Chapter 12
Social and preventative medicine
By the end o this chapter you should be able to:
a discuss the causative relationships among diet,
obesity and diabetes;
b describe the eects o ats on the
cardiovascular
cardiova scular system, including reerence to
plaque ormation, atherosclerosis, coronary
heart disease, hypertension and strok
stroke;
e;
c investigate the immediate eects o exercise on
investigate
the body;
d discuss the consequences o exercise on
the body and the benets o maintaining
a physically t body, with reerence to the
prevention o chronic diseases, VO
VO2 max and
cardiac eciency;
Diet and health
What a person eats, and how much they eat, can
have
ha ve a very large eect on their health. Eating a
balanced diet is a good way to increase the chance
o ha
having
ving a long and healthy lie.
lie. A balanced
diet can be dened as a diet containing all o the
dierent nutrients required by the body, and that
supplies the appropriate amount o energy. Table
12.1 lists the main nutrients that should be present
in the diet, and describes how these nutrients are
used in the body.
SAQ  Obesity results rom consistently eating nutrients
1 a Which o the nutrients listed in Table
Table 12.1 are
organic chemicals?
b Which o the nutrients listed in Table
Table 12.1 can
be used by the body in respiration, to release
energy and make ATP?
244
e describe the mechanisms o inection or AIDS
and dengue ever and their causativ
cau sativee agents,
including the process o inection and the
replication o the disease-causing organisms;
  explain how AIDS and dengue ever are
transmitted;
g assess the impacts o AIDS and dengue ever
regionally,, including reerence to social and
regionally
economic issues;
h discuss the roles o social, economic and
biological actors in the prevention and control
o AIDS and dengue ever.
Obesity
We have already seen how eating too much and
exercising too little can cause a person to become
seriously overweight, and that this greatl
greatly
y increases
the risk o developing Type
Type 2 diabetes (page 187).
A person who is very overweight is said to be
obese. Obesity is sometimes dened as having
a body mass index (BMI) greater than 27. The
ormula or calculating BMI is:
weight in kilograms
(height in metres)2
that contain more energy than the body uses. The
‘spare’ energy
energy is stored in the orm o at, which
builds up as adipose tissue underneath the skin
and around the body organs.
organs. Obesity seriously
increases the risk o developing not only Type
2 diabetes,
diabetes, but also heart disease and arthritis
(Figure 12.1 and Figure 12.2).
 Chapter 12: Social and preventative medicine

Nutrient Function Good ood sources Notes

carboh
carbohyd
ydra
rates
tes providi
prov iding
ng ener
energy
gy,, whic
which
h is bread, rice, carbohydrates include sugars
carbohydrates
released by respiration inside potatoes, pulses and starches; starches are better
body cells (beans, lentils and than sugars because they take
peas), breakast longer to digest and the energy
cereals in them is released more steadily
proteins ormation o ne
new cells and meat, eggs, sh, proteins contain 20 dierent
tissues, and o many important dairy products, amino acids, o which 8 are
substances, including pulses essential in the diet as the body
haemoglobin, collagen and cannot make them rom other
enzymes; can be respired to amino acids
provide energy
lipids making cell membranes, and dairy products, lipids contain several dierent
steroid hormones; provi
providing
ding red meat, oily atty acids,
acids, o which two are
energy when broken down in sh, plant oils essential in the diet; oods
respiration–ats provide twice containing lipids are also
as much energy per gram as important sources o at-soluble
carbohydrates or proteins vitamins
vitamin A making the pigment rhodopsin, meat, egg yolks, daily doses at around 100 times
(at soluble) ound in the rod cells in the eye carrots the recommended daily intake
and essential or vision are toxic
vitamin C making collagen citrus ruits,
(water blackcurrants,
soluble) potatoes
vitamin D or
orma
mati
tion
on o bone
boness and
and te
teet
eth
h dairy
dairy oo
oods
ds,, oi
oilly this vitamin is also made in the
(at soluble) sh, egg yolks skin when exposed to sunlight
iron ormation o haemoglobin meat, beans, shortage o iron in the diet is a
chocolate, common cause o anaemia
shellsh, eggs
calcium bone ormation and blood dairy products, lack o calcium in the diet can
clotting sh increase the risk o osteoporosis

Table 12.1 Nutrients and their roles in the body.

The incidence o obesity has been steadily

increasing. Most people have easy access to as
much ood as they want, and much o this ood is
very ‘energy-dense’–it contains a lot o kilojoules
per gram. This is oten true o ast ood, such as
burgers and ries. On the other side o the coin,
many people do not use up a great deal o energy
each day; we have become much more sedentary,
spending more time sitting and relaxing rather
than walking or playing sport. The combination o 
eating more and exercising less is building up what Figure 12.1 A normal mouse and an obese mouse.
245
 Chapter 12: Social and preventative medicine
Figure 12.2 Obesity is most damaging when
at accumulates around the abdomen. It greatly
increases the risk o developing Type
Type 2 diabetes.
What causes obesity?
There’s no doubt that some people have a
much greater tendency to put on weight than
others. While quite a bit o this can be put
down to environment and liestyle–including
the diet eaten, amount o exercise taken and
straightorward willpower–scientists have long
believed that there is also a strong genetic
infuence on our likelihood o becoming obese.
For example, studies o identical twins show
that they have
have a very high resemblance in their
tendency to become obese, even i they are
brought up in completely dierent envir
environments
onments..
It seems likely that genetic infuences on
obesity are polygenic–that is, there are many
dierent genes that each hahave
ve a small eect.
There are just a ew examples o a single gene
that can have a large eect, but they are very
rare. For example, a two-year-old boy who
weighed almost 30 kg was ound to have a
mutation in a gene that normally codes or a
246
many nutritionists are calling the ‘obesity time
bomb’. The increasing number o people who are
obese now will result in an increasing number o 
people with obesity-related diseases in the uture.
Diet, obesity and diabetes
In Chapter 10, we saw that there are many dierent
risk actors or Type 2 diabetes. The prevalence
o diabetes in the Caribbean is increasing, and–as
people’ss genes are not changing–it appears that
people’
this is due to changes in liestyle.
Obesity is a major risk actor or diabetes (page
187). Some research suggests that, at least in the
West, around 90% o cases o Type 2 diabetes are
caused by being overweight. Worryingly, more
and more children are becoming obese, and this
is believed to be greatly increasing the numbers
o people who are likely to develop diabetes as
they get older. Figure 12.3 shows the change in
the percentages o young people who are obese
in the USA, and a similar situation exists in the
Caribbean.
protein called leptin, which has been linked to
the control o appetite.
The discovery o leptin was rst made in mice,
in 1994. Various strains o mice are kept and
bred in laboratories,
laboratories, and one o these strains is
extremely obese (Figure 12.1). The obese mice
were ound to have a single gene mutation that
prevented them rom making leptin. Leptin
is made in at storage cells, in adipose tissue.
The more at there is, the more leptin is made.
Leptin travels in the blood to all parts o the
body, where it has several dierent target organs.
Among these is the brain–leptin provides an ‘I
am ull’ signal to the brain, suppressing appetite.
As at stores dwindle, less leptin is produced and
the mouse eels hungrier. The obese mice ha h ave no
leptin, so their brains never get a ‘ull’ signal, and
they always eel hungry.
There were high hopes that this discovery
might help to explain obesity in humans.
continued ...

