Chronic diseases are diseases or conditions that persist or progress over a long time. Chronic diseases develop slowly. Chronic illnesses are prolonged, do not resolve spontaneously, and are rarely cured completely. Chronic diseases are the leading cause of death in the United States and around the world. The World Health Organization (WHO) estimates that chronic diseases cause about 35 million, or 60%, of the 60 million deaths every year. Chronic diseases such as cardiovascular disease and cancer are by far the biggest killers in this category, but other chronic diseases, such as the ones discussed in this chapter, still kill 10 million people every year—more than twice the number of annual deaths from AIDS and tuberculosis combined.
Chronic diseases are an important part of women’s health. Not only are they very common, but they are often much more prevalent in women than they are in men. In this lecture, we’ll review osteoporosis, arthritis, diabetes, certain autoimmune diseases, and Alzheimer’s disease—chronic diseases that have dramatic effects on the health of women in the world today. Other chronic diseases, such as herpes, cardiovascular disease, and cancer, are reviewed in other chapters.
Rates and severity of chronic diseases vary among racial and ethnic groups. The reasons for these differences are not always clear, but they have a serious impact on women’s health needs.
The costs of treating chronic diseases and caring for people with them dramatically affect both the national economy and millions of individual people’s lives. Overall, the medical care costs for chronic diseases account for more than 75% of America’s $1.5 trillion in medical care costs. Individuals with chronic diseases sometimes struggle with paying for appropriate care, often having to turn to public insurance programs such as Medicaid or Medicare for coverage. Keeping a full-time job may become increasingly difficult for those with a chronic disease, so the option of employer-sponsored health insurance may be lost for them.
Osteoporosis (literally “porous bone”) is an age-related, debilitating disorder characterized by a general decrease in bone mass and structural deterioration of bone tissue. Osteoporosis develops when bone resorption occurs too quickly or bone replacement occurs too slowly. Osteoporosis is a major cause of bone fractures in postmenopausal women and a leading cause of frailty. It affects approximately 8 million women, with millions more at increased risk of developing osteoporosis due to low bone mass. The following factors put a woman at risk for developing osteoporosis.
The following risk factors for osteoporosis are modifiable. The earlier a woman begins healthful habits that promote stronger bone health, the lower her chance of developing osteoporosis (or suffering an osteoporosis-related injury) in the future.
Osteoporosis is often called a “silent disease” because neither pain nor specific symptoms are associated with this condition. Three times as many women have osteoporosis than report having the condition. This makes screening for osteoporosis especially important for women at risk.
In the absence of a cure for osteoporosis, prevention is the best strategy currently available to women. Lifestyle and personal behaviors are the key osteoporosis prevention strategies. A woman should not start smoking and she should quit if she already smokes. Calcium and vitamin D also play important roles in achieving peak bone mass, maintaining bone mass prior to menopause, and preventing bone loss in the postmenopausal years. Additionally, participating in weight-bearing and muscle-strengthening exercises on a regular basis is important for both osteoporosis prevention and overall health.
Arthritis, defined as any inflammation of the joints, encompasses more than 100 diseases and conditions that affect joints, the surrounding tissues, and other connective tissues. The most common forms of arthritis are osteoarthritis, rheumatoid arthritis, and gout. Arthritis and other rheumatic conditions (conditions affecting the joints and muscles) are among the most common chronic conditions and the leading causes of disability in the United States.
Osteoarthritis, also called degenerative joint disease, is a common chronic health problem, affecting more than 21 million people. In osteoarthritis, the surface layer of cartilage erodes, causing bones under the cartilage to rub together. This friction results in joint pain, swelling, and loss of movement of the joints. Rheumatoid arthritis is a chronic inflammatory disease with increasing prevalence among older adults. It currently affects more than 2.1 million people in the United States. With this disease, inflammation occurs in the joint lining but may extend to other tissues and cause bone and cartilage erosion, joint deformities, movement problems, and activity limitations. Gout is a painful form of arthritis caused by an excess of uric acid in the body. This excess can result from an increase in the production of uric acid in the body or the inability of the kidneys to adequately clear uric acid. The following three pictures, from left to right, show a healthy joint, a joint affected by osteoarthritis, and a joint affected by rheumatoid arthritis.
Arthritis is the leading chronic condition among women and a major cause of activity limitation. Two to three times more women than men are affected by rheumatoid arthritis. Risk of arthritis also increases with age, with nearly half of the elderly population being affected by some form of arthritis. Some people are genetically predisposed to arthritis, placing them at higher risk for developing the disease. Other risk factors associated with arthritis are modifiable, although altering these factors does not necessarily decrease a person’s risk.
