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Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay ideal cholesterol hdl ratio discount tricor 160mg free shipping, an increased risk of respiratory problems for the baby cholesterol shrimp squid order tricor canada, and greater complications in subsequent pregnancies cholesterol levels range canada order genuine tricor, including uterine rupture and placental implantation problems what cholesterol medication has the least side effects discount tricor 160mg on line. Cesarean deliv ery on maternal request should not be performed before a gestational age of 39 weeks has been determined cholesterol levels vary day to day order tricor overnight delivery, utilizing the most accurate gestational dating criteria available cholesterol hdl ratio emedicine 160mg tricor fast delivery. Maternal request for cesarean delivery should not be moti vated by the unavailability of effective pain management. This form of delivery is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for gravid hysterectomy increase with each cesarean delivery. In women undergoing scheduled cesarean delivery, whether primary or repeat, the presence of fetal heart tones should be confirmed and documented before the surgery. There is insufficient evidence to warrant further fetal moni toring before scheduled cesarean deliveries in low-risk patients. However, in women requiring unscheduled cesarean delivery, fetal surveillance should con tinue until abdominal sterile preparation has begun. Antimicrobial prophylaxis is recommended for all cesarean deliveries, unless the patient is already receiving appropriate antibiotics (eg, for chorio amnionitis), and should be administered within 60 minutes of the start of the cesarean delivery. When this is not possible (eg, need for emergent delivery), prophylaxis should be administered as soon as possible. Given that cesarean delivery approximately doubles the risk of venous thromboembolism (although in the otherwise normal patient, the risk still remains low: approximately 1 per 1,000), placement of pneumatic compression devices before cesarean delivery is recommended for all women not already receiving thromboprophylaxis. However, cesarean delivery in the emergency setting should not be delayed because of the timing necessary to implement thromboprophylaxis (see also ?Deep Vein Thrombosis and Pulmonary Embolism in Chapter 7). When the cesarean delivery is performed for fetal indications, consideration should be given to sending the placenta for pathologic evaluation. Multiple Gestation the following factors should be considered in the delivery of multiple gestations. Labor and delivery?Confirmation of fetal presentations by ultrasound examination is indicated on admission. Pediatric and anesthesia personnel should be immediately available, as well as blood bank services. Although cesarean delivery frequently is used for three or more fetuses, there are reports suggesting that vaginal delivery of triplet gestations, in appropriately monitored patients, is safe. In general, twins presenting as vertex?vertex should be anticipated to deliver vagi nally. If the presenting twin is nonvertex, cesarean delivery is preferred by most physicians. In vertex?nonvertex presentations, vaginal delivery of twin B in the nonvertex presentation is a reasonable option. Intrapartum and Postpartum Care of the Mother 195 Support Persons in the Delivery Room Childbirth is a momentous family experience. Obstetric providers willingly should provide opportunities for those accompanying and supporting the woman giving birth to be present. These support persons must be informed about requirements for safety and must be willing to follow the directions of the obstetric staff concerning behavior in the delivery room. They also should understand the normal events and procedures in the labor and delivery area. They must conform to the dress code required of personnel in attendance in a delivery room. Both the obstetrician and the patient should consent to the presence of fathers, partners, or other support persons in the delivery room. Support persons should realize that their major function is to provide psycho logic support to the mother during labor and delivery. Continuous support during labor from physicians, midwives, nurses, doulas, or lay individuals may be beneficial for women. Continuous presence of a support person appears to reduce the likelihood of medication for pain relief, operative vaginal delivery, cesarean delivery, and 5-minute Apgar scores less than 7. The judgment of the obstetric staff, the individual obstetrician, the anesthe siologist, and pediatric support personnel, as well as the policies of the hospital, determines whether support persons may be present at a cesarean delivery. Postpartum Maternal Care Immediate Postpartum Maternal Care Monitoring of maternal status postpartum is dictated in part by the events of the delivery process, the type of anesthesia or analgesia used, and the complica tions identified. Postanesthesia pain management should be guided by protocols established by the anesthesiologists and obstetricians in concert. Blood pressure