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# 1.2 Who is at risk of cardiovascular disease?

## What do we mean by risk?

Risk probability of occurrence of unwanted event or outcome.
In context of hazards anything that could potentially harm.
Probability precise mathematical meaning- calculated give numerical
value for size of risk.
Can calculate chance of accident or disease.
Not necessarily suffer, by looking at past circumstances of people
taken same risk, can estimate chance you will suffer same fate.
Working out probabilities
When measuring risk always quote time period for the risk.
When calculating probability for health, 1 in 3909 more meaningful
than percentage.
If calculated risk of developing lung cancer in lifetime approx.
probability 1 in about 1600.
However because lung cancer much more likely if smoke, risk for
smokers far greater.
When looking at calculated risk values need to think of exposure to the
hazard.
Perception of risk
People will overestimate risk of something happening if the risk is
o Involuntary
o Not natural
o Unfamiliar
o Dreaded
o Unfair
o Very small
Tendency to overestimate risk of sudden imposed dangers where
consequences are severe, and underestimate risk if it has an effect in
the long-term future, even if effect is severe.
Useful distinction between risk and uncertainty.
When lack data to estimate risk precisely, uncertain about risk
Different types of risk factor
Probabilities use figures for whole population, giving averages which
make assumption that everyone has same chance of having CVD.
Averages take no account of any risk factors- things that increase
chance of having harmful outcome.
Many different risk factors contribute to health risks
o Heredity
o Physical environment
o Social environment
o Lifestyle and behaviour choices

## Identifying risk factors- correlation and causation

To determine risk factors for particular disease- scientists look for
correlation between potential risk factors and occurrence of disease.
Two variables positively correlated when increase in one accompanied
by increase in other.
If values of one variable decrease while other increases there is
negative correlation.
Correlation between two variables does not necessarily mean that the
variables are causally linked.
Two variables causally linked when change in one is responsible for
change in other.
Easy to think of variables that are correlated but with no causation.
Because of logical gap between correlation and causation that scientist
carry out experiments in which they can control variables, to see if
altering one variable really does have predicted effect.
Scientists often set up null hypothesis.
Assume for sake of argument there will be no difference between
experimental group and control group, then test this hypothesis using
statistical analysis.

## 1.3 Risk factors for CVD

Identifying risk factors for CVD
Large scale studies undertaken find risk factors for many common
diseases.
Epidemiologists, scientists who study patterns in occurrence of disease,
look for correlation between a disease and specific risk factors.
Two common designs for this type of study
o Cohort studies- group of people followed over time to see who
develops disease
o Case-control studies- group of people who have disease
compared with people who dont have disease.
Cohort studies
Follow group of people over time to see who develops disease and who
doesnt.
During study peoples exposure to risk factors recorded so any
correlation between risk factors and disease development can be
identified.
May take long for condition to develop so these studies can take years
and be very expensive.
Case-control studies
Group of people with disease (cases) compared with control group of
individuals who dont have the disease.
Information is collected about risk factors they may have been exposed
to, allowing factors that may have contributed to the development of
the disease to be identified.

## Control group should be representative of population from which case

group was drawn.
Sometimes controls individually matched to cases; known diseases
factors such as age and sex, are then similar in each case and control
pair.
This allows scientists to investigate potential role of unknown risk
factors.
Should be noted factors used to match up the cases ad controls cannot
be investigated within the study, important not to match on variables
which could potentially turn out to be risk factors.
Features of a good study
To identify correlations between risk factors and disease studies need
to be carefully designed.
When designing an epidemiological study, key questions should be
considered.

Clear aim
Well designed study should include clearly stated hypothesis or aim.
Design of study must be appropriate to stated hypothesis or aim and
produce results that are valid and reliable.
Representative sample
Representative sample must be selected form wider population that
the studys conclusion will be applied to.
Selection bias occurs when those who participate in the study are not
representative of the target population.
Differences between people asked to take part in a study and those
who actually respond should also be considered before generalising
findings to the target population.
The proportion of individuals who drop out of a study after it has begun
should be kept to a minimum.
Particularly important for cohort studies which follow people over long
periods of time.
Peoples who drop out of studies often share common features.
Important to monitor characteristics of remaining participants to
ensure that they are still representative of the target population.
Valid and reliable results
Any methods used must produce valid data, from measurement that
provide information on what the study set out to measure.
Method used to collect results must be reliable.
A reliable method used at different times, or by different people will
produce similar results.
Disease diagnosis must be clearly defined to ensure different doctors
record and measure symptoms in the same way.
A sample must be large enough to produce results that could not have
occurred by chance.

