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meats, dairy products, and fresh fruits and vegetables. Lack of physical ability or

transportation to shop for food might present significant barriers to some older

adults. Lack of family and social supports may also present a barrier to nutri-

tional health, as studies show that older adults who eat alone are more likely to

decrease their food intake (Center for the Advancement of Health, 2006).

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UIDELINES

The USDA has created a new resource, called the MyPyramid Plan, which is de-

signed to help individuals make better choices regarding their nutritional health.

The plan is accessible online at www.mypyramid.gov. The plan allows a con-

sumer to enter information about age, sex, and activity level, and it provides an

easy-to-read estimate of what and how much should be eaten, including the total

number of calories recommended per day. For those who are interested in a more

detailed and daily assessment of diet quality and physical activity, there is a pro-

gram called MyPyramid Tracker. This program allows one to assess food intake

in terms of calories/energy and then subtracts the energy expended from activ-

ity, and it allows participants to monitor their progress online for up to a year.

The MyPyramid Plan website also has a teaching component designed for pro-

fessionals who are interested in teaching others to better understand the federal

food guidance program. The professional section includes a variety of resources

to be used in teaching consumers about the concepts of the USDA’s food pyramid,

including Power Point slide presentations, sample menus, food intake patterns,

calorie levels, and downloadable printed materials.

The American Diabetes Association (n.d.) has created its own version of the

food pyramid for people with Type 2 diabetes, which can be accessed at

www.diabetes.org. The website provides food exchange lists to help with meal

planning. The website also provides a learning center for those who have been

recently diagnosed, as well as answers to many commonly asked questions about

treatment, complications, and other concerns. There is a great variety of educa-

tional programs throughout the country that have shown success in improving

the health literacy and diet of older adults with Type 2 diabetes. The ADA web-

site contains a state-by-state directory of educational programs that meet na-

tional standards for excellence in diabetes education.

An important national program aimed at improving the nutritional health of

older adults is Meals on Wheels. Meals on Wheels delivers two nutritionally bal-

anced meals per day to older adults who are home-bound and have limited in-

comes. Many communities have similar programs aimed at helping older adults to

eat well. The Seattle Senior Farmers’ Market Nutrition Program provides fresh,

locally grown fruits and vegetables to low-income seniors. Research shows that

seniors who participated in this program consumed more servings of fruits and

vegetables (D. B. Johnson, Beaudoin, Smith, Beresford, & LoGerfo, 2004).

As with many health promotion activities, the primary care physician plays

a critical role in effecting change in the nutritional habits of older adults. Physi-

cians should conduct nutrition screenings with older patients to identify high-

risk individuals. Physician counseling interventions aimed at adult patients

at increased risk for diet-related chronic disease produced significant changes

in the average daily intake of healthy foods (Center for the Advancement of

Health, 2006).

Health Promotion 187

REDUCING FALLS

Falling, or more particularly, the avoidance of falling, is an area of health promo-

tion that deserves far more attention than it has received. Although the profes-

sional literature reflects an increasing recognition of the importance of

preventing falling in regard to health maintenance for older adults, risk of injury

from falling is frequently unrecognized by older adults (Baker et al., 2005). Yet

both the risk of falling and the seriousness of injuries that may be sustained in

falling represent major sources of ill health among older adults.

COPE OF THE

ROBLEM

Over a third of seniors living in the community experience at least one fall annu-

ally, and as age increases, so too does the likelihood of falling (Center for the Ad-

vancement of Health, 2006). In considering all trauma patients over a 4-year

period, falls were found to be the cause of injury 7 times more often among those

older than 65 compared to younger adults: 48% versus 7% (Sterling, O’Connor, &

Bonadies, 2001). The same study found falls to be the cause of death 7 times more

frequently as well: 55% versus 7.5%. In fact, for adults 65 and older, unintentional

falls are the leading cause of injury death, with 13,569 deaths in 2003, almost

twice the number of motor vehicle traffic fatalities (CDC, 2006). Nearly 60% of all

fatal falls among older adults occur in their home (Sattin, 1992), a finding that

should not be surprising given the increased likelihood of both falling and spend-

ing more time in the home environment as one ages. White men over the age of 85

have the highest rate of death following falls (Sattin, 1992).