levels and pulse should be monitored at least every 15 minutes for 2 hours, and more frequently and for longer duration if complications are encountered. Nursing staff assigned to the delivery and immediate recovery of a woman should have no other obligations. Discharge from the delivery room, which may involve recovery from an anesthetic, should be at the discretion of the physician or certified nurse?midwife or the anesthesiologist in charge. After cesarean delivery, policies for postanesthesia care should not differ from those applied to nonobstetric surgical patients receiving major anesthesia. Policy should ensure that a physician is available in the facility, or at least is nearby, to manage anesthetic complications and provide cardiopul monary resuscitation for patients in the postanesthesia care unit. The patient should be discharged from the recovery area only at the discretion of, and after communication between, the attending physician or a certified nurse midwife, anesthesiologist, or certified registered nurse anesthetist in charge. Vital signs and additional signs or events should be monitored and recorded as they occur. Subsequent Postpartum Care the medical and nursing staff should cooperatively establish specific postpar tum policies and procedures. In the postpartum period, staff should help the woman learn how to care for her own general needs and those of her neonate, and should identify potential problems related to her general health. If routine post partum orders are used, they should be printed or written in the medical record, reviewed and modified as necessary for the particular patient, and signed by the obstetric caregiver before the patient is transferred to the postpartum unit. When a labor, delivery, and recovery room is used, the same guidelines should apply. Bed Rest, Ambulation, and Diet It is important for the new mother to sleep, regain her strength, and recover from the effects of any analgesic or anesthetic agents that she may have received during labor. In the absence of complications, she may have a regular diet as soon as she wishes. Because early ambulation has been shown to decrease the incidence of subsequent thrombophlebitis, the mother should be encouraged to walk as soon as she feels able to do so. If the patient has an intravenous line in place, her fluid and hemodynamic status should be Intrapartum and Postpartum Care of the Mother 197 evaluated before it is removed. Urogenital Care Traditional teaching includes that the patient should be taught to cleanse the vulva from anterior vulva to perineum and anus rather than in the reverse direc tion. Orally administered analgesics often are required and usually are sufficient for relief of discomfort from episiotomy or repaired lac erations. Pain that is not relieved by such medication suggests hematoma for mation and mandates a careful examination of the vulva, vagina, and rectum. Beginning 24 hours after delivery, moist heat in the form of a warm sitz bath may reduce local discomfort and promote healing. Often women have difficulty voiding immediately after delivery, possibly because of trauma to the bladder during labor and delivery, regional anesthesia, or vulvar?perineal pain and swelling. In addition, the diuresis that often follows delivery can distend the bladder before the patient is aware of a sensation of a full bladder. To ensure adequate emptying of the bladder, the patient should be checked frequently during the first 24 hours after delivery, with particular atten tion to displacement of the uterine fundus and any indication of the presence of a fluid-filled bladder above the symphysis. Although every effort should be made to help the patient void spontaneously, catheterization may be necessary. If the patient continues to find voiding difficult, use of an indwelling catheter is preferable to repeated catheterization. The woman who chooses not to breastfeed should be reassured that milk production will abate over the first few days after delivery if she does not breastfeed. During the stage of engorgement, the breasts may become painful and should be supported with a well-fitting brassiere. Women who do not wish to breastfeed should be encour aged to avoid nipple stimulation and should be cautioned against continued manual expression of milk. This is best addressed by administering the medications on an as-needed basis according to postpartum orders. Most mothers experience considerable pain in the first 24 hours after cesarean delivery. Although at one time pain most often was treated by intramuscular injections of narcotics, newer techniques, such as spinal or epidural opiates, patient-controlled epidural or intravenous analgesia, and potent oral analgesics, provide better pain relief and greater patient satisfaction. Regardless of the route of administration, opioids potentially can cause respiratory depression and decrease intestinal motility. Therefore, adequate supervision and monitoring should be ensured for all post partum patients receiving these drugs. Postpartum Immunizations Attention should be given to maternal immunizations before hospital discharge. Likewise, a patient who is identified