332 Exam 2
What did the Hispanic HANES involve?
The Hispanic Health and Nutrition Examination Survey (HHANES) was a nationwide probability sample of approximately 16,000 persons, 6 months-74 years of age. Hispanics were included in past health and nutrition examinations, but neither in sufficient numbers to produce estimates of the health of Hispanics in general, nor specific data for Puerto Ricans, Mexican Americans, or Cuban Americans.
The current NHANES was born out of what act?
The National Health Survey Act of 1956
What is the WIC dietetic internship?
The Texas WIC Dietetic Internship is designed to assist qualified nutritionists employed within the Texas WIC program to become registered dietitians
Food availability
The amount of food that is produced
What occured in 1974?
The first WIC Program opened in Kentucky
Why was this sample selected?
The sample was selected so that certain population groups thought to be at high risk of malnutrition (persons with low incomes, preschool children, women of childbearing age, and the elderly) were oversampled
Definition of epidemiology:
The study of the distribution and determinants of health related states and events in specified populations and the control of health problems
Who/ how many does the survey examine?
The survey examines a nationally representative sample of about 5,000 persons each year located in 15 different counties
Meals for Kids
This program provides low income children in after school programs across the city of Austin with a nutritious evening meal each weekday, as well as a monthly lesson from a registered dietician on nutrition
objective of NHANES
To assess the health and nutritional status of adults and children in the United States
How did the new food packages better accommodate cultural food preferences?
Tofu & soy milk as an option instead of milk
How did the new food packages align with the current infant feeding practice guidelines of the American Academy of Pediatrics ?
-Delays introduction of infant cereal -Adds infant foods, including fruits, vegetables, and meats -Eliminates infant juice
What is unique about each individual WIC facility?
-Each WIC allows their clinic to be run in its own unique way -Like could be on a military base, school, portable trailer -Gives a lot of control to the local managers
Nutritional Epidemiology definition
-Epidemiological method used to observe the relationship of diet to health and disease
How does the food packaging system work?
-Go in an have an assessment, based on the category you fall in is the type of food package you receive -Redeem vouchers or food-checks (now electronic debit cards) to obtain specific foods at participating retail outlets
What is checked during this screening?
-Height, weight and BMI -Hct/Hgb
Where are the meals prepared?
-In a central kitchen in East Austin -planned by a registered dietitian -Tray line type of service -Volunteers come by and pick them up
Enactment
-Law is referred to appropriate agency responsible for issuing guidelines or regulations -Publication or proposed guidelines- mandatory comment period of 30 to 60 days for public response -Given a number, a letter, and a name
How much of the RDA does each meal contain?
1/3
We are currently on the:
114th Congress January 3, 2015, until January 3, 2017
What year did NHANES I range from?
1971-75
What year did the Hispanic HANES range from?
1982-84
Congress is bicrameral meaning?
2 houses HOR and Senate
How long does A "Congress" cover?
2 years
What year did the IOM make a report about WIC?
2002
What was this 2002 IOM report called?
2002 Institute of Medicine (IOM) report: Dietary Risk Assessment in the WIC Program
How do we monitor food consumption/ dietary intake from a National level?
3 distinct data sets that are related on food and nutrient available for consumption USDA ERS
How many different meal options are offered?
6
How many different WIC food packages are available?
7
Mike's Place
A 1X per week program for folks with Alzheimer's Disease and other types of memory loss and dementia, also serves as a source of support and rest for caregivers
How does contract formula work?
A company like Abbott labs will come in and bid for that contract Contract to provide all of the formulas for that hospital
Cohort (or incidence) studies
A group of people are followed overtime to see who develops a particular disease and what risks they have been exposed to -Done with people who have things in common -primarily pro (can be both pro and retro)
Discretionary Spending
Choices made in defense, energy assistance, nutrition assistance -Can change depending on what the budget is
Combination Meal
Clients can combine any of these choices to make a custom meal suitable for their needs (ex: a meal that is both soft and bland)
Case Control
Comparing a group with a disease with a group that does not have it and identifying differences in diet and behavior -retrospectively because you wont know until the person develops the disease -Cons: relying on memory
When was BRFSS established?
Conducted continuously since 1984
What occurred in 1972?
