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Lifetime positive lifestyle education aimed at reducing the incidence of coronary heart disease 1981

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LIFETIME POSITIVE LIFESTYLE EDUCATION AIMED AT REDUCING THE INCIDENCE OF CORONARY HEART DISEASE by WILLIAM SIDNEY ORNSTEIN B.Sc, McGill University, 1946 A Thesis Submitted i n P a r t i a l Fulfilment of The Requirements for the Degree of MASTER OF SCIENCE (Health Services Planning) i n THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept t h i s t he s i s as conforming to the r equ i r ed standard THE UNIVERSITY OF BRITISH COLUMBIA September 1981 © WILLIAM SIDNEY ORNSTEIN, 1981 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f jL/tH-L-r/J q /r~A } CrM'QLD £y The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e V ancouver, Canada V6T 1W5 (? /7cn A B S T R A C T A review of a portion of the vast amount of l i t e r a t u r e on the subject of Coronary Heart Disease reveals that although the incidence of mortality from this disease has declined by over 20 per cent since the 1960's, i t i s s t i l l a major cause of death i n Canada. There seems to be general agreement that there are c e r t a i n " r i s k f a c t o r s " fo r Coronary- Heart Disease and that these can be modified p o s i t i v e l y by intervention such as education v i a the media, and c o u n s e l l i n g , as has been done i n such studies as MRFIT, the Stanford Program, North K a r e l i a , and "Know Your Body" Program. Many investigators now agree that Coronary Heart Disease i s a "pediatric disease" and that measures to reduce the e f f e c t s of the known ri s k factors should be i n i t i a t e d early i n l i f e . This reduction can best be achieved by an education program which commences at least as early as at the kindergarten l e v e l and continues throughout l i f e i n the school and i n the work mil i e u . Governments w i l l be the main source of funds for the develop- ment and implementation of health education programs, but w i l l a l s o provide support for the education and h i r i n g of h e a l t h educators. Other resources w i l l be the health professionals i n a l l d i s c i p l i n e s and at a l l l e v e l s ; industry, both at the o c c u p a t i o n a l and consumer l e v e l s ; the media; and various community f a c i l i t i e s . In a d d i t i o n to incentives i n the form of reduced insurance premiums o f f e r e d by the private sector to participants i n positive l i f e s t y l e programs, there could be tax incentives to individuals and to industry for such par- t i c i p a t i o n , or for the provision of f a c i l i t i e s to encourage p a r t i c i - pation. I t i s suggested that the various programs aimed at hel p i n g Canadians to develop positive l i f e s t y l e s for the prevention of Coro- nary Heart Disease be "married" into one i n t e r - r e l a t e d , continuous program so that there i s some rat i o n a l relationship between programs at a l l l e v e l s . This would provide the continuous exposure necessary for enhancement of the learning process. Some recommendations are made for future studies. Dr. J. H. Milsum Thesis Chairman TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGEMENTS. . . . i x PREFACE TO TABLES x CHAPTER I. REVIEW OF THE LITERATURE 1 A. THE EXTENT OF THE PROBLEM 1 1. Introduction 1 2. Epidemiology 3 3. Risk Factors 7 4. Pathogenesis 17 B. GOVERNMENT RECOMMENDATIONS AND PROGRAMS 21 1 . Lalonde Report 21 2. Operation L i f e s t y l e 25 3. Par t i c i p a c t i o n 26 C. TREATMENT OR PREVENTION 27 1. Nature of Fatal I l l n e s s Has Shifted ; 29 2. Major Causes of Death are L i f e s t y l e Related 30 D. RISK FACTOR REDUCTION TRIALS 33 1 . MRFIT 34 2. Stanford Program 34 3. North Karelia . 35 4. "Know Your Body" Program 36 E. CURRENT STATISTICAL TREND — CHD 37 1. Are the Figures Real? 37 2. Possible Causes for the Decline 39 3. Recommendations 44 - i v - - V - CHAPTER Page I I . RISK FACTOR INTERVENTION 46 A. DIET AND GROWTH AND DEVELOPMENT 46 1. Atherosclerosis as a "pediatric disease" 46 2. _ Hypercholesterolemia 47 3. L i f e s t y l e Development 48 4. Diet Modification 48 5. Weight Control 48 6. Physical A c t i v i t y 49 7. School Assessment — Weight and Diet 50 8. Factors Affecting Dietary Habits 51 9. Recommendations 51 B. SMOKING 53 1 . WHO Committee Recommendations 53 2. Smoking Habits of Children • 54 3. Public Beliefs — CHD 56 4. Smoking and Risk 62 5. Passive Smoking 65 6. Programs for Children 65 7. Insurance Premium Benefits for Non-Smokers 69 8. Rights of Non-Smokers 70 C. HYPERTENSION • 71 D. EXERCISE 74 E. STRESS 78 F. FINDINGS AND RECOMMENDATIONS 82 1 . Improving Health — General 82 2. Prevention for the Young 83 I I I . EDUCATIONAL PROGRAM PROPOSALS FOR THE PREVENTION OF CORONARY HEART DISEASE 87 A. INTRODUCTION 87 B. SCHOOL SYSTEMS 89 1. Parental Influences 89 2. School Influences 90 3. Measurement and Evaluation 92 - v i - CHAPTER Page C. THE MARKETPLACE 93 1 . Occupational • 93 2. Consumer Aspects 94 3. Public Space • 95 D. GOVERNMENT'S ROLE 96 1 . As A Source of Information 96 2. In Decision Making and Legislation 98 E. HEALTH PROFESSIONS 101 F. MEDIA 104 G. INSURANCE COMPANIES 105 H. AVAILABILITY OF COMMUNITY RESOURCES 105 1. Health Promotion Service 105 2. Health Hazard Appraisal 107 I. RECOMMENDATIONS 108 IV. CONCLUSIONS .* 110 BIBLIOGRAPHY 114 GLOSSARY OF TERMS 124 LIST OF TABLES TABLE page 1.1 DEATHS FROM AHD AND "ALL CAUSES" IN EIGHT COUNTRIES. . . . 4 1.2 DEATHS FROM AHD IN CANADA BY SEX AND AGE, 1 976. and.,1 978 5 1.3 DEATHS FROM IHD FOR PROVINCES BY SEX, 1978 6 1.4 SEPARATIONS BY PRIMARY DIAGNOSIS BY SEX AND AGE FOR ALL PERSONS HOSPITALIZED IN THE PROVINCE 1978 .8 1.5 PATIENT DAYS BY PRIMARY DIAGNOSIS BY SEX AND AGE FOR ALL PERSONS HOSPITALIZED IN THE PROVINCE 1978 9 1.6 YEARS OF POTENTIAL LIFE LOST MEASURED AGAINST A LIFE EXPECTANCY OF 70 10 1.7 CHANGE (PER PERSON) IN USE OF CERTAIN PRODUCTS FROM 1963 TO 1975 43 1.8 DECLINE IN DEATH RATE DUE TO HEART DISEASE AND STROKE FROM 1963 TO 1975 43 11.1 "WHAT DO YOU FEEL ARE THE MAJOR LIKELY CAUSES OF HEART ATTACKS IN PERSONS UNDER 60 YEARS OF AGE?". . . . 58 11.2 "YOU MENTIONED (REPEAT VERBATIM RESPONSES IN ORDER) WHICH ONE OF THESE DO YOU FEEL IS THE SINGLE MOST IMPORTANT CAUSE OF HEART ATTACKS IN PERSONS UNDER 60 YEARS OF AGE?" 59 11.3 "FROM WHAT YOU HAVE HEARD OR READ, CAN HEART ATTACKS IN PERSONS UNDER 60 BE PREVENTED, OR IS THERE VERY LITTLE THAT CAN BE DONE TO PREVENT HEART ATTACKS?" 60 11.4 "WHAT WOULD YOU RECOMMEND TO SOMEONE CLOSE TO YOU IN ORDER TO HELP HIM OR HER PREVENT A HEART ATTACK?". . . .61 - v i i - LIST OF FIGURES FIGURE Page 1.1 RELATIVE INCIDENCE RATE OF CORONARY HEART DISEASE 14 1.2 THE INFLUENCE OF CIGARETTE SMOKING, HIGH CHOLESTEROL AND HIGH BLOOD PRESSURE ON THE LIKELIHOOD OF HEART ATTACK 15 1.3 THE NATURAL HISTORY OF CORONARY ARTERY DISEASE 19 1.4 LIFESTYLE AND ENVIRONMENT ACCOUNT FOR TWO THIRDS OF YEARS OF LIFE LOST 31 I I . 1 EFFECT ON RE-INFARCTION FROM "QUITTING" SMOKING 64 - v i i i - A C K N O W L E D G E M E N T S The author g r a t e f u l l y acknowledges the assistance, c r i t i c i s m and support of many persons. To Dr. John H. Milsum, Director, Division of Health Systems, Health Sciences Centre, University of B r i t i s h Columbia, B.C., and my thesis-Gommi-ttee-Chairman; "I express -my s i n c e r e s t — a p p r e c i a t i o n for- his patience and guidance through v i r t u a l l y every page of t h i s the- s i s . — S p e c i a l mention nrastTrls-o i)-e made -of the co-operation -and genuine i n t e r e s t I received from the other members of my Committee. Thank you to Dr. P a t r i c i a Vertinsky, Associate Professor, Education, UBC, and to Dr. Fred Bass, Community Medicine, City of Vancouver. Many thanks to Dr. Anne Crichton and Dr. Mort Warner of the Department of Health Care and Epidemiology, UBC, for their continuous encouragement during the course work, as well as for t h e i r v a l u a b l e suggestions during the i n i t i a l phases of the thesis. To those people with whom I corresponded and who provided me with material as well as suggestions, I express my sincere a p p r e c i a - t i o n . Special thanks to Susan and her "Bl a z i n g F i n g e r s " f o r the tremendous e f f o r t i n producing the proofs and f i n a l d r a f t on such short notice. F i n a l l y , my deepest thanks to Anita, who suffered through the proof-reading, to Lois, Linda, Lianne and Paula, f o r without t h e i r support and confidence as well as gentle pushing, none of t h i s would have been possible. - i x - PREFACE TO TABLES Tables 1.2 and 1.3 were taken from S t a t i s t i c s Canada, "Causes of Death" for the years 1976 and 1978. These tables, however, only i n - dicate the actual numbers of persons who died during the years s p e c i - f i e d of the diseases i n d i c a t e d without reference to the r a t e . In simplest terms these are absolute numbers. Such statements have lim i t e d u t i l i t y u n t i l f u r t h e r q u a l i f i e d with respect to two features: (1) i n what population were these cases observed; and (2) when were they observed. This l a t t e r feature has already been indicated as 1976 and 1978. To allow for d i f f e r e n c e s i n population s i z e , the frequencies must be expressed i n the form of rates. A rate i s defined as the frequency of a disease or c h a r a c t e r - i s t i c expressed per unit of size of the population or group i n which i t i s observed. For example, i n Table 1.2, having determined that the pop- ul a t i o n of males aged 40-44 i n Canada i n 1976 was 643,600, one could •then determine the death rate for that age group for that year as 76 per 100,000 population, knowing that 489 males i n that age group had died of Coronary Heart Disease i n 1976. By comparing t h i s r a t e to other age groups i n the same year, one could determine whether r i s k increased or decreased with age. S i m i l a r l y , i f the same age groups were used to com- pare the death rate for Coronary Heart Disease for two d i f f e r e n t years, one could determine whether the r a t e s were i n c r e a s i n g or decreasing. Using this information, the author would conclude that primary preven- t i o n as discussed in this thesis would be most effective i n the younger age groups. Tables 1.4 and 1.5 also indicate absolute numbers without reference to population and, t h e r e f o r e , the same ra t e determinations would apply. CHAPTER I REVIEW OF THE LITERATURE A review of the l i t e r a t u r e was conducted i n the f o l l o w i n g areas: A. The extent of the problem of premature death due to Coronary Heart Disease. B. Government, group and i n d i v i d u a l recommendations and programs. C. Treatment or Prevention. D. Risk Factor Reduction T r i a l s . E. Current S t a t i s t i c a l Trend — CHD. A. THE EXTENT OF THE PROBLEM 1 . Introduction The Committee on Diet and Cardiovascular Disease, Health and Welfare Canada [1976] i n t h e i r statement f o r the p u b l i c p o i n t out that Canadians enjoy one of the highest standards of l i v i n g i n the world and have a l i f e expectancy from b i r t h of 69.3 years for men and 76 years for women. These l i f e expectancies are similar to those of other Western nations, and higher than i n l e s s i n d u s t r i a l i z e d nations. However, the Committee also points out that i n Canada there i s a high frequency of disease and death from atherosclerosis (hard- ening of the arteries causing heart attacks, s t r o k e s , e t c . ) . Close to 50 per cent of a l l deaths i n Canada are r e l a t e d to a t h e r o s c l e r o - s i s . This condition occurs not only i n o l d age, but a l s o a f f e c t s - 1 - - 2 - s i g n i f i c a n t numbers of Canadians i n middle age. Because Canadian men 45 to 54 years of age have more than twice as many deaths from arter- i o s c l e r o t i c heart disease as men i n Sweden, i t i s reasonable to inf e r that something can be done to reduce the high death rate i n Canada from t h i s cause, especially i n the middle-age groups. According to further f i n d i n g s of the Committee, some r i s k factors are d e f i n i t e l y known f o r a t h e r o s c l e r o s i s and such of i t s complications as heart attacks. These r i s k factors include elevated blood f a t s ( c h o l e s t e r o l and t r i g l y c e r i d e ) , high blood pressure, smoking and diabetes. I t i s their o p i n i o n that most Canadians can improve thei r health and l i f e expectancy by avoiding overeating and smoking. They state that medical examinations should i n c l u d e mea- surement of blood cholesterol, t r i g l y c e r i d e s , sugar and blood p r e s - sure. If any of these are found to be e l e v a t e d , i n v e s t i g a t i o n and treatment should be carried out by a physician. In addition to these d e f i n i t e health measures, the Committee advises Canadians to practise moderation i n the use of those foods and beverages which tend to elevate blood f a t s , and to avoid foods which provide c a l o r i e s without es s e n t i a l vitamins and m i n e r a l s . To help the public select a suitable d i e t , the Committee recommends some ge n e r a l d i e t a r y g u i d e l i n e s . These w i l l be found l a t e r i n t h i s t h e s i s . Cardiovascular disease i s one of the major causes of morbid- i t y i n the 40 to 70 year age group. Therefore, a program to delay or prevent cardiovascular disease d u r i n g the p r o d u c t i v e , middle-age - 3 - period of l i f e i s important. ~ I t - i s a l s o important-to r e a l i z e t h a t one quarter of the people who have heart attacks die before reaching h o s p i t a l , so that only prevention of atherosclerosis and i t s c l i n i c a l complications can s i g n i f i c a n t l y reduce the incidence of sudden deaths from this cause. An estimate of the annual cost i n 1975 i n Canada of i l l n e s s attributed to cardiovascular disease ( i n c l u d e s hypertensive cardiovascular disease) i s $1.23 b i l l i o n [Canadian Heart Foundation, 1975]. This includes loss of income due to morbidity and mortality. 2. Epidemiology ( i ) International S t a t i s t i c s . The frequency of a t h e r o s c l e - r o t i c heart disease (AHD) [AHD has the same meaning as other commonly used abbreviations; CHD (coronary heart disease) and IHD (ischaemic heart disease)] d i f f e r s considerably i n various countries. Table 1.1 shows deaths from AHD per 100,000 males-aged 35 - 64/ i n - s e v e r a l countries i n 1965 [WHO, 1970]; Canada ranks high, between the U.S.A. and the Netherlands. As can be seen from t h i s t a b l e , over 41 per cent of "deaths from a l l causes" i n Canada were due to AHD. ( i i ) Canadian S t a t i s t i c s . At age 35 AHD begins to appear as a s i g n f i i c a n t cause of death i n the Canadian population. From age 40 i t i s the p r i n c i p a l cause of death and i n subsequent age groups there i s an ever-increasing proportion of deaths at t r i b u t a b l e to AHD (Table 1.2). Only the age groups 30 - 34 and higher are shown because death from AHD below the age of 30 i s not s i g n i f i c a n t . Table 1.3 shows the number of deaths from AHD for provinces by sex. TABLE 1.1 DEATHS FROM AHD AND "ALL CAUSES" IN EIGHT COUNTRIES * DEATHS PER 100,000 MEN AGES 35 - 64 DEATHS FROM AHD DEATHS FROM "ALL CAUSES" t 1 GREECE 78 712 JAPAN 79 986 YUGOSLAVIA 116 950 ITALY 187 985 NETHERLANDS 243 831 CANADA 407 985 U.S.A. 461 1,266 FINLAND 534 1,432 Prepared from W.H.O. [1968] Deaths per 100,000 men in 1965 from coronary heart disease and from a l l causes for ages 35-64, age-standardized (average of the three death rates for ages 35-44, 45-54, 55-64). - 4 - TABLE 1.2 DEATHS FROM AHD IN CANADA BY SEX AND AGE 1976 AND 1978 AGE (YEARS) 30-34 35-39 40-44_ 45-49 50-54 55-59 60-64 65-69 70-74 M 97 229 489 1135 1978 2717 3636 4299 4616 1976 F 14 36 88 184 369 638 1202 1955 2548 M 79 224 476 996 1779 2698 3524 4344 4530 1978 F 13 48 96 198 384 678 1201 1816 2703 Prepared from S t a t i s t i c s Canada, 1976 and 1978. TABLE 1.3 DEATHS FROM IHD FOR PROVINCES BY SEX 1978 CANADA NFLD P.E.I. NOVA SCOTIA NEW BRUNSWICK QUEBEC ONTARIO MANITOBA SASKL ALTA. B.C. M 30,237 593 186 1,308 931 7,255 11,631 1,508 1,238 2,026 3,536 F 20,376 360 129 764 618 4,819 8,549 978 741 1,126 2,285 - 7 - Morbidity, i n respect to AHD, i s harder to determine than mortality. Nevertheless, based on h o s p i t a l data, diseases of the cardiovascular system are found to be one of the p r i n c i p a l causes of h o s p i t a l i z a t i o n . AHD accounted for 7,600,000 hospital days out of a t o t a l of 38,600,000 i n 1970 i n acute general h o s p i t a l s [Lalonde, 1975]. Hospital discharge s t a t i s t i c s f o r the province of B r i t i s h Columbia [1978] give some idea of the morbidity, i n respect to AHD, for t h is Province (Table 1.4). Table 1.5 shows the number of days of stay a s s o c i a t e d with Ischaemic Heart Disease and r e l a t e d diseases [ B r i t i s h Columbia, 1978]. The cost to the i n d i v i d u a l , the f a m i l y and to the e n t i r e country can be determined f a i r l y accurately from the f o l l o w i n g s t a - t i s t i c s . Calculations of the years of p o t e n t i a l l i f e l o s t by each cause of death i n Canada for 1971, measured against a l i f e expectancy of 70 and eliminating causes of infa n t mortality, are shown i n Table 1.6 [Lalonde, 1975]. 3. Risk Factors Hippocrates wrote over 2,000 years ago of the c i t i z e n s of the I s l e of Cos, "Those who are c o n s t i t u t i o n a l l y very fat are more apt to die quickly than those who are t h i n " [1923]. Since Hippocrates noted th i s relationship between obesity and CHD, there has been a s i z e a b l e accumulation of epidemiologic data that has attempted to e s t a b l i s h a relationship between certain metabolic and p h y s i c a l f a c t o r s and the TABLE 1.4 SEPARATIONS BY PRIMARY DIAGNOSIS BY SEX AND AGE FOR ALL PERSONS HOSPITALIZED IN THE PROVINCE 1978 CANADIAN LIST NUMBER AND DIAGNOSIS SEX TOTAL ADULTS AND CHILDREN* 25-44 45-59 60-74 75+ 78. HYPERTENSIVE DISEASE M F 784 1 ,023 105 109 241 284 299 393 122 230 79. ACUTE MYOCARDIAL INFARCTION M F 3,521 1 ,511 221 42 1,118 260 1 ,537 645 645 563 80. OTHER ISCHEMIC HEART DISEASES M F 8,763 5,833 412 110 2,511 903 3,456 2,161 2,384 2,656 ALL DIAGNOSES M F 174,802 230,263 33,661 75,117 32,715 32,611 36,632 31,654 19,738 20,482 Neonates and age groups to 24, although not shown by groups, are, nevertheless, included in the. t o t a l s . TABLE 1.5 PATIENT DAYS BY PRIMARY DIAGNOSIS BY SEX AND AGE FOR ALL PERSONS HOSPITALIZED IN THE PROVINCE 1978 CANADIAN LIST NUMBER AND DIAGNOSIS SEX TOTAL ADULTS AND CHILDREN* 25-44 45-59 60-74 75+ 78. HYPERTENSIVE DISEASE M 6,869 F 8,717 654 815 1 ,597 1 ,945 2,815 3,419 1,672 2,488 79. ACUTE MYOCARDIAL INFARCTION M 42,886 F 21,846 2,566 635 13,117 4,015 19,349 9,317 7,854 7,878 80. OTHER ISCHEMIC HEART DISEASES M 82,833 F 68,341 2,445 697 17,829 6,459 30,041 21,058 32,518 40 ,11 1 ALL DIAGNOSES M 1,569,362 F 1,883,808 231,434 293,360 428,522 316,373 451,939 295,519 391,268 377,761 Neonates and age groups to 24, although not shown by groups, are, nevertheless, included i n the t o t a l s . TABLE 1.6 YEARS OF POTENTIAL LIFE LOST MEASURED AGAINST A LIFE EXPECTANCY OF 70 TOTAL POTENTIAL CAUSE YEARS OF LIFE LOST MOTOR VEHICLE ACCIDENTS 213,000 ISCHAEMIC HEART DISEASE 193,000 ALL OTHER ACCIDENTS 179,000 RESPIRATORY DISEASES AND LUNG CANCER 140,000 SUICIDE 69.000 - 10 - - 11 - development of CHD and Myocardial Infarction (M.I.). These s t u d i e s indicate that a r e l a t i o n s h i p exists between the presence of diabetes, hypertension, abnormalities i n l i p i d metabolism and cigarette smoking and the development of CHD. In studies conducted by the Health Insurance Plan of New York C i t y [Shapiro, et a l . , 1969], i n which the p o p u l a t i o n represented approximately 120,000 people between the ages of 25 and 64, various r i s k factors were observed which relate to CHD. I t was observed that the incidence of acute M.I. and death w i t h i n 48 hours was twice as high i n the smokers as compared to the non-smoking group. This was seen i n both males and females, with cigar and pipe smokers represen- t i n g an intermediate r a t e between the c i g a r e t t e smokers and non- smokers. P h y s i c a l a c t i v i t y was a l s o an important f a c t o r i n the study, with death within 48 hours being four times as great i n the p h y s i c a l l y l e a s t active group as compared to the most a c t i v e group. A combination of smoking and decreased physical a c t i v i t y was a s s o c i - ated with the highest incidence of death within 48 hours, with an i n - cidence of 5.8 per 1,000 i n this group as compared to 0.69 per 1,000 i n the non-smoking, physically active group. They also observed that i n men who had discontinued smoking, their M.I. incidence a f t e r f i v e years was s i m i l a r to that of the men who had never smoked. The Framingham data [Kannel et al_., 1967] indicates that obe- s i t y i s an important factor i n the development of both angina pector- i s and sudden death. In r e l a t i o n to t h i s , both hypertension and elevated serum cholesterol produce an increased e f f e c t on the r i s k - 12 - of sudden death or angina i f i n d i v i d u a l s are obese. Spain ejt a l . [1973] looked at the relationship of sudden death to smoking i n f e - males, and observed that only 28 per cent of women dying suddenly from causes other than CHD were