as susceptible to rubella virus infection should receive the rubella vaccine in the postpartum period. In addition, women who are susceptible to varicella should be offered varicella vaccination before discharge. During the flu season, women who were not vaccinated antepartum should be offered the seasonal flu vaccine before discharge. A woman who is unsensitized and Rh D-negative and who gives birth to a neonate who is Rh D-positive or Du-positive (ie, weak Rh positive) should receive 300 micrograms of anti-D immune globulin postpartum, ideally within 72 hours, even when anti-D immune globulin has been administered in the antepartum period. No further administration of anti-D immune globulin is necessary when the infants of Rh D-negative women are also Rh D-negative. A shorter hospital stay may be considered if the infant does not require continued hospitalization. When the physician and the mother want a shortened hospital stay, the following minimal criteria should be met. The medical and nursing staff should be sensitive to potential problems associated with shortened hospital stays and should develop mechanisms to 200 Guidelines for Perinatal Care address patient questions that arise after discharge. With a shortened hospital stay, a home visit or follow-up telephone conference by a health care provider, such as a lactation nurse, within 48 hours of discharge is encouraged. Postpartum Nutritional Guidelines Postnatal dietary guidelines are similar to those established during pregnancy (see also Chapter 5). The minimal caloric requirement for adequate milk production in a woman of average size is 1,800 kcal per day. In general, an additional 500 kcal of energy daily is recommended throughout lactation. A balanced, nutritious diet will ensure both the quality and the quantity of the milk produced without depletion of maternal stores. Fluid intake by the mother is governed by thirst (see also ?Breastfeeding in Chapter 8). Mothers at nutri tional risk should be given a multivitamin supplement with particular emphasis on calcium and vitamin B12 and vitamin D (see also Chapter 5). Maternal postpartum weight loss can occur at a rate of 2 lb per month without affecting lactation. On average, a woman will retain 2 lb more than her prepregnancy weight at 1 year postpartum. There is no relationship between body mass index or total weight gain and weight retention. Residual postpartum retention of weight gained during pregnancy that results in obesity is a concern. Special attention to lifestyle, including exercise and eating habits, will help these women return to a normal body mass index. Postpartum Considerations ^ Before discharge, the mother should receive information about the following normal postpartum events. Care of the breasts, perineum, and bladder Intrapartum and Postpartum Care of the Mother 201. Signs of complications (eg, temperature elevation, chills, leg pains, episiotomy or wound drainage, or increased vaginal bleeding) the length of convalescence that the patient can expect, based on the type of delivery, also should be discussed. For women who have had a cesarean delivery, additional precautions may be appropriate, such as wound care and temporary abstinence from lifting objects heavier than the newborn and from driving motor vehicles. The earliest time at which coitus may be resumed safely after childbirth is unknown. Although a common recommendation is that sexual activity should be delayed until 6 weeks postpartum, there are no data to direct this statement. Sexual difficulties that are common in the early months after childbirth should be discussed. Healing at the episiotomy site can cause the woman some discomfort during intercourse within the first year following delivery. At the time of discharge, the family should be given the name of the person to contact if questions or problems arise for either the mother or the newborn. Arrangements should be made for a follow-up examination and specific instruc tions conveyed to the woman, including when contact is advisable. In general, the following points should be reviewed with the mother or, preferably, with both parents; specific information to be conveyed is discussed within this section. Immediate needs of the newborn (eg, feeding methods and environmen tal supports) 202 Guidelines for Perinatal Care. Feeding techniques; skin care, including umbilical cord care; tempera ture assessment and measurement with a thermometer; and assessment of neonatal well-being and recognition of illness. Roles of the obstetrician, pediatrician, and other members of the health care team concerned with the continuous medical care of the mother and the newborn. Importance of maintaining newborn immunization, beginning with an initial dose of the hepatitis B virus vaccine. Postpartum Contraception ^161^291 Discussion of contraceptive options and prompt initiation of a method should be a primary focus of routine antenatal and postpartum care. The benefits of child spacing include decreases in preterm delivery and perinatal mortal ity, and most women wish to avoid pregnancy for at least several months, if not considerably longer, after delivering a baby.