We also produce leptin, and it was thought that
perhaps giving people leptin might suppress
their appetites and help them to lose weight.
But results o trials have not been encouraging.
Leptin may play a role in our desire to eat, but
it isn’t a magic bullet that can reduce obesity.
Indeed, many obese people already have high
levels o leptin in their blood, and it seems
that the problem is more in the way the brain
responds to it than the actual production o  one o the many genes that are proba
leptin by the at cells.
Various other studies have ound potential
candidate genes that might aect the tendency
to put on weight. One o the best studies was
reported in 2007. A group o researchers in
Europe had been looking or a genetic link to
the tendency to develop Type 2 diabetes. They
had screened 2000 people with Type 2 diabetes,
and ound a strong correlation with the presence
o a particular allele called FTO. The link was
so strong that the team decided to expand their
study, and to look not only at diabetes but also
20
15
   % 12–19 year-olds
   /
  e
   t
  a
  r 10
  y
   t
   i
  s
  e
   b
   O
0
1971–1974 1976–1980
Figure 12.3 Change in percentages o young people who are obese (data rom the USA).
Chapter 12: Social and preventative medicine
obesity. They used a huge sample o 38 759
obesity.
people, rom Britain, Italy and Finland. They
ound that people who were heterozygous or
this allele were, on average, 1.2 kg heavier than
people who did not have it. People who were
homozygous or the allele were, on average,
3 kg heavier.
heavier. Around 50 % o people were
heterozygous and 16 % homozygous.
It looks as though this research has identied
probably
bly involved
involved
in determining the likelihood o becoming obese.
There must be many more yet to be discovered.
But we cannot put all the blame on genes. There
is no suggestion that our genes have changed in
the last 50 years, but there is no doubt
d oubt that the
proportion o obese people has increased greatly.
greatly.
This can only be down to liestyle. Some o us
may nd it more dicult than others to keep
our weight down, but we can still take care over
diet and exercise and try to maintain weight at a
healthy level.
Age group
2–5 year-olds
6–11 year-olds
1988–1994 2003–2006
247
 Chapter 12: Social and preventative medicine
Symptoms o diabetes
Studies in the Caribbean indicate that at least 50%
o people with diabetes do not know that they have
it. Every second person who is diagnosed with
diabetes already has developed some complications,
as a result o having the disease or some time but
not being treated or it. There is no doubt that
diagnosing the disease early allows the person to
manage their diabetes successully, and helps them
to maintain a much higher level o health.
Many people have Type 2 diabetes or years
without knowing it. First symptoms can go
unrecognised. The person may eel tired or thirsty
all the time, but as the development o these
symptoms is slow they may just creep up stealthily
and be unnoticed.
An understanding o what is going wrong can
explain these symptoms
symptoms.. Imagine that a diabetic
person eats a meal containing a lot o sugar. As
this is absorbed, blood glucose levels go well abo
above
ve
normal, but the liver and muscle cells are not
alerted and do not
n ot take corrective action.
The very high blood glucose levels mean that
the kidneys (Chapter 8) are not able to stop
glucose being excreted in the urine. Instead o  constant. The patient may need to check their
being stored in the liver as glycogen, much o  blood glucose regularly
the glucose is lost rom the body. Later, when the
glucose in the blood has been used in respiration,
and i the person does not eat again, blood glucose
levels may drop well below normal. The liver cells
have
ha ve not stored any as glycogen, so they cannot
release glucose to bring up the level in the blood.
The person eels very tired and may even become
unconscious.
Having
Ha ving a high blood glucose level is known
as hyperglycaemia. It is usually dened as a level
above
abo ve about 250 mg per 100 cm3 (15 mmol dm−3).
In the short term, hyperglycaemia makes the
person eel unwell. They may have a dry mouth
and blurred vision. They may also eel very thirsty,
because the high concentration o glucose in the
body fuids reduces their water potential; this is
detected by the hypothalam
hypothalamus,us, which sends nerve
impulses to parts o the brain that control eelings
o thirst. The person may be conused. Sometimes
hyperglycaemia is associated with ketoacidosis,
caused by the presence o substances called
248
ketone bodies in the blood. The ketone bodies are
produced rom atty acids in the liver, and can be
used as respiratory substrates. However, in diabetes
they may be produced aster than they are used
and high concentrations o them can be dangerous.
Up to 10% o diabetic people admitted to hospital
with ketoacidosis die.
Having
Ha ving a low blood glucose level is known as
hypoglycaemia. The person eels exceptionally tired
and may become conused and show irrational
behaviour. Hypoglycaemia is not restricted to
people with diabetes. Many
Many normal people can
become mildly hypoglycaemic
hypoglycaemic i they have not
eaten or a while, and be quite unaware that their
mood and behavi
behaviour
our have changed as a result.
However, a person with diabetes is more likely to
suer severe attacks o hypoglycaemia. I caught
early, hypoglycaemia is easily treated by eating
something sugary.
Treating diabetes
As yet, there is no cure or diabetes. The
management o diabetes mellitus revolves
revolves around
keeping blood glucose concentrations reasonably
reasonably
regularly,, which is generally done
with a simple sensor providing a digital readout
(Figure 12.4).
Urine can also be checked or glucose,
glucose, using a
dipstick, or example (Figure 12.5). I the illness is
under control, then there should be no more than
very small amounts o glucose present in urine.
In Type 2 diabetes, a well-controlled diet may
Figure 12.4 Measuring blood glucose
concentration.

Figure 12.5 Measuring glucose concentration in
urine.
be able to keep symptoms at bay. I the patient
is obese, then weight loss through diet and
exercise will be the rst target. It is oten possible
to manage Type 2 diabetes, at least in the early
stages,, through diet alone. The person needs to
stages
eat small meals at reasonably regular intervals,
never fooding their blood with excess glucose and
never allowing blood glucose levels to drop too
low. Polysaccharides are a better carbohydrate
source than sugars, because it takes time or them
to be digested and then absorbed, spreading out
the time over which sugars are absorbed into the
blood and avoiding a sharp ‘spike’ in blood glucose
concentration.
SAQ  that supply the heart muscle with oxygenated
2 Suggest why testing the concentration o  blood. It is the leading cause o death in the
glucose in blood is more useul than testing the
concentration o glucose in urine.
Chapter 12: Social and preventative medicine
SAQ 
3 The graph shows the changes in blood glucose
concentration in a person who ate 50 g o 
carbohydrate
carbohy drate as wholemeal bread, and others
who ate 50 g o carbohy
carbohydrate
drate as lentils and as
soya beans.
a Explain the shape o the curve when bread
was eaten.
b Describe the dierences between this curve
and the ones showing the results ater lentils
and soya beans were eaten.
c Suggest reasons or these dierences.
Diet and heart disease
I you live to be 80 years old, your heart will beat
at least 2.5 billion times. Your lungs will infate and
defate at least 600 million times. Inevitably the
body systems become less ecient as we get older,
older,
but there is a great deal that we can do to help
to keep both the cardiovascular system and the
gaseous exchange system working strongly, even as
we age.
Coronary heart disease, oten abbreviated to
CHD, is a common disorder o the blood vessels
oxygenated
Caribbean (Figure 12.6).
The ability o the cardiac muscle to contract
depends on it receiving a continuous supply o 
249
 Chapter 12: Social and preventative medicine

120
  r
  e
  p heart disease
  s
   h
   t
  a cancers
  e
   d  n
  o
   f   i 80
  o   t
  r   a
   l
  e  u cerebrovascular
cerebrovascular disease (stroke)
   b  p
  o
  m  p diabetes mellitus
  u   0
  n
   /   0
   0
  e   0
   t
illness resulting rom high blood pressure
  r   0
  a 40
   1 HIV / AIDS
  y
   t
   i
   l
  a
   t accidents
  r
  o
   M acute respiratory inection

