CHAPTER 10
FACTS AND FEELINGS ABOUT DISEASE PREVENTION AND HEALTH PROMOTION

This chapter contains information drawn from an early release of the January to June 2003 National Health Interview Survey, with estimates from 1997 through 2002 for comparison, which asks about the health behaviors of Americans—the lifestyles and health risks they assume, such as being overweight, smoking, consuming alcohol, and how they feel about their health. It also considers the effects of self-care, diet, social activities, and personal relationships on health and wellness.

MOST AMERICANS FEEL FINE

When asked how they rate their own health and the health of their families, more than two-thirds of Americans report that their households enjoy very good or excellent health, and the proportion that feel this way has remained consistent from 1997 to 2001. (See Figure 10.1.) More than one-third of the survey respondents considered their families and themselves to be in excellent health, although more men (37.4 percent) than women (34.5 percent) gave themselves this top rating. Only 6.8 percent rated their health status as fair, and only 2.4 percent said their health was poor. (See Figure 10.2.)

Because many health problems occur more frequently among older adults (age sixty-five and older), it is not surprising that fewer older adults assess their health as excellent or very good than people younger than age eighteen years old or those age eighteen to sixty-four. Figure 10.3 shows how self-assessed health status changes with age. The percentage of people of either sex whose health was assessed as excellent or very good decreased with age: 82.6 percent for those aged under eighteen years, 66.6 percent for those aged eighteen to sixty-four years, and 38.6 percent for those aged sixty-five years and older. (See Figure 10.3.) Self-assessed health status also varies by race and ethnicity, with more non-Hispanic whites reporting their health as excellent or very good (70.8 percent) than Hispanic people (57.8 percent) and non-Hispanic blacks (56.9 percent). (See Figure 10.4.) These differences may reflect the fact that racial and ethnic minority groups have been identified as medically underserved populations in many parts of the United States.

Few Americans take advantage of corporate wellness programs to help them stay healthy, according to the results of a November 5, 2003, Harris Interactive poll, although one-fourth know that their employers offer them. Only about 9 percent of employees responded that they participate in programs focusing on exercise (5 percent), weight loss (2 percent), diet and nutrition (2 percent), and smoking cessation (less than 0.5 percent). Of those who participated in wellness programs, almost all (99 percent) reported that they were "very helpful" (44 percent) or "somewhat helpful" (55 percent). Other wellness programs offered include alcohol or drug abuse assistance programs, psychological and family counseling, or help or counseling for those with health or medical problems.

DISEASE PREVENTION AND HEALTH PROMOTION

Eating a nutritious diet, maintaining a healthy weight, and getting regular exercise are important health promotion and disease prevention measures. Although there is some evidence that Americans' diets have improved, the Centers for Disease Control and Prevention (CDC) reports that only about one-fourth of adults eat the recommended amounts of fruits and vegetables. (See Figure 10.5.) Together, good nutrition and regular exercise reduce the risks of developing heart disease, stroke, some cancers, diabetes, and osteoporosis. The CDC estimates that at least 300,000 deaths per year are the result of unhealthy eating and physical inactivity. In the United States, obesity has reached epidemic proportions—in 2000 some forty-five million adults were obese and about eight million children and teens age six to seventeen years were overweight.

This section looks at childhood and adult immunization and modifiable risk factors such as low physical activity, being overweight and obesity, tobacco use, and excessive alcohol consumption (one type of substance abuse)—five of the ten leading health indicators selected for inclusion in Healthy People 2010. (The other leading health indicators, chosen because of their importance as public health issues, their ability to motivate action, and the availability of data to measure progress made to address them, are responsible sexual behavior, mental health, injury and violence, environmental quality, and access to health care.)

IMMUNIZATION AGAINST DISEASE

One of the most powerful primary prevention measures available is immunization against infectious diseases. Immunization rates are leading health indicators for the assessment of the health status of a country, city, ethnic group, or other population.

Childhood Immunizations

Diseases that used to kill or disable many thousands of children, such as mumps, measles, diphtheria, and poliomyelitis, now are preventable through immunizations. Polio and diphtheria, two diseases that once struck terror in the hearts of parents, have been virtually eliminated. The Childhood Immunization Initiative is a proven national strategy to achieve high vaccination levels among children during their first two years of life. The very success of the nation's immunization efforts since the 1960s, however, has given some parents a false sense of security and made them feel that having their children vaccinated is not a critical priority. If immunization rates decline, however, these dreaded diseases could become active again.