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In addition cholesterol levels different units purchase 160 mg tricor visa, a greater proportion of patients in infliximab groups demonstrated sustained response and sustained remission than in the placebo groups (Table 5) cholesterol levels effects body purchase 160mg tricor fast delivery. Of patients on corticosteroids at baseline cholesterol test results explained australia buy tricor without prescription, greater proportions of patients in groups treated with infliximab were in clinical remission and able to discontinue corticosteroids at Week 30 compared with the patients in the placebo treatment groups (22% in infliximab treatment groups vs cholesterol emboli in eyes definition order tricor. The infliximab-associated response was generally similar in the 5 mg/kg and 10 mg/kg dose groups cholesterol young adults buy tricor 160 mg fast delivery. Patients enrolled had a median age of 51 years with a median disease duration of 0 cholesterol chart of meat 160mg tricor with visa. More patients treated with infliximab reached a major clinical response than placebo-treated patients (Table 7). The inhibition of progression of structural damage was observed at 54 weeks (Table 9) and maintained through 102 weeks. Patients were between 18 and 74 years of age, and had ankylosing spondylitis as defined by the modified New 4 York criteria for Ankylosing Spondylitis. Doses of 5 mg/kg of infliximab or placebo were administered intravenously at Weeks 0, 2, 6, 12 and 18. Improvement was observed at Week 2 and maintained through Week 24 (Figure 3 and Table 10). Results of this study were similar to those seen in a multicenter double-blind, placebo-controlled study of 70 patients with ankylosing spondylitis. During the 24-week double blind phase, patients received either 5 mg/kg infliximab or placebo at Weeks 0, 2, 6, 14, and 22 (100 patients in each group). At Week 16, placebo patients with <10% improvement from baseline in both swollen and tender joint counts were switched to infliximab induction (early escape). Similar responses were seen in patients with each of the subtypes of psoriatic arthritis, although few patients were enrolled with the arthritis mutilans and spondylitis with peripheral arthritis subtypes. At Week 24, patients treated with infliximab had less radiographic progression than placebo-treated patients (mean change of -0. Patients treated with infliximab also had less progression in their erosion scores (-0. The patients in infliximab group demonstrated continued inhibition of structural damage at Week 54. Most patients showed little or no change in the vdH-S score during this 12 month study (median change of 0 in both patients who initially received infliximab or placebo). More patients in the placebo group (12%) had readily apparent radiographic progression compared with infliximab group (3%). Patients with guttate, pustular, or erythrodermic psoriasis were excluded from these studies. No concomitant anti-psoriatic therapies were allowed during the study, with the exception of low-potency topical corticosteroids on the face and groin after Week 10 of study initiation. At Week 24, the placebo group crossed over to infliximab induction therapy (5 mg/kg), followed by maintenance therapy every 8 weeks. Patients originally randomized to infliximab continued to receive infliximab 5 mg/kg every 8 weeks through Week 46. Seventy-one percent of patients previously received systemic therapy, and 82% received phototherapy. At Week 16, the placebo group crossed over to infliximab induction therapy (5 mg/kg), followed by maintenance therapy every 8 weeks. Fifty-five percent of patients previously received systemic therapy, and 64% received a phototherapy. These patients were randomized to receive either placebo or infliximab at doses of 3 mg/kg or 5 mg/kg at Weeks 0, 2, and 6. Treatment success, defined as ?cleared or ?minimal, consisted of none or minimal elevation in plaque, up to faint red coloration in erythema, and none or minimal fine scale over <5% of the plaque. Overall lesions were graded with consideration to the percent of body involvement as well as overall induration, scaling, and erythema. Treatment success, defined as ?clear or ?excellent, consisted of some residual pinkness or pigmentation to marked improvement (nearly normal skin texture; some erythema may be present). In addition, in a subset of patients who had achieved a response at Week 10, maintenance of response appears to be greater in patients who received infliximab every 8 weeks at the 5 mg/kg dose. See latest Centers for Disease Control guidelines and recommendations for tuberculosis testing in immunocompromised patients. Biannual radiographic assessments of hands and feet in a three-year prospective follow-up of patients with early rheumatoid arthritis. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. Instruct patients of the importance of contacting their doctors if they develop any symptoms of an infection, including tuberculosis and reactivation of hepatitis B virus infections. Advise patients to report any symptoms of a cytopenia such as bruising, bleeding or persistent fever. If you do not know if you have lived in an area where histoplasmosis, coccidioidomycosis, or blastomycosis is common, ask your doctor. If your baby receives a live vaccine within 6 months after birth, your baby may develop infections with serious complications that can lead to death. