Final Exam Flashcards
Is attempting to enhance athletic performance new?
No it dates back to 776 BC in the Greek Olympic Games
- 1800 heroin
- 1960s amphetamine
- 1970s-80s anabolic androgenic steroids
- 1998 - EPO
- 2003 THG
What is ergogenic aid?
- “energy giving”
- consists of substances, procedures, methods or techinques believed to:
1- improve physical work capacity
2- physiological function
3- athletic performance
What is doping?
Practice of enhancing performance through use of foreign substances or other artificial means
- derived from Dutch word Dop
- used to be used for horses initially
What is the natural Health products directorate
- Organization that came into effect in 2004
- role: is to provide Canadians with ready access to a range of natural health products that are safe, effective and of high quality, while respecting freedom of choice, philosophical and cultural diversity.
how does one get their product on the NHP directorate?
- manufacturer must obtain natural health product number from health canada (get license)
- this will inform that it has been reviewed, safe and quality.
In order to receive a license from health canada, a manufacturer must have what?
- product name
- product license holder
- NPN
- product’s medicinal ingredients
- products non medicinal ingredients
- dosage form
- recommendation or purpose
- risk associated with use
What conditions must a product have to be NHP?
- cannot be classified as controlled drug or substance by food and drugs
What are negatives aspects of NHP?
- efficacy is not teste -> it is the responsibility of the manufacturer
- only need license by justice department
Name examples of NHP?
- vitamins and minerals
- herbal remedies
- homeopathic medicines
- traditional medicine ie: Chinese
- probiotics
- others: AA, essential F.A
What are the different categories of NHP or drugs used to improve performance?
1- increase muscle growth (most popular)
2- speed recovery from training
3- increase CRE
4- aid weight control
Name the different types of substances taken to increase muscle strength and define them? do all require prescription?
1- androgenic anabolic steroids (AAS):
2- human chorionic gonadotropin (HCG):
- taken from placenta of pregnant woman
- used to increase testicular testosterone production
3: human growth hormone (HGH):
4: dehydroxyepiandrosterone (DHEA)
- OTC is banned in canada
5: androstenedione (ANDRO)
- is a precursor
- OTC is banned in canada
6- insulin:
- can result in shock
7- insulin like growth factor (IGF-I)
- stimulated by growth hormone
8- beta- agonist
- used for asthma
- relax muscles in the airways
As NHP (dont require prescription) 9- protein supplement, AA sup, polypeptide supplement , metabolic optimizing meals
What are side effects of growth hormones?
- increase blood glucose []
- high [insulin]
- carpal tunnel syndrome
- heart enlargement
- increase blood fat levels
- acromegaly
- heart, nerve, bone and joint diseases
What are side effects of Beta-agonist
- insomnia
- heart arythmies
- anxiety
- anorexia
- nauseas
- heart attach/failure
- heart enlargement
What substances are used to speed recovery from training?
- > creatine monohydrate:
- chromium picolinate
- carbohydrate beverages
What do substances that speed recovery do?
Used to replenish depleted body fuel supplies that are important during exercise and recovery
How does creatine monophosphate work?
- used to increase recovery, power, strength, muscle size
- used for short term, high intensity, REPETITIVE exercise
- this will increase creatine phosphate levels in muscles
How does chromium picolinate work?
Will increase action of insulin and carbohydrate metabolism
how do carbohydrate beverages work?
- increase action of insulin and carb metabolism
- during or right after exercise
- speeds up replenishment of liver and muscle glycogen
What drugs are used to increase training intensity and overcome fatigue?
Would use stimulants such as:
- amphetamines
- caffeines
- ephedra
Describe the use of amphetamines?
- used by athletes to overcome fatigue and increase intensity
- will stimulate the CNS
- has side effects such as: aggressiveness, paranoia, hallucinate, heart arrhythmia
how does caffeine work to increase training intensity
Stimulates the CNS
How does ephedra work?
- it stimulates CNS
- but its use is banned OTC and by FDA since 2004
What substances are used to increase CRE?
- erythropoietin and darbepoietin (re-engineered form:
- > drugs are used to treat anemia in cancer or kidney disease
- will stimulate the growth of RBC
What are the substances that aid in weight control?
- prescription that are appetite suppressants (Diethylpropion, phentermine)
- drugs affecting Metabolic rate (caffeine, phenylpropanolamine (PPA) & ephedra, both banned in canada)
- diuretics: will promote loss of fluids from body, in order to accentuate muscle definition
What is testosterone?
- a steroid-base hormone
- is an anabolic androgenic hormone synthesized from choletestor
What does testosterone regulate?
1- tissue repair
2- secondary sex characteristics
3- various growth function
In men, what cells secrete testosterone?
In women?
Leyding cells in the testes
In women:
- secreted from ovaries and adrenal glands
- women have a much lower [] than men
Describe androgenic anabolic steroids?
- are synthetic derivatives of male sex hormones (ie: testosterone)
- can be administered orally or by injection
- used by: (Olympic, professional, college, strength athl, body builders, ins. Out of org. Sports too)
what are designer steroids?
Designed in the lab to avoid detection
- modifies structure
- ie: THG, oral turinabol
Describe Bhasin and Al’s research of androgenic anabolic steroid
- studied the effects of steroids in 40 healthy, 19-40 yrs
- had placebo and testosterone enanthat give for over 10 weeks
- > initially larger dose for 6 days, then replacement dose
Saw:
- large increase in placebo group that exercise
- even larger increase in the testosterone group that exercised
- not change in placebo fo those that did not exercise
- increase in performance for those that dont exercise
What are the normal ranges of steroids in the body?
M: 10-42 mmol/L
F: 0.7 to 2.8 mmol/L
Name all of the possible side effects of using steroids?
- increased aggression
- depression
- increased arousal, self-esteem
- insomnia
- mood swings, psychosis
- increased blood cholesterol/TGA
- increases LDL
- decreases HDL (increases CVD chances)
- increase hypertension, risk of HA, stroke
- prostate cancer, liver tumour, acne, alopécie
What are the main symptoms of AAS in men and women?
Men:
- decrease [test]
- decrease stem count
- testicular atrophy
- impotence, infertility
- gynecomastia (breast development
Female:
- masculinization (voice)
- hiscutism (body, facial hair)
- clitoral enhancement
- menstrual irregularities
What is a prohormone?
