What are health-risk behaviors? - Chapter 3

What is health behavior?

It is shown that someone's health can be directly related to someone's health behavior. What still needs to be done is establishing the precise (causal) relationships between specific behaviors and diseases.

Many people exhibit healthy behavior for a different primary reason than their health. They exercise for their condition and eat healthy to look better. When scientists describe health behavior, they often mention the actions that have a direct impact on health. But more definitions also include the personal differences and motivations of people. Behavior that is unhealthy for one person can be healthy for the other. Consider, for example sports, for someone who is underweight and someone who is overweight. Matarazzo describes this as a behavioral pathogen, which stands for unhealthy behavior, and behavioral immunogen, which stands for healthy behavior.

Belloc and Breslow described the Alameda Seven. They started a large-scale study among 7,000 healthy adults. These adults where followed from 1960. Afterwards they examined what kind of health behaviors people respected and which diseases they developed or did not develop. Men and women who performed 6 out of 7 of the behaviors in the final analysis lived 7 and 11 years longer respectively. The behaviors were the following:

• Sleeping 7-8 hours a night.
• Not smoking.
• Consuming no more than 1-2 alcoholic drinks per day.
• Getting regular exercise.
• Not eating between meals.
• Eating breakfast.
• Being no more than 10 percent overweight. 

These behaviors have a cumulative effect on health. The more of the behaviors you do, the healthier you live. In addition, non-smoking and regular physical exercise, for example, have a greater positive effect than the two points added together. The above and other research by Breslow and Belloc showed that only 4% of people perform all seven points. 7 to 13% of people perform fewer than 4 points. This is about the same for men and women. A logical fact is that the longer the healthy behavior is carried out, the longer it has a positive effect on health.

Health-risk behavior

The World Health Organization (WHO) has drawn up a list of risk factors that annually account for one third of the total number of deaths. Globally, alcohol use, tobacco use, high blood pressure, high body mass index, high cholesterol, high blood glucose, low fruit and vegetable intake and physical inactivity account for over 60 per cent of cardiovascular deaths. 

Behaviors that are associated with an increased risk of death (mortality) are:

• Heart disease: smoking tobacco, high-cholesterol diet, lack of exercise.
• Cancer: smoking tobacco, alcohol, diet, sexual behavior.
• Stroke: smoking tobacco, high cholesterol diet, lack of vaccination.
• Pneumonia, flu: smoking tobacco, lack of vaccination.
• HIV / AIDS: unprotected sexual intercourse.

What are the negative effects of smoking, drinking and illicit drug use?

Smoking

Nicotine is the third most used psycho-affective substance. Approximately 4.9 million people died in 2000 as a result of tobacco use. Active smoking accounts for 90 percent of lung cancer cases. Although nicotine is a legal drug, the government earns a lot of money from it because of the high taxes. Compared to the 1950s, the prevalence for smoking has dropped considerably. At the moment there are particular concerns about the increase of smoking e-cigarettes among people younger than 25, because it is unclear what the long term effects are. Unfortunately, the numbers of women who quit smoking are a lot lower than men, and more young girls start smoking. Due to the decrease of people who smoke, the number of lung cancer cases has also decreased. An increasing part of the cases of lung cancer is female.

Ethnic differences are found in smoke prevalences. In Great Britain it was found that smoke prevalence for minority groups is lower than among the total population. A number of exceptions (outliers) were found among the minority groups. There are also age differences in prevalence. The prevalence is highest among men between 25 and 34 years old, and lowest among people over 65 years old.

