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Katie is the founder and creator of Three Jane, an independent jewelry company established in New York City's West Village. Originally recognized for her best-selling map necklace, Katie licensed out the concept to A. Jaffe, a 122-year-old engagement ring brand.
Join us as we introduce you to everyone you need to know to start your own business.


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Andrew Lincoln Admits He Left 'The Walking Dead' at the Wrong Time
Andrew Lincoln Admits He Left The Walking Dead at the Wrong Time
Ryan Scott
— March 29, 2019
Rick Grimes is no longer a part of The Walking Dead (at least not the show), but Andrew Lincoln thinks that he may have picked the wrong time to leave. One of the most shocking surprises during season 9 was the departure of Lincoln as Rick, who had fronted the show since the very first episode. News got out that he was set to leave during this season ahead of time, but it was no less surprising for fans. Lincoln was ready to go, but he has expressed some regret, at least in regards to the timing of it all.
This comes from Norman Reedus, who plays Daryl Dixon on the zombie drama and is one of very few original cast members who remain. Reedus was recently interviewed about the upcoming season 9 finale. During the interview, he revealed that he spoke with his buddy Andrew Lincoln on the phone and, during their chat, Lincoln had this to say.
"It's funny because I talked to Andy the other day. And he was like, 'Man, I picked the wrong time to leave the show because it's so f*****g good right now.' I'm like, 'Yeah, you did, dude. You picked the wrong time.'"
It's not so much that Andrew Lincoln regrets his decision to leave, at least based on what Norman Reedus is relaying here. It's more that he believes that the quality of storytelling is so good that he regrets not being able to be a part of it. Critics and fans, at least the ones who are still watching, would seem to back that up. The most recent episode, The Calm Before, despite being the least-watched episode in the show's history, was praised by critics and viewers alike as one of the best episodes in years. According to Reedus, viewers have even more to look forward to in the season finale.
"I will say visually the last episode is nothing like you've ever seen on The Walking Dead before. It's completely different. It was so fun to shoot. It's a different look, 1000%, in the end. It's a huge, visually explosive episode that's going to be visually stunning... There are some personalities at the very end that get wrapped up in a certain way, like you think a person's far to the left and they end up far to the right. We ended on a way that's kind of The Great Escape. It's not a wrap-it-all-up-in-a-bow episode. It's definitely a moving forward sort of vibe. It's just huge."
The network has already renewed the show for season 10, so we're, at the very least, getting one more season. They've also got plans for a trilogy of movies starring Andrew Lincoln as Rick Grimes, as well as another spin-off series in development. The Walking Dead season 9 finale airs this Sunday on AMC. This news was first reported by Entertainment Weekly.
Topics: The Walking Dead
The Walking Dead: World Beyond Gets April Premiere Date, New Images Revealed
The Walking Dead Limited Event TV Spin-Offs May Resurrect Dead Characters
The Walking Dead Season 10 Midseason Finale Recap: A Traitor Faces Justice
Walking Dead Spin-Off Gets Titled The Walking Dead: World Beyond, New Trailer Arrives
The Walking Dead Season 10 Is the Highest Rated Season Ever


text:
title: Uphill paths
localeTitle: مسارات شاقة
---
## المشكلة 411: مسارات صعود

هذا هو كعب. [ساعد مجتمعنا على توسيعه](https://github.com/freecodecamp/guides/tree/master/src/pages/certifications/coding-interview-prep/project-euler/problem-411-uphill-paths/index.md) .

[سيساعدك دليل النمط السريع هذا على ضمان قبول طلب السحب](https://github.com/freecodecamp/guides/blob/master/README.md) .