- a precursor of a hormone, a prehomrone
- ie: androstenedione which is a precursor of testosterone
estrogen has estrone as precursor
What do manufacturers claim of prohormones do?
- will improve blood [test]
- increase muscular strength
- Increase muscle mass and size
- help decrease body fatness
- help sexual performance
Why were androstenedione use banned in 2004?
Their chronic use may increase the risk of:
- CVD
- impaired liver function
- gynomastia in me
- breast cancer in women
- pancreatic cancer in men
- prostate cancer inmen
What did research who do supplementation in healthy young/middle/older men of androstenedione?
- no result of increased [test]
- no muscle mass or strength or body comp
- actual decrease in HDL which would increase risk of CVD
- resulted in significant increase in estrogen, estrone, estradiol []
Describe the Kicma and all research experiment?
-showed increase in testosterone in women
Describe creatine?
- is a nutritional supplement
- first used in 1992
- composed of AA 9met, arg, gly)
- important for short duration, high intensity exercise
- is a substrate for ATP formation
What are sources of creatine?
Endogenous: synthesized by liver, kidney, pancreas
Exogenous: meat and fish
Where is creatine stored?
- in skeletal muscles (98%) 40% as creatine, 60% as creatine phosphate
- heart
- brain
- testes
What is the recommended dosage of creatine?
Two methods:
Loading:
- initial 20g/day for 4-5 days, will increase in 20% muscle
- maintenance dose: 2g/day
No-loading:
- 3G/day will also give rise to 20% increase but slower
At recommended exogenetic effect will bring?
Improved repetitive performance
Describe caffeine, its sources etc?
- known as 1,3,7 trimethylxanthine
- is CNS stimulant
- has diuretic effects (increases urination)
- is the most widely ingested psychoactive drug
What are sources of caffeine?
- caffe, teas, cocoa, cola nuts cola drinks, guarana
Is caffeine ergogenic?
Yes, as it increases performance of p.a
What are side effects of chronic use?
- dépendance
- tolerance
- drug craving
- withdrawal symptoms (headache, fatigue, decreased energy, anxiety, nausea, vomiting
Describe erythropoietin
- hormone released by kidneys when oxygenation is decreased
- acts on BM to increase RBC which will increase hB and oxygen carrying capacity
- wil improve VO2 max and CVE exercise and performance
What are the risks of using EPO?
- increase viscosity of blood + dehydration
- hypertension
- stroke
- heart atttack
- heart failure
- pulmonary Edema (fluid in lungs)
- flu-like symptoms
- hyperkalemia (increases [k] higher than normal)
- death
What are the different steps to developing a fitness plan?
1- set goals 2- select activities 3- set a target FITT principle 4- set up system of mini-goals and rewards 5- include lifestyle P.A in your program 6- develop tools for monitoring 7- make a commitment
how should the “set goals” step be ?
- can be general or long term (ie: decrease risk of chronic disease, increase energy)
- can be specific or short term ( increases VO2max by 10%, lower BMIA of 26 to 24.5
- have SMART goals (specific, measurable, attainable, realistic, time-frame specific
What is necessary in order to set goals?
Need an assessment test
How often should you measure progress?
Every 3 months
how should you select activities for your fitness plan? What are two strategies?
- best to have exercise that develop all health related components:
- CVE, muscular strength, muscular endurance, flexibility, Heath body composition
First strategy:
- select one activity for each component of Physical fitness
Second strategy:
- cross training
- use several different activities to develop a particular physical component 9ie: for CVE; running, cycling, swimming
What are the factors to consider when selecting exercise for fitness plan?
- fu and interest
- current skills and level of fitness
- time/convenience
- special health needs
- most popular is walking
What are the FITT principle recommendations for CVE
F: 3-5 days/wk
I: 57 / 64-95% MHR
30/ 40-89 HRR
T: 20-60 min in 10 min or more
T: continuous rhythmic activities using large muscle groups
Name FITT principles for resistance
F: 2-3 non cons days/wk
I: sufficient to fatigue muscles
T: 8-12 reps/exercise, 1 or more set
T: For all major muscle groups 8-10 exercises
What is FITT for flexibility training?
F: 2-3 days/wk min
5-7 days/wk max
I: stretch to discomfort
T: 2-4 reps/exercise held for 10-30 seconds
T: stretching exercise for all major joints
PHAC says what about CVE T (from FITT) about when benefits occur?
Must have at least 150 min/wk of mod int.
Or 75 min/wk of rig. Intensity
What are minigoals and rewards system?
To break the goals into mini goals (several steps) and have a target date for each with a reward
How to monitor progress?
Develop tools such as a record of daily progress (reps, time etc.)
How does the commitment occur?
- make a contract with info and sign it
What are guidelines to put your plan into action?
- start slow, increase fitness
- find buddy
- ask for support
- vary activities (crosstraining)
- cycle duration/intensity of workout
- adapt to changing env. & schedule
- expect fluctuations and lapses
- choose other healthy lifestyle behaviours
Describe what cross-training is and how it Helps
- Can prepare you for wider range of activities and challenges
- Helps to develop balanced total body fitness
- help to build upper + lower body
- decreased risk of injury and overtraining
- can alter on different days or within single workout
What are the guidelines for exercising in children (5-11) and adolescent (12-17)
- they need a lot of exercise daily
- minimize sedentary life
- min 60 min of mod-Vit intensity aerobic P.A / day
- choose dynamic family outings
If under 12yrs old what should be emphasized?
Emphasize skill development & fitness rather than excellence and competitive sports
If adolescent what should be emphasized?
- combine participation and training in lifetime sports
What are guidelines for pregnant woman
- continue a mild to moderate routine 3 or more times / week (HR of 100-160
- use ratings of perceive exertion instead of HR (should be 11-13)
- favor non or low-weight bearing
- during first semester -> drink lots o fluids and exercise in well ventilated areas
- after birth (resume exercise routine gradually)
What should be avoided in exercise for pregnant women?
- vigorous until exhaustion (especially 3rd trimester)
- avoid supine positions that can cut blood flow (after first trimester)
- prolonged motionless standing
- exercise with loss of balance (esp. 3rd)
- exercise that may injure abdomen, stress joint and carry risk of fall (ie: contact sports, skiing)
- exercise involving extremes in barometric pressures (diving, climbing)
What exercise is recommended for preventing incontinente and speedy after birth recovery?