Figure 10.6 shows the gains made in the percentage of children ages nineteen to thirty-five months who have been immunized against diphtheria, measles, pertussis (whooping cough), polio, and tetanus. By 2001, 77 percent of all children had received the recommended vaccines, often called the 4:3:1:3 series. About 93 percent of children had received haemophilus influenza type b (Hib) immunizations, and 76 percent were immunized against varicella (chicken pox).

In December 2002 the American Academy of Pediatrics announced a change in their recommendations for who should receive vaccination against influenza. They reported that young, healthy children are at high risk of hospitalization for influenza infection; therefore, healthy children between six and twenty-four months of age, household contacts and out-of-home caregivers of all children younger than twenty-four months of age, and health care professionals should receive the flu vaccine. However, during the flu season of 2003 to 2004 an unusually high demand led to a shortage of the flu vaccine.

Adult Immunizations

Annual immunization against influenza is not strongly recommended for healthy young adults; however, it is advised for older adults. Of older adults (age sixty-five and older) who responded to the National Health Interview Survey, nearly two-thirds reported receiving immunization against influenza from 1997 to 2002. The slight decline observed between 2000 and 2001 was the result of delayed availability of the influenza vaccine. (See Table 10.1.)

Figure 10.7 shows that from January through June 2003 more than half of the survey respondents age sixty-five and older reported ever receiving pneumococcal vaccine. These rates of immunization have steadily increased since 1997 from 42.4 percent to 56 percent in 2002.

PHYSICAL ACTIVITY

Lack of physical exercise not only contributes to risk for heart disease but also increases the risk of colon cancer, diabetes, high blood pressure, osteoporosis, and arthritis. Regular physical activity also is linked to improved mental health, reducing mild anxiety and depression. Health professionals agree that even moderate amounts of exercise, such as walking thirty minutes per day, five times per week (as opposed to strenuous physical activity such as running), provides substantial health benefits. Despite the mounting evidence demonstrating the potent disease prevention and health promotion benefits of exercise, the CDC found that 60 percent of American adults do not exercise enough to reap health benefits and 25 percent do not exercise at all during their leisure time.

Physical activity is the first leading health indicator of Healthy People 2010, the source document that serves as a blueprint for improving the health status of Americans. Healthy People 2010 defines regular leisure-time physical activity as performing light to moderate physical activity for thirty minutes or longer, five or more times per week, or vigorous physical activity for twenty minutes or longer, three or more times per week. Adults responding to the NHIS surveys were given this definition of regular leisure-time activity.

Figure 10.8 shows a slow, steady increase in the percent of adults age eighteen and older who engage in regular leisure time activity, from 29.9 percent in 1998 to 32.5 percent in 2002. The percent of adults who participated in regular leisure-time physical activity declined with advancing age, and women in every age group were less likely than men to report physical activity. (See Figure 10.9.) When the survey results were adjusted for age and sex, regular leisure-time physical activity was highest among whites (35.9 percent), followed by African American (26.5 percent) and Hispanic (24.7 percent) adults. (See Figure 10.10.)

The President Makes Physical Fitness a Top Priority for the Nation

Concern about Americans' inactivity prompted President George W. Bush to announce on June 20, 2002, a federal effort to improve fitness levels among adults and children. He called it The President's Challenge. In a campaign that recalled a similar one launched by President John F. Kennedy four decades earlier, President Bush appointed a presidential council and issued an executive order along with twelve pages of recommendations on how Americans could improve their health and fitness. The president urged Americans to follow his example of running three miles per day and lifting weights to stay fit. His recommendations also included warnings about the health risks of obesity, smoking, and alcohol and drug abuse.

As part of President Bush's encouragement to get fit and healthy, the President's Council established an interactive Web site (www.presidentschallenge.org) that allows users to choose their age category, fitness level, and activity preference. An interactive activity log and award points also are featured for motivation.

Physical Activity Benefits Older Adults Too

Until recently, older adults were not advised by health professionals to exercise regularly because it was believed that the risks, such as heart attack, falls, and muscle injuries, outweighed the benefits of improved muscle tone, flexibility, circulation, and mood. Historically, an exercise stress test to detect cardiovascular disease was considered an essential part of a pre-exercise medical evaluation. During 2000 researchers from the Yale University School of Medicine Department of Epidemiology and Public Health concluded that not all older adults require an exercise stress test before beginning physical

activity. Dr. Thomas M. Gill and his colleagues published their findings in the July 19, 2000, issue of the Journal of the American Medical Association.