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PCD All CDC
Preventing Chronic Disease
Older American Indians' Perspectives on Health, Arthritis, and Physical Activity: Implications for Adapting Evidence-Based Interventions, Oregon, 2013
ORIGINAL RESEARCH — Volume 13 — June 23, 2016
Kathleen P. Conte, PhD; Marc B. Schure, PhD; R. Turner Goins, PhD
Suggested citation for this article: Conte KP, Schure MB, Goins RT. Older American Indians' Perspectives on Health, Arthritis, and Physical Activity: Implications for Adapting Evidence-Based Interventions, Oregon, 2013. Prev Chronic Dis 2016;13:160098. DOI: http://dx.doi.org/10.5888/pcd13.160098external icon.
Despite the high prevalence of arthritis and physical disability among older American Indians, few evidence-based interventions that improve arthritis self-management via physical activity have been adapted for use in this population. The purpose of this study was to identify beliefs about health, arthritis, and physical activity among older American Indians living in a rural area in Oregon to help select and adapt an arthritis self-management program.
In partnership with a tribal health program, we conducted surveys, a focus group, and individual interviews with older American Indians with arthritis. Our sample comprised 6 focus group participants and 18 interviewees. The 24 participants were aged 48 to 82 years, of whom 67% were women. Forms B and C of the Multidimensional Health Locus of Control (MHLC) instrument, modified for arthritis, measured MHLC.
The concepts of health, arthritis, and physical activity overlapped in that health was a holistic concept informed by cultural teachings that included living a healthy lifestyle, socializing, and being functionally independent. Arthritis inhibited health and healthy behaviors. Participants identified barriers such as unreliable transportation and recruiting challenges that would make existing interventions challenging to implement in this setting. The Doctor subscale had the highest MHLC (mean = 4.4 [standard deviation (SD), 1.0]), followed by the Internal subscale (3.9 [SD, 1.4]) and the Other People subscale (2.8 [SD, 1.1]).
Existing evidence-based programs for arthritis should be adapted to address implementation factors, such as access to transportation, and incorporate cultural values that emphasize holistic wellness and social interconnectedness. Culturally sensitive programs that build on indigenous values and practices to promote active coping strategies for older American Indians with arthritis are needed.
American Indians have the highest prevalence of arthritis of any population in the United States (1). Although physical activity is considered a central component of nonpharmacologic arthritis management (2), American Indians are less likely to engage in physical activity than are people from other racial/ethnic groups (3). The Centers for Disease Control and Prevention (CDC) publishes a list of recommended evidence-based physical activity programs for arthritis (4). However, to our knowledge, no studies have described successful adaptations of these programs for use among American Indians, or in rural settings, where as many as 48% of older American Indians reside (5). These statistics illustrate the need for culturally tailored physical activity programs to manage arthritis for American Indians. For evidence-based programs to be effective, adaptations may be needed to ensure that programs align with the cultural values of the new target population and context of the new setting (6). Understanding lay health beliefs can provide insight into motivations that underlie individuals' health behaviors and coping strategies and inform relevant adaptations to existing programs (7). The purpose of this study was to identify beliefs about health, arthritis, and physical activity among older American Indians to help select and adapt an arthritis self-management and physical activity program for a tribe in rural Oregon.
In 2013, we collaborated with a federally recognized tribe's health program in rural Oregon to interview older, tribal-dwelling adults about their meaning of health, experience of arthritis, and interest in a group-based physical activity program. The study protocol was approved by the Oregon State University institutional review board and the tribe's Health Board and Tribal Council. Partners from the tribal health clinic and the study team recruited participants by word-of-mouth and by distributing flyers at local events and facilities. We used purposive sampling to target older adults with arthritis and ensure that men were sufficiently represented. Enrolled tribal members who had self-reported arthritis and identified as older adults were eligible to participate. The tribe did not want to exclude people who might benefit from a program for older adults, so people who identified as older adults self-selected into the study. Previous studies indicate that reservation-dwelling American Indians aged 45 years have health status similar to that of non-American Indians aged 65 years (8).
We scheduled several 90-minute focus groups at various times during February through September 2013. Only 6 people attended the first focus group, and subsequent groups were canceled because of insufficient registration. Therefore, we offered community members the option of participating in 30- to 45-minute in-depth face-to-face interviews. Our final sample of 24 participants included 6 focus group attendees and 18 interviewees. The focus group and interviews were audio-recorded and transcribed verbatim. Participants completed a self-administered survey and received $50 for their participation.
The self-administered survey collected data on age, sex, education level, and marital status. Health was measured with a self-reported 6-item response (range, 1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good, 6 = excellent) (9). Participants ranked arthritis interference with daily activities in the past 6 months on a 10-point scale where 0 indicated no interference and 10 indicated unable to carry on any activities (10). Locus of control, or the extent to which people believe their health is within their control, due to chance, or in the hands of others, is predictive of health behaviors (11), so we included 2 forms of the Multidimensional Health Locus of Control (MHLC) instrument in the questionnaire (12). We used the MHLC Form B to assess locus of control associated with general health and Form C to assess locus of control associated with arthritis. Form B, previously validated among American Indians (13,14), assesses general health locus of control via three 6-item subscales (Internal, Powerful Others, and Chance). The condition-specific Form C, modified for arthritis, subdivides the Powerful Others scale into two 3-item subscales: Doctors and Other People.
In collaboration with tribal partners, we developed a semistructured guide adapted for both the focus group and interviews. The open-ended questions reflected 4 domains: the participants' definition of health, effect of arthritis on peoples' lives, barriers to physical activities, and preferences for a physical activity program.
Using Stata v12 (StataCorp LP) for the self-administered survey data, we obtained the mean scores for health variables and for each MHLC subscale. Cronbach's α was acceptable for Form B (range, α = 0.65–0.83) and Form C (α = 0.77–0.87) except for the Other People subscale (α = 0.37; Table 1). Alpha levels for the MHLC typically range from 0.60 to 0.75 (12,13).
For the qualitative data, we used inductive content analysis to analyze the focus group and in-depth interview data (15). Initially, the 3 researchers separately reviewed and coded a transcript to develop initial codes. The initial codes were reviewed and consolidated to produce a codebook that the researchers used to code the remaining transcripts. Each transcript was independently and iteratively coded by at least 2 of the researchers, with new codes added as needed. We grouped similar codes into domains on the basis of the interview guide and created new categories as needed, then examined the codes for overarching themes. The researchers met throughout the process to discuss coding, resolve disagreements, and identify exemplar quotes for major themes. We conducted a subgroup analysis of the focus group to identify differences between the modes of data collection. NVivo qualitative software (QSR International) was used to organize the data.
The full sample consisted of 16 women and 8 men, and the median age was 65 years (range, 48–82 y) (Table 2). Approximately 71% of participants had some college education, and 33% were married. Mean self-rated health was 3.5 (SD, 1.1), and arthritis interference was 5.2 (SD, 2.5). For the MHLC Form B, the Internal scale ranked highest at 4.4 (SD, 1.2), followed by Powerful Others at 3.5 (SD, 1.1) and Chance at 2.7 (SD, 1.0) (Table 1). For the MHLC Arthritis-Specific Form C, the Doctor scale had the highest mean score (4.4; SD, 1.0), followed by Internal (3.9; SD, 1.4) then Other People (2.8; SD, 1.1). We did not find significant differences between focus group and in-depth interview participants on any measures.
Qualitative findings
The qualitative findings and representative quotes are organized by the domains outlined in the interview guide (Table 3). Major themes were generally consistent across focus groups and interviews; however, focus group participants reported being more physically active and more thoroughly discussed barriers to accessing medical care.
Participants attributed their definitions of health to cultural values taught to them via their upbringing, traditions, and oral teachings from elders and family members. Health was a holistic concept that involved the mind, body, spirit, and caring for others. Living a healthy lifestyle that emphasized all these dimensions was considered central to health. Most participants described their upbringing as "healthy" in that they ate native foods (eg, salmon, roots, and berries) and participated in cultural activities that were physically active (eg, collecting roots and berries, fishing, hiking, preparing sweat houses, and riding horses). Several participants were concerned that there was a shift away from community events that promoted social engagement, creating fewer opportunities for the older adults to engage with youth and to pass down teachings about health.
All participants included functional ability in their definition of health. Functional ability was described as "being active." For example, one participant said, "being able to move every day, able to do something." Similarly, health involved independence and the ability to care for oneself, which enabled individuals to care for others. Illness and pain were seen as barriers to being active and healthy. Despite drawing the connection between healthy lifestyles as a way to facilitate health, participants struggled to maintain healthy behaviors and attributed these difficulties to changes in their local environment, in which availability of fast foods has increased and opportunities for physical activity have decreased.
The effect of arthritis on participants' lives ranged from minimal and sporadic to overpowering and constant. Arthritis pain affected participants' ability to complete activities of daily living, engage with family, take part in leisure activities, and get around. Many participants reported barriers to accessing medical care for their arthritis because of lack of local specialists and high staff turnover at the local clinic. Additionally, focus group participants discussed that clinicians did not understand or care about their pain or treat them respectfully. Several participants were unsure what arthritis was and confused arthritis pain and its treatment with their other conditions, such as spinal injuries, shingles, neuropathy, diabetes, and asthma.
Mechanisms for coping with arthritis pain were active and passive strategies that included using prescription and over-the-counter medications, nonpharmaceutical approaches, and physical movement. For some, medications were helpful in reducing pain but others experienced only minimal relief. Although over half of participants reported taking medications for arthritis, many preferred nonmedical interventions for arthritis and a few completely avoided clinical care. Nonpharmaceutical pain management included using heat or ice and rest, and traditional tribal remedies, including making teas from local plants and using sweat lodges and mineral baths. Many participants reported using mental strategies such as distraction and ignoring the pain.
Participants reported that "moving" was beneficial to reducing arthritis pain, but when probed about types of movements, they answered using generalized statements such as "I move around so I won't get stiff;" or "I stretch . . . my legs and arms." Few participants noted that physical activity, though initially painful, helped with their arthritis symptoms. Although almost all of the focus group participants engaged in some physical activity, no interview participants engaged in physical activity on a regular basis. Overall, the most common type of physical activity was walking.
Barriers to physical activity included the following themes: health status and pain, environmental and community factors, and lack of motivation. Many participants reported that pain caused by arthritis, chronic conditions, or injuries interfered with their ability to be active. Environmental and community barriers included lack of transportation, unsafe walking locations, and the cost of joining an exercise facility. Personal motivation was identified as both a barrier and a facilitator to physical activity. Some participants discussed how by motivating themselves, they were able to overcome arthritis pain to be active. They cited previous examples of using self-motivation to do healthy behaviors — including walking and losing weight — but described motivation as dwindling or insufficient to maintain these behaviors. Consequently, more than half of the sample identified lack of motivation as a barrier to currently being physically active. Those who wanted to be active reported being motivated by family, wanting to be healthy, and wanting to avoid negative outcomes that they had witnessed family members and friends experience.
Many participants had questions about arthritis, its causes and treatments, and about safe ways to exercise. Despite seeking information, participants voiced mixed interest in participating in an ongoing educational and physical activity program. About half of the sample was interested in a group exercise class, but some said they would not participate at all. Those interested in a program raised concerns that it would be difficult to find a suitable location, the classes might not be well-attended, and reliable transportation would be an issue. Given the transportation difficulties, a twice- or thrice-a-week class was not preferred. Participants suggested that engaging younger adults with families and youth in a health and physical activity program would be beneficial for the community. Other suggestions included providing transportation and incentives to participate, and recruiting through word-of-mouth, through locals or the leader providing personal outreach and encouragement, and by sharing success stories of local people who had improved through a similar program.
Our study examined older American Indians' perceptions of health, arthritis, and physical activity to aid in identifying or adapting a suitable evidence-based program for a rural tribal community. Arthritis posed barriers to health and healthy behaviors, including physical activity. Meanings of health were couched in participants' native values, upbringing, and traditions. Participants discussed the importance of being functionally independent in relationship to caring for themselves and others and to participating in cultural activities. This finding corroborates those of other studies that found that rural lay definitions of health are highly contextual, informed by rural lifestyles and local traditions (16). Similar to other American Indian populations, our sample lacked knowledge about arthritis and physical activity (17). Yet, participants were aware that movement was important for alleviating stiffness and immobility. Furthermore, there was a clear interest in learning about nonpharmaceutical coping strategies from both physically active and inactive participants. Together, these findings suggest that a culturally relevant physical activity program is desirable in this community. However, participants also identified critical barriers that should be addressed before such a program could be successfully implemented in their community.
Our findings suggest that only a few of the CDC-recommended physical activity programs for arthritis might be adaptable for this community. From an implementation perspective, most of the CDC-recommended programs require special facilities (eg, fitness facility or pool) and license fees that would be prohibitive in rural communities (see reference no. 4 for a detailed description of CDC-approved physical activity programs for arthritis). All of the programs are group-based and require regular meetings over an extended period that may pose challenges given the transportation issues identified. A possible adaptation to improve implementation could involve a peer-to-peer program conducted in-home or via telephone instead of in a group setting. Telephone-based coaching programs have shown promising results in promoting healthy behaviors (18). Furthermore, peer education programs are as effective as professionally delivered programs and are a viable option in communities where resources are limited (19). They also provide added benefits of localized knowledge and social support that that can support the health of rural older American Indians (20). Although several peer-led evidence-based arthritis programs exist (4), none are designed for in-home delivery or have been tested for use in rural settings.
In addition to the feasibility issues, existing programs should be adapted to ensure that messages and activities align with the values, contexts, and traditions unique to this tribe. Furthermore, any adaptations must align with the programs' theoretical basis. Theory-based programs are not only more effective than those without (21), but also provide a framework for explaining the link between program components and resulting behavioral changes. Adaptations that significantly drift from the program's theory-based components may result in decreased effectiveness or other undesirable outcomes (22). Attitudes, beliefs, and values, for example, are culturally informed constructs that are common to many behavioral change theories (23). Understanding the target populations' beliefs and values about the program topic has implications for program adaptations. In our study, for example, the value that health is holistic indicates that a program focused solely on physical activity and arthritis might be too limited, and information about other aspects of healthy lifestyles, including nutrition, social relationships, and spiritual well-being, should be included to maximize relevance.
The participants in this study also emphasized the importance of health as a mechanism for caring for family members and for participating in social and cultural activities. They reflected on the teachings about health from their elders, and discussed their desire to engage with the youth in their community. This emphasis on the importance of social relationships has been reflected among other minority groups; other researchers suggest that common Western-based theoretical constructs, such as self-efficacy, that form the theoretical basis for interventions do not sufficiently represent the importance of relationships among minority groups in influencing health behavior (24). Interventions whose components draw from Western-based constructs may not be easily adapted to minority populations. Instead, interventions that attend to local contexts and values must be developed and tested to improve effectiveness, relevance, and acceptability.