- performing 3-5 sets of 10 kegel daily
- involves tightening of muscles of pelvic floor for 5-15 secs
What are exercise reco (CVE, flex, strength, balance) for older adults (over 65yrs old)?
CVE:
- 150min or more of mod to vig/ week
Strength:
- activities involving major group muscles
- 2 or more days/ week for at least 10 min
Flexibility:
- 2 or more days/week for at least 10 min
Balance training:
- two days per week
What should older adults do in their fitness exercise?
- drink adequate amounts of water
- avoid exercise in too hot or cold
- warm up slowly
- do as much as you can
- increase intensity/duration gradually
- cool down slowly until HR is under 100 bpm
What are the recommendations for the most popular activity of walking? To lose weight without any other adjustment
30 min, 5x per week:
- results in loss of 2.5kg in 6-12 months, without dieting and exercise intensity
What is reco for waking to promote wellness?
- walk at moderate intensity(9-10km/hr) for 150-300 min/wk
OR - jog (at 70% of effort or more) for 75-150 min/wk
What is speed of walking?
Jogging?
Running?
Walk - <8km
Jog - 8-12
Run - pace above jogging
What are the major forms of CVD?
1- atherosclerosis 2- heart disease and heart attacks 3- stroke 4- congestive heart failure 5- hypertension
What is atherosclerosis?
- disease in which inner layers of the artery walls are made thick and irregular by deposits of fatty substance (plaque)
- is slow, progressive hardening and narrowing of arteries by plaque (deposits of fat, cholesterol and other subst.)
- atherosclerosis is a form of arteriosclerosis
What are the main risk factors of atherosclerosis?
- cigarette
- physical inactivity
- high [cholesterol]
- high B.P
- diabetes mellitus
What are health consequences of atherosclerosis?
- coronary heart disease (CHD)
- angina lector is
- heart attack (myocardial infarctus - MI)
- stroke (Cerebral vascular accident - CVA)
- decreased supply of blood and O2 to other organs/tissues
what intermittent claudication?
- occurs in periphery -> calf hurts and then goes away
- temporary decrease of blood supply to tissue
What is coronary heart disease?
When coronary arteries are susceptible to plaque buildup
What is angina pectoris?
- a lack of blood supply to heart which results in chest pain
- is NOT a heart attack
- can be stable or unstable
What is a heart attack
- caused by blockage of coronary arteries
What is a stroke?
Caused by blockage of cerebral artery or ruptured blood vessel
What are the different heart diseases / heart attacks?
- coronary thrombosis: a heart attack caused by a blood clot in one of the coronary arteries supplying blood to heart
- angina pectoris (tightness of chest, heavy pressure, breastbone, shoulder neck arm)
- arrhythmia: irregularity in force of rhythm of heart beat. Too quick, too slow or in irregular fashion
- sudden cardiac death (cardiac arrest)
What are sudden cardiac death caused by?
Ventricular fibrillation (an arrhythmia)
What are the symptoms before a sudden cardiac arrest?
No signs really excep fainting
- 1 hr before, may have chest pain, nausea, shortness of breath
What do you do if sudden cardiac arrest occur?
- call 911
- CPR
- automated external defibrillator (AED)
What are the most common symptoms of heart attack?
- chest discomfort
- upper body discomfort (arms, chest, jaw, shoulders)
- shortness of breath (can occur before or with chest pains)
- others: cold sweats, light headed, dizziness
- not all heart attack involve pains (women feel other symptoms)
Describe chest discomfort?
- center or left
- may stay or leave and come back
- pressure squeezing feeling
- can feel like heart burn or indigestion
- can be mild or severe
how do women symptoms differ in heart attacks them men?
- most likely to have other sings, such as shortness of breath, unusual fatigue, cold sweats, nausea, vomiting, pain back, shoulder
how can you diagnose a heart disease?
- exercise stress test + ECG
- MRI
- electron beam computed tomography (EBC)
- echocardiogram
- angiogram
What are treatment of heart diseases?
- low fat diet
- reg exercise
- smoking cessation
- take aspirin daily (81mg)
- prescription drugs
- balloon angioplasty
- implantation of coronary stents
- coronary bypass surgery
What is a stroke?
- occurs when blood supply to brain is cut off
- can cause permanent disability or be fatal:
- paralysis, walking disability, speech imp, memory loss, change in behavior
What are the two major types of strokes?
Ischemic stroke (80%) hemorrhagic stroke (20%)
Describe an ischemic stroke and the two different types?
Is a blockage of a vessel. Can be:
1- thrombotic stroke:
- blood clot formed in brain - in cerebral or carotid artery which has been narrowed by atherosclerosis
2- embolic stroke: caused by embolus - wondering blood clot that is carried by blood stream and gets wedged in cerebra; artery
Describe hemorrhagic stroke and two types
When a blood vessel in brain burst, spilling blood into surrounding tissue
1- intracerebral hemorrhage: blood vessel ruptures within the brain
2- subarachnoid hemorrhage: blood vessel on the brain surface ruptures and bleeds into space between brain and skull
What are signs and symptoms of a stroke?
- sudden numbness or weakness of face, arms, legs -> especially one side)
- sudden confusion, trouble speaking, understanding speech
- trouble seeing
- trouble walking, dizziness, loss of balance
- sudden severe headache
What are effective treatment of stroke?
- quick recognition of sighs
- correct diagnosis of type
- use clot dissolving and antihypertensive drugs (TPA - which will break down clot. Must be used within 3 hrs, maybe 4.5 hrs new research)
What are silent strokes?
- do not cause noticeable symptoms
- leave victims at higher risk for more serious strokes
- contributes to loss of mental and cognitive skills
What are transient ischemic attack (TIA)
- same signs as stroke
- symptoms usually less than 1-2 hrs but up to 24 hrs
- may occur once or more often
- usually warning sign that more are coming
Describe congestive heart failure
Results in heart inability to pump all blood that returns to it because heart cannot maintain a regular heart rate and force
- consequences: fluid back up in body resulting in edema (legs, ankles, sometimes lungs)
What is edema?
Occurs when capillaries leak fluid
What are factors that can damage the hearts pumping mechanism?
- high blood pressure
- heart attack
- atherosclerosis
- viral infection
- rheumatic fever
- birth defects
What are treatments for congestive heart failure?
- decrease workload on heart
- modify salt intake
- drugs to help eliminate fluid
What are risk factors for CVD? What are the three categories?
Controllable (lifestyle factors + health)
Uncontrollable (health)
What are the controllable lifestyle risk factors for CVD?
