Social Determinants of Health

The Role of Physical Activity in Fitness

According to the CDC (2007), physical inactivity is one of the three behaviors (along with smoking and poor diet) that contributed to almost 35% of all deaths in the US in the year 2000, as these behaviors often contributed to the development of diseases. Sadly, the older adult population is the least active of all age groups (CDC, 2003). In 2002, 32% of adults age 65 and older died from heart disease, 22% died from cancer, and 8% died from a stroke. In total, these three conditions represented 61% of all deaths among this age group (CDC, 2007). Perhaps the most disturbing recognition is that the eventual deaths associated with these conditions were largely preventable. Baby Boomers today stand a very good chance of dramatically reducing their risk for developing a chronic disease as long as they include regular physical activities in their daily lives and receive appropriate direction regarding these activities.

Data and Statistics

Adverse Childhood Experiences (ACEs) are categorized into three groups: abuse, neglect, and family/household challenges. Each category is further divided into multiple subcategories. Participant demographic information is available by gender, race, age, and education. The prevalence of ACEs is organized by category. All ACE questions refer to the respondent's first 18 years of life. Abuse Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt. Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured. Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you. Household Challenges Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother's boyfriend. Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs. Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide. Parental separation or divorce: Your parents were ever separated or divorced. Criminal household member: A household member went to prison. Neglect1 Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.2 Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it2, you didn't have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

Scope of Decision Making by a Doctor

Best interests requires consideration of: The dignity and uniqueness of every person; The possibility and extent of preserving the patient's life; The preservation, improvement or restoration of the patient's health or functioning; The relief of the patient's suffering; Any medical conditions; and Such other concerns and values as a reasonable person in the patient's circumstances would wish to consider.

Self Determination

Every adult with decisional capacity has the right to consent to or refuse medical treatment even if that decision will result in the patient's death. The right to refuse treatment is a liberty interest protected by the due process clauses of the New York State and U.S. Constitutions The Patient Self-Determination Act (PSDA) is a federal law, and compliance is mandatory. It is the purpose of this act to ensure that a patient's right to self-determination in health care decisions be communicated and protected. Through advance directives--the living will and the durable power of attorney--the right to accept or reject medical or surgical treatment is available to adults while competent, so that in the event that such adults become incompetent to make decisions, they would more easily continue to control decisions affecting their health care.

Social Determinants Across the Life Stages

From infancy through old age, the conditions in the social and physical environments in which people are born, live, work, and age can have a significant influence on health outcomes. Children Early and middle childhood provide the physical, cognitive, and social-emotional foundation for lifelong health, learning, and well-being. A history of exposure to adverse experiences in childhood, including exposure to violence and maltreatment, is associated with health risk behaviors such as smoking, alcohol and drug use, and risky sexual behavior, as well as health problems such as obesity, diabetes, heart disease, sexually transmitted diseases, and attempted suicide.6 Features of the built environment, such as exposure to lead-based paint hazards and pests, negatively affect the health and development of young children. Adolescents Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people's health and well-being. Addressing young people's positive development facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population. Adolescents who grow up in neighborhoods characterized by poverty are more likely to be victims of violence; use tobacco, alcohol, and other substances; become obese; and engage in risky sexual behavior.7 Adults Access to and availability of healthier foods can help adults follow healthful diets. For example, better access to retail venues that sell healthier options may have a positive impact on a person's diet. These venues may be less available in low-income or rural neighborhoods. Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the modern workplace and are increasingly affecting the health and lives of U.S. adults. Research has shown that workers experiencing these stressors are at higher risk of injuries, heart disease, and digestive disorders.8 Older Adults Availability of community-based resources and transportation options for older adults can positively affect health status. Studies have shown that increased levels of social support are associated with a lower risk for physical disease, mental illness, and death.9

