Transcript High-density lipoproteins (HDLs)

CHAPTER
OUTLINE Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Chapter 11
Preventing
Cardiovascular
Disease
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Cardiovascular Diseases
Any disease that
affects the heart and
the blood vessels
Examples
Coronary heart disease
Peripheral vascular
disease
Congenital heart disease
Rheumatic heart disease
Atherosclerosis, strokes
High blood pressure
Congestive heart failure
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Cardiovascular Diseases
About 20% of the U.S. population has some form
of cardiovascular disease
In the year 2002, more than 35% of all deaths in
the U.S. were attributable to heart and blood vessel
disease
About 1.2 million people in the U.S. have heart
attacks each year—500,000 of them die as a result
About 45% of heart attack deaths occur within 1
hour of the onset of symptoms, before the person
reaches a hospital
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Cardiovascular Diseases
Although heart and blood vessel disease is
still the number one health problem in the
U.S., the incidence declined by 32%
between 1960 and 2000
Health education: more people now are
aware of the risk factors for cardiovascular
disease and are changing their lifestyle to
lower their own risk
Incidence of Cardiovascular Disease in the
United States for Selected Years: 1900–2000
11.2
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Critical Thinking
What are your feelings about your
own risk for diseases of the
cardiovascular system?
Is this something that you need to
concern yourself with at this point in
your life? Why or why not?
Other Risk
Factors for
CHD
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
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Other Risk
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CHD
Coronary Heart Disease (CHD)
The major form of cardiovascular disease
In CHD the arteries that supply the heart with
oxygen and nutrients are narrowed by fatty
deposits such as cholesterol and triglycerides
Narrowing of the coronary arteries diminishes
blood supply to the heart muscle, which can
precipitate a heart attack
11.3
The Heart and Its Blood Vessels
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Coronary Heart Disease
Single leading cause of death in U.S., accounting for
20% of all deaths and half of all cardiovascular deaths
More than half of the people who died suddenly from
CHD had no previous symptoms
80% of deaths from CHD in people under age 65
occur during the first heart attack
The risk of death is greater in the least educated
segment of the population
Cardiovascular
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Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Coronary Heart Disease
Almost all risk factors are preventable and
reversible
The individual can reduce risk by participating
in a healthy lifestyle program
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Major CHD Risk Factors
Physical inactivity
Abnormal electrocardiogram
Abnormal cholesterol profile
Elevated triglycerides
Elevated homocysteine
Inflammation
Diabetes
Other Risk
Factors for
CHD
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Major CHD Risk Factors
High blood pressure
Excessive body fat
Smoking
Tension and stress
Personal and family history
Age
Other Risk
Factors for
CHD
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
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CHD
Other Risk
Factors for
CHD
Physical Inactivity
Improving cardiorespiratory endurance
through increased physical activity
reduces the overall risk for heart disease
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
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CHD
Other Risk
Factors for
CHD
Regular Physical Activity
Daily physical activity and a regular aerobic exercise
program help control most heart disease risk factors
Increases cardiorespiratory endurance
Decreases and controls blood pressure
Reduces body fat
Lowers blood lipids
(cholesterol and triglycerides)
Improves HDL cholesterol
Helps control diabetes
Cardiovascular
Diseases
Coronary Heart
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Profile
Leading Risk
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CHD
Other Risk
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CHD
Regular Physical Activity
Daily physical activity and a regular aerobic exercise
program help control most heart disease risk factors
Decreases low-grade inflammation
Increases and maintains good heart
function, sometimes improving certain
ECG abnormalities
Motivates toward smoking cessation
Alleviates tension and stress
Counteracts a personal history of
heart disease
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Diseases
Coronary Heart
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Physical Activity and Exercise
“
Based on the overwhelming amount of
scientific data in this area, evidence of the
benefits of aerobic exercise in reducing heart
disease is far too impressive to be ignored.”