Beyond the cost of human suffering, falls result in a very significant financial

cost to the society. These costs include out-of-pocket costs to the faller or his or

her family, costs to insurance companies, and significant costs to both Medicare

and Medicaid. Rizzo et al. (1998) report that the average health care cost of a fall

was nearly $20,000, without including the cost of physician services. The collec-

tive cost of all fall-related injuries was estimated at $20 billion in 2000 (Center for

the Advancement of Health, 2006) and has been projected to rise to over $27 bil-

lion by 2020 (Englander, Hodson, & Terregrossa, 1996).

ISKS FOR

ALLING

Risk of falling is generally recognized as being multifactorial. The factors in-

volved can be divided into those that are internal to the individual and those that

are external or environmental. Intrinsic factors include balance, strength, and gait

issues, cognitive impairment, the use of medications, and various disease states

and illness. External or environmental factors “create challenges to balance that

must be overcome to avoid falling” (King & Tinetti, 1995, p. 1150). The degree to

which an external factor may actually result in precipitating a fall depends on the

combination of the strength of the external risk balanced against the degree to

which the older person is able to accommodate the risk and maintain balance.

Thus, stairs, wrinkled rugs, poor lighting, misplaced furniture or other belong-

ings, and a host of other conditions can present external risks for falling.

It is important to appreciate that the risk that each of these factors might rep-

resent can be evaluated only in the context of an individual older adult’s compe-

tence, especially with regard to balance and strength, as suggested by Lawton

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and Nahemow’s (1973) model of personal competence and environmental press.

Following the logic of that model, it will be apparent that the risk of experienc-

ing a fall increases as the number of risk factors present increases. Among the

oldest old, it is common to find several risk factors—both internal and exter-

nal—co-occurring, and it is this population that is at the highest risk of falling

and of sustaining serious injury in doing so. A profile of older fallers would re-

flect that older White women who report more chronic disability, more medica-

tion use, less physical strength, lower muscle mass, and poorer balance and who

are slower are at greatest risk of falling (de Rekeneire et al., 2003).

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Clearly the risks for falling are not evenly distributed across the older population.

Some people experience fewer internal and external risks, and some people have

greater strength and balance to recover from a threat to balance and a potential

fall. To that end, interventions to reduce falls and injury from falls should be de-

signed specifically for either low- or high-risk individuals. Among low-risk older

adults, there is mixed evidence in support of group delivery of fall risk education

programs, exercise and balance improvement programs, strength training, and as-

sessment of one’s living environment for external risk factors. Although the evi-

dence for such interventions is inconsistent, the low cost of incorporating many of

these interventions into existing programs in senior centers, senior housing, and

elsewhere probably justifies their use.

Among older adults who are known to be at high risk of falling, interventions

are more appropriately tailored to the specific needs presented. Among this

higher risk population, the evidence of intervention effectiveness is stronger.

Starting with a comprehensive review of fall risk, successful interventions for fall

prevention have included treatment of existing health problems (orthopedic, car-

diovascular, and neurological), modification of medications to avoid interactive

effects, removal of environmental risks, advice on the appropriate use of assistive

devices, and physical therapy to improve strength, balance, range of motion, and

gait problems (American Geriatrics Society, 2001; King & Tinetti, 1995).

There is evidence that targeted interventions to prevent falls are cost-effective

as well. In a controlled group study, Rizzo, Baker, McAvay, and Tinetti (1996)

tested an individualized prevention intervention with 153 older adults with an

average age of nearly 78 years. The intervention cost an average of $905 to deliver

(range: $588 to $1,346). Even with this fairly costly intervention, the health care

costs of the intervention group averaged approximately $2,000 less than for the

randomized control group. In short, fall prevention appears to be a financially vi-

able opportunity for increased health promotion through prevention.