The researchers found that although vigorous exercise briefly increases risk of heart attack among older people, "regular exercise and physical activity may actually reduce the overall risk, possibly through improvements in cardiac risk factors and overall fitness." Further, the researchers believe, "In addition to being expensive and of unproven benefit, the current policy of routine exercise stress testing potentially could deter many older persons from participating in an exercise program."

Aerobic activity does not need to be strenuous to be healthful, according to the CDC. Older adults also can benefit from strength training—stronger muscles help reduce the risk of falling and improve the ability to perform routine tasks of daily life.

OLDER ADULTS SHOULD ALSO EXERCISE CAUTION.

To ensure safety the researchers advise older adults to start with low-intensity activities, such as balance exercises, tai chi, self-paced walking, and lower-extremity resistance training. They favor gradually increasing the intensity and duration of exercise. Older exercisers who fare well in low-intensity activities may progress to more intensive training, such as fast walking, swimming, or bicycling. Still, before beginning intensified exercise programs, the blood pressures and heart rates of older adult exercisers should be monitored by health care practitioners.

OBESITY

Whereas excessive alcohol consumption remained about the same and smoking continued to decline from 1997 to 2002, the prevalence of obesity, defined as body mass index (BMI) of thirty kg/m2 or more, among adults steadily climbed from 19.4 percent in 1997 to 23.8 percent from January through June of 2003. (See Figure 10.11.) Young adults of both sexes had the lowest rate of obesity (20.4 percent for adults age twenty to thirty-nine). The highest prevalence of obesity was among adults age forty to fifty-nine, with more than one-fourth (28.0 percent) describing themselves as obese. (See Figure 10.12.) Overall, African-Americans were more likely to be obese than Hispanics or whites, and among the three racial and ethnic groups, the prevalence of obesity was highest among African-American women (38.7 percent) and lowest among white women (21.1 percent). (See Figure 10.13.)

Diet and Mortality

Although the U.S. Department of Agriculture's (USDA) nutrition guidelines, along with most health professionals, endorse a low-fat diet rich in fruits, vegetables, and fiber, there has been little research to support the health benefits of this diet. A groundbreaking study, "A Prospective Study of Diet Quality and Mortality in Women," published in the April 26, 2000, issue of the Journal of the American Medical Association, confirmed the role of diet and nutrition in the health and longevity of women.

The study was the first global measure of the relationship between diet and mortality. It is different from earlier research in several important ways—its large sample size, length of follow-up, and rigorous scientific design and research methods. Further, instead of examining the health risks or benefits of a single food group or nutrient, researchers looked at the health effects of complex diets involving multiple food groups and combinations of foods. Because Americans' diets are composed of a variety of foods, this approach offers real-world applicability in terms of the findings.

Investigators tracked the health and diets of 42,254 women using a written sixty-two-item questionnaire. They calculated Recommended Food Scores (RFS) to measure overall diet quality for each woman. The RFS is calculated by assigning one point for each of twenty-three food items consumed at least once a week. RFS points were earned for fruits and fruit juices, dried beans, vegetables, green salad, potatoes, baked or stewed chicken or turkey, and baked or broiled fish. RFS points also were given for dark breads such as whole wheat, rye, or pumpernickel; cornbread, tortillas, and grits; high-fiber cereals such as bran, granola, or shredded wheat; cooked cereals; 2-percent milk and beverages with 2-percent milk; and 1-percent or skim milk.

The RFS was designed to measure healthy eating—dietary quality independent of reported amounts. This is important because the portion sizes of foods consumed often are reported inaccurately. In general, women who earned the higher RFS were those whose diets closely conformed with current USDA recommendations. Statistical analyses to assess the relationship between diet, health, and risk of mortality looked at the variables of age, race, education attained, BMI, smoking, alcohol consumption, energy intake, and physical activity. It also considered the interaction of diet with other factors, such as history of heart disease, cancer, or diabetes, and use of hormone replacement therapy during menopause.