Congress authorized a 2-year pilot program to provide supplemental foods to pregnant and breastfeeding women, infants and children at nutritional risk. - found that it made a huge impact
Low potassium
Contains less than 1,000 mg of potassium for those undergoing kidney dialysis. Juice is substituted for milk with this meal.
Types of Observational studies
Correlational (or ecological) studies Cross-sectional (or prevalence) studies Case-control studies Controlled trials Cohort (or incidence) studies
Ways in which dietary intake are measured at the individual level?
Diet history 24-hour recall Diet record Food frequency
Which is the gold standard?
Diet record - 3, 4, or 7 days
Who regulates PACs?
Federal Election Commission (FEC)`
What type of program is WIC?
Federal grant program
What was developed to address the issues of the 2002 IOM report?
Value Enhanced Nutrition Assessment (VENA)
Care Calls
Volunteers are "phone friends" to homebound clients, and call either 1X a day for a friendly check in or 2X a week for a longer chat
Handy Wheels
Volunteers for this program are sent to the homes of those in need 1 Saturday per month to make minor, safety related home repairs and improvements
Groceries To Go Program
Volunteers grocery shop 2X a month for clients who can still do some cooking, but can't get the store on their own
Medi Wheels
Volunteers provide transportation for clients who need to get to and from regular medical appointments
What was this 2005 IOM report called?
WIC Food Packages: Time for a Change
Who does WIC count as members of a household?
WIC counts all of the members of a household, related or non-related
What is the nutrition data component called?
What We Eat in America
What does WIC stand for?
Women, Infants, and Children (The Special Supplemental Nutrition Program for Women, Infants, and Children)
Does an unborn baby count as a household member?
Yes
Do these stands get reimbursed?
Yes The farmers, farmers' markets or roadside stands then submit the FMNP coupons to the bank or State agency for reimbursement
Who does the assessment for elibibilty?
a MOWAM social worker
Comorbidity:
a condition that exists with another illness
The National Health Survey Act of 1956 provided for the establishment of what?
a continuing National Health Survey to obtain information about the health status of individuals residing in the US
MOWAM in Ausin began as
a program of 8 volunteers serving 29 seniors
How old must a person be to participate in the survey?
at least 18 years old
Short term services
available to those with temporary meal needs
What year did MOWAM begin and what was the name?
began in 1972 as an East Austin-based, grassroots organization -then called United Action for the Elderly, Inc.
what is unique about NHANES?
combines interviews and physical examinations
Relative risk:
comparison of the risk between 2 groups (high risk vs low risk)
Mandatory spending
For entitlements- programs that require payments to anyone who is eligible
Mortality:
death how many people died People who died from the disease
The NHANES interview includes:
demographic, socioeconomic, dietary, and health-related questions
Morbidity:
disease things that can lead to death sickness
NHANES findings are the basis for?
for national standards for such measurements as height, weight, and blood pressure
WIC determines income based on?
gross income
Data from NHANES is used in?
in epidemiological studies and health sciences research, which help develop sound public health policy, direct and design health programs and services, and expand the health knowledge for the Nation
The judicial branch, or court system:
interprets the laws and settles legal disagreements
Disadvantages of Metabolic or Feeding Studies
labor intensive and expensive
Congress is which branch
legislative
Risk:
likelihood of individuals exposed to risk factors developing a particular health problem
The NHANES examination component consists of:
medical, dental, and physiological measurements, as well as laboratory tests administered by highly trained medical personnel
How many meals does MOWAM now prepare each year
over 1 million meals
What are standing committees?
permanently established to create and approve legislation, to authorize programs, and to supervise program implementation -Subsets of legislatures that focus on different topics
Policy making:
process by which authorities decide what actions to take to address a problem or set of problems -legislative process
Prevalence:
proportion of a group possessing a disease at a specific time (ex: prevalence of diabetes in 2000)
Budget appropriation
provides money for programs -May be for a single year, specified period of years (multiyear appropriations), or an indefinite number of years (no year appropriations) -Continuing resolutions may be needed during vote
The term Congress refers to:
refers to a particular meeting of the Federal legislature
What does MOWAM do?
seeks to nourish and enrich the lives of the homebound and other people in need through programs that promote dignity and independent living
NHANES has been conducted as a:
series of surveys focusing on different population groups or health topics
What does it meant to be Diet Based Risk?
such as a poor eating habits which can lead to poor nutritional and health status
What does it mean to be at Medically Based Risk?
such as history of poor pregnancy outcome, underweight status, or iron deficiency anemia
NHANES is a major program of the:
the National Center for Health Statistics (NCHS)
Growth charts and NHANES
Growth charts have a normal value -These averages come from NHANES data -As the population increases in weight overall, that could affect the average on these -Ex: head circumference, height, height vs weight, BMI
H.O.P.E.