heavy smokers, whereas i n those women dying suddenly of CHD, 62 per cent were heavy smokers. The mean age at the time of death was 19 years less for those who smoked h e a v i l y than that for the non-smokers. In two comparative study periods from 1949 to 1959 and between 1967 and 1971, there was a change i n the r a t i o of male to female sudden deaths. In the f i r s t period there was a 12 to 1 CHD sudden death r a t i o for males to females as compared to 4 to 1 for the period of 1967 to 1971. They a t t r i b u t e d t h i s change to an increase i n smoking by women. Using the standard acceptable upper ranges of r i s k factors of serum ch o l e s t e r o l , blood pressure and smoking, Epstein [1973] s t a t e s that 38 per cent of Americans would be defi n e d as having a l l three r i s k factors abnormal. These 38 per cent generate 59 per cent of a l l subsequent heart attacks. The r i s k of having an acute heart a t t a c k i s nine times higher i n persons having a l l three r i s k f a c t o r s than those i n which a l l of these r i s k f a c t o r s a r e w i t h i n the lower range of normal. Epstein sugests, "the important point to r e a l i z e i s that there i s a r i s k factor l e v e l at which f a i l u r e to i n s t i t u t e pre- ventive action might be considered more serious than the r i s k of tak- ing an action f o r which there i s yet no s c i e n t i f i c basis i n terms of d i r e c t evidence." He suggests that although there may not be s c i e n - t i f i c data to indicate that change i n r i s k factors would be important - 13 - for an i n d i v i d u a l patient's w e l l being, i t i s worthwhile with the c u r r e n t i n f o r m a t i o n to t r e a t these r i s k f a c t o r s by community e f f o r t s . Keys [1971] states that d i e t unquestionably a f f e c t s the con- centration of l i p i d s , especially cholesterol,, i n the blood serum of man. He maintains that these l i p i d s are c e r t a i n l y involved i n ather- ogenesis, although he notes that there i s some argument about d e t a i l s and the sequence of events. However, he feels that there i s general agreement on the fact that atherosclerosis i s basic to coronary heart disease. "So much attention to the e f f e c t of the d i e t on the cholesterol c o n c e n t r a t i o n i n the serum i s j u s t i f i e d by the well-established f a c t that the incidence of Coronary Heart Disease i s r e l a t e d to the cholesterol l e v e l . Figure 1.1 summarizes data from follow-up studies on men i n Framing- ham, Mass., i n Albariy, N.Y., and i n Minneapolis- St. Paul, Minn. On the average, men with serum cholesterol values of 260. or more proved to be 4.3 times more s u s c e p t i b l e to Coronary Heart Disease than men of the same age i n the same community who had c h o l e s t e r o l v a l u e s under 2 00." one Figure 1.2 i l l u s t r a t e s the increase i n factor i s present i n the same i n d i v i d u a l . r i s k when more than FIGURE 1.1 RELATIVE INCIDENCE RATE OF CORONARY HEART DISEASE 202 100% 134 47 60 93 Under 200 - 220 - 240 - 260 + 200 219 239 259 R e l a t i v e incidence r a t e of Coronary H e a r t Disease among men c l a s s i f i e d according to entry l e v e l of serum cholesterol and followed there- a f t e r f o r 31,197 man years during which 251 cases developed. Average of data from the Framingham Study (courtesy of Dr. T. R. Daw- ber), from the Albany Study (courtesy of Dr. J . T. Doyle) and from Minneapolis-S t . P a u l [Keys et a l . , 1971]. - 14 - FIGURE 1.2 THE INFLUENCE OF CIGARETTE SMOKING, HIGH CHOLESTEROL AND HIGH BLOOD PRESSURE ON THE LIKELIHOOD OF HEART ATTACK (Adapted from Schroeder, The Sciences, September 1974) 384 236 120 AVERAGE RISK 100 77 NONE CIGARETTES CIGARETTES & CHOLESTEROL CIGARETTES &. CHOLESTEROL & BLOOD PRESSURE - 15 - - 16 - Upon examining a group of younger coronary patients, Rosenman and Friedman [1971] became suspicious about the p o s s i b l e e f f e c t s of socioeconomic stresses on the incidence of Coronary Heart Disease. They found that the substantial majority of these younger p a t i e n t s exhibited a p a r t i c u l a r personality s t r u c t u r e and behaviour p a t t e r n which they l a t e r termed "pattern type A." By t h e i r d e f i n i t i o n , pattern type A i s characterized primari- l y by aggressiveness, ambition, drive, competitiveness and a profound sense of time urgency. Some or most of these t r a i t s are present i n various degrees i n most men, but according to Rosenman and Friedman, the man with pattern type A has them to an excessive and o f t e n i n o r - dinate degree. Although they designated the absence of the type A emotional i n t e r p l a y as the converse p a t t e r n type B, they f e l t i t would be erroneous to think of t h i s cleavage as being sharply de- fi n e d . Apparently the man with p a t t e r n type A simply e x h i b i t s an excessive degree of certain s p e c i f i c emotional t r a i t s that may be variously present to a much lesser degree i n a man with pattern type B. Thus, the authors liken the facets of type A to an elevated body temperature or blood pressure, both of which are normally present i n lesser degree i n a l l men. The results of their studies would appear to indicate that the personality and behaviour p a t t e r n of an i n d i - v i dual are s i g n i f i c a n t l y and independently related to his prospective candidacy for Coronary Heart Disease. 4. Pathogenesis Coronary heart disease i s a c l i n i c a l d i s o r d e r that r e s u l t s from damage to the coronary a r t e r i e s , the l a t t e r being c a l l e d Coro- nary Artery Disease or a t h e r o s c l e r o s i s [ F r i e d b e r g , 1966]; a non- technical term for i t i s hardening of the a r t e r i e s . Myocardial i n - f a r c t i o n i s one of the most common forms of c l i n i c a l c o r o n a r y disease. The t y p i c a l atherosclerotic l e s i o n s are small nodules i n the wall of the blood v e s s e l s 7 which are v i s i b l e as yellow f a t t y plaques. In recent years the e t i o l o g i c importance of l i p i d i n f i l - t r a t i o n i n the atheromatous plaques has been s t r o n g l y emphasized [Diosy, 1977], So-called " f a t t y streaks" begin to appear i n the i n t i m a of the aorta of man by s i x months of age i n a l l populations studied [McGill, 1968; Strong and Mc G i l l , 1969]. A study of f a t t y streaks i n human coronary arteries has shown a correla t i o n between f a t t y streaks and the extent of raised lesions i n young persons on the one hand, and the development of atherosclerotic h e a r t disease i n older sub- j e c t s on the other [Tejada e_t â L., 1968]. Despite the absence of c l i n i c a l m a n i f e s t a t i o n s of coronary heart disease i n children, Stamler e_t a l . [1 972]claim that the gen- es i s of atherosclerosis l i e s i n the childhood years. Autopsy studies of young American soldiers with traumatic war deaths have i n d i c a t e d that s i g n i f i c a n t coronary atherosclerosis was present i n 45 to 77 per cent of the cases [Glueck, 1980]. This opinion i s shared by Lupien [1980] who states: - 18 - "Existing evidence indicates that atheroscle- r o s i s begins i n childhood and that l e s i o n s progress through s e v e r a l stages before be- coming c l i n i c a l l y apparent i n middle and l a t e adult l i f e . The athero- s c l e r o s i s observed i n adults cannot be dissociated from the many en- vironmental and genetic factors which undoubt- edly play a role i n the development of athero- s c l e r o t i c lesions at an early age." I t i s recognized that hyperlipidemia i s related to f a t i n f i l - t r a t i o n of a r t e r i e s and atheroma formation. The natural consequence of atherosclerotic lesions i n the coronary arteries i s an impairment of blood flow, which i n turn w i l l lead to the c l i n i c a l and pathologi- c a l m a n i f e s t a t i o n s of coronary a r t e r y d i s e a s e . Severe coronary atherosclerosis always leads to myocardial damage, but lesser degrees of a r t e r i a l involvement may not cause a permanent damage i n the heart muscle. Coronary artery disease may remain asymptomatic f o r a long time and i s a frequent cause of unexpected sudden death. In most cases the latent phase i s foll o w e d by a symptomatic phase charac- ter i z e d by episodes of angina pectoris at one end of the scale and by myocardial i n f a r c t i o n on the other. In this context, angina pectoris and myocardial i n f a r c t i o n are the two extremes of the c l i n i c a l spec- trum. The natural history of coronary a r t e r y disease as o u t l i n e d above i s i l l u s t r a t e d i n Figure 1.3. Once i n the symptomatic phase, characterized either by angina or by myocardial i n f a r c t i o n , the mor- t a l i t y rate remains r e l a t i v e l y constant, approximately four per cent per year [Diosy, 1977]. FIGURE 1.3 THE NATURAL HISTORY OF CORONARY ARTERY DISEASE ASYMPTOMATIC SYMPTOMATIC ANGINA PECTORIS NO s ATHEROSCLEROSIS f DEAD ATHEROSCLEROSIS S SUDDEN DEATH MYOCARDIAL INFARCTION Adapted from Ross, American Journal of Cardiology, 36: 496, 1975. - 20 - The chief manifestation of angina p e c t o r i s i s pain i n the chest. The i n t e n s i t y of pain can vary from mild to quite severe. I t i s a deep v i s c e r a l sensation, d u l l , aching or heavy. The discomfort of angina i s c h a r a c t e r i s t i c a l l y f e l t behind the breast bone. The pain may radiate widely, frequently to the l e f t arm, shoulder or jaw. I t i s usually triggered by physical a c t i v i t y . Less frequent, but not uncommon, pr e c i p i t a t i n g factors are a heavy meal, cold weather and emotions. Typi c a l l y , anginal pain p e r s i s t s for a short period of time, usually not more than three to f i v e minutes. I t i s relieved by rest. In the diagnosis of angina pectoris the patient's description of the pain i s most h e l p f u l . Physical examination i s of only limited value, because abnormal physical findings i n the heart are u s u a l l y absent between attacks. Angina pectoris i s frequently the f i r s t symptom of * the presence of a marked degree of artferiosclerosis. Cardiovascular disease of ~a degenerative kind i s manifested by two p r i n c i p a l changes that progress with age -- degeneration of the a r t e r i a l walls and r i s i n g blood pressure [de Hass, 1968]. These two changes tend to occur together but need not do so. The under- l y i n g causal mechanisms may well be d i f f e r e n t i n each case and so may the f i n a l l e t h a l event. Kuller and Reisler [1971] have attempted to explain these interactions. High levels of a r t e r i o s c l e r o s i s combined with hypertension tend to produce a high incidence of both heart attacks and strokes (as i n U.S. Negroes). A r t e r i o s c l e r o s i s without hypertension tends to be associated with a high incidence of heart *A r t e r i o s c l e r o s i s i s usually an early stage of atherosclerosis. - 21 - attacks and an intermediate l e v e l of strokes (as i n U.S. w h i t e s ) . Hypertension unaccompanied by high levels of coronary a r t e r i o s c l e r o - s i s tends to be associated with a high incidence of strokes but not heart attacks (as i n Japan). B. GOVERNMENT RECOMMENDATIONS AND PROGRAMS 1. Lalonde Report During the preparation of the Lalonde Report, a s o r t of map of the health t e r r i t o r y , the Health F i e l d Concept, was developed by Laframboise [1973]. I t envisages that the health f i e l d can be broken up into four broad elements: Human Biology, Environment, L i f e s t y l e and Health Care Organization. Up to at least 1975, when the Lalonde Report was p u b l i s h e d , most of society's e f f o r t s to improve health, and the bulk of d i r e c t health expenditures, had been focused on the Health Care Organiza- t i o n , which consists of the quantity, q u a l i t y , arrangement, nature and relationship of people and resources i n the p r o v i s i o n of h e a l t h care [Lalonde, 1975]. Yet, when the present main causes of sickness and death i n Canada are i d e n t i f i e d , e.g., coronary heart d i s e a s e , cancer, we find that they are rooted i n the other three elements of the Concept: Human Biology, Environment and L i f e s t y l e . I t i s appar- ent, according to the Report, that vast sums are being spent treating diseases that could have been prevented i n the f i r s t p l a c e . There- fore, greater attention to the f i r s t three conceptual elements i s needed i f d i s a b i l i t y and early death are to be reduced. - 22 - The L i f e s t y l e category consists of the aggregation of d e c i - sions by individuals which a f f e c t t h e i r h e a l t h and over which they have more or less control. Personal d e c i s i o n s and h a b i t s t h a t are bad, from a health point of view, create self-imposed r i s k s . When those r i s k s r e s u l t i n i l l n e s s or death, the victim's l i f e s t y l e can be said to have contributed to, or caused, his own i l l n e s s or death. The Lalonde Report goes on to point out that the Concept was designed with two aims i n view: to provide a greater understanding of what contributes to sickness and death, and to f a c i l i t a t e the i d e n t i f i c a t i o n of courses of action that might be taken to improve health. One of the issues a r i s i n g from the use of the Health F i e l d Concept i s whether or not i t i s possible to div i d e e x t e r n a l i n f l u e - nces on health between the environment, about which the i n d i v i d u a l can do l i t t l e , and l i f e s t y l e , i n which he can make choices. P a r t i c u - l a r l y cogent are arguments that personal choices are d i c t a t e d by en- vironmental factors, such as the peer-group pressures to s t a r t smok- ing cigarettes during the teens. Further, i t i s argued that some bad personal habits are so ingrained as to constitute a d d i c t i o n s which, by d e f i n i t i o n , no longer permit a choice by a simple a c t of w i l l . Smoking i s one of the l i f e s t y l e problems referred to i n this vein. The Report points out that i f the incidence of sickness can be reduced by prevention, then the cost of present s e r v i c e s w i l l go down, or at least the rate of increase w i l l diminish. This w i l l make money available to extend health insurance to more and more s e r v i c e s - 23 - and to provide needed f a c i l i t i e s , such as ambulatory care centres and extended care i n s t i t u t i o n s . In an attempt to discover those groups i n the general popula- t i o n to which one must address one's s e l f re m o d i f i c a t i o n of l i f e - s t y l e s , one should id e n t i f y the s p e c i f i c population at r i s k . This i s the population which i s making the greatest adverse c o n t r i b u t i o n to the average for Coronary Heart Disease, for example. Populations at r i s k are obtained through an a n a l y t i c a l pro- cess which matches up three kinds of information: causes of mortal- i t y and kinds of morbidity, underlying reasons for their occurrence, and susceptible segments of the population. For example, the process of i d e n t i f y i n g a population at r i s k would be as f o l l o w s : m o r t a l i t y from coronary-artery disease, predisposing morbid condition: athero- s c l e r o s i s ; contributing factors: high serum l i p i d s , hypertension and and diabetes, obesity, high-fat d i e t , lack of exercise, stress, r e l a - t i v e absence of estrogens, c i g a r e t t e smoking; p o p u l a t i o n at r i s k : males over 40 with foregoing conditions or habits. I t i s suggested by the Report that t r a d i t i o n a l medicine w i l l tend to concern i t s e l f with treating the m o r t a l i t y - m o r b i d i t y end of the spectrum while the course of action suggested by the Health F i e l d Concept would be to focus on reducing the contributing factors i n the population at r i s k , once that population has been i d e n t i f i e d . The i d e n t i f i c a t i o n of h i g h - r i s k populations as targets f o r national risk-reduction programs depends on a number of f a c t o r s i n - cluding the gravity and incidence of various kinds of sickness and - 2 4 - death, the a v a i l a b i l i t y of p r a c t i c a l measures, and the c o s t s . Some h i g h - r i s k p o p u l a t i o n s , such as candidates f o r Coronary Heart D i s e a s e are r e a d i l y i d e n t i f i a b l e . In order to apply the Health F i e l d Concept, answers to h e a l t h problems w i l l be sought i n each o f the f o u r c a t e g o r i e s o f Human B i o l o g y , Environment, L i f e s t y l e and H e a l t h Care O r g a n i z a t i o n . A l - though much has already been done, as w i l l be seen l a t e r , some of the c o n t i n u i n g burdens on res e a r c h , a r e , f o r example: to determine and measure the e f f e c t s of va r i o u s e nvironmental h a z a r d s to b o t h mental and p h y s i c a l h e a l t h ; t o i d e n t i f y t h e l i n k s b e t w e e n t h e l i v i n g h a b i t s , o r l i f e - s t y l e , o f i n - d i v i d u a l s , a n d t h e l e v e l s o f b o t h mental and p h y s i c a l h e a l t h ; - to undertake s t u d i e s t o f i n d o u t how Canadians can be i n f l u e n c e d t o t a k e more i n d i v i d u a l r e s p o n s i b i l i t y f o r the h e a l t h of t h e i r minds and b o d i e s , and f o r reducing the r i s k s which t h e y im- pose on t h e m s e l v e s by n e g l e c t i n g im- po r t a n t l i f e s t y l e h e a l t h f a c t o r s . - 25 - 2. Operation L i f e s t y l e In the Health F i e l d Concept category of L i f e s t y l e the Depart- ment of National Health and Welfare now i s a c t i v e i n the f o l l o w i n g areas: Drug Abuse. The Department promotes, develops and implements measures to deal with the problems of the -non-medical use of drugs including the promotion and evaluation of research and s t u d i e s , the analysis and dissemination of data, the provision of a n a l y t i c a l s e r - vices and the promotion of innovative services. Alcohol Abuse. The Department undertakes a c t i v i t i e s r e l a t e d to alcohol abuse. These include determining the nature, extent and implications of the problem of alcohol abuse. Tobacco Smoking. The h e a l t h hazards of c i g a r e t t e smoking have been well documented and publicized through education and adver- t i s i n g a c t i v i t i e s . Research and control a c t i v i t i e s are also c a r r i e d out. Fitness and R e c r e a t i o n . The Department administered the Fitness and Amateur Sports Act and provided funds f o r the n a t i o n a l Sport and Recreation Centre. Two-directorates, Recreation Canada and Sport Canada, recommended grants and provided services i n mass physi- c a l recreation and competitive sports r e s p e c t i v e l y — s e r v i c e s were also provided to the National Advisory Council on Fitness and Amateur Sport. N u t r i t i o n . The Department, through i t s Health P r o t e c t i o n Branch, has r e c e n t l y c a r r i e d out a n a t i o n a l n u t r i t i o n survey to assess the n u t r i t i o n a l s t a t u s and d i e t a r y intake of C a n a d i a n s . - 26 - Reliable data were c o l l e c t e d , i d e n t i f y i n g n u t r i t i o n a l h a b i t s and de f i c i e n c i e s , their incidence and t h e i r r e l a t i o n s h i p to age, sex, income and region. Indian and Northern Health S e r v i c e s . The Department has undertaken some a c t i v i t i e s to encourage Indians and Northern r e s i - dents to pursue l i f e s t y l e s conducive to good health; health s t a t i o n s and centres have been engaged i n teaching p u b l i c h e a l t h p r a c t i c e s . Included are special programs for tr a i n i n g native persons as h e a l t h educators, for alcohol abuse and for fitness and recreation. Personal Health. The Department has developed h e a l t h s t a n - dards and guides, promoted health education and provided i n f o r m a t i o n and consulting services i n such f i e l d s of health as mental, d e n t a l , c h i l d and maternal, chronic i l l n e s s e s , aging, r e h a b i l i t a t i o n and family planning. Contagious Diseases. Of s p e c i a l importance has been the i n i t i a t i o n of measures to control gonorrhea and s y p h i l i s . 