Ch #11 Other Chronic Diseases and Conditions

Informed Decision Making

A disease such as Alzheimer's presents different issues. Early diagnosis appears to have little effect on treatment or management of the disease. It does, however, afford both the patient and family members time to arrange for who will make future healthcare, financial, long-term care, and any other decisions necessary for the patient. Many issues need to be considered with Alzheimer's disease because as the disease progresses, a person will no longer be able to make rational decisions or care for himself or herself. A woman who is considering becoming a caregiver for a person with this disease needs to understand the time and commitment involved before making such a decision. Early diagnosis assists people in this preparation. The Internet can help patients and their families learn more about chronic diseases, and cope with their effects. It provides individuals with information about symptoms, diagnosis, and treatment, and with support groups and individuals who understand first—hand what it is like to live with a chronic disease. As with all information sources, there are risks related to information received on the Internet, including claims for supposed "miracle cures" for certain disorders, and information that is misleading or inaccurate. As with all other topics, women should make every effort to go to trusted sources to get information about chronic diseases. (See the websites listed at the end of this chapter.)

Symptoms for Alzheimer's Disease

Alzheimer's disease disrupts three key processes in the nerve cells of the brain: communication, metabolism, and repair. This disruption causes many nerve cells to stop functioning, lose connections with other nerve cells, and die. The disease advances by stages, from early, mild forget- fulness to severe loss of mental function (i.e., dementia). Symptoms usually first appear after age 65. The disease first destroys neurons in parts of the brain that control memory; as a result, a person's ability to do easy and familiar tasks begins to decline. People in the initial stages of disease often think less clearly and forget the names of familiar people and common objects. Later in the disease, they may forget how to do simple tasks, such as brushing their teeth. The cerebral cortex, particu- larly the area responsible for language and reasoning, is affected next, disrupting a person's language skills and ability to make judgments. Personality changes also may occur. Emotional outbursts and disturbing behavior, such as wandering and agitation, become more frequent as the disease runs its course. Eventually, many other areas of the brain are involved. All of these brain regions atrophy, and the person becomes bedridden, incontinent, totally helpless, unresponsive to the outside world, and susceptible to a variety of illnesses and infections. People with Alzheimer's disease often die from pneumonia.

Alzheimer's Disease

Alzheimer's disease is an irreversible, progressive brain disorder that affects thinking, memory, and behavior. The changes result from the death of brain cells and the breakdown of the connections between them. The progression of Alzheimer's disease and the resulting cognitive decline vary from person to person. People with this disease usually live anywhere from 3 to 20 years after first showing symptoms. Alzheimer's disease is the most common cause of dementia, with approximately 5.4 million people currently suffering from it. This number will grow as the population ages. The risk of developing Alzheimer's disease increases with age; however, the disease and symptoms of dementia are not a part of normal aging. Alzheimer's disease affects many areas of mental function, including memory, language, behavior, and thought processes. These changes are linked with distinct changes in the brain, most notably the development of amyloid plaques and neurofibrillary tangles. Plaques are dense deposits of protein and cellular material that form outside and around the brain's neurons. Researchers are not certain whether the plaques cause the disease or are simply a by—product of the disease process. Tangles are insoluble twisted fibers that build up inside neurons. A form of a protein called tau is the main component of the tangles. In healthy neurons, tau proteins help stabilize a cell's structure. In brains affected by Alzheimer's disease, the tau protein is chemically altered and cannot hold the structure together; the resulting collapse is responsible for malfunctions in communication. There are two forms of Alzheimer's disease. Late—onset Alzheimer's disease is the most common form, usually occurring in people over the age of 60. This form of the disease progresses slower and has less of a genetic link than early—onset Alzheimer's disease. Early—onset Alzheimer's is less common, but more severe than the late onset form of the disease. Early-onset Alzheimer's disease can appear in a person's 40s or 50s and progress rapidly within a few years.

Risk Factors for Gout

Arthritis is the leading chronic condition among women and a major cause of activity limitation. Women are two to three times more likely than men to have rheumatoid arthritis. Risk for arthritis increases with age, with nearly half of the elderly population being affected by some form of arthritis. Some people are genetically predisposed to arthritis, placing them at higher risk for developing the disease. Other risk factors are modifiable, although altering these factors does not guarantee prevention. Obesity, which increases the risk of many types of arthritis, is one such factor. Arthritis is nearly twice as common among people who are obese as it is among people of a healthy weight. Joint injuries from sports, infectious diseases such as Lyme disease, and occupations that require repetitive joint use and knee bending are other factors that increase a person's risk of arthritis. Table 11.4 summarizes the major risk factors associated with arthritis. Because women are more likely than men to have rheumatoid arthritis, researchers have been studying the role of hormones in the development of the disease, though investigations conducted to date have produced contradictory results. Arthritis is not uniformly distributed across the United States. The reasons for the inequitable distribution are unclear, but are the subject of ongoing research. As Fig— ure 11.4 shows, arthritis is most common in the Midwest and the South, but arthritis affects at least one in five adults in every state.

Autoimmune Diseases

Autoimmune diseases are those diseases in which the immune system attacks normal components of the body. More than 80 serious, chronic illnesses are collectively referred to as autoimmune diseases, and these diseases involve the nervous, gastrointestinal, and endocrine systems, as well as skin and other connective tissue, eyes, blood, and blood vessels. Autoimmune diseases are about three times more common in women than they are in men, and they most frequently first manifest during the childbearing years. Autoimmune diseases include multiple sclerosis, type 1 diabetes, scleroderma, rheumatoid arthritis, thyroid disorders, Sjogren's syndrome, systemic lupus erythematosus (SLE), and Hashimoto's disease. Rheumatoid arthritis, type 1 diabetes, SLE, and thyroid disease are the most common autoimmune diseases. Together, autoimmune diseases represent the fourth largest cause of disability among women in the United States.

Risk Factors for Thyroid Diseases

Both Hashimoto's disease and Graves' disease are inherited conditions. Women over 20 years old are at an increased risk for these conditions, though the disorder may occur at any age and does affect men. Other risk factors associated with thyroid disorders include a family history of thyroid disease, previous thyroid concerns (such as enlargement, goiter, or nodules), or a transient thyroid condition during pregnancy. Having one of these risk factors increases the risk of developing a thyroid disorder, but does not inevitably lead to one. Likewise, people Without Known risK factors can still develop thyroid disorders.