CESSATION OF NEGATIVE HABITS: SMOKING

AND ALCOHOL CONSUMPTION

When we think of habits that result in potentially untoward consequences and

that are widely practiced in contemporary society, two stand out as especially

pernicious: smoking tobacco and misusing beverage alcohol. In both these cases,

the behaviors are widespread, well-documented as physically addictive, and as-

Health Promotion 189

sociated with a wide range of negative outcomes. Thus, we focus on tobacco

smoking and alcohol misuse as examples of personal habits that represent the an-

tithesis of health promotion.

OBACCO

: S

COPE OF THE

ROBLEM

Tobacco use has been recognized as the foremost avoidable cause of death in the

United States, accounting for approximately 430,000 deaths annually (CDC,

1997). Smoking among older adults is far less common than among adults younger

than 65. In part, this certainly reflects the reduction by premature death of many

smokers from tobacco-related illness. However, adult smoking has declined in the

United States since the original surgeon general’s warning of health risks in 1964,

and only 10.1% of American older men and 8.6% of American older women con-

tinue to smoke cigarettes. The rates for older men have declined quite steadily

since the mid-1960s, and after peaking in the mid-1980s, rates have declined for

older women as well (CDC, 2004a). The downward trend seen in more recent

years among older adults probably reflects the aging of a cohort that has been

more steadily rejecting tobacco use over its adult lifetime.

Clearly, the use of tobacco is associated with a wide variety of disease out-

comes, including a number of cancers, vascular diseases, pulmonary diseases,

gastrointestinal diseases, and accidental burns. Most smokers see the value of

quitting, yet older smokers among today’s population face a number of obstacles.

These include long-term behavioral habituation, physical addiction, and a fatalis-

tic attitude that the damage from tobacco use has already been done and little

benefit would be gained by quitting (Appel & Aldrich, 2003).

However, smoking cessation is beneficial to all age groups. “The benefits of

smoking cessation are most clearly seen in coronary heart disease. One year after

stopping smoking the excess risk of heart disease is reduced by 50% and after 10

to 15 years of abstinence the risk of heart disease is the same as for a person who

has never smoked” (Gosney, 2001). Not only does smoking cessation improve

health functioning, but it also provides an economic savings—in the purchase

price of tobacco as well as health care copays and deductibles—that promotes eco-

nomic well-being for many seniors.

Empirically Supported Interventions There are a number of tobacco cessation inter-

ventions that have strong empirical evidence supporting their use. In 2000, the

U.S. Public Health Service (Fiore et al., 2000), released an update to its 1996 Smok-

ing Cessation Clinical Practice Guideline No. 18 reflecting updates in current re-

search. The new publication, Treating Tobacco Use and Dependence provides both

brief and intensive interventions that were evaluated by a consensus panel of ex-

perts. Those interventions that were supported with multiple well-designed ran-

domized clinical trials providing a consistent pattern of findings are reviewed in

this chapter. Most important, based on this same standard of evidence, the con-

sensus panel reported that age does not reduce the benefits of quitting smoking

and that interventions that have been shown to be effective with the general pop-

ulation are also effective with older adults.

Brief tobacco cessations are those designed to be fitted into the very brief

time that typifies physician appointments. As with brief alcohol interventions,

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discussed later, brief tobacco interventions basically take advantage of the patient-

professional relationship to draw attention to the issue of quitting tobacco and mo-

tivating the patient to do so. Because a large majority of older smokers see a

physician at least annually, the opportunity to employ brief interventions is wide-

spread. For patients who indicate a willingness to quit tobacco use, the brief inter-

vention may be represented by the “five As”: Ask if the patient is willing to quit;

advise the patient to quit in a “clear, strong and personalized manner”; assess the

willingness to quit at this time; assist the patient in quitting by arranging counsel-

ing and pharmacotherapy; and arrange for follow-up (Fiore et al., 2000).

For patients who are unwilling to quit tobacco use at this time, the “five Rs”

are recommended:

1. Encourage the older adult to indicate the relevance of quitting in his or her

own life. This may include personal health concerns or social circumstances

such as the health of others in the home.

2. Assist the older adult to articulate the risks of tobacco use, emphasizing

those that are most relevant to the individual.