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Liver Injury In rare cases, some patients taking infliximab products have developed serious liver problems. Tell your doctor if you o have a fever that does not go away o look very pale o bruise or bleed very easily Nervous System Disorders In rare cases, patients taking infliximab products have developed problems with their nervous system. Signs of an allergic reaction can include: o hives (red, raised, itchy patches of skin) o high or low blood pressure o difficulty breathing o fever o chest pain o chills Some patients treated with infliximab products have had delayed allergic reactions. The delayed reactions occurred 3 to 12 days after receiving treatment with infliximab products. Tell your doctor if you develop red scaly patches or raised bumps on the skin that are filled with pus. The side effects that happened more in children were: anemia (low red blood cells), leukopenia (low white blood cells), flushing (redness or blushing), viral infections, neutropenia (low neutrophils, the white blood cells that fight infection), bone fracture, bacterial infection and allergic reactions of the breathing tract. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechani cal, photocopying, recording, or otherwise, without prior written permission from the publisher. Enders for 12 years, and together, they developed the attenuated measles virus vaccine, which was licensed in the United States in 1963 and which has resulted in a dramatic decline in the incidence of measles. Once the measles vaccine was proven to be effective domestically, Sam was eager to see its suc cess taken globally, and currently it is used worldwide. By 2011, more than a billion chil dren had received the measles vaccine as a key part of the initiative to eliminate measles worldwide. In addition to his investigations of measles, Sam has been involved in studies of smallpox, polio, rubella, infuenza, pertussis, and Haemophilus infuenzae type b vaccines. He is a giant in the feld of immunizations and has served on virtually every committee or panel in the United States and internationally dealing with vaccine development, licen sure, and policy. Sam served as Chairman of the Department of Pediatrics at Duke University School of Medicine from 1968 to 1990. Davison Professor of Pediatrics from 1972 to 1997, and he currently is the Wilburt C. During his time at Duke, Sam has inspired countless medical stu dents, pediatric residents, and infectious diseases fellows with his passion for clinical excel lence, knowledge both in the lecture hall and at the bedside, compassion for ill children, and wisdom as mentor and counselor. He has an enviable memory, both for medical facts and for names and attributes of his generation of ?medical children, and he often is seen at meetings giving handshakes, hugs, smiles, and personal greetings. Geme Award from the Federation of Pediatric Organizations, the Bristol Award and a Society Citation from the Infectious Diseases Society of America, the Howland Award from the American Pediatric Society, the Gold Medal from the Albert Sabin Vaccine Institute, the Alfred I. In addition, he has been elected to the Institute of Medicine of the National Academy of Sciences. Sam and Cathy raised 8 sons and daughters and now share the joys of spend ing time with their many grandchildren. Sam is devoted to his family, his students, his patients, and his friends and is a true gentleman and scholar. Sam Katz has left a huge mark on the feld of pediatrics and vaccinology and is a giant of 20th century medicine. This edition of the Red Book is dedicated to Sam to thank him on behalf of all the children and pediatricians whose lives are better through his contributions. With the limited time available to the practitioner, the ability to quickly obtain up-to-date infor mation about new vaccines and vaccine recommendations, emerging infectious diseases, new diagnostic modalities, and treatment recommendations is essential. Another important resource is the visual library of Red Book Online, which has been updated and expanded to include more images of infectious diseases, examples of classic radiologic and other fndings, and recent epidemiology of infectious diseases. The Committee on Infectious Diseases relies on information and advice from many experts, as evidenced by the lengthy list of contributors to Red Book. Most important to the success of this edition is the dedication and work of the edi tors, whose commitment to excellence is unparalleled. As noted in previous editions of the Red Book, some omissions and errors are inevi table in a book of this type. This edition of the Red Book is based on information available as of February 2012. Information is provided in hard copy and as digital versions, which can be downloaded to mobile devices and contain links to supplemental information, including visual images, graphs, maps, and tables. Seemingly unanswerable scientifc questions, the complexity of medical practice, ongoing innovative technology, continuous new information, and inevitable differences of opinion among experts all are addressed when preparing the Red Book. In some cases, other committees and experts may differ in their interpretation of data and resulting recommendations. In certain instances, no single recommendation can be made because several options for management are equally acceptable. In making recommendations in the Red Book, the committee acknowledges differences in viewpoints by use of the phrases ?most experts recommend. Inevitably in clinical practice, questions arise that cannot be answered easily on the basis of currently available data. For many conditions, an expert in the feld of infectious diseases should be consulted. Through this process of lifelong learning, the committee seeks to provide a practical and authoritative guide for physicians and other health care professionals in their care of infants, children, and