The Key to a Sharp Mind

cognitive decline, especially memory deficit associated with aging, is a concern of many Baby Boomers in regard to their parents as well as themselves." maintaining cognitive ability and slowing age-related cognitive decline have become hot topics for researchers and the general public. the media has been abuzz with hopeful news that we may be able to keep our brain fit just as we keep our body fit, and thereby age successfully. ; interventions to enhance cognitive functioning, for example, enriched environments and cognitive activities; Cognitive Reserve Until relatively recently, the dominant view of cognitive aging has been that of pervasive, progressive, and irreversible decline. However, current theoretical underpinnings of enhancing cognitive fitness later in life, i.e., at age 65 and older, are based on the concepts of cognitive reserve and neural plasticity. Both constructs are exciting and hopeful because they imply that the older adult can actively help to preserve his/her intellectual capacity. Cognitive reserve theory explains why some individuals are more resilient or adaptive to brain pathology and can function well in everyday life despite neuronal damage. It implies that people have more cognitive capacity than needed for survival, and that we can draw from an extra "reserve" when needed (Stern, 2006; Vance & Crowe, 2006). According to cognitive reserve theory, a higher reserve arises from a combination of greater overall cognitive efficiency, greater proliferations of brain neurons, more connections between neurons, and an enhanced ability to compensate by recruiting generalized neurons for specific tasks at hand and using alternative strategies to solve problems (Grady, 2006). *The investigations into the hypotheses of cognitive reserve suggest that childhood cognition, educational and IQ levels, professional attainment, occupational complexity, and lifestyle characteristics, such as level of activity and nutrition, all lead to greater cognitive reserve (Richards & Sacker, 2003; Scarmeas & Stern, 2003).* Although older, retired adults are not able to build cognitive reserve via childhood educational and occupational attainment, they can make changes in their current lifestyle through engagement in educational and other cognitive-enhancing activities. Vance and Crowe (2006) suggest that the steps to prevent loss or to increase cognitive reserve include engaging in cognitively stimulating activities and using cognitive training techniques. The reserve model is a dynamic process that applies across the life course, suggesting that cognitive ability is modifiable at all life stages (Richards, Sacker, & Deary, 2006). These notions clearly have significant positive implications for the aging Baby Boomer. Neurogenesis Similarly encouraging is the theory of neurogenesis. For most of the twentieth century, scientists believed that brain cells, unlike hair cells, skin cells and other cells in the body, could not reproduce; i.e., a human would have no more neurons at death than he or she had at birth - and would probably have significantly fewer. Then, near the end of the last century, researchers discovered that two brain structures, the hippocampus (a structure involved in memory and learning) and the olfactory bulb (the brain structure involved in the perception of odor) could generate new cells. Even adults beyond the age of 65 had the capacity for neurogenesis in these two structures (Gould, Beylin, Tanapat, Reeves, & Shors, 1999). This phenomenon, originally discovered in bird models, has also been found in other animal models, most often rats or mice, and sometimes dogs. Such research must use animal models because it entails sacrificing animals to examine their brain for signs of new cells. However, among neuroscientists, there is no doubt that what has been observed in other mammals is also true of humans, and that this potential exists throughout the lifespan (Bruel-Jungerman, Rampon, & Laroche, 2007). Along the lines of neurogenesis, there is evidence to suggest that there can also be growth in the connections between neurons. Vigorous physical activity appears to enhance neuronal growth, while learning, which involves using the cells, appears to promote new connections (Olson, Eadie, Ernst, & Christie, 2006). Taken together, the factors that can produce structural and functional changes in the brain are referred to collectively as an "enriched environment." Although all of the research to date has used animal models, usually rats or mice, the potential is encouraging for humans. Improving Cognitive Capacity through Enriched Environments Having an "enriched environment" seems to be the key to improving cognitive capacity. In 2006 the community of scientists on the cutting edge of research regarding the role of physical and cognitive exercise in promoting cognitive vitality made the following recommendation: The concept of the "enriched environment" currently employed in animal studies to promote physical activity, socialization, and problem solving, needs to be explored in human studies (Studenski et al, 2006). Having an "enriched environment" seems to be the key to improving cognitive capacity. Such an environment comprises increased opportunities for physical activity, learning, and social interaction. In their experiments using animal models, Kempermann, Kuhn, and Gage (1997) found that even a short-term exposure to such an environment led to a striking, five-fold increase in new neurons, along with a substantial improvement in behavioral performance. They observed more learning, more exploratory behavior, and more locomotor activity in enriched environments. These results are strong evidence that signs of neuronal aging in humans can be diminished by sustaining an active and challenging life, even if these stimulating activities start later in life. There are both cognitive and physical pursuits which, if performed to an appropriate level of intensity and frequency, will promote various benefits for older adults. For example, an eight-year, longitudinal study of over 1,000 older adults in Finland found that higher levels of physical and leisure activity were associated with, and predictive of mental well-being in later life, thus suggesting these activities are appropriate target areas for prevention of cognitive decline (Lampinen, Heikkinen, Kauppinen, & Heikkinen, 2006). Cognitive Activities Cognitive scientists study cognition in terms of specific functions, such as attention, recall, expressive and receptive language, motor coordination, and executive functions that include planning and problem solving as well as stress management and emotional modulation. Many researchers, as well as the general public, believe that these skills inevitably decline with age. Hence, there have been quite a few attempts over the past decades to train people in these specific functions as a defense against time. In general, results of empirically supported studies using healthy older adults suggest that specific skills can be improved when targeted by an intervention (Studenski et al., 2006; Willis et al., 2006). A few studies have found evidence of generalized benefit from cognitive training programs. For example, the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (Willis et al., 2006) showed that cognitive training in the areas of reasoning, memory, or speed of processing improved cognitive function in adults 65 years and older who are living independently, and the improvement lasted at least five years, if there was some booster training. The benefits of all types of cognitive training were detectable on the specific trained skill after five years, but only training in reasoning ability had a self-reported impact on preserving ability to function well in everyday life. One emerging and promising area of research is the design and evaluation of interventions that offer ecologically valid activities in "real life" environments, because of their increased likelihood for acceptance and adherence by older adults. One example is the Experience Corps (EC) project that has forged a partnership between older adults and the public schools (Glass et al., 2004). In this project, teams of older adults worked in elementary school classrooms where they participated in teaching literacy and math skills as well as conflict resolution. Older adults deemed at the greatest risk for cognitive impairment who participated in this project showed improvement in executive functioning and memory skills (Carlson et al., 2004). Another innovative program is the first intergenerational Charter School in Cleveland, Ohio. In this program, children aged six to twelve learn in the company of older adults, some of whom have been diagnosed as having Alzheimer's Disease (Whitehouse & George, 2008). The program, initiated in 2003, creates opportunities for older adults to contribute to their community by sharing their knowledge and experience, while exercising multiple cognitive skills. Specific activities are described on the school website <www.tisonline.org/>. The long-term cognitive benefits of participating in such a program are not yet known, but anecdotal evidence suggests that volunteering in this award-winning program enhances quality of life for the older adult while providing service in the community. Physical Activities and Cognition Physical fitness training, specifically aerobic training, has been found to have robust benefits for cognition. In the original 2003 article, the work of Colcombe and Kramer (2003) was cited as evidence of the relationship between physical activity and cognition. In our 2003 article we noted these researchers had concluded that when it came to the question of whether or not aerobic fitness training is beneficial to the older adult, the researchers had provided an unequivocal yes. While Colcombe and Kramer were successful in validating the beneficial effects of physical activity on cognition, they noted that numerous moderating effects, such as type of fitness training, program duration, session duration, and their respective