Arthritis has many consequences, including physical and psychological symptoms as well as effects on one’s social well-being. No single test can diagnose arthritis. Instead, a medical and family history and a physical exam to check the joints, reflexes, and muscle strength are the first steps in diagnosis.
Maintaining an appropriate weight is an important preventive measure. Losing weight through healthful eating and regular exercise also can help reduce the effects of osteoarthritis. Women can also take precautions to avoid injuries during sports and exercise that can increase the risk for arthritis (or make existing arthritis worse). Another cause of arthritis is Lyme disease, a disease caused by the bacterium Borrelia burgdorferi . These bacteria are transmitted to humans by the bite of infected deer ticks. Drugs and surgery are possibilities for women who already have arthritis.
Diabetes mellitus is a disease characterized by abnormal glucose production or metabolism. A person with diabetes has either a deficiency of insulin (the hormone produced by the pancreas and needed to convert glucose to energy) or a decreased ability to use insulin. As a result, glucose builds up in the bloodstream and, without treatment, will damage organs and contribute to heart disease. Diabetes is becoming more common in the United States. In 2007, 23.6 million people, or 7.8% of the U.S. population, had diabetes. There are three major kinds of diabetes: type 1, type 2, and gestational diabetes. Type 1 diabetes is often classified as an autoimmune disease, although genetic and environmental factors can also play a role in its development. In this type of diabetes, the body’s immune system attacks the cells that produce insulin, the hormone that regulates blood glucose. Type 1 diabetes often first appears in childhood or adolescence, and it accounts for about 5% of cases of total cases of diabetes. About 90% to 95% of people with diabetes have type 2 diabetes. In this form of diabetes, cells are unable to use insulin properly. Gestational diabetes occurs when women become intolerant to glucose during pregnancy. After pregnancy, gestational diabetes usually, but not always, goes away.
Several risk factors for diabetes have been identified, including having a first-degree relative (mother, father, or sibling) with diabetes, being overweight, and having hypertension or abnormal high-density lipoprotein (HDL) or triglyceride levels. Certain racial and ethnic groups are at increased risk for type 2 diabetes, including African Americans, Hispanics, and American Indians/Alaska Natives.
Symptoms of type 1 diabetes usually develop over a short period of time. They may include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme tiredness. If not treated with insulin, a person can lapse into a coma and eventually die. Symptoms of type 2 diabetes develop gradually. Although they are not as noticeable as symptoms of type 1 disease, type 2 symptoms are similar and include frequent urination, unusual thirst, weight loss, blurred vision, feelings of fatigue or illness, frequent infections, and slow healing of sores.
The most alarming part of diabetes is the severity of the complications associated with the disease (Table 11.6). Diabetes is the leading cause of new cases of blindness in adults aged 20 to 74 years. Diabetes also causes about 44% of end-stage kidney failures. Because unregulated diabetes causes thickening of blood, circulation issues are common. As a result, many people have trouble with wound healing, especially in their extremities. Adults with diabetes are two to four times as likely to develop heart disease or stroke as those without diabetes. In fact, heart disease is the leading cause of diabetes-related deaths. Diabetes is known to affect brain function, cognitive decline, dementia, depression, and stroke. These complications frequently occur together, leading to poor quality of life, with considerable social and economic implications.
The routine test for diagnosing diabetes is a fasting plasma glucose test. A doctor may choose to perform an oral glucose tolerance test, which involves a fasting blood sample followed by numerous blood samples after glucose syrup is ingested. The “gold standard” for diagnosing diabetes is an elevated blood sugar level after an overnight fast (not eating anything after midnight).
Autoimmune diseases, in which the immune system attacks normal components of the body, are more common among women than among men. More than 80 serious, chronic illnesses are collectively referred to as autoimmune diseases, and these diseases involve the nervous, gastrointestinal, and endocrine systems, as well as skin and other connective tissue, eyes, blood, and blood vessels. Approximately 75% of autoimmune diseases occur in women, most frequently first manifesting during the childbearing years. Autoimmune diseases represent the fourth largest cause of disability among women in the United States. In some cases, hormone levels appear to be correlated with autoimmune diseases or autoimmune disease symptoms. How hormones and autoimmune diseases interact is not fully understood.
Lupus is a complex chronic inflammatory disorder in which the immune system forms antibodies that target healthy tissues and organs. It can be a mild, moderate, or severe disease. Although lupus may affect men and women of any age, it is primarily a disease of young women of childbearing age. This condition affects women 10 to 15 times more often than it does men, and it affects African American women two to three times more often than it does white women. There are large gaps in our understanding about lupus, such as how it can occur for unknown reasons, whether it is induced by drugs, and how or why symptoms appear and disappear.