The research found a clear relationship between dietary patterns and risk of mortality. As RFS increased, mortality decreased. The inverse relationship held true for all types of cancer, heart disease, stroke, and all other causes combined. The investigators stated: "Our study suggests that women reporting dietary patterns that included fruits, vegetables, whole grains, low-fat dairy, and lean meats, as recommended by current dietary guidelines, have a lower risk of mortality."

Women with the lowest scores were at the greatest risk of mortality—their risk was a full 30 percent higher than the risk of women with the highest RFS. The investigators concluded: "Our results provide evidence in support of the prevailing food-based dietary guidelines and suggest that diets complying with current dietary recommendations are indeed associated with improved health outcomes."

Childhood Overweight and Obesity

According to the CDC, since the early 1970s the percentage of children and teens who are overweight has more than doubled, reaching about 15 percent in 2004. A large number of overweight children are developing obesity-related medical problems rarely before seen in children, such as diabetes, high cholesterol, and high blood pressure. Obese children also are at increased risk of developing heart disease, osteoarthritis, and some cancers (breast, stomach, and pancreatic cancers) later in their lives. Compounding the health risks are psychological, emotional, and social problems faced by children who are overweight, especially preteen and adolescent girls.

WHAT CAUSES CHILDHOOD OBESITY?

Children are overweight or obese for the same reason as overweight adults—they consume more calories than they expend. Although there is evidence of a genetic tendency for obesity, children mainly become overweight from behaviors, attitudes, and preferences they learn early in life. Relationships with food develop in response to family and cultural values and practices and the influences of school, peers, and media. According to the CDC, 60 percent of young children and adolescents eat excessive amounts of saturated fat and sodium, and less than 20 percent eat adequate amounts of fruits and vegetables (Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity, 2002).

Why are so many kids overweight? Many health professionals point to high-fat convenience and fast foods and time spent playing video and computer games instead of taking part in outdoor, physical activities. Television viewing, media advertising, dwindling school physical education programs, and neighborhoods where it is unsafe for children to play also have been blamed. Parents also influence children's eating habits. For example, it is known that parents with eating disorders, obsessive dieters, and those with unhealthy eating habits are powerful, negative role models for children. More often than not, parents make food choices for their children.

Many Americans Are Making Healthier Food Choices

A 2002 nationwide survey conducted by the consumer research firm Yankelovich Monitor for the July 2002 issue of Cooking Light, a monthly magazine devoted to healthy eating, found that choosing healthy foods is a priority for many Americans. Two out of three survey respondents said making healthy food choices was more important than convenience, new flavors, or traditions. Forty-five percent said they eat more healthy foods than they did five years ago, and nearly one-fourth said they chose to prepare home-cooked meals so they could control the healthfulness of ingredients and preparation.

The survey results were consistent with the findings of USDA reports that found Americans have increased their consumption of fruit and vegetables (up more than 20 percent) and poultry (more than 100 percent) during the past thirty years; beef consumption has dropped by more than 10 percent. The USDA also found that the American diet has less fat—thirty years ago Americans obtained 40 percent of their calories from fat, whereas fat now accounts for 33 percent of total calories consumed. Although these trends are promising, Americans are encouraged to modify their diets further to comply with the USDA recommendation that fat consumption be limited to less than 30 percent of daily caloric intake.

SMOKING

The proportion of adults who smoke cigarettes has declined consistently, from nearly 25 percent in a 1997 survey to 21.6 percent from January through June 2003. (See Figure 10.14.) In 2003 more men than women identified themselves as former smokers (24 percent of men and 19.4 percent of women) and more women reported that they had never smoked. In every age group, more men than women identified themselves as current smokers. For both men and women, the prevalence of current smoking declined with advancing age. (See Figure 10.15 and Figure 10.16.) White men and women were more likely to smoke than black or Hispanic men and women. (See Figure 10.17.)

Although the trend in smoking has been consistently downward, it will have to drop sharply—more than 10 percent from the estimated 21.6 percent reported during January through June 2003—during the coming years to meet the objective of just 12 percent set forth in HealthyPeople 2010. A study conducted by the CDC in 2000 found that although 70 percent of smokers said they wanted to quit, success rates for quitting varied depending on the race, ethnicity, and education level of smokers. Among smokers who had quit, the highest success rates were among whites (51 percent), whereas 45 percent of Asian-Americans, 43 percent of Latinos, and 37 percent of blacks stopped smoking. Nearly 75 percent of smokers who had quit held graduate degrees and 64 percent were college graduates, whereas less than half of those who had not completed high school were able to quit smoking. The success rate for quitting also increased with income.