Alcohol consumption

Alcohol is the second most used psychoactive substance in the world. Between 1990 and 2000 there was a significant increase in alcohol consumption between the ages of 11 and 15 years. In 2010 there appeared to be a decrease in this age group. The prevalence of heavy drinking in the 16-24 age group has also decreased. In older age groups, consumption has been relatively stable in Western Europe over the past two decades. Different individuals respond differently to the same amount of alcohol. This depends on factors such as body weight, food intake and metabolism, and a person's cognitions and expectations. Many countries have specific national guidelines regarding the 'standard unit' of alcohol and guidelines regarding maximum gram per day. Countries who do not have national guidelines tend to follow WHO guidelines for sensible drinking:

• Women should not drink more than two drinks per day on average.
• For men, no more than three drinks a day on average.
• Try not to exceed four drinks on any one occasion.
• Do not drink alcohol in some situations, such as when driving, if pregnant, or in certain work situations.
• Abstain from drinking at least once a week.

Drug use

Between 3.5 and 9 per cent of the world's population has used an illegal drug in the last year. The most used drug is cannabis. 

Negative health effects

Smoking

Carbon monoxide reduces the oxygen circulation in the blood, which effectively reduces the amount of oxygen feeding the heart muscles; nicotine makes the heart work harder by increasing blood pressure and heart rate; and together these substances cause narrowing of the arteries and increase the likelihood of thrombosis (clot formation). Tobacco products contain carcinogenic tars and carbon monoxide, which are thought to be responsible for approximately 30 percent of cases of coronary heart disease, 70 percent of lung cancer and 80 percent of cases of chronic obstructive airways disease. Among non-smokers, passive smoking is considered to account for 25 percent of lung cancer deaths. Passive smoking also forms a risks to unborn babies.

Alcohol

Alcohol is a central nervous system depressant. Low doses cause behavioral disinhibition, while high levels lead to 25-fold increase in the likelihood of an accident, and extremely high doses can cause coma and even death. How much alcohol is consumed on average differs greatly per country in Europe. Liver cirrhosis is one of the causes of death related to alcohol. Others are cancer and chronic liver disease. Men are twice as likely to die from alcohol than women. In young people it can lead to physical or mental health problems and behavioral problems or school performance problems. Negative social consequences also occur (domestic violence, loss of relationships, absence from work). Another concern is the relationship between alcohol consumption and deficiencies in judgment in the area of ​​sexual activity and unprotected sex.

Evidence shows that moderate alcohol consumption can be protective of health. It reduces the circulation of LDL (bad fat). This is especially true for women. It has been proposed that red wine may also be beneficial by inhibiting the initiation of carcinogenesis, the process by which normal cells become cancer cells. 

Illicit drug use 

Illicit drug use can lead to HIV and Hepatitis C because of the method of ingestion.

Addiction

The reasons why people start smoking, drinking or using drugs are the following:

• Genetics: with regards to smoking, there is some evidence of genetic factors and the reception and transport of the neurotransmitter dopamine being involved in initiating and continuing smoking.
• Curiosity: starting to smoke, drink or use drugs often has to do with curiosity.
• Modeling, social learning and reinforcement: children with peers, siblings or parents who smoke or drink around them are more likely to smoke or drink themselves than children with non-smoking people around them.
• Social pressure: many adolescents start smoking, drinking or taking drugs under the social pressure of friends. Young people want to belong to the group.
• Weight control: some people smoke because they want to lose weight. Instead of eating sweets, they smoke a cigarette. This occurs more often among young girls than among young males.
• Image and reputation: young boys take their health into consideration rather than young girls when they come into contact with smoking or drinking. Girls often find it more important to be cool than to be healthy. For many boys physical condition (and therefore status) is more important.
• Risk taking: smoking, drinking or drug use among young people is often accompanied by other problematic behaviors, such as truancy and going out at a young age.
• Stress: experiencing a lot of stress leads to more smoking.
• Health cognitions: many smokers, drinkers or drug users have expectations of stress reduction, anxiety reduction and other behavioral benefits. Users also often hold unrealistic optimistic beliefs about the possibility of controlling their behavior and avoiding negative health consequences.
• Self-concept and self-esteem: many behaviors of adolescents originate in the desire to improve reputation and social identity. Smoking, drinking or drug use sometimes help to fit in the group.

What happens when continuing unhealthy behavior and developing dependency?