With larger samples more reliable estimates for the wider population
can be calculated.
Potential effect of all variables that could be correlated with the disease
should be considered when designing the study.
Matching case and control groups on variables known to correlate with
the disease being studied will ensure that only the factor under
investigation is influencing the outcome.

## Risk factors for CVD

Chances of having CHD or stroke increased by several inter-related risk
factors, majority common to both conditions. These include :
o High blood pressure
o Obesity
o Blood cholesterol and other dietary factors
o Smoking
o Genetic inheritance
Age and gender
Risk of CVD higher for men than women in the UK.
In both sexes, prevalence of CVD increases with age.
May be due to effects of ageing on arteries; tend to become less elastic
may be more easily damaged.
With increasing age risk associated with other factors may increase
causing a rise in number of cases of disease.
High blood pressure
Elevated blood pressure, known as hypertension considered to be one
of most common factors in developments of CVD.
High blood pressure increases likelihood of atherosclerosis occurring.
Blood pressure is measure of hydrostatic force of blood against the
walls of a blood vessel
Blood pressure is higher in arteries and capillaries than in veins.
Pressure in artery highest during phase of cardiac cycle when
ventricles have contracted and forced blood into the arteries. This is
the systolic pressure.
Pressure is at its lowest in the artery when the ventricles are relaxed.
This is the diastolic pressure.
Measuring blood pressure
Sphygmomanometer traditional device measure b.p
Consists of inflatable cuff wrapped round upper arm and manometer or
gauge that measures pressure.
When cuff inflated blood flow through artery in upper arm stopped.
As pressure in cuff released blood starts to flow through artery.
This flow of blood can be heard using stethoscope positioned on artery
below cuff.

Pressure reading taken when blood first starts to spurt through artery
that has been closed. This is the systolic pressure.
Second reading taken when pressure falls to point where no sound
heard in artery. This is the diastolic pressure.
Blood pressure reported as two numbers one over other eg 140/85.
This means systolic pressure of 140 mmHg and diastolic pressure of 85
mmHg. For average healthy person expect systolic pressure of between
100-140 and diastolic pressure between 60-90.

## What determines your blood pressure?

Contact between blood and walls of blood vessels causes friction, this
slows down flow of blood.
Peripheral resistance.
Arterioles and capillaries offer greater total surface area, resisting flow
more, slowing blood down causing b.p to fall.
Fluctuation in pressure in arteries caused by contraction and relaxation
of the heart.
As blood expelled from heart pressure higher.
During diastole elastic recoil of blood vessels maintains pressure and
keeps blood flowing.
If smooth muscle in walls of artery or arteriole contract, vessels
constrict, increasing resistance.
In turn b.p raised.
If smooth muscles relax, lumen dilated, so peripheral resistance
reduced b.p falls
Any factor that causes arteries and arterioles to constrict can lead to
higher b.p.
Eg. natural loss of elasticity with age, release of hormones such as
adrenaline or high salt diet. High b.p can lead to atherosclerosis.
One sign of high b.p is oedema, fluids building up in tissues causing
swelling
At arterial end of capillary blood under pressure.
This forces fluid and small molecules normally found in plasma out
through capillary walls into intercellular spaces forming tissue fluid.
Capillary walls prevent blood cells and larger plasma proteins from
passing through, so these stay inside capillaries.
If b.p rises above normal more fluid may be forced out of capillaries.
In such circumstances fluid accumulates within tissues causing
oedema.
Carbohydrates
Monosaccharides
Single sugar units with general formula (CH2O)n where n is number of
carbons in molecule.
Monosaccharides- glucose, galactose, and fructose are hexose sugars.