influences on the effectiveness of the training, need to be considered in future research. ...new evidence has surfaced that has further validated the role of aerobic conditioning in the preservation of cognition. Spirdusso, Poon, and Chodzko-Zajko (2008) observed that there are moderators, e.g., age, gender, or education, and mediators, e.g., physical activity, physical resources, disease state, or mental resources that influence the effectiveness of physical activity on cognition. While it is often stated in the literature that physical activity has an effect on one's cognitive ability, including one's ability to learn, retrieve, and problem solve, Spirdusso et al. have suggested that there are mediating factors, such as our physical resources, our disease state, and our mental resources that influence just how well physical activity will work in effecting a positive change in cognition. Further, they have observed that moderating factors, such as age, gender, education, estrogen levels, and genotype, must be considered. The reader is directed to the book, Exercise and Its Mediating Effects on Cognition, by Spirduso et al. for a more complete discussion of this particular topic. More recently, new evidence has surfaced that has further validated the role of aerobic conditioning in the preservation of cognition. Colcombe et al. (2006), in an effort to determine whether aerobic fitness training of older adults increased brain volume in regions associated with age-related decline, subjected two groups of volunteers to either six months of aerobic training or six months of toning and stretch training (20 young adults served as controls and underwent no training). It was determined that the training promoted significant increases in both grey (the neurons of the cortex) and white (the connecting pathways) matter regions. Their evidence suggests that cardiovascular fitness and training is associated with the sparing of brain tissue in aging humans, and with maintaining and enhancing cognitive functioning in older adults. Cognitive, Physical, and Social Functioning Cognitive training alone and physical training alone each have benefits for cognitive function. However, when an individual engages in both types of training, there appears to be a multiplier effect in which each enhances the impact of the other. Olson et al. (2006) noted that the two work together to enhance cognitive function, especially in the hippocampus where learning occurs. Oswald et al. (2006) provided cognitive, physical, and also psycho-education training together. They reported that over a five-year period, they observed significant training effects, including fewer depressive symptoms in the participants compared to a control group, which did not receive the training. Newson and Kemps (2006), too, found that the combination of physically and cognitively stimulating activities was related to better cognitive performance. In their study, participants recorded their engagement (time and effort) in such physical activities as running, swimming, and jogging; and cognitive activities, such as reading a book and completing crossword puzzles. They were then tested on a visual imagery task which made demands on cognitive function. By choosing this task for their test, Newson and Kemps claimed that the results of their study are indicative of a broad range of cognitive demands people face. The data analysis suggested that cognitive activities promoted performance on complex cognitive tasks better than the physical activity, but both physical and cognitive activity promoted general cognitive function. The authors concluded that both physical and cognitive stimulation offer protection against cognitive decline with age, but likely take different paths in doing so. Meaningful activities are those that require skill, concentration, feedback, deep involvement, and also a sense of flow, i.e, loss of awareness of the passage of time due to focused concentration (Hartman-Stein & Potkanowicz, 2003). Professionally conducted, community-based cultural programs are examples of such activities. In a study of 166 healthy older adults, participants were assigned to a singing chorale intervention or comparison group of usual activities and were followed for 12 months (Cohen et al., 2006). The intervention group reported better morale and less loneliness, as well as a higher overall rating of physical health, including less medication use, fewer doctor visits, and fewer instances of falls. This positive effect suggests that organized group activities have potentially important health promotion and disease prevention benefits. Additionally, Cohen et al. (2006) identified health-promoting activities for older adults, to be those that provide either a sense of mastery, and/or require the involvement of simultaneous bilateral brain involvement, and/or include meaningful social engagement. Fave and Massimini (2005) surveyed people from several cultures on the psychological features of optimal activity in daily life. They consistently found that optimal experience was most closely associated with activities that were complex, highly structured, and enjoyable, and that provided opportunities for self-expression, required a high level of concentration to do the task, and would lead to skill development. Stern (2006) stated that what seems to matter is that there be a variety of activities both intellectual and social in nature that are challenging to the individual. Commercial Brain Fitness Products Several commercial brain exercise products are currently available such as Posit Science's "Brain Fitness," "My Brain Trainer," and Nintendo's "Brain Age" programs. Some of these are listed in Table 2. Currently, though, there are more commercial products designed as brain exercises than there are empirically supported research studies of the effectiveness of these products. Based on her review of the current literature, LaRue (2008) concluded that there is no one cognitive activity or combination of activities that can currently be identified for reducing the risk of dementia. She made the following cognitive-activity recommendations for older adults: Carve out time for cognitively stimulating activities that have been enjoyable throughout your life. Add some new challenging pursuits, as time and energy allow. Aim to engage in cognitively challenging pursuits several times a week. Participate in social interactions. Table 3 provides a listing of self-help books and consumer education related to brain fitness. The sources cited throughout this paper speak with one voice: the characteristics of activities that people most want to engage in are challenging, require skill, allow the person to get involved at a deep level, and at least some of the time, have an element of social involvement. Summary ...we, as fitness and healthcare professionals, must champion the cause of making regular physical activity and cognitive training a part of every Baby Boomer's daily life. In summary, as was the case in the original article from 2003, "the news for the baby boomer generation is indeed positive regarding their upcoming late life years" (Hartman-Stein & Potkanowicz, 2003). The research community has provided evidence that just as physical exercise benefits the body, so also exercising the brain can have protective and enhancing effects. We are beginning to gather the evidence that just as physical exercise is not only good but also necessary for the body, so also cognitive challenge is necessary to keep the brain working well. These new understandings make it an exciting time to contemplate the future of aging, a time when older adults can be fully functioning without the prevalence of some of the declines and deficits that we have here-to-fore accepted as an unavoidable side effect of getting older. The Next Wave As was stated at the beginning of this article, on October 15th, 2007, Kathleen Casey-Kirschling became the first of the Baby Boomer generation to ride the silver tsunami by applying for her social security benefits. The actual definition of a tsunami is a series of waves. With the expectations of the first wave of Baby Boomers being as high as they are, the assumption can safely be made that the next wave of Baby Boomers and the waves of Baby Boomers to follow will have higher and greater expectations for themselves compared to those in the first wave. Simply put, they will want more out of life in their later years compared to their predecessors. In order to accommodate them we, as fitness and healthcare professionals, must champion the cause of making regular physical activity and cognitive training a part of every Baby Boomer's daily life. Table 1. Comparison Table - Physical Activity: Recommendations for Older Adults, 2003 vs. 2007 Category 2003 Physical Activity Recommendations (Hartman-Stein & Potkanowicz, 2003) 2007 Physical Activity Recommendations (Nelson et al, 2007) Aerobic Activity (i.e. cardiorespiratory fitness) 3-5 days/week 30-60 minutes accumulated time 55-90% of Maximum Heart Rate Minimum 30 minutes, on 5 days each week at moderate intensity (5-6 on a 10-point [pt]. scale) Or If capable, 20 minutes, on 3 days each week at vigorous intensity (7-8 on a 10pt. scale) Muscle Strengthening Progressive in nature and individualized, 8-10 exercises, consisting of one set of 8-12 repetitions on 2-3 days per week Minimum 2 non-consecutive days per week, 8-10 exercises, 10-15 repetitions at moderate (5-6 on a 10pt. scale) to high (7-8 on a 10pt. scale) intensity Flexibility Participate in flexibility training that addresses the major muscle groups and their respective ranges of motion 2-3 days per week Participate in flexibility training that addresses the major muscle groups and their respective ranges of motion on at least two days of the week for at least 10 minutes each time Balance No formal recommendation Passively addressed as a part of the overall recommendation Older adults should intentionally pursue and participate in exercise to improve/maintain balance rather than passive inclusion as part of an overall program