0
1985 1990 1995 2000

Figure 12.6 The eight leading causes o death in the Caribbean between 1985 and 2000.

oxygen. The muscle uses the oxygen or aerobic
respiration,
respiration, which provides the energy that it uses
or contraction. I the oxygen supply ails,
ails, then
the muscle cannot contract. Heart muscle lacking
oxygen quickly dies.
CHD is caused by atherosclerosis in the
coronary arteries (page 110). Atheroscler
Atherosclerosis
osis is
sometimes known as ‘hardening o the arteries’.
Atherosclerosis
Atherosclerosis can lead to the coronary arteries
becoming blocked. Usually,
Usually, the blockage is due
to the build-up o material inside the artery walls,
which makes the space through which blood can
fow–the lumen–much narrower. Atherosclerosis
SAQ  deposits are known as an atheromatous plaque
4 These questions are about the data in
Figure 12.6.
a What was the major cause o death in the
Caribbean countries in each o the years
shown in the graph?
b Describe the changes in mortality due to
diabetes between 1985 and 2000, and suggest
reasons or these changes.
c Describe the changes in mortality due to
HIV/AIDS between 1985 and 2000, and
suggest reasons or these changes
ch anges..
250
can also occur in other arteries, including those
supplying the brain.
Atherosclerosis develops slowly, and people do
not normally show any symptoms until they are
at least 40 years old. It occurs naturally as part
o the ageing process. However
However,, in some people it
progresses
progr esses more rapidly and this can be due to a
variety o actors that tend to damage the lining
o arteries
arteries.. These include high blood pressure,
pressure, the
presence o harmul chemicals such as those in
tobacco smoke, or low-density lipoproteins (LDLs,
described on pages 252–253). The damage
damage,, and
the attempts by the body to repair itsel, build
up tissue and chemicals in the artery wall. These
(Figure 12.7).
Once the plaque has reduced the lumen o a
coronary artery by 50% or more, the fow o blood
through the artery cannot keep up with the oxygen
requirements o the heart muscle during exercise.
The person experiences pain when exercising,
known as angina. The pain is oten in the let
shoulder,, chest and arm, but or some people also
shoulder
in the neck or the let side o the ace.
Blood clots can orm on and around the plaque.
Such a blood clot is called a coronary thrombosis.
This happens because platelets in the blood come
 Chapter 12: Social and preventative medicine

blood in lumen atheromatous a plaque is rigid

plaque
protective inner 
artery wall normal artery
lining o the artery
wall is elastic
blood clots

damage to wall

1 Part o the lining o the artery
is damaged.
2 Gradually, over time, cells
divide in the artery wall and
there is a build-up o lipids.
3 Exercise or stress can make the
plaque break. Blood enters the
crack. Platelets in the blood are
activated and a clot orms. Part
o the clot may break o.

Figure 12.7 The development o an atheromatous

atheromatous plaque.

into contact with collagen in the artery wall. The
platelets then secrete chemicals that stimulate the
blood to orm a clot.
The blood clot narrow
narrowss the artery even more.
It may break o and get stuck in a smaller vessel.
The part o the heart that is supplied by this blood
vessel stops beating, and some o the muscle cells
may die. This is known as a myocardial inarction
and is an extremely dangerous
dangerous condition.
straight away. I less muscle is aected, the pain
may be less severe, and the patient may wait several
hours beore calling a doctor. Sometimes,
Sometimes, they
may not even realise that they hahave
ve had a minor
inarction, and do nothing. The pain is usually elt
near the centre o the thorax, behind the sternum,
and is described as ‘crushing’ or ‘bursting’.

Myocardial inarction
‘Myo’ means ‘muscle’, and the myocardium is the
muscular wall o the heart. ‘Inarction’ is a term
describing the loss o sucient blood fow to a
tissue to allow it carry out its normal activity
activity..
Around 90% o instances o myocardial inarction
are caused by a coronary thrombosis.
thrombosis.
I the inarction involves a large amount o 
muscle, the person may die almost immediately.
Severe myocardial
myocardial inarction may cause the heart
to stop beating. This is called cardiac arrest (heart
attack) (Figure 12.8). No pulse can be elt, and the
victim rapidly loses consciousness
consciousness.. Figure 12.8 A paramedic applying chest
Others may not lose consciousness, but compressions to get the heart to beat again ater
experience such severe pain that they call or help cardiac arrest.
251
 Chapter 12: Social and preventative medicine

The commonest time o day or acute protein

myocardial
my ocardial inarction is rst thing in the morning, phospholipid
when the patient has just got up. There is another
peak around 5 p.m. Friday is the commonest day cholesterol
o the week or a myocardial inarction,
inarction, and there
are ewer at weekends. No-one really understands
the reasons or these patterns
patterns,, but it is thought that
stress or excitement may be involved, causing a rise
in blood pressure, which may
may rupture a plaque in a
coronary artery.

Diet and coronary heart disease

It seems that every week there is some new advice
about what
what we should and should not do to other lipids
(triglycerides
maintain a healthy heart. For example, in the and steroids)
1950s, people were told to drink milk and eat eggs 10 nm
to stay healthy. Then the health experts decided
that these, and many other ‘atty’ oods, were bad Figure 12.9 Lipoproteins.
or us. Why so much conusion?
The diculty is that we cannot quickly and Cholesterol is not soluble in water, and so it
easily do properly controlled experiments into the cannot be transported in solution in the blood
eect on human health o a particular actor in plasma. It is carried in the blood plasma in the
the diet. There are too many variables involved orm o  lipoproteins –tin
 –tiny
y balls made up o various
that we cannot control. In particular, it seems that lipids, cholesterol and proteins (Figure 12.9).
small dierences in our genes make us respond to a Lipoproteins come in several varieties,
varieties, with
particular type o diet in dierent ways.ways. dierent proportions o protein molecules and
However
Howev er,, there is a great deal o evidence that lipid molecules, including cholesterol.
ch olesterol. Proteins
shows that having
having a high level o cholesterol in tend to be denser than lipids, so the more protein
the blood does increase the risk o suering rom there is, the greater the density o the lipoprotein.
CHD.. What is less clear is the extent to which diet
CHD The lipoproteins are named according to their
aects blood cholesterol levels.
levels. There is evidence densities (Table 12.2).
that eating a diet high in saturated ats can increase HDLs usually pick up cholesterol rom body
your blood cholesterol level and thereor
thereoree your cells that are dying, or whose membranes are
risk. However, other investigations have ailed to being restructured, and transport it to the liver
liver..
nd hard evidence that makes a direct link between LDLs usually carry lipids and cholesterol rom the
the amount o cholesterol that you you eat and your liver to other parts o the body.
body. Chylomicrons are
risk o heart disease. It appears that eating a lot o  ormed in the wall o the ileum rom ats which
saturated
satura ted ats is more harmul than eating a lot o 
cholesterol. High-density a lot o protein
lipoproteins–HDLs and relatively small
HDLs and LDLs amounts o lipids
The structures, properties
properties and unctions o ats Low-density more lipid and less
(lipids) and cholesterol were described in Unit 1, lipoproteins–LDLs protein than HDLs
Chapter 1. Cholesterol is an important constituent
Chylomicrons contain a lot o lipid
o cell membranes. I we do not take in enough in
and very little protein
our diet, then the liver makes cholesterol that
that can
be transported around the body and used by cells. Table 12.2 Types o lipoproteins
lipoproteins..
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 Chapter 12: Social and preventative medicine

have been digested and absorbed. They transport

have
lipids rom the small intestine to the liver
liver..