3. P a r t i c i p a c t i o n . This i s b a s i c a l l y a p u b l i c i t y campaign by the Department of National Health and Welfare to make Canadians more conscious of the health hazards of overconsumption and the b e n e f i t s of exercise. However, the impact of this program on actual behaviour seems to have been small. - 27 - C. TREATMENT OR PREVENTION In a series of a r t i c l e s i n The F i n a n c i a l Post, Bennett and Krasny [March 26 - May 7, 1977] point out that the c o s t of Canada's excellent system i s proportionately higher than any other country, except for the United States and possibly Sweden and the Netherlands. In 1975, this country devoted to h e a l t h care 7.2 per cent of the Gross National Product or approximately $495 per capita. Our extraordinary health-care sytem has been b u i l t over the past 15 to 20 years — a building job that has carried a considerable price tag, r e f l e c t e d i n the rapid and accelerating growth of h e a l t h care spending. Since 1960, the t o t a l of public and private per capi- ta expenditure has increased at an annual r a t e of more than 10 per cent. From a per capita base of $100 i n 1960, the annual growth was nine per cent i n the 1960's, 10 per cent i n the early 1970's. As far as can be determined, i t approached 15 per cent i n the years 1974 to 1976 i n c l u s i v e , reaching approximately $495 i n 1975 and an estimated $570 i n 1976. However, more important than the growth i n per c a p i t a spend- ing i s the change expressed as a p r o p o r t i o n of the Gross N a t i o n a l Product. Bennett and Krasny indicate t h a t the long-term trend was upward i n the 1960's, from 5.5 per cent of GNP i n 1960 to 7.3 per cent, one-third higher, i n 1971. The percentage then dipped to 6.9 per cent i n the next two boom years, r e t u r n i n g to 7.2 per cent i n 1975 as economic growth slowed and health care outlays continued to r i s e . - 28 - The decline i n proportion of GNP from 1971 to 1 975 suggests that Canada's h e a l t h - c a r e c o s t s have not been "out of c o n t r o l " . However, i n 1975 and 1976, the growth of the b i l l at a 15 per cent rate, which translates into an increment of $1.5 b i l l i o n a n n u a l l y , has focused the attention of governments and the p u b l i c on the cost of health care. Is t h i s concern with costs r e a l l y j u s t i f i e d ? Given the pre- cious nature of health, i t could be argued that 7.2 per cent of the Gross National Product i s small, and whatever a d d i t i o n a l p r o p o r t i o n i s spent i s worthwhile, i f i t saves l i v e s and r e s u l t s i n improved health status f o r Canada. A Gallup p o l l conducted i n the 1970's showed that 84 per cent of Canadians rated health care as good value for their tax d o l l a r s — a higher score than that achieved by any other public service. There i s no doubt t h a t many s u f f e r e r s , such as those with kidney f a i l u r e , have been helped by advances i n sickness care, due to advances i n technological medicine. But evidence i s mounting that most p o t e n t i a l gains f o r the o v e r a l l p o p u l a t i o n have now been achieved, and that further s i g n i f i c a n t improvements i n h e a l t h l i e outside the application of more of today's medical science. In com- mon with other Western nations, Canada has been experiencing ever- diminishing health returns from the increasingly large sums that have been invested i n care d e l i v e r y . I t i s t h i s f a c t that j u s t i f i e s p o l i c y makers' concern over the potential resources crunch. - 29 - In the three decades from 1931 to 1961, Canada increased i t s spending on health care by 1 3/4 percentage p o i n t s of GNP and l i f e expectancy increased by nearly eight years. In the following decade, when the proportion of GNP devoted to health care also grew by 1 3/4 points, l i f e expectancy rose by only one year. And, while figures on nonfatal i l l n e s s are d i f f i c u l t to come ±>y, a v a i l a b l e data suggest that Canadians are not less sick now than they were previously. While the causes of these diminishing health returns i n Can- ada and other developed countries are many and complex, two stand out: 1. Nature of f a t a l i l l n e s s has s h i f t e d . E a r l y i n the 1900's, influenza, tuberculosis, pneumonia, and i n t e s t i n a l diseases such as dysentery were the greatest causes of premature death. By 1940, with improvement i n l i v i n g conditions and advances i n medical science, these diseases had lo s t much of their importance and by the 1960's they were largely eliminated. Canadians' l i f e expectancy rose accordingly. These diseases have now been replaced by degenerative i l l - nesses, p a r t i c u l a r l y heart disease and cancer, which are chronic and do not respond to the kind of medicine, f o r example, as treatment with p e n i c i l l i n , that was so s u c c e s s f u l i n the f i r s t h a l f of the Century. As a r e s u l t , while resources that were inves t e d i n h e a l t h care up to 1960 yielded substantial health dividends, today the f u r - ther infusion of money helps t r e a t i l l n e s s e s t h a t l a s t f o r a long time and does not re s u l t i n comparable gains. - 30 - 2. Major causes of death are l i f e style related. As i n f e c - tious i l l n e s s e s have been conquered, a c c i d e n t s , heart d i s e a s e , and si m i l a r l i f e s t y l e related a f f l i c t i o n s have taken a p r o p o r t i o n a t e l y greater t o l l on Canadians' health (Figure 1.4). I t i s estimated that smoking-induced disease alone k i l l s 250 Canadians a day. Neither smoking-induced i l l n e s s nor other l i f e style-related maladies can be ameliorated by spending more on h e a l t h care. Indeed, as Lalonde [1975] writes, "the organized health care system can do l i t t l e more than serve as a catchment net for the victims." Spending more on medical care w i l l , therefore, not b r i n g the l i f e expectancy of middle-aged male Canadians to the l e v e l of t h e i r counterparts i n Sweden, the leading country in most he a l t h i n d i c e s . Rather, more exercise, less smoking, and a better d i e t w i l l w h i t t l e down the 50 per cent greater heart disease rate of Canadian men. Based on the current use of acute hospital f a c i l i t i e s and on patient v i s i t s to t h e i r p h y s i c i a n , there i s a preoccupation with acute disease. Closely related to this preoccupation i s the c o r r e s - ponding skewing of resources toward treatment of sickness and away from prevention. "Prevention" covers many a c t i o n s , from promoting physical f i t n e s s , through regulation of unsafe p r a c t i c e s , to under- taking public health measures. To be sure, the cost effectiveness of some of these, e.g., comprehensive annual physicals, i s being increa- singly challenged. Nevertheless/ i t seems f a i r to say that i n the ov e r a l l e f f o r t to improve Canadians' health, the potential impact of prevention i s d r a s t i c a l l y underexploited. FIGURE 1.4 LIFESTYLE AND ENVIRONMENT ACCOUNT FOR TWO-THIRDS OF YEARS OF LIFE LOST BEFORE 70 DISEASE CEREBROVASCULAR ± 1 3 % DISEASE 2.8% . Source: Hea l th F i e l d I n d i c a t o r s f o r P o l i c y P l a n n i n g , Hea l th and We l f a re Canada, 1974. - 31 - - 32 - In the provinces, spending i s as biased as i t i s at the Fed- e r a l l e v e l . In Alberta, for example, more than 96 per cent of a l l health care spending by the province and municipalities i n 1973 went on hospitals and medical care, l e s s than four per cent on p u b l i c health and preventive services. S i m i l a r l y , the $650,000 "Dialogue on Drinking" campaign undertaken i n the 1 970's by N a t i o n a l Health and Welfare was f i g h t i n g $37 m i l l i o n spent annually on a d v e r t i s i n g by brewers and d i s t i l l e r s i n Canada. Coronary bypass surgery was introduced i n 1967 to combat coronary artery disease, the nation's Number 1 k i l l e r . In the oper- ation, doctors graft portions of a leg vein around the clogged p a r t of the artery, thus creating a detour or bypass f o r the blood. In 1 978, according to an a r t i c l e i n the Medicine s e c t i o n of TIME [May 28, 1979], more than 80,000 such operations were performed i n the United States. The average cost: $10,000 to $15,000. Despite i t s growing use, the procedure i s highly c o n t r o v e r s i a l . Though i t r e - li e v e s patients from severe pain, there i s heated debate over whether i t i s better than less expensive and less r i s k y medicinal treatments i n prolonging l i f e . In a speech delivered to the National Health Forum, Chicago, I l l i n o i s [March 20, 1967] and e n t i t l e d " N a t i o n a l Health Goals and Objectives," the late J. Douglas Coleman, former head of New York's Blue Cross, observed: - 33 - " p o s i t i v e h e a l t h i s not something t h a t one human can hand to or r e q u i r e o f a n o t h e r . P o s i t i v e health can be achieved only through i n t e l l i g e n t e f f o r t on the p a r t of each i n d i - v i d u a l . Absent that e f f o r t , h e a l t h p r o f e s - sionals can only insulate the i n d i v i d u a l from the more catastrophic r e s u l t s of his ignorance, self-indulgence or lack of motivation." So f a r , health promotion, or pr e v e n t i v e medicine, has met with more ta l k than r e a l success, largely because i t has had l i t t l e money i n comparison with sickness treatment. Funds and a d m i n i s t r a - t i v e e f f o r t have been spread too t h i n l y to have much impact. An ef f e c t i v e strategy must increase the emphasis on h e a l t h promotion, concentrating where i t w i l l do the most good. D. RISK FACTOR REDUCTION TRIALS Breslow [1978], w r i t i n g i n Prev e n t i v e Medicine, maintains that there i s a rapidly growing s c i e n t i f i c and professional consensus that r i s k factor intervention should be int e n s i v e l y explored as a way of maintaining and improving h e a l t h during the present e r a . This idea of r i s k factor intervention has emerged from three i n t e r r e l a t e d streams of study, and action against the c a r d i o - v a s c u l a r d i s e a s e s , cancer, c i r r h o s i s of the l i v e r , accidents and chronic lung disease — the major, current health problems i n the i n d u s t r i a l i z e d nations of the worId. These three streams of inter r e l a t e d studies, i . e . , the i d e n - t i f i c a t i o n of (a) bodily changes; (b) i n d i v i d u a l l i v i n g h a b i t s as r i s k factors; and (c) reduction of i n d i v i d u a l r i s k factors and t h e i r - 34 - effe c t s — have led to the i n i t i a t i o n of several studies of r i s k fac- tor intervention. 1. MRFIT Probably the best known study among American epidemiolo- g i s t s i s the Multiple Risk Factor Intervention T r i a l [MRFIT]. Twenty United States centres, sponsored by the N a t i o n a l Heart, Lung, and Blood I n s t i t u t e , are collaborating i n a study of 12,866 men aged 3 5 to 57 years at high r i s k of CHD. These men were s e l e c t e d on the basis of the Framingham Risk score (serum cholesterol, d i a s t o l i c B.P. and cigarette smoking) from 370,599 volunteers. The 20 centres are now conducting a randomized c l i n i c a l t r i a l involving group and i n d i - v i d u a l i n s t r u c t i o n and extending over several years to determine whe- ther a special intervention program d i r e c t e d simultaneously at the three r i s k factors w i l l r e s u l t i n a reduction of incidence and morta- l i t y from CHD, cardiovascular and t o t a l mortality, and/or s i g n i f i c a n t reduction of the r i s k f a c t o r s [ J o u r n a l of Chronic Diseases, 1977, DHEW Publ. No. (NIH) 77-1211, 1977]. 2. Stanford Program A f i e l d experiment i n three northern C a l i f o r n i a towns, known as the Stanford Heart Disease Prevention Program, focused on the same three r i s k factors but mainly with a campaign i n the t o t a l community and with some special e f f o r t directed toward high r i s k i n - dividuals [ Farquhar et al_., 1977] and [Maccoby et. al_., 1 977]. Base- l i n e and subsequent annual surveys d i s c l o s e d t h a t , a f t e r two years - 35 - of a multimedia campaign i n two communities and intensive in s t r u c t i o n of a sample of high r i s k i n d i v i d u a l s i n one of them, the r i s k for CHD declined 15 to 20 per cent among t o t a l p a r t i c i p a n t s and 3 0 per cent among the intensive i n s t r u c t i o n , high r i s k group. 3. North Karelia In North K a r e l i a , Finland, a largely r u r a l area having a population of 180,000 with an extremely high CHD r a t e , a community- wide campaign has been underway since 1972 to reduce the cardiovascu- l a r disease morbidity and mortality, e s p e c i a l l y among the middle-aged male population. The campaign involves: mass public health informa- t i o n ; t r a i n i n g of p r o f e s s i o n a l personnel; o r g a n i z a t i o n of p u b l i c health and related services; environmental changes such as encourage- ment of low-fat dairy products; and patient information services such as r e g i s t r i e s . I t i s also directed against the same three r i s k f a c - t o r s , i . e . , high serum c h o l e s t e r o l l e v e l s , hypertension, and c i g - arette smoking, and promotes the e a r l y d i a g n o s i s , treatment, and r e h a b i l i t a t i o n of cardiovascular patients. After 4.5 years, f i n d i n g s included: decreased c i g a r e t t e smoking, increased consumption of low-fat milk, increased p r o p o r t i o n of the population under a n t i - hypertensive therapy, decreased blood pressure, a considerable r e - duction i n the incidence of strokes -- from 3.6 per 1,000 males i n 1 972 to 1.9 i n 1975, and from 2.8 to 1.8 per 1,000 females -- and a s l i g h t decline i n the myocardial i n f a r c t i o n rates [Koskela et a l . , 1976], [Puska, 1978] and [Puska et a l . , 1978]. - 36 - While these three major controlled t r i a l s , MRFIT, Stanford, and North K a r e l i a , are, or have been, underway, several other s i g n i - f i c a n t studies of r i s k f a c t o r i n t e r v e n t i o n are being conducted i n other population groups. 4. "Know Your Body" Program One of the most inter e s t i n g i s the American Health Foundation "Know Your Body" program, aimed at 10- to 15-year-old school children [Williams et a l . , 1977]. The program includes medical screening i n school, delivery of a "Health Passport" to each p a r t i c i p a n t , general health education i n the classroom aimed a t ch r o n i c disease preven- t i o n , and additional intervention directed at high r i s k groups. The presumption that r i s k factors for chronic disease would e x i s t i n a population of si x t h to eighth grade American school children was con- firmed: 1.7 per cent showed blood pressure exceeding either 140 mm. of mercury s y s t o l i c or 90 mm. of mercury d i a s t o l i c ; 2.0 per cent scored "poor" on the modified Harvard Step Test; 8.0 per cent were current cigarette smokers; 15.6 per cent weighed 120 per cent or more of " i d e a l " weight; and 17.4 per cent had c h o l e s t e r o l l e v e l s of 180 mg. per cent or more. In a l l , 36 per cent of the c h i l d r e n had a t le a s t one r i s k factor and seven per cent had two or more. Thus, i t appears that attention to r i s k factors should not await adulthood, but should begin with school-age children. - 37 - E. CURRENT STATISTICAL TREND — CHD 1. Are the Figures Real? In their preface to the Proceedings of the Conference on the Decline i n Coronary Heart Disease M o r t a l i t y , Havlik and F e i n l e i b [1979] note that although heart attacks are s t i l l the major cause of death and d i s a b i l i t y i n the United States, a major decrease i n Coro- nary Heart Disease mortality has occurred i n that country during the l a s t 15 years. The purposes of the Conference were: 1. To consider whether the greater than 20 per cent d e c l i n e i n Coronary Heart Disease mortality since 1968 i s r e a l , 2. To discuss possible causes, 3. To recommend further studies to elucidate the causes. The major conclusions reached were: 1. The decrease i n Coronary Heart Disease mortality i s r e a l and not a r e s u l t of a r t i f a c t s or changes i n death c e r t i f i c a t e coding, 2. Both primary and prevention through changes i n r i s k f a c - tors and fundamental and c l i n i c a l research leading to better medical care probably have contributed to, but do not f u l l y explain, the de- c l i n e , 3. A precise qu a n t i f i c a t i o n of the causes r e q u i r e s f u r t h e r studies, e s p e c i a l l y those designed to document whether the frequency of non-fatal coronary events i s changing. - 38 - If the t o t a l number of heart a t t a c k s i s decreasing or the severity of c l i n i c a l disease i s l e s s e n i n g , t h i s would favor r i s k factor reduction as being the probable cause of the d e c l i n e i n mor- t a l i t y . If the t o t a l CHD incidence i s unchanged, i t would support the conclusion that fundamental and c l i n i c a l research l e a d i n g to modern medical treatment i s the probable cause of the d e c l i n e i n mort a l i t y . I t was emphasized that many other causes of death (except lung cancer, chronic lung disease, and suicide-homicide) are d e c l i n - ing at almost the same rate as Coronary Heart Disease, suggesting a more general positive health force operating i n the United S t a t e s , such as higher income or better access to medical care. U.S. figures on hospital discharges, with the diagnosis of Coronary Heart Disease, have not changed markedly during the period 1968 to 1977. In addition, the percentage of i n d i v i d u a l s dying i n the h o s p i t a l with a diagnosis of Coronary Heart Disease appears to have decreased only s l i g h t l y . However, i t i s possible that the diag- nostic categories used by the p a r t i c i p a t i n g h o s p i t a l s have changed, r e s u l t i n g i n a d i s t o r t e d p i c t u r e . Also admission p r a c t i c e s have changed with more p a t i e n t s e n t e r i n g f o r coronary angiography and e l e c t i v e cardiac surgery. One large prepaid health care plan i n the United States found that the number of discharges with a diagnosis of Coronary Heart Disease has decreased each year since 1971, while the case f a t a l i t y rate has not changed. In contrast, within a community with a compre- - 39 - hensive medical record system the incidence of new coronary events among those having no previous coronary disease has not changed over recent years, while the frequency of deaths among those with known coronary heart disease has decreased. Such limited and i n c o n s i s t e n t observations cannot meaningfully be extrapolated to the United States as a whole and the question of trends i n heart attack i n c i d e n c e r e - mains unanswered. In addition, because of the la c k of appropriate pathological and/or c l i n i c a l s t u d i e s , i t i s not known whether the frequency or severity of a t h e r o s c l e r o t i c l e s i o n s i n the pop u l a t i o n has changed over time. A population decrease i n the amount and seve- r i t y of coronary artery narrowing would support the conclusion that a fundamental change i n atherosclerotic r i s k factors i s a l i k e l y cause for the decline i n mortality. 