Healthy Options Program for the Elderly -Volunteers deliver an extra bag of non-perishable groceries, provided by the Capital Area Food Bank, to our most needy clients 1 Saturday a month Gives the more needy clients a bag of groceries
What are some of the outcome variables of interest?
Height, weight, smoking, alcohol use, weight control practices, diabetes, preventive health problems, mammography, pregnancy, cholesterol screening practices, awareness, treatment, and modified food frequencies for dietary fruit and vegetable consumption
Advantages of contract formula?
Helps the government to provide lower cost formula
What were some of NHANES landmark findings and public health results
High blood lead levels -Lead out of gasoline Low folate levels -Mandatory food fortification Rising levels of obesity -Public health action plan Racial and ethnic disparities in Hepatitis B -Universal vaccination of all infants & children Overweight prevalence figures -led to the proliferation of programs emphasizing diet and exercise, stimulated additional research, and provided a means to track trends in obesity Undiagnosed diabetes -increase public awareness, especially among minority populations, have been intensified
What classifies a person as being financially eligible?
Households with incomes at or below 185% of the federal poverty income level are eligible
Why was WIC developed?
In the late 1960's, a Presidential Commission studied malnutrition in America & found that many people had health problems due to poor nutrition
How did the new food packages align with the Dietary Guidelines for Americans?
Increases fiber by adding: -fresh and frozen fruits and vegetables -whole grain bread, oatmeal, brown rice, corn and whole wheat tortillas Reduces saturated fat and cholesterol by decreasing amounts of: -milk (low-fat milk for women and children age 2 and over) -eggs -cheese
non-connected committee
Independent No ties to an organization or group at all Committee is formed for one particular reason Have to pay all of their administrative costs from all of the money they have
Which is the major survey for assessing the health and wellness of adults and children?
NHANES
What are the 2 major ways that data is collected?
NHANES BRFSS
What does NHANES stand for?
National Health and Nutrition Examination Survey
What % of people in Travis County were living in poverty in 2008?
Nearly 8%
Who is eligible for MOWAM?
Primarily elderly but also takes disabled people into account 1) Primarily homebound 2) Unable to easily prepare nutritious meals 3) Without consistent daytime assistance from another person 4) Able to accept meals during the delivery time frame
Meal Delivery Program
Provides clients with 5 hot meals and 1 frozen meal each week. The meals are delivered Monday through Friday between 11 am and 1 pm.
Nutrient availability
Purely how many vitamin A per person, vitamin C, protein, carbs, ect
What classifies a person as being residentially eligible?
Reside in Texas & in the county in which you are applying -Live in the area that your WIC clinic serves - Have to go to the one that is closest to your home
Second Meals
Shelf-stable, boxed, 5 day supplies of meals or breakfasts for those who are most nutritionally at risk (in addition to the 5 meals per week through MOW)
What descriptive variables does the survey ask about?
State, age, sex, race and ethnic origin, education, employment status, and income (demographics)
How did the new food packages better accommodate special needs participants?
Supplemental foods in addition to formula
Loss adjusted food availability
Taking into account things that are lost during manufacturing (like waste materials that are not suitable for consumption) -Like spoiling -Like things not getting to destination
What is NHANES 1?
The First National Health and Nutrition Examination Survey
NCHS is part of the
Centers for Disease Control and Prevention (CDC)
Soft meal
Prepared in bite sized pieces for people who have dental problems or are unable to cut food
The executive branch includes
President and President Cabinet
At the state level, who administers WIC funding?
- Department of State Health Services - unlike the NSLP -In Texas, the major branch of WIC is here in Austin
At the federal level, who administers WIC funding?
- U.S.D.A's Food and Nutrition Service (FNS) - Just like SNAP
What is given to check if a person is at nutritional risk?
- an initial health and diet screening
What are PACs?