Reasons for continuing unhealthy behavior are not necessarily the same as starting unhealthy behavior. In general, the following factors are mentioned in distinguishing people who continue to drink safely from people who develop problematic drinking:

• Genetics and family history: children of problem drinkers have a greater chance of developing problematic drinking.
• Certain psychopathology or personality risk factors, for example an anxious predisposition
• The social learning experience: the social learning theory considers alcohol abuse or dependence as socially acquired and learned behavior that has received reinforcement. 

The addictive potential of smoking are due to the fact that nicotine stimulates reward pathways in the brain, including the neurotransmitter dopamine to release natural opiates (beta-endorphins), which means that someone has to keep smoking in order not to experience withdrawal symptoms. Continuing to smoke means avoiding withdrawal symptoms. Higher educated people have a lower chance of developing problematic drinking. In elderly people, problematic drinking is also influenced by physical health, access to social opportunities, and financial status. Wealthy elderly people have drinking problems more often. For some individuals, however, it is related to loneliness or physical illness. People who continue to use resources often report these reasons:

• Pleasure reinforces positive attitudes towards it.
• Habit: habit formation is a crucial barrier to behavior change. 
• Coping: it is often a way of coping or controling anxiety.
• A lack of belief in their ability to stop the behavior. 

Behavior cessation

Even when you are between 50 and 60 years old, to quit smoking still has a mayor positive effects on your health. If you quit before the age of 30, you can still prevent 90% of the extra risk at lung cancer.

Quitting smoking is more common among people with a high SES than people with a low SES and even more with a higher level of education. This is probably due to knowledge and understanding of health consequences. If you don't have family and friends around you who smoke, it is easier to quit smoking than when people around you smoke.

Treating dependence

How dependency problems and the people who have them are viewed by society have changed over time. In the 17th and 18th centurie, it was still your own fault if you became addicted. It was attributed to a weak personality. In the 19th century, it was said that an addict was the victim of an evil and powerful substance. At the beginning of the 20th century, the responsibility was placed back onto the individual, but programs were developed to treat addiction.

During the early 20th century, the behaviorism brought new methods to treat addiction. The social learning theory and the conditiong theory are based on learning through observation and reward. In the same way that the behavior is taught, it can also be unlearned.

Nowadays, it is also common in Europe that a treatment method consists of controlling substance use. For example, consumption is limited to a certain amount per day, or it is replaced with a drink that contains less alcohol. Health promoting efforts therefore have two targets, primary prevention in terms of educating children about safe levels of consumption and the risks of smoking, drinking or drug use, and secondary prevention in terms of changing the behavior of those who already engaged in them. 

Unprotected sexual behavior

Although most cases of HIV (around 70%) occur in Africa, we also have to worry about some parts of Europe. In the UK, 42 thousand people are HIV-positive. About 14 thousand of them suffer from AIDS. HIV is mostly spread through sex between men, then sex between men and women and to a small extent through the unsafe use of needles. Unsafe anal sex between men is common. Heterosexual infection has greater consequences for women than for men.

Negative health consequences of unprotected sexual intercourse

There is an increase in the prevalence of sexually transmitted diseases (STDs). People are worried about this. The SOA chlamydia is easy to prevent by using a condom. A virus known as Human Papilloma Virus (HPV) is related to abnormal tissue and cell growth involved in the development of genital warts and cervical cancer. While condom use reduces the risk of infection, HPV is present in the whole genital area, therefore a condom alone is insufficient to prevent transmission. HPV is startlingly prevalent and therefore, the discovery of a vaccination against those types of HPV, which cause 70 percent of cervical cancer, has been billed as a major public health discovery. 

The use of condoms

Sexually transmitting the HIV virus can easily be prevented by having safe sex. Here are some facts about the use of condoms. Young people use condoms more often than older people. Women use a condom less often than men. People mostly use a condom when they have a new partner, but condom use decreases again when someone often has a new partner. Especially men who have a number of regular sex partners use a condom less often than other people. Female condom use is less influenced by the amount of new partners they have.