2. Possible Causes for the Decline Changes i n Coronary Heart Disease care have probably had an impact on the d e c l i n e , according to the Conference p a r t i c i p a n t s . Programs such as the NHLBI-sppnsored Myocardial I n f a r c t i o n Research Units and Specialized Centres of Research on Ischemic Heart Disease have contributed to such changes. These programs have had an impact through support of extensive m u l t i d i s c i p l i n a r y , fundamental and c l i - n i c a l research on the diagnosis and treatment of ischemic heart disease. In 1963 the f i r s t coronary care unit was organized i n the United States. Now specialized h o s p i t a l care i n c l u d i n g monitoring, prevention, and treatment of c a r d i a c arrhythmias has become the - 40 - standard form of treatment f o r i n d i v i d u a l s with acute myocardial i n f a r c t i o n . The reported m o r t a l i t y o c c u r r i n g from acute coronary heart disease t r e a t e d i n h o s p i t a l s f e l l from about 30 to 20 per cent; however, i f a causal relationship between coronary care u n i t s and the c o n t i n u i n g d e c l i n e i n coronary h e a r t disease m o r t a l i t y e x i s t s , one must assume that each year more h o s p i t a l s are adopting such treatment p r i n c i p l e s and therapy continues to improve. In addi- t i o n , the impact w i l l be l i m i t e d by the r e a l i t y that up to 70 per cent of coronary heart disease deaths occur out of the h o s p i t a l . Further, i n their summary of the Conference proceedings, Hav- l i k and F e i n l e i b note that the contribution of improved general med- i c a l and c a r d i o l o g i c a l care i s d i f f i c u l t to a s c e r t a i n . There i s no doubt that there have been improvements i n d i a g n o s i s and therapy, es p e c i a l l y for patients with angina pecto r i s , but the s p e c i f i c impact of these advances on the decline i n m o r t a l i t y cannot be estimated. The same i s true of surgical care. The use of coronary by-pass sur- gery has increased exponentially i n the United States. I t i s accep- ted that for some s p e c i f i c coronary a r t e r y l e s i o n s , l o n g e v i t y has increased; controversy exists on i t s e f f e c t s on a l l l e s i o n s . How- ever, the u t i l i z a t i o n of this s u rgical procedure has r e l a t i v e l y r e - cently been introduced, and, thus, could not account for the d e c l i n e i n mortality commencing i n the 1960's. Changes i n r i s k f a c t o r s f o r a t h e r o s c l e r o s i s p r o v i d e an a t t r a c t i v e hypothesis for explaining some of the d e c l i n e ; however, here, too, the data are limited. Although the percentage of smokers - 41 - and the amount of tar and nicotine i n cigarettes have dropped i n the United States since the release of the f i r s t Surgeon General's report i n 1964, the frequency of individuals smoking two or more packs of cigarettes has not changed, according to a t l e a s t one survey. In addition, women, who have enjoyed the greatest decline i n m o r t a l i t y , have inconsistently changed t h e i r smoking h a b i t s . Consumption of cigarettes did increase during the post-World War I I e r a , which may have a f f e c t e d the subsequent increase i n coronary h e a r t disease deaths. There i s substantial evidence, the Report goes on, that the awareness and e f f e c t i v e treatment of hypertension have increased dramatically over the l a s t few years. Improved therapy of hyperten- sion i s an appealing explanation of some of the decline i n m o r t a l i t y since there has been a greater drop i n mortality i n women, espec i a l l y black women. Presumably i t i s this group which has taken most advan- tage of treatment for hypertension. On the other hand, m o r t a l i t y from hypertensive heart disease and stroke began to d e c l i n e some years before e f f e c t i v e medical therapy for hypertension was available and during a time when coronary heart disease mortality was i n c r e a s - ing. There have been n u t r i t i o n a l changes over recent years with decreases i n consumption of cholesterol and saturated f a t s , e s p e c i - a l l y i n the form of less egg and butter consumption and increases i n intake of polyunsaturated f a t s . However, o v e r a l l meat consumption has increased as has t o t a l f a t intake, and an i n c r e a s i n g frequency - 42 - of obesity i n certain groups suggests excess c a l o r i e consumption. The net e f f e c t on blood c h o l e s t e r o l l e v e l s cannot be determined accurately but i t appears that there may have been an o v e r a l l reduc- t i o n i n blood cholesterol levels of up to fi v e per cent. This change i s c o n s i s t e n t with the o v e r a l l e f f e c t of the o b s e r v e d d i e t a r y changes. Depending on the assumptions that are made, such a change could translate into some f i v e per cent or greater decrease i n coro- nary heart disease deaths i n middle-aged men. If reductions i n blood pressure and reduced smoking are con- sidered along with the cholesterol reduction i n an appropriate mathe- matical equation, much of the decline i n coronary heart disease mor- t a l i t y , at least i n middle-aged men, could be explained, according to Havlik and Feinle i b . Preliminary data from the World Heath Organiza- t i o n and the Food and Agriculture Organization indicate that d i e t a r y and smoking changes opposite to those i n the United S t a t e s , i . e . , increases, have been occurring i n many foreign c o u n t r i e s . The s t a - t i s t i c a l r elationship of these r i s k factor changes to coronary h e a r t disease m o r t a l i t y trends shows an apparent a s s o c i a t i o n . V i c k e r y [1978] i s very positive about the co r r e l a t i o n between the change i n the use of c e r t a i n products and the d e c l i n e i n death r a t e due to heart disease and stroke. He uses the following t a b l e s to make h i s point. TABLE 1.7 GRANGE (PER PERSON) IN USE OF CERTAIN PRODUCTS FROM 1963 to 1975 Product Change A l l tobacco products 22.4% decline F l u i d milk and cream 19.2% decline Butter 31.9% decline Eggs 12.6% decline Animal Fats and Oi l s 56.7% decline Vegetable Fats and Oi l s 44.1% increase TABLE 1.8 DECLINE IN DEATH RATE DUE TO HEART DISEASE AND STROKE FROM 1963 to 1975 Decline % Age Heart Disease Stroke 35 - 44 27.2 19.1 45 - 54 27.4 31 .7 55 - 64 23.5 34.1 65 - 74 25.3 33.2 75 - 84 12.8 21 .9 85 + 19.3 29.4 In addition to the changes i n these tables, he notes that the number of persons exercising regularly has increased dramatically. - 43 - - 44 - Exercise as noted above by Vickery and, i n p a r t i c u l a r , j o g - ging, have i n c r e a s e d i n f requency i n the U n i t e d S t a t e s , but t h i s trend has been a recent development and has i n v o l v e d o n l y c e r t a i n groups. Its e f f e c t on a decline i n m o r t a l i t y b e g i n n i n g i n the mid- 1960's must be minimal, a l t h o u g h a g r e a t e r f u t u r e impact i s pos- s i b l e . 3. Recommendations Although there was general agreement among the p a r t i c i p a n t s a t the Conference that the decline i n coronary heart disease i s r e a l , the probable cause or causes could not be p r e c i s e l y i d e n t i f i e d . Further research i s urgently needed to c l a r i f y these i s s u e s . The following recommendations were made for further relevant studies: (a) Change data c o l l e c t i o n systems to v e r i f y broad trends i n m o r t a l i t y due to ischemic h e a r t disease and to e s t a b l i s h i n c i d e n c e rates by c o l l e c t i n g data on m o r b i d i t y from ischemic heart disease. (b) E v a l u a t e c o n t r i b u t i o n s made and f u t u r e o p p o r t u n i t i e s f o r a f f e c t i n g m o r b i d i t y and m o r t a l i t y by p r e v e n t i v e and t h e r a p e u t i c p a t i e n t management. I t i s a p p a r e n t t h a t p r e v e n t i v e measures w i l l have t h e i r major impact on the e a r l y m a n i f e s t a t i o n s of the disease process, and treatment on the l a s t m a n i f e s t a t i o n s or c o m p l i c a t i o n s of the d i s e a s e . This e v a l u a t i o n i s b e s t accom- plished by testing s p e c i f i c hypotheses, for example: do ingestion of contraceptive p i l l s and cigarette smoking increase morbidity and mortality?; how e f f e c t i v e are s p e c i f i c drugs, coronary care units and surgery?; are there differences i n morbidity and m o r t a l i t y among socioeconomic classes?; etc. - 45 - (c) Continue to support b a s i c research, both c l i - n i c a l and n o n - c l i n i c a l , i n c l u d i n g s t u d i e s o f : (1) L e s i o n development; (2) L e s i o n d e t e c t i o n ; (3) Myocardial performance; (4) . C l i n i c a l management; (5) E p i d e m i o l o g i c a l l y d e f i n e d r i s k f a c t o r s . CHAPTER I I RISK FACTOR INTERVENTION A. DIET AND GROWTH AND DEVELOPMENT 1. Atherosclerosis as a "pediatric disease" In the section on Pathogenesis found e a r l i e r i n t h i s t h e s i s , i t was noted that atherosclerosis begins early i n childhood. Stamler [1972], Glueck [1980] and Lupien [1980] a l l c i t e d evidence to sub- sta n t i a t e this f a c t . The concept that atherosclerosis begins i n childhood and that c l i n i c a l disease i n the adult i s i t s d i r e c t consequence, has l e d to the proposal that atherosclerosis i s a "pediatric disease", and th a t measures to reduce the effects of known r i s k factors should be i n i t i - ated early i n l i f e . Valuable information pertinent to assessing the po t e n t i a l b e n e f i c i a l e ffects of dietary modification i n childhood on the subsequent development of atherosclerosis may be obtained by i n - s t i t u t i n g appropriate preventive measures for those children at high r i s k for atherosclerotic vascular disease, such as children with p r i - mary or secondary hyperlipidemia, hypertension, or diabetes, and f o r the progeny of adults with hyperlipidemia, e s s e n t i a l hypertension, diabetes or premature myocardial i n f a r c t i o n . The results of i n s t i t u - t i n g preventive measures i n these groups should be assessed care- f u l l y . Such information may provide the c r i t i c a l evidence e s s e n t i a l for deciding whether further a l t e r a t i o n s i n n a t i o n a l d i e t patterns for children are necessary or desirable [ F i l e r , 1972]. - 46 - - 47 - 2. Hypercholesterolemia. P r e l i m i n a r y data from the i n i t i a l screening of the 3,000 children of ages 11 to 14 studied by W i l l i a m s et a l . [1 977], indicate t h a t hypercholesterolemia may be the most common r i s k f a c t o r f o r coronary heart disease i d e n t i f i a b l e among children. One-third of a sample of Wisconsin school c h i l d r e n (age 5-14) had cholesterol l e v e l s over 200 mg.% (mean 186.5 mg.%) i n a study by Golub j atnikov ejt a_l • [ 1 972]. Kannel and Dawber [ 1 972] recommend that a l l children with cholesterol levels over 160 mg.% be monitored on a periodic basis, based on the b e l i e f that U.S. c h o l e s - t e r o l levels must be brought into the range of c o u n t r i e s l i k e Japan where coronary heart disease rates are low and cholesterol values do not reach 160 mg.% u n t i l middle age. In his commentary on the c h o l e s t e r o l controversy Rapaport [1980] feels that i f lowering of c h o l e s t e r o l and saturated f a t s i n the d i e t i s to prevent atherosclerosis, i t should be i n i t i a t e d a t a time when a t h e r o s c l e r o s i s i s s t i l l i n i t s formative stage, i . e . , early i n the natural history of the disease. He finds himself i n agreement with Adams [1980] who recom- mends a prudent d i e t , low i n cholesterol and saturated f a t s , to the general population of c h i l d r e n and adolescents. He f e e l s t h a t as long as the dietary recommendations are kept reasonable, reduction of cholesterol and saturated fats i n the d i e t should not impose undue hardships on the population as a whole. The American Heart A s s o c i a - tion's current recommendation of less than 35 per cent of t o t a l c a l - ories i n the d i e t as f a t , with no more than one-third from saturated - 48 - f a t and no more than 300 mg. of cholesterol per day, cannot be con- sidered, i n Rapaport's opinion, a stringent, n u t r i t i o n a l l y d e f i c i e n t , or unpalatable d i e t to thrust upon the pediatric or the adult popula- t i o n . 3. L i f e s t y l e development An a d d i t i o n a l argument for r i s k - f a c t o r modification i n c h i l d - hood has been that desirable patterns of l i f e s t y l e may be more read- i l y established i n childhood, and may p e r s i s t throughout l i f e . There i s l i t t l e data available concerning this question, and indeed, i t has been suggested t h a t the process of e s t a b l i s h i n g good preve n t i v e health practices i n childhood i s at least as complex as the process of changing adult behaviour [Levanthal, 1973]. 4. Diet Modification A t h i r d reason for considering, i n infancy and childhood, the e f f e c t of dietary modification on growth and development, i s t h a t modifications aimed at adults w i l l change f a m i l y e a t i n g p r a c t i c e s , and hence those of children. In i n f a n t s , there i s no evidence that a modest increase i n cholesterol intake and a modest increase i n p o l y - unsaturated f a t t y acid i s detrimental. Human breast milk would seem to be the i d e a l food i n infancy. 5. Weight Control Obesity among school children i n the United States i s h i g h l y prevalent a f f e c t i n g from f i v e to 15 per cent of children between the ages of eight to 15 years [Rogers and Reese, 1964] and [Wilmore and McNamara, 1974]. Body weight i n childhood i s c o r r e l a t e d with sub- - 49 - sequent adult weight according to Heald and Hollander [1965]. I t has been well established that obesity i s an important r i s k factor assoc- iated with a reduction of life s p a n , increased prevalence of diabetes m e l l i t u s , and heart disease [Kannel et a l . , 1967]. One of the recommendations of the Report of the Committee on Diet and Cardiovascular Disease i s that excess body f a t should be controlled at a l l ages. In c h i l d r e n , r e l a t i v e l y l i t t l e i s known about the e f f e c t of graded c a l o r i c r e s t r i c t i o n on optimal growth, and several studies have emphasized the d i f f i c u l t i e s of maintaining o p t i - mal growth and p o s i t i v e nitrogen balance i n c h i l d r e n during c a l o r i c r e s t r i c t i o n [Lowe, 1967]. Accordingly, general unsupervised r e s t r i c - t i o n i n this group may be i l l - a d v i s e d . Attention to the other end of the "energy equation", that i s , an increase i n p h y s i c a l a c t i v i t y through organized programs i n schools and communities may help to re- duce the incidence of childhood obesity, and subsequent adult obesity [Abraham and Nordsieck, 1960] without compromising normal growth and development. 6. Physical A c t i v i t y According to the 1970 survey on N a t i o n a l P h y s i c a l F i t n e s s (U.S.), 45 per cent of American a d u l t s do not engage i n organized physical a c t i v i t y either i n d i v i d u a l l y or as p a r t of a group. Pre- liminary data from the present school program i n the United States indicate that 20 per cent scored f a i r or poor on the pulse recovery index of a modified Harvard Step Test. - 50 - 7. School Assessment Weight and Diet A 1975 national n u t r i t i o n survey established that there were poor eating habits, such as breakfast skipping, l a t e n i g h t snacking and low nutrient intakes [Nutrition Canada, 1975]. In a 1980 school assessment, above average body f a t levels were reported i n 8 3 to 9 3 per cent of B.C. school children [Ministry of Health, 1 980]. Other n u t r i t i o n related concerns include anorexia nervosa, d i a b e t e s , and hyperact i v i t y . School foods have come under c l o s e i n s p e c t i o n , b r i n g i n g to attention the need for improvement i n safety of food handling and the n u t r i t i o n a l q u a l i t y of foods, p a r t i c u l a r l y "accessory" foods a v a i l - able i n concessions and vending machines. A recent study of acces- sory foods i n Kelowna showed that i n secondary sc h o o l s , 4 8 per cent of available accessory foods were c l a s s i f i e d i n the lowest category as to food value, i . e . , foods low i n i r o n , calcium, vitamins A, C, and D, and high i n c a l o r i e s , sugar, f a t and/or s a l t . Only 16 per cent of foods were i n the most desirable category [School Food Survey Report, 1980]. As as r e s u l t of the same survey, i t was found that 2 7 of the schools had contracts with MacDdnalds r e s t a u r a n t f o r p e r i o d i c "Big Mac Days." In some cases the schools i n i t i a t e d d a i l y d e l i v e r y of food to the school from MacDonalds.' This p r a c t i c e causes cons i d e r - able concern as i t also provides t r a i n i n g i n consumer choices which are not conducive to health, according to the M i n i s t r y of Health. Similar concern i s raised by the sale of junk foods i n concessions at sporting events, and for other fund-raising projects. - 51 - 8. Factors Affecting Dietary Habits Many factors a f f e c t the dietary habits of the population i n - cluding s o c i a l , c u l t u r a l , psychological, r e l i g i o u s and economic i n - fluences. Some examples, of these are: (a) Improved Transportation. A greater variety of foods i s now available throughout the year, p a r t i c u l a r l y fresh, out-of-season produce. (b) Changes i n L i f e s t y l e . With more leisure time, and with more females employed outside the home, there i s increased use of packaged convenience foods, take-out meals, meals-on-wheels, and the number of meals consumed outside the home. (c) Urbanization has led to less s e l f - s u f f i c i e n c y i n f a m i l y food production. Social i n f l u e n c e s c r e a t e " s t a t u s " or " p r e s t i g e " foods [Lowenberg et a l . , 1 968] f o r example, white f l o u r and meat. Intensive a d v e r t i s i n g programs promote p a r t i c u l a r foods, some of which have l i t t l e n u t r i t i o n a l value and are i n the "junk food" cate- gory. (d) Increased immigration from many countries has introduced new foods and new cooking methods. 9. Recommendations The Committee on Diet and C a r d i o v a s c u l a r Disease [Health & Welfare Canada, 1976], after reviewing the information a v a i l a b l e on the relationship between d i e t and c a r d i o v a s c u l a r disease b e l i e v e s that there i s an adequate b a s i s f o r recommending changes i n the Canadian d i e t . These are: - 52 - (a) a reduction i n fat-derived c a l o r i e s , to 3 0 to 35 per cent of t o t a l c a l o r i e s , mainly through a decrease i n saturated f a t ; (b) a p a r t i a l substitution of polyunsaturated f o r saturated f a t ; (c) a reduction i n dietary c h o l e s t e r o l i n t a k e to 400 mg. d a i l y or l e s s ; (d) a d i e t which contains l e s s a l c o h o l , s a l t and refined sugars, and more whole grain products, f r u i t s and vegetables; and (e) the prevention and control of obesity through reducing excess calories and increasing physi- c a l a c t i v i t y . However, precautions should be taken that no deficiency of vitamins and min- er a l s occurs when t o t a l calories are reduced. In the Toronto Star, June 24, 1981, Michael McAteer reported that d a i l y n u t r i t i o n a l snacks or meals f o r thousands of i n n e r - c i t y elementary school children could be provided by October of this year, i f the Toronto Board of Education plans are realized. The meal program i s one r e s u l t of a four-year study of e l e - mentary education i n nine inn e r - c i t y schools that suggested a n u t r i - t i o n education program improved student attentiveness and behaviour. Thus when n u t r i t i o u s snacks were provided at p i l o t schools over a "two-year period, students soon began to change eating habits, switch- ing from junk food to nutritious food and even s t a r t e d i n f l u e n c i n g t h e i r f a m i l i e s ' eating habits by helping i n grocery shopping and meal planning. John Bates, the Board of Education's inner-city co-ordinator, said that he has discussed the program with s e v e r a l food companies and i s confident that the private sector w i l l provide the $100,000 - 53 - worth of food necessary f o r implementation of the program. This would only represent a p o r t i o n of the estimated t o t a l c o s t of the program. The proposal i s to provide d a i l y snacks f o r about 6,000 junior kindergarten to Grade 3 students i n 40 s c h o o l s , and d a i l y meals for about 1,000 students i n 12 s c h o o l s . A f t e r the program's f i r s t two years, both f e d e r a l and p r o v i n c i a l m i n i s t r i e s of h e a l t h w i l l be asked to finance the program so i t can be expanded to Grade 6. The program i s c a l l e d SCORE — School and Community Organizing to Revitalize Education. B. SMOKING 1. WHO Committee Recommendations New adverse e f f e c t s on h e a l t h as a r e s u l t of smoking were revealed at a WHO Expert Committee on Smoking C o n t r o l meeting i n Geneva i n October 1978 [Burckhardt, 1 979]. Besides confirming yet again what was already known about tobacco and heart d i s e a s e , r e s - piratory diseases, cancer of the lung and other forms of cancer, the experts brought out new evidence of the harm done by cigarettes, par- t i c u l a r l y to women and children. Women who smoke during pregnancy have lighter and therefore more f r a g i l e babies, whose very l i v e s may be imperilled and who are most susceptible to bronchitis and pneumon- i a during their f i r s t two years of l i f e . The Committee adopted the following recommendations: - 54 - (a) that non-smoking should be regarded as the normal s o c i a l behaviour and that a l l a c t i o n which can promote the development of t h i s attitude be taken; (b) there should be a t o t a l p r o h i b i t i o n of a l l forms of tobacco promotion; (c) promotion of the e x p o r t o f tobacco and tobacco products should be d i s c o u r a g e d . Tobacco-growing and manufacturing industries should be progressively reduced i n s i z e as rap i d l y as possible; (d) governments should recognize the s e r i o u s danger f o r smokers i n c e r t a i n i n d u s t r i a l occupations, and develop special programs to e r a d i c a t e smoking from these i n d u s t r i e s , u t i l i z i n g l e g i s l a t i o n where necessary; (e) measures should be taken to e s t a b l i s h upper l i m i t s for appropriate emission products of cigarettes; these l i m i t s should be progres- s i v e l y lowered as rapidly as i s practicable; every tobacco packet should contain a health warning and i n f o r m a t i o n as to e m i s s i o n l e v e l s ; (f) special educational techniques s u i t a b l e to the s o c i o c u l t u r a l s i t u a t i o n , p a r t i c u l a r l y those where communication i s d i f f i c u l t , should be developed. 