Cholesterol and CHD

LDLs have
have a tendency to deposit the cholesterol
that they carry in the damaged
d amaged walls o arteries
arteries..
This cholesterol makes up a large proportion o 
an atheromatous plaque (Figure 12.7). There is
a positive link between the level o LDLs in the
blood and the risk o suering rom CHD and
possibly a heart attack.
HDLs, on the other hand, seem actually to
protect against CHD. They remove cholesterol
rom tissues,
tissues, including the tissues in the walls o 
blood vessels.
In the past, health proessionals were simply
simply
concerned about the quantity o cholesterol in the
blood. Now attention has shited to the relative
proportions o ‘good’ HDLs and ‘bad’ LDLs. LDLs. The
higher the proportion o HDLs, the lower the risk
o heart disease.
So how can someone increase their proportion
o HDLs? Diet does have an eect in some people.
A diet that is very rich in saturated ats (ats rom
animal-derived oods) may result in a high LDL
concentration. A person who eats that sort o  arm), resulting rom the orce produced when
diet may benet rom switching to one that is low
in saturated ats. This would probably involve
reducing the amounts o meat and dairy products
in the diet, and increasing the amounts o plant-
derived oods and sh. Almost all studies show a
link between eating sh and protection
against CHD.
Blood pressure, hypertension and stroke
Blood pressure is the pressure exerted by the
blood on the walls o the blood vessels through
which it fows. Although most scientists now use
the internationally recognised units or pressure–  increases the risk o suering rom a myocardial
either Pa (pascals) or N m−2 (newtons per square
metre)–the medical proession still tends to use the
old units o mm Hg (millimetres o mercury). This
is because the old styles o instruments used the
height to which a column o mercury was raised as
the method o measuring blood pressure (Figure
12.10).
Figure 12.10 Measuring blood pressure using a
sphygmomanometer.
When your blood pressure is measured, two
numbers will be recorded. The rst is the systolic
blood pressure. This is the maximum pressure
in the artery (usually the brachial artery in the
the ventricles contract. The second number is the
diastolic blood pressure. This is the pressure in the
artery at the end o diastole–that is, when the heart
muscle is most relaxed. Perhaps surprisingly, it is
the diastolic pressure that reveals most about the
condition o the circulatory system.
Having
Ha ving a persistently high diastolic pressure
is known as hypertension. Medical opinion o 
exactly what consitutes hypertension is divided,
but in general it is considered
co nsidered to be anything above
140/90 (140 is the systolic pressure,
pressure, and 90 the
diastolic pressure). Long-term hypertension greatly
greatly
myocardial
inarction or stroke.
Hypertension has numerous causes and
risk actors. It is generally associated with
atherosclerosis
atheros clerosis,, and so obesity and diet are
involved.
invol ved. A high salt intake and smoking
cigarettes (pages 276–278) also increase the risk o 
developing hypertensi
hypertension.
on.

253
 Chapter 12: Social and preventative medicine

SAQ 
5 A study ollowed 639 people with a amily history o the people had been given 40 mg o statin
o CHD over a period o 14 years. Some had each day over this period. The other hal were
an LDL : HDL of more than 8, while some had an given a placebo–a pill that looked like a statin
LDL : HDL of less than or equal to 8. The graph pill but did not contain any drug. Neither the
shows the probability of survival of a person in each people in the trial, nor the researchers who
of these groups over the 14 years of the study. collected and analysed the results, knew which
people were taking the statin and which were
100 LDL taking the placebo. The table shows the results.
>8
HDL
LDL
Even
Events
ts du
duri
ring
ng st
stud
udy
y per
perio
iod
d Given
Give n Given
≤8
HDL statin placebo
90
   % total number o people 13 28 1 507
   /
   l
  a who died
  v
   i
  v
  r
  u number who died rom 5 87 707
   S
80
CHD
number who died rom 1 94 230
other circulatory diseases
70
0 2 4 6 8 10 12 14
number who suered a 8 98 1 212
Years rom start o study rst, non-atal heart attack

a Explain why the survival probability is 100%
at 0 years.
b Suggest why the graph is drawn so that it goes
down in steps rather than in a smooth line.
c Describe the conclusions that can be dradrawn
wn
rom these data.
6 Statins are drugs that inhibit an enzyme in
liver cells which catalyses one o the reactions
involved
involv ed in the synthesis o cholesterol. In July
2002, the results o a ve-year study,
study, involving
more than 20 000 people, were published. Hal  have described in c.
a Suggest why those people who did not take
statins were given a placebo.
b Suggest why the trial was organised so that the
researchers interacting with the people, and
collecting the results, did not know who was
given statins and who was taking the placebo.
c Discuss what the results suggest about the
eectiveness o statins in reducing the risk o 
developing coronary heart disease
disease..
d Suggest how statins bring about the eects you

Stroke doubles with each 1 kPa (7 mm Hg) rise in diastolic

A stroke is an acute instance o damage to the blood pressure.
brain, caused by problems with the blood vessels Brain cells have a metabolic rate, and must
supplying it. About 80% o strokes are caused by have
ha ve good supplies o oxy
oxygen
gen and glucose or
a blood clot that orms in a vessel as the result o  respiration. They begin to die i deprived o these
atherosclerosis. The remaining 20% are caused by or more than a ew minutes.
bleeding into brain tissue (Figure 12.11). The eects o the stroke will depend on the parts
The risk actors or stroke are, as might be o the brain in which neurones die. For
For example,
expected, the same as those or coronary heart a stroke in the right side o the cerebrum is likely
disease. A person with hypertension has a to aect movement on the let side o the body.
body.
considerably
considerabl y increased risk o strok
stroke.
e. The risk As this side o the brain is concerned with spatial
254

Proving the link
For many years, doctors have urged people with
high blood pressure to eat less salt, to decrease
their risk o developing coronary heart disease or
having a stroke.
But there was no hard evidence to support this
recommendation. Despite doctors’ and scientists’
suspicions, no-one had actually shown that
reducing the salt in your diet is good or your
health. Because the evidence was so shaky (and
some people suggested that the little evidence
there was even showed that a low-salt diet was
bad or you) many people did not ollow their
doctor’s advice.
It was not until April 2007 that a careul
piece o research actually showed that this link
Figure 12.11 CT scan o a section through the
head o a woman who has suered a stroke on the
let side o the brain.
awareness, the person may have problems with
 judging distance and so nd diculty with walking
walking
or picking up objects
objects.. A stroke in the let side o  runners will try to run at the maximum speed that
the cerebrum will aect language
language.. Memory is oten
harmed no matter which side o the brain the
stroke aects.
Chapter 12: Social and preventative medicine
genuinely exists–yes,
exists–yes, eating less salt really is good
or your health.
The research ollowed
ollowed 2400 people with high
blood pressure–all volunteers–over a period o 
15 years. Hal were shown how to look or low-
salt oods when they were shopping, and eat a
low-salt diet, while hal ate a ‘normal’ diet, with
as much salt as they wanted.
The results showed that those eating a low-
salt diet had a 20% lower risk o death rom
all causes. In all, 200 people had developed
cardiovascular
cardiov ascular disease. O these, 112 came rom
the group that had not been recommended to
eat a low-salt diet. Only 88 were in the low-salt
group.
Exercise and health
Numerous studies show that taking regular
exercise has very great benecial eects on health.
It reduces the incidence o chronic diseases such
as coronary heart disease and Type 2 diabetes. It
aects processes in the brain, and in most people it
makes them eel happier, more energetic and more
positive about their lives.
Aerobic exercise
Muscles need oxygen and an energy source such
as glucose to provide them with the ATP they
need or contraction. The oxygen is used to allow
aerobic respiration
respiration to take place. I oxy
oxygen
gen is not
supplied to the muscles ast enough, they can get
by on anaerobic respiration or a while. But this
produces lactate (lactic acid), and as this builds up
the muscles stop working.
An endurance athlete is thereore limited in his
or her perormance by the rate at which oxygen
can be supplied to the muscles. The harder the
muscles are working, the aster the rate at which
they use energy, and thereore the aster the rate
that oxygen must be supplied to them. Marathon
they can keep up or several hours. Their training
increases the ability o the heart and lungs to get
oxygen to the muscles as ast as possible over a
255
 Chapter 12: Social and preventative medicine

long period o time.