Introduction

Chronic diseases persist or progress over a long time. They develop slowly, do not resolve spontaneously, and are rarely cured completely. While infections cause 21 few chronic diseases, genetics and lifestyle factors, such as diet, physical activity, and environmental exposures, play the biggest role in how chronic diseases appear and develop. Many of these diseases manifest themselves in young women, ereating health issues that these individuals must learn to live with for the rest of their lives. Living with a chronic disease can become an encompassing process, especially when the disease causes frequent illness and necessitates many visits to physicians. Some women begin to consider the management of their illness to be a full—time job. Others try to live as they did before diagnosis, not wanting their condition to become central to their lives. Women's responses to chronic disease are as individual as the women themselves. In all cases, how- ever, active support networks via family, friends, healthcare providers, disease support groups, or therapy can help ease the burden of disease management. Support can help the woman cope with the physical, emotional, and financial ramifications of having a chronic disease. Unhealthful diets, smoking, lack of exercise, continued stress, and other risks contribute to the appearance and progression ofinany chronic diseases. These lifestyle risk factors contribute to high blood pressure, high cholesterol levels, diabetes, obesity, arthritis, and other conditions, which in turn can lead to conditions such as stroke, heart attack, some forms of cancer, chronic bronchitis, and emphysema. Chronic diseases are the leading cause of death in the United States and around the world. The World Health Organization (WHO) estimates that chronic diseases cause about 35 million, or 60%, of the 60 million deaths every year. Cardiovascular disease and cancer (see Chapter 10) are by far the biggest killers in this category, but other chronic diseases, like the ones discussed in this chapter, still kill 10 million people every year—more than twice the number of annual deaths from AIDS and tuberculosis combined. This chapter reviews osteoporosis, arthritis, diabetes, fibromyalgia, major autoimmune diseases, and Alzheimer's disease—chronic diseases that have dramatic effects on the health of women in the world today. Discussions of some other chronic diseases, such as herpes and AIDS (Chapter 7), appear in other chapters.

Diabetes

Diabetes is a disease characterized by abnormal glucose production or metabolism. A person with diabetes has either a deficiency of insulin (the hormone produced by the pancreas and needed to convert glucose to energy), or a decreased ability to use insulin. As a result, glucose builds up in the bloodstream, and, without treatment, will damage organs and contribute to heart disease. Cells without glucose also starve without their primary source of energy, leading to fatigue, irritability and other symptoms. Diabetes has become an extremely harmful and pervasive epidemic; it is now the seventh leading cause of death in the United States; additionally, every year, millions of people experience diabetes-related complications including blindness, nerve damage, amputations, heart disease, hypertension, or stroke. There are three major kinds of diabetes: type 1, type 2, and gestational diabetes. Type 1 diabetes is often classified as an autoimmune disease, though genetic and environmental factors can also influence its development. In this type of diabetes, the body's immune system attacks the cells that produce insulin, the hormone that regulates blood glucose. Type 1 diabetes often first appears in childhood or adolescence, and it accounts for about 5% of total cases of diabetes. About 90% to 95% of people with diabetes have type 2 diabetes. In this form of diabetes, cells develop insulin resistance, meaning that cells need increasing doses of insulin to absorb and use glucose. Gestational diabetes occurs when women become intolerant to glucose during pregnancy. After pregnancy, gestational diabetes usually goes away, but may return during later pregnancies or as type 2 diabetes. Women who have had gestational diabetes are at an increased risk of developing type 2 diabetes within the next 5 to 10 years. Most people with type 1 diabetes develop the disease early in life, while type 2 diabetes generally occurs later in life; however, the rise in childhood obesity is leading to a dramatic surge in the incidence of type 2 diabetes among Children and adolescents. In 2011, 25.8 million people, or 8.3% ofthe U.S. population, had diabetes. Figure 11.5 shows the number of people diagnosed with diabetes over the past 30 years. Because many people with diabetes go undiagnosed, these numbers underestimate the true prevalence of the disease. According to the Centers for Disease Control and Prevention's (CDC's) most recent analysis: I Almost one—half of the people with diabetes are female. About 10.8% of women age 20 or older have diabetes. I Women of color are the hardest hit by type 2 and gestational diabetes; the prevalence is at least two to four times higher among Black, Hispanic, American Indian, and Asian/ Pacific Islander women than among White women. I The risk of diabetic ketoacidosis (DKA), often called diabetic coma, is 50% higher among women than men. I Heart disease is the leading cause of diabetes—related deaths. Adults with diabetes have heart disease rates and risk for stroke rates about two to four times higher than adults without diabetes. Researchers have also identified prediabetes, a condition in which a person has abnormally high blood—glucose levels, but does not have diabetes. An estimated 79 million adults in the United States—about one out of five adults had prediabetes in 2010. Prediabetes often progresses to Type 2 diabetes, but weight loss and regular exercise can prevent or delay this progression.

Diagnosis for Alzheimer's Disease

In the absence of a conclusive diagnostic test, healthcafe providers rely on symptoms, medical history, and physical and neurological examimitions to diagnose Alzheimer's disease. These tests allow healthcare providers looking for Alzheimer's disease to diagnose it with up to 90% accuracy; however, many people with Alzheimer's disease are never diagnosed. The only way to conclusively identify the disease is through autopsy, by examining the characteristic plaques and tangles in the brain. It is important to rule out other illnesses or medications that can cause dementia. Severe depression in the elderly, which can often be treated successfully, is often accompanied by memory loss and therefore is often confused with Alzheimer's. However, depression and Alzheimer's disease do coexist in many patients. Researchers are studying brain—imaging techniques to better detect biological changes or signs of dysfunction in the brain. The earlier an accurate diagnosis of disease can be made, the better the chance of managing symptoms and helping patients and their families plan for future care while the patient is still able to take part in the decision making process.