2. Smoking Habits of Children When the Surgeon General's 1964 Report on Smoking and Health was released, numerous individuals and organizations designed various a c t i v i t i e s to encourage people to quit smoking. As a r e s u l t , a t t i t u - d i n a l as well as behavioural change were considerably a l t e r e d among adults. Yet the number of teenage smokers continued to increase [St. Pierre and Lawrence, 1975]. With 3,200 youngsters between the ages of 12 and 18 who take up smoking each day i n the United S t a t e s , we are witnessing presently an addition of one m i l l i o n new smokers each year [Albino and Davis, 1975]. - 55 - Cigarette consumption among school c h i l d r e n probably ranks second i n prevalence as a r i s k factor for coronary heart disease as w e l l as a for tobacco-related cancers and emphysema. Williams et a l . [1977] found i n their study that 10 per cent of their 11- to 14-year ol d students were already regular smokers. These findings are s i m i - l a r to national data which indicate an i n c r e a s e from t h i s l e v e l to about 40 per cent by graduation from high s c h o o l . They found that during the previous decade smoking among teenage g i r l s had increased much more rapidly than for boys. While the cigarette habit does not produce a substantial threat to cardiovascular health i n adolescence, nonetheless the t o l l i s exacted l a t e r i n l i f e when continued depend- ence on tobacco enhances the cardiovascular system's v u l n e r a b i l i t y to atherosclerosis, ischemic heart disease, a o r t i c aneurysm, and p e r i - pheral vascular disease. The causes for this increase have been i n v e s t i g a t e d exten- s i v e l y , according to a report by Heit [1979]. Educators have studied the re l a t i o n s h i p between numerous v a r i a b l e s and adolescent smoking behaviour, yet there are no s p e c i f i c predeterminates which indicate a predisposition towards smoking. We do know that smoking i n i t i a t i o n i s a r e s u l t of one's susceptability to i n i t i a t i o n within a s o c i a l en- vironment conducive to smoking [ M e t t l l i n , 1 976]. Many promotional agents are suspected of promulgating adolescent c i g a r e t t e smoking. Among these may be advertisements, peer group pressure, a d u l t be- haviour, smoking lounges i n schools and cigarette vending machines i n many public establishments. - 56 - In response to the continued r i s e i n teenage smoking be- ha v i o u r , h e a l t h educators have become very concerned about the strategies and methods to be used for encouraging a l t e r a t i o n i n s t u - dents' behaviour. The schools are often considered a f i r s t l i n e of defence i n promoting p o s i t i v e h e a l t h behaviour. The teachers, as change agents can introduce various a c t i v i t i e s which can help s t u - dents develop desirable h e a l t h knowledge, a t t i t u d e s and behaviour [Chen and Ralcip, 1975]. In t h i s regard, numerous h e a l t h p r o f e s - sionals and health organizations support the proposition that educa- ti o n e f f o r t s during the elementary school years can serve as an im- petus for the development of decision-making s k i l l s i n r e l a t i o n to health attitudes and behaviour. 3. Public B e l i e f s — CHD Shekelle and Liu [1978] describe the r e s u l t s of a survey of public b e l i e f s about causes and p r e v e n t i o n of heart a t t a c k s . The survey was conducted from September 1 976 through March 1 977 i n the population of persons who were 20 to 59 years of age and who were residents of Cook, Du Page, and Lake Counties, I l l i n o i s . This area includes Chicago and most of i t s suburbs. Random d i g i t - d i a l i n g was used to sele c t a random sample of households (Sudman, Applied Samp- l i n g ) , and Kish's method (Survey Sampling) was followed to s e l e c t randomly one respondent from each household. Each respondent's answers were weighted by the number of e l i g i b l e persons i n that household since, with this method of sampling, the chance of s e l e c t - ing an i n d i v i d u a l i s inversely proportional to the size of the house- hold. The responses to various questions asked are shown i n the - 57 - following tables (II.1 to I I . 4 ) . Of p a r t i c u l a r i n t e r e s t i n Table II.4 i s that 30 per cent mentioned q u i t t i n g smoking i n answer to the question of what the respondent would recommend to someone c l o s e to them i n order to help him or her prevent a heart attack. TABLE II.1 WHAT DO YOU FEEL ARE THE MAJOR LIKELY CAUSES OF HEART ATTACKS IN PERSONS UNDER 60 YEARS OF AGE?" * E D U C A T I 0 N NOT FOUR-YEAR HIGH SCHOOL HIGH SCHOOL COLLEGE GRADUATE GRADUATE GRADUATE TOTAL*" R E S P O N S E % % % % Stress, Worry, Nervous Tension, Pressure 20 36 47 36 Overweight 27 29 34 30 Cigarette Smoking 24 28 32 28 High Blood Pressure 20 18 30 21 Not Enough Exercise 9 16 25 17 Don11 Know 28 17 9 16 Cholesterol, Fat i n Diet or Blood 12 12 15 13 Heredity, Family History 3 11 16 11 Not Enough Rest, Working Too Hard 10 12 8 11 * Survey of Chicago-area adults 1976 to 1977. [Shekelle and L i u , 1978]. + Percentages do not add up to 100% because each respondent could give several responses. Responses given by less than 10% of respondents have been omitted. TABLE 11.2 "YOU MENTIONED (REPEAT VERBATIM RESPONSES IN ORDER) WHICH ONE OF THESE DO YOU FEEL IS THE SINGLE MOST IMPORTANT CAUSE OF HEART ATTACKS IN PERSONS UNDER 60 YEARS OF AGE?"* - E D U C A T I O N NOT FOUR-YEAR HIGH SCHOOL HIGH SCHOOL COLLEGE GRADUATE GRADUATE GRADUATE TOTAL R E S P O N S E % % % % Stress, Worry, Nervous Tension, Pressure 15 20 20 19 Overweight 1 7 14 14 14 High Blood Pressure 1 1 10 16 12 Cigarette Smoking 4 9 10 9 Not Enough Exercise 2 6 4 5 Not Enough Rest, Working Too Hard 2 5 2 4 Heredity, Family History 0 4 3 3 Cholesterol, Fat in Diet or Blood 5 2 3 3 Other 14 10 15 11 No Single Most Important Cause 1 1 2 2 Don't Know 1 2 2 2 No Response to Previous Question 28 17 9 16 TOTAL 100 100 100 100 * Survey of Chicago-area adults, 1976 to 1977. [Shekelle and L i u , 1978]. TABLE II.3 "FROM WHAT YOU HAVE HEARD OR READ CAN HEART ATTACKS IN PERSONS UNDER 60 BE PREVENTED ^ OR IS THERE VERY LITTLE THAT CAN BE DONE TO PREVENT HEART ATTACKS?" E D U C A T I O N NOT FOUR-YEAR HIGH SCHOOL HIGH SCHOOL COLLEGE GRADUATE GRADUATE GRADUATE TOTAL R E S P O N S E % % % % Can be Prevented 62 75 88 76 Very L i t t l e Can be Done 13 13 6 11 Unsure 25 12 6 13 TOTAL 100 100 100 100 * Survey of Chicago-area adults, 1976 to 1977. [Shekelle and L i u , 1978]. TABLE II.4 "WHAT WOULD YOU RECOMMEND TO SOMEONE CLOSE TO YOU IN ORDER TO HELP HIM OR HER PREVENT A HEART ATTACK?"* E D U C A T I O N NOT FOUR-YEAR HIGH SCHOOL HIGH SCHOOL COLLEGE GRADUATE GRADUATE GRADUATE TOTAL R E S P O N S E % % % % + Eat Proper Diet (not otherwise specified) 21 31 34 30 Quit Smoking 33 28 35 30 Exercise 13 22 35 24 Get Medical Examination 9 20 29 20 Reduce Stress, Worry 14 16 23 17 Lose Weight 10 14 17 14 Avoid Fatty Foods 8 7 5 7 Check Blood Pressure 6 6 8 6 Get Enough Rest 6 6 5 6 Avoid Overexertion 6 6 5 6 Reduce Cholesterol Intake 4 4 8 5 Survey of Chicago-area Adults, 1976 to 1977. [Shekelle and L i u , 1978]. Percentages do not add up to 100% because each respondent could give several responses. Responses given by less than 5% of respondents have been omitted. - 62 - The authors caution that the generality of these re s u l t s must be tempered by the nonresponse rate (27.6 per cent) and by the r e - s t r i c t i o n to the Chicago area. However, Louis Harris and A s s o c i a t e s obtained the f o l l o w i n g r e s u l t s to a question about major l i k e l y causes of "heart trouble" i n a nationwide survey of adults p u b l i s h e d i n 1973: 37 per cent named emotional pressure, worry, or anxiety; 33 per cent overweight; 29 per cent, smoking; 13 per cent, high blood pressure; and eight per cent, f a t t y foods or cholesterol. These r e - s u l t s are s i m i l a r to those obtained i n the Chicago survey (Table II.1 and the s i m i l a r i t y suggests that the Chicago findings may be broadly applicable. A c r i t i c i s m sometimes leveled at public e d u c a t i o n a l e f f o r t s i s that while they may change knowledge, such programs do not change behaviour. This i s an overly s i m p l i s t i c view, and the experience of the Stanford Heart Disease Prevention Program [Farquhar e_t a l . , 1977] has shown that educational programs d i r e c t e d a t whole communities through the mass media may, i n f a c t , be e f f e c t i v e i n reducing the prevalence of r i s k factors for cardiovascular disease. L a r g e - s c a l e , sustained programs of public education about primary p r e v e n t i o n of coronary heart disease are c l e a r l y needed and might well lead to sub- s t a n t i a l reduction i n the l e v e l of r i s k for a t h e r o s c l e r o t i c c a r d i o - vascular disease. 4. Smoking and Risk An a r t i c l e i n the Toronto S t a r , Wednesday, June 24, 1981 stated that the r i s k of suffering a non-fatal r e - i n f a r c t i o n i s l e s s than half as great for people who quit cigarette smoking as i t i s for - 63 - those who continue to smoke. This f i n d i n g was from a survey con- ducted by a privately-run medical insurance organization i n C a l i f o r - nia and was based on records of tens of thousands of i t s c l i e n t s . I t concluded that "qu i t t i n g smoking appears to r e s u l t i n a s u b s t a n t i a l reduction i n coronary and t o t a l mortality." (Figure II.1) The Kaiser-Permanente medical care o r g a n i z a t i o n s a i d i t checked the records of coronary check-ups given non-smokers, p e r s i s - tent smokers and those who had given up smoking, against the death records of the State of C a l i f o r n i a . The survey r e s u l t s showed that the r i s k of dying from coronary heart disease was 2.22 times greater among people who persisted i n smoking c i g a r e t t e s than i t was among those who quit. [Friedman, G.D. i n Havlik & F e i n l e i b , 109-14, 1979]. An a r t i c l e on the e d i t o r i a l page of the June 2, 1981 issue of Medical Post comments on a proposal c u r r e n t l y before the B r i t i s h Agencies for Adoption and F o s t e r i n g . If the proposal i s passed, adoption agencies i n the United Kingdom may soon automatically r e j e c t smokers as potential adopters of newborn babies. The a r t i c l e p o i n t s out that adoption agencies do not knowingly hand over babies to parents known to drink to excess or those who l i v e a r e c k l e s s l i f e . Yet smoking i s associated with a shorter l i f e expectancy. This may mean that parents cannot assure the same long-term care that non- smoking parents can be expected to give. Smoking fat h e r s are known to die.much younger of heart disease and cancer than non-smoking controls. FIGURE II.1 EFFECT ON RE-INFARCTION FROM "QUITTING" SMOKING CONTINUED TO SMOKE (N = 174, 43%) STOPPED SMOKING (N = 231, 57%) 4 8 12 16 20 Months Following Previous Infarction. 24 From Wilhelmsson, C., Vedin, J.A., Elmfeldt, D., Tibblin, and Wilhelmsen, L., "Smoking and Myocardial Infarction," Lancet j , 415 (1975). - 64 - - 65 - 5. Passive Smoking There i s also the issue of p a s s i v e smoking. Recently the Japanese found that non-smoking wives were at greater hazard from a l l kinds of diseases i f their husbands smoked. Nothing was s a i d about children i n that study but i t seems manifestly evident that i f smok- ing affects a d u l t women i t must a l s o a f f e c t growing c h i l d r e n , at l e a s t as severely. A recent b u l l e t i n from Health and Welfare Canada [1981] further discusses the health e f f e c t s of second-hand smoke. Three recent studies [White and Froeb, 1980], [Hirayama, 1981] and [Trichopoulos et a l . , 1981] provide further evidence that exposure to second-hand smoke ("passive smoking") increases the r i s k of serious health e f f e c t s . This new evidence complements e a r l i e r work which demonstrated increased r i s k of a t t a c k s of angina p e c t o r i s when susceptible persons were exposed to smoky rooms [Aronow, 1 978] and impaired pulmonary function among the children of smokers [Tager et a l . , 1979]. Children brought up i n houses which a l s o contain smoking i) parents must face a higher r i s k of death or i n j u r y by household f i r e s caused by accidents with cigarettes. And there i s the greater r i s k that when the c h i l d grows he/she w i l l smoke. C h i l d r e n l a r g e l y emu- la t e their parents. 6. Programs for Children Finding out how to prevent c h i l d r e n from ever s t a r t i n g to smoke i s the object of a study being undertaken by Dr. A l l e n Best, Chairman of the Health Studies Department of the U n i v e r s i t y of Waterloo [Homemakers1 , July-August 1981]. His research i n v o l v e s 24 - 66 - schools i n the Kitchener-Waterloo and Oxford County a r e a s of Ontario. S t a r t i n g at the Grade 6 l e v e l , before most c h i l d r e n have begun to smoke, he i s attempting to provide a program that w i l l keep them from smoking two or three yeas late r i n l i f e when most c h i l d r e n s t a r t to smoke. Traditional school-based programs have emphasized the long-range consequences of smoking, with f e a r f u l messages about i t s future e f f e c t s . These, he has found, have l i t t l e i n f l u e n c e on either children or adults. Considerations of death and dying and future i l l h e a l t h seem j u s t not to be i s s u e s with k i d s . What i n f l u e n c e s them to s t a r t smoking i s that they see t h e i r f r i e n d s doing i t , they see t h e i r parents doing i t , and a d v e r t i s i n g creates the image that i t ' s the smart thing to do. Their own self-esteem or lack of i t , and going through a rebellious stage, may also influence them. To conteract such strong s o c i a l influences to smoke, Best i s providing what he c a l l s a " s o c i a l innoculation" program sim i l a r to an innoculation program for a physical disease. The children are given a small dose of what may happen to them later on so that when they do get exposed to larger doses i n the r e a l world, they w i l l be immune to i t . They are shown, through discussion, videotapes and role playing, what situations they may encounter and how to cope with them. What i s important says Best, i s the fact that they recognize what i s going on, and practice their reactions i n advance. They a l s o t a l k about the immediate effects of smoking on t h e i r heart r a t e , on how they - 67 - f e e l , and how well they do i n sports. Then, i n f r o n t of the c l a s s , each pupil makes a public commitment about what he or she w i l l do about smoking. Most say that they w i l l never smoke; a few say that they w i l l only experiment. The process not only commits them, but sta r t s to change the s o c i a l norms i n the class, observes Best, as the students r e a l i z e t h a t most of t h e i r classmates are not going to smoke. After the i n i t i a l " i n n o c u l a t i o n " i n Grade 6, students are given "booster shots" i n Grades 7 and 8 c o n s i s t i n g of f u r t h e r d i s - cussion and r o l e p l a y i n g . No one can l i e about whether they are smoking since students give s a l i v a samples, which are tested f o r s a l i v a thiocyanate, a byproduct of smoking. I t works, and the f a c t that the kids believe i n i t works too. At the end of this school year the test and c o n t r o l groups had completed Grade 7. At the time of t h i s r e p o r t few had e x p e r i - mented with smoking, which indicates short-range success. Perhaps the program w i l l need to be continued through high s c h o o l . S i m i l a r programs i n the United States have reduced the students' expected smoking pattern by h a l f . B r i t i s h school children w i l l be persuaded not to experiment with cigarettes through a novel campaign launched by the B r i t i s h Health Education C o u n c i l b u i l t around the character of Superman (Medical Post, February 10, 1981). They w i l l be asked to help i n the f i g h t against smoking, represented by an e v i l new opponent for Superman, Nick O'Teen. - 68 - The campaign with the o v e r - a l l slogan of "never say yes to a cigarette" w i l l cost $1.25 m i l l i o n and i s being mounted because r e - search shows that one i n three of B r i t a i n ' s a d u l t smokers s t a r t e d before they were nine. S t a t i s t i c s a l s o show that 80 per cent of children who smoke go on to be regular smokers when they grow up. The f i g h t between Superman and Nick O'Teen w i l l be f e a t u r e d i n advertisements during c h i l d r e n ' s t e l e v i s i o n programs, and w i l l appear i n children's comics. C h i l d r e n can i n d i v i d u a l l y r e c e i v e a poster and eight-page comic by r e t u r n i n g a s p e c i a l coupon, and primary-school teachers are being asked to p a r t i c i p a t e i n the campaign. The campaign follows a p i l o t p r o j e c t i n 1979 when c h i l d r e n were offered a glossy poster of Superman with the message: "With my amazing X-ray v i s i o n , I can see the harm c i g a r e t t e s do i n s i d e people's bodies. That's why I don't smoke." Over 70,000 requests were received for the poster. A follow-up study showed 94 per cent of children asking for the poster had kept i t , and 68 per cent had displayed i t on their bedroom walls. However, the Health Education Council i s aware the e f f e c t of the campaign i s l i k e l y to be effaced by tobacco a d v e r t i s i n g . "The ubiquitous and a t t r a c t i v e tobacco industry advertising around them i s perpetuating the old, discredited 'glossy' smoking image. We must hope government a c t i o n w i l l continue to erode them," a spokesman sai d . - 69 - 7. Insurance Premium Benefits for Non-Smokers Insurance companies are now recognizing the h e a l t h value of non-smoking, or of smoking cessation, and are using lower premiums as either "reward" or "incentive." For example, one large insurance company offers the following premium r e d u c t i o n s to non-smokers, or those who have kicked the habit, on a $100,000 l e v e l term po l i c y : INITIAL MONTHLY COST IN $ — MALE AGE STANDARD RATE NON-SMOKER 30 24. 32 13. 59 35 31 . 18 15. 82 40 43. 19 19. 60 45 62. 67 29. 46 50 88. 67 42. 08 55 121 . 18 58. 46 60 167. 08 85. 45 64 215. 82 124. 99 In the June 17, 1980 issue of Medical Post there appeared a report by David Beaumont that physicians i n B r i t i s h Columbia want to reward restaurants that set aside areas for non-smoking diners. In a campaign featuring a mailing to 6,000 B.C. h o t e l s and r e s t a u r a n t s , the B r i t i s h Columbia Medical Association (B.C.M.A.) i s offering qual- i f y i n g restaurants a framed award from the President of the B.C.M.A. commending them for promoting a clean environment for customers. - 70 - 8. Rights of Non-Smokers "Inhaling second-hand smoke makes the heart beat f a s t e r , the blood pressure go up and increases the l e v e l of carbon monoxide i n the blood," said B.C.M.A. p a s t - p r e s i d e n t Mel Petreman of Nanaimo. "As doctors concerned with disease prevention as w e l l as cure, we must take a l e a d e r s h i p r o l e i n lowering the in c i d e n c e of smoke- rel a t e d emphysema, bronchitis, lung cancer and heart disease." Increasingly, the p r o t e c t i o n of non-smokers' r i g h t s i s an issue that s t i r s Canadians across the country [Health and Welfare Canada, 1980]. Most smokers and non-smokers, according to t h i s a r t i c l e , are convinced that the l a t t e r are e n t i t l e d to a smoke-free environment. When the arguments i n v o l v e d are considered from a r a t i o n a l , rather than emotional perspective, the outright l e g i t i m a c y and necessity of protecting non-smokers become evident. Thus, c i t i e s such as Ottawa, Toronto, H a l i f a x , Hamilton and others have passed non-smokers' r e l i e f by-laws. On July 22, 1980 the Canadian Council on Smoking and Health submitted to the Minister of National Health and Welfare model l e g i s - l a t i o n to protect the rights of non-smokers. Commonly known as "The Non-Smokers' R e l i e f Act", the proposed b i l l would r e s t r i c t smoking i n publi c areas and buildings under federal j u r i s d i c t i o n . Over the past two decades, M i n i s t e r s of Health and Welfare have p u b l i c l y s t a t e d t h a t smoking was hazardous to Canadians'-health, according to the b u l l e t i n , and that "tobacco smoke i s the source of Canada's No. 1 preventable health hazard." Yet, to date, the only p i e c e of l e g i s l a t i o n on smoking and h e a l t h i s the 1908 Tobacco Restraint Act! The Council stressed that government i n t e r v e n t i o n on t h i s issue i s not only imperative but legitimate. The Act, as submitted by the Council, cannot be seen as an infringement upon I n d i v i d u a l rights since i t goes to great length to respect smokers by p r o v i d i n g for smoking sections, while recognizing i n fact that non-smoking i s now the s o c i a l norm. C. HYPERTENSION Hypertension i s a major cause of s t r o k e , heart f a i l u r e and kidney f a i l u r e . I t i s also a " s i l e n t " health problem: many people with hypertension are unaware t h a t they have i t because they f e e l perfectly w e l l . Hypertension l i t e r a l l y means high blood p r e s s u r e . I t does not mean being i r r i t a b l e , excitable or highly tense. In a l l human beings, blood pressue varies from day to day and from moment to moment. I t r i s e s when we are excited, for example, and i t f a l l s when we rest or sleep. These changes are perfectly normal. However, when blood pressure r i s e s above normal l e v e l s , and stays that way, i t may cause the problems c i t e d above or i t may lead to heart attack. In a small percentage of i n d i v i d u a l s , hypertension can be traced to a specifc disease or c o n d i t i o n . When t h i s c o n d i t i o n i s cured, sometimes through surgery, the hypertension o f t e n disappears as well. However, the most common kind of hypertension i s r e f e r r e d to as "essenti a l " or "primary" hyertension, and at present i t s cause i s unknown. This type of hypertension cannot be cured, but i t can be controlled i n most cases, thus reducing the r i s k of secondary prob- lems, notably of heart attack. - 72 - Despite the lack of firm e t i o l o g i c data on hypertension, i t i s clear that 20 per cent or more of American c h i l d r e n , based on the i r negative l i f e s t y l e , are currently destined to become hyperten- sive adults with perhaps one-third undiagnosed. Preventive programs, encompassing what are known at present to be predisposing factors, as well as focusing on both detection and medical compliance, w i l l be necessary to