Another construct in need of further attention is that of the health locus of control. Overall, participants had high Internal locus of control on the general health scale, a finding that has been linked to healthy lifestyles including regular exercise (25). On further examination, however, separating out Doctors from Powerful Others via the arthritis-specific scale evidenced that doctors are attributed a higher level of control, a finding that has elsewhere been associated with poor health (26). Given the desire of our participants to avoid medical treatments and medications for arthritis, this finding is potentially confusing. One reason for this disconnect may lie in the qualitative findings that participants have difficulties accessing local and culturally sensitive health providers. O'Hea et al hypothesized that restricted access to health information could cause individuals to view their control of health as directly related to their ability to access health professionals (27). That is, people living in rural settings where transportation and access to health information is difficult may perceive that they are unable to take active control of their health given the difficulties in accessing resources. Developing and increasing accessibility to culturally appropriate information about arthritis self-management strategies has the potential to empower individuals to better manage their health.
Limitations to this study were the small sample size and the self-selection of participants, which should restrict generalizations of our findings to other American Indian groups. We had difficulty recruiting participants to focus groups, probably because of the transportation barriers identified by participants. Another limitation is that social desirability bias, especially in the focus group, may have affected responses by inflating reports of physical activity. Finally, the Cronbach α for the Other People subscale for Arthritis-Specific Form C was notably low, which suggests it had either poor internal consistency or too few items (only 3). Although the MHLC has been validated among American Indians, there are 566 distinct federally recognized tribes (28), each with its own values and traditions. Future studies are needed to further validate Form C among American Indians and to more thoroughly examine the applicability and implications of the health locus of control construct across tribes.
A tailored arthritis program that is relevant to local and cultural lifestyles, values, and beliefs of older, rural American Indians is needed to empower individuals to effectively manage their arthritis symptoms and reduce reliance on passive coping strategies. Adapting programs to improve implementation aspects for rural settings, such as delivering telephone or in-home programs, and incorporating culturally based values, such as integrating other aspects of health that acknowledge the holistic and social dimensions of health, are 2 potential considerations. A low-cost intervention strategy for older adults with arthritis that provides benefits of improved physical functioning and decreasing disability will be a significant contribution to mitigating the effect of arthritis among older American Indians.
This research was made possible from funds provided by the College of Public Health and Human Sciences at Oregon State University through a donation received from PacificSource Health Plans as part of their Healthy Life Initiative. The contents are solely the responsibility of the authors and do not necessarily represent the official views of Oregon State University or PacificSource Health Plans.
We thank our tribal partners and community for their support and assistance on this project. We also thank the participants for their contributions to this study.
Corresponding Author: Kathleen Conte, PhD, The Australian Prevention Partnership Centre and the Menzies Centre for Health Policy; Charles Perkins Centre, D17; University of Sydney; Sydney, NSW, 2006 Australia. Telephone: 61-2-8627-4649. Email: kathleen.conte@sydney.edu.au.
Author Affiliations: Marc B. Schure, Montana State University, Bozeman, Montana; R. Turner Goins, Western Carolina University, Cullowhee, North Carolina.
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Goins RT, Spencer SM, Williams K. Lay meanings of health among rural older adults in Appalachia. J Rural Health 2011;27(1):13–20. CrossRefexternal icon PubMedexternal icon
Mathews AE, Laditka SB, Laditka JN, Wilcox S, Corwin SJ, Liu R, et al. Older adults' perceived physical activity enablers and barriers: a multicultural perspective. J Aging Phys Act 2010;18(2):119–40. PubMedexternal icon
O'Hara BJ, Bauman AE, Eakin EG, King L, Haas M, Allman-Farinelli M, et al. Evaluation framework for translational research: case study of Australia's get healthy information and coaching service. Health Promot Pract 2013;14(3):380–9. CrossRefexternal icon PubMedexternal icon
Cohen JL, Sauter SV, deVellis RF, deVellis BM. Evaluation of arthritis self-management courses led by laypersons and by professionals. Arthritis Rheum 1986;29(3):388–93. CrossRefexternal icon PubMedexternal icon
Conte KP, Schure MB, Goins RT. Correlates of social support in older American Indians: the Native Elder Care Study. Aging Ment Health 2015;19(9):835–43. CrossRefexternal icon PubMedexternal icon
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Flay BR, Snyder F, Petraitis J. The theory of triadic influence. In: DiClemente RJ, Kegler MC, Crosby RA, editors. Emerging theories in health promotion practice and research. 2nd edition. New York (NY): Jossey-Bass; 2009. p. 451–510.
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Table 1. Mean Scores of Arthritis-Specific and General Domains of Health Locus of Control of Older Adult American Indians With Arthritis, Multidimensional Health Locus of Control Instrument, Oregon, 2013
Cronbach's a
Mean (Standard Deviation)
Arthritis-specifica
.82 4.4 (1.0)
Powerful others
a Mean score range, 1–6; higher scores indicate attributing greater control to respective domain.
Table 2. Sociodemographic and Health-Related Characteristics of Older American Indians With Arthritis, Oregon, 2013
Overall Sample (N = 24)
Age, y, median (range)
Sex, n (%)
Education, n (%)
<High school diploma
High school or general educational development
Marital status, n (%)
Self-rated healtha, mean (SD)
Arthritis interference scaleb, mean (SD)
Abbreviation: SD, standard deviation.
a Range, 1–6; higher scores indicate greater self-reported health.
b Range, 1–10; higher scores indicate greater self-reported interference from arthritis.
Table 3. Qualitative Themes Identified During Focus Groups and Interviews With Older American Indians Discussing Health, Arthritis, and Physical Activity Programs, Oregon, 2013
Sample Quotations
Domain 1: Meaning of Health
The meaning of health is informed by cultural teachings passed down from elders and family
• "We had traditional meals (when we were raised) like. . . Indian roots. . . . That's what (my grandparents) taught you, was to eat healthy foods and not . . . the stuff they have now." (Female, I1)
• "I was raised . . . with my uncles. They were there to give you good advice. . . . Always some way to take care of your body." (Male participant, FG1)
Health is holistic
• "(Health is) taking care of your body physically, spiritually, emotionally, honoring your food." (Female participant, I7)
Living a healthy lifestyle is central to health
• "(Health) means if I want to live or die, I've got to stick to my diet and do my exercise because . . . being healthy is going to keep me alive." (Male participant, I15)
Health is the ability to move, to be active, and to take care of self and others
• "(Health is) where you can be more active at cooking . . . taking care of yourself. And take care of children and able to work." (Female participant, I5)
• "(Health is) to be able to get up every day, get out of bed, feed myself, and dress myself." (Female participant, I11)
Health is freedom from pain and illness
• "(Health is) getting up without having to take . . . the 8 pills I take and not wait the hour for it to kick in." (Male participant, I12)
The ability to live a healthy lifestyle has changed over time and affects the community
• "We lived off the land. . . . My grandparents cooked. They canned. They had cellars. I'm talking the old lifestyle that we lived." (Male participant, I15)
• "We have youth that aren't well and they could be if they have things to look forward to like knowing more about health. . . . Some kids don't have that. They don't have the guidance and they need somebody to show them that there are better things for your body." (Female participant, I1)
Domain 2: Living with arthritis
Description of arthritis pain ranges from minimal to severe
• "It doesn't really bother me much . . . it'll come and go." (Female participant, I1)
• "Literally, some days . . . I wake up crying because it hurts so badly, and I just don't want to do nothing." (Female participant, I6)
Arthritis impacts ability to complete activities of daily living, to engage with family, and to do leisure activities
• "I can't wash my own clothes" (Female participant, I2)
• "It's becoming less of a joy to go out and feed the horses." (Male participant, I13)
• "You don't even want to hold a baby. You might drop it." (Female participant, FG2)
• "I was bead working before, making moccasins. I can't do that now." (Female participant, I3)
Confusion about what arthritis is and where it comes from
• "I don't know if I have arthritis or osteoarthritis . . . . I don't know the meaning of either one." (Female participant, FG5)
Use of medication
• "With medication (my arthritis is) really good now" (Female participant, I2),
• "(Medicine) didn't really relieve my pain. It just took the edge off." (Female participant, I3)
Culturally based strategies
• "What really helped me was going to a sweat lodge." (Female participant, I6)
• "We have medicinal, Native American plants that we use for arthritis." (Female participant, FG4)
• "(I) try to get (the pain) out of my head." (Female participant, I5)
• "It's mind over matter." (Male participant, I14)
• "Sometimes (moving) will hurt, but I notice it feels good afterwards. I won't be stiff and I'll get around better." (Female participant, I1)
Access to medical care is challenging because of lack of local doctors, and the perception that Western doctors are not responsive
• "We just don't have an arthritis doctor for us here on the reservation." (Female participant, FG6)
• "(Clinicians) don't really take it to hear that you're suffering. . . . That's part of the reason why people don't go to the clinic. . . . I think it's natural for Native Americans to go back to old ways without any doctors and attention or somebody to help you out." (Male participant, FG1)
Domain 3: Barriers and facilitators to physical activity
Arthritis or other health conditions
• "It seems like after I had my surgery, I had a harder time walking." (Female participant, I9)
• "I can only do so much walking and then my stomach and back gets weak. . . . It was several years ago I had a hernia." (Female participant, I3)
Lack of safe and accessible locations
• "Where you gonna walk without running into all these dogs along (the road)?" (Male participant, I16)
• "Our native buildings should have our own gym." (Female participant, I11)
Lack motivation or confidence that physical activity will help
• "I guess I just don't want to be really active." (Female participant, I4)
• "Physical exertion and stretches. . . . I told myself they're not helping. I feel like they're making it worse." (Male participant, I13)
Focus on family
• "Someday there's going to be grandkids and I have to be chasing . . . them. So I need to love myself now." (Female participant, I5)
Fear of getting worse
• "I just don't wanna get real bad like my friend. . . . She could hardly get around." (Female participant, I7)
Wanting to be healthy
• "I try to stay on top of it because you know in the long run it is gonna affect me and nobody else." (Female participant, I8)
Domain 4: Preferences for program design
Interest in learning about arthritis
• "I am very interested in learning . . . pain management through exercise, nutrition and proper care versus the medication side of it." (Female participant, FG4)
Preferences for group or solitary physical activity
• "I'd rather do it on my own." (Female participant, I1)
• "I've been looking into going to something like that with more of a structured thing instead of just showing up and hoping someone comes." (Female participant, I11)
Schedule group classes around other community activities; provide transportation
• "If you could (offer a program) at breakfast (at the senior center), right after it or before it, then you could do that all in one." (Female participant, I5)
• "My main (barrier to participating) is transportation because I don't drive." (Male participant, I12)
Recruit by encouraging community members, engaging youth, and by showcasing successful community members
• "The main thing is to encourage them. I know a lot of people that . . . need that 'come on let's be a partner,' somebody to let them know 'I'll go with you.'" (Female participant, I1)
• "(Try) to get youth involvement and family activities they can all do together. It'd be fun. Might get more participation. That seemed to work (on another occasion)." (Male participant, I6)
• "(If you) get people out on the floor and they're all looking like, 'Oh, them are Indian guys. They are Indian women. If they can do it, I can do it, too.'" (Male participant, I15)
Abbreviation: I, interview; FG, focus group.
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
Page last reviewed: June 23, 2016
Content source: National Center for Chronic Disease Prevention and Health Promotion
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If you've ever seen an eastern bluebird up close, you'll understand the attraction of building birdhouses for them. These delicate songbirds have striking blue feathers, unlike any other you'll see in Nature–and they need our help. Bluebird populations have declined to just 17 per cent of the levels seen 50 years ago. Effective nesting boxes could turn this situation around, but to make a real difference, we'll need a lot of bluebird houses. An inexpensive and easy-to-build design can help this plight. Get your kids involved and you can teach them a little about woodworking and the vanishing eastern bluebird at the same time. I built several with the help of my own children.
Although you can certainly make a batch of bluebird houses using smooth lumber, I recommend rough-cut 1×6 and 1×8 cedar. The main reason is you can find it at a good price from sawmills in most parts of Canada. It's also rot-resistant, safe for birds and perfectly suits an outdoor location. The only trouble with rough-cut wood is you'll find a natural variation in board thickness. So-called 1″ rough lumber might be anything from 7/8″ to 1 1/8″ thick, depending on how the sawmill was set up. But, as you'll see, my design takes care of these discrepancies. You won't even have to do a whole lot of cutting to get parts to fit. These truly are easy-going birdhouses.
Start by sawing all the listed parts to length only; cutting to width comes later. Use 1x6s to make everything but the roof–you'll need a 1x8 for this part. You can also edge-glue narrower wood to get the 6 3/4" roof dimensions required.
I chose a roof angle of 12º from level for no other reason than it looks good. Use a chop saw or a tablesaw to cut mitres on the top ends of the sides. You'll also need to create bevelled edges on the door, the back piece, and the front and back edges of the roof. As you'll see in the plans, the angled cuts that extend across the width of the parts are called "mitre" cuts, while the angles across the thickness of the boards are "bevel" cuts. In this project, all are 12º from square.
Now it's time to saw some of the parts to width. In preparation for assembly, cut the door, the bottom and the back to 4" widths. To bring the pieces together, I used a combination of weatherproof glue and 2"-long stainless-steel screws. You might be able to get away with finishing nails, but weather can cause them to become loose over time, while screws will hold firm.
Start assembly by placing the back and door on their edges on your workbench, with one side member resting on top. You won't be fastening the door at this stage, but you still need it as a spacer to hold up the side. Align the top and back edges of the back and side pieces (the ones cut 12º from square), then drive two screws to secure the joint. Flip the unit over and secure the second side in the same way, also using the door as a spacer. At this stage, you'll have a three-sided, trough-shaped assembly.
As I mentioned before, rough lumber of the same nominal size can vary in thickness quite a bit; that's why I had you wait until now to cut the roof to width. Measure the actual left-to-right width of your birdhouse so far, then add a total of 3/4" for the overhang you'll need (3/8" on each side). Saw the roof to the correct size. Place the roof on top of the body and fasten it with four screws driven down into the sides.
Until this moment, the width of your door has been the same as the back, but now's the time to change that. Cut the door piece 1/8" narrower to allow it to open and close easily without rubbing on the sides. The plans show how the door is hinged at the top, pivoting on two screws driven in through the sides. This allows easy access to the inside of the house for cleaning. Slide the recut door into place on the front of the house.
For best appearance and operation, position the door 3/16" back from the front edges of the sides and 1/8" down from the roof. Position the two hinge screws 1" down from the top of the house and drive them through the sides and into the edges of the door. Close the door so there's a consistent amount of overhang all the way down, then get ready to fasten the bottom piece in place.
The length of the bottom is shorter than the front-to-back opening it covers, and there's a good reason for this. The resulting slot creates a drainage gap at the back of the house to let any stray water escape. Position the bottom 3/16" up from the bottom edge of the sides, and set it back far enough from the front to act as a stop for the door. Once again, the door's thickness will vary, depending on the wood you use, but that's fine. Position the bottom piece wherever necessary so the door closes evenly all the way down the sides.
Bluebirds like a 1 1/2"-diameter access hole in their nesting boxes. Before you bore the access hole, use 2 1/2" and 3" hole saws to create round patterns of grooves (or kerfs) around the perimeter of the access hole (see the plans for details). This makes it easier for birds to grab the wood with their feet as they land and take off from the house. When these kerfs are done, bore a 1 1/2"-diameter hole all the way through the door to create the entrance.
When it comes time to mount the birdhouse, open the door and drive a couple of 3"-long deck screws through the back and into a post or fence. Drive a single 2"-long screw through the side of the house to lock the door shut and keep the hatchlings safe inside. When it's time to spring clean your birdhouse, you can remove the screw and swivel the door open.
It costs just a few dollars and only takes about 20 minutes to make each bluebird house, but wildlife conservation isn't the only reason to make them. Few other kids' projects are as simple, long-lasting and useful as a birdhouse. And the only thing better than a new crop of bluebirds in your yard is the smiles from the kids who helped to make it happen.