Fibromyalgia

Fibromyalgia is a disease characterized by pain. People with fibromyalgia experience widespread pain throughout their bodies for most, if not all, of their waking lives. This pain lowers quality of life and reduces peoples' ability to function. Other symptoms associated with fibromyalgia include fatigue, depression, trouble sleeping, headaches, tingling or numbness in the limbs, and irritable bowel syndrome. The causes of fibromyalgia are largely unknown. One theory is that people with fibromyalgia have a low pain threshold, meaning that the brain over-interprets stimuli as pain. Some evidence indicates that fibromyalgia may develop after some viral infections, as an autoimmune response, or through a combination of factors. About 5 million people in the United States, or about 2% of the population, have fibrornyalgia. Accurate estimates are difficult, however, because the condition often goes undiagnosed. This may be because the symptoms are nonspecific or because providers believe that the condition is "all in the head" of the sufferer (it was not until 1990 that the medical community recognized fibromyalgia as a genuine, diagnosable condition). Diagnosis of fibromyalgia is made if a person feels pain in response to a firm touch in 11 out of 18 defined points on the head, legs, chest, and arms, and if other conditions are ruled out. Fibromyalgia is about seven times more common in women than it is in men. It is most likely to appear during or after middle age, though it also appears among young adults. Other risk factors include obesity and having rheumatoid arthritis, lupus, or family history of fibromyalgia. Although fibromyalgia is rarely deadly, it can be an extremely debilitating condition. On average, working adults with fibromyalgia miss three times number the days from work due to illness as people without fibromyalgia. On average, people with fibromyalgia also incur about $3,500 a year in medical bills. Treatment for fibromyalgia focuses on managing and learning to live with symptoms. Medications, such as acetaminophen (Tylenol), antidepressants, and antiseizure drugs may help some people with fibromyalgia. However, the eflects of these medications are modest, usually reducing pain by 30% to 50% in about one—half of patients. Regular physical exercise appears to reduce pain, insom- nia, and improve quality of life; exercise also provides the same benefits to people with fibrornyalgia as it does to people without the condition. Cognitive—behavioral therapy (CBT), in which the patient works with a psychologist to develop and maintain healthful thoughts and behaviors, helps to reduce symptoms and helps people cope with them. A multimodal approach to treatment that includes medication, exercise, and CBT appears to provide the most overall benefits.

Prevention and Treatment for Osteoporosis

In the absence of a cure, prevention and management are the best strategies available for women with osteoporosis and for women at all stages of life. Lifestyle and personal behaviors are the key osteoporosis prevention strategies. A woman should not start smoking, and she should quit if she already smokes. An inadequate supply of calcium over a woman's lifetime is a major risk factor for developing osteoporosis. Calcium plays an important role in achieving peak bone mass, maintaining bone mass before menopause, and preventing bone loss in the postmenopausal years. Vitamin D is necessary for intestinal absorption of calcium. Calcium and vitamin D reduce the risk of fracture of the spine, hip, and other sites. The typical diet of U.S. women contains less than 600 milligrams of calcium per day, about half the recommended amount for women. Dietary calcium is preferable; however, supplements can help a woman meet the recommended dose of LOGO—1,200 milligrams per day (see Chapter 9). The skin manufactures vitamin D after exposure to sunlight; vitamin D—fortified milk, cereal, egg yolks, saltwater fish, and liver can also provide vitamin D through the diet. Those people who cannot obtain enough vitamin D naturally should include 200—600 IU (International Units) in their diets per day. Regular weight—bearing and muscle—strengthening exercise is important for osteoporosis prevention and overall health. These exercises improve agility, strength, and balance, thus reducing a woman's risk of falls and decreasing her risk of fractures. Weight-bearing exercises (exercises in which bones and muscles work against gravity) include walking, hiking,jogging, stair-climbing, dancing, and tennis. Muscle—strengthening exercise, such as weight—lifting, improves muscle mass and bone strength. Treatment involves managing osteoporosis—associated fractures, universal prevention measures, and medical treatment of the underlying disease. Current osteoporosis recommendations indicate that all persons who have had osteoporotic vertebral or hip fractures and those with a bone mineral density diagnostic of osteoporosis should receive treatment. In women with a bone mineral density above the osteoporosis range, treatment may be indicated depending on the number and severity of other risk factors. The Food and Drug Administration (FDA) has approved several classes of medications that can help reduce or prevent the progress of osteoporosis; women with osteoporosis or at risk for developing osteoporosis should talk with their healthcare providers about these treatments. Preventing fall-related fractures is a special concern for women with osteoporosis. Many factors can cause falls, including impaired vision or balance, certain chronic dis eases, and certain medications. A woman with osteoporosis should be aware of any factors that may affect her balance or gait, and she should discuss these changes with her healthcare provider. Making some simple adjustments to one's living area and behaviors can also greatly lower risk of falls (Table 11.3).

Gout

Gout is a painful and potentially disabling form of arthritis that was first described more than 2,000 years ago by the Greek physician Hippocrates. Unlike other forms of arthritis, which are typically persistent, symptoms of gout can appear, typically for a few days or a few weeks, and then disappear for long periods. However, when symptoms are present they can be quite painful and debilitating. Gout is caused by an excess of uric acid in the body. This excess can result from an increased production of uric acid due to a metabolic disorder or the inability of the kidneys to adequately clear uric acid. Consumption of certain foods (such as shellfish) and an excess of alcoholic beverages may increase uric acid levels and precipitate gout attacks, but studies are not conclusive on these associations. Some medications and transplant drugs can also increase uric acid levels. With time, elevated levels of uric acid in the blood may be deposited around joints, especially in the feet and toes. Eventually, the uric acid may form needle—like crystals in joints, leading to acute painful gout attacks. Uric acid may also collect under the skin, where it is known as tophus, or in the urinary tract as kidney stones. About 3 million people in the United States have gout. While gout and its complications occur more commonly in men, gout is also common among women who have experienced menopause and people with kidney disease. Gout is strongly associated with obesity, hypertension, hyperlipidemia, and diabetes. Some families have a genetic predisposition to gout. African Americans and people with poor kidney function are more likely to have gout attacks. Diagnosing gout can be difficult because infections or other kinds of arthritis can mimic a gout attack. Given that its treatment is specific to gout, proper diagnosis is essential. The definitive diagnosis of gout depends on finding uric acid crystals in the joint fluid during an acute attack. However, uric acid levels in the blood alone are often misleading and may provide "false positive" (indicating gout when it is not present) or "false negative" (missing gout when it exists) results. Treatments can now control most cases of gout; how ever, because of their potential side effects, individual patients often work with their healthcare providers to find the treatment that is best for them. Colchicine has been a standard treatment for acute gout since the 1800s. However, while colchicine is effective, it can cause nau sea, vomiting, diarrhea, and other side effects. Because of these side eflects, nonsteroidal anti—inflammatory drugs (NSAlDs) have become the treatment of choice for most acute attacks of gout. NSAIDs may also have significant toxicity, but if used over a short term, they are generally well tolerated. However, some people are unable to take NSAIDs because of other medical factors such as ulcer disease, poor kidney function, or use of blood thinners. Elderly patients often cannot tolerate NSAIDs because of their multiple side effects. Corticosteroid-type medications are also used to treat gout attacks and can be given as pills or by injection. Decisions about appropriate treatments must be tailored to the individual and depend on his or her kidney function and other medical factors. With correct treatment, gout can be well controlled in almost all cases.