Physically Fit

...a set of attributes or characteristics that people have or achieve that relates to the ability to perform physical activity. These characteristics are usually separated into either health-related or skill-related components Although many people aspire to possess the skill-related components associated with physical fitness, e.g., agility, balance, coordination, speed, power, and reaction time, we benefit more on a day-to-day basis, and certainly in the long term, from the health-related components of physical fitness. That is not to say that skill-related attributes cannot be attained or achieved by the older adult; but rather that the general population of older adults benefits more significantly from possessing the health-related attributes. health-related physical fitness: ...is associated with the ability to perform daily activities with vigor, and the possession of traits and capacities that are associated with a low risk of premature development of hypokinetic diseases (e.g. those associated with physical inactivity, like obesity, diabetes, and hypertension). The combination of high levels of both health-related fitness, and its associated traits and capacities, such as cardiovascular endurance, muscular fitness, flexibility, body composition, and physiologic fitness (fitness that relates to the status of metabolic systems, body compositional factors, and bone mineral density) can increase a Baby Boomer's chances of enjoying a life filled with satisfying personal experiences, a life of good quality, and a life of pursuits not hindered by physiological setbacks...

Living Wills

A living will is a document signed by a person with decisional capacity that contains his or her instructions about treatment to be followed if he or she becomes incapable of making treatment decisions directly. A living will is an advance directive. The living will provides guidance and may limit an agent or surrogate's decision making authority. Health Care Agent and Surrogate are required to make decisions consistent with the patient's wishes and instructions as set forth in the living will. Health care providers are obligated to disseminate information about a patient's right to execute advance directives to take effect when the patient no longer has capacity. When an advance directive has been presented to a physician or health care provider, a copy of the directive must be placed in the patient's medical record. A Health Care Agent or Surrogate can not make a decision contrary to the instructions given the living will, unless the agent or surrogate has a valid reason for disregarding the living will, such as: The patient revoked the living will; The patient gave more recent, superseding instructions. A Health Care Agent and Surrogate have no legal authority to override a patient's living will in order to replace the patient's wishes with the agent's beliefs. If the Health Care Agent or Surrogate refuses to make decisions consistent with the patient's wishes as expressed in the living will, a health care provider may seek a court order to resolve the dispute.

Major Findings

Adverse Childhood Experiences (ACEs) are common. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course. As the number of ACEs increases so does the risk for the following*: Dose-response describes the change in an outcome (e.g., alcoholism) associated with differing levels of exposure (or doses) to a stressor (e.g. ACEs). A graded dose-response means that as the dose of the stressor increases the intensity of the outcome also increases. Alcoholism and alcohol abuse Chronic obstructive pulmonary disease Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease Liver disease Poor work performance Financial stress Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy Risk for sexual violence Poor academic achievement

Health care decisions when the patient is incapacitated

Health Care Agent; If no Health Care Agent, Surrogate pursuant to FHCDA; Certain health care providers pursuant to FHCDA; Court; If patient on psychiatric unit, special laws apply and may need court order; If patient is developmentally disabled or mentally retarded, special laws apply permitting actively involved family members in order of priority to make major medical decisions Special process for DNR and decisions to withhold or withdraw life-sustaining treatment under SCPA §1750-b. Health Care Agent: Subject to any express limitations in the health care proxy, an agent has the authority to make any and all health care decisions that the patient could make. PHL § 2982(1) Surrogate: Subject to decision-making standards and limitations in FHCA, the surrogate has the authority to make any and all health care decisions that the patient could make. PHL §2994-d(3)(i)

Conflicts

Health Care Proxy Law - Notwithstanding a determination that the patient lacks capacity to make health care decisions, where a patient objects to a health care decision made by the agent, the patient's objection or decision shall prevail until a court order is obtained finding that the patient lacks capacity to make health care decisions. PHL § 2983(5) FHCDA: If the patient objects to a treatment decision made by a Surrogate, a court order must be obtained finding that the patient lacks capacity (unless already adjudicated incompetent for all purposes) and authorizing the treatment. PHL § 2994-c(6) If a Health Care Agent or Surrogate directs the provision of life-sustaining treatment, the denial of which would be likely to result in the patient's death, the health care provider that does not wish to provide such treatment must nonetheless comply with the decision pending either transfer of the patient to a willing provider or court order.

Adolescents who experience major depressive episodes (MHMD-4.1)

Healthy People 2020 objective MHMD-4.1 tracks the proportion of adolescents aged 12-17 years who experienced a major depressive episode (MDE) in the past 12 months. HP2020 Baseline: In 2008, 8.3% of adolescents aged 12-17 years had an MDE in the past 12 months. Most Recent: In 2015, 12.5% of adolescents aged 12-17 years had an MDE in the past 12 months. HP2020 Target: 7.5%, a 10% improvement over the baseline. Disparities were observed for a number of population groups in 2015. For example: Non-Hispanic black adolescents aged 12-17 years had the lowest rate of experiencing an MDE in the past 12 months, 9.0%. The rates for other racial and ethnic groups were: 16.1% of adolescents who identify with 2 or more races; 79.2% higher than the best group rate 13.4% of non-Hispanic white adolescents; 49.2% higher than the best group rate 13.0% of American Indian or Alaska native adolescents; 45.0% higher than the best group rate 12.9% of Native Hawaiian or other Pacific Islander adolescents; not significantly different than the best group rate 12.6% of Hispanic or Latino adolescents; 40.9% higher than the best group rate 10.1% of Asian adolescents; not significantly different than the best group rate A higher proportion of adolescent females aged 12-17 years had an MDE in the past 12 months, 19.5%, compared to adolescent males, 5.8%. The rate for females was more than 3 times that for males. Among age groups, adolescents aged 12-13 years had the lowest rate of experiencing an MDE in the past 12 months, 7.8%. The rates for other age groups were: 13.8% of adolescents aged 14-15 years; 76.8% higher than the best group rate 15.5% of adolescents aged 16-17 years; twice the best group rate

Prior Decisions

If the patient has no health care agent but already made a decision regarding the proposed health care, the consent of a surrogate is not required. Decision may be expressed orally or in writing. Such prior decision must be documented in the patient's medical record. Prior to implementing the decision, reasonable efforts must be made to notify the surrogate if one has been identified, except that if the prior decision is to withhold or withdraw life sustaining treatment, diligent efforts to notify the surrogate are required. An Ethics Committee may be convened to consider and respond to any health care matter presented to it by a person connected with the case, including: Providing advice on ethical aspects of treatment; Making recommendations about treatment; and Resolving disputes. The Ethics Committee's recommendations are advisory and generally not binding. A special proceeding may be commenced under PHL § 2992 with regard to any dispute regarding a health care proxy including a proceeding to: Determine the validity of the proxy; Have the agent removed on the grounds that the (a) agent is not reasonably available, willing and competent to fulfill his or her obligations, or (b) is acting in bad faith; or Override the agent's decision about health care treatment on the grounds that (a) the decision was made in bad faith, or (b) the decision is not in accordance with the decision making standards. Who Can Commence a Special Proceeding? A health care provider; Patient; Family member; Close friend; Guardian, Conservator for or committee of the patient; Commissioner of DOH, OMH or OPWDD. Court Proceedings Under FHCDA PHL § 2994-r A patient, any person on the surrogate list, hospital administrator, attending physician, a health care or social services practitioner, any duly authorized state agency and any member of the Ethics Committee may commence a special proceeding in regard to any matter arising under the FHCDA, including: Patient's objection to determination of incapacity; Designation of surrogate; Court order to withhold or withdraw life-sustaining treatment; and Dispute about proposed health care.