3. Encourage the older adult to identify the rewards of smoking cessation,

again with attention to those that are most relevant to the individual.

4. Help the patient identify the roadblocks or barriers to successfully quitting

and indicate the ways these barriers might be overcome.

Repeat these intervention steps whenever contact is made with the individual,

acknowledging that many people make repeated attempts before achieving

success.

In addition to these brief interventions, more intensive interventions involving

counseling and pharmacotherapy are also recognized as having strong clinical

support. Although much of the brief intervention research was conducted with

physicians, there is encouraging research to suggest that these techniques are ef-

ficacious for use by all clinicians, including social workers. Further, when these

procedures are employed by multiple clinicians in multiple settings, effectiveness

is enhanced. Settings for which clinical evidence exists include proactive tele-

phone counseling and group and individual counseling (Fiore et al., 2000).

Given the strong evidence indicating the deleterious effects of tobacco use and

the equally strong support for these fairly easy to employ cessation interventions,

every social worker and other human service professional should be assisting

older adults who smoke to quit. Perhaps no other single action can have a more

profound effect on health promotion.

LCOHOL

: S

COPE OF THE

ROBLEM

The use of beverage alcohol among adults in American society is common. For

older adults, problematic alcohol has been noted in a range of residential settings,

including skilled nursing homes (Klein & Jess, 2002). Although its use decreases

by age from young adulthood on, over 41% of older adults consume alcohol—about

52% of men and nearly 34% of women (CDC, 2004a). Certainly, it is noteworthy

that in many social settings, including much retirement housing, utilization has

been reported to be much higher (Mirand & Welte, 1996). Using community, hos-

pital, and nursing home surveys, I. Johnson (2000) found prevalence rates for

“problem drinking” among older adults ranging from 2% to 53%. This wide vari-

Health Promotion 191

ance reflects both definitional and sampling differences. “Alcohol dependence”

and “heavy drinking” (often defined as more than two drinks per day) are com-

monly in the range of 10% of older persons.

When considering alcohol use by older adults it is important to note that sim-

ple use does not constitute a problem in and of itself; indeed, there is empirical

support for the claim that alcohol consumption may even convey health benefits

(Barry, Oslin, & Blow, 2001). However, even modest use places the older drinker at

risk for a number of reasons, including a reduction in retained body fluids, a

thinning of the blood-brain barrier, a reduction in the capacity to process ethanol,

and the degree of likely interactions with other appropriately used pharmaceuti-

cals, prescribed and OTC (Klein, 2003). Thus, in addition to the risks represented

by the consumption of alcohol itself, risk assessment must include the extensive

array of independent factors with which even small amounts of alcohol may pro-

duce an interactive effect. At-risk drinking is simply “alcohol use that increases

the risk of consequences from drinking” (Blow, 2000). Whereas clinical interven-

tions are clearly appropriate for problematic drinking patterns, it is among so-

called low-risk drinkers that health-promotive interventions hold the greatest

promise—both because of the degree to which alcohol consumption is wide-

spread among older adults, and because of the general success of interventions di-

rected at reducing nonproblematic drinking. Although it might lean toward

overgeneralizing, nonproblematic or low-risk drinking among older adults might

be more productively conceptualized as at-risk drinking because of the prepon-

derance of interaction potentials with negative health and social consequences.

Precise estimates of such drinking are even more difficult to obtain than for al-

cohol dependence or “problem drinking.” In addition to the methodological chal-

lenges for these, low- or at-risk drinking carries a challenge that is common in

preventive research: identifying the potential for an emergent problem, not the ac-

tual problem itself. The anticipated growth in the number of older adults who ar-

rive in their senior years with more relaxed views concerning the use of alcohol

and other drugs will only serve to exacerbate these potential problems (Patterson

& Jeste, 1999).

Empirically Supported Interventions The decision to intervene with an older drinker

is complicated by the difficulties surrounding the identification of at-risk or other

problem drinking behaviors. Many of the social controls that have operated to

moderate drinking over one’s lifetime are reduced or eliminated for older adults.