Economic Dimensions

In addition to harming individuals, chronic diseases have major effects on the economy. More than 90 million Americans live with chronic diseases, and chronic diseases (incliuding cardiovascular disease and cancer) account for 70% of all deaths in the United States. More than 75% of America's $2 trillion in medical care costs (about $1.5 trillion) come from chronic diseases. Chronic diseases decrease life expectancy and account for one—third of the years of potential life lost before age 65. The costs associated with specific chronic diseases are huge. The total annual costs of diabetes are estimated to be $174 billion per year—about $116 billion in direct medical expenses, and about $58 billion in indirect costs like premature death, work loss, and disability. Arthritis and related conditions create expenses of more than $128 billion a year. Bone fractures caused by osteoporosis cost Americans $12 to $18 billion per year. The costs of health care, home care, and hospice for people with Alzheimer's disease and other forms of dementia in 2011 were $183 billion; these costs are expected to increase to $1.1 trillion annually (in 2011 dollars) by 2050. People with chronic diseases often struggle to pay for appropriate medical care. Men and women with diabetes have, for example, more than twice the average medical expenses of people without diabetes. Keeping a full-time job with a chronic disease may become increasingly difficult, so people who desperately need health insurance may not be able to receive it from their employers. This means that they may have to turn to public insurance programs such as Medicaid or Medicare for coverage or go without care. People with chronic diseases also experience costs in their personal relationships as the strain of dealing with chronic disease damages marriages, friendships, or other relationships. Women are usually the primary caregivers for loved ones and family members with chronic diseases. Whether they or someone in their family is suffering, women carry the majority of the burden of care and support for patients.

Symptoms for Lupus

Lupus has been called "the great imitator" because of its varied symptoms, which often mimic other, less serious illnesses. Lupus is characterized by periods of remission when no symptoms are present. The two most common symptoms are painful, swollenjoints and a skin rash. In addition to being nonspecific, symptoms of lupus vary from person to person because lupus can affect any organ or organ system. Although lupus can affect any part of the body, most people experience symptoms in only a few organs. Table 11.6 summarizes the symptoms of lupus. The origins of lupus remain a mystery and have been the subject of considerable speculation and research. Cigarette smoking is one of many environmental exposures, as are infectious agents, silica exposure, and hormonal and dietary factors such as vitamin D, which are hypothesized to be linked to the development of SLE. However, the root causes of lupus likely involve more than these factors.

Lupus

Lupus is an autoimmune disease that is still not fully understood. In patients with lupus, the immune system forms antibodies that target healthy tissues and organs. Lupus can be a mild, moderate, or severe disease, Although lupus may affect men and women ofany age, it is primarily a disease that aliens women during their childbearing years. Lupus affects women 10 to 15 times more often than it does men, and it affects African American women 2 to 3 times more often than it does White women. Lupus presents in three forms. Discoid lupus, also known as cutaneous lupus, only affects the skin and causes a rash that usually appears on the face and upper body. Only about 10% of people with discoid lupus will progress to the systemic form of lupus, which can involve any organ or system of the body. Systemic lupus erythematosus (SLE) is the most common and more severe form of the disease; it is characterized by unpredictable periods of disease activity and periods of symptom-free remission. SLE can afiect many parts of the body, including joints, skin, kidneys, lungs, heart, blood vessels, nervous system, blood, and brain. Drug—induced lupus is a reaction to some prescription medicines. The symptoms of this type of lupus are similar to SLE, but do not affect the kidneys or central nervous system. Drug-induced lupus usually disappears when the medication is discontinued.

Treatment and Prevention for Lupus

Lupus is characterized by periods of symptoms called "flare-ups." The symptoms are unpredictable and inconsistent when they present. Women with lupus can take preventive measures to help prevent flare—ups. People who are photosensitive should avoid sun exposure and regularly use sunscreen to prevent rashes. Exercise is important to prevent muscle weakness and fatigue, while support groups, counseling, meditation, and other techniques can help to reduce stress. Treatment usually involves non steroidal anti-inflammatory drugs (NSAIDs) to ease muscle and joint pain. Corticosteroids are used on a short-term basis to treat skin rashes. Some people find antimalarial agents, such as Plaquenil or Amlen, helpful for skin and joint symptoms, as well as oral ulcers. Immunosuppressant drugs may he used in serious cases of lupus, when major organs are losing their ability to function. These drugs suppress, or turn down, the immune system to limit the damage done to the organ(s) and reduce inflammation. Serious side effects may occur with their use, including nausea, vomiting, hair loss, bladder problems, decreased fertility, and increased risk of cancer and infection.

Prevention and Treatment for Gout

Maintaining an appropriate weight is an important preventive measure. For people who are overweight or obese, losing weight through healthful eating and regular exercise also can help reduce the effects of osteoarthritis. Taking precautions during exercise can also reduce the chance of joint injury. Women should participate in warm—up and cool—down periods when performing any type of exercise or sports—related activities. They should also incorporate strength—training exercises into their routines. Other methods for preventing joint injury and damage to ligaments and cartilage, which in turn can prevent osteoarthritis, include avoiding contact sports and repetitive joint motion; wearing braces, pads, and proper shoes; and exercising on appropriate surfaces. Regular exercise decreases impairment by increasing muscle and joint function. Research has shown that weakness in a woman's quadricep muscles is a risk factor for osteoarthritis of the knee, and that exercise can significantly benefit knee osteoarthritis pathology. Another cause of arthritis is Lyme disease, a disease caused by the bacterium Barre/id burgdorferi. These bacteria are transmitted to humans by the bite of infected deer ticks and cause about 30,000 infections in the United States each year. After several months of being infected, more than half of people who are not treated with antibiotics experience recurrent attacks of painful and swollen joints. About 10% to 20% of these people develop chronic arthritis. Strategies to prevent Lyme disease include using insect repellants, wearing long—sleeved shirts and pants when walking in wooded areas, and checking one's body for ticks immediately upon return. The goals of treating arthritis are to decrease pain, improve joint care by slowing down or stopping joint; damage, and improve a person's sense of well—being an; ability to function. Exercise is one of the best treatmen for arthritis. Physical activity maintains healthy and stro muscles, preserves joint mobility, and maintains flexibility. It is important to exercise when pain is least severe recognize when rest is necessary. Resting the body reduces active joint inflammation and pain and prevents pain overexercising. Canes, splints, or braces can temporarily take pressure off~ joints or provide extra support. Control ling body weight through a healthful diet also helps reduce stress on weight~bearing joints and limit further injury. Many people with osteoarthritis or rheumatoid arthritis use medications to reduce pain and inflammation, as well as prevent joint damage. Medications include: I NSAIDs, either in prescription or over—the-counter form, can reduce pain, swelling, and inflammation. I Topical pain—relieving creams, rubs, and sprays, such as those containing capsaicin, can be applied directly to the skin to relieve pain. I Corticosteroids (anti-inflammatory hormones) can provide short—term relief of pain, stiffness, and swelling and can reduce the risk of joint swelling I Hyaluronic acid, a medication for joint injection, can relieve pain associated with osteoarthritis of the knee. I For rheumatoid arthritis, disease—modifying antirheumatic drugs (DMARDs) may produce significant improvement. DMARDs can alter the course of rheumatoid arthritis and preventjoint and cartilage destruction. These medications, however, can cause serious side effects, and are not appropriate for everyone. I Biologic response modifiers (BRMs) inhibit proteins called cytokines that contribute to inflammation and joint damage in rheumatoid arthritis. BRMs must be injected under the skin or given as an infusion into a vein. I Immunosupprcssants appear to be very effective in restraining the active immune system, the causal factor behind rheumatoid arthritis. These medications can cause side efi'ects, however, and their effectiveness appears to diminish over time. Surgery can also be a treatment option for arthritis. Surgery can resurface and reposition bones, replace joints, remove loose pieces of bone or cartilage, reconstruct tendons, or remove inflamed synovial tissue. Alternative methods oftreatment for arthritis, such as acupuncture and yoga, can also help relieve symptoms.