The cause of lupus is unknown, although it is hypothesized that genetic, hormonal, and environmental factors play a role. The two most common symptoms of lupus are painful, swollen joints and a skin rash. Lupus has been called “The Great Imitator” due to its array of varied symptoms that often mimic other, less serious illnesses. Symptoms can range from mild to life threatening. Lupus is characterized by periods of remission in which no symptoms are present
The clinical diagnosis of systemic lupus involves taking note of symptoms of lupus, such as skin rash, joint pain, chest pain, seizures, and photosensitivity, and reviewing a person’s history of medications. A complete blood count and urinalysis may provide evidence of the involvement of the kidneys and blood vessels. The antinuclear antibody test (ANA) may be used to rule out a diagnosis of lupus. It is positive in virtually all people with lupus and is the best diagnostic tool for lupus available.
Lupus is characterized by periods of symptoms called “flare-ups.” The symptoms are unpredictable and inconsistent when they present. Because we don’t understand the root causes of lupus, treatment often focuses on preventing or reducing the severity of symptoms. To reduce flare-ups, women with lupus can take certain preventive measures. People who are photosensitive should avoid sun exposure and regularly use sunscreen to prevent rashes. Exercise is important to prevent muscle weakness and fatigue, whereas stress reduction can be achieved through support groups and counseling. Treatment usually involves nonsteroidal anti-inflammatory drugs (NSAIDs) to ease muscle and joint pain.
The thyroid is a small gland, shaped like a butterfly, located in the middle of the lower neck. Its primary function is to control the body’s metabolism—the rate at which cells perform duties essential to living. A properly functioning thyroid will maintain the right amount of hormones needed to keep the body’s metabolism functioning at a steady state. Thyroiditis is an inflammation of the thyroid gland. When the thyroid produces too much hormone, the body uses energy faster than it should; this condition is called hyperthyroidism . When the thyroid doesn’t produce enough hormone, the body uses energy slower than it should; this condition is called hypothyroidism .
Both Hashimoto’s disease and Graves’ disease are inherited conditions. Risk factors include being a woman older than 20 years, although the disorder may occur at any age and may affect men. Risk factors for thyroid disorders include factors that do not seem to be a direct cause of the disease, but seem to be associated with it in some way. Having a risk factor for thyroid disorders makes the chances of developing a condition higher but does not inevitably lead to a thyroid disorder. Likewise, people without known risk factors can still develop thyroid disorders.
The most common causes of hypothyroidism and hyperthyroidism, respectively, are Hashimoto’s disease and Graves’ disease. Hashimoto’s disease is an autoimmune condition caused when the immune system reacts against the thyroid gland. Because people with hypothyroidism lack enough thyroid hormones to properly run their metabolisms, they often have symptoms associated with having low energy People with hyperthyroidism have an excess of thyroid hormones that increases the body’s metabolism by as much as 60% to 100%, often causing symptoms associated with being overstimulated
Thyroid disease can be difficult to diagnose because its symptoms are easily confused with other conditions. A comprehensive history and physical examination are integral to a diagnosis of thyroiditis. Laboratory testing is also important. Treatment for Hashimoto’s disease is based on determining the correct amount of thyroid hormone (thyroxine) needed to stimulate the thyroid gland. Gradually increasing doses of thyroxine are given until a person’s blood levels become normal. Annual checkups are necessary to confirm that the prescribed dose is still appropriate. Graves’ disease is treated with antithyroid drugs to prevent the thyroid gland from manufacturing thyroid hormone.
Alzheimer’s disease is an irreversible, progressive brain disorder that evolves gradually and results in memory loss, behavior and personality changes, and a decline in cognitive abilities. It is one of a group of disorders that cause dementia (cognitive decline). The risk of developing Alzheimer’s disease increases with age, although the disease and symptoms of dementia are not a part of normal aging.
It is not fully understood what causes Alzheimer’s disease, but it is clear that its onset can be triggered by a number of factors that interact differently in people. Researchers believe that age, genetic background, and possibly lifestyle all are contributing factors. Familial Alzheimer’s disease (FAD) follows a pattern of inheritance. It often has an early onset, meaning that it occurs most often in people younger than 65. FAD often progresses faster than the more common form of Alzheimer’s disease, which typically occurs in people age 65 and older.