1- tobacco use 2- unhealthy weight 3- physical inactivity 4- unhealthy diet 5- stress
What are health related controllable risk factors
- high blood pressure
- cholesterol levels
- diabetes mellitus
- atrial defibrillation
Describe how tobacco use affect risks for CVD?
- risk increases with length, intensity and exposure
- 70% more chance of dying fro CVD
- double risk of cervical cancer for women
- second hand smoking also bad
how does tobacco damage cv system?
- damages lining of arteries
- decreases HDL, increases LDL
- increase triglycerides
- increases BP and HR
- CO displaces O2 in blood
- causes platelets to stick together (clotting)
- speed development of fatty deposits in arteries
How does an unhealthy weight affect risk of CVD?
2-3x more risk of CVD in obese ppl excess weight: - puts strain on heart = high BP - high cholesterol - type II diabetes - abdominal obesity
how does physical inactivity affect CVD risk
- 60 % of Canadian are sedentary
- exercise lowers risk by:
- decreases BP
- increases HDL
- maintaining desirable weight
- improve blood vessel conditions
- prevent type II
- contra diabetes
How can drug and alcohol abuse affect CVD?
- stimulant drug can cause H.A, stroke, sudden cardiac death (cocaine, ecstasy, methamphetamine)
- injected drug can cause infections
- increase alcohol can cause increase risk of heart disease and stroke
how does high blood pressure affect risk of CVD?
it increases risk of
- Heart attacks
- congestive heart failures
- stroke
- kidney failure
- blindness
- most controllable risk factor for stroke!
What are recommended changes for high blood pressure?
- decrease weight
- regular p.a
- a healthy diet with fruits, whole grains, rich in vit. K, ca, fibre (DASH)
- low sodium
- mod alcohol consumption
What is the health canada guidelines fo sal consumption?
AI: 1500 mg/day
TUL: 2300 mg/day
What are cholesterol levels? What do they do in body?
- fatty / waxy substance that circulates through bloodstream
- important component of: cell membrane, sex hormones, vit. D, fluid that coats lunc=gas, myelin sheath around nerves
What can excess cholesterol cause?
- can clog arteries and increase risk of CVD
how do our bodies obtain cholesterol?
Liver production:
- 80% of total body cholesterol
- ingesting high saturated and trans F.A increase liver production of cholesterol
Food:
- 20% of cholesterol
- comes from animal source
What are lipoproteins?
- are carriers of lipids (cholesterol, TAG, phospholipids) in human body
- composed of all three + proteins
- exists in a variety of forms
What are the different forms of lipid carriers?
- chylomicrons
- very low density lipoproteins (VLDLs)
- low density lipoproteins (LDL)
- high density lipoproteins (LDL)
Describe chylomicrons?
- synthesized in small intestine after meal
- transports dietary lipids from small I. To blood to various tissues (adipose, msucle,liver)
- goes in lymphatic system
Describe VLDL?
- lipoproteins synthesized in liver to transport endogenous lipids to various tissues of body
Describe LDL?
- Formed in liver by breaking down VLDLs
- transport cholesterol from liver to organs that need it
- bad cholesterol because excess amounts is deposited in blood vessels ie: arteries and may then be oxidized by free radicals resulting in inflammation/damage
Describe HDL?
- formed mainly in liver
- transports cholesterol from body;s tissue back to liver for recycling or excretion
- “good cholesterol”
A high risk for CVD includes?
- high total cholesterol
- high LDL
- low HDL
- high triglyceride blood []
How do you improve cholesterol levels?
- > primary goals: reduce LDL to healthy levels
- choose unsaturated over saturated and trans F.T
- increase soluble fibre intake
- fruits, veggies, whole grain
- consume plant Stanton’s ad plat sterols
- soy protein
- exercise regularly
- > supplemental goal: raise HDL
- exercise reg.
- lose weight
- no smoking
- alter amount and type of dietary fat
Which lipoprotein is synthesized in the liver to transport endogenous cholesterol to various tissues of body?
VLDL
Which lipoprotein is formed in liver and transports cholesterol from body back to liver for recycling or excretion?
HDL
How does diabetes mellitus increase risk of CVD?
Increased glucose can damage lining of arteries and therefore more vulnerable to atherosclerosis
Name the different types of diabetes and describe them?
Type I:
- insulin dependent
- juvenile onset <30yrs
- 5-10% of diab
- is acute
- decrease B cells which secrete insulin
- results in frequent ketoacidosis
Type 2:
- non insulin dependent
- 90-95%
- adult onset (now over 25yrs)
- slow
- linked to obesity
Gestational diabetes
- 2-5 % of pregnancy
Other types that result from:
- specific genetic syndromes
- surgery, drugs,malnutrition, infection
What is a normal, impaired and diabetic level of glucose in blood?
Normal < 5.6
Impaired 5.6<7
Diabetic >7
Why are risks increase if diabetic for CVD?
- increase blood glucose
- atherosclerosis
- hypertension
- obesity
- unhealthy cholesterol and triglycerides level
- platelet/blood clotting
Describe atrial defibrillation?
- Type of arrhythmia
- most common
- risk increased with age
- can lead to stroke/heart failure
- can lead to tachycardia >150 bpm
- resp for 1/4 of all stroke at >40yrs
What are the uncontrollable risk factors for CVD?
- hereditary (unfavourable sets of genes, modifiable by lifestyle)
- aging (> 65 higher risk of H.A, >55 30% higher risk of stroke)
- being a male (women until 50 are protected by estrogen)
- ethnicity (First Nation and inuits have higher rates of CVD)
- Inflammation
how does inflammation play a role in CVD?
- occur when artery is injured such as in smoking, hypertension, high total or LDL levels.
- can be measured by CRP protein test (c-reactive protein)
- high CRP increase risk for H.A + stroke (also harmful for arteries)
- gum disease can influence progress of Hear disease
What are the possible risk factors currently being studied?
- elevated homocysteine levels
- severe Vit. D deficiency (associated with heart dysfunction)
- infectious agents (chlamydiae, CMV, helicobacter)
- Gum disease (gingivitis - inflamed gums)
- fibrinogen (proteins involved in clotting, high levels believed to be marker for CVD)
how does elevated homocysteine affect CVD?
- AA that may damage lining of blood vessel
- levels are higher in men>women
- higher in those with diets low in folic acid, vit b12, vit b6
- levels can be lowered by eating fruits, veggies, supplements and grains
how to protect yourself vs CVD?