Alcohol consumption causes a decrease in condom use among young and older people, heterosexuals and homosexuals. This is possibly due to risk behavior associated with alcohol use. Research has shown that women are confronted with obstacles when considering condom use. These include the following points:

• Difficult or embarrassing to propose condom use to the male partner.
• Anticipating male objection to a female suggesting condom use (denial of their pleasure).
• Worry that suggesting condom use to a potential partner implies that either they or the partner is has a STD.
• Lack of self-efficacy or mastery in condom use.

What does an unhealthy diet entail?

Fat intake and cholesterol

35% of cancer deaths are due to a poor diet.

Many fatty foods (especially fast foods) contain many of the bad types of fat, which causes many Low Density Lipoproteins better known as LDL. This LDL brings cholesterol into the bloodstream, where it sticks to the veins. This can lead to atherosclerosis. Not all fatty foods are bad. Fatty fish contains a lot of omega-3 fats, which are actually beneficial for health. This causes an increase in HDL levels (good cholesterol). It is important to keep the levels of LDL as low as possible. When someone is on a diet, it is therefore important that they not only limit fat intake. Because of this you get too little of some necessary substances. It is important to reduce the intake of bad fats and carbohydrates (which are often found in bread, pasta, potatoes), but also to continue to eat a varied diet. Atherosclerosis (formation of fatty plaque in the arteries) should not be confused with arteriosclerosis (loss of elasticity and hardening of the arteries). 

Salt

High salt intake can cause high blood pressure or hypertension. Low salt intake can cause reduced systolic pressure (the maximum pressure in arterial vessels when the blood is pumped into the veins) and diastolic pressure (the minimum pressure in the artery vessels that remains when the heart relaxes). However, the degree of reduction in blood pressure was not related to the amount of salt reduction. 

Obesity

Obesity is often expressed in body mass index (BMI), which is calculated as a person's weight in kilograms divided by their height in metres squared (weight in kg) / (height in centimeters) 2. An individual is considered to be:

• Normal weight if their BMI is between 20 and 24.9.
• Mildly obese or 'overweight' (grade 1) if their BMI is between 25 and 29.9,
• Moderate or clinically obese (grade 2) if their BMI falls between 30 and 39.9
• Severly obese (grade 3) if theit BMI is 40 or greater. 

The immediate risks of being overweight are hypertension, heart problems, type II diabetes and back pain. The risk of heart problems is only present if someone is overweight for a long time (20 to 30 years). Being overweight is also the most common health problem among European children. Obesity can also lead to psychological problems, such as low self-esteem and social isolation.

Prevalence of obesity 

In 1999, about 31% of the European adult population were obese, and 10% had clinically obesity. Excess body weight is now one of the most common child disorder in Europe. For women an increased risk of obesity is related to low social class, for men this does not apply. To start a successful intervention, one must understand which factors are involved in the development of obesity. The social learning theory focuses on the strong influence of others and associative learning. Reinforcement determines whether behavior will occur again in the future.

What causes obesity?

The most logical explanation for being overweight is that someone gets more energy than he or she consumes. However, research among twins and adoption studies show that some people also have a genetic predisposition to obesity. Other explanations that are given are:

• Some people are born with a greater number of fat cells. The evidence for this statement is still limited. For example, the number of fat cells will dramatically increase in a serverly obese person, making it increasingly difficult to maintain a healthy weight.
• Some people have a slower metabolism. However, a consistently lower metabolism is not found among overweight people.
• It is suggested that there is a hormone that regulates appetite. Obese individuals have deficiences or lack of control in this hormone (leptine).
• The neurotransmitter serotonin is involved in the satisfied feeling after eating. When a serotonin agonist (a drug that influences the effect of a certain neurotransmitter) is introduced into the body induced satiety, and reduced the frequency and quantity of food intake en body weight. This subject requires further investigation.

Biological and genetic explanations for obesity cannot explain everything. Environmental factors such as a sedentary lifestyle, little to no exercise and eating the wrong food must also be included.