Normal Electrocardiogram
The electrocardiogram or ECG provides a
record of the electrical impulses that stimulate
the heart to contract
11.4
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Stress Electrocardiogram
Also known as a
graded exercise
stress test or a
maximal exercise
tolerance test
A stress ECG
reveals the
tolerance of the
heart to increased
physical activity
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Stress ECG Guidelines
Men over age 45 and women
over age 55
A total cholesterol level above
200 mg/dl or an HDL
cholesterol below 35 mg/dl
Hypertensive and diabetic
patients
Cigarette smokers
People with an abnormal
resting ECG
Individuals with a family history
of CHD, syncope, or sudden
death before age 60
All individuals with symptoms
of chest discomfort,
dysrhythmias (abnormal
heartbeat), syncope, or
chronotropic incompetence
(heart rate that increases
slowly during exercise and
never reaches maximum)
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Coronary Heart
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Abnormal Cholesterol Profile
Blood lipids are carried in the bloodstream by
molecules of protein known as
High density lipoproteins (HDLs)
Low density lipoproteins (LDLs)
Very low density lipoproteins (VLDLs)
Chylomicrons
11.7
The Atherosclerotic Process
Cholesterol Guidelines
11.2
Heart Disease
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Key Term
High-density lipoproteins
(HDLs): Cholesterol
transporting molecules in the
blood (“good” cholesterol)
that help clear cholesterol
from the blood
Leading Risk
Factors for
CHD
Other Risk
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CHD
Cardiovascular
Diseases
Key Term
Low-density
lipoproteins (LDLs):
Cholesterol transporting
molecules in the blood
(“bad” cholesterol) that
tend to increase blood
cholesterol
Coronary Heart
Disease Risk
Profile
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CHD
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HDL-Cholesterol
HDL-cholesterol acts as a "scavenger,"
removing cholesterol from the body and
preventing plaque from forming in the arteries
The strength of HDL is in the protein
molecules found in their coatings
When HDL comes in contact with cholesterolfilled cells, these protein molecules attach to
the cells and take their cholesterol
Cardiovascular
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Profile
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CHD
Other Risk
Factors for
CHD
HDL-Cholesterol
For the most part, HDL-cholesterol is
determined genetically
Generally, women have higher levels
than men
The female hormone estrogen tends to
raise HDL, so premenopausal women
have a much lower incidence of heart
disease
Cardiovascular
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CHD
Ways to Increase
HDL-Cholesterol
Habitual aerobic exercise
(> 6 METs, 3 times/week for 20 min/session)
Weight loss (if necessary)
Niacin supplementation
Quitting smoking
Increasing consumption of beta carotene
Drug therapy
Cardiovascular
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CHD
LDL-Cholesterol
Tends to release cholesterol, which then may
penetrate the lining of the arteries and speed
up the process of atherosclerosis
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
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CHD
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Factors for
CHD
Ways to Lower
LDL-Cholesterol
Loss of body fat (if necessary)
Dietary changes
Drug therapy
Participation in a regular aerobic exercise
program
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LDL-Cholesterol
It is better to lower LDL-cholesterol without
medication, as drugs can cause muscle
and joint pain and alter liver enzyme levels
People with heart disease must often take
cholesterol-lowering medication, but it is
best if medication is combined with
lifestyle changes to augment the
cholesterol-lowering effect
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Coronary Heart
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CHD
Ways to Lower
LDL-Cholesterol
Choose a diet low in fat, saturated fat, and
cholesterol
Saturated fat should be replaced with
monounsaturated and polyunsaturated fats
because the latter tend to decrease LDLcholesterol
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Ways to Lower
LDL-Cholesterol
Total daily fiber intake should be 25 to 38 grams per
day, including a minimum of 10 grams of soluble fiber
Total fat consumption must be less than 30% of total
daily caloric intake
Saturated fat consumption should be under 7% of the
total daily caloric intake
Average cholesterol consumption should be much
lower than 200 mg per day
Cardiovascular
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CHD
Diet & Cholesterol
A drawback of very low fat diets (less than
25% fat) is that they tend to lower HDLcholesterol and increase triglycerides
If HDL-cholesterol is already low,
monounsaturated and polyunsaturated fats
should be added to the diet
Cardiovascular
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Ways to Lower
LDL-Cholesterol
Consume 25 grams of soy protein a day
Consume red meats fewer than three times per week, and
no organ meats (liver, kidneys)
Eat fish instead of red meat
Do not eat commercially baked foods
Avoid foods that contain transfatty acids, hydrogenated fat,
or partially hydrogenated vegetable oil
Drink low fat milk (1% or less) and choose low fat dairy
products
Cardiovascular
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Coronary Heart
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Profile
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CHD
Other Risk
Factors for
CHD
Ways to Lower
LDL-Cholesterol
Limit egg consumption to less than 3 eggs per week
Bake, broil, grill, poach, or steam food instead of frying
Refrigerate cooked meat before adding to other dishes;
remove fat hardened in the refrigerator before mixing
meat with other foods
Avoid fatty sauces made with butter, cream, or cheese
Cardiovascular
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Coronary Heart
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Profile
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CHD
Other Risk
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CHD
Cholesterol-Lowering
Medications
There are now very effective medications to treat
elevated cholesterol and triglycerides
Most notable are the statins group, which can lower
cholesterol by up to 60% in 2 to 3 months
Statins
Slow down cholesterol production and increase the
liver's ability to remove blood cholesterol
Decrease triglycerides and produce a small increase in
HDL levels
Cardiovascular
Diseases
Coronary Heart
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Profile
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CHD
Triglycerides
Also known as free fatty acids
In combination with cholesterol, triglycerides
speed up the formation of plaque in arteries
Triglycerides are carried in the bloodstream
primarily by very low density lipoproteins
(VLDLs) and chylomicrons
11.4
Triglycerides Guidelines
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Triglycerides
Found in
Poultry skin
Lunch meats
Shellfish
Manufactured mainly in the liver, from
refined sugars, starches, and alcohol
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Profile
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Ways to Lower Triglycerides
Cut down on high-triglyceride foods
Decrease overall fat consumption
Quit smoking
Reduce weight (if necessary)
Participate in aerobic exercise
Cardiovascular
Diseases
Critical Thinking
Are you aware of your
blood lipid profile?