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Q: I am getting following error during fetching record I am getting this error I getting this error after submit and i am going to fetching record it give this error. I had given message when error occur it not not error then execute other function. i getting some set headers error so please let me know where i mistake
/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/lib/utils.js:419
        throw err;
              ^
Error: Can't set headers after they are sent.
    at ServerResponse.OutgoingMessage.setHeader (_http_outgoing.js:331:11)
    at ServerResponse.res.set.res.header (/home/hacker201501/VAIBHAO/ndd/node_modules/express/lib/response.js:524:10)
    at ServerResponse.res.json (/home/hacker201501/VAIBHAO/ndd/node_modules/express/lib/response.js:189:36)
    at Promise.<anonymous> (/home/hacker201501/VAIBHAO/ndd/app/controllers/categories_controller.js:110:26)
    at Promise.<anonymous> (/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/node_modules/mpromise/lib/promise.js:157:8)
    at Promise.EventEmitter.emit (events.js:107:17)
    at Promise.emit (/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/node_modules/mpromise/lib/promise.js:79:38)
    at Promise.reject (/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/node_modules/mpromise/lib/promise.js:106:15)
    at Promise.error (/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/lib/promise.js:89:15)
    at Query.execFind (/home/hacker201501/VAIBHAO/ndd/node_modules/mongoose/lib/query.js:1664:13)