EXCESSIVE ALCOHOL CONSUMPTION

During January through June 2003, 19.8 percent of Americans had at least five drinks in one day on at least one occasion in the past year. There was no significant upward or downward trend in excessive drinking from 1997 to 2002. (See Figure 10.18.) Some researchers feel that it is unwise to assume that these statistics accurately reflect rates of problematic drinking in the United States because they believe that many survey respondents deny or misrepresent their alcohol consumption and others who drink too much alcohol are undercounted.

In 2002 among both men and women, younger adults were more likely to drink alcohol excessively. Of all eighteen- to twenty-four-year-old respondents, 33.2 percent admitted to excessive drinking; 26.4 percent of those ages twenty-five to forty-four, 14.5 percent of persons ages forty-five to sixty-four, and just 3.8 percent of adults age sixty-five and older admitted to excessive drinking. In every age group, more men than women consumed excessive alcohol. (See Figure 10.19.) Figure 10.20 shows that more white adults (22.8 percent) drank excessively (had five or more drinks in one day at least once in the past year) than African-American (12.1 percent) or Hispanic adults (16.2 percent).

THE SELF-CARE MOVEMENT

In the United States and other developed countries, where does most medical care take place? Is it delivered in hospitals, clinics, or physicians' offices? The correct answer, according to Lowell Levin, Ed.D., M.P.H., emeritus professor of epidemiology and public health at the Yale University School of Medicine, is "none of the above." Dr. Levin says most medical care is delivered in bathrooms, with kitchens running a close second. Naturally the caregiver in these settings is not a physician, nurse, or other health care professional. Levin contends that lay people—frequently mothers—deliver most medical care.

Although Americans traditionally have cared for themselves with treatments ranging from cod liver oil to vitamin E to chicken soup, today many people are taking even greater responsibility for their own health and wellness. They are seeking to prevent disease through diet and lifestyle changes and treating themselves for minor medical problems before visiting a health care practitioner. Many Americans also may rely on the Internet for health information and advice.

Most Americans rely on their own best judgment when it comes to dealing with everyday health problems. In a 1997 joint survey conducted by Prevention Magazine and the American Pharmaceutical Association, respondents were asked what they would do first if they had each of twelve different symptoms and/or conditions. Most said they would self-treat first for headaches (80 percent), upset stomachs (76 percent), diarrhea (75 percent), cold or cough (73 percent), fever (71 percent), menstrual cramps (69 percent), and muscle or joint pain (59 percent). Survey participants said that for more serious conditions, such as chest pain (78 percent), toothaches (63 percent), and yeast infections (48 percent), they would consult with a physician before taking any action.

Dr. Levin and other health educators characterize these self-care educated consumers as curious, assertive, proactive about their health, and intensely interested in complementary and alternative medicine. As a group, self-care consumers expect to be treated respectfully by practitioners. Critics view the self-care movement as antiphysician and dangerous for consumers, and they contend that "a little knowledge may be dangerous," prompting patients to make unwise choices or to reject effective treatment. Dr. Levin uses the same argument to bolster his plea to enlarge significantly the breadth and scope of school and community health education programs.

Self-Help Groups

Once considered a form of alternative medicine, self-help groups (also known as mutual aid or peer support groups) have developed to address a host of medical problems, such as diabetes, arthritis, cancer, and alcoholism, as well as psychological and health-related issues, such as bereavement (grief following the death of a loved one), smoking cessation, caregiver support, and coping with disability.

ARE THEY EFFECTIVE FOR EVERYONE?

Although group facilitators, self-care educators, and self-help group members believe that the groups work, there is no scientific evidence demonstrating that participation in self-help groups reduces morbidity or mortality for any specific medical condition. The lack of scientific evidence does not refute or challenge the groups' claims of effectiveness. Instead it underscores the difficulties involved in researching and assessing the outcomes of organized groups, even those widely acknowledged as beneficial, such as Alcoholics Anonymous.

Self-help groups vary in terms of leadership, composition, therapies offered, the setting in which mutual aid occurs, and the involvement of health professionals. This variability challenges researchers attempting to analyze the data available. Another question that researchers ask is, "When mutual aid group members recover, even when the improvement is measurable, how much improvement should be credited to involvement in the group?"