adolescents. However, this list only begins to cover the many in depth changes that have occurred in each chapter and section. New data inevitably will outdate current information in the Red Book, so health care professionals need to remain informed of ongoing developments and resulting changes in recommendations. Throughout the Red Book, Web site addresses enable rapid access to new information. When using antimicrobial agents, physicians should review the package inserts (product labels) prepared by manufacturers, particularly for information concerning contraindications and adverse events. No attempt has been made in the Red Book to provide this information, because it is available readily in the Physicians Desk Reference, online ( As in previous editions of the Red Book, recommended dosage schedules for antimicrobial agents are provided (see Section 4, Antimicrobial Agents and Related Therapy) and may differ from those of the manufac turer as provided in the package insert. This book could not have been prepared without the dedicated professional compe tence of many people. Special appreciation is given to Tanya Lennon, assistant to the editor, for her work, patience, and support. I thank Mimi for always being there and for her patience, understanding, and never-ending support. Of special note is the person to whom this edition of the Red Book is dedicated, Samuel L. Throughout the Red Book, the number of Web sites where additional current and future information can be obtained has increased. All Web sites are in bold type for ease of reference, and all have been verifed for accuracy and accessibility. Direct links to visual images have been added throughout the electronic version of the Red Book. These include images of clinical manifestations, maps showing geo graphic locations of specifc diseases, graphs and tables of disease rates, and micro biologic fndings. Standardized approaches to disease prevention through immunizations, antimicro bial prophylaxis, and infection-control practices have been updated throughout the Red Book. Reference to use of tetracycline and fuoroquinolone agents in children has been standardized throughout the book, with reference to a standardized approach to use in children. Policy updates released after publication of this edition of the Red Book will be posted on Red Book Online. The table includes hepatitis A, hepatitis B, invasive pneumococcal disease, rotavirus hospitalizations, and varicella. Web sites for access to Interactive Web-based immunization schedulers for children, adolescents, and adults have been added. Eight vaccines covered by the Vaccine Injury Compensation Program were reviewed, using 158 causality conclusions. The Allergic Reactions to Egg Protein section has been updated to state that tri valent inactivated infuenza vaccine is well tolerated by nearly all recipients who have an egg allergy. The approach to vaccine hesitant parents has been updated and Web sites where educational material that can be provided to parents have been added. In the Pregnancy section, recommendations for immunization of pregnant women with infuenza and Tdap vaccines have been updated. Other vaccines, including yel low fever vaccine, with potential use in pregnancy, are reviewed.

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Delayed onset of sleep could be the result of worry and anxiety during midlife cholesterol levels by age purchase tricor overnight, and improvements in those areas should improve sleep cholesterol questions cheap tricor 160mg line. Demographic Sleep Less than 7 hours According to a 2016 National Single Mothers 43 determination of cholesterol in eggs discount tricor amex. Sleep deprivation suppresses immune responses that fight off infection xanthelasma/ cholesterol eyelid deposits cheap tricor 160 mg mastercard, and can lead to obesity cholesterol levels european purchase tricor online now, memory impairment cholesterol medication and gout cheap tricor 160mg overnight delivery, and hypertension (Ferrie et al. Insufficient sleep is linked to an increased risk for colon cancer, breast cancer, heart disease and type 2 diabetes (Pattison, 2015). A lack of sleep can increase stress as cortisol (a stress hormone) remains elevated which keeps the body in a state of alertness and Source hyperarousal which increases blood pressure. During deep sleep a growth hormone is released which stimulates protein synthesis, breaks down fat that supplies energy, and stimulates cell division. Results indicated that irregular sleep schedules, including highly variable bedtimes and staying up much later than usual, are associated in midlife women with insulin resistance, which is an important indicator of metabolic health, including diabetes risk. By disrupting circadian timing, bedtime variability may impair glucose metabolism and energy homeostasis. Exercise, Nutrition, and Weight the impact of exercise: Exercise is a powerful way to combat the changes we associate with aging. Exercise builds muscle, increases metabolism, helps control blood sugar, increases bone density, and relieves stress. Unfortunately, fewer than half of midlife adults exercise and only about 20 percent exercise frequently and strenuously enough to achieve health benefits. Many stop exercising soon after they begin an exercise program, particularly those who are very overweight. The best exercise programs are those that are engaged in regularly, regardless of the activity. A well-rounded program that is easy to follow includes walking and weight training. Having a safe, enjoyable place to walk can make the difference in whether or not someone walks regularly. Weight lifting and stretching exercises at home can also be part of