How does a physician make a determination of capacity?

In order to make valid treatment decisions, a person must be able to (a) recognize there is a decision to be made, (b) understand the needed information, (c) understand the treatment options, (d) understand the likely consequences of each option (i.e. risks, burdens, and benefits), and (e) rationally manipulate the information to come up with a decision consistent with his or her values. A determination that the patient lacks capacity to make health care decisions must be made by the patient's attending physician to a reasonable degree of medical certainty. Special rules apply when incapacity is due to mental illness or a developmental disability.

Pre-Exercise Screening

In the original 2003 article, the recommendations offered for physical activity were prefaced by the recommendations that (a) before beginning any exercise program, the individual should consult with a physician to insure that he or she is healthy enough to begin an exercise program, and (b) the individual should seek the advice and guidance of an exercise professional certified through a recognized certifying body, Both of these recommendations still stand and are strongly encouraged. older adults can now begin the screening process and initiate a self-directed physical activity program through the use of a new screening tool called the EASY tool, which is an acronym for Exercise Assessment and Screening for You. ...is a tool developed to help older individuals, their health care providers, and exercise professionals identify different types of exercise and physical activity regimens that can be tailored to meet the existing health conditions, illnesses, or disabilities of older adults. The authors go on to say that the EASY tool can be completed either independently by the older adult or with the assistance of a healthcare or exercise professional. The authors contend that pre-exercise screening should not keep people from being physically active (and many screening tools do so), but rather should set people on their way to being physically active, given that physical activity in all age groups is good. The EASY tool is available online at the EASY website <www.easyforyou.info/>.

Health Impact of Mental Health

Mental health and physical health are inextricably linked. Evidence has shown that mental health disorders—most often depression—are strongly associated with the risk, occurrence, management, progression, and outcome of serious chronic diseases and health conditions, including diabetes, hypertension, stroke, heart disease, and cancer.4, 5 This association appears to be caused by mental health disorders that precede chronic disease; chronic disease can intensify the symptoms of mental health disorders—in effect creating a cycle of poor health.5 This cycle decreases a person's ability to participate in the treatment of and recovery from mental health disorders and chronic disease. Therefore, while efforts are underway to reduce the burden of death and disability caused by chronic disease in the United States, simultaneously improving mental health nationwide is critical to improving the health of all Americans.

Mental Health Across the Life Stages

Mental health disorders are a concern for people of all ages, from early childhood through old age. Children and Adolescents Approximately 20% of U.S. children and adolescents are affected by mental health disorders during their lifetime. Often, symptoms of anxiety disorders emerge by age 6, behavior disorders by age 11, mood disorders by age 13, and substance use disorders by age 15.6 15% of high school students have seriously considered suicide, and 7% have attempted to take their own life.7 Mental health disorders among children and adolescents can lead to school failure, alcohol or other drug abuse, family discord, violence, and suicide.8 Adults It is estimated that only about 17% of U.S. adults are considered to be in a state of optimal mental health.1 An estimated 26% of Americans age 18 and older are living with a mental health disorder in any given year, and 46% will have a mental health disorder over the course of their lifetime.1 Almost 15% of women who recently gave birth reported symptoms of postpartum depression.1 Older Adults Alzheimer's disease is among the 10 leading causes of death in the United States. It is the 6th leading cause of death among American adults and the 5th leading cause of death for adults age 65 years and older.9 Among nursing home residents, 18.7% of people age 65 to 74, and 23.5% of people age 85 and older have reported mental illness.1

Disparities and Social Determinants

Race and ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual's ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations. Social determinants are often a strong predictor of health disparities. For example: -In 2007 to 2008, the Asian or Pacific Islander population had the highest rate of high school graduation among racial and ethnic groups, with 91.4% of students attending public schools graduating with a diploma 4 years after starting 9th grade compared to rates among non-Hispanic white (81.0%), American Indian or Alaska Native (64.2%), Hispanic (63.5%), and non-Hispanic black (61.5%) populations. -According to the National Assessment of Adult Literacy, African American, Hispanic, and American Indian or Alaska Native adults were significantly more likely to have below basic health literacy compared to their white and Asian or Pacific Islander counterparts. Hispanic adults had the lowest average health literacy score compared to adults in other racial and ethnic groups.10 -In 2007, African Americans and Hispanics were more likely to be unemployed compared to their white counterparts. Further, adults with less than a high school education were 3 times more likely to be unemployed than those with a bachelor's degree.11 -Low socioeconomic status is associated with an increased risk for many diseases, including cardiovascular disease, arthritis, diabetes, chronic respiratory diseases, and cervical cancer as well as for frequent mental distress.11 -Low-income minorities spend more time traveling to work and other daily destinations than do low-income whites because they have fewer private vehicles and use public transit and car pools more frequently.11

Determinants of Mental Health

Several factors have been linked to mental health, including race and ethnicity, gender, age, income level, education level, sexual orientation, and geographic location. Other social conditions—such as interpersonal, family, and community dynamics, housing quality, social support, employment opportunities, and work and school conditions—can also influence mental health risk and outcomes, both positively and negatively. For example, safe shared places for people to interact, such as parks and churches, can support positive mental health. A better understanding of these factors, how they interact, and their impact is key to improving and maintaining the mental health of all Americans.