Through retirement and increased social isolation, social contacts and workplace

involvement may not operate to reduce opportunities for alcohol consumption.

Further, many of the negative effects of alcohol consumption are commonly mis-

taken for normal aspects of the aging process, including forgetfulness, balance and

gait problems, and depression. Many professionals incorrectly believe that the po-

tential for developing problems with alcohol is substantially reduced by age 50

(Atkinson, 1993). In a nationally representative study of primary care physicians,

less than 1% made a substance abuse diagnosis when presented with typical symp-

toms (National Center on Addiction and Substance Abuse, 1998). Social workers

and other health care professionals are also hesitant to diagnose substance abuse

problems among older adults (Googins, 1984; Ondus, Hujer, Mann, & Mion, 1999;

Stewart & Oslin, 2001). The most recent Clinician’s Guide oftheNationalInstitute

on Alcohol Abuse and Alcoholism (2005) suggests a single screening question to

distinguish problem drinkers from others: How many times in the past year have

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you had five (five for men; four for women) or more drinks in a day? Based on a

client’s response, interventions may range from the brief intervention discussed

later to medically managed withdrawal and treatment.

Certainly among older adults who exhibit problematic drinking behaviors, gen-

eral health is promoted by reductions in drinking or by complete abstinence. Tra-

ditional approaches, including counseling and pharmacotherapy, have been shown

to be successful with older adults (Schonfeld & Dupree, 1990). Older adults re-

spond particularly well to treatment utilizing age-segregated older adults groups

(Atkinson, 1995; Blow, Walton, Chermack, Mudd, & Brower, 2000; Zimberg, 1996).

The most promising evidence-based intervention for drinking issues with non-

problematic older adults may well be the brief intervention. Clinical trials of the brief

intervention have been impressive: 10% to 30% of nondependent problem drinkers

reduced their drinking to moderate levels after a brief intervention (Babor & Grant,

1992; Fleming, Barry, Manwell, Johnson, & London, 1997). As implied by the name,

brief intervention procedures incorporate assessment, negotiating and goal setting,

behavioral modification techniques, self-help information, and follow-up reinforce-

ment and are intended to be presented in one or two face-to-face interactions in the

context of a health office setting (Fleming & Manwell, 1999). Flemming and Manwell

present a review of over 20 empirical studies utilizing this method. As part of an

overall strategy of health promotion, the bit of time required to reduce the risk that is

inherent in alcohol consumption by older adults is a solid investment.

SOCIAL AND INTELLECTUAL ENGAGEMENT

One of the most commonly held myths associated with aging is that significant

losses in mental functioning such as from dementia or Alzheimer’s disease are an

inevitable part of the aging process. Although it is true that there are some

changes in mental ability associated with aging, the vast majority of older adults

do not experience significant changes in their cognitive health. Current research

shows that intellectual stimulation and social engagement, in combination with

healthy lifestyle activities including regular physical activity and good nutrition,

play a key role in maintaining cognitive health and preventing cognitive decline in

older adults (Butler, Forette, & Greengross, 2004).

COPE OF THE

ROBLEM

It is estimated that up to 10% of older persons have dementia, and at least 10%

more have mild cognitive impairment (Rundek & Bennett, 2006). Estimates vary

regarding the prevalence of Alzheimer’s disease, mainly due to the fact that the

disease cannot be diagnosed with certainty until the patient has died and the

brain tissue is analyzed. It is estimated that approximately 10% of older adults

over age 65 may have Alzheimer’s disease (Rowe & Kahn, 1998).

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In a groundbreaking longitudinal study on healthy aging and dementia, Snow-

don (2001) has followed 768 Catholic nuns between the ages of 75 and 107 since

1991. By analyzing the pathology of the brains of nuns who have died, as well as

looking at their lifetime history, the study has made incredible advances in un-

Health Promotion 193

derstanding why it is that a substantial number of the participants who showed

mild to moderate stages of Alzheimer’s disease pathology in postmortem exami-

nations showed no symptoms of cognitive impairment prior to their death. The

study suggests that it is possible to resist the genetic and pathological forces of

Alzheimer’s disease through lifestyle and environmental changes.