Prevention and Treatment for Diabetes

Managing type 1 diabetes requires a regimen of multiple daily insulin injections, a carefully calculated diet, planned physical activity, and home blood glucose testing several times a day. Treatment of type 2 diabetes is also based on diet control, exercise, and blood glucose testing, and for some people may entail oral medications or insulin. Daily management is important to prevent blood sugar levels from going too high or too low. A person with diabetes should eat a healthful diet and monitor the amount of carbohydrates (starches and sugars) that he or she eats. Because simple carbohydrates, such as sugars and refined grains. can quickly raise blood glucose levels, their consumption should be limited. If blood sugar levels rise too high, as in hyperglycemia, a person may become very ill. Early signs of hyperglycemia include high blood sugar, high levels of sugar in the urine, frequent urination, and increased thirst. Hyperglycemia should be treated as an emergency situation and emergency services (such as 911) should be called immediately. The opposite problem, hypoglycemia (low blood sugar levels), may occur if a person with diabetes takes too much insulin. Hypoglycemia can cause a person to become nervous, shaky, confused, or even pass out. Consumption of food or drink with sugar in it can counteract low blood sugar.

Diagnosis for Gout

No single test can diagnose arthritis. Instead, healthcare providers use a variety of tools, such as a medical history, family history, and physical exams to check the joints, reflexes, and muscle strength. Radiographs can determine the amount of damage done to a joint by showing cartilage loss, bone damage, and bone spurs. In the early stages of arthritis, before damage is evident, radiographs are not useful; however, they are helpful in later stages for monitoring the progression of the disease. Blood tests to determine the cause of the symptoms, a test for rheumatoid factor (an antibody present in most rheumatoid arthritis patients), and a joint aspiration (drawing fluid from the joint for examination) may also be used for diagnosing arthritis.

Screening and Diagnosis for Osteoporosis

One red flag that signals a woman might have osteoporosis is a bone fracture that results from minimal trauma. To test for osteoporosis, a bone mass measurement (also referred to as a bone mineral density test) must be taken. Methods for measuring bone mineral density are pain- less, noninvasive, and safe. Traditional tests measure bone density in the areas most susceptible to fractures caused by osteoporosis: the spine, the hip, and the wrist. Newer machines measure density in the finger, the kneecap, the shin bone, and the heel. Women who should be tested include: I All postmenopausal women younger than age 65 who have one or more additional risk factors for osteoporosis besides menopause. I All women age 65 or older. I Postmenopausal women with fractures. I Women who are considering therapy for osteoporosis or who want to monitor the effectiveness of certain osteoporosis treatments.

Osteoarthritis

Osteoarthritis, also called degenerative joint disease, is the most common form of arthritis, affecting more than 27 million people. A milder form of arthritis than rheumatoid arthritis, it is seen in all age groups but is most common among older adults. About one in seven adults, and about one in three adults over the age of 65, suffer from osteoarthritis. Osteoarthritis is more common in women than in men, especially after age 50. In osteoarthritis, the surface layer of cartilage erodes, causing bones under the cartilage to rub together. This friction causes joint pain, swelling, and loss of movement of the joints. This disease most often afiects the knees, but it also affects the hips, hands, neck, lower back, and other joints. Hip and knee osteoarthritis are the leading causes of arthritis disability and the primary reasons for joint replacement surgery.

Osteoporosis

Osteoporosis is an age—related disease characterized by a reduction in bone mass and structural deterioration of bone tissue. Bone is living, growing tissue that changes through out life. Bone remodeling is the process that removes older bone (resorption) and replaces it with new bone (formation) to maintain a healthy skeleton. Until a woman's mid—20s, new bone forms faster than resorption occurs, until peak bone mass is reached—after age 30, bone resorption begins to exceed bone formation. The first few years after menopause are the most significant for bone loss. As bone is lost, the skeletal structure weakens, leading to an increased risk of fracture. Osteoporosis develops when bone resorption occurs too quickly or bone replacement occurs too slowly (Figure 11.2). Osteoporosis is a major cause of bone fractures in postmenopausal women and a leading cause of frailty. It affects approximately 8 million women, with millions more at increased risk of developing osteoporosis due to low bone mass. This translates to one in two women older than age 50 having an osteoporosis—related fracture in her lifetime. Osteoporosis is responsible for more than 1.5 million fractures per year, including 300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures, and more than300,000 fractures at other sites. Table 11.2 outlines risk factors for osteoporosis. Hip fractures are especially serious. Only 25% of hip fracture patients will make a full recovery: 40% will require nursing home care, 50% will need a cane or walker, and 24% of those over age 50 will die within 12 months of the fracture. Women have two to three times as many hip fractures as men, and White, postmenopausal women have a one in seven chance of hip fracture during their lifetime. The rate of hip fracture increases at age 50, doubling every 5 to 6 years. Nearly one—half of all women who reach age 90 have suffered a hip fracture. Hip fractures present long—term problems when they occur.