Here if my getfunction
exports.get_subcategory = function(req, res){
    var subcategoryData = req.query;
    console.log('auth_token');
    console.log(req.query.auth_token);
    console.log('query');
    console.log(subcategoryData);
    User.findOne({auth_token: req.query.auth_token}, function(user_error, user){
        if (user_error) res.json({status: 'Error', message: 'Login require'});
        if (!user) res.json({status: 'Error', message: 'Invalid user'});
        if (user){
            SubCategory.find({category: req.query.category}, function(categoryError, subcatgory){
                if (categoryError) res.json({status: 'Error', message: 'Category error'});
                if (!subcatgory) res.json({status: 'Error', message: 'No category found'});
                if (subcatgory) {
                    res.json({status: 'OK', data: subcatgory});
                }
            })
        }
    })
}

i didn't understand what happen

A: I went through your code, made some changes.
Now it should work, try this.
exports.get_subcategory = function(req, res){
    var subcategoryData = req.query;
    User.findOne({
                    auth_token: req.query.auth_token
                }, function(user_error, user){
                        if (user_error)
                            res.json({status: 'Error', message: 'Login require'});
                        SubCategory.find(
                                        {category: req.query.category},
                                        function(categoryError, subcatgory){
                                            if (categoryError)
                                                res.json({status: 'Error', message: 'Category error'});

                                            res.json({status: 'OK', data: subcatgory});

                                        }
                        )

                }
    )
}

redpajama_set_name: RedPajamaStackExchange


text:
Фёдор Я́ковлевич Фалале́ев (, Вятская губерния — 12 августа 1955, Москва) — советский военачальник, маршал авиации (1944).

Молодость
Родился в многодетной (18 детей, из которых 12 умерли в младенчестве или в детстве) семье крестьянина.  Окончил  начальную (3-х годичную) школу в родном селе с продолжением образования (ещё 2 года) школу в селе Вавож. Работал в родительском хозяйстве. С 14 лет «мальчиком» и продавцом в купеческих лавках в селах Большая Уча и Вятские Поляны. С весны 1917 года работал резчиком обойм и конторщиком на Ижевском оружейном заводе. В период Ижевско-Воткинского восстания в августе 1918 году встал на сторону большевиков, скрылся из занятого восставшими Ижевска в Можгу, где работал в отделе социального обеспечения Можгинского волостного революционного комитета. Также вступил в созданный этим ревкомом вооружённый отряд. Работал; в 1918 году вступил в РКП(б).