The Nun Study found that heart disease and stroke significantly increased a

person’s risk for dementia, and that the brain infarcts caused by strokes seem to

“trip a switch,” making the developing of dementia much more likely. Snowdon

(2003) noted other conditions that may overwhelm the brain and trigger the clin-

ical onset of Alzheimer’s symptoms: brain trauma, depression, metabolic abnor-

malities, and specific nutritional deficits. Other researchers have found that

cardiovascular risk factors such as high cholesterol, high blood pressure, smok-

ing, and diabetes can also produce an increased risk of cognitive impairment

(Almeida, Norman, Hankey, Jamrozik, & Flicker, 2006).

The greatest protective factors associated with the prevention of dementia and

the development of the symptoms related to Alzheimer’s disease are social en-

gagement, intellectual engagement, and educational background. The Nun Study,

as well as the work of others, has shown conclusively that the higher the level of

schooling, the lower the risk of developing Alzheimer’s disease (Raiha, Kaprio,

Koskenvuo, Rajala, & Sourander, 1998; Rundek & Bennett, 2006; Snowdon, 2001).

Routine engagement in cognitively stimulating leisure activities over one’s life-

time, continuing into older adulthood, is strongly associated with a reduced risk

of Alzheimer’s disease (Wilson et al., 2002).

Regular social engagement is proven to reduce a person’s overall mortality and

risk for significant losses in cognitive functioning. In general, people who are

married live longer than unmarried people, and people who are active members

of religious or civic organizations live longer than people without such group af-

filiations (Rowe & Kahn, 1998). Although it is important to older adults to feel

connected and involved with their immediate and extended families, research

shows that social activities outside of the family may have a bigger impact on cog-

nitive function than social contacts with family (Glei et al., 2005).

Several studies have found a clear link between physical activity and lower

risks of cognitive impairment. The MacArthur Study reported that older men and

women were more likely to maintain high cognitive capacity when they engaged

in vigorous physical activity. A potential explanation was found in laboratory ex-

perimentation measuring the effects of exercise on the brains of rats. Increased ex-

ercise corresponded with increases in a nerve growth factor that promoted new

brain cell growth (Rowe & Kahn, 1998). A study of over 18,000 women found that

those who participate in regular moderate physical activity showed significantly

better cognitive function than inactive women, and another study found that older

men who walk more are less likely to develop dementia, including Alzheimer’s

disease (Center for the Advancement of Health, 2006).

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The well-known saying “Use it or lose it” applies to the brain and cognitive func-

tion just as much as it does to the rest of the body. Older adults should be encour-

aged to participate in an active lifestyle that includes frequent participation in

a wide range of cognitively, physically, and socially engaging and challenging

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activities. Some of the specific leisure activities associated with reduced risk of de-

mentia are reading, playing board games, playing musical instruments, and danc-

ing (Verghese et al., 2003). Other recommended activities are memory games,

crossword puzzles, walking, gardening, and simply socializing with others. “Inter-

estingly, watching television was associated with approximately a 20% increased

risk of developing cognitive impairments” (Rundek & Bennett, 2006, p. 795).

Older adults should be encouraged to participate in social groups that are mean-

ingful to them. Most older adults can readily identify a circle of family and friends

that provide support, but others may require encouragement and support from a

professional to help them make connections in their communities (Rowe & Kahn,

1998). Many communities throughout the country have developed senior centers

that provide regular opportunities for social contact and engagement, as well as in-

volvement in cognitively and physically stimulating activities. Local parks and

recreation departments often host social events and offer classes specifically de-

signed for seniors, and some of these programs even offer transportation services.

Memory loss is not inevitable, and healthy older adults who are experiencing

memory losses can participate in training and practice programs to improve their

cognitive function. “Many people are amazed to learn that elderly men and

women who have experienced some cognitive decline can, with appropriate train-

ing, improve enough to offset approximately 2 decades of memory loss” (Rowe &

Kahn, 1998, p. 137). Even people who are diagnosed with dementia or Alzheimer’s

can still benefit from the protective factors of intellectual activity. A research

study conducted with elderly patients with dementia found that cognitive stimu-

lation therapy improved cognition and quality of life for participants (Spector

et al., 2003). Day activity programs designed for older adults often offer stimula-

tion therapy as part of their daily routine.