Health Impact of Social Determinants

Social and physical determinants affect a wide range of health, functioning, and quality of life outcomes. For example: -Access to parks and safe sidewalks for walking is associated with physical activity in adults.2 -Education is associated with: Longer life expectancy Improved health and quality of life Health-promoting behaviors like getting regular physical activity, not smoking, and going for routine checkups and recommended screenings.3 -Discrimination, stigma, or unfair treatment in the workplace can have a profound impact on health; discrimination can increase blood pressure, heart rate, and stress, as well as undermine self-esteem and self-efficacy.3 -Family and community rejection, including bullying, of lesbian, gay, bisexual, and transgender youth can have serious and long-term health impacts including depression, use of illegal drugs, and suicidal behavior.4 -Places where people live and eat affect their diet. More than 23 million people, including 6.5 million children, live in "food deserts"—neighborhoods that lack access to stores where affordable, healthy food is readily available (such as full-service supermarkets and grocery stores).5

Updated Recommendations for Aerobic Activity

Spirdusso, Francis, and MacRae (2005) noted that estimates of minimal levels of aerobic capacity for independent living are approximately 13 milliliters of oxygen per kilogram of mass for each minute of activity (or 3.7 METS, where 1 MET=3.5 ml X kg-1 X min-1). Estimates place the age-related decline in aerobic capacity at approximately 1% per year, for each year after the age of 25 (Spirdusso et al.2005). Furthermore, the rate of decline is thought to increase between the ages of 65 and 75 and then again between the ages of 75 and 85. Sufficient aerobic capacity not only helps to maintain an independent lifestyle, it also contributes to the prevention of multiple chronic disease processes. Being physically active is an important tool in promoting healthy aging. With respect to aerobic activity, and relative to one's fitness level, moderate-intensity aerobic activity is defined as a rating of 5-6 on a 10-point scale, where 0 is sitting, 10 is an all out effort, and 5-6 involves a noticeable increases in heart rate and breathing (Nelson et al., 2007). Similarly, and using the same 10-point scale, vigorous-intensity aerobic activity is defined as a rating of 7 or 8, at which point large increases in heart rate and breathing are noted (Nelson et al.). The new recommendations from the ACSM and the AHA (Nelson et al., 2007) suggest that in order to maintain and promote health, the older adult needs to participate in moderate-intensity aerobic activity for a minimum of 30 minutes on five (5) days each week. Or, if capable, the older adult can engage in vigorous-intensity aerobic activity for 20 minutes on three (3) days each week. It should be noted that the recommendations also indicate that a combination of both moderate- and vigorous-intensity aerobic activity can be performed to meet these aerobic activity recommendations. An important point to remember is that these recommendations for aerobic activity are in addition to the normal, light-intensity activities of daily living (ADLs) which include self care or cooking, or moderate-intensity activities (e.g. walking around the office or walking from the parking lot) lasting less than 10 minutes respectively.

The ACE Pyramid

The ACE Pyramid represents the conceptual framework for the ACE Study. The ACE Study has uncovered how ACEs are strongly related to development of risk factors for disease, and well-being throughout the life course. early death disease, disability and social problems adoption of health-risk behaviors social, emotional and cognitive impairment disrupted neurodevelopment adverse childhood experiences Mechanism by which adverse childhood experiences influence health and well being throughout the lifespan conceoption to death

Some is Good, More is Better

The preceding recommendations represent the minimum levels of involvement with respect to aerobic activity and muscle strengthening. Being minimum recommendations, the older adult can expect to experience the minimum in the way of outcomes. Nelson et al. (2007) point out that if older adults wish to: (a) improve their personal fitness, (b) improve their management of an existing condition or disease where higher levels of physical activity may have greater therapeutic value, and/or (c) reduce their risk of premature health conditions or mortality from chronic conditions related to physical inactivity, they should strive to engage in activities that exceed the minimum levels. This recommendation assumes that the older adult does not have a condition that would preclude higher levels of physical activity. Further, the older adult should also pursue additional muscle-strengthening, higher-impact, and weight-bearing activities in an effort to further maintain and enhance skeletal health. Examples of these muscle-strengthening and weight-bearing activities include increasing the number of muscles or muscle groups trained, working at progressively higher intensities, and jogging rather than walking. Perhaps most encouraging for the older adult are studies showing that the older adult possesses a capacity for change, both aerobically and muscularly, that is similar to the young adult (Frontera, Meredith, O'Reilly & Evans, 1988; Kohrt et al., 1991; Meredith et al., 1989). While the exact mechanism of change in the older adult has yet to be fully elucidated, the message is quite clear: physical activity contributes to successful and healthy aging. Although it cannot be definitively stated that physical activity extends life, it can be said that physical activity improves life, given its influence on the incidence and onset of chronic disease.

Updated Recommendations for Flexibility and Balance

The recommendations for flexibility have remained relatively unchanged, except for recommendations regarding frequency and duration. Older adults are still encouraged to participate in some form of flexibility training; however, they are now encouraged to do so on at least two days of each week for at least 10 minutes each time. As we stated in the original article (Hartman-Stein & Potkanowicz, 2003), "When we take the time to consider just how important freedom of movement and flexibility are in everyday living, it becomes easier to see the significant role that flexibility training can play in maintaining one's quality of life." An element not directly addressed in the 2003 article is the current recommendation that older adults should intentionally pursue and participate in exercises and training that improve balance and reduce the risk of falls. In the past, balance training was considered a passive component of some other training mechanism or regimen. The current recommendations suggest that as a way to prevent falls in those individuals with a known risk for falls; for example, older adults with mobility problems or those who fall frequently, the older adult should perform exercises that will contribute to the maintenance and improvement of balance (Nelson et al., 2007). To add to that, the older adult should pursue these activities even if he or she does not present with known risks, given that prevention is the key to reducing the risk of falls.

Suicides (MHMD-1)

