in children is associated with parental obesity.⁷⁹ Maintaining weight within a healthy body mass index range throughout life is recommended for optimal health. Although body mass index may be limited with respect to assessing adiposity because it fails to discriminate between muscle and fat and identify regional adipose depositions, it remains a useful supplementary clinical index.¹⁶¹ Physical therapy has a primary role in preventing and managing overweight and obesity in every client or patient, regardless of age, given obesity’s serious multisystem consequences, psychosocial sequelae, and threat to life participation and satisfaction.¹⁶²

Cancer

The risk factors for cancer are well documented and include environmental and behavioral factors such as nutrition (fats and refined foods), inactivity, poor air quality and smoking, psychological factors, and ingestion of and exposure to chemicals. Cancer, hallmarked by an overgrowth of cells, eventually compromises normal organ function.

Cancers associated with the highest mortality rates include lung, colorectal, and pancreatic cancer.¹⁶³ Smoking has been implicated as a risk factor for many cancers, not only those involving the respiratory tract. The role of lifestyle factors in cancer remission has not been studied in detail.

Cancer prevention and rehabilitation have become a specialty area, requiring an integrated knowledge of pathophysiology, psychosocial implications, and management interventions.164,165 Routine assessment of health behaviors and risk factors and healthy living recommendations may help avert the diagnosis of many cancers or mitigate their effects. To date, evidence that walking is an effective strategy to prevent cancer has been best established for colon cancer,⁸⁶ although breast cancer and prostate cancer have also been reported to be positively affected by regular aerobic exercise including walking.^166,167

Musculoskeletal Health

Osteoporosis and arthritis contribute to considerable morbidity and secondarily to mortality. Because both of these conditions have lifestyle components, a lifestyle risk factor review should be included in every initial assessment to establish a baseline of musculoskeletal health. Moderate levels of physical activity, including walking, are associated with a substantially lower risk for hip fractures in postmenopausal women.¹⁶⁸ Thus assessment of both nonmodifiable and modifiable risks is a major component of the health assessment as a means of minimizing morbidity and potential mortality.⁹ Osteoporosis and associated morbidity, particularly in older age groups, is a serious health issue that warrants monitoring. Establishing baseline information on bone health in every patient is prudent, given the relationship between bone health and lifestyle behaviors (e.g., activity and nutrition—smoking and heavy consumption of meat, alcohol, and coffee). Although older, postmenopausal women have been the focus of bone health studies, other groups are also at risk for osteoporosis and should not be overlooked: older men; inactive children, particularly girls; and individuals with chronic conditions who may be less able to undertake weight-bearing activities and physical activity. In a study of the development of bone mass and strength in girls and young women, only exercise (not daily calcium intake) was associated with bone density and strength.¹⁶⁹ This finding stresses the singular importance of bone building in young people to help offset osteoporosis later in life and associated decrement in quality of life.

Psychological Health

Mental health problems and depression are prevalent in Western society despite its affluence. Based on one descriptive study, individuals with mental health conditions such as schizophrenia tend to have poor physical health and die prematurely from cardiovascular disease.¹⁷⁰ Compared with women who have schizophrenia, men with the condition consumed less fruit, vegetables, whole grains, and rice than recommended. Further, the incidence of smoking and obesity in both sexes was higher than in the general population. Cholesterol levels were high and activity levels low. This study suggested cause for concern about both the physical and psychological well-being of individuals with mental health conditions and indicated the need for further investigation of the physical health and well-being of people with mental challenges.