If not, what keeps you
from having a blood
chemistry test done?
What are the benefits of
having it done now as
opposed to later in life?
Coronary Heart
Disease Risk
Profile
Leading Risk
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CHD
Other Risk
Factors for
CHD
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
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CHD
Other Risk
Factors for
CHD
Homocysteine
Clinical data indicates that many heart
attack and stroke victims have normal
cholesterol levels
A high concentration of the amino acid
homocysteine in the blood is thought to
enhance plaque formation and subsequent
blockage of arteries
Cardiovascular
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Coronary Heart
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CHD
Homocysteine
Homocysteine is an intermediate amino acid
in the interconversion of two other amino
acids: methionine and cysteine
This interconversion requires the B vitamin
folate (folic acid) and vitamins B6 and B12
Cardiovascular
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Homocysteine
A large number of people have high
blood levels of homocysteine due to a
Genetic inability to metabolize
homocysteine
Deficiency in the vitamins required for its
conversion
Cardiovascular
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CHD
Homocysteine
Five servings of fruits and vegetables daily
can provide sufficient levels of folate and
vitamin B6 to remove and clear
homocysteine from blood
Cardiovascular
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Homocysteine
Vitamin B12 is found primarily in animal flesh
and animal products
Vitamin B12 deficiency is rarely a problem
(1 cup of milk or an egg provides the daily
requirement)
The body recycles most of this vitamin, thus, a
deficiency takes years to develop
Cardiovascular
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Coronary Heart
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Other Risk
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CHD
Inflammation
Scientists are looking at inflammation as a
major risk factor for heart attacks
Low-grade inflammation can occur in a variety
of places throughout the body
For years it has been known that
Inflammation plays a role in CHD
Inflammation hidden deep in the body is a common
trigger of heart attacks, even when cholesterol
levels are normal or low and arterial plaque is
minimal
Cardiovascular
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C-reactive protein (CRP)
A protein whose blood levels increase
with inflammation
Physicians have turned to CRP to evaluate ongoing
inflammation in the body
People with elevated CRP are more prone to
cardiovascular events
The risk of a heart attack is even higher in people with
both elevated CRP and cholesterol, resulting in an
almost 9-fold increase in risk
11.6 High-Sensitivity CRP Guidelines
Relationship between CReactive Protein and
Cholesterol and Risk of
Cardiovascular Disease
11.8
Cardiovascular
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CHD
C-reactive Protein (CRP)
Levels decrease with statin drugs
Also helpful are exercise, weight loss, proper
nutrition, and aspirin
Omega-3 fatty acids inhibit proteins that
cause inflammation
Excessive intake of alcohol and high protein
diets increase CRP
Aspirin therapy may also help control
inflammation
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Diabetes Mellitus
A condition in which blood glucose is unable to enter
the cells because
The pancreas totally stops producing insulin
The pancreas does not produce enough to meet the
body's needs
The cells develop insulin resistance
The role of insulin is to “unlock” the cell to escort
glucose into the cell
Diabetes affects more than 17 million people in the U.S.