Гражданская война
В Красной Армии с мая 1919 года, доброволец. В гражданскую войну служил командиром отделения пулемётной команды и пулемётного взвода 7-го запасного батальона в Казани, Малоархангельске и Калуге, с ноября 1919 — комиссаром пулемётной школы запасного полка в Калуге и Мценске, с апреля 1920 — секретарём политотдела инспекции пехоты 13-й армии в Изюме. Воевал на Восточном фронте РККА против армий А. В. Колчака, в 1920 году был переведён на Юго-Западный фронт и воевал против армии генерала П. Н. Врангеля и многочисленных банд на южной Украине, особенно против махновцев.

Межвоенный период
С декабря 1920 года — помощник начальника учета и информации политуправления Вооружённых Сил Украины и Крыма в Харькове. Осенью 1921 года назначен военкомом штаба в сводно-маневренную группу войск Украины по борьбе с бандитизмом, затем — заместителем командующего группы по политчасти. Штаб группы в то время находился в Изюме. С конца 1921 года — помощник комиссара 82-х пехотных командных курсов в Изюме. С сентября 1922 года — помощник комиссара 4-й Киевской артиллерийской школы, с июля 1924 года — военный комиссар 14-й Полтавской пехотной школы. С октября 1924 года — военный комиссар 238-го стрелкового полка 80-й стрелковой дивизии (Мариуполь). В 1928 году окончил Высшую тактическо-стрелковую школу командного состава РККА имени Коминтерна «Выстрел», назначен командиром стрелкового батальона в 240-м Краснолуганском стрелковом полку. С ноября 1929 года — командир и военком 240-го стрелкового полка. В 1931 году окончил курсы командиров-единоначальников при Военно-Политической академии РККА имени Н. Г. Толмачёва в Ленинграде.

С августа 1932 года — в Военно-Воздушных Силах. Был назначен инспектором Смоленской авиационной бригады. В мае 1933 года направлен на учёбу в Первую военную школу лётчиков имени Мясникова, учился в составе спецгруппы командиров, переведённых в авиацию из других родов войск. В этой же группе учились будущий маршал авиации С. В. Жаворонков и будущий генерал-майор авиации и Герой Советского Союза Ф. Г. Коробков. После окончания школы в 1933 году сразу продолжил обучение на оперативном факультете Военно-воздушной академии РККА им. проф. Жуковского, которую окончил в 1934 году. С января 1935 года — командир и военком 4-й дальнеразведывательной авиационной эскадрильи (Смоленск), в те годы сам летал на самолёте Р-6 и прыгал с парашютом, а эскадрилья много лет не имела лётных аварий. с августа 1936 года — командир 116-й смешанной авиационной бригады в Смоленске, а с августа 1938 года командовал Сещенской авиационной бригадой. В августе 1939 года назначен заместителем командующего по ВВС 3-й армии и одновременно — Витебской армейской группы, на этих постах принимал участие в Польском походе РККА в сентябре 1939 года на территории Западной Белоруссии.

С июня 1940 года — заместитель командующего ВВС Особой Краснознамённой Дальневосточной армии. С января 1941 года — генерал-инспектор авиации РККА. С апреля 1941 года — первый заместитель начальника Главного управления ВВС Красной Армии.

Великая Отечественная война

Вскоре после начала Великой Отечественной войны был назначен командующим ВВС 6-й армии на Юго-Западном фронте. Но уже в июле 1941 года был назначен заместителем командующего ВВС Юго-Западного фронта, а через несколько дней — командующим ВВС Юго-Западного направления. В июне 1942 года снят с должности из-за задержки выполнения одного из постановлений Государственного комитета обороны (о демонтаже реактивных снарядов РС-82 с истребителей).

В июле 1942 года по предложению командующего ВВС РККА А. А. Новикова назначен заместителем командующего Военно-Воздушных сил РККА, а в октябре 1942 года — начальником штаба ВВС РККА. В ноябре 1942 года по указанию И. В. Сталина его должность именовалась "начальник штаба — заместитель командующего Военно-Воздушных сил РККА", и тогда же он был назначен членом Военного Совета ВВС РККА. Многократно заменял командующего ВВС во время его многочисленных выездов на фронт.

Весной 1943 года пережил первый инфаркт. После возвращения в строй в июне 1943 года назначен заместителем командующего Военно-Воздушных сил РККА. В феврале-апреле 1944 года находился в госпитале из-за второго инфаркта, но сразу после выхода из госпитале вылетел на фронт. С апреля 1945 года — вновь начальник штаба — заместитель командующего Военно-Воздушных сил РККА. На этих должностях значительную часть времени провёл в действующей армии, координируя действия участвовавших в наиболее крупных операциях нескольких воздушных армий. В таком качестве участвовал в Донбасской операции (1943), в освобождении Южной Украины, в Крымской операции 1944 года, в Белорусской, Прибалтийской, Восточно-Прусской операциях. За годы войны трижды повышен в воинских званиях.

В 1942—1943 годах являлся главным представителем от СССР на переговорах по вопросам создания и боевой деятельности будущего знаменитого истребительного авиационного полка «Нормандия-Неман», в 1945 году участвовал в работе Потсдамской конференции и на встрече военных делегаций союзных держав в Норвегии — Англии, Франции, США.

Послевоенный период

С июля 1946 года — начальник Военно-воздушной академии в Монино. Сыграл большую роль в переводе академии на мирные программы обучения и в её послевоенном развитии. По его инициативе в 1947 году был издан уникальный сборник статей 100 учащихся академии — Героев Советского Союза о наиболее интересных боевых эпизодах и о приёмах ведения воздушных боёв (переиздан в 2005 году под наименованием: Фалалеев Ф. Я. Сто сталинских соколов. В боях за Родину).

В феврале 1949 года перенёс третий инфаркт, после которого полностью уже не восстановился. С мая 1950 года — в отставке по болезни (по личной просьбе). Жил в Москве. Похоронен на Новодевичьем кладбище.

Автор мемуаров (изданы после его смерти).

Его единственная дочь Клацетта Фёдоровна (24.01.1924- 08.10.2019, участница Великой Отечественной войны), в 1950 году вышла замуж за Героя Советского Союза Александра Ивановича Петрова.

Воинские звания
 полковник (1935)
 комбриг (20.02.1938)
 генерал-майор авиации (4.06.1940)
 генерал-лейтенант авиации (27.03.1942)
 генерал-полковник авиации (17.03.1943)
 маршал авиации (19.08.1944)

Награды

 Орден Ленина (21.02.1945);
 Три ордена Красного Знамени (27.12.1941, 03.11.1944, 15.11.1950);
 Два ордена Суворова 1-й степени (20.04.1944 , 18.08.1945);
 Орден Кутузова 1-й степени (29.07.1944);
 Орден Суворова 2-й степени (14.02.1943);
 Орден Красной Звезды (22.02.1941);
 Орден «Знак Почёта» (14.05.1936);
 Медаль «XX лет Рабоче-Крестьянской Красной Армии» (22.02.1938);
 Медаль «За оборону Сталинграда» (22.12.1942);
 Медаль «За победу над Германией в Великой Отечественной войне 1941—1945 гг.» (9.05.1945);
 Командорская степень Ордена Почётного легиона (Франция, 10.12.1944);
 Военный крест 1939—1945 (Франция, 1944);
 Орден «За военные заслуги» 1-й степени (Болгария, 9.02.1946);

Мемуары
 Фалалеев Ф. Я. В строю крылатых. Из воспоминаний. — Ижевск, «Удмуртия», 1978.