Glucose important- main sugar used by all cells in respiration. Starch &
glycogen made up of glucose subunits. When starch & glycogen
digested form glucose which is reabsorbed and transportes in cells,
Galactose occurs in our diet as part of disaccharide lactose found in
milk.
Fructose occurs naturally in fruit, honey.
Monosaccarides rapid source of energy readily absorbed.

Disaccharides
Two single sugar units join together to form dissacharide in
condensation reaction.
Condensation reaction water molecule released as two sugar
molecules combine in reaction.
Bond that forms between two glucose molecules known as a glycosidic
bond.
Bond in maltose known as 1.4 glycosidic bond as forms between
carbon 1 on one molecule and carbon 4 on other.
Sucrose- formed from glucose and fructose, usual form of sugar
transport in plants
Maltose- formed from two glucose molecules disaccharide produced
when amylase breaks down in starch.
Lactose- galactose and glucose make up lactose- sugar found in milk
Monosaccharides eaten rapidly absorbed into blood sharp rise in
blood sugar.
Polysaccharides and disaccharides have to be digested into
monosaccharides before absorption.
Takes time monosaccharides released slowly eating complex
carbohydrates does not cause swings in blood sugar levels as does
monosaccharides.
Lactose sugar present in milk. Many adults intolerant to lactose.
Solution is to hydrolyse milk converts disaccharide lactose into
monosaccharides glucose and galactose.
Industrially carried out using enzyme lactase. Lactase immobilised in
gel, milked poured in continuous stream through column containing
beads of immobilised enzyme.
Polysaccharides
3 main types of polysaccharide found in food: starch and cellulose in
plants and glycogen in animals. Although polymers of glucose molecule
they are sparing soluble and do not taste sweet.
Starch and glycogen energy storage molecules in cells.
These polysaccharides are suitable for storage as are compact and low
solubility in water.
Do not affect concentration of water in cytoplasm and do not affect
water movement in and out of cell by osmosis.
Starch- storage carbohydrate found in plants made up of mixture of
two molecules amylose and amylopectin.

## Amylose composed of straight chain of between 200 and 5000 glucose

molecules with 1, 4 glycosidic bonds between adjacent glucose
molecules. Position of bond causes chain to coil up in spiral shape.
Amylopectin is a polymer of glucose but has side branches. A 1, 6
glycosidic bond hold each side branch onto main chain.
Compact structure of starch and insoluble nature makes excellent
storage molecule.
Does not diffuse across cell membranes and has very little osmotic
effect within cell.
Starch major source of energy in our diet.
Bacteria fungi and animals store glycogen instead of starch. Numerous
side branches mean it can be rapidly hydrolysed easy access to
stored energy. Humans, glycogen stored in liver and muscles.
Cellulose in diet known as dietary fibre, referred to as non- starch
polysaccharide.
Indigestible in human gut, cellulose important function in movement of
material through digestive tract.
Lipids
Lipids make foods feel creamier and smoother. Supply over twice
energy of carbohydrates.
Lipids organic molecules found in every type of cell insoluble in water
but soluble in organic solvents such as ethanol.
Most common lipids eaten are triglycerides, used as stores in plants
and animals.
Triglycerides made up of three fatty acids and one glycerol molecule
linked by condensation reaction.
Bond between fatty acid and glycerol is ester bond.
Three ester bonds formed in triglyceride.
Saturated fats
If fatty acid chain in lipid contains maximum number of hydrogen
atoms said to be saturated.
In saturated fatty acid hydrocarbon chain is long and straight.
No carbon-carbon double bonds in saturated fatty acid and no more
hydrogens can be added.
Animal fats from meat and dairy products main source of saturated
fats.
Straight saturated hydrocarbon chains can pack closely together.
Strong intermolecular bonds between triglycerides made up of
saturated fatty acids results in fats that are solid at room temperature.
Unsaturated fats
Monounsaturated fats have one double bond between two of carbons in
each fatty acid
Polyunsaturated fats have large number of double bonds.
Double bond causes kink kinks prevent unsaturated hydrocarbon
from packing closely together.
Weaker intermolecular bonds between unsaturated triglycerides results
in oils that are liquids at room temperature