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Diabetes
People with chronically elevated blood
glucose levels may have problems
metabolizing fats, which can make them more
susceptible to
Atherosclerosis, coronary heart disease, heart
attacks, high blood pressure, and strokes
Diabetics also have lower HDL cholesterol
and higher triglyceride levels
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Diabetes
An 8-hour fasting blood glucose level above
126 mg/dl on two separate tests confirms a
diagnosis of diabetes
A level of 126 or higher should be brought to
the attention of a physician
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Key Terms
Type 1 Diabetes: Insulin-dependent diabetes
(IDDM)
Also called juvenile diabetes
The pancreas produces little or no insulin
Type 2 Diabetes: Non-insulin-dependent
diabetes (NIDDM)
The pancreas either does not produce sufficient
insulin or it produces adequate amounts but cells
become insulin-resistant
Accounts for 90% to 95% of all diabetes cases
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Diabetes
Although diabetes has a genetic predisposition, type 2
is related to
Overeating, obesity, and lack of physical activity
Once limited primarily to overweight adults
Now accounts for almost half of new cases in children
More than 80% of all type 2 diabetics are overweight
or have a history of excessive weight
In most cases, type 2 can be corrected through
Diet, weight loss, and regular exercise
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Diabetes
Both moderate and vigorous physical activity
are associated with increased insulin
sensitivity and decreased risk for diabetes
The key to increase and maintain proper
insulin sensitivity is regularity of the exercise
program
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Diabetes
A healthy diet is beneficial because it is
High in complex carbohydrates and water-soluble
fibers (found in fruits, vegetables, oats, and beans)
Low in saturated fat and sugar
Aggressive weight loss, especially if combined
with exercise, often allows diabetic patients to
normalize blood sugar level without the use of
medication
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Syndrome X
As cells resist insulin's action, the pancreas
releases even more insulin in an attempt to
keep blood glucose from rising
A chronic rise in insulin appears to trigger a
series of abnormalities referred to as
syndrome X or metabolic syndrome
These abnormal conditions include
Low HDL-cholesterol, high triglycerides, an
increased blood clotting mechanism, and high
blood pressure
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Syndrome X
Syndrome X patients should distribute daily caloric
intake so that
45% of the calories are derived from carbohydrates
(primarily low-glycemic)
40% from fat (30% to 35% mono- and polyunsaturated
fats, and 5% to 10% saturated fat)
15% from protein
Syndrome X patients also benefit from
Weight loss (if overweight)
Exercise
Smoking cessation
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Key Terms
Blood pressure: A measure
of the force exerted against
the walls of the vessels by
the blood flowing through
them
Systolic blood pressure:
Pressure exerted by the
blood against the walls of the
arteries during the forceful
contraction (systole) of the
heart; higher of the two
numbers in blood pressure
readings
Diastolic blood pressure:
Pressure exerted by the
blood against the walls of the
arteries during the relaxation
phase (diastole) of the heart;
lower of the two numbers in
blood pressure readings
Hypertension: Chronically
elevated blood pressure
Hypotension: Low blood
pressure
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High Blood Pressure
The “silent killer”
A blood pressure above 140/90 mm Hg
One in three adults is hypertensive
High blood pressure is a risk factor for
CHD, congestive heart failure, strokes, kidney
failure, and osteoporosis
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Blood Pressure Guidelines
Rating
Systolic Diastolic
Normal
Prehypertension
Hypertension
120 or lower 80 or lower
121-139 81–89
140 or higher 90 or higher
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Critical Thinking
Do you know what your most
recent blood pressure reading was,
and did you know at the time what
the numbers meant?
How would you react if your doctor
instructed you to take blood
pressure medication?