reduce morbidity and mortality from this disease. According to s t a t i s t i c s found i n Health H i g h l i g h t s 1976-77 [DHEW 1978a], only on e - f i f t h (21%) of the 23 m i l l i o n American hyper- t e n s i v e s are t a k i n g medication on a r e g u l a r b a s i s . More than one-half (54.9%) have not been told by a physician that they have the disease, and the remainder either are not receiving proper treatment, or have stopped taking medication. Hypertension i s more common among blacks than among whites. More than half of a l l blacks between the ages of 55 and 64 years have d e f i n i t e hypertension, compared with less than one-third of a l l whites. Although the prevalence of hypertension increases with age, the problem i s p a r t i c u l a r l y s e r i o u s f o r young black men. One i n seven (13.7%) of the 25-34 age group and nearly one in three (32.0%) of those aged 35-44 years have d e f i n i t e hypertension. Up to age 54, hypertension i s more prevalent among men than among women; a t ages 55-74 i t i s more prevalent among women. In a recent a r t i c l e on heart d i s e a s e , TIME [June 1, 1981] states that one of the most important reasons f o r the drop i n the U.S. death rate from strokes and heart attacks i n the past decade may - 73 - be the aggressive campaign waged by the N a t i o n a l Heart, Lung and Blood I n s t i t u t e and the American Heart A s s o c i a t i o n to detect and tr e a t hypertension. The disease can be diagnosed e a s i l y enough by taking multiple blood pressure readings. Normal i s u s u a l l y around 120/80 mm. of Mercury though the figure may vary widely, depending on the i n d i v i d u a l . The higher number i s c a l l e d s y s t o l i c pressure and refers to the highest pressure reached as the blood pushes against artery walls when the heart c o n t r a c t s and pumps blood; the- lower fi g u r e , the d i a s t o l i c pressure, i s the lower pressure which p r e v a i l s between beats, when the heart i s at r e s t . P e r s i s t e n t measurements over 140/90 mm. of Mercury are needed to establish that a person has hypertension. In the MRFIT program mentioned e a r l i e r [1976] c o n t r o l of hypertension i s c a r r i e d out i n a p r o g r e s s i v e manner. B a s i c a l l y , reduction of s a l t intake and weight loss are implemented f i r s t . I f these hygienic measures alone f a i l to b r i n g hypertension under co n t r o l , a variety of anti-hypertensive drugs are used. D i a s t o l i c blood pressure f e l l i n both groups -- 86.9 mm Hg (mm Hg or m i l l i - metres of mercury i s the usual manner of expressing blood pressure readings) from 92.6 mm Hg i n the usual-care group, compared to 82.3 mm Hg from 92.8 mm Hg i n the special-intervention group of patients. Six general recommendations for the detection, evaluation and treatment of high blood pressure i n adults are given i n the Report of the Joint National Committee [U.S. Dept. of HEW, 1978b]. - 74 - 1 . Any group measuring blood pressure should have resources a v a i l a b l e f o r r e f e r r a l , confirmation, and follow-up. 2. V i r t u a l l y a l l p a t i e n t s with a d i a s t o l i c pressure of 105 mm Hg or greater should be t r e a t e d w i t h a n t i h y p e r t e n s i v e d r u g therapy. 3. For persons with d i a s t o l i c pressures of 90-1 04 mm Hg, t r e a t m e n t s h o u l d be ind i v i d u a l i z e d with consideration given to other r i s k factors. 4. The evlauation of patients with high blood pressure can be limited to a few b a s e l i n e tests i n most instances. 5. The stepped-care (medication) approach outlined i n the report i s advocated as a c o s t - e f f e c t i v e method of t r e a t i n g most patients. 6. Treatment of p a t i e n t s w i t h h i g h b l o o d pressure includes plans f o r f a c i l i t a t i n g long-term maintenance of blood pressure c o n t r o l . D. EXERCISE I t i s no secret that the general standard of p h y s i c a l f i t - ness i n Canada i s shocking when compared to that seen i n Northern European countries. There has been something of a re-awakening of in t e r e s t i n physical f i t n e s s , but i t i s mostly among young people and, i f anything, i s spotty, according to an e d i t o r i a l i n Medical Post, [September 26, 1978]. Of course there are explanations. Television tends to make spectators of us a l l , including the, young. The easy a v a i l a b i l i t y of the family car causes cries of pain at the prospect of a walk of even a block or two. And when school sports enter the p i c t u r e they are \ - 75 - l i t t l e more than extensions of the play-time r e c e s s . Many p u b l i c schools have few f a c i l t i e s . Even when they do, requirements are often minimal. Ontario, f o r example, r e q u i r e s that two 30-minute periods of physical education be given a week between kin d e r g a r t e n and Grade 8 — hardly a program to b u i l d sturdy bodies. A f t e r Grade, 8 there i s absolutely no requirement a t a l l ! Very o f t e n p h y s i c a l education policy i s l e f t to each school board and sometimes to the school p r i n c i p a l . The Canadian Medical Association and i t s p r o v i n c i a l counter- parts have taken i t on themselves to press governments to provide more physical and health education. In Manitoba, f o r exmaple, the Manitoba Medical Association (M.M.A.) i s pressing for a l l children i n that province to be provided with a d a i l y 30-minute p h y s i c a l educa- t i o n and training period. In an a r t i c l e i n the Vancouver Sun (July 26, 1978), Dr. E r i c Bannister, Chairman of the Department of Kinesiology at Simon Fraser University, states that corporations, business and industry must take d i r e c t r e s p o n s i b i l i t y for th e i r employees' health. At the same time, federal and pr o v i n c i a l governments must back the e f f o r t through tax write-offs for buildings and f a c i l i t i e s provided f o r s t a f f e x e r c i s e programs. Bannister s t a t e s , " t h i s w i l l cost l e s s than the $5.2 b i l l i o n l o s t i n 1977 through absenteeism and sick pay." Dr. Roy Shephard of the University of Toronto has stated that moderate exercise training can set back the deterioration of physio- l o g i c a l work capacity by almost nine years [Medical Post, March 24, - 76 - 1981]. This contribution to l o n g e v i t y by e x e r c i s e i s achieved by increasing the cardiovascular reserve, decreasing hypertension, obe- s i t y , and serum l i p i d s . S p e c i f i c a l l y , r e g u l a r e x e r c i s e can reduce the re s t i n g heart rate and increase the maximum oxygen capacity. Some large corporations are already involved i n the trend to i n d u s t r i a l f i t n e s s programs. In the United S t a t e s , General Motors has spent $825 m i l l i o n on an employee h e a l t h program, more than i t spends each year to buy s t e e l from i t s p r i n c i p a l supplier. Xerox has a country f i t n e s s r e t r e a t . A few Canadian companies — most notably Labatt's i n London and James Richardson and Sons i n Winnipeg -- have "whipped up" employee enthusiasm and given them a place to work i t out. In V i c t o r i a , Gordie Stewart co-ordinates a program f o r govern- ment employees and a t t r a c t s about 400 r e g u l a r s . F i n n i n g T r a c t o r ' s noonhour sessions a t t r a c t about 50 of 350 employees who could possib- l y attend. B.C. Telephone has started a f i t n e s s centre at i t s Bound- ary Road headquarters, while I.C.B.C., the Royal Bank and a few other companies h e l p pay f o r what i t costs employees to j o i n k e e p - f i t classes at the YMCA. In the United States, at least one insurance company, O c c i - dental L i f e , o f f e r s substantial discounts to "serious runners." To apply, according to the advertisement, "You simply must not smoke and must have run a minimum of three times per week -- 20 minute dura- tions — over the l a s t 12 months." They claim that the premium p r i - c ing recognizes " f i t n e s s age" rather than c h r o n o l o g i c a l age. D i s - counts range up to 15 per cent (or more) off a l l whole l i f e insurance plans. - 77 - Exercise i s one of the l i f e s t y l e f a c t o r s t h a t has become q u i t e "popular" i n the l a s t few years. In s p i t e of t h i s , the controversy surrounding i t s benefits i n decreasing the l i k e l i h o o d of developing CHD, s t i l l rages on. In the t e x t by Rapaport [1980], there i s a presentation by Albert Oberman, who takes the a f f i r m a t i v e position, and one by Oglesby Paul, taking the negative. Noting good arguments by both authors, Rapaport, as editor, makes the f o l l o w i n g observations. F i r s t , he points out, there i s no evidence that exer- cise among the general public without CHD i s seriously detrimental to health. Although certain musculoskeletal problems have surfaced due to jogging programs, these have not been of l i f e - t h r e a t e n i n g or serious consequence. Second, i t i s also clear that those who engage i n r e p e t i t i v e exercise enjoy psychological b e n e f i t s as w e l l as im- proved physical conditioning. Thus, Rapaport maintains, i t appears to be prudent advice to recommend exercise to the general p u b l i c as part of a better, healthful way of l i f e . He b e l i e v e s that everyone should be engaging i n those kinds of e x e r c i s e that each enjoys. A person should be encouraged to do the kinds of a c t i v i t i e s and sports that give him pleasure, help him relax and forget the mental stresses of d a i l y l i f e , and improve his physical c o n d i t i o n i n g . However, i t does not seem j u s t i f i e d , i n his opinion, to coerce the p u b l i c i n t o this type of program based upon the assertion that p a r t i c i p a t i o n i n such a program w i l l reduce the l i k e l i h o o d of subsequent CHD. - 78 - Other authors, however, have more d e f i n i t e o p i n i o n s . Vickery [1978] maintains that exercise may w e l l be the s i n g l e most important thing one can do i f one wants to l i v e a long and healthy l i f e . He says that while exercise has a wide v a r i e t y of b e n e f i c i a l e f f e c t s , the most remarkable are i n the prevention of heart d i s e a s e . To quote Vickery, "The message i s clear: when i t comes to protecting your heart, there i s no substitute for exercise." E. STRESS According to Glass [1977], the interaction between psycholo- g i c a l and physiological variables indicates that attempts by Type A i n d i v i d u a l s to master uncontrollable s t r e s s f u l events may be a s s o c i - ated with coronary heart disease. Such events may i n c l u d e job d i s - s a t i s f a c t i o n s , economic f r u s t r a t i o n , and excessive work and respon- s i b i l i t y . I t seems to be generally agreed that s t r e s s can c o n t r i b u t e to coronary disease through the body's general r e a c t i o n s to averse stimulation. Such stimulation leads to discharges i n the sympathetic nervous system and to production of related hormones such as adrena- l i n and noradrenalin. These hormonal substances, c a l l e d c a t e c h o l a - mines, can accelerate the rate of a r t e r i a l damage and induce myocar- d i a l lesions. Glass goes on to p o i n t out that these hormones can also potentiate the aggregation of blood p l a t e l e t s , and the r e l e a s e of p l a t e l e t contents i s considered to be an important f a c t o r i n atherogenesis as well as i n the genesis of thrombosis. - 79 - There i s some evidence i n d i c a t i n g that c l i n i c a l and psycho- pharmacologic techniques may prove e f f e c t i v e i n depressing Type A behaviour. For example, Sigg [1974] suggests that the administration of psychotropic drugs of the sedative type might reduce emotional and muscular tension c h a r a c t e r i s t i c of Pattern A i n d i v i d u a l s . Sigg a l s o proposes that beta-adrenergic receptor blocking agents may be u s e f u l i n a program designed to a l t e r ways i n which coronary-prone persons cope with psychosocial stress. Since the catecholamines appear to figure i n the Type A response to uncontrollable stressors, a s p e c i f i c blockade of beta receptors by propranolol-type drugs seems a p p r o p r i - ate. A number of non-drug methods of a l t e r i n g Type A have a l s o been suggested. These include transcendental meditation, r e l a x a t i o n e x e r c i s e s , biofeedback, and b e h a v i o u r m o d i f i c a t i o n and group therapy. The controversy surrounding Type A behaviour as being an i n - dependent r i s k factor for coronary heart disease i s h i g h l i g h t e d i n a recent text by Rapaport [1980]. The views of the proponent, Meyer Friedman, and the opponent, Jeremiah Stamler, are both presented i n d e t a i l with a comment by the e d i t o r . Friedman admits t h a t d e s p i t e the widespread confirmation of most of the studies he conducted with Rosenman r e l a t i n g Type A behaviour to the prevalence and incidence of CHD, there s t i l l remain i n v e s t i g a t o r s who are r e l u c t a n t to accept such a r e l a t i o n s h i p . He quotes K l e i n who, i n reviewing the 1974 Rosenman and Friedman book on Type A behaviour, wrote, - 80 - "When the history of the pandemic of ischemic heart disease i s w r i t t e n . . .one f a c t w i l l stand c l e a r . The gap between medicine and p s y c h i a t r y has h i n d e r e d r e c o g n i t i o n and research of the behavioural and psychosomatic aspects of the disease." He concluded that the i r work on Type A behavour and i t s r e l a t i o n s h i p to CHD w i l l seem " l i k e a voice crying i n the wilderness." Friedman asks i f no attempt should be made to a l t e r or modi- fy Type A behaviour pattern u n t i l i t s causal role i n c l i n i c a l CHD i s established beyond a l l possible c r i t i c i s m . Irrespective of the data accumulated i n the future, i t may s t i l l take a long time to convince a l l c a r d i o l o g i s t s of the pathogenic importance of the Type A be- haviour pattern. In this connection Friedman reminds us of a comment by the distinguished p h y s i c i s t who once declared that new concepts rarel y get accepted by r a t i o n a l persuasion of the opponents. He be- lieved that sometimes one simply has to wait u n t i l the opponents d ie out. Friedman, himself, has found i t very d i f f i c u l t to a l t e r Type A behaviour i n any person who has not succumbed to the c l i n i c a l onset ( i . e . , angina pectoris or in f a r c t i o n ) of CHD. He b e l i e v e s , there- fore, that behaviour modification might most p r o f i t a b l y be confined to Type A behaviour persons who have already suffered from and sur- vived a myocardial i n f a r c t i o n . He claims that approximately 75 per cent of these persons are susceptible to behaviour modification. Stamler, on the other hand, points out that although "modern stress" factors play some role i n the pathogenicity of CHD along with other accepted f a c t o r s , they are not "key" f a c t o r s i n the modern - 81 - epidemic. In his summary, Stamler [1980] makes the two following statements: 1. "The available data are s u f f i c i e n t to charac- t e r i z e Type A behaviour pattern as a p o s s i b l e or probable r i s k factor for epidemic CHD, but they are not yet s u f f i c i e n t to meet a l l the c r i t e r i a necessary to designate i t as a f u l l y e s t a b l i s h e d major r i s k f a c t o r a l o n g w i t h " r i c h " d i e t , hypercholesterolemia, hyperten- sion, and cigarette smoking. 2. Any implication that Type A behaviour i s the "key" factor i n the genesis of the modern CHD epidemic i s unfounded i n data and f a l l a c i o u s i n reasoning." Rapaport, i n his comments on the two p r e s e n t a t i o n s , agrees that cardiologists have been slow to accept Type A behaviour as a r i s k factor i n the development of CHD. However, i n defence of the c a r d i o l o g i s t , he points out that i t i s hard to accept a concept that i s d i f f i c u l t to measure qu a n t i t a t i v e l y . He feels that the results of Friedman and Rosenman's ef f o r t s to modify Type A behaviour and, thus, a f f e c t CHD by r i s k factor intervention w i l l be of paramount i n t e r e s t . He points out that the reduction of approximately 25 per cent i n mor- t a l i t y from CHD over the past decade probably r e f l e c t s improvements i n the medical and s u r g i c a l management of c l i n i c a l CHD on the one hand, and the results of t r a d i t i o n a l r i s k - f a c t o r intervention on the other. However, although this intervention through p u b l i c and pro- f e s s i o n a l education has been successful i n contributing to a lowering of CHD mortality, i t s e f f e c t on the prevalence of CHD i s , u n f o r t u - nately, unknown. Rapaport f e e l s t h a t i f the work of Friedman and - 8 2 - Rosenman i s borne out with f u r t h e r study, and i f behaviour can be successfully modified as well, then we can hopefully look forward to further exploitation of the inroads that have led to the rec e n t , en- couraging decline i n CHD mortality. If not, Type A behaviour w i l l be relegated to those unmodifiable c a t e g o r i e s such as age and f a m i l y h i s t o r y . F. FINDINGS AND RECOMMENDATIONS 1. Improving Health — General The prospects for improving health through reducing r i s k fac- tors have reached the point where i t i s possible to project a s y s t e - matic approach, according to Breslow and Somers [1977] i n t h e i r a r t i c l e on a l i f e t i m e health monitoring program. Such an approach involves selecting for each nodal period of human growth and d e c l i n e -- pregnancy, infancy, childhood, adolesence, young and l a t e r a d u l t periods — the p a r t i c u l a r r i s k factors about which something can be done to improve the lik e l i h o o d of present and future health. This i s d i f f e r e n t from the "annual check-up" of an e a r l i e r day i n that a ser- ious e f f o r t i s made to select the periods as well as the physical and counselling procedures which the evidence indicates carry the gr e a t - est p o t e n t i a l . Similar approaches are known by a v a r i e t y of terms: multiphasic health testing, health hazard appraisal, "Know Your Body" program. The common thread i s recognition that prudent i n t e r p r e t a - t i o n of available evidence creates the o p p o r t u n i t y f o r a t r u l y new thrust i n preventive medicine. We need no longer r e l y exclusively on - 83 - immunization against certain communicable diseases but can now extend prevention to attack several forms of cardiovascular disease, cancer and other major diseases of our e r a . That i s the s i g n i f i c a n c e of current prospects for improving h e a l t h through reducing r i s k f a c - t o r s . In the meantime, i t i s possible to assemble the present per- tinent data and base immediate action on prudent i n t e r p r e t a t i o n of that data. With the growth of evidence about r i s k f a c t o r s , and i n the face of the tremendous premature m o r t a l i t y and mo r b i d i t y i n - v o l v e d , i t has become a p u b l i c h e a l t h duty to seek s y s t e m a t i c , r a t i o n a l application of available means for c o n t r o l l i n g r i s k factors. The f a c t that information i s rap i d l y accumulating and that more i s needed does not excuse us from doing what we already can do with rea- sonable effectiveness. When top executives are under too much str e s s , i t costs their companies b i l l i o n s of d o l l a r s a year, according to Gerald F i s h e r , President of the Centre for Organization Development i n Rochester, New York [1978]. He cited a survey showing that heart a t t a c k s , many of them related to stress on the job, c o s t more than $26 b i l l i o n a year i n d i s a b i l i t y payments and medical b i l l s . F i s h e r a l s o pointed put that t h i s does not include the costs of poor decisions that might have been made before those attacks, nor the loss the company suffers when a key executive i s absent. 