The suicide rate increased 22.0% between 2005 and 2015, from 10.9 to 13.3 per 100,000 population (age adjusted). In 2015, several population groups in specific demographic categories had the lowest suicide rate, including the non-Hispanic black population and females. Between 2008 and 2015, the proportion of adolescents aged 12-17 years who had a major depressive episode (MDE) in the past 12 months increased 50.6%, from 8.3% to 12.5%. In 2015, several population groups in specific demographic categories had the lowest rate of an MDE in the past 12 months, including the non-Hispanic black population, males, and persons aged 12-13 years. Healthy People 2020 objective MHMD-1 tracks the suicide rate for the total population. HP2020 Baseline: 11.3 suicides per 100,000 population (age adjusted) occurred in 2007. HP2020 Target: 10.2 suicides per 100,000 population (age adjusted), a 10% improvement over the baseline. The suicide rate for the total population increased by 22.0% between 2005 and 2015, from 10.9 to 13.3 per 100,000 population (age adjusted). Disparities were observed for a number of population groups in 2015. For example: Among racial and ethnic groups, the non-Hispanic black population had the lowest suicide rate, 5.8 per 100,000 population (age adjusted). The age-adjusted rates for other racial and ethnic groups were: 17.0 suicides per 100,000 population among non-Hispanic white persons; more than 2.5 times the best group rate 12.6 suicides per 100,000 population among American Indian or Alaska Native persons; more than twice the best group rate 6.4 suicides per 100,000 population among Asian or Pacific Islander persons 6.2 suicides per 100,000 population among Hispanic or Latino persons Females had a lower suicide rate than males (6.0 versus 21.1 per 100,000 population, age adjusted). The rate for males was 3.5 times the rate for females. Suicide rates varied by age group. Rates for age groups were: 5.4 suicides per 100,000 population among persons aged 12-17 years 14.4 suicides per 100,000 population among persons aged 18-24 years 16.4 suicides per 100,000 population among persons aged 25-44 years 19.6 suicides per 100,000 population among persons aged 45-64 years 16.6 suicides per 100,000 population among persons aged 65 years and over Persons living in metropolitan areas had a lower suicide rate (12.5 per 100,000 population, age adjusted) than persons living in non-metropolitan areas (17.6 per 100,000 population, age adjusted). The suicide rate for persons living in non-metropolitan areas was 40.9% higher than that for persons living in metropolitan areas.

Life Sustaining Treatment - Surrogate

Treatment would be an extraordinary burden to the patient and the attending physician, with the concurrence of an independent physician, determine that: The patient has illness or injury that can be expected to cause death in six months; or The patient is permanently unconscious. The provision of treatment would involve such pain, suffering or other burden that it would be inhumane or extraordinarily burdensome and the patient has an irreversible or incurable condition as determined by two physicians.

Scope of Decision Making by a Proxy

Under PHL § 2982(2), a health care agent can make any decision the patient could have made in accordance with: The patient's wishes, including his or her religious and moral beliefs; or If the patient's wishes are unknown, and cannot with reasonable diligence be ascertained, the patient's best interests. Decisions about artificial nutrition and/or hydration can only be made if the health care agent has reasonable knowledge of the patient's wishes. A surrogate can make any decision the patient could have made in accordance with: The patient's wishes, including his or her religious and moral beliefs; or If the patient's wishes are unknown, and cannot with reasonable diligence be ascertained, the patient's best interests. PHL § 2994-d(4) Additional standards apply for decisions to withdraw or withhold life-sustaining treatment, including DNR and artificial nutrition and hydration. PHL § 2994-d(5) A health care provider must comply with the health care decisions made by the Health Care Agent or Surrogate in good faith to the same extent as if such decisions has been made by the patient, subject to any limitations in the health care proxy, FHCDA, or if the patient objects. Health care decisions by a health care agent have priority over decisions by any other person, except the patient. PHL § 2982(4) Under FHCDA, if another person on the surrogate list objects to a Surrogate's healthcare decision and the dispute cannot be resolved, the dispute must be referred to the Ethics Committee. PHL § 2994-f(2)(c)

End of Life Legal Issues

We often use the terms "capacity" and competency" interchangeably, but they are very different concepts. Every adult is presumed to have capacity to make medical decisions unless there has been a prior court determination or a court appointed guardian is authorized to decide about health care for the adult. "Competence" and "Capacity" (short for "decision-making capacity") are often used interchangeably. Competence is a legal term. Competence is presumed unless a court has determined that an individual is incompetent. A judicial declaration of incompetence may be global, or it may be limited (e.g., to financial matters, personal care, or medical decisions). Decision-making capacity, on the other hand, is a clinical term that is task-specific. A physician may determine that a patient does not have the capacity to make a decision for or against surgery, but may have the capacity to decide if she wants pain meds. Capacity can change. Capacity is defined as the ability to (1) understand and appreciate the nature of proposed health care, including the benefits of, and alternatives to, proposed health care; and (2) reach an informed decision. PHL § 2994-a(5) The determination of capacity does not mean that the person is free from all mental impairment.

Students who graduate with a regular diploma 4 years after starting 9th grade (AH-5.1)

Where We've Been and Where We're Going The on-time graduation rate in public schools, defined by the percentage of students awarded a high school diploma 4 years after starting 9th grade, increased by 4%, from 79% for school-year 2010-11 to 82% for 2013-14, moving toward the HP2020 target of 87%. For the 2013-14 school year, Asian or Pacific Islander, non-Hispanic students had the highest rate of on-time graduation. On-Time High School Graduation (AH-5.1) Healthy People 2020 objective AH-5.1 tracks the on-time graduation rate from public high schools. HP2020 Baseline: In the 2010-11 school year, 79% of students attending public schools graduated with a regular diploma 4 years after starting 9th grade. HP2020 Target: 87%, a 10% improvement over the baseline, which was established for the 2010-11 school year. The on-time graduation rate increased from 79% in the 2010-11 school year to 82% in the 2013-14 school year. On-time high school graduation rates varied among racial and ethnic groups in the 2013-14 school year 89% asian or pacific islander, non-hispanic 87% white, non-hispanic 76% hispanic 72% black, non-hispanic 70% american indian or alaska native, non-hispanic Among racial and ethnic groups, the Asian or Pacific Islander, non-Hispanic population had the highest (best) rate of on-time graduation, 89% for the 2013-14 school year. Rates for other subgroups were: White, non-Hispanic: 87% Hispanic: 76% Black, non-Hispanic: 72% American Indian or Alaska Native, non-Hispanic: 70%

Updated Recommendations for Muscle Strengthening

With respect to muscle-strengthening activities, a moderate-intensity effort is defined as a rating of 5-6 on a 10-point scale, where 0 is no movement and 10 is a maximal effort for the muscle group (Nelson et al., 2007). Using the same 10-point scale, a high-intensity effort is defined as a rating of 7 or 8. According to the new recommendations (Nelson et al., 2007), older adults should strive to engage in activities that maintain or increase muscular strength on a minimum of two days each week. To that end, older adults should choose 8-10 exercises that use major muscle groups and perform them on two or more non-consecutive days each week. Each exercise, and its associated resistance (weight) should allow for 10-15 repetitions, with the level of effort being moderate to high (relative to one's ability).