Память

 Памятник-бюст в поселке Монино во дворе школы № 1
 Памятник-бюст в селе Большая Уча
 Именем Маршала названы улицы в Ижевске, в Монино и в Можге
 Именем Маршала названа средняя школа № 1 в Монино
 Именем Маршала названа средняя школа в селе Большая Уча Удмуртии, в которой он учился.

Примечания

Источники
 Биографическая справка на сайте выпускников Качинского ВВАУЛ
 Советская военная энциклопедия. Т. 8: «Ташкент» — Ячейка стрелковая. — 690 с. — М.: Военное издательство, 1980. — 105 000 экз. — С.246.
 Командный и начальствующий состав Красной армии в 1940—1941 гг.: Структура и кадры центрального аппарата Народного комиссариата обороны СССР, военных округов и общевойсковых армий: Документы и материалы. — М.; СПб.: Летний сад, 2005.
 Руденко С. И. Маршал авиации Ф. Я. Фалалеев (К 80-летию со дня рождения) // Военно-исторический журнал. — 1979. — № 5. — С.94-96.

Участники Гражданской войны в России (красные)
Выпускники курсов «Выстрел»
Выпускники Качинского высшего военного авиационного училища
Выпускники Военно-воздушной инженерной академии имени Н. Е. Жуковского
Лётчики СССР
Участники Польского похода Красной армии (1939)
Лётчики Великой Отечественной войны
Начальники штабов в Великой Отечественной войне
Начальники Военно-воздушной академии имени Ю. А. Гагарина
Персоналии:Ижевский машиностроительный завод
Члены РКП(б)
Похороненные на Новодевичьем кладбище
Участники советско-японской войны (СССР)

redpajama_set_name: RedPajamaWikipedia


The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study shows approximately 15% had resistant hypertension.
Approximately one in ten people with high blood pressure (nearly 100 million people worldwide) are resistant-hypertension.
What is Resistant Hypertension? Resistant hypertension refers to a blood pressure that stays stubbornly above the target in spite of the treatment with three drugs one among them is a diuretic. High blood pressure cannot be classified as "Resistant" until treatment failure with three-drug combination one among them should be a diuretic.
The true resistant hypertension is difficult to quantify because many patients suffer from 'pseudo-resistant' hypertension.
What is Pseudo-Resistant Hypertension? Pseudo-resistant hypertension refers to poorly controlled hypertension that appears to be resistant, but not. Most common reasons for pseudo-resistant hypertension are medication non-compliance, non-adhere to lifestyle advice, BP measurement error, white-coat hypertension, and other medication use that interfere with blood pressure.
Research suggests 28 % of treated hypertensive individuals are considered resistant to treatment.
How do I know whether I am resistant or pseudo-resistant hypertension?
Pseudo-resistance must be ruled out with a thorough hypertension adhesion review, followed by BP measurement with proper technique.
Assessing adherence to drug therapy - It is difficult to assert whether a patient truly adheres to an optimal dose of the 3-drug regimen. Hypertension adhesion review or patient noncompliance include whether taking the right medicines, correct dosage, and in time. Additionally, whether following healthy lifestyle choices that help lower blood pressure.
Rule out measurement error - Confirm BP measurement using an appropriately sized cuff, patient correctly positioned, and test after at least a 5-minute rest. Over 50% of apparent resistant hypertension are due to improper or inaccurate blood pressure measurement. The most common error is using the smaller cuff.
Rule out white-coat effect – Some individuals' experience BP raise only in doctor's office called white-coat effect. Confirm BP is not affected by white coat effect and wrongly consider as resistant hypertension. To burst this error, your doctor might order ambulatory blood pressure monitoring. For ambulatory BP monitoring, you need to wear a pager-sized automatic blood pressure recorder for 24 hours. Alternatively, you can use home blood pressure monitor to check your BP several times a day.
Other drugs that interfere BP control - heavy alcohol consumption, non-steroidal anti-inflammatory drugs (NSAIDs such as aspirin, ibuprofen, naproxen, and celecoxib), oral contraceptives or estrogen, antidepressants (such as bupropion, venlafaxine), and herbal supplements (such as Ginseng, licorice) will make BP difficult to control.
Patients with resistant hypertension are 50% more likely to experience an adverse cardiovascular event compared with patients with BP controlled by at least three antihypertensive agents.
If you ruled out all the above possible errors, then you are diagnosed with resistant hypertension. Otherwise pseudo-resistant hypertension and needs to correct the errors to achieve your target.
High blood pressure causes arterial stiffness. Thus uncontrolled hypertension over time leads to resistant hypertension.
Patients with resistant hypertension have the common clinical characteristic that includes obesity, diabetes, chronic kidney disease, older age, arterial stiffness, and left ventricular hypertrophy.
Renal artery stenosis – Formation of artery plaque in blood vessels that nourish the kidneys. It is a hidden contributor to resistant hypertension.
Obstructive sleep apnea – Sleep conditions characterized by breath-pause while sleeping. Sympathetic nervous system activation plays a crucial role in the pathogenesis of hypertension in patients with OSA. Sympathetic overactivity may result in blood pressure elevation via vasoconstriction and increased systemic vascular resistance, increased cardiac output, and enhanced fluid retention. Increased aldosterone levels have been observed in OSA patients with resistant hypertension.
Arteriosclerosis – The hardening and stiffening of the arteries. High blood pressure stems from hardening of arteries.
Other BP interference - Obesity or heavy intake of alcohol or other substances that can interfere with blood pressure, which results in resistant hypertension.
Overactive adrenal glands (Cushing's syndrome) - Excess production of aldosterone by adrenal glands subsequently decrease renin levels. This excess leads to hypertension, metabolic alkalosis, hypernatremia, and potassium loss resulting in hypokalemia. This vicious cycle leads to resistant hypertension. Aldosterone stimulates sodium retention, increase arterial stiffness, endothelial dysfunction, and impaired baroreflex function.
Chronic Kidney Disease - renal disease represents one of the forms of target organ damage induced by hypertension. It seems that the relationship between hypertension and CKD is bidirectional; a vicious cycle leads to resistant hypertension. Treatment resistance in patients with CKD is due to sodium and fluid retention.
Laboratory evaluation includes renal function by assessing potassium, urea & creatinine levels and a urine dipstick to assess albumin and hemoglobin levels. An ultrasound test to assess renal size. It will help to identify small kidneys typical of the non-diabetic renal disease, or asymmetrical kidneys were seen in the renovascular disease.
Non-adherence to therapy may be a much more common cause of resistant (actually pseudo-resistant) hypertension than appreciated.
In the case of pseudo-resistant hypertension, the treatment should focus on to determine the cause of the noncompliance and to alleviate it.
You already know, resistant hypertension is difficult to manage. Thus you need to help the medication to work efficiently with some healthy changes in your lifestyle.
Strictly comply with the medicine - take right medicines, correct dosage, and in time.
Limit the sodium salt - stay away from foods high in sodium. You know processed foods are loads of sodium.
Healthy diet - Eat more vegetables and fruits, avoid sugar, and change to whole grain instead of refined carbs.
Watch your weight - Reducing calorie intake and increasing exercise help to lost weight.
Stop tobacco use - Tobacco will harden your arteries and thus raises the blood pressure. You BP are already resistant to treatment. Thus you must stop tobacco use.
Limit alcohol - Excess alcohol elevates your blood pressure; limit alcohol no more than one drink a day for women and two for men.
Reduce stress - Mental, emotional, physical stressors can raise your blood pressure. Meditation, yoga, tai chi, and breathing can lower it.
Studies show just 5 to 10% of resistant hypertension patients have an underlying secondary cause for their elevated blood pressure.
Resistant hypertension may be due to some underlying problem. Thus the treatment should focus on this underlying problem.
Abnormal body fluid balance is usually due to kidney disease, in such a case dialysis might help. Providing treatment to the kidney disease help to normalize body fluid and then blood pressure.
A hormone imbalance induced resistant hypertension can be corrected by normalizing the hormonal profile.
Renal artery stenosis induced resistant hypertension can be corrected by opening the blocked arteries with balloon angioplasty often improves blood pressure.
Obstructive sleep apnea induced resistant hypertension can be managed by using continuous positive airway pressure (CPAP), the best treatment choice for patients with OSA.
Obesity or heavy intake of alcohol or other substances induced resistant hypertension can be reversed by cutting down alcohol or other problematic substances and work to lose weight.
Resistant hypertension patients have a 3-fold increase in the risk of a cardiovascular event compared with controlled hypertension.
No clinical trials have studied the effectiveness of specific drug regimens for the resistant hypertension treatment.
The available evidence emphasizes the use of low dose spironolactone as the preferred fourth drug if the potassium level in the blood is ≤4.5 mmol/L. With higher blood potassium levels, intensification of the thiazide-like diuretic drug should be considered.
An initial combination of thiazide diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blocker is often helping better control.
For aged men who may have prostate disease, long-acting alpha-blockers such as doxazosin are very useful.
For low potassium levels, aldosterone antagonist such as spironolactone or eplerenone may be very effective.
Other most commonly used antihypertensive agents are hydralazine in multiple daily divided doses, along with beta-blocker for controlling the heart rate, methyldopa, and clonidine.