A 1999 study by the Harvard Medical School suggests that peer support groups may be harmful for some patients. A comparison of breast cancer patient health outcomes reported poorer results—increased physical discomfort and emotional distress—among women who participated in support groups. Harvard Medical School researchers followed 480 women with newly diagnosed, early-stage breast cancer. They found that participants in peer support groups suffered more psychosocial distress and worse quality of life than women who did not attend peer support groups. This lone study offers preliminary support for the observation that self-help groups may not be beneficial for everyone.

SATISFYING WORK, SOCIAL ACTIVITIES, AND PERSONAL RELATIONSHIPS ARE KEY TO HEALTH AND WELLNESS

Family, friends, active interests, and community involvement may do more than simply help people enjoy their lives. Social activities and relationships actually may enable people to live longer by preventing or delaying development of many diseases, including dementia. During the past two decades, research has demonstrated that social experiences, activities, relationships, and work stress are related to health, well-being, and longevity. The kind of work stress that causes the greatest harm to physical and mental health is effort–reward imbalance—when great effort is made and the effort is neither recognized nor rewarded. Although women appear more vulnerable to job stress, men's health seems more dependent on the availability of social relationships and emotional support.

Several studies have shown that marriage or living with a partner has greater health benefits for men than women because traditionally women are caregivers. Newer findings question whether the nurturing qualities of women are solely responsible for married men's improved health. Recent research reveals that men and women living alone have better health than those with unsatisfactory relationships with their partners. An alternative explanation of these findings may be that healthier people are more likely to marry than those with health problems.

Dr. Laura Fratiglioni and her colleagues at the Stockholm Gerontology Research Centre found that among Swedish older adults, the risk of developing dementia increased with increased social isolation. The quality, rather than frequency, of social contacts was more important in staving off impairment. People who had infrequent but satisfying interactions with families and friends fared better than those with unhappy or stressful relationships. The Swedish project also suggests that a variety of strong relationships is important—a single bond is insufficient to reduce risk. Older adults with several kinds of enduring relationships such as marriage, children, friends, and relatives were at lowest risk.

A promising finding from the study published in the April 2000 Lancet is the observation that one relationship may substitute for another. This is a key concern because death of a spouse or close friend may increase the survivor's risk for social isolation. The observation that strong connections with children, relatives, and friends can substitute for relationships with spouses or partners is especially significant for widowed, divorced, or never-married older adults.

Along with personal relationships, social activities also seem to protect against disease and increase longevity, even when the activities do not involve physical exercise. An annual study tracked the health and longevity of 2,761 older adults living in New Haven, Connecticut. After thirteen years, the researchers determined that "Social and productive activities that involve little or no enhancement of fitness lower the risk of all cause mortality as much as fitness activities do."

Pets Are More Than Best Friends; They Can Help Keep People Healthy

Research conducted during the late 1990s found that pet ownership was associated with better health. At first it was believed that the effects were simply increased well-being—the obvious delight of hospital and nursing home patients petting puppies, watching kittens play, or viewing fish in an aquarium clearly demonstrated pets' abilities to enhance mood and stimulate social interactions.

A study published in the Journal of the American Geriatrics Society (vol. 47, no. 3, March 1999) found that attachment to a companion animal was linked to maintaining or slightly improving the physical and psychological well-being of older adults. Parminder Raina and his colleagues followed nearly one thousand older adults for one year and found that pet owners were better able to perform the activities of daily living and were more satisfied with their physical health, mental health, family relationships, living arrangements, finances, and friends. These findings were confirmed further by a study published in Psychosomatic Medicine December 2002 (J. Blascovich, B. Mendes, vol. 64, no. 5) using both men and women and dogs and cats.

Other research revealed the specific health benefits of human interaction with animals. One study followed people who had suffered heart attacks and found that after one year pet owners had one-fifth of the mortality rate of people without pets. Several researchers have observed that petting dogs and cats actually lowers blood pressure. The physiologic mechanisms responsible for these health benefits are as yet unidentified; however, some researchers think that pets connect people to the natural world, enabling them to focus on others, rather than simply on themselves. Other investigators observe that dog owners walk more than people without dogs and credit pet owners' improved health to exercise. Nearly all agree that the nonjudgmental affection pets offer boosts health and wellness.