## Other types of lipid

Cholesterol short lipid molecule. Steroid sex hormones and some
growth hormones produce from cholesterol.
Cholesterol made in liver from saturated fats.
Phospholipids similar to triglycerides but one of fatty acids replaced by
negatively charged phosphate group.
Fats supply essential fatty acids that body need but cannot synthesise.
Fat soluble vitamins (A, D,E & K) can only enter dissolved in fats.
The energy balance
Getting it right
Department of health publishes dietary guidelines for most nutrients
dietary reference values (DRVs)
o An estimated average requirement (EAR)
o A lower reference nutrient intake (LRNI)
o A higher reference nutrient intake (HRNI)
Provide range of values in which a healthy balanced diet should fall.
Getting it wrong
Need constant supply of energy to maintain essential body processes.
Energy needed for essential processes called basal metabolic rate
(BMR) and varies between individuals. BMR higher in:
o Males
o Heavier people
o Younger people
o More active people
If eat fewer kilojoules than you use you have negative energy balance
and energy stored in body used to meet demand. Regular shortfall in
energy intake result in weight loss
If routinely eat more than use you have positive energy balance.
Additional energy will be stored and you will put on weight.
Defining overweight and obese
Body mass index (BMI) conventionally used method of classifying body
weight relative to persons height. To calculate BMI body mass (in kg)
divided by height (in metres) squared.
BMI does not have an exact correlation with fat levels in the body.
Evidence that waist-to-hip ratio is better measure of obesity than BMI
and shows a highly significant association with risk of heart attack.
Waist to hip ratio calculated by dividing waist circumference by hip
circumference.
Waist is measured unclothed at narrowest point between rib margin
and top of hip bone.
Hip circumference measured in light clothing at widest point around
buttocks. Non-stretchable tape measure used attached to spring scale
of mass 750g.
Consequences of obesity
Obesity increase risk of CHD and stroke even without other risk factors
present.
More excess fat especially around middle greater risk to heart.

## Obesity also greatly increases chance of type II diabetes.

Obesity can also raise your blood pressure and elevate your blood lipid
levels, two classic risk factors for CVD.
Why is cholesterol such a problem?
Considerable amount of evidence to show that higher blood cholesterol
levels increases risk of CHD.
Estimated that in UK 45% deaths from CHD in men and 47% deaths
from CHD in women due to raised blood cholesterol level.
Like all lipids, cholesterol not soluble in water.
In order to be transported in bloodstream, insoluble cholesterol is
combined with proteins to form lipoproteins.
Low density lipoproteins (LDLs) - main cholesterol carrier in blood.
o Triglycerides from saturated fats in our diet combine with
cholesterol and protein to form LDLs.
o These circulate in bloodstream and bind to receptor sites on cell
membranes before being taken up by the cells.
o Excess LDLs in diet overload membrane receptors leading to high
blood cholesterol levels.
o Saturated fats may also reduce activity of LDL receptors so LDLs
not removed from blood, further increasing blood cholesterol
levels.
o Cholesterol may be deposited in artery walls causing atheromas
High density lipoproteins (HDLs) HDLs have higher percentage of
proteins compared with LDLs hence higher density.
o High density lipoproteins are made when triglycerides from
unsaturated fats combine with cholesterol and protein.
o HDLs transport cholesterol from the body tissues to the liver
where it is broken down.
o This lowers blood cholesterol levels and helps remove fatty
plaques of atherosclerosis.
Monounsaturated fats thought to help in removal of LDLs from blood.
Polyunsaturated fats though to increase activity of LDL receptor sites
so LDLs actively removed from blood.
LDLs associated with formation of plaque whereas HDLs lower blood
cholesterol deposition.
Desirable to maintain high level of HDL and lower level of LDL.
Eating low fat diet which avoids saturated fats will help reduce total
blood cholesterol, especially LDL cholesterol which constitutes major
component of cholesterol risk for CVD.
Smoking
Smoking cigarettes one of major risk factors for development of CVD.
Constituents in smoke affect circulatory system in following ways.
o Haemoglobin in r.b.c carries CO from smoke instead of oxygen.
This reduces supply of oxygen to the cells. Any narrowing of
arteries due to atherosclerosis will reduce blood flow through
arteries in heart & brain. Result in increased heart rate as body
reacts to provide enough oxygen for cells.