Even i you have no intention o becoming a
marathon runner,
runner, your tness and general health
will almost certainly benet rom regular aerobic
exercise –that is,
is, exercise in which
which the muscles get
most o their energy rom aerobic respiration.
respiration. It
can take almost any orm you like to mention, so
long as it is done at a rate that you can keep up or
a reasonable amount o time time.. Walking, swimming,
swimming,
dancing and cycling, as well as long-distance
running, are all orms o aerobic exercise
(Figure 12.12).

Short-term eects o aerobic exercise

The ways in which aerobic exercise aects the Figure 12.12 Students on campus at Fouillole
Fouillole
circulatory and gaseous exchange systems are University Pointe a Pitre Grande Terre
summarised in Table 12.3. Guadeloupe, French West Indies. Walking and
running are the two most common methods o 
Eects on the circulatory system taking eective aerobic exercise.
When you are about to start exercising, your
brain sends nerve impulses along a sympathetic Eect o aerobic exercise
exercise
nerve to the sino-atrial node (SAN)–the heart’s Circulation more nerve impulses to the heart
pacemaker–stimulating
pacemaker–stim ulating it to contract at a aster pacemaker, increasing heart rate
rate. So your heart starts beating aster even beore
more adrenaline secretion,
you have begun the exercise. You might also begin
increasing heart rate
to secrete more o the hormone adrenaline into the
blood, which has the same eect on the heart as nitric oxide secretion, dilating
the sympathetic nerve. arterioles,, which increases blood
arterioles
Once exercise begins, and the muscles are fow back to the heart and
respiring at a aster rate
rate,, cardiac output is urther increases cardiac output
increased. This is brought about by nitric oxide, a diversion o blood to muscles by
gas which acts as a hormone. When muscles are changes in dilation o arterioles
using up oxy
oxygen
gen quickly, the concentration o 
dilation o arterioles supplying
oxygen
oxy gen in the blood vessels in the muscles alls, and
skin capillaries, increasing heat
the cells in the blood vessel walls respond to the
loss rom the skin
lowered oxygen
oxygen concentration by secreting nitric
oxide.. The nitric oxide makes the muscles in the
oxide Gaseous breathing rate increases
walls o arterioles relax, which widens the lumen exchange tidal volume increases
o the arterioles (vasodilation) and allows more
increases in the acidity o 
blood to fow through and more quickly. This in
the blood are detected by
turn increases the rate at which blood fows back
chemoreceptors; inormat
inormation
ion
to the heart in the veins.
is then sent to the brain, which
The heart is designed so that it pumps out blood
increases rate and extent o 
at the same rate that blood fows into it. (You can
diaphragm and intercostal muscle
imagine what might happen i it did not do this this.)
.)
contractions
So extra blood fowing in, stretching the muscles
in the heart wall, causes the heart to contract more Table 12.3 Short-term eects o exercise.
256

orceully. This increases the stroke volume –the
volume o blood orced out o the heart each
time the ventricles contract. The stretching also
stimulates the SAN, increasing the rate at which it
res o nerve impulses.
The blood vessels in various parts o the body
also respond to the increased demand or oxygen
and glucose by the muscles. We have seen that
arterioles in the muscles widen (dilate). At the
same time, arterioles supplying blood to other
parts o the body whose needs are less urgent,
such as the digestive system, contract and reduce
blood fow. This allows more blood to fow to
the muscles.
muscles. At rest, the percentage o the blood
fowing through the muscles is around 20%, but
during strenuous exercise it can be over 80%.
All this muscular activity generates a lot o  The person being invest
heat in the body. It is important that it can escape,
and this is speeded up by dilation o the arterioles
supplying blood to the skin surace
surace.. This increases
the rate at which heat is lost by radiation.
Eects on the gaseous exchange system
Just as heart rate increases during
du ring exercise,
exercise, so does
ventilation rate.
rate. Breathing becomes aster and
deeper, increasing the rate at which oxygen diuses
into the blood in the lungs, and carbon dioxide
diuses out.
The increased rate o respiration in the muscles
causes an increased quantity o carbon dioxide to
diuse rom them into the blood. Chemoreceptors
in the medulla o the brain and in the walls o the
carotid arteries (which carry blood rom the aorta
to the head) detect this by monitoring the pH o  in the muscles
the blood. A high concentration o carbon dioxide
lowers the pH, making the blood more acidic.
I a low pH is detected, nerve impulses will be
sent rom the respiratory centre in the medulla to
the intercostal muscles and the diaphragm muscles,
making them contract harder and more quickly quickly..
This increases the rate at which new air is brought
into the lungs and stale air removed, which in turn
maintains a large concentration gradient between
the alveoli and the capillaries.
capillaries. At rest, ventilation
rate may be about 10 dm3 min –1. During intense
exercise,, values o well over 100 dm3 min –1 are
exercise
achieved.
Chapter 12: Social and preventative medicine
SAQ
7 For each o the changes described in Table 12.3,
explain how they help the body to cope with
aerobic exercise.
Investigating the immediate eects o 
exercise on the body
A convenient type o exercise to carry out is a step
test. This has the advantage that it can be done in
exactly the same way by dierent people, or by the
same person at dierent times.
times.
A platorm o some kind – a gym bench or a
rmly positioned chair – is required. The height
o the platorm is usually between 10 cm and
25 cm high.
investigated
igated rst rests or
several minutes,
minutes, and their resting pulse rate is
measured at least twice. They then step up and
down onto the platorm a given number o times times,,
or until they are exhausted. Their pulse rate is then
measured again every minute ater the exercise has
stopped, until it has returned
to normal.
I a metronome is available, then the rate o 
stepping can be controlled. The metronome is
set to a particular number o beats per minute
(or example,
example, 24 steps per minute) and the person
matches their stepping to this rhythm.
Long-term eects o aerobic exercise
Taking regular aerobic exercise over a long period
o time can cause major changes to take place
muscles,, circulatory system and gaseous
exchange systems.
systems. The magnitude o these
changes is, in general, proportional to the amount
and intensity o training that is done. However,
However,
dierent people can respond very dierently to
identical training, and there seems to be a strong
genetic component to thisthis..
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 Chapter 12: Social and preventative medicine
Changes in the muscles
Many changes take place in the muscles that are
used in training. These changes are specic–they
do not aect other muscles
muscles.. They include:
an increase in the cross-sectional area o  increases the ability o the blood to carry
•
slow-twitch
slow-twit ch muscle bres (see page 259) This
increases the mass o muscle that can be used
during aerobic exercise,
exercise, as well as increasing the
overall size o the muscles.
muscles.
an increase in the number o capillaries in the
•
muscle,, and also in the ratio o capillaries to
muscle
muscle bres.
bres. This increases the volume o  o blood that is orced out o the heart with
blood in the muscle, improving oxygen supply.
an increase in the concentration
con centration o myoglobin in
•
the muscle. Myoglobin is a respiratory pigment
that stores oxygen, so this increases the amount
o oxy
oxygen
gen stored within the muscle.
an increase in the number and size o  trained person decreases when they are resting,
•
mitochondria in the muscle bres and
thereore an increase in respiratory enzymes.
Mitochondria are the sites where the Krebs
cycle and oxidative phosphorylation occur, so
this increases the rate at which these processes
can occur within the muscle.
an increase in the glycogen stores, which can
•
be rapidly broken
broken down to glucose or use as a
respiratory substrate.
Changes in VO2 max and the circulatory system
When a person increases the rate at which they
are exercising, their rate o oxy
oxygen
gen consumption
increases too. However, there comes a point where
they can no longer get any more oxygen to their
muscles,, or where their muscles just cannot use
muscles
oxygen any aster, at which point the muscles
have to switch over to anaerobic respiration. The
maximum rate at which oxygen is used, beore the
muscles have to make the switch, is called VO2 max.
VO2 max increases with training. A trained
athlete can have a higher work rate beore
their muscles switch to the less energy-ecient
anaerobic respiration.
respiration. The changes in the muscles
described above contribute to this. Changes in
the cardiovascular system also contribute to this
258
improvement, by increasing the rate at which
oxygen can be supplied to the muscles
muscles.. The
changes include:
an increased number o red blood cells. This
•
oxygen.
an increase in the size o the heart muscle,
•
especially in the walls o the let ventricle. This
increases the orce with which the muscle can
contract and orce blood out o the heart.
an increase in stroke volume –that is,
is, the volume
•
each beat.
an increase in cardiac efciency –that is, is, the work
•
output that the heart produces or each unit o 
oxygen that it uses.
As a result o these changes, the heart rate o the
because the greater stroke
stroke volume means that the
same quantity o blood can be moved around
the body using a slower heart rate. However, the
maximum possible stroke volume is considerably
increased, so the person can exercise harder and
still manage to get enough blood into their muscles
to supply the oxygen that they need. The heart rate
recovery period–that is,is, the time taken or the heart
rate to return to normal ater exercise–decreases
with training. This is oten used as a good measure
o how a person’s
person’s tness is improving during a
training programme.
Changes in the gaseous exchange system
Training increases the rate at which oxygen can
be brought into the body and carbon dioxide
removed. Everyone’s breathing rate and depth
increase when they exercise, but the degree to
which this happens is impro
improved
ved by regular aerobic
training. For example, while a ‘normal’ person
might be able to increase their ventilation rate by
up to ten times, a really
really t endurance athlete may
be able to increase theirs by as much as 20 times.
Top Olympic-standard rowers may have ventilation
rates o 200 dm3 min –1. Maximum oxygen intake is
also achieved more quickly in a trained person.
 Chapter 12: Social and preventative medicine