-"political arm" of interest group -Raises money to support candidates whose views are favorably aligned with the group's missions and goals -A PAC is a group or legal entity formed to raise and contribute money to the campaigns of candidates likely to advance the group's interests
Cross-sectional (or prevalence) studies
-"snapshot" of a population- comparing dietary intake, disease, and other variables in a population -Looking at one population at one time -Ex: high caloric intake and diabetes
Separate Segregated Fund
-Associated with a company, corporation, trade org, org, union, etc. (Like AND) -Has to be a separate segregated fund -Can not use dues or money given for other causes for political activity -Have to collect funds separately and for that cause -Can have their administrative costs come out of the larger org
How did the new food packages provide better promotion & support for long-term breastfeeding?
-Breast pumps and breastfeeding support provided, as needed -For exclusively breastfeeding women >Increased amount of food >Addition of salmon to increase DHA and omega 3 in breastmilk -For exclusively breastfed infants >Increased amounts of infant fruits and vegetables >Addition of infant meats
What did the NHANES household interview involve?
-Broad range of health conditions -Environmental and occupational exposures -Health behaviors -Nutrition and dietary supplements (unique to NHANES) -Prescribed medications
Important House committees for Dieticians?
-Committee on Agriculture -Committee on Education and Work Force
Correlational (or Ecological) studies
-Compares collective data that represents a population - compares groups, not individuals -Monitoring a group or population to see what is common in their diet/ lifestyles -Ex: looking at a group of people who live in the Mediterranean and looking at what types of food they eat and what types of diseases they get because of this
What does a federal grant program mean?
-Congress authorizes a specific amount of funds each year for the program -Not an entitlement program -Can only fund up to a certain amount of people
Role of Congress
-Makes the laws/ policies -Initiate, modify, authorize, and appropriate funds
Disadvntages of contract formula?
-Means that parents don't get a choice of brands -Anything other than contract formulas or using contract differently requires a doctor's prescription -Client then has to be assessed to determine if special formula is appropriate
What are Randomized clinical trials?
-More of the types where you think about double blind, randomized -One person is recommended one type of diet and another one is randonmly recommended a different diet -Ex: to see the affects of omega 3 Giving one person a supplement with omega 3 and one person with a placebo
Difference between NHANES and BRFSS?
-NHANES is a national survey -NHANES gives a full medical workup -Have to be chosen to be in NHANES, cant just sign up (You have to have the demographics that make you representative to a wide proportion of people) - NHANES survey Children as well
How is MOWAM ran?
-Nationwide program, has local branches -an independent, locally-run organization, non profit -Run off of donations, capital area food bank, ect
Client Assistance Program
-Only if funds are available -Assists clients with paying for their basic needs...like rent, light, gas and phone bills -Help with other needs to help clients live more comfortable, secure, independent lives... like shower chairs that are not paid for by Medicare, microwaves, and telephones -Helps get more blankets...through drives
Bland Meal
-Prepared without food or spices known to irritate the stomach or intestinal tract for people with digestive disorders like ulcer, diverticulitis, hiatal hernias, GERD -Made without foods like tomatoes that could cause irritation
Congregate Meal Program
-Provides a place (like at a Senior Center or local center) for older adults to gather for games, physical activity, conversation, and a shared nutritious lunchtime meal -Have to be 60 years or older -Research shows that when seniors eat with other people, they eat more
How is the telephone survey conducted?
-Random Digit Dialing (very random, not statistical) -on home phones, cell phones, and mail
What Does AND PAC do?
-Receives voluntary contributions from AND members and consolidates them into a single fund -Makes contributions to the campaigns of candidates for federal office who support AND's mission, vision and priorities -Enhances AND's visibility with policy makers and increases ANDs influence in political venues -Boosts the powers of the dietetics professionals view on key legislative issues
Important Senate committees for Dieticians?
-Select Committee on Aging -Committee on Agriculture, Nutrition, and Forestry -Committee on Finance
What did the NHANES examination involve?
-Standardized physical exam -Conducted at mobile exam center -Medical & dental exams -Physiological measurements -Laboratory test -Administered by trained medical personnel
What did this report say?