## o Nicotine in smoke stimulates production of adrenaline increase

in heart rate and causes arteries and arterioles to constrict
raise blood pressure.
o Numerous chemicals in smoke can cause damage to lining of
arteries triggering atherosclerosis.
o Smoking also linked with reduction in HDL cholesterol level
Inactivity
Physical inactivity one of most common risk factors for heart disease.
Has been shown that being active can halve risk of developing CHD.
Moderate exercise helps prevent h.b.p and can help lower it.
Exercise helps maintain healthy weight also seems to raise HDL
cholesterol levels without affecting LDL cholesterol levels.
Also reduces chance of developing type II diabetes and helps in
controlling condition.
Person more physically active more likely to survive a heart attack than
inactive person.
Genes and CHD
Some single gene disorders that increase likelihood of early
development of CHD.
Inheritance of CVD not simple case of single faulty gene for condition
being passed from one generation to the next.
Several genes that can affect likelihood of developing CVD.
Apolipoprotein gene cluster identified as associated with CHD and
other conditions such as Alzheimers disease.
Apolipoproteins are protein component of lipoproteins.
Mostly formed in liver and intestines and have important roles in
stabilising structure of lipoproteins and recognising receptors involved
in lipoprotein uptake on the plasma membrane of most cells in the
body.

## Several types of Apolipoproteins including:

o Apolipoproteins A (APOA) - major protein in HDL helps in removal
of cholesterol to liver for excretion. Mutations in gene are
associated with low levels HDL and reduced removal of
cholesterol levels of the blood, leading to increased CHD.
o Apolipoprotein B (APOB)- main protein in LDL molecule which
transfers cholesterol from the blood to cells. Mutations of gene
result in higher levels of LDL in the blood and higher chance of
CVD.
o Apolipoprotein E (APOE) major component of HDLs and very low
density lipoproteins (VLDLs) which are also involved in removal of
excess cholestrol in the blood to the liver.
Numerous mutations in the APO genes effects of these mutations
modified in different environments when in different combinations
making it impossible to estimate the effect of a single gene or single
environmental risk factor.
Other risk factors
The role of antioxidants

During reactions in the body unstable radicals result when an atom has
an unpaired electron. Radicals are highly reactive and can damage
enzymes and genetic material.
This type of cell damage has been implicated in development of some
types of cancer, heart disease and premature ageing.
Some vitamins including vitamin C, beta carotene and vitamin E can
protect against the radical damage.
They provide hydrogen atoms and stabilise the radical by pairing up its
unpaired electron.
Salt
High salt diet causes kidney to retain water.
Higher fluid levels in blood result in elevated blood pressure with
associated CVD risks.
Stress
Evidence that CHD sometimes linked to poor stress management,
In stressful situations release of adrenaline causes arteries and
arterioles to constrict resulting in raised b.p.
Alcohol
Heavy drinkers far greater risk of heart disease.
Heavy drinking raises b.p and can cause irregular heartbeat
Excess alcohol consumption can result in direct tissue damage
including damage to the liver brain and heart.
Such damage contributes increased risk of CVD.
High level of alcohol can damage liver cells.
Impairs the ability of liver to remove glucose and lipids from the blood.
In liver alcohol is converted to ethanol. A three carbon carbohydrate.
Some may end up in VLDls increasing risk of plaque deposition.

## Risk of CVD can be reduced through

Stopping smoking, maintaining resting blood pressure, maintaining low
blood cholestrol levels, maintaining normal BMI
Taking more physical exercise and moderate or no use of alcohol.
Controlling blood pressure
Three main types of drugs used to treat h.b.p
ACE inhibitors
Effective antihypertensive drugs which reduce the synthesis of
angiotensin II .
This hormone causes vasoconstriction of blood vessels t help control
blood pressure.
These prevent the hormone being produced from an inactive form
angiotensin I, reducing vasoconstriction and lowering b.p.
Side effects; dry cough dizziness abnormal heart rhythms and
reduction in function of the kidney.
Calcium channel blockers
Block calcium channels in the muscle cells. Blood vessels do not
constrict and this lowers the b.p.