Slow-twitch and ast-twitch muscle fbres

There are two dierent types o muscle bres in
the skeletal muscles in the human body. They are
known as slow-twitch and ast-twitch bres.
During aerobic exercise, it is mostly the slow-
twitch bres that are working. These bres
b res are
adapted or continuous aerobic respiration. They
contain a lot o myoglobin, which makes them
look dark red, so they are sometimes known as
‘red bres’.
During intensive, short-term exercise, such as
sprinting, the ast-twitch bres are used. They
are adapted or producing ATP by anaerobic
respiration. They thereore
thereore do not require stores
o oxygen, and do not contain much myoglobin.
They are sometimes known as ‘white bres’.
See i you can explain how each o the
structural dierences between slow-twitch and
ast-twitch bres, shown in the diagram, adapt
them or their dierent ways o generating ATP.

Slow-twitch fbres Fast-twitch fbres

produce ATP through aerobic respiration produce ATP through

anaerobic respiration
contain large numbers o 
mitochondria contain ew mitochondria

contain large quantities o  contain little myoglobin

myoglobin
have a relatively large diameter 
have a relatively small (about twice that o a slow-twitch fbre)
diameter 
are supplied by relatively ew capillaries
are supplied by large
numbers o capillaries

SAQ 
8 A group o untrained people undertook a
training programme involving aerobic exercise 3.8
over a period o 13 weeks. The graph shows    1
   −
  n 3.6
   i
the mean VO2 max o these people during the   m
   3

training period.   m3.4

   d
   /
a Explain the meaning o the term ‘VO2 max’.   x
  a 3.2
b Describe the changes in VO2 max during this   m
   2
training programme.    O3.0
   V
c Suggest reasons or the changes that you 2.8
describe. 0 2 4 6 8 10 12 14
Weeks of training

259
 Chapter 12: Social and preventative medicine

SAQ 
9 During aerobic exercise, most respiration taking lactate in the blood or this person beore and
place in the muscles is aerobic. However, even at ater the training programme.
low rates o exercise some anaerobic respiration
respiration a i Describe the relationship between blood
also happens. lactate concentration and intensity o 
exercise, up to a power output o 175 W.
12
ii Suggest reasons or this relationship.
relationship.
  n b The lactate threshold is the point at which
  o
   i
   t
  a 10
  r
   t before more lactate is being produced than can be
  n
  e   3 8 training cleared rom the blood.
  c   −

  n   m
  o   d i Name the organ
o rgan that is responsible or
  c   l 6
  e   o
   t
  a   m
   t
breaking down lactate.
  m4
  c   /
  a
   l after 
ii Use the graph to determine the power
   d
  o
  o
2 training outputs at which the person reached their
   l
   B lactate threshold beore training, and ater
0
50 100 150 200 250 300 350 training.
Power output / W iii Explain three changes in the body that
could contribute to this increase in the
A person undertook a programme o aerobic lactate threshold ater training.
training. The graph shows the relationship c Explain how an increase in lactate
between the intensity o exercise, measured as threshold could improve the perormance
power output in watts, and the concentration o  o an endurance athlete such as a rower or
marathon runner.

Inectious diseases charities, who have to step in to care or people

There are many inectious diseases that can cause
serious illness. In the Caribbean, two inectious
diseases that are having a considerable impact on
society are HIV/AIDS
HIV/AIDS,, and dengue ever.
The eects o HIV/AIDS on society
We have already looked at HIV/AIDS in some
detail. In Chapter 10, we described how the human
immunodeciency virus is transmitted rom one
person to another, and looked at its lie cycle.
In Chapter 11 we saw how the virus aects the
immune system and causes AIDS.
Unlike most diseases, it is people in the prime
o their lives who are most likely to be aected by
HIV/AIDS,, and most likely to die as a result o 
HIV/AIDS
this inection. This means that many children are
let with no parents to care or them. Older people,
who depended on their grow
grown-up
n-up children or care
and support, may lose this essential support to
help them to continue to live independent lives.
This puts an extra burden on the State and on
260
who have
have lost essential members o their amilies.
amilies.
The workorce
workorce o the Caribbean is also aected,
as many people who would be important members
o the working community can no longer continue
to do their jobs normally.
HIV/AIDS is a signicant drain on the resources
available or healthcare. Money is spent on
education, testing and diagnosis (or example, all
pregnant women are routinely tested or HIV) and
treatment. Where drugs are available, they will
need to be taken or the rest o a patient’s
patient’s lie.
Dengue ever 
Dengue ever is a disease caused by a virus.
The virus is transmitted by the mosquito Aedes
aegypti . These mosquitoes are thereore vectors
or dengue ever.
The dengue ever virus, oten abbreviated to
DENV,, belongs to a amily o viruses called
DENV
faviviruses
faviviruses.. The structure o
o  a mature virus
particle is shown in Figure 12.13, and the way in
 Chapter 12: Social and preventative medicine