Vargas-Salfate, S, Paez, D, Khan, SS, Liu, JH and Gil de Zúñiga, H (2018) System justification enhances well-being: A longitudinal analysis of the palliative function of system justification in 18 countries. British Journal of Social Psychology.
According to the palliative function of ideology hypothesis proposed by System Justification Theory, endorsing system-justifying beliefs is positively related to general psychological well-being, because this fulfils existential, epistemic, and relational needs. We discuss and address three main issues: (1) the role of societal inequality, (2) comparisons by social status, and (3) cross-sectional versus longitudinal research. We used a longitudinal survey of representative online samples (N = 5,901) from 18 countries. The results supported the main argument proposed by the theory, in that system justification was positively and significantly related to life satisfaction and negatively related to anxiety and depression. The pattern of results suggested that the palliative function of system justification is more homogeneously distributed across individual and collective measures of social status than proposed by the theory, because the function was unaffected either by society-level inequality or by individual-level social status. These results allow us to infer that one of the reasons for the high stability of social arrangements is located in the psychological domain of palliative effects.


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        </pluginManagement>
        <plugins>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-resources-plugin</artifactId>
                <version>2.7</version>
                <configuration>
                    <encoding>UTF-8</encoding>
                </configuration>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-compiler-plugin</artifactId>
                <version>3.2</version>
                <configuration>
                    <source>1.6</source>
                    <target>1.6</target>
                    <encoding>UTF-8</encoding>
                </configuration>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-jar-plugin</artifactId>
                <version>2.5</version>
                <configuration>
                    <archive>
                        <manifest>
                            <addClasspath>true</addClasspath>
                        </manifest>
                    </archive>
                </configuration>
                <executions>
                    <execution>
                        <goals>
                            <goal>test-jar</goal>
                        </goals>
                        <configuration>
                            <useDefaultManifestFile>false</useDefaultManifestFile>
                            <archive>
                                <addMavenDescriptor>false</addMavenDescriptor>
                                <manifest>
                                    <mainClass>uk.co.caprica.vlcj.test.basic.TestPlayer</mainClass>
                                    <addClasspath>true</addClasspath>
                                </manifest>
                                <manifestEntries>
                                    <Class-Path>${project.artifactId}-${project.version}.jar</Class-Path>
                                </manifestEntries>
                            </archive>
                        </configuration>
                    </execution>
                </executions>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-source-plugin</artifactId>
                <version>2.4</version>
                <executions>
                    <execution>
                        <id>attach-sources</id>
                        <goals>
                            <goal>jar-no-fork</goal>
                            <goal>test-jar-no-fork</goal>
                        </goals>
                    </execution>
                </executions>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-javadoc-plugin</artifactId>
                <version>2.10.1</version>
                <configuration>
                    <author>true</author>
                    <charset>UTF-8</charset>
                    <doctitle>${project.name} ${project.version} API Documentation</doctitle>
                    <docfilessubdirs>true</docfilessubdirs>
                    <encoding>UTF-8</encoding>
                    <footer>(C)2015 Caprica Software Limited</footer>
                    <show>public</show>
                    <javadocVersion>1.8</javadocVersion>
                    <quiet>true</quiet>
                    <failOnError>true</failOnError>
                </configuration>
                <executions>
                    <execution>
                        <id>attach-javadocs</id>
                        <goals>
                            <goal>jar</goal>
                        </goals>
                    </execution>
                </executions>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-assembly-plugin</artifactId>
                <version>2.5.3</version>
                <configuration>
                    <attach>false</attach>
                </configuration>
                <executions>
                    <execution>
                        <id>user_distribution</id>
                        <phase>package</phase>
                        <goals>
                            <goal>single</goal>
                        </goals>
                        <configuration>
                            <descriptors>
                                <descriptor>src/main/assembly/dist.xml</descriptor>
                            </descriptors>
                        </configuration>
                    </execution>
                </executions>
            </plugin>
            <plugin>
                <groupId>org.apache.maven.plugins</groupId>
                <artifactId>maven-dependency-plugin</artifactId>
                <version>2.10</version>
                <executions>
                    <execution>
                        <id>copy-dependencies</id>
                        <phase>package</phase>
                        <goals>
                            <goal>copy-dependencies</goal>
                        </goals>
                        <configuration>
                            <includeScope>runtime</includeScope>
                            <outputDirectory>${project.build.directory}/dependencies</outputDirectory>
                            <overWriteReleases>false</overWriteReleases>
                            <overWriteSnapshots>false</overWriteSnapshots>
                            <overWriteIfNewer>true</overWriteIfNewer>
                        </configuration>
                    </execution>
                </executions>
            </plugin>
            <plugin>
                <artifactId>jdeb</artifactId>
                <groupId>org.vafer</groupId>
                <version>1.3</version>
                <executions>
                    <execution>
                        <phase>package</phase>
                        <goals>
                            <goal>jdeb</goal>
                        </goals>
                        <configuration>
                            <verbose>true</verbose>
                            <dataSet>
                                <data>
                                    <src>${project.build.directory}/${project.build.finalName}.jar</src>
                                    <type>file</type>
                                    <mapper>
                                        <type>perm</type>
                                        <prefix>/usr/share/vlcj/lib</prefix>
                                    </mapper>
                                </data>
                                <data>
                                    <src>${project.build.directory}/dependencies</src>
                                    <type>directory</type>
                                    <mapper>
                                        <type>perm</type>
                                        <prefix>/usr/share/vlcj/lib</prefix>
                                    </mapper>
                                </data>
                                <data>
                                    <src>README.md</src>
                                    <type>file</type>
                                    <mapper>
                                        <type>perm</type>
                                        <prefix>/usr/share/doc/vlcj</prefix>
                                    </mapper>
                                </data>
                                <data>
                                    <src>doc/copyright</src>
                                    <type>file</type>
                                    <mapper>
                                        <type>perm</type>
                                        <prefix>/usr/share/doc/vlcj</prefix>
                                    </mapper>
                                </data>
                            </dataSet>
                        </configuration>
                    </execution>
                </executions>
            </plugin>
        </plugins>
        <resources>
            <resource>
                <directory>src/main/resources</directory>
                <filtering>true</filtering>
                <excludes>
                    <exclude>.gitignore</exclude>
                </excludes>
            </resource>
        </resources>
    </build>

</project>