an effective program. Walking, jogging, cycling, or swimming can release the tension caused by stressors. Promoting exercise for the 78 million "baby boomers" may be one of the best ways to reduce health care costs and improve quality of life (Shure & Cahan, 1998). According to the Office of Disease Prevention and Health Promotion (2008), the following are exercise guidelines for adults. Aerobic activity should occur for at least 10 minutes and preferably spread throughout the week. However, eating less does not typically mean eating right and people often suffer vitamin and mineral deficiencies as a result. All adults need to be especially cognizant of the amount of sodium, sugar, and fat they are ingesting. The American Heart Association (2016) reports that the average sodium intake among Americans is 3440mg per day. High sodium levels in the diet is correlated with increased blood pressure, and its reduction does show corresponding drops in blood pressure. Adults with high blood pressure are strongly encouraged to reduce their sodium intake to 1500mg (U. Excess Fat: Dietary guidelines also suggests that adults should consume less than 10 percent of calories per day from saturated fats. The American Heart Association (2016) says optimally we should aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat. Diets high in fat not only contribute to weight gain, but have been linked to heart disease, stroke, and high cholesterol. Excess sugar not only contributes to weight gain, but diabetes and other health problems. Men tend to gain fat on their upper abdomen and back, while women tend to gain more fat on their waist and upper arms. The calories consumed are combined with oxygen to release the energy needed to function (Mayo Clinic, 2014b). People who have more muscle burn more calories, even at rest, and thus Source have a higher metabolism. To compensate, midlife adults have to increase their level of exercise, eat less, and watch their nutrition to maintain their earlier physique. Obesity: As discussed in the early adulthood chapter, obesity is a significant health concern for adults throughout the world, and especially America. Being overweight is associated with a myriad of health conditions including diabetes, high blood pressure, and heart disease. The study looked at 1,394 men and women who were part of the Baltimore Longitudinal Study of Aging. Scientists speculate that fat cells may produce harmful chemicals that promote inflammation in blood vessels throughout the body, including in the brain. Concluding Thoughts: Many of the changes that occur in midlife can be easily compensated for, such as buying glasses, exercising, and watching what one eats. However, the percentage of 323 middle adults who have a significant health concern has increased in the past 15 years. The study compared the health of middle-aged Americans (50-64 years of age) in 2014 to middle-aged Americans in 1999. Results indicated that in the past 15 years the prevalence of diabetes has increased by 55% and the prevalence of obesity has increased by 25%. At the state level, Massachusetts ranked first for healthy seniors, while Louisiana ranked th th last. Lifestyle has a strong impact on the health status of midlife adults, and it becomes important for midlife adults to take preventative measures to enhance physical well-being. Those midlife adults who have a strong sense of mastery and control over their lives, who engage in challenging physical and mental activity, who engage in weight bearing exercise, monitor their nutrition, receive adequate sleep, and make use of social resources are most likely to enjoy a plateau of good health through these years (Lachman, 2004). Climacteric the climacteric, or the midlife transition when fertility declines, is biologically based but impacted by the environment. The average age of menopause is approximately 51, however, many women begin experiencing symptoms in their 40s. These symptoms occur during perimenopause, which can occur 2 to 8 years before menopause (Huang, 2007). A woman may first begin to notice that her periods are more or less frequent than before. After a year without menstruation, a woman is considered menopausal and no longer capable of reproduction. Symptoms: the symptoms that occur during perimenopause and menopause are typically caused by the decreased production of estrogen and progesterone (North American Menopause Society, 2016). Additionally, the declining levels of estrogen may make a woman more susceptible to environmental factors and stressors which disrupt sleep. It often produces sweat and a change of temperature that can be disruptive to sleep and comfort levels. Unfortunately, it may take time for adrenaline to recede and allow sleep to occur again (National Sleep Foundation, 2016). The loss of estrogen also affects vaginal lubrication which diminishes and becomes waterier and can contribute to pain during intercourse. Estrogen is also important for bone formation and growth, and decreased estrogen can cause osteoporosis resulting in decreased bone mass. Depression, irritability, and weight gain are often associated with menopause, but they are not menopausal (Avis, Stellato & Crawford, 2001; Rossi, 2004). Weight gain can occur due to an increase in intra-abdominal fat followed by a loss of lean body mass after menopause (Morita et al. Depression and mood swings are more common during menopause in women who have prior histories of these conditions rather than those who have not. Additionally, the incidence of depression and mood swings is not greater among menopausal women than non-menopausal women. Hormone Replacement Therapy: Concerns about the effects of hormone replacement has