## Side effects headaches dizziness swollen ankles abnormal heart

rhythms constipation.
Diuretics
Increase the volume of urine produced by kidneys thus remove excess
fluids and salt.
Leads to decrease in blood plasma volume and cardiac output which
lowers the b.p.
Dizziness nausea and cramps are side effects
Cholesterol lowering drugs
Main type used are statins, statin work by inhibiting an enzyme
involved in the production of LDL cholesterol.
A diet to reduce the risk of CVD
Energy balanced, reduced saturated fat, more polyunsaturated fats,
reduced cholesterol and reduced salt.
More non-starch polysaccharides such as pectin and guar gums. These
polysaccharides known as soluble fibre has been found to lower blood
cholesterol.
Include oily fish contain omega-3 fatty acids. Essential for cell
functioning linked to reduction in heart disease.
Include functional foods containing sterols and stanols.
Anticoagulants and platelet inhibitory drugs
Tendency for platelet aggregation and clotting is reduced by platelet
inhibitory drugs and anticoagulant drugs. Aspirin reduces the
stickiness of the platelets. Risk of bleeding in gastrointestinal tract
with aspirin.
Risk of bleeding may outweigh the benefits. Risk and benefits need to
be considered for each individual patient.
Warfarin is an anticoagulant drug; it affects the synthesis of clotting
factors. Benefits may be greater than aspirin for some patients but the
risk of bleeding is higher than with aspirin.
An artery can burst due to an aneurysm where blood builds up behind
a section of artery that has narrowed as a result of atherosclerosis.

## 2.1 The effects of CF on the lungs

Lungs allow rapid gas exchange between the atmosphere and the
blood.
Air drawn into lungs via trachea due to low pressure created by the
movement of the ribs and diaphragm.
Trachea divides into two bronchi which carry air to and from the lung.
Within each lung tree- like system of tubules ending in narrow tubes
bronchioles attached to alveoli which are the site of gas exchange.
Nothing unusual about having layer of mucus in tubes of gas exchange
system
Thin coating of mucus in tubes produced by goblet cells. Any dust or
debris that enter airways become trapped in the mucus.
Continually removed by cilia that cover the epithelial cells lining tubes
of the gas exchange system.

However those who have CF have mucus that is drier resulting in sticky
mucus that cilia can find more difficult to move.
Sticky mucus increases the chance of lung infection and makes gas
exchange less efficient.
How sticky mucus increases the chance of lung infections
Microorganisms become trapped in the mucus in the lungs.
Some of these can cause illness they are pathogens.
Mucus normally moved by cilia into back of mouth cavity where it is
either coughed or swallowed reducing risk of infection. Acid in stomach
kills most microorganisms that are swallowed.
With CF the mucus layer so sticky cilia cannot move mucus
Mucus production still continues as it would in normal lung and airways
build up with thickened mucus.
Low levels of oxygen in mucus, partly because oxygen diffuses slowly
through it and partly because epithelial cells use up more in CF
patients.
Harmful bacteria thrive in anaerobic conditions.
W.b.c fight infection within the mucus but as they break down,
releasing DNA which makes the mucus even stickier.
Repeated infections can eventually weaken the bodys ability to fight
the pathogens and cause damage to the structures of the gas
exchange system.
How sticky mucus reduces gas exchange
Gases such as oxygen cross the walls of the alveoli into the blood
system by diffusion.
Living organisms have to exchange substances with their surroundings.
E.g. they take in oxygen and nutrients and get rid of waste materials
such as CO2.
In unicellular organisms whole cell surface membrane is the exchange
surface.
Substances that diffuse in or out of a cell move down a concentration
gradient.
Gradient maintained by cell continuously using the substances
absorbed and producing waste.
Larger an organism more exchange has to take place to meet the
organisms needs.
Larger multicellular organisms have more problems absorbing
substances because of size of organisms surface area compared with
its volume.
This is known as the surface area to volume ratio, calculated by
dividing an organisms total surface area by its volume.
As organisms get larger s.a per unit of volume gets less. If larger
organisms relied on body surface for exchange of substances they
could not survive as exchange would be too slow.
Relying on outer body surface for gas exchange is only possible in
organisms with a very small volume or in large organisms that have a
high enough surface area to volume ratio.