- eat heart earthy diet
- exercise regularly
- avoid tobacco
- know and manage blood pressure
- develop ways to handle stress and anger
- know your risk factors
What is a heart healthy diet?
- decrease fat and cholesterol
- increase fiber intake (soluble fiber)
- decrease sodium, increase K
- mod. Alcohol consumption
- DASH to stop hypertension
What is the cholesterol/ fat consumption tolerance for all Canadians vs. Ppl with risks?
All:
- total fat: not more than 30% of TDCalories
- sat fat: Not morethan 1/3 of total fat = 10%
Ppl at risk:
- T.F: 25-35%
- sat fat. Less than 7% of total DC
why are soluble fibers important in diet?
Traps bile the liver needs to make cholesterol
- is associated with 40-50% decrease in risk
- need 25-38 g
What is the reco for K+
4700 mg/day
What is the reco for sodium?
For healthy:
TUL: 2300mg/day
Hypertensive ind.:
1500 mg/day
What is reco for alcohol consumption
M- not more than 2 drinks/ day
W - no more than 1 drink per day
This will increase HDL and decrease stroke risk
how often should you measure you BP?
If not at risk: once every 2 years
If at risk: yearly
If high: followed by physician
How often should you get your lipoprotein profile verified? What is the LDL goal?
If above 20 yrs -> every 5 years
LDL goal depends on risk factors such as smoking, high BP, history etc.
What is stress?
- Collective physiological and emotional response to any stimulus that disturb homeostasis
- general physical and emotional state that accompanies
What i homeostasis?
- state os stability and consistency of ind. physiological functioning.
- state that pH, body temp,
- range are all maintained
What is a stressor. What are types?
- any physical or psychological event or condition that produces physical and emotional rxn
- a situation that triggers physical and emotional runs
Eustress and distress
What is a stress response?
- physiological changes associated with stress
The physicals motion also rxn to a stressor
What systems are activated in a stress response?
The nervous system and the endocrine system
What are the different organizations of the. Nervous system?
- CNS (brain and spinal cord) and PNS (afférent and efferent)
afferent
-somatic SN and visceral SN.
Efferent
- autonomic N.S (automatic)
- somatic N.S (voluntary)
Autonomic has:
- parasympathetic and sympathetic
What is the role of parasympathetic NS?
- moderate excitatory effects of sympathetic
- slows metabolism and restores energy
- in control when relaxed
- aids in digestion, storing food, promoting growth
what are examples of effects of parasympathetic NS?
- constrict pupils
- decrease HR
- constrict bronchi
- stimulate peristalsis
- constrict bladder
What is the role of sympathetic NS?
- reacts to danger and other challenges by increasing body processes
- activated during arousal (exercise, emergencies)
- nerves use NE to exert their effects
- commands the body to mobilize all energy resources to respond to crisis
What are examples of effects of sympathetic?
- dilates pupils
- increase HR
- dilate bronchi
- stops digestion
- relaxes bladder (why want to pee when stressed)
What is the role of the endocrine system?
Is a target of the Sumpathetic N.S
- is a system of glands/tissues and cells that secrete hormones and other chemical messenger in blood stream that influence metabolism and processes
- release from adrenal gland (cortisol, epinephrine, NE)
- helps prepare body
Where is ACTH released from?
Pituitary gland and informs adrenal cortex to release cortisol
What is the fight to flight reaction?
- Defense reaction that prepare for conflict by triggering hormonal, CV, metabolic and other changes
What are the fight or flight pathways?
Endocrine:
Stressor -> hypothalamus -> pituitary gland -> ACTH -> adrenal glands
NS pathway:
Stressor -> brai > autonomic NS -> adrenal gland
how does one return to homeostasis?
- Peripheral N.S takes command when stressful situation stops
- initiates adjustments necessary
- calms body
- decreases HR and BP
- dries sweaty palms
- returns to normal breathing
What can influence how one reacts to a stressor?
The cognitive appraisal
What are two factors that can reduce magnitude of stress response?
- successful prediction of stressor
- perception of having control
What are behavioural response to stressors contrôle by?
- somatic NS and is under conscious control
What are effective Behavioural responses?
- talking, laughing, exercising, mediating, learning time-management skills
What are ineffective behavioural responses
- overheating
- expressing hostility
- tobacco, drugs, alcohol
What are common emotional responses to stressors?
- anxiety
- Depression
- fear
What is a personality?
- sum of behavioural and emotional tendencies
- affects how ppl perceive and react to stress
- what affects personality:
- > personality type
- > hardiness
- > resilience
What are the different personality types?
A - ultra competitive, impatient, aggressive -> increase heart disease
B- relaxed, more tolerant, less frustrated
C- difficulty expressing emotion, hopelessness, exaggerated response to stress
D- Tends towards neg emotional state (anxiety, depression) avoids socialization. Worry of others
What is hardiness?
- Particular form of optimism
- one sees challenges as opportunity to grow and learn
- perceives less situations as stressful also less intense
What is resilience?
- personality traits associated with social/academic success in groups at risk for stress (low income, phys. disability)
- associated with emotional intelligence
- 3 basic types
What are the three basic types of resilience?
1- non reactive resilience
2-homeostatic resilience (returns to baseline quickly)
3- positive growth resilience (person learns. And grows from experience)
What are the total response to stress (as a whole)
Physical:
- dry mouth
- gridding teeth
- headaches
- HBP
- pounding heart
Emotional:
- anxiety
- depression
- irritability
- fatigue
Behavioural
- Craig
- trouble sleeping
- trouble eating
- sexual
- social isolation
The more intense the ____ response the more intense the ___ response
Emotional
Physical
what is the general adaptation syndrome (GAS)?
- developper by Hans Selye
- used to describe a universal/predictable response to all stressors
- can be applied to Eustress and distress
- has three stages
What are the 3 stages of the GAS?
Stage 1: alarm stage
- activation of sympathetic and endocrine system
- fight to flight reaction
- body is susceptible to disease and injury
Stage 2: resistance or adaptation stage
- body develop new level of homeostasis when prolonged stress
- more resistant to disease/jury than normal
Stage 3: exhaustion
- if stressor persist or too many stressors will result in exhaustion
What is allostatic load?