-The way dietary risk is established is faulty -change the whole dietary analysis process/ the way they did dietary analysis and nutrition education -Need to make it more motivationally interview based -Talk to the patient about what they are concerned about, what their issues are, and what they want to learn about
P.A.L.S. (Pets Assisting the Lives of Seniors)
-Through a collaboration between MOWAM and Blue Dog Rescue, identified clients are receiving a monthly supply of pet food delivered to their residence by a volunteer -MOWAM, Town Lake Animal Center, Emancipet, ect provide free vet services to the pets of homebound MOWAM clients during a 1 day Senior Pet Fair in April
What was the problem with WIC food packages?
-WIC food packages had remained largely unchanged for 30 years until 2009 > Limited >People got a lot of foods that they would not be able to use very much >Provided a lot of calories and nutrients but a lot of foods that people wouldn't really be able to use much >High in fat
Process of a law
-When a new idea is introduced, it is drafted and then needs to be put on the calendar -Can start in the House or the Senate -Needs to then go to the committees -The committees talk about it, explore it, make changes to it -They are the ones who decide if it should go to the floor for a vote -If it doesn't make it out of committee than it dies in committee -If it makes it out of committee than it can be voted on and if it gets enough votes then it becomes a law -From there it is enacted into law (if not vetoed) -Then they appropriate the funds to provide the money for it
What are Metabolic or Feeding Studies?
-You know exactly what is going into the patient -Like how much calories, fat, or everything that is going in -Not just self reported
Medical Nutrition Therapy
-a plan of care that focuses on the assessment, nutrition diagnosis, treatment plan, evaluation and continued monitoring of a patient/client -Based on "Best Evidence" -Supports effectiveness and necessity of RD services
Policy:
-course of action chosen by public authorities to address a given problem -A framework that directs the selection of actions to be followed by individuals, organizations, governments, or communities to meet the needs of society and individuals -ex of nutrition policies= agriculture and healthcare
Budget authorization
-establishes programs -Sets a ceiling on spending -Does NOT provide money -Says that for program, this is how much of the budget is going to go towards that -How much they are allowed to spend for that program
How long does Texas Legislation meet?
-every 2 years odd numbered for 140 days -Not ongoing
Food frequency questionnaire disadvantages
-have to answer the question as is -Can not modify the question -People tend to underestimate or overestimate
Why is political activity so important for the AND (Academy for Nutrition and Dietetics)?
-helps to continue to fund programs that we believe as dieticians believe are important for the overall health of a population -A way to get our services covered (If our services are covered under insurance it helps dieticians out, especially in hospital situations) -Continuing with the dietician as the expert
Regular Meal
-no sugar -no salt -suitable for diabetics
What did this commission find evidence that good nutrition was related to?
-positive pregnancy outcomes -the decrease of permanent physical damage to infants and small children due to malnutrition (People are likely to be better, productive members of society if they are healthy and decreases the cost of raising that child)
What did the IOM recommend when it came to meeting the DGA?
-recommended that all women and children ages 2 to 5 years should be presumed to be at dietary risk based on failure to meet the Dietary Guidelines for Americans - the minimum is that all people will qualify for failure to meet DGA
AND PAC
-the only PAC focused on food nutrition and health -funded by donations to contribute to campaigns -Try to get people elected who believe in the importance of nutrition
What is the role of the NCHS?
-the responsibility for producing vital and health statistics for the Nation -responsibility for survey development and data collection
Nutritional Epidemiology can be used to
-to monitor and describe food consumption, nutrient intake & nutrition status of population groups -Also to develop & evaluate intervention programs
Evidence Based Medicine
-use strategies, treatments, and protocols that have been proven to be effective by research and well done studies that are controlled and are peer reviewed using the best practices and standards when conducting research -is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients
2 steps for providing the money
1) Budget authorization 2 ) Budget appropriation
What are the 4 measurements of WIC eligibility?
1) Categorically eligible 2) Financially eligible 3) Residentially eligible 4) At Nutrition Risk
Types of epidemiological studies?
1) Experimental Studies 2) Observational Studies
Food availability (per capita) data system involves 3 subsets which are:
1) Food availability 2) Loss adjusted food availability 3) Nutrient availability
Two types of spending:
1) Mandatory spending 2) Discretionary Spending
What are the two main categories of nutritional risk that WIC uses?
1) Medically Based Risk 2) Diet Based Risk
Two types of experimental studies
1) Metabolic or Feeding Studies 2) Randomized Clinical Trial
What does WIC provide? (4)
1) Nutrition assessment & education 2) Supplemental food packages 3) Breastfeeding encouragement & support 4) Referrals to health care & other programs
In 2009, Texas WIC food packages changed in order to to?