In people with Alzheimer’s disease, three key processes in the brain are disrupted—nerve cell communication, metabolism, and repair. This disruption ultimately causes many nerve cells to stop functioning, lose connections with other nerve cells, and die. The disease advances by stages, from early, mild forgetfulness to severe loss of mental function (i.e., dementia). The disease first destroys neurons in parts of the brain that control memory; as a result, a person’s ability to do easy and familiar tasks begins to decline. Later in the disease, they may forget how to do simple tasks, such as brushing their teeth. Personality changes also may occur. Emotional outbursts and disturbing behavior, such as wandering and agitation, become more frequent as the disease runs its course. Eventually, many other areas of the brain are involved.
At this time, there is no definitive diagnosis for Alzheimer’s disease. The only way to conclusively diagnose it is through autopsy, by examining the characteristic plaques and tangles in the brain. Currently, health-care providers use several tools to make a “best guess” about possible Alzheimer’s disease in a person who is having difficulties with memory or other mental functions. There is no cure for Alzheimer’s disease, but the FDA has approved several medications for its treatment. These drugs may temporarily delay memory decline for some individuals, but none of the currently approved drugs stop the underlying degeneration of brain cells.
Ask the students: What are some ways to possibly prevent chronic diseases? [Possible answers: Healthy lifestyle through nutrition and regular exercise can reduce the likelihood of diabetes and arthritis; avoiding smoking and getting enough calcium and vitamin D can reduce the likelihood of osteoporosis.] Ask the students: What are some ways that diseases can be managed? [Possible answers: exercising and a nutritious diet can help with arthritis and diabetes (among others); drugs and medical care can reduce or slow the symptoms of almost all chronic diseases; working on maintaining balance can reduce the likelihood of falls, and thus reduce the risk of fractures in people with osteoporosis.]
Learning Module Eleven: Women's Health
Chapter 11Other Chronic Diseases and Conditions
Chronic Diseases: What Are They, and Why Are They Important?• Diseases that persist for a long time• Rarely cured completely• Biggest cause of death and disability around the world.
Chronic diseases are common, and they also affect women more than men.• Chronic diseases are responsible for 70% of deaths in the U.S. (men and women).• Greater rates of arthritis, immune diseases, Alzheimer’s disease for women• Lupus afflicts women 9X more often than men• Hypothyroidism is 50X more common in womenWomen are also more likely to be caretakers for other people with chronic diseases.
Racial/Ethnic and Socioeconomic Dimensions• White and Asian women have osteoporosis more often than African American women• African American women are more likely than white women to die following a hip fracture• American Indians and Alaskan Natives have the highest prevalence rates of diabetes• Blacks and whites have somewhat equal rates of arthritis, but blacks have a higher rate of activity limitations due to arthritis and a higher prevalence of severe pain
Modifiable Risk Factors for Osteoporosis• Diet low in calcium and vitamin D• Sedentary lifestyle• Cigarette smoking• Estrogen deficiency• Low weight and body mass index• Certain medications – Glucocorticoids, anticonvulsants• Amenorrhea• Anorexia nervosa or bulimia
Screening and Diagnosis for OsteoporosisWomen who should be tested:• All postmenopausal women younger than age 65 who have one or more additional risk factors for osteoporosis besides menopause• All women age 65 and older• Postmenopausal women with fractures• Women who are considering therapy for osteoporosis or who want to monitor the effectiveness of certain osteoporosis treatments
Treatment and Prevention of Osteoporosis• Adequate supply of calcium• Vitamin D• Participate in weight-bearing and muscle- strengthening exercises• Estrogen replacement therapy• Drugs: alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), teriparatide (Forteo), nasal calcitonin spray• Fall-prevention strategies
Arthritis• Arthritis—inflammation of the joints—affects an estimated 43 million Americans (1 of 6 people) – Osteoarthritis: degenerative joint disease – Rheumatoid: chronic inflammatory disease – Gout: excess uric acid in the body
Healthy Joint vs. OsteoarthriticJoint vs. Rheumatoid Arthritis
Symptoms of Arthritis• Achy, stiff joints• Small bony knobs on fingers (osteoarthritis) Diagnosis of Arthritis• No single test can diagnose arthritis• Family history and physical exam to check joints, reflexes, and muscle strength• Radiographs• Blood tests• Joint aspiration
Prevention and Treatment of Arthritis• Maintaining weight through diet and exercise• Avoiding contact sports and repetitive joint motion• Preventing Lyme disease (vaccine, insect repellent)• Drugs: NSAIDs, topical pain relievers, corticosteroids, hyaluronic acid, disease- modifying antirheumatic drugs, biologic response modifiers, immunosuppressants• Surgery is another treatment option
Diabetes Mellitus• 18.6 million cases of diabetes—half of the cases are womenTypes of diabetes• Type 1: Usually appears during childhood• Type 2: Most cases of diabetes• Gestational diabetes: Develops in 2% to 5% of pregnant women
Risk Factors for Diabetes• Having a first-degree relative with diabetes• Being overweight• Having hypertension, abnormal high-density lipoprotein (HDL) or triglyceride levels• Racial groups: African American, Hispanics, American Indians/Alaskan Natives
Symptoms of DiabetesType 1 Type 2• Frequent urination • Any type 1 symptoms• Unusual thirst • Frequent infections• Extreme hunger • Cuts/bruises that are hard to heal• Unusual weight• Extreme fatigue• Blurred vision
Diagnosis of DiabetesRoutine tests• Fasting plasma glucose test/oral glucose tolerance test• Normal sugar level = 70–110 mg/DL; blood sugar level above 126 mg/dL on at least two occasionsTreatment and prevention of diabetes• Daily insulin injections• Diet control• Physical activity• Home blood glucose testing several times a day
Autoimmune Diseases• Diseases in which the body’s immune system turns inward rather than outward.• More than 80 different illnesses, usually occurring among women.• Hormone related?