Signs and Symptoms for Osteoporosis

Osteoporosis is often called a "silent disease" because neither pain not specific symptoms are associated with this condition. Only one out of four women who has osteoporosis is aware of the condition. Some women notice a loss of height as the vertebrae weaken, collapse, and consequently fracture. When the bones in the spine fracture, a woman loses a small amount of height. The spine also begins to curve as multiple fractures occur.

Racial/Ethnic and Socioeconomic Dimensions

Rates and severity of chronic diseases vary among racial and ethnic groups, often in complex ways. Black women, for example, typically have a higher bone mineral density than White and Asian American women. This puts Black women at a lower absolute risk of developing osteoporosis. However, due to other factors, such as general health status and reduced access to health care, Black women are more likely to die if they have a serious osteoporosis—related injury. Racial differences are also evident with arthritis. Although Black women are about as likely as White women to have arthritis, they are more likely (10.1% versus 7.9 to have more serious symptoms that limit their daily activities. Overall, Black people with doctor—diagnosed arthritis have a higher prevalence of severe pain attributable to arthritis, compared with Whites (34.0% versus 22.6. Diabetes is also more prevalent among non—White populations. As Figure 11.1 shows, non-Hispanic blacks, followed by Hispanics and Asian Americans, have the highest prevalence rates of diabetes in the United States.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory disease with increasing prevalence among older adults. It currently affects 1.5 million people in the United States, and is twice as common in women as in men. Rheumatoid arthritis is an autoimmune disease, meaning that the person's immune system attacks the body's own cells. The exact causes for this immune response are still unknown. In this condition, the immune system attacks the cells inside the synovial fluid and cartilage in the joint, causing inflammation, pain, and swelling. Eventually, the synovial fluid and cartilage may be mostly destroyed (Fig— ure 11.3), which can lead to severe disability. In addition to attacking the joint lining, the immune system may attack other tissues. If faulty immune response affects other organs, such as the lung and the heart, a person may be more likely to die from respiratory and infectious diseases. Rheumatoid arthritis generally occurs in a sym metrical pattern, meaning that it will involve both the left and right hands, not just one of them. The disease varies significantly between individuals: Some people have flare ups followed by periods of remission, whereas others have severe disease that is continuously active. Rheumatoid arthritis can also go away and not return.

Risk Factors for Diabetes

Risk factors for diabetes include having a first—degree relative (mother, father, or sibling) with diabetes, and, for gpe 2 diabetes, being overweight, having hypertension, or abnormal high-density lipoprotein (HDL) or nighteride levels. African Americans, Hispanics, and American Indians/ Alaska Natives are at increased risk for developing type 2 diabetes (see Figure 11.1). American Indians have the highest rate of diabetes in the United States—16% of American Indians and Alaska Natives age 20 years or older and receiving care from the Indian Health Services have diabetes. It's Your Health provides a checklist of factors to ascertain personal risk for diabetes.

Risk Factors for Osteoporosis

Smoking is detrimental to bone health, as it can cause early menopause and increase the rate of bone loss. The effects of smoking on bone health have been difficult to analyze in more detail because possible confounding factors, such as lifestyle differences between smokers and nonsmokers, may also play a role. Smokers are often thinner, drink more alcohol. are more likely to lead sedentary lifestyles, and tend to have earlier menopause than nonsmokers do—all of which are risk factors for poor bone health. Additionally, inadequate calcium intake and a lack of regular weight—bearing exercise also increase the risk for developing osteoporosis. Some medications used to treat other chronic conditions may also cause bone loss. For example, long-term use of glucocorticoids (medicines prescribed for diseases includ- ing arthritis, asthma, Crohn's disease, and lupus) can lead to a loss of bone density and increase in fractures. Antidrugs, gonadotropin-releasing hormone (GnRH) analogs, excessive use of aluminum-containing antacids, certain cancer treatments, and excessive thyroid hormone also may cause bone loss. The health benefits of these medications may be worth the risk of possible bone loss, however. Women using these medications should discuss their options for osteoporosis prevention and best treatment regimens with their healthcare providers. Medical conditions, including diseases of the thyroid gland such as hyperthyroidism and hypothyroidism, may lead to bone loss. Amenorrhea (lack of menstrual periods) or diseases that lead to amenorrhea, such as anorexia nervosa, cause estrogen deficiencies, which in turn lead to accelerated bone loss (Table 11.2).

Symptoms for Gout

Symptoms of arthritis depend on the specific disease affecting the joints. Osteoarthritis evolves slowly. Early in the disease, joints may ache after physical work or exercise. Small bony knobs may appear on the joints of the fingers, causing the fingers to become enlarged, gnarled, achy, stiff, and numb. Osteoarthritis in the knees or hips may make it difficult for a person to walk or bend. Rheumatoid arthritis is typically the most painful, disabling form of arthritis. Symptoms, which include pain, stiffness, and swelling of multiple joints, do not always respond to treatment. As a result of these symptoms, people with arthritis typically lead inactive or less active lives, placing them at greater risk for other diseases, including heart disease, hypertension, diabetes, colon cancer, obesity, depression, and anxiety.