- long term wear and tear of stress response
- is the increase susceptibility to disease after repeated prolonged stress -> due to effect of stress response itself
- depends on many factors (genetic, life experiences, emotional/behavioural response)
A high allostatic load may be due to?
- frequent stressor
- poor adaptation to common ones
- inability to shut down stress response
- imbalances in stress responses
high A.L is linked to?
- heart disease
- increase HBP
- obesity
- decrease brain and immune functioning
What are specific conditions that stress can affect?
- immune system
- disease and inflammation (MS, heart, Type II)
- CVD
- others: digestive problems, tension headache, insomnia, menstrual irregularities, impotence, psychological problems
how can stress affect the immune system?
- lowers its ability to fight, vulnerable to colds/infection
- asthma/allergy
- susceptible to cancer
- flare up of chronic diseases
What results from chronic stress?
Prolonged exposure to cortisol levels which may accelerate course of disease that induce inflammation (MS, heart, type II)
What increases risk of CVD
Certain types of emotional response
What are common sources of stress?
- major life changes
- daily hassles
- university/college stressor
- job related stresses or
- relationships & stress
how to manage stress?
- exercise
- nutrition
- sleep
- communication (through self-disclosure, listening, feedback)
- conflict resolution
- strategies to improve time-management skills
- cognitive techniques
- relaxation techniques
what are the recommendation for sleep and why is it good?
7-9 hours To improve: - mood - feelings of competence, self-worth - increase mental functioning
- lack can be both cause and effect
What are consequence of sleep deprivation?
- slows response of stress hormone
- decrease mental/physical processes
- irritability/headaches
- more forgetful
- increase risk of suicide
What are extreme symptômes of sleep deprivation?
Hallucination/ psychotic
Increase heart attack risk
What are basic négociation strategies?
- clarify issue
- what each want
- decide how to negotiate
- solidify agreement
- review, renegociate
What are strategies to improve time-management skills
- set priorities
- schedule tasks
- set realistic goals
- keep track
What are cognitive techinques for?
To reduce stress by breaking negative impact of ideas/beliefs to reduce:
- focusing on negative
- expecting the worst
- minimizing achievements
- blaming others
- expecting perfections
What are techniques to break negative impacts of beliefs?
1- monitor yourself talk (attempts to decrease hostile, critical thoughts)
2- modify expectations (take life as it comes)
3- live in present
4- go with the flow (what you cant change)
5- cultivate sense of humour (healthy laughter)
What is a relaxation technique used for?
To reach a physiological state characterized by feeling of warmth and quiet mental alertness
Who identified the relaxation response?
Hebert Benson
What is the relaxation response?
- opposite of F or F
- characterized by:
- > decrease HR, breathing, metabolism
- > increase blood flow to brain and skin
- > shift in brain waves from beta to alpha
What are the relaxation techniques to achieve relaxation response
- progressive relaxation
- visualization
- deep breathing
- listening to music
- meditation
- others: (biofeedback, hypnosis -selfhyp, massage, Hathaway yoga, taijiquan (tai chi)
Describe the progressive relaxation technique (deep muscle relax)
- involves tensing and relaxing muscles one by one
- alternating muscle tension relaxation
- inhale -contract / exhale-relax
- .> consciously relaxing sends message to other body system to decrease their stress response
Describe visualization (imagery)
Creates or recreates mental pictures of place or experience
Describe deep breathing
- deep, slow association with relaxation
- rapid shallow is associated with stress response
- for relaxation: more belly breathing, tension -release breathing
what is meditation wha are the two general types?
“Self-reflective thought”
- involves quieting the mid to achieve deep relaxation
1- exclusive meditation
- focus on single word/though and eliminate others
- easier
2- inclusive meditation
- mind is allowed to wonder uncontrolled from thought to thought
What is biofeedback?
- help ppl reduce stress response by having them made aware of their level of physical arousal
- some measure of stress (skin, sweat) is monitored
- objective is to transfer what is learned to biofeedback to life
Describe Hathaway yoga
Means: “union of mind, body and soul
- developed system of physical postures, called asanas designed to cleanse body, unlock energy path and increase level of consciousness
- increases strength, flexibility and stress relief
Describe taijiquan?
- martial art dev. In china
- movements are called forms -> slow gradual graceful acne that mimics animals
- promotes:
- > relaxation/concentration
- dev. Of body awareness, balance, muscular strength and endurance and flexibility
What are counterproductive strategies for coping with stress?
unhealthy coping technique such as:
- alcohol
- tobacco
- other drugs
- binge eating
how else can you deal with stress?
- getting help:
- > peer & support groups
- professional (psychiatrist, psychologist)
When is emotional response to stress considered serious?
- if depression, anxiety interferes with school/ work performance
- suicide attempts/ consideration
- hallucination, delusions, loss of memory
- alcohol/drug impair normal functioning - > experiencing withdrawal
What is the second leading cause of death in 15-25?
Suicide
What are symptoms of depression?
- negative self concept
- pervasive feelings of sadness/hopelessness
- loss of pleasure
- loss of appetite/weight loss
- insomnia/ disturbed sleep
- restlessness/fatigue
- thought of worthlessness/guilt
- thoughts of death/ suicide
What is them ost common cause of death in canada?
Cancer
What % of caner death could have been avoided and by changing what?
- over 60%
- by change of lifestyle such as tobacco smoking which is 1/3 of cancer deaths
- diet/exercise and relationship to cancer death also 1/3
what is cancer?
- abnormal, uncontrollable growth of cells which if untreated can lead to death
What is a tumour? What are the types?
- benign tumor:
- > non- cancerous, not capable of spreading
- > composed of cells similar to surrounding normal cell and enclosed in membrane preventing penetration of neighbouring tissues
Malignant tumor:
- cancerous, capable of spreading
- capable of invading surrounding structures (blood vessel, lymph, nerves)
how does a tumor spread?
- through metastasis - spreading of one part to the next
- > primary tumor
- > secondary tumor (cancer cells that have spread)
how does metastasis develop?
1- mutation
2- hyperplasia (reproduce too much -> then further mutation)
3- dysphasia (when irregular shape and increase in production)
4- malignant: if tumor beings invading underlying tissues
What are the main causes of cancer?
1- genetic factors - role of DNA 2- tobacco use 3- dietary factors 4- obesity and inactivity 5- carcinogens in environement
What is the basic unit of hereditary, which some control cell division and play critical role in developing cancer?
Genes
What is a mutation?