2. Prevention for the Young Preliminary data from the sample of 3,000 11- to 14-year o l d public school children i n the study by Williams ejt al_. [1 977] i n d i - - 84 - cate that about 40 per cent have one or more r i s k f a c t o r s f o r coro- nary heart disease (overweight, elevated c h o l e s t e r o l , c u r r e n t c i g a - r e t t e smoker, poor p h y s i c a l f i t n e s s , h y p e r t e n s i o n , or d i a b e t e s ) . Inclusion of family history as a r i s k factor increases t h i s percen- tage. Morrison et a l . [1980] consider family h i s t o r y to be a prac- t i c a l t o o l for i d e n t i f i c a t i o n of r i s k f o r coronary heart d i s e a s e , hypertension, stroke, and diabetes. They f e e l that s e r i a l r i s k f a c - tor measurements i n children from CHD-, hypertension-, s t r o k e - , and diabetes-positive families should be useful i n the early r e c o g n i t i o n and documentation of coronary heart disease f a c t o r l e v e l s which, i n turn, should f a c i l i t a t e primary intervention designed to ameliorate or prevent the development of CHD. I t would appear that, i n the view of these investigators, the roots of atherosclerosis, certain cancers, and stroke begin i n c h i l d - hood, and that i n many cases these "roots" are related to our person- a l habits and s t y l e of l i v i n g . Adult h a b i t s are u s u a l l y much more d i f f i c u l t to change than the same habits i n younger people, p a r t i c u - l a r l y those related to smoking [Botvin et a l . , 1 980], o v e r n u t r i t i o n [Glanz, 1980], i n a c t i v i t y , and health maintenance i n g e n e r a l . Pre- ventive l i f e s t y l e patterns acquired early i n childhood are the pre- ferred a l t e r n a t i v e . Because the family l i v e s together, eats together, e x e r c i s e s together, and sometimes smokes together, primary prevention must also be family oriented. The most e f f i c i e n t v e h i c l e f o r such a program may be the school system, since this i n v o l v e s almost a l l c h i l d r e n , - 85 - their parents and educators, and can be geared to teach the healthy l i f e s t y l e concepts which are e s s e n t i a l for prevention. A l s o i t can take advantage of important peer pressure phenomena, which have been found to be e f f e c t i v e i n anti-smoking and o b e s i t y c o n t r o l programs based i n the schools. Elementary school children i n C a l i f o r n i a are the focus of a project aimed at preventing c a r d i o v a s c u l a r d i s e a s e . The p r o j e c t , "Heartland" i s , according to an a r t i c l e i n the July 28, 1981 issue of Medical Post, a preventive health program designed to persuade young- s t e r s to avoid the r i s k f a c t o r s a s s o c i a t e d with c a r d i o v a s c u l a r disease — poor n u t r i t i o n , smoking, and lack of exercise. Developed by the University of Southern C a l i f o r n i a ' s Schools of Medicine and Education, and funded by the American Heart A s s o c i a - t i o n , the program i s expected to help reduce c a r d i o v a s c u l a r disease rates. According to Dr. Eric Kosower, project director: "Heartland provides students with the know- ledge and decision-making s k i l l s necessary to reduce heart disease i n t h e i r f u t u r e . The c u r r i c u l a are designed not j u s t to present facts about the importance of r i s k f a c t o r s to heart disease, but, more i m p o r t a n t l y , to motivate students and t h e i r families to assume r e s p o n s i b i l i t y for their own health and w e l l - being." The project materials, which include f i l m s t r i p s , a c t i v i t y sheets and cartoon-like characters,' are divided into a kindergarten through third-grade program and a fourth-through-sixth grade program. - 86 - The early elementary students become comfortable w i t h words l i k e " c a p i l l a r i e s " and "stethoscope", and pa r t i c i p a t e i n p r a c t i c a l a c t i - v i t i e s l i k e l i s t e n i n g to each others' heartbeat, counting pulse beats before and aft e r exercise, and planning healthful menus. The upper elementary program explains more complex aspects of cardiovascular health, including hypertension and blood pressure mea- surement, the theory behind a balanced d i e t , computation of i d e a l weight, heart s t r u c t u r e and f u n c t i o n , and the concept of c a r d i o - pulmonary re s u s c i t a t i o n . Another important p a r t of the upper e l e - mentary program i s a campaign against smoking. Students l e a r n , for example, of the greater r i s k of death from heart disease that smokers carry. According to Dr. Kosower, the long-range goal of the p r o j e c t i s to cut down on cardiovascular disease. The he a l t h p r o f e s s i o n a l s involved expect the Heartland project to reduce the rates. Primary prevention of heart d i s e a s e , c e r t a i n cancers, and strokes has been demonstrated (KNOW YOUR BODY PROGRAM) to be an es s e n t i a l and re a d i l y adoptable component of a comprehensive school health program. By combining screening for disease r i s k f a c t o r s , giving children their r e s u l t s i n a Health Passport, and p r o v i d i n g innovative l e a r n i n g a c t i v i t i e s i n a he a l t h education c u r r i c u l u m , children can be motivated to assume r e s p o n s i b i l i t y for t h e i r own future health and modify t h e i r l i f e s t y l e s so as to reduce r i s k of disease. The i n i t i a l phase of a p i l o t program encompassing these concepts (the KNOW YOUR BODY PROGRAM) has demonstrated that t h i s approach to primary prevention of chronic d i s e a s e i s welcomed en t h u s i a s t i c a l l y by students, parents, and educators. CHAPTER I I I EDUCATIONAL PROGRAM PROPOSALS FOR THE PREVENTION OF CORONARY HEART DISEASE "Tomorrow's solutions to cardiovascular diseases w i l l be extensions of today's p a r t i a l answers. Since many predispos- ing factors are known, the way i s a l - ready open to prevention, p a r t i c u l a r l y through early detection programmes and the wider application of health educa- t i o n . . .Prevention, t h e r e f o r e , w i l l require an awareness of the problems, followed by a conscious choice on the p a r t of the i n d i v i d u a l . To promote awareness, health education programmes i n schools, f a c t o r i e s , and other places of work, as well as v i a the mass media, w i l l emphasize healthy n u t r i t i o n and the a c t i v e use of l e i s u r e time, i n - c l u d i n g s p o r t , not as an o c c a s i o n a l means of escape but as an i n t e g r a l part of everyday l i f e . The d r i v e to reduce cigarette smoking w i l l further help to prevent cardiovascular disease." [Selby, 1974, p.6] A. INTRODUCTION With improvements i n medical care and t h e i r wide d i f f u s i o n under universal health insurance i n Canada, we now have a s i t u a t i o n where increases i n medical care appear to contribute only m a r g i n a l l y to health. There i s no reason to b e l i e v e that the c u r r e n t h e a l t h problems of Canadians would be s i g n i f i c a n t l y a l l e v i a t e d by increases i n the numbers of hospitals or p h y s i c i a n s . Some p r o v i n c i a l h e a l t h reports, as well as the Lalonde Report, demonstrate growing govern- mental awareness of the fact that expenditures f o r personal h e a l t h services contribute only small and decreasing marginal b e n e f i t s to health. - 87 - - 88 - Growing disenchantment with the escalating costs of personal health services would suggest the need f o r new programs of preven- t i o n , research, environmental control, health promotion, and h e a l t h education. Unfortunately, the various p r o v i n c i a l governments, as w e l l as the Federal government, seem to be u n w i l l i n g to spend more money on health. I f the new programs suggested above are to be im- plemented, tradeoffs w i l l probably have to be made, since new pro- grams w i l l i nevitably require developmental and start-up funds. Tradeoffs impose the need to d e a l with a number of p o l i t i - c a l l y charged areas. Changes, such as those suggested above, require a number of p o l i t i c a l decisions which may prove unpopular, and w i l l probably be opposed by people i n general as w e l l as by pressure groups that may be o r i e n t e d toward the present system of disease treatment. Governments find i t extremely d i f f i c u l t to make p o l i t i c a l decisions i n areas where they perceive the existence of resistance to change. However, i t i s possible to believe that the same forces that brought our present system of medical care into being could be chan- neled to bring about the necessary tradeoffs so that a comprehensive program of disease prevention could be developed. We could then move from a disease-oriented system of care to a health-oriented one. For example, instead of building new hospitals with acute beds, the same funds could be diverted into the educational system to t r a i n h e a l t h educators. Vayda [1977] f e e l s that a growing disenchantment with the e f f i c a c y and cost of personal health s e r v i c e s was one stimulus f o r - 89 - the Lalonde Report which suggests the need for new programs of pre- vention, research, environmental c o n t r o l and h e a l t h promotion. If these new programs are proposed at the same time that l i m i t a t i o n s on additi o n a l expenditures are contemplated, i t f o l l o w s , according to Vayda, that new programs must be at the expense of old ones. B. SCHOOL SYSTEMS If our health care system i s to emphasize disease prevention, a program of health education w i l l have to be developed to educate people to be concerned about t h e i r h e a l t h when they are w e l l , and not, as i s usually the case, only when they become i l l . New a t t i - tudes are needed to encourage the public to p a r t i c i p a t e a c t i v e l y i n preventive programs. The task of health education i s not merely to provide information but to cu l t i v a t e people's sense of r e s p o n s i b i l i t y towards t h e i r own health and that of t h e i r community. Many people may f i n d i t d i f f i c u l t to change their attitudes or behaviour, and may even become confused or ho s t i l e when health education makes demands that seem incompatible with their chosen way of l i f e . In order to resolve t h i s c o n f l i c t and get the message ac r o s s , some changes are needed i n the techniques and psychology of health education. 1 . Parental Influences As children form an important t a r g e t group f o r e d u c a t i o n a l programs, parents should be taught to provide h e a l t h education from the e a r l i e s t age. Ideally, parents should enhance the o p p o r t u n i t i e s for t h e i r children's health by f o s t e r i n g healthy personal. h a b i t s . - 90 - Acquiring healthy eating and exercise h a b i t s i n childhood may have l i f e l o n g b e n efits. An appropriate balance of food intake and p h y s i - c a l a c t i v i t y promotes normal weight. Excessive i n t a k e of s a l t , sugar, and f a t s should be avoided. Parents can emphasize these points through personal example. Preparing young children for peer group pressures with r e - gard to smoking, alcohol use, drug use, and sexual a c t i v i t y can en- hance their a b i l i t y to deal with these pressures l a t e r . Parents are essential to the provision of comprehensive h e a l t h education which can help children to acquire s k i l l s to cope with problems they w i l l confront as teenagers. 2. School Influences Compulsory and systematic programs of health education should be incorporated i n t o school c u r r i c u l a , covering such topics as n u t r i - t i o n , smoking, dental hygiene, e x e r c i s e , drugs, and sexual a c t i v i - t i e s . Governments w i l l i n e v i t a b l y be i n v o l v e d i n h e a l t h education, with the Ministry of Education being r e s p o n s i b l e f o r planning and co-ordination on a p r o v i n c i a l , or i d e a l l y , a n a t i o n a l l e v e l of t e a - cher education and school programs. One of the f i r s t p r i o r i t i e s w i l l be to "create" health educators. The current s i t u a t i o n seems to be a "chicken and egg" one where student teachers are not being taught health education, and at the same time, no p r o v i s i o n i s made i n the schools for teaching health education. The present system s p l i t s the r e s p o n s i b i l i t y among several teachers, e.g., physical education, home economics, science, counsellors, school nurse, etc. However, nobody - 91 - i s responsible for putting i t a l l together into a comprehensive pro- gram. With the emergence of health educators, programs w i l l be de- veloped for a l l levels of education, taking i n t o account the a t t e n - t i o n span of the younger pupils as well as the l e v e l of comprehension of a l l students. Programs should take into account peer pressures at the d i f f e r e n t age l e v e l s , and should be t a i l o r e d so that negative pressures are neutralized at l e a s t as much as possible. Every e f f o r t should be made to create i n t e r e s t and encourage p a r t i c i p a t i o n i n the programs. One of the more valuable ways to upgrade students' aware- ness and i n t e r e s t i n p o s i t i v e h e a l t h care i s through the use of health promotion f i l m s . These films should help the student to em- pathize with the "characters" and situations shown i n the f i l m s . The aim of t h i s e d u c a t i o n a l t o o l i s to make the students r e a c t i n a thoug h t f u l and r e s p o n s i b l e way to the messages contained i n the f i 1ms. Because there are bound to be geographic as well as f i n a n c i a l constraints, elementary grades i n larger schools, and even a l l grades i n smaller r u r a l schools could use teachers who have had h e a l t h edu- cation t r a i n i n g so that they would be b e t t e r equipped to cover the sub j ect. Health education i n the schools should s t a r t a t the pre- school l e v e l , or kindergarten, and continue through elementary and high school. I t should also be made available at the u n i v e r s i t i e s . The u n i v e r s i t i e s ' F a c u l t y of Education w i l l have the u l t i m a t e - 92 - r e s p o n s i b i l i t y for t r a i n i n g the health educators with input from the Faculties of Medicine, Dentistry, Physical Education, Nursing, Phar- macy, Home Economics, Social Work and possibly others. 3. Measurement and Evaluation There i s also a need to develop evaluation methods for deter- mining the effectiveness of these programs, and to measure such var- i a b l e s as knowledge, atti t u d e s , and behaviour change, i n a d d i t i o n to determining the e f f e c t on morbidity and mortality from coronary heart disease. According to Williams et a l . [1980], e v a l u a t i o n of a h e a l t h education program may be made on several l e v e l s . If knowledge change precedes attitude change which precedes behavioural change which, i n turn, may r e s u l t i n c l i n i c a l l y measurable physiologic changes, then one may evaluate educational e f f e c t i v e n e s s at a l l of these l e v e l s . While behaviour change may not be demonstrated w i t h i n one or two years, i f cognitive and a t t i t u d i n a l changes have occurred behavioural change may occur i n the future. In t h i s study, the h e a l t h h a b i t s survey of s e l f - r e p o r t e d health behaviour, by means of a health knowledge questionnaire, i n i - t i a l l y focused only on cigarettes and alcohol. This has been expand- ed to include d i e t , exercise, s t r e s s , and family history i n order to develop a more comprehensive and balanced a p p r a i s a l . P r e l i m i n a r y v a l i d a t i o n of students' self-reported cigarette smoking behaviour by measuring plasma cotinine levels has shown a high degree (>95%) of agreement. - 93 - C. THE MARKETPLACE 1. Occupational As was indicated e a r l i e r i n t h i s t h e s i s , some c o r p o r a t i o n s have already made f a c i l i t i e s available for those employees who desire to p a r t i c i p a t e i n e x e r c i s e programs, i n p a r t i c u l a r . However, to date, most corporate programs are not comprehensive and only o f f e r a p a r t i a l answer to those who wish to a l t e r t h e i r l i f e s t y l e s to the optimal extent. Ideally, the larger business o r g a n i z a t i o n s should employ a f u l l - t i m e health educator whose r e s p o n s i b i l i t i e s would en- compass program development as well as education. Most corporations require employees to undergo a medical ex- amination of some sort (usually s u p e r f i c i a l ) . I f t h i s i s s e t up to uncover certain r i s k factors as well as to determine p h y s i c a l f i t - ness, the prospective employee would a t l e a s t have the knowledge necessary to make an informed decision re personal l i f e s t y l e m o d i f i - c a t i o n . He/she could then e n r o l l and p a r t i c i p a t e i n the appro p r i a t e company program. An al t e r n a t i v e to "in-house" programs would be the a v a i l a b i - l i t y of s i m i l a r programs i n a f a c i l i t y such as the YMCA. As an em- ployee benefit, the p a r t i c i p a t i n g company would pay the annual mem- bership fee. These programs should not only be a v a i l a b l e to top executives of the corporation, but to a l l employees. P a r t i c i p a t i o n should be v o l u n t a r y , but i n c e n t i v e s could be o f f e r e d t o those employees who pa r t i c i p a t e on a regular basis. - 94 - Rapid advances w i l l be seen i n occupational h e a l t h l a r g e l y because economic considerations, such as greater e f f i c i e n c y and r e - duced costs of absenteeism, w i l l motivate employees and governments to p a r t i c i p a t e a c t i v e l y i n preventive measures and i n the improvement of working conditions. Where companies provide "in-house" f a c i l i t i e s such as gymnasia, locker rooms, showers, etc., tax write-offs for the cost of building and maintaining these f a c i l i t i e s should be allowed by Revenue Canada. The work environment should make a v a i l a b l e a l l of those f a c i l i t i e s necessary for the well-motivated employee to p a r t i c i p a t e i n positive l i f e s t y l e behaviour. 2. Consumer Aspects Industry can be involved i n preventive programs i n other ways as we l l . The food processors, for example, could produce, promote and s e l l n u t r i t i o u s products as e a s i l y and as s u c c e s s f u l l y as they now do with less desirable products. Reducing the s a l t , sugar, and/ or animal, f a t content of many commercially available foods would cer- t a i n l y not render them inedible as less harmful agents could be sub- s t i t u t e d i n many cases. Company-run cafeterias should o f f e r n u t r i - tious and well-balanced meals at reasonable prices. According to Wilbur e t a l . [1981], many h e a l t h o f f i c i a l s c i t e the use of vending machines as a c o n t r i b u t o r to f o o d - r e l a t e d health problems l i k e obesity. The authors are of the o p i n i o n that die t - r e l a t e d health promotion, therefore, requires greater co-opera- t i o n between public health agencies and private industry. They des- - 95 - cribe a co-operative program which was undertaken by the N a t i o n a l Heart, Lung, and Blood I n s t i t u t e with the N a t i o n a l Automated Mer- chandisers Association. The primary o b j e c t i v e was to i n v e s t i g a t e whether lower-calorie snacks would be a t t r a c t i v e to customers. The results strongly support the position that l o w e r - c a l o r i e vending items can s e l l c o m p e t i t i v e l y with r e g u l a r - c a l o r i e items. The most prominent f i n d i n g i s the tremendous impact of p r o d u c t a v a i l a b i l i t y . Where ava i l a b l e , lower-calorie items assumed a l a r g e proportion of s a l e s . This may r e f l e c t the f a c t t h a t many lower- c a l o r i e items, per se, are not unappealing to most consumers. Pro- duct recognition, taste, and product s a t i s f a c t i o n p l a y a prominent r o l e i n guiding food selections i n addition to good health c o n s i d e r - ations. The study also showed that well-designed "point of purchase" n u t r i t i o n materials w i l l a t t r a c t attention, a necessary p r e r e q u i s i t e for any education endeavour. As n u t r i t i o n education moves from the classroom into the mainstream where food d e c i s i o n s are made, p l e a - sant, engaging, and upbeat materials become important v e h i c l e s f o r d e l i v e r i n g n u t r i t i o n information e f f e c t i v e l y . 