changed the frequency with which estrogen replacement and hormone replacement therapies have been prescribed for menopausal women. Most women do not have symptoms severe enough to warrant estrogen or hormone replacement therapy. If so, they can be treated with lower doses of estrogen and monitored with more frequent breast and pelvic exams. These include avoiding caffeine and alcohol, eating soy, remaining sexually active, practicing relaxation techniques, and using water-based lubricants during intercourse. Menopause and Ethnicity: In a review of studies that mentioned menopause, symptoms varied greatly across countries, geographic regions, and even across ethnic groups within the same region (Palacios, Henderson, & Siseles, 2010). After controlling for age, educational level, general health status, and economic stressors, white women were more likely to disclose symptoms of depression, irritability, forgetfulness, and headaches compared to women in the other racial/ethnic groups. African American women experienced more night sweats, but this varied across research sites. Finally, Chinese American and Japanese American reported fewer menopausal symptoms when compared to the women in the other groups. Overall, the Chinese and Japanese group reported the fewest symptoms, while 325 white women reported more mental health symptoms and African American women reported more physical symptoms. Further, the prevalence of language specific to menopause is an important indicator of the occurrence of menopausal symptoms in a culture. Hmong tribal women living in Australia and Mayan women report that there is no word for "hot flashes" and both groups did not experience these symptoms (Yick-Flanagan, 2013). When asked about physical changes during menopause, the Hmong women reported lighter or no periods. They also reported no emotional symptoms and found the concept of emotional difficulties caused by menopause amusing (Thurston & Vissandjee, 2005). Similarly, a study with First Nation Source women in Canada found there was no single word for "menopause" in the Oji-Cree or Ojibway languages, with women referring to menopause only as "that time when periods stop" (Madden, St Pierre-Hansen & Kelly, 2010). While some women focus on menopause as a loss of youth, womanhood, and physical attractiveness, career-oriented women tend to think of menopause as a liberating experience. Japanese women perceive menopause as a transition from motherhood to a more whole person, and they no longer feel obligated to fulfill certain expected social roles, such as the duty to be a mother (Kagawa-Singer, Wu, & Kawanishi, 2002). Overall, menopause signifies many different things to women around the world and there is no typical experience. Erectile dysfunction refers to the inability to achieve an erection or an inconsistent ability to achieve an erection (Swierzewski, 2015). Plaque is made up of fat, cholesterol, calcium and other substances found in the blood. If testosterone levels decline significantly, it is referred to as andropause or late-onset hypogonadism. Identifying whether testosterone levels are low is difficult because individual blood levels vary greatly. Low testosterone is also associated with medical conditions, such as diabetes, obesity, high blood pressure, and testicular cancer. Most men with low testosterone do not have related problems (Berkeley Wellness, 2011). For women, decreased sexual desire and pain during vaginal intercourse because of menopausal changes have been identified (Schick et al. A woman may also notice less vaginal lubrication during arousal which can affect overall pleasure (Carroll, 2016). Men may require more direct stimulation for an erection and the erection may be delayed or less firm (Carroll, 2016). As previously discussed men may experience erectile dysfunction or experience a medical conditions (such as diabetes or heart disease) that impact sexual functioning. Couples can continue to enjoy physical intimacy and may engage in more foreplay, oral sex, and other forms of sexual expression rather than focusing as much on sexual intercourse. Risk of pregnancy continues until a woman has been without menstruation for at least 12 months, however, and couples should continue to use contraception. People continue to be at risk of contracting sexually transmitted infections, such as genital herpes, chlamydia, and genital warts. Practicing safe sex is important at any age, but unfortunately adults over the age of 40 have the lowest rates of condom use (Center for Sexual Health Promotion, 2010). Hopefully, when partners understand how aging affects sexual expression, they will be less likely to misinterpret these changes as a lack of sexual interest or displeasure in the partner and more able to continue to have satisfying and safe sexual relationships. Brain Functioning the brain at midlife has been shown to not only maintain many of the abilities of young adults, but also gain new ones. Some individuals in middle age actually have improved cognitive functioning (Phillips, 2011). The brain continues to demonstrate plasticity and rewires itself in middle age based on experiences. Research has demonstrated that older adults use more of their brains than younger adults. In fact, older adults who perform the best on tasks are more likely to demonstrate bilateralization than those who perform worst. Additionally, the amount of white matter in the brain, which is responsible for forming connections among neurons, increases into the 50s before it declines. Emotionally, the middle aged brain is calmer, less neurotic, more capable of managing emotions, and better able to negotiate social situations (Phillips, 2011).

Diseases

References