FUTURE RESEARCH DIRECTIONS

The most significant area for additional study in health promotion is almost cer-

tainly how to motivate older adults to initiate and sustain good practice with re-

spect to those health-promotive activities that are already well understood. We

know a great deal more about the practices that are reviewed in this chapter than

is being practiced by most older adults. The Healthy People 2010 (DHHS, 2000) tar-

gets for screening and inoculation are respectably high and would appear to be

within reach. However, exercise patterns, nutritional habits, and the proclivity for

falling all provide substantial room for improvement for most older adults. After

40 years of clear warnings about the hazards of smoking tobacco, use rates among

older adults are dropping; perhaps similar warnings about the potential hazards

associated with alcohol use—especially the indirect hazards through interaction

with other drugs—will result in a more thoughtful use of beverage alcohol.

Future research aimed at documenting what works in health promotion should

seek to identify the subgroups for whom particular approaches might be most

beneficial. As with attention to cultural and ethnic variation in so much of the

human services research, health promotion strategies should incorporate the sub-

tleties and nuances that will make interventions more readily practiced among

various groups of older adults. Similarly, we know that prevention efforts (e.g.,

for falls) are most effective when they are targeted to those at highest risk. Future

health promotion research should seek further clarity about the preventive inter-

ventions that work best with specified high-risk groups.

Health Promotion 195

CONCLUSION

It is our duty, my young friends, to resist old age; to compensate for its defects by a

watchful care; to fight against it as we would fight against disease; to adopt a regi-

men of health; to practice moderate exercise; and to take just enough food and

drink to restore our strength and not to overburden it. Nor, indeed are we to give

our attention solely to the body; much greater care is due to the mind and soul; for

they, too, like lamps grow dim with time, unless we keep them supplied with oil.

(Cicero, c. 44

./1946)

We do not agree with Cicero that we have a duty to resist old age; age is some-

thing that accumulates by the day. Each day should be celebrated. However, we

agree with Cicero that the celebration of each day is made easier when we take

good health into advanced age. Like the World Health Organization, Cicero

draws our attention to psychological and spiritual dimensions of health rather

than just an absence of disease. Even to the recommendations for exercise and

moderation in our habits of consumption, Cicero anticipated some of the best con-

temporary advice for health promotion.

To be sure, contemporary life has brought new aspects to health promotion. On

the positive side of the equation, modern health care has added the dimensions of

health screening and vaccinations to a regimen of health promotion. Screening for

common ailments has better enabled us to anticipate some of the conditions that

assault our health and to initiate earlier treatment of those conditions so as to

avoid more serious complications of delayed treatment. Vaccinations allow us to

avoid other conditions completely, or nearly so. Yet, in part as a function of these

successes, we have created new challenges to our health. As so many of us have

commonly come to experience the frailties of our eighth and ninth decades, falls

and chronic diseases have become increasingly present in our lives. But even as

these challenges present themselves, a commitment to health promotion at both

the personal and societal level works to mitigate many of the deleterious accompa-

niments. Exercise reduces the likelihood of falling; mental and social engagement

moderates or delays some of the loss experienced from dementia. Such are the

benefits of health promotion. The core principles of health promotion can be re-

duced to the fundamental principles of primary prevention with which we started

this chapter. When we seek to avoid those problems of aging that can be antici-

pated, protect the strengths and resources that we are fortunate enough to carry

into our advanced age, and seek always to promote forward-looking goals—both

large and small—toward which our energies might be directed, we find ourselves

promoting good health. Unfortunately, even rigorous attention to prevention and

health promotion will not displace the role of remedial health care; however, both

the costs and the inconvenience of ill health can be profoundly reduced. At every

level—for individuals, families, communities, and the society as a whole—these

opportunities should be pursued.

REFERENCES

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