which the virus reproduces inside human cells is Dengue ever was originally conned to
shown in Figure 12.14. There are several dierent tropical countries,
countries, but recently it has
h as been
orms (serotypes) o the virus and, unortuna
unortunately
tely,, spreading to countries urther north and south o 
immunity against one orm does not provide the equator. Figure 12.15 shows the distribution
immunity against the others
others.. o dengue ever in the Americas in 2006. Dengue
ever is a serious disease in the Caribbean, and
in some years, such as 2010, the numbers o 
virus envelope–  virus capsid–a inections rise to epidemic proportions.
proportions. The
modifed plasma protein coat number o cases o dengue ever are increasing
membrane taken
rom a human cell worldwide,
world wide, and it is considered to be a serious
public health problem. In 2010, there were 30
times more cases worldwide
worldwide than in 1960. No-
one is quite sure why this is, but it may be a
combination o the greater number o people
RNA–carries code travelling
travelling around the globe, and global warming
or making new
viruses
increasing the breeding range o the Aedes aegypti 
mosquitoes.

Inection with the dengue virus

proteins that attach to The A. aegypti mosquitoes
aegypti mosquitoes that transmit the
human cells to help
the virus invade proteins that dengue virus breed in any small pools o water
catalyse stages in that they nd–or example, in old tyres, water
virus replication
storage containers and old oil drums. This means
25 nm
that they are present in both cities and in rural
areas.. The mosquitoes are most active during the
areas
Figure 12.13 The dengue virus day, especially at dawn and dusk, which is when

8 The fnished virus takes

1 Virus attaches
some o the cell’s plasma
to a human cell.
membrane with it and it
Proteins on the
is modifed to orm the
virus link with
envelope o the virus.
proteins on the
plasma membrane. 7 Vesicles containing
the partly assembled
virus particles move
2 Virus enters towards the plasma
the cell in an membrane and leave
endosome. the cell.

6 Partly assembled
virus particles are
3 The virus
transerred to a
breaks down.
Golgi body.
Its RNA is
released.

4 The virus RNA controls 5 Virus components

the synthesis o new begin assembly
virus components, within membrane
using the cell’s RER. compartments.

Figure 12.14 Replication

Replication o the dengue virus.
261
 Chapter 12: Social and preventative medicine
6143–346550
2040–6143
22–2040
0–1
no data
Figure 12.15 Distribution o dengue ever in the
Americas (number o cases in 2006).
they are most likely to bite a person.
Female A. aegypti mosquitoes
aegypti mosquitoes eed on blood.
When they bite, they inject saliva, which contains
an anti-clotting agent and thereor
thereoree enables the
blood to fow reely into their mouthparts. When
an inected mosquito bites a person, the virus
enters the person’s body in the mosquito’s saliva.
The virus can enter many dierent types o  viruses.)
cells in the skin. The proteins in the outer coat
o the virus can bind to proteins in the plasma
membranes o the skin cells, allowing the virus to
enter the cells.
The entry o the virus stimulates the body’s
immune system into action. Cytokines are
produced, which stimulate the generation o  the pain, but aspirin and ibuproen should be
antibodies by B-lymphocytes. Some o the
antibodies bind to the viral proteins, which causes
phagocytes to engul the viruses. Unortunately,
in many cases the phagocytes do not kill the virus
262
eectively, but instead harbour viruses that actually
continue to duplicate themselves inside the cells.
These cells, and other white blood cells attacked by
the viruses, accumulate in the lymph nodes.
The antibody production also causes the
prolieration and action o T-killer cells
(T-cytotoxic cells) that carry receptors matching
the viral antigens. The role o these cells is to
kill inected or abnormal cells, but they are not
particularly eective against cells invaded by this
virus.
Symptoms and treatment
Dengue ever is an unpleasant illness, with
symptoms similar to infuenza. The person has a
high temperature, a rash, a severe headache and
pain in the muscles and joints. They may eel sick
and vomit, and probably will not want to eat.
The illness generally lasts up to 10 days, but many
people will not eel ully better or up to one month.
Although dengue ever is very unpleasant, it
is not a particularly dangerous illness. However,
in some cases a much more serious condition
develops,, called dengue haemorrhagic ever. This
develops
results rom damage to the cells lining the blood
vessels (the endothelium), and disruption o the
normal blood-clotting process. Fluid leaks rom
the blood vessels and accumulates in the tissues
tissues..
This may happen in many dierent organs, and can
result in very serious illness that is atal in about
5% o cases.
As or many viral diseases, there are no drugs
that can be taken to kill the dengue ever virus.
(Antibiotics only work against bacteria, not
viruses .) Treatment
Treatment consists o making the person
as comortable
comortable as possible
possible,, and ensuring
en suring that they
continue to take plenty o fuids, especially i they
are losing liquid through vomiting. This can oten
be done at home, but in serious cases the person
may need to be connected to an intravenous drip
in hospital. Paracetamol can be taken to reduce
avoided, because they can worsen the bleeding that
may occur.
occur. The great majority o people make a
ull recovery
recovery..
 Chapter 12: Social and preventative medicine

Prevention being bitten by the A. aegypti mosquitoes

As yet, no vaccine has been developed to immunise
people against dengue ever
ever.. Researchers are
currently working on this, trying to produce a
vaccine that will protect people against all the
dierent orms o the virus. There are already
already
some possible vaccines undergoing trials, and
there is hope that there could be a useul vaccine
available by as early as 2015.
For the moment, however, the only way to
prevent yoursel
yoursel getting dengue ever is to avoid
aegypti mosquitoes.. I 
you know that you are in an area where dengue
ever is present, you can use insecticides such as
DEET on your skin to deter the mosquitoes, and
wear clothing that covers your arms and legs.
Everyone can help by clearing up rubbish that
may collect water and proprovide
vide breeding grounds
or the mosquitoes. Another approach, useul with
larger bodies o water
water,, is to introduce sh or other
organisms that will eed on the mosquito larvae.

Summary
Obesity is dened as hahaving
ving a body mass index greater than 27. Being obese increases the risk o 
•
developing Type
Type 2 diabetes
diabetes.. People become obese through eating a diet that contains more energy
than their body uses
uses..
Atherosclerosis is a condition that develops when the walls o the blood vessels lose their elasticity.
Atherosclerosis elasticity.
•
I this happens in the coronary arteries, a person has coronary
co ronary heart disease (CHD). Atherosclerosis
Atherosclerosis
develops as plaques orm in artery walls, due to the build-up o cholesterol.
A diet rich in saturated ats increases the risk o developing CHD. Having
Having a low ratio o HDL : LDL
•
cholesterol also increases this risk.
Hypertension (high blood pressure) is oten associated with atherosclerosis.
atherosclerosis. Other risk actors include
•
a diet containing a lot o salt, and smoking cigarettes. Hypertension increases the likelihood o 
developing CHD,
CHD, and also o o  suering a stroke.
stroke.
Aerobic exercise helps to maintain tness. Regular exercise increases the maximum rate at which
•
oxygen can be used by the body, known as VO2 max, and cardiac eciency
eciency.. Exercise can help to
maintain body weight at a healthy level, and reduce the risk o the development o chronic diseases
such as Type 2 diabetes.
AIDS and dengue ever are serious inectious diseases that are caused by viruses. The dengue ever
•
virus is transmitted by the mosquito vector Aedes aegypti . The mosquitoes breed in any body o 
water,, so an important method o control is to remove rubbish in which water
water water may collect, or to add
predators o mosquito larvae to ponds.