Symptoms and Complications for Diabetes

Symptoms of type 1 diabetes usually develop over a short period of time. Symptoms include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. A person with type 1 diabetes needs insulin on a regular basis to survive. Without insulin, a person can lapse into a coma and eventually die. Symptoms of type 2 diabetes develop gradually. Although they are not as noticeable as symptoms of type 1 disease, type 2 symptoms are similar and include frequent urination, unusual thirst, weight loss, blurred Vision, feelings of fatigue or illness, frequent infections, and slow healing of sores. The most alarming part of diabetes is the severity of the complications associated with the disease (Table 11.5). Diabetes is the leading cause of new cases of blindness in adults 20 to 74 years of age: Each year, an estimated 12,000 to 24,000 people become blind because of diabetic eye disease. Early detection and treatment can prevent 90% of these cases of blindness. Diabetes is also the leading cause of end—stage renal disease (ESRD) or kidney failure, accounting for about 44% of new cases. At least half of the new cases of diabetes-related kidney failure could be prevented each year. Severe complications of diabetes, however, should not be considered an unavoidable part of diabetes. With proper care and management, most diabe- tes complications can be prevented. Because the high glucose levels of unregulated diabetes can literally thicken the blood, people with diabetes often develop complications relating to poor circulation. As a result, many people have trouble healing from injuries, especially in their extremities. About 60% to 70% of people with diabetes suffer damage to their nervous system, including impaired sensation or pain in the feet. If severe, the nerve damage can require lower—limb amputation. More than 60% of nontraumatic lower—limb amputations occur among people with diabetes. Amputations are also caused by infection related to non healing diabetic foot ulcers. New treatments for nonhealing diabetic foot ulcers include genetically engineered replacement dermis, growth hormone products, and better wound management programs Adults with diabetes are two to four times as likely to develop heart disease or stroke as those without diabetes. The additional risk from diabetes is related to how well a person cares for his or her condition. A woman with diabetes who manages her blood glucose levels, gets regular exercise, and monitors her diet will have a much lower risk of heart disease than a women with poorly controlled glucose levels, eats an unhealthful diet and leads a sedentary lifestyle. Women with poorly controlled diabetes also are at risk of diabetic ketoacidosis (DKA), a serious condition in which acid levels increase in the blood. Diabetes is known to affect brain function and increase the risk for cognitive decline, dementia, depression, and stroke. These complications frequently occur together, leading to poor quality of life and compounding the need for medical care. Diabetes, often associated with high blood pressure, may contribute to cognitive decline in elderly diabetics as well as to increased frequency and severity of cerebral vascular events. Pregnancy presents special risks to diabetic women. Women are more likely to have healthy pregnancies if their diabetes is well controlled before they become pregnant and throughout the pregnancy. The risk of serious congenital malformations and macrosomia (large birthweight) in babies born to mothers with diabetes is greater than in the general population. Due to the increased incidence of babies with high birthweights, women with diabetes are three to four times more likely to have a cesarean delivery than are women without diabetes. In addition, 3% to 5% of pregnancies among women with diabetes result in death of the newborn, compared with 1.5% for women who do not have diabetes.

Symptoms for Thyroid Disease

Table 11.7 summarizes clinical manifestations of Hashimoto's disease and Graves' disease. However, many people have no symptoms, and symptoms rarely occur all at once.

Risk Factors for Lupus

The cause of lupus is unknown, although genetic, hormonal, and environmental factors appear to play a role. Lupus is known to occur within families, although no specific gene for it has been found. Environmental factors, including infections, exposure to sunlight, stress, and certain medications, play a role in triggering flare-ups of the disease. Because the cause of lupus is unknown, it has been difficult to determine its risk factors.

Risk Factors for Alzheimer's Disease

The causes of Alzheimer's disease are not fully known. Multiple factors, including age, genetic background, and possibly lifestyle, influence its development and progression. Some studies have, implicated severe or repeated head injuries. lower education levels, and environmental agents as risk liietors; however, more research is needed to determine the exact relationship among these risk factors and the development of Alzheimer's. The risk of developing Alzheimer's increases with age. One out of every 10 persons 65 years or older is a victim of Alzheimer's disease, although early-onset victims may be in their 40s or 50s. Approximately 20% of Americans between the ages of 75 and 84, and almost one-half of those 85 years or older, suffer from Alzheimer's disease. Genetics plays a strong role in the development of early— onset Alzheimer's disease. As many as 50% of early-onset cases are caused by defects in three genes located on three different chromosomes. Even if only one of these mutations is inherited from a parent, a person will inevitably develop a form of early-onset Alzheimer's. Genetics play a role in late—onset disease as well; however, a person can inherit the gene associated with late—onset Alzheimer's and not get the disease. Similarly, people with late—onset Alzheimer's may not have any genetic factor.

Diagnosis for Lupus

The clinical diagnosis of systemic lupus involves noting potential symptoms, such as skin rash, joint pain, chest pain, seizures, and photosensitivity, and reviewing a per son's history of medications. A complete blood count and urinalysis may provide evidence of the involvement of the kidneys and blood vessels. Ihe antinuclear antibody (ANA) test may be used to rule out a diagnosis of lupus, as it is positive in virtually all people with lupus and is the best diagnostic tool available for lupus. Antinuclear antibody is not a definitive test, however, because other illnesses, certain medications, or other factors can produce a "false positive" ANA even in a person without lupus.

Diagnosis for Diabetes

The routine test for diagnosing diabetes is a fasting plasma glucose test. A doctor may choose to perform an oral glucose tolerance test, which involves a fasting blood sample followed by numerous blood samples after glucose syrup is ingested. The "gold standard" for diagnosing diabetes is an elevated blood sugar level after an overnight fast (not eating anything after midnight). A value above 126 mg/dL on at least two occasions typically means a person has diabetes. People without diabetes have fasting sugar levels that generally run between 70 and 110 mg/dL. A fasting glucose level of 100 to 125 mg/dL indicates prediabetes, as well as a higher chance of developing type 2 diabetes in the future.

Arthritis

The term arthritis, which means "inflamed joints," includes more than 100 diseases and conditions that affect joints, the surrounding tissues, and other connective tissues. Arthritis affects about 50 million adults in the United States, making it the most common cause ofdisability in the country. Common forms of arthritis are osteoarthritis, rheumatoid arthritis, and gout. The underlying cause of arthritis can result from injury, wear and tear on thejoints, an autoimmune response, or a bacterial or viral infection. No matter the cause, however, similar processes occur in the joints as the disease develops. Healthy joints are usually protected by cartilage, a flexible connective tissue, and synovial fluid, a viscous, protective fluid. Cartilage and synovial fluid cushion joints from impacts and allow them to move smoothly. If something damages or wears down the cartilage and synovial fluid, the bones may rub together, and stiifness, rigidity, and pain during movement may result. Eventually a scar between the bones may develop, resulting in joint deformity. Arthritis and other rheumatic conditions (conditions affecting the joints and muscles) are among the most common chronic conditions and the leading causes of disability in the United States. Arthritis affects more than one out of five adults, most of whom are women, and limits the activity of more than 20 million Americans. The prevalence of arthritis will continue to increase as the population ages. Although aging is a risk factor, nearly three of every five people with arthritis are younger than 65 years of age. By 2030, 65 million Americans 18 years or older will have doctor—diagnosed arthritis.