Larger organisms have variety of special organs that increase the s.a
for exchange, increasing the s.a to volume ratio. Eg. Lungs provide a
large surface for gas exchange in mammals while minimising heat and
water loss form the moist surface.
Gas exchange surfaces
Within lungs alveoli provide large surface are for exchange of gases
between air and blood.
Large surface area of the alveoli, numerous capillaries around the
alveoli, thin walls of the alveoli and capillaries meaning a short
distance between the alveolar air and the blood in the capillaries.
Bodys demand for oxygen is enormous, diffusion across alveolar wall
needs to be fast.
Rate of diffusion dependent on three properties of gas exchange
surfaces
Surface area rate of diffusion is directly proportional to s.a. As the s.a
increases the rate of diffusion increases.
Concentration gradient. Rate of diffusion is directly proportional to
difference in concentration across the gas exchange surface. Greater
the concentration gradient faster the diffusion.
Thickness of gas exchange surface- rate of diffusion is inversely
proportional to thickness of the gas exchange surface. Thicker the
surface are slower diffusion.
Known as Ficks law
Large surface are of the alveoli, steep concentration gradient between
the alveolar air and the blood and the thin walls of the alveoli and the
capillaries combine to ensure rapid diffusion across the gas exchange
surface.
How sticky mucus might affect gas exchange
Sticky mucus layer in the bronchioles of person with CF tends to block
narrow airways, preventing ventilation of the alveoli below the
blockage.
Reduces number of alveoli providing surface are for gas exchange.
Blockages are more likely at the narrow ends of the airways.
These blockages often allow air to pass when person breathes in but
not when they breathe out, resulting in over- inflation of the lung tissue
beyond the blockage.
This can damage the elasticity of the lungs.

## In people with CF mucus layer on surface of epithelial cells is sticky

because it contains less water than normal.
Reduced water level due to abnormal salt and water transport across
the cells surface membrane caused by a faulty transport protein
channel in the membrane.
Proteins have a wide range of functions in living things
Antibodies, enzymes and many hormones are all protein molecules.
All proteins are composed of the same basic units amino acids.
20 different amino acids that occur commonly in proteins.

Those amino acids that animals have to obtain in their diet are known
as essential amino acids.
All amino acids contain an amine group, a carboxylic acid group and a
hydrogen attached to the central carbon atom.
Each type of amino acid has a different side chain called an R group.
Primary structure
2 amino acids join in a condensation reaction to form a dipeptide with a
peptide bond forming between the two subunits.
This process can be repeated to form polypeptide chains which may
contain thousands of amino acid.
A protein is made up of one or more polypeptide chain.
Sequence of amino acids in the polypeptide chains is known as the
primary structure of a protein.
Secondary structure
Chain of amino acid may twist to form an alpha helix. Within the helix
the hydrogen bonds form between the C=O of the carboxylic acid and
the NH of the amine group of different amino acids stabilising the
shape.
Several chains may link together with hydrogen bonds holding the
parallel chains in an arrangement known as the beta pleated sheet.
Within one protein molecule there may be sections with alpha helices
and other sections that contain beta pleated sheets.
Tertiary and quaternary structure
A polypeptide chain often bends and folds to produce a precise 3d
shape.
Chemical bonds and hydrophobic interactions maintain this final
tertiary structure of the protein.
An R group is polar when sharing of electrons within it is not quite
even.
Polar R groups attract other molecules, like water and are therefore
hydrophilic. The non-polar groups are hydrophobic.
Non-polar hydrophobic R groups are arranged so they face the inside of
the protein excluding water from the centre of the molecule.
A protein may be made up of several polypeptide chains held together.
For example haemoglobin, the protein found in r.b.c that carries oxygen
is made up of four polypeptide chains held together in a structure
known as the quaternary structure.
Only proteins with several polypeptide chains have a quaternary
structure; single chain proteins stop at the tertiary level
Conjugated proteins
Some proteins are known as conjugated proteins- they have another
chemical group associated with their polypeptide chains.
Globular and fibrous proteins