- any change in are up of genes
- can be inherited or environemetally caused 9mutagen
What is a mutagen?
- one that cause cancer: carcinogen
- ie: radiation, certain viruses (CMV), chemical substances we breathe
What is an oncogene?
- Gene in which. Mutations are associated with conversion of normal cell to cancer cell
- when undamaged: plays a role in controlling/restricting cell growth - called Tumour Repressor genes
What is an example of inherited gene?
BCRA1 (breast cancer gene 1)
- increases risk of breast ad ovarian cancer
- most mutations occur after birth
Rare: 5-10% of breast cancer
10-15% of ovarian cancer occur because of mutation. Rest are inherited.
What does cancer promote?
- accelerate the growth of cells = less tie fo repair DNA damage
- do not directly produce mutations, but unable to fix mistakes
- ie: estrogen that stimulates growth in female reproductive organs
Smoking is responsible for % lung cancer and all cancer death?
85% of lug cancers and 30% of all cancer death
- include: larynx, mouth, pharynx, esophagus, stomach, pancreas, kidneys, bladder, cervix
What dietary factors affect cancer rates?
-> dietary fat and Meet
-> alcohol
-> food cooked at high temp
Help:
-> fiber (helps cancer)
-> fruits/ veggies (high evidence_
-> foods with phytochemicals
What type of diet can increase risk of colon, prostate, stomach cancer?
- high in fat and meat is associated with colon, prostate, stomach cancer
- diets favouring omega 6 polyunsaturated are at higher risk
What type of risk does alcohol consumption give you?
- increase in breast cancer
- if with alcohol, increased oral cancer
Why do foods cooked at high temp dangerous?
- acrylamide which is a probable carcinogen is found at high levels of starch based food that are fried at high temps
Has fiber been proven to have cancer fighting abilities?
No - but provides positive effects
how do fruits and veggies affect cancer?
- high evidence that reduce risks of cancer
- essential nutrients act as antioxidant (vit C,E, carotenoid, selenium)
What type of foods have phytochemicals and are good to prevent cancer?
- carotenoid in deep green vegies and orange
What is obesity and inactivity associated with?
- colon, breast, endometrial, kidney and prostate cancer
Research has shown a relationship btw increase ____ and decrease ___ risk
P.A
Cancer
What are the different carcinogens in environement that could affect cancer risk?
- ingested chemicals
- environmental and industrial pollution
- radiation
- microbes
What type of injested chemicals are dangerous for cancer?
- nitrates/nitrite
- > found in preservatives
- > not carcinogens on their own but can combine with chemical in stomach and form nitrosamines which is highly carcinogenic
- foods cured with nitrite
- > can cause esophageal cancer and stomach
- regular exposure to charred meats
What is the % of cancer death cause by air/water pollution, vs. Workplace?
2% vs. 5% (work place is more important)
Radiation?
All sources of radiation are potentially carcinogenic
- xrays, radioisotopes, un rays
how do microbes affect risk of cancer? What % are cause by them?
- 15% of worlds cancers
- certain HPV can cause oropharyngael, cervical
- helicobacter pylori bacterium can cause ulcers, stomach cancer
- EBV virus, that causes mono may contribute to Hopkins disease, cancer of pharynx and stomach
- human herpes virus 8 -> linked to sarcome, + certain types of lymphoma
- hep b and C together may cause 80% of liver cancer
Name the different microbes that play a role in cancer?
- HPV
- helicobacter pylori
- EBV
- human herpes virus 8
- hep b and c
Give cancer statistics
> 200K diagnosed per year
- 90% are over 50 yrs
- 49% (men), 45% in women
Wha does incidence mean? Prevalence?
New cases of disease
Number of existing cases
What are the most common types of cancers?
- lungs
- colon and rectal
- breast
- prostate
What is the second leading cause of cancer deaths in males and M/F combined?
- colon & rectal
What is the most common type of cancer in women and 2nd leading in cancer death in women?
Breast
What is the 3rd leading cause of cancer death in male?
Prostate
What is the first cause of cancer death in male and female?
Lung cancer
What are the risk factors for lung cancer?
- tobacco smoke
- long term exposure
- exposure to asbestos
What are lung cancer symptoms?
- cough, chest pain
- usually found at invasive stage
What is prognosis for lung cancer?
5 yr survival of 17%
What is treatment of lung cancer?
- combination of surgery, radiation, chemo
What are risk factors for colon and rectal cancer?
- age is major factor ( 90% diag are over 50yrs)
- preexisting polyps
- genetics
- lifestyle factors (inactivity, obesity, red meat, simple sugars, excessive alcohol, smoking)
What are symptoms of colon and rectal cancer?
Bleeding from rectum
Change in bowel habits
What is the 5 yrs survival rate of colon/rectal?
90% if early
65% overall
how is colon/rectal diagnosed?
- high sensitivity fecal occult blood test (FOBT)
- > if you are 50-74 -> every 2 years
- > high risk, tested more
- if FOBT is positive:
- Colonoscopy
- sigmoidoscopy
- surgery
how to prevent colon/rectal cancer?
- oral contraceptive for women
- diet rich in fruits/veggies whole grain
- adequate folic acid, ca, mg, vit D
- regular use of non steroid (ibuprofen, aspirin)
What is the 5yr survival rate i breast cancer?
Early - 98%
All stages: 88%
What are genetic risk factors for breast cancer?
- strong genetic factors
- early on set mentrusation
- late menopause
- not having children
- having first child after 30
- using hormone replacement therapy
- obesity, alcohol,smoking
- estrogen: promotes cell growth in response to tissues produced by fat cells. Can be increased by alcohol
What are symptoms of breast cancer?
- lump
- thickening
- irritation, redness, flaky
- nipple discharge
- pain, change in size
How does breast cancer diagnosis occur?
- 50-74: mammography every 2 years
- digital mammography which is more accurate
- breast self-awareness not recommended anymore but be familiar
- if lump: get biopsies or scanned
What are treatment of breast cancer?
- surgery: lumpectomy or mastectomy
- chemo/radiation
- drugs: SERMS, heceptin (antibody receptor)
How to prevent breast cancer?
- low fat, veggie diet
- reg exercise
- limit alcohol
- body weight
- increase vit D
What are the risk factors in prostate?
- age strong predictor (75% 65 and older)
- family history
- inherited genetic predisposition (5-10%)
- ethnicity
- diet
- obesity
- sexually transmitted
- type II diabetes
What is the 5 yr survivalof prostate cancer?