Autoimmune Diseases Lupus: A Poorly Understood Disease• Immune system forms antibodies that target healthy tissues and organs• Primarily a disease of young women of childbearing age (affects women 10 to 15 times more often than men), more likely to affect African American women• Symptoms can go away and then return• Types – Discoid (cutaneous) lupus – Systemic lupus erythematosus (SLE) – Drug-induced lupus
Lupus (cont.)Risk factors of lupus• Exact cause is unknown—genetic, hormonal, and environmental factors involvedSymptoms of lupus• Painful, swollen joints or arthritis• Skin rash – Butterfly-shaped across face – Triggered by sun exposure• Frequent fevers• Prolonged or extreme fatigue• Anemia• Kidney involvement
Lupus (cont.)Diagnosis of lupus • Take note of symptoms – Skin rash, joint pain, chest pain, seizures, photosensitivity, review of history of medications • Complete blood count • Antinuclear antibody test (ANA) • Urinalysis
Lupus (cont.)Treatment and prevention of lupus• Avoid sun exposure and use sunscreen• Exercise• Nonsteroidal anti-inflammatory drugs (NSAIDs)• Corticosteroids• Antimalarial agents• Immunosuppressant drugs• Steroids
Thyroid DiseaseThyroiditis: inflammation of the thyroid, the gland controlling the body’s metabolismTwo forms:• Hypothyroidism: underactive thyroid—body burnsenergy too quickly• Hyperthyroidism: overactive thyroid—body burnsenergy too slowly
Risk Factors for Thyroid Disease• Age and gender (women over age 20)• Family history of a family member with thyroid disease• Previous thyroid concerns or conditions
Symptoms of Hashimoto’s Disease and Graves’ Disease Hashimoto’s Disease (Hypo) Graves’ Disease (Hyper)• Weight gain • Weight loss• Fatigue and listlessness • Increased energy expenditure• Difficulty concentrating • Nervousness and irritability• Dry skin • Sweating more than normal• Sensitivity to cold • Heat intolerance• Constipation • Diarrhea• Goiter • Bulging of the eyes
Diagnosing and Treating Thyroid DiseaseDiagnosis of thyroid disease• Thyroid-stimulating hormone (TSH) test• Blood tests measuring levels of thyroxine (T4) can confirm presence of diseaseTreatment and prevention of thyroid disease• Annual checkups• Thyroxine for Hashimoto’s disease• Antithyroid drugs for Graves’ disease
Alzheimer’s Disease (cont.)Risk factors for Alzheimer’s disease• Age• Female gender• Genetic background – Familial Alzheimer’s disease (FAD)• Other possible factors – Lifestyle – Severe or repeated head injuries – Lower education levels – Environmental agents
Alzheimer’s Disease (cont.)Symptoms of Alzheimer’s disease• Memory loss• Decline in ability to perform simple tasks• Less clear thinking and forgetfulness• Affected language and reasoning skills• Lack of ability to make judgments• Personality changes• Emotional outbursts• Wandering and agitation
Alzheimer’s Disease (cont.)Diagnosis of Alzheimer’s disease• Person’s history, complete physical exam; various laboratory tests; brain scans; tests for measuring memory, language skills, and other brain activitiesTreatment of Alzheimer’s disease• Controlling symptoms and delaying memory loss with drugs• Maintaining a calm, safe, structured environment
Discussion: Informed Decision Making• Prevention, when possible• If prevention isn’t possible, find the disease early, and manage it to reduce symptoms and promote healthier living• Examples?