Other Risk
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CHD
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CHD
High Blood Pressure
Treatment
Increase physical activity
Follow recommended dietary guidelines to reduce
blood pressure
Lose weight if above recommended body weight
Practice stress management
Do not smoke cigarettes or use tobacco
Consider drug therapy
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Hypertension & Exercise
Hypertensive people who are physically active
have a lower risk of mortality from all causes
than inactive individuals with normal blood
pressure
The death rates for unfit individuals with low
systolic blood pressure are much higher than
in highly fit people with high systolic blood
pressure
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Effects of Aerobic Exercise
on Blood Pressure
An individual can expect exercise-induced
reductions of approximately 3 to 5 mm Hg
in resting systolic and diastolic blood
pressures (both through aerobic exercise
and strength training)
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Exercise and High Blood
Pressure Treatment
Moderate-intensity aerobic exercise program
50% intensity
30 to 45 minutes
5 to 7 times per week
Moderate-resistance strength-training program
8 to 12 exercises
1 to 3 sets of 12 to 15 repetitions to near fatigue
2 times per week
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Hypertension & Diet
Eat less salt and sodium-containing foods
Consume more potassium-rich foods
Such as potatoes, bananas, orange juice,
cantaloupe, tomatoes, and beans
Do not consume more than 2 alcoholic
beverages a day if you are a man, 1 if you are
a woman
Follow the dietary approach to stop
hypertension (DASH)
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Dietary Approach to Stop
Hypertension (DASH)
7 or 8 daily servings of grains, bread, cereal, or pasta
8 to 10 daily servings of fruits and vegetables
2 or 3 daily servings of nonfat/low-fat dairy products
2 or less daily servings of meat, poultry, or fish (less
than 3 ounces per serving)
4 or 5 servings per week of beans, peas, nuts, or seeds
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High Blood Pressure
Medication
Antihypertensive drugs often are the first
choice of treatment
Antihypertensive drugs produce many side
effects
Lethargy, sleepiness, sexual difficulties, higher
blood cholesterol and glucose levels, lower
potassium levels, elevated uric acid levels
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CHD
Excessive Body Fat (Obesity)
Recognized as an independent risk factor for CHD
Risks attributed to obesity, however, often are caused
by other risk factors that usually accompany
excessive body fat
Risk factors such as high blood lipids, hypertension,
and diabetes usually improve with increased physical
activity
Overweight people who are physically active may not
be at increased risk for premature death
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CHD
Smoking
More than 47 million adults and 3.5 million
adolescents in the U.S. smoke cigarettes
Smoking causes about 435,000 annual
deaths in the U.S.
In relation to CHD
Smoking speeds up the process of atherosclerosis
Causes a threefold increase in the risk of sudden
death following a myocardial infarction
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Smoking
Increases heart rate
Raises blood pressure
Irritates the heart, increasing the risk of fatal
cardiac arrhythmias
Decreases HDL-cholesterol
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Tension & Stress
People who are not able to relax have a
constant low-level strain on the cardiovascular
system that could manifest itself in heart
disease
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Tension & Stress
Individuals who are under a lot of stress and
do not cope well need to take measures to
counteract the effects of stress
One way is to identify the sources of stress
and learn how to cope with them
Take control: examine and act upon the things
that are most important, ignore less
meaningful details
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Personal History
Individuals who have had cardiovascular
problems are at higher risk for disease than
those who have never had a problem
People with such history should control other
risk factors as much as they can
Most risk factors are reversible, so they can
greatly decrease the risk for future problems
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Family History
Genetic predisposition toward heart disease
has been clearly demonstrated
All other factors being equal, a person with
blood relatives who now have or have had
heart disease runs a greater risk than
someone with no such history
In some cases, there is no way of knowing
whether a person has a true genetic
predisposition or if it is poor lifestyle habits
that led to the problem
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Critical Thinking
Do you have any relatives that
have suffered from
cardiovascular disease?
If so, what steps are you taking
to prevent a cardiovascular
event in your life?
Is there something you can do
to help others in your family do
the same?
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Age
Age is a risk factor because of the higher
incidence of heart disease in older people
This tendency may be induced partly by other
factors stemming from changes in lifestyle as
we get older
Less physical activity, poor nutrition, obesity
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Age
Although the aging process cannot be stopped, it
certainly can be slowed down
Physiological versus chronological age is important in
preventing disease
Some individuals in their 60s or older have the body of
a 20-year-old
20-year-olds often are in such poor condition that they
almost seem to have the body of 60-year-olds
Risk factor management and positive lifestyle habits
are the best means of slowing down aging
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Gum Disease
Oral bacteria that builds up with dental plaque
can enter the blood stream and contribute to
inflammation and blood vessel plaque
formation, increase blood clots, and thus
increase heart attack risk
Daily flossing for 1 to 2 minutes is the best
way to prevent gum disease
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Snoring
Loud snoring has been linked to
cardiovascular disease
People who snore heavily may suffer from
sleep apnea, in which the throat closes for a
brief moment, causing breathing to stop
In one study, individuals who snored heavily
tripled their risk of a heart attack and
quadrupled the risk of a stroke
Cardiovascular
Diseases
Coronary Heart
Disease Risk
Profile
Leading Risk
Factors for
CHD
Other Risk
Factors for
CHD
Aspirin
Aspirin therapy is recommended to prevent
heart disease
A daily aspirin dose of 81 mg (equivalent of a
baby aspirin) can prevent or dissolve clots that
cause heart attacks or strokes
The incidence of a nonfatal heart attack is
decreased by about 32% with daily aspirin use
End of Chapter