100 all stages
What is diagnosis of prostate cancer?
- rectal examination
- ultrasound
- biopsy
- protaste specific antigen blood test: can yield false +, talk about it close to 50y, family history, have symptoms
What are treatments for prostate cancer?
Surgical if malignant
- radiation
- alternative + chemo, hormones
What are three important cancers in women?
- cervical
- uterine/endometrial
- ovarian
What is prevalence of cervical cancer?
- in women in their 20-30s
- in part sexually transmitted (HPV)
What are risk factors of cervical cancer?
- HPV infection
- STIs that cause warts
- prior infection of herpes, chlamydias
- smoking
What is diagnosis of cervical cancer?
- pelvic examination
- Pap test smear (cervical dysplasia)
What are treatment for cervical?
- removal of abnormal cells through surgery or ultra cold cryoscopie laser
How to prevent cervical cancer?
- paptest if sexually active by 21
- avoid HPV
- sexual abstinence
- monogamous sex
- codons
- gardasil vaccine
What is uterine/endometrial cancer and what is its prevalence?
- cancer of lining of uterus or endometrial
- in over 55yr
What are risk factors to uterine/endometrial?
Similar to breast
how do you diagnose utérin/endometrial?
Pelvic examination
What is treatment of uterine/endo?
- surgically (hysterectomy)
- radiation
- hormones
- chemo
What are symptoms of ovarian cancer?
- bloating, pelvic abdo, pain
- difficulty eating, full quickly
- urinary problems
how is ovarian cancer diagnosed?
- no approved screening test
- often no warming signs and why diagnosed late
- pelvic exam or transvaginal ultrasound
How to prevent ovarian cancer?
- anything that decreases the # of ovulation cycles
- > pregnancy
- > breast feeding
- > oral contraceptives
What are risk factors for skin cancer?
- # of sunburnt /also severe as a child
- suntans
- being fair skinned
- family history
- having any moles
- high altitude
- almost all extensive UV exposure
Describe UVA/UVB
UVA:
- longer wavelength
- less likely to cause sunburn
- damages connective tissue
- = prématuré agin
- human carcinogen
UBA:
- shorter wavelength
- causes of sunburn
- damages eye/immune
- carcinogen
What are the main types of skin cancers?
1- basal cell carcinoma (in deepest layer of skin)
2- squamous CC (surface layers)
* both are 95% of skin cancers, found in chronically exposed areas,appears in pale wax like, pearly nodules, painless
3- melanoma (ca occur elsewhere in body, common risk areas (back, chest, abdomen, legs) appears at site of preexisting moles
What is diagnosis for skin cancer - melanoma?
ABCD test
- A- asymmetry
- B -border irregularity
- C - color variation
- D - diameter larger than 1/2 cm
How to prevent skin cancer?
- time of day and location of sun exposure
-> 10-2 pm
-> clouds will allo 80% to UV to pass - UVs are highly reflective ( snow, water, sand)
- UVs can penetrate 1 m of water
- protection
-> clothing, hat, sunglasses
-> sunscreen SPF equal or over 15, 30 for fairskin
— SPF, only UVB are water resistant
— apply 30 min before exposure
— reapply every 2 hrs
What are neck and head cancers and prevalence?
- oral, pharynx, larynx, nasal cavity
- 2 x more in men than women (as of 40 yrs for men)
What are risk factors for neck and head cancers?
- tobacco use
- excessive alcohol
What is 5 yr survival head/neck?
62%
How to treat?
- chemo, surgery, radiation
Describe testicular cancer?
- rare
1% of cancer in men 20-35
Risk factors:
- age
- ethnicity (Caucasian>latin, Asia AfA
- men with undescended testicular
Symptoms:
- lump, swelling or nodules
- sudden collection of fluid
- feeling of heaviness
- pain
Treatment:
- surgical
- chemo
Describe pancreatic cancer prevalence and risk factors
- usually advance before it appears
- no good cure
Risk factors:
- smoking
- male
- African
- age>60
- history
- diabetes
- obese, P.IN
- diet high in meat
Who is more at risk of bladder cancer?
Male>female
Caucasian > African American
Smoking
What are symptoms of bladder cancer?
- blood in urine
- increase requency
Who is at risk of kidney cancer?
- age > 50
- smoking
- obese
- history
What are symptoms of kidney?
- fatigue
- pain on side
- blood in usine
Describe risk factors, symptoms and treatment of brain cancer?
- commonly dev. For no reason
- ionizing radiation can be risk
Symptoms
- headache
- fatigue
- behavioural change
- seizures
Treatment:
- surgery, radiation, chemo
Describe leukaemia?
- cancer that starts in bone marrow
- spreads to lymph, sleep, liver, other organs
Risk factors?
- smoking
- radiation
- certain chemicals
- infections
Symptoms of leukaemia?
- fatigue
- anemia
- weight loss
- infection
Describe lymphoma, types and risk factors
Begins in lymph nodes
- two types
- > HL
- > NHL (more common, more deadly)
RF:
- genetics
- radiation
- chemicals/infectio
How should you help in detecting cancer?
- self- monitoring is the first line of défense (RF, history)
- inform of specific screening test
What are the differen stages of cancer and what do they mean?
0: in situ
1: small and contained within organ
2: larger + spread to surrounding tissues (close to lymph nodes)
3: larger + spread to surrounding tissues
4: prend through blood or lymphatic system and started to metastasized
What are the different types of treatments for cancer?
- surgery (most effective - less when blood or metastasized)
- chemo
- radiation (xray and gamma rays also damage normal cells)
Others: - BM transplant, stem cell, vaccines, gene. Modified immune cells
- anti angiogenesis agents (starve cancer cells of blood supply)
- protostomes inhibitors (stops action of malfunction protostomes
- enzyme activators/blockers (calpase, telomerase)
- monoclonal antibody (rituximab), created to bind to specific cancer cells
what are guidelines to prevent cancer?
- avoid tobacco
- control diet and weight
- exercise reg. (Linked to lower rates of colon and others)
- protect skin from sun
- avoid env. & occupational carcinogens
What are 7 major warming signs of cancer?
1- change in bowel/bladder 2- sore that doesn’t heal 3- usual bleeding/discharge 4- thickening or lump in breast or elsewhere 5- indigestion or difficulty swallowing 6- obvious change in wart/mole 7- nagging cough or hoarseness