263
 Chapter 12: Social and preventative medicine

Questions
Multiple choice questions
1 Which o ollo
ollowing
wing best describes a ‘balanced diet’?
A one which provides an adequate intake o nutrients needed or maintenance o body and
good health
B one which contains
co ntains carbohydrates,
carbohydrates, lipids and proteins
C one which provides an adequate intake o energy and nutrients needed or maintenance o 
body and good health
D one which provides an adequate intake o energy needed or maintenance o body and good
health
2 One way o dening obesity is by the Body Mass Index (BMI). The ormula or BMI is:
body mass in kg
A
height in metres
body mass in g
B
height in metres
(height in metres)2
C
body mass in kg
body mass in kg
D
(height in metres)2

3 Image I shows a healthy coronary artery while image II shows the artery when it became unhealthy.

I II

What is the name o the disease and a cause that is characterised by image II?
A coronary heart disease–diet high in saturated ats
B plaque ormation–diet high in cholesterol
C ather
atherosclerosis–diet
osclerosis–diet high in sh oils
D coronary heart disease–diet high in unsaturated ats
4 Which o the ollowing is not an immediate eect o exercise on the body?
A increased heart rate
B vasoconstriction in skeletal muscles
C rise in blood pressure
D vasodilat
vasodilation
ion in skeletal muscles

continued ...

264
 Chapter 12: Social and preventative medicine

5 A girl has been running every day to improve her level o physical tness.
tness. Which o the ollowing
is a long-term benet to the girl in improving her physical
physical tness?
A less glycogen and at stored in skeletal muscle
B reduction in blood cholesterol concentration
C increase in number o alveoli in lung
D reduction in tidal volume at rest
6. What is the causative
causative pathogen o dengue ever?
A protoctist
B bacterium
C virus
D ungus
7 What is the vector o dengue ever?
A the emale Aedes aegypti mosquito
aegypti mosquito
B the male Aedes aegypti mosquito
aegypti mosquito
C the emale Anopheles mosquito
D the male Anopheles mosquito
8 Which o the ollowing is not a method by which HIV is transmitted?
A rom mother to child across the placenta
B receiving blood through transusions
C sharing needles without sterilisati
sterilisation
on
D sharing eating utensils
9 Which o the ollowing is an impact o HIV/AIDS in the Caribbean region?
A It has little eect on the work orce.
B It is not a major cause o death in the region.
C It does not drain resources or education.
D It has improved educational awareness
awareness o sexually transmitted disease.
disease.
10 Which cells o the immune system are susceptible to HIV?
A T helper cells with CD8 receptors
B T cytotoxic cells with CD4+ receptors
C T helper cells with CD4+ receptors
D T cytotoxic cells with CD8 receptors

continued ...

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 Chapter 12: Social and preventative medicine

Structured questions
11 a What
What are the components o a balanced diet? [3 marks]
b Obesity is now a global problem.
i Dene the term ‘obesity’. [1 mark]
ii Explain how poor diet can lead to obesity
obesity.. [3 marks]
iii A man is 1.65 m tall and weighs 82 kg. Calculate his Body Mass Index (BMI).
Show calcul
calculations.
ations. [2 marks]
iv Comment on the BMI value obtained in iii. [1 mark]
c Obesity is linked to many diseases including diabetes.
diabetes.
i Distingu
Distinguish
ish between Type 1 and Type 2 diabetes. [2 marks]
ii Explain how obesity is linked to Type 2 diabetes. [3 marks]
12 a Students perormed an experiment to determine
deter mine their cardiovascular eciency by
observing their pulse rates during various activities. They rst took their resting pulse
rate,, then perormed various activities.
rate activities. The duration o the stepping exercise was
3 minutes.
i Wha
Whatt do you understand by the term ‘resting pulse rate’? [1 mark]
ii Explain whwhyy resting pulse rate is taken as a measure o one’
one’ss physical tness
tness.. [2 marks]
iii Wh
Why y was the resting pulse rate taken beore the exercise began? [2 marks]
iv Suggest how the students could use a step test during this experiment. Students
were provided
provided with
with a stepping stool o 4 cm, a stopwatch
stopwatch and a digital pulse meter.
meter. [3 marks]
The results below are rom one o the students rom the class.

Activity At rest Standing Exercise Recovery ater 1 min

Pulse rate per minute 76 101 13 0 89

v Using the ormula below, calculate the student’s cardiovascular eciency.

duration o exercise in seconds × 100
cardiovascular
cardiovascular eciency =
recovery pulse × 5.6
[2 marks]
vi Using the inormation below, assess the studen
student’s
t’s cardiovascul
cardiovascular
ar ecienc
eciencyy. [1 mark]
Cardiovascular
Cardiov ascular eciency is assessed as:
0–27 = very poor 28–38 = poor 39–48 = air
49–59 = good 60–70 = very good 71–100 = excellent
b State three short term eects o exercise on the body
body.. [3 marks]
c State three long term eects o exercise on the body [3 marks]
13 HIV is described as a retro
retrovirus
virus and is transmitted in a variety o wa
ways.
ys.
a Explain why HIV is describ
described
ed as a retrovirus. [1 mark]
b Describe three ways in which HIV is transmitted. [3 marks]
c The gure below shows the inection cycle o HIV in a T helper lymphocyte.

continued ...

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 Chapter 12: Social and preventative medicine

The table below describes the various steps o the inection but they are not
no t in order.

8
7

6
3

Identiy stages 1– 8.

1– 8

Description Stage
reverse transcription: making o DNA copy rom viral RNA
transcription: special enzymes create mRNA
binding: attachment o HIV proteins to CD4+ surace receptor o 
T helper cell
viral assembly and maturation: new viral particles are assembled and
become more inectious
translation: new viral proteins are produced
budding: T-helper cell lyses and releases inectious new viral cells
RNA rom virus is released into T helper cell
integration: HIV DNA is added into the cell’s DNA using viral
enzyme, integrase

[4 marks]

continued ...

267
 Chapter 12: Social and preventative medicine

d The drug therapy that is employed to treat people inected with HIV is known as
HAART (highly active anti-retroviral therapy). This therapy contains a combination
o drugs which target dierent stages o the viral inection cycle. Suggest two ways
that these drugs may slow the onset o HIV
HIV.. [2 marks]
e AIDS is the nal and most serious stage o HIV inection. What are the signs
indicating that this stage has been reached? [2 marks]
  Explain why
why the number o people who are inected with HIV is usually greater than
the number o people with AIDS. [3 marks]

Essay questions
14 a Discuss the eects o ats on the cardiov
cardiovascular
ascular system. [10 marks]
b Explain how plaque is ormed in blood vessels
vessels.. [5 marks]
15 a Using a graph, explain what is meant by the term
ter m ‘VO2 max’. [4 marks]
b What actors may infuence a person’s VO2 max? [4 marks]
c Suggest how a person may improve their VO2 max. [4 marks]
d A ootballer has reached his VO2 max. Suggest what happens to his muscles i he
continues playing. [3 marks]
16 Both HIV/AIDS and dengue are diseases that have
have both social and economic impact
on the Caribbean region.
a Discuss the transmission, incubation period, symptoms and prevention o dengue. [8 marks]
b HIV inections can lead to AIDS. Describe three symptoms o AIDS. [3 marks]
c Discuss the impact o AIDS and dengue in the Caribbean. [4 marks]

268