Age related Determinants

http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No3Sept09/Articles-Previous-Topics/Update-and-Baby-Boomer-Generation.html Those born between 1946 and 1964 will start to reach the age of 65 by 2011; and estimates now suggest that by 2030 the number of adults 65 years of age and over will be 71 million, or, 20% of the United States (U.S.) population Physical fitness includes both health-related fitness and skill-related fitness. In this

End of Life Disparities

http://www.dartmouthatlas.org/ For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America. Manhattan: $11,044 Medicare reimbursements per patient varied nearly twofold in 2014 across hospital referral regions, from less than $7,000 per patient in Anchorage to more than $13,000 per patient in Miami. Modern technology has vastly extended the ability to intervene in the lives of patients, most dramatically so when life itself is at stake. But the capability to intervene is not uniformly deployed, and health care providers do not share a uniform propensity to hospitalize dying patients or to use technology at the end of life. The American experience of death varies remarkably from one community to another. Manhattan 13.7 Long Island 13 The intensity of care in the last six months of life is an indicator of the propensity to use life-saving technology. The question of whether more medical intervention is better must be framed in terms of the potential gain in life expectancy for populations living in regions with greater intensity of intervention. Our research has provided evidence that populations living in regions with lower intensity of care in the last six months of life did not have higher mortality rates than those living in regions with higher care intensity. More than 80% of patients say that they wish to avoid hospitalization and intensive care during the terminal phase of illness, but those wishes are often overridden by other factors. If more intense intervention does not improve life expectancy, and if most patients prefer less care when more intensive care is likely to be futile, the fundamental question is whether the quality of care in regions with fewer resources and more conservative practice styles is better than in regions where more aggressive treatment is the norm. For rates pertaining to the last six months of life, the denominator was the Medicare population who died during the measurement year. Numerator events were determined using the Medicare Provider Analysis and Review (MedPAR) file. Rates for inpatient care per capita were computed using only the portion of the event (hospital stay or ICU stay) falling within the six-month period prior to death. Rates were age, sex and race adjusted using the indirect method. Event measures based on a count of fewer than 11 patients are not displayed for reasons of patient confidentiality. Rates with fewer than 26 expected events are also suppressed because of a lack of statistical precision. These cells are marked "na."

Effects of Childhood Stress Across the Life Span

https://www.cdc.gov/violenceprevention/acestudy/about.html The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and later-life health and well-being. The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors. The CDC continues ongoing surveillance of ACEs by assessing the medical status of the study participants via periodic updates of morbidity and mortality data.

LHI for Mental Health

https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Mental-Health The burden of mental illness in the United States is among the highest of all diseases, and mental disorders are among the most common causes of disability. Recent figures suggest that, in 2004, approximately 1 in 4 adults in the United States had a mental health disorder in the past year—most commonly anxiety or depression—and 1 in 17 had a serious mental illness. Mental health disorders also affect children and adolescents at an increasingly alarming rate; in 2010, 1 in 5 children in the United States had a mental health disorder, most commonly attention deficit hyperactivity disorder (ADHD). It is not unusual for either adults or children to have more than one mental health disorder. Mental health is essential to a person's well-being, healthy family and interpersonal relationships, and the ability to live a full and productive life. People, including children and adolescents, with untreated mental health disorders are at high risk for many unhealthy and unsafe behaviors, including alcohol or drug abuse, violent or self-destructive behavior, and suicide—the 11th leading cause of death in the United States for all age groups and the second leading cause of death among people age 25 to 34. Mental health disorders also have a serious impact on physical health and are associated with the prevalence, progression, and outcome of some of today's most pressing chronic diseases, including diabetes, heart disease, and cancer. Mental health disorders can have harmful and long-lasting effects—including high psychosocial and economic costs—not only for people living with the disorder, but also for their families, schools, workplaces, and communities. Fortunately, a number of mental health disorders can be treated effectively, and prevention of mental health disorders is a growing area of research and practice. Early diagnosis and treatment can decrease the disease burden of mental health disorders as well as associated chronic diseases. Assessing and addressing mental health remains important to ensure that all Americans lead longer, healthier lives. The Leading Health Indicators Are: Suicide (MHMD-1) Adolescents with a major depressive episode in the past 12 months (MHMD-4.1)

Social Determinants

https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Social-Determinants A range of personal, social, economic, and environmental factors contribute to individual and population health. For example, people with a quality education, stable employment, safe homes and neighborhoods, and access to preventive services tend to be healthier throughout their lives.1 Conversely, poor health outcomes are often made worse by the interaction between individuals and their social and physical environment. Social determinants are in part responsible for the unequal and avoidable differences in health status within and between communities. The selection of Social Determinants as a Leading Health Topic recognizes the critical role of home, school, workplace, neighborhood, and community in improving health. The Leading Health Indicators Are: Students graduating from high school 4 years after starting 9th grade (AH-5.1) Although education is the Leading Health Indicator for this topic, many of the Healthy People 2020 objectives address social determinants as a means to improve population health.

Leading Health Indicators (LHI)

https://www.healthypeople.gov/2020/leading-health-indicators/Leading-Health-Indicators-Development-and-Framework Leading Health Indicators Development and Selection Process The process of selecting the Leading Health Indicators (LHIs) mirrored the extensive collaborative efforts undertaken to develop Healthy People 2020. The process was led by the Healthy People 2020 Federal Interagency Workgroup, with approximately 50 members from across the U.S. Department of Health and Human Services (HHS) and other Federal departments. Reports by the Institute of Medicine of the National Academy of Sciences and the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 provided several recommendations for HHS to consider in developing the final set of LHIs. In addition, consideration was given to other indicator sets, such as the National Prevention Strategy mandated by the Affordable Care Act, as well as to key priorities of the secretary and the assistant secretary for health, to ensure alignment among the various prevention initiatives within HHS and across the Federal government. Leading Health Indicators Framework The Healthy People 2020 LHIs were selected and organized using a Health Determinants and Health Outcomes by Life Stages conceptual framework. This approach is intended to draw attention to both individual and societal determinants that affect the public's health and contribute to health disparities from infancy through old age, thereby highlighting strategic opportunities to promote health and improve quality of life for all Americans. Determinants of Health and Health Disparities Biological, social, economic, and environmental factors—and their interrelationships—influence the ability of individuals and communities to make progress on these indicators. Addressing these determinants is key to improving population health, eliminating health disparities, and meeting the overarching goals of Healthy People 2020. Health Across Life Stages LHIs are being examined using a life stages perspective. This approach recognizes that specific risk factors and determinants of health vary across the life span. Health and disease result from the accumulation (over time) of the effects of risk factors and determinants. Intervening at specific points in the life course can help reduce risk factors and promote health. The life stages perspective addresses 1 of the 4 overarching goals of Healthy People 2020: "Promote quality life, healthy development, and health behaviors across all life stages."