Thyroid Disease

The thyroid is a small gland, shaped like a butterfly, located in the middle of the lower neck. Its primary function is to control the body's metabolism—the rate at which cells perform duties essential to living. To control body metabolism, the thyroid produces two hormones, T4 and T3, that regulate cell energy. A properly functioning thyroid will maintain the right amount of hormones needed to keep the body's metabolism functioning at a steady state. The pituitary gland, located in the center of the skull below the brain, monitors and controls the quantity of thyroid hormones in the bloodstream. When the pituitary gland senses either a lack of thyroid hormones or a high level of thyroid hormones, it will adjust its own thyroid—stimulating hormone (TSH) and send messages to the thyroid to regulate hormone production. Thyroiditis is an inflammation of the thyroid gland (Figure 11.6). When the thyroid produces too much hormone, the body uses energy faster than it should; this condition is called hyperthyroidism. When the thyroid doesn't produce enough hormone, the body uses energy slower than it should; this condition is called hypothyroidism. An estimated 27 million Americans have overactive or under active thyroid glands, but more than half of them go undiagnosed. Hypothyroidism results from an underactive thyroid. Hypothyroidism can be caused by a lack of iodine in the diet. Another common cause is a condition known as Hashimoto's thyroiditis, or Hashimoto's disease. This autoimmune condition occurs when the immune system reacts against the thyroid gland. About 8 million Americans have this condition, and most of them are women. Because people with hypothyroidism lack enough thyroid hormones to properly run their metabolisms, they often have symptoms associated with having low energy. (See Table 11.7 for a full list of symptoms.) Hyperthyroidism occurs when the body produces too much thyroid hormone. Because the excess of thyroid hormone increases the body's metabolism by as much as 60% to 100%, people with hyperthyroidism often feel symptoms associated with being overstimulated. Graves, disease, an autoimmune disorder in which the immune system stimulates the thyroid, causes about 80% of hyperthyroid cases. Hyperthyroidism is 8 to 10 times more common in women than in men. People with hyperthyroidism may develop moderate to severe eye problems, which may cause bulging of the eyes, blurring of vision, or damage to the eyes.

Treatment and Research for Alzheimer's Disease

There is no cure for Alzheimer's disease. The FDA has approved several medications for its treatment; however, these medications usually provide little benefit, may cause harmful side effects, and do not stop the underlying degeneration of brain cells. In the absence of effective medication, treatment for Alzheimer's disease focuses on managing symptoms and making lifestyle changes to help the patients and their caregivers cope with the progression of the disease. Therapies include the management of problematic behaviors, home or "environmental" modifications, and the use of appropriate communication techniques. Support and education for caregivers and family members are also crucial to the best care of people with Alzheimer's. The care of a person who has Alzheimer's disease is challenging on many fronts. More than 70% of people with Alzheimer's live at home, Where family and friends provide their care. Care can be emotionally devastating, physically demanding, and a financial burden. Caregivers are subject to high levels of chronic stress, and caregiver burnout is a major factor in the inability to continue caring for a person with Alzheimer's at home. Physical activity, good nutrition, and social interaction are important for keeping Alzheimer's patients as functional as possible. Maintaining a calm, safe, structured environment also helps patients feel better and remain independent longer. Drugs can help soothe agitation, anxiety, depression, and sleeplessness, and may help boost participation in daily activities. Genetic research is an important area of Alzheimer's disease study. Scientists have found genetic links to the two forms of Alzheimer's disease. In the 1980s, researchers found that mutations (or changes) in certain genes on three chromosomes cause early-onset disease. A person has a 50% chance of developing early-onset disease if one parent has any of these genetic mutations. Certain forms of the apolipoprotein E (APOE) gene can also influence the development of late-onset disease. Scientists are now intensively searching for other genes that may be linked to Alzheimer's. Lifestyle changes are often the first step in preventing the development of chronic conditions or in slowing their progression. A healthy diet, regular exercise, and avoidance of harmful substances are standard methods for health promotion. Other important approaches toward disease prevention include being knowledgeable about chronic diseases and their symptoms and visiting one's healthcare provider regularly. A woman who knows her body may be able to recognize changes or problems readily and prevent or slow progression of disease before symptoms begin or complications arise. For osteoporosis prevention purposes, a woman usually only needs to have a bone mineral density test two or three times during her lifetime. Preventive measures such as medication may be an appropriate option for women with decreasing bone density. A significant aspect of arthritis treatment involves learning ways to ease pain and perform daily activities. A diagnosis of arthritis should encourage women to become more active in their own health care and learn better ways to manage their diseases. Some diseases can cause significant damage if left undiagnosed and therefore untreated. Uncontrolled diabetes, for example, can lead to serious illness and possibly death. With appropriate treatment and by managing their condition, however, women with diabetes can live complete and satisfying lives.

Screening and Diagnosis for Thyroid Disease

Thyroid disease can be difficult to diagnose because its symptoms are easily confused with other conditions. A comprehensive history and physical examination are integral to a diagnosis of thyroiditis. An examination typically includes weight and blood pressure; pulse rate and cardiac rhythm; and examination of the thyroid, neuromuscular system, eyes, skin, and the cardiovascular and lymphatic systems. Laboratory testing is also important. The thyroid-stimulating hormone (TSH) test is generally used as a screening test because it can often identify thyroid disorders before the onset of symptoms. Blood tests measuring levels of thyroxine (T4) can confirm the presence of thyroid disease. If thyroid disease is caught early, treatment can control the disorder before symptoms become severe.

Treatment for Thyroid Disease

Treatment for Hashimoto's disease is based on determining the correct amount of thyroid hormone (thyroxine) needed to stimulate the thyroid gland. Gradually increasing doses of thyroxine are given until a person's blood levels become normal. Annual checkups are necessary to confirm that the prescribed dose is still appropriate. During pregnancy, doses ofthyroxine usually increase; as a person ages, doses usually decrease. Overtreatment of hypothyroidism with thyroid hormone can result in bone loss. Graves' disease is treated with antithyroid drugs to prevent the thyroid gland from manufacturing thyroid hormone.

Epidemiological Overview

Understanding, preventing, and managing chronic cone- ditions are important steps for maintaining satisfactory health. The prevalence of chronic conditions is difficult to ascertain because of differences and inconsistencies in diagnostic criteria and the lack of national reporting symptoms. Many chronic diseases affect women more often than they do men. I Of the 10 million Americans estimated to have osteo- porosis, 8 million are women and 2 million are men. I Osteoarthritis and rheumatoid arthritis, two of the most common health problems in the United States, are far more prevalent in women than in men. I Diabetes affects 26 million people in the United States. Women make up almost half of this total; about 11% of adult U.S. women have diabetes. I About 75% of the people with autoimmune diseases are women. These diseases typically appear during women's childbearing years. Table 11.1 shows the disproportionate female—to—male ratios in autoimmune diseases. Reproductive hormones appear to affect when (and how often) these diseases appear: Many autoimmune diseases improve during pregnancy and then reappear after delivery, appear after menopause, or get worse during pregnancy. I Women are more likely than men to develop Alzheimer's disease, primarily because women live longer men and the likelihood of developing Alzheimer's disease increases as a person ages. Women are also likely to be the primary caregivers for their parents, spouses, and other family members with the disease.