1) align with the Dietary Guidelines for Americans 2) align with the current infant feeding practice guidelines of the American Academy of Pediatrics 3) to provide better promotion & support for long-term breastfeeding 4) to better accommodate cultural food preferences
2 types of PACS
1) non-connected committee 2) separate segregated fund
Goals of MOWAM
1)Feed people and keep them from starving 2)Nutrition is there to prevent people from going back into the hospital 3)Prevent hospital admission 4)Helping people stay in their homes longer 5)Able to check in on people
What does BRFSS stand for
Behavioral Risk Factor Surveillance System
Food frequency questionnaire advantages
Easiest and cheap -Can be done on a scantron
What is the WIC Farmers' Market Nutrition Program?
Eligible WIC participants are issued FMNP coupons in addition to their regular WIC food instruments These coupons are used to buy fresh, unprepared locally grown fruits, vegetables and herbs
Pureed Meal
Entire meal is pureed to a paste for people who cannot chew or swallow foods easily Like for people who aren't able to swallow well or don't have dentures
What does IOM stand for?
Institue of Medicine
What typically can be bought from WIC recipients at the store?
It is the lowest cost that is available at the store Usually store brands
Cons of NHANES
Labor intensive so sample sizes are much lower
What is BRFSS?
Largest telephone health survey in the world -A form of data collection about the health and wellness in the US -State by state surveillance system -Conducted through the CDC
Where are Metabolic or Feeding Studies done?
Like in patient or a place where all the meals are provided by a place
Country Wheels
MOWAM employs a driver who delivers 7 frozen meals 1X a week to needy clients who live in isolated, rural areas (outside of the normal delivery lines)
What does MOWAM stand for?
Meals and Wheels and More
What classifies a person as being categorically eligible?
Means that you fit the category, are one of the people that they serve 1)Pregnant women 2)Women who are 6 months post-partum (have had a baby in the past 6 months) 3)Women who are breastfeeding a baby under one year of age 4) Infants and children under 5 5) Parents, step-parents, guardians, and foster parents of infants and children under five can apply for their children
What are examples of other services that WIC can refer clients to?
Medicaid / Food Stamps / TANF Child Health Insurance Family Planning Prenatal Care Texas Health Steps (EPSDT) Medical and Dental Services Early Childhood Intervention Parenting Classes Substance Abuse Programs
How many people are interviewed in one year?
More than 350,000 adults
What classifies a person as being nutrition risk eligible?
Must "Be at nutritional risk" -widest range of qualifications
James Lind
Notice the association between fruits and veggies/ citrus intake and scurvy
After 1974- today?
Now serves 50 states, many Intertribal Organizations (ITO's), DC, Puerto Rico, the Virgin Islands & Guam
Who can accept FMNP coupons?
Only from farmers, farmers' markets or roadside stands that have been approved by the State agency to accept FMNP coupons
How long has the MOWAM in Austin served?
Over 40 years of service in the Greater Austin area
Cohort
People assembled on the basis of common characteristics and followed over time to determine a health related outcome
What does PAC stand for?
Political Action Committees
NHANES program began in?
the early 1960s
What are experimental studies?
the intentional alteration of, or intervention in, the course of disease
In 1994:
the organization changed its name to Meals on Wheels and More
Incidence:
the proportion of a population that develops a disease over time (ex: 2000-2010 the development of diabetes is x) -not counting the people who already have it
What happened in 1999?
the survey became a continuous program that has a changing focus on a variety of health and nutrition measurements to meet emerging needs
The info from NHANES is used to?
to assess nutritional status and its association with health promotion and disease prevention
Findings from NHANES are used to?
to determine the prevalence of major diseases and risk factors for diseases
What was the goal of VENA?
to expand the purpose of nutrition assessment from eligibility determination to improved nutrition education -basically educate them in a more tangible way
What is epidemiology used for?
used to investigate, control, and prevent epidemics of INFECTIOUS DISEASE
Who did NHANES conduct its survey on?
was conducted on a nationwide probability sample of approximately 32,000 persons 1-74 years of age
Epidemiology includes:
wellness and illness, but wellness is hard to measure So the measures of health are expressed in terms of illness Perception is a big part of it