3. Public Space The Canadian C o u n c i l on Smoking, M i n i s t e r s of Health and Welfare, the Medical Associations, as well as numerous authors, have discussed the r i s k s associated with cigarette smoking for the smoker. Of equal importance, according to more recent evidence, i s the prob- lem of second-hand smoke, or "passive smoking" as d i s c u s s e d e a r l i e r - 96 - i n the thesis. Non-smokers i n public places should at le a s t have the r i g h t to be protected, by l e g i s l a t i o n i f necessary, from the effects of this pollutant i n view of the proven r i s k . D. GOVERNMENT'S ROLE 1. As a Source of Information "The Government's function i n hea l t h education i s to enable people to make sound decisions about t h e i r h e a l t h , to equip them with the informat i o n and s k i l l s as well as other resources needed to t r a n s l a t e these d e c i s i o n s i n t o action, and to aid i n the remov- a l of l e g a l , economic, p h y s i c a l , or other b a r r i e r s t h a t might p r e v e n t them from a c t i n g a c c o r d i n g l y . I t should be understood t h a t as f a r as government actions are concerned the proposals are intended solely to pro- vide opportunities and incentives for people to assume f u l l "responsibi l i t y for their own health." [Cooper, 1977] People have a r i g h t to know about the effects on their health of the kinds and amounts of food they eat, of overmedication, and the benefits of non-smoking, regular exercise, and moderation i n a l c o h o l consumption. To f u l f i l l these r e s p o n s i b i l i t i e s a health education program must be comprehensive, w i t h i n the l i m i t s of our knowledge of the li n k s between behaviour and health, or disease, as the case may be. I t must maintain the support of ^the entire population as w e l l as the - 97 - affected groups, i . e . , those "at r i s k " , and i t must ensure the active p a r t i c i p a t i o n of the l a t t e r , at l e a s t , i n program and p o l i c y design. To be successful, h e a l t h education s t r a t e g i e s must i n c o r - porate what i s now known about the " r i s k f a c t o r " determinants of coronary h e a r t d i s e a s e . They should a l s o attempt to n e u t r a l i z e s o c i a l and economic influences on people's l i v e s which discourage hea l t h f u l change. Health education programs should be designed to encourage s p e c i f i c changes i n health behaviour and to provide the i n d i v i d u a l with the opportunity to acquire the techniques or s k i l l s needed to bring about and maintain that change. The task i s to make i t easier for people to follow h e a l t h f u l practices and less desirable to choose unhealthful behaviour. Even the most e f f e c t i v e d i e t education message i s blunted f o r the c h i l d growing up where junk foods are e a s i l y obtained, and where, i n some cases, they are used as treats or rewards. S i m i l a r l y , where smoking i s made to appear c u l t u r a l l y acceptable, e i t h e r s o c i a l l y or by the media, the task of health education may be overwhelming unless the program design includes steps to counter these influences. Since most unhealthful p r a c t i c e s are not d i s e a s e - s p e c i f i c , preventive education programs should concentrate on modifying those p r a c t i c e s , such as smoking, o v e r e a t i n g or e x c e s s i v e a l c o h o l consumption, which lead to d i s e a s e , r a t h e r than on any s p e c i f i c disease i t s e l f . - 98 - 2. In Decision Making and L e g i s l a t i o n (a) Public Education. Each l e v e l of Government, not o n l y c o n s t i t u t i o n a l l y , but morally as well, has a r e s p o n s i b i l i t y to p r o - vide the means f o r the p u b l i c to a t t a i n a " h e a l t h y s t a t e , " r a t h e r than simply being r e l i e v e d of symptoms of i l l n e s s . G e n e r a l l y speak- i n g , one could s a f e l y assume t h a t most people have a d e s i r e to be p h y s i c a l l y and mentally healthy. However, i n r e c e n t y e a r s , so many r e s p o n s i b i l i t i e s f o r our welfare have been l i t e r a l l y handed over to one l e v e l of government or another, t h a t we have come to r e l y more and more on t h i s source for guidance and p r o v i s i o n . Given these f a c t s , a well-designed campaign to convince the decision-makers i n Ottawa, as well as i n our p r o v i n c i a l and municipal governments, that they should support and promote programs i n preven- t i v e medicine as w e l l as r e s e a r c h i n t h i s a r e a , s h o u l d meet wit h success. One of the stumbling blocks, as I see i t , i s the f a c t t h a t r e s u l t s from programs designed to prevent coronary h e a r t d i s e a s e do not come r a p i d l y . Perhaps i t w i l l take a t l e a s t a g e n e r a t i o n to prove that a given program i s e f f e c t i v e . . However, i n view of the tremendous costs of the disease insofar as h o s p i t a l i z a t i o n and t r e a t - ment are concerned, as well as costs i n the form of absenteeism, los s of income to the p a t i e n t and h i s family, and loss of p o t e n t i a l y e a r s of l i f e , i t would c e r t a i n l y seem more p r o f i t a b l e (or a t l e a s t l e s s c o s t l y ) for the p u b l i c , through the various l e v e l s of government, to support preventive approaches. - 99 - The governments, through their M i n i s t r i e s of Education, as we l l as l o c a l Boards of Education, should be a c t i v e l y i n v o l v e d i n helping to design and implement health education programs i n schools a t a l l grade l e v e l s . Money should be made available to the Faculties of Education at the v a r i o u s u n i v e r s i t i e s to t r a i n s p e c i a l h e a l t h educators, and school d i s t r i c t s should have money a v a i l a b l e to h i r e these s p e c i a l i s t s . (b) Use of the Media. Government should be the spark that i f u e l s p u b l i c education programs on t e l e v i s i o n , on r a d i o , i n the press, and through other p u b l i c v e h i c l e s f o r the dissemination of t h i s type of program, e.g., pamphlets f o r p h y s i c i a n s ' o f f i c e s and public health u n i t s . A l l such " a d v e r t i s i n g " should be p a r t of a larger community program and not ju s t used i n i s o l a t i o n . (c) In the Marketplace. Although the revenue from c i g a r e t t e and alcohol sales represents a considerable p o r t i o n of the govern- ment's budget, on the income side, t h i s should not be permitted to create a c o n f l i c t of i n t e r e s t s i t u a t i o n when considering support of po s i t i v e l i f e s t y l e programs by the health and education m i n i s t r i e s . There should at l e a s t be po s i t i v e direction and support from govern- ment for regulations governing non-smoking i n p u b l i c places as w e l l as i n public means of transportation. Although there are p r e s e n t l y some government programs that caution the p u b l i c on the overuse or abuse of alcohol, these are probably not used as continuously or f r e - quently as they should be for maximum impact and do not seem to be linked to other community programs to form a " t o t a l package." - 100 - There should be some disincentive associated with the use of cert a i n "junk" foods that have high sugar, s a l t , and/or animal f a t content. For example, a special tax, such as the tax on c i g a r e t t e s and alcohol, should be imposed on s o - c a l l e d n o n - n u t r i t i o n a l foods. On the other hand, foods that are as r e a d i l y a v a i l a b l e and meet the c r i t e r i a of Nutriti o n Canada, should be s o l d without t h i s s p e c i a l tax. (d) Community Resources and Industry. There are many health- directed resources i n our community that could b e n e f i t g r e a t l y from government support, and, given t h i s support, that could provide even more positive l i f e s t y l e services than they now do. The c o s t to the i n d i v i d u a l of p a r t i c i p a t i n g i n a disease prevention program should be tax deductible. In addition, the cost of b u i l d i n g and m a i n t a i n i n g f a c i l i t i e s for employees so that they can continue this p a r t i c i p a t i o n i n the work milieu, should also be tax deductible f o r the p r o v i d e r s of the f a c i l i t i e s . I t seems t r i t e to even mention the governments' r o l e i n a l l areas related to disease and health, yet i t i s important to a t l e a s t mention b r i e f l y some of the areas where government support i s e i t h e r e s s e n t i a l or very h e l p f u l . There are, no doubt, many areas which have not been covered i n this section of the thesis, such as the sub- s i d i e s from government to tobacco growers. But i f we could o b t a i n a po s i t i v e response i n at least those areas already covered, t h i s would be a huge step forward i n the f i g h t to prevent or s i g n i f i c a n t l y r e - duce both mortality and morbidity from coronary heart disease. - 101 - E. HEALTH PROFESSIONS Our health care system at present i s d i s e a s e - o r i e n t e d . I f people are i l l , physicians look after them and get paid. However, i f they prevent i l l n e s s , and thus save the government a great deal of money, they do not get paid. Although many physicians do counselling and are paid for i t , the fee i s r e l a t i v e l y small. Physicians are usually inadequately trained to cope with the new role of positive l i f e s t y l e counsellor. They are more comfortable dealing with i l l n e s s because that i s what medical schools and h o s p i - t a l s t r a i n them to do. Thus t h e i r education w i l l have to change be- fore a s i g n i f i c a n t number of physicians w i l l become involved i n pre- ventive health care services. Physicians, themselves, must be pre- pared to change from being the "providers of care" to becoming the "preventors of i l l n e s s . " Training should equip the physician to co- ordinate health care programs within the community, and to become the overseers of health care and education. [Bethesda Conference Report, 1981]. The public must be involved i n convincing governments that preventive medicine, i n the long run, can reduce the o v e r a l l costs of health care. The various health ministers must r e a l i z e that higher fees for preventive services w i l l have to be paid i n order to obtain these services from properly trained physicians. The preventive med- i c i n e c l i n i c s and private p r a c t i c e s t h a t c u r r e n t l y e x i s t , seem to draw mainly from those individuals who are well-motivated with r e - spect to l i f e s t y l e modification, and who are prepared to pay for this - 102 - service. The number of these i n d i v i d u a l s would c e r t a i n l y increase i f the educational program mentioned e a r l i e r was i n e f f e c t and continui- ty was established with community and employer health programs. Physicians and health agencies must mount a sustained e f f o r t to promote preventive measures a g a i n s t such " k i l l e r s " as coronary heart disease. This transformation of medical care p r i o r i t i e s w i l l r e q u i r e a commitment from government, h e a l t h agencies , m e d i c a l schools, hospitals and physicians. This i s not an easy task and w i l l require mobilization of s c i e n t i f i c , medical and public opinion. In order to reduce h e a l t h care c o s t s , p a t i e n t s should be w i l l i n g to accept certain levels of care from other health care per- sonnel, e.g., nurse p r a c t i t i o n e r s . These "physician extenders" could check blood pressure, perform screening for l i p i d abnormalities, par- t i c u l a r l y i n high-risk patients, counsel these p a t i e n t s re d i e t as w e l l as other preventive programs. For this type of p r a c t i c e to be- come a r e a l i t y , acceptance by physicians and government, i n a d d i t i o n to acceptance by patients, i s e s s e n t i a l . I t i s important for a l l health p r o f e s s i o n a l s to s e t a good example for t h e i r patients. For example, few p a t i e n t s would accept as serious the advice of a physician re cessation of smoking i f that advice were given while the physician himself/herself were smoking. Neidhardt [1980] maintains that as a role model the medical profession has done a good job over the past 20 years. He claims that the percentage of smokers among physicians has dropped substan- t i a l l y to near 20 per cent. P h y s i c i a n s have co-operated to share - 103 - o n - c a l l s e r v i c e s , thus p r o v i d i n g time o f f as a way of decreasing t h e i r s tress. He concludes that when the p h y s i c i a n acts as a r o l e model, both physician and patient enjoy the benefits. Several years ago, the dental profession embarked on a pro- gram of preventive d e n t i s t r y , and today well-developed education programs e x i s t i n most dental p r a c t i c e s . The concern expressed by physicians that the size of their practice would be reduced i f they prevented i l l n e s s [Jenkins, 1 978] does not seeem to have a f f e c t e d dentists i n the same way. By the same token, d e n t i s t s are t r a i n e d to counsel patients on preventive measures and they employ d e n t a l hygienists, the dental equivalent of the nurse p r a c t i t i o n e r , to per- form c e r t a i n procedures which do not require the high-priced time and s k i l l of the dentist. Their fee s t r u c t u r e a l s o provides s u i t a b l e remuneration for preventive dentistry. As they now do i n maternity and p e d i a t r i c c l i n i c s , p u b l i c h e a l t h u n i t s should make a v a i l a b l e p o s i t i v e l i f e s t y l e education c l i n i c s . These should be available to those individuals who wish to pa r t i c i p a t e because they are so motivated, as w e l l as to those who are referred by t h e i r p h y s i c i a n s because they are "at r i s k . " In addition to having suitably-trained counsellors or health educators, these public health units should make a v a i l a b l e well-designed and w e l l - w r i t t e n pamphlets, as w e l l as i n t e r e s t i n g and m o t i v a t i n g audiovisual material. - 104 - F. MEDIA In order to achieve the widespread changes i n l i f e s t y l e t h a t are necessary for an eff e c t i v e public health attack on coronary heart disease, i t w i l l be necessary to d i r e c t programs a t l a r g e groups of i n d i v i d u a l s . I f such programs are d i r e c t e d a t whole communities rather than at small groups or i n d i v i d u a l s , the cost of the programs w i l l be reduced. The programs and i n s t r u c t i o n a l methods to be used should be developed through the co-operation of various l e v e l s of government, who w i l l provide most of the funds, p h y s i c i a n s , h e a l t h educators, d e n t i s t s , media professionals, and other experts whose input could be expected to enhance these programs. A l l m a t e r i a l should be pre- tested. I t should be appropriate for a l l media channels, i . e . , f o r newspapers, radio, t e l e v i s i o n , and even popular p e r i o d i c a l s . There should be some attempt to provide continuity with s c h o o l , community and corporate h e a l t h programs. The sources of the m a t e r i a l used should be cre d i b l e . Some method of measuring impact of the programs needs to be developed. For optimal e f f e c t i v e n e s s , the programs should be designed for prolonged exposure, since "one-shot" e f f o r t s are l i k e l y to be a waste of e f f o r t and money. Since education i n a democratic society i s based on persuasion rather than c o e r c i o n , r e - su l t s w i l l l i k e l y be produced slowly. - 105 - G. INSURANCE COMPANIES As mentioned e a r l i e r , many insurance companies are now pro- v i d i n g incentives, i n the form of lower premiums, to p o l i c y holders who are non-smokers. These premiums, which are c o n s i d e r a b l y lower than those for smokers, should provide the impetus, for young people i n p a r t i c u l a r , to q u i t smoking. There i s a t l e a s t one insurance company i n the United States that provides s i m i l a r i n c e n t i v e s f o r p o l i c y h o l d e r s , or pr o s p e c t i v e p o l i c y h o l d e r s , who are r e g u l a r joggers. I t i s g r a t i f y i n g for me to see pr o f i t - o r i e n t e d organizations take the i n i t i a t i v e i n providing incentives to c l i e n t s , or prospec- t i v e c l i e n t s , who are w i l l i n g to demonstrate r e s p o n s i b i l i t y for t h e i r own health, by doing some of those things generally considered impor- tant i n the prevention of chronic diseases such as coronary heart disease and certain respiratory diseases and cancers. I t would seem l o g i c a l that i f insurance companies, with their a c t u a r i a l tables, are w i l l i n g to take a chance on those policyholders who develop or prac- t i c e p o s i t i v e l i f e s t y l e s , so should our various levels of government. Surely, the private sector i s not recklessly throwing away p o t e n t i a l p r o f i t s . H. AVAILABILITY OF COMMUNITY RESOURCES 1 . Health Promotion Service The Health Promotion Service (HPS), another American Health - 106 - Foundation r i s k factor p r o j e c t , focuses on reducing m o r b i d i t y and m o r t a l i t y from CHD, cancers and s t r o k e , as w e l l as absenteeism, h o s p i t a l i z a t i o n , and medical care costs among employee groups. The program c o n s i s t s of three phases -- pre-screen education, m i n i - examination, and follow-up — and when applied i n s e v e r a l companies has attracted about half of their employees. Forty per cent of the participants were found to have a single r i s k factor and 2 0 per cent multiple r i s k factors. At least moderate short-term success i s being achieved i n respect to intervention regarding c i g a r e t t e smoking and cholesterol l e v e l s . United States companies increasingly provide health education and screening examination programs as a means of disease prevention and health promotion. For example, the New York Telephone Company has offered i t s employees such a s e r v i c e f o r many years. The Ford Motor Company provides a cardiovascular r i s k intervention program for i t s corporate executives i n Dearborn, Michigan. New York State makes available to i t s l a r g e l y sedentary p u b l i c employees a program of heart disease i n t e r v e n t i o n , d i r e c t e d l a r g e l y to p h y s i c a l f i t n e s s [Bjurstom and Alexiou, 1978]. Commissioned by Mount Sinai H o s p i t a l , a Louis Harris survey of a representative sample o f the 92 companies headquartered i n Chicago and Cook County which are l i s t e d i n the For- tune Double 500 disclosed that 40 per cent of them provided some kind of health education or preventive health program for the i r employees. Among these, almost a l l included physical screening and alcohol abuse prevention or treatment; and about 50 per cent i n c l u d e d smoking - 107 - cessation c l i n i c s , weight reduction classes, opportunities for physi- c a l exercise at work, and/or n u t r i t i o n classes. 2. Health Hazard Appraisal Another approach to control of disease precursors has been c a l l e d Health Hazard Appraisal (HHA) or the P r a c t i c e of P r o s p e c t i v e Medicine by i t s advocates [ H a l l & Zwemer, 1979] and [Robbins and H a l l , 1 970]. The scheme e s s e n t i a l l y i s to a s s i s t p h y s i c i a n s i n es- tablishing r i s k p r o f i l e s or a p p r a i s a l s f o r t h e i r p a t i e n t s using a manual for determination of 49 precursors, of which 16 lead to most of the preventable deaths i n the community. Hsu and Milsum [1 978] describe the HHA program at the U n i v e r s i t y of B r i t i s h Columbia as follows: "Health Hazard Appraisal (HHA) helps i n d i v i - duals to place t h e i r h e a l t h status i n broad perspective. The i n d i v i d u a l ' s r i s k s a s s o c i - ated with many common l i f e s t y l e f a c t o r s are assessed and some s i g n i f i c a n t ways of reducing these r i s k s are o f f e r e d i n a comprehensive computer print-out. . .the objective of HHA i s to improve the q u a l i t y , and to avoid the fore- shortening of i n d i v i d u a l l i v e s through i t s stimulation of behavioural change. . ." While these many p i l o t projects and a few c o n t r o l l e d t r i a l s of multiple r i s k factor intervention are underway, evidence continues to accumulate concerning the association of p a r t i c u l a r r i s k f a c t o r s with disease and mortality. For example, data from s e v e r a l studies [Morris et a l . , 1973] and [Paffenbarger and Hale, 1975] appear to be - 108 - s t e a d i l y buttressing the idea that too l i t t l e physical a c t i v i t y i s a s i g n i f i c a n t factor i n cardiovascular disease. I . RECOMMENDATIONS Suggestions have been made i n the preceding sections of t h i s chapter with respect to various programs that could be developed to provide continuous education toward p o s i t i v e l i f e s t y l e s . Some of these programs already e x i s t , to a certain extent, i n one or more of the areas suggested, but there seems to be no conscious " l i n k " be- tween these programs and what I f e e l i s the most important one, namely, the school program. I t would be presumptuous of me to imply that this thesis con- tains a l l of the data required to reduce or a b o l i s h coronary heart disease. I have attempted to l i n k some of the l i t e r a t u r e which d i s - cusses the recognized and accepted (not n e c e s s a r i l y u n i v e r s a l l y ) "main" causes of CHD with that l i t e r a t u r e which discusses t r i a l s where some of these causes, or r i s k factors, have been modified i n a p o s i t i v e manner. The positive r e s u l t s , i n the form of reduced mor- t a l i t y from CHD, achieved i n these t r i a l s , suggest t h a t f u r t h e r intervention through education from childhood, a v a i l a b i l i t y of p o s i - t i v e l i f e s t y l e programs to the entire community, government support for preventive education and programs, media and i n d u s t r y i n v o l v e - ment, as well as a public t h a t accepts r e s p o n s i b i l i t y f o r s t a y i n g w e l l rather than worrying about health when i t i s no longer present, - 109 - w i l l go a long way toward affecting not only mortality from CHD but morbidity as well. CHAPTER IV C O N C L D S 1 0 N S 1. Coronary Heart Disease continues to be one of the major causes of death i n Canada i n s p i t e of a d e c l i n e i n m o r t a l i t y com- mencing i n the 1960's. 2. The l i t e r a t u r e which has appeared i n the l a s t 20 years recognizes c e r t a i n r i s k f a c t o r s which are a t l e a s t p a r t i a l l y responsible for the development of Coronary Heart Disease. 3. Studies i n various countries have demonstrated that the r i s k factors can be altered favorably by well-designed i n t e r v e n t i o n programs. 4. Numerous authors now agree that Coronary Heart Disease i s a "pediatric disease," i . e . , atherosclerosis i s found to begin e a r l y i n childhood. 5. The data seem to indicate that a well-designed, compre- hensive, l i f e t i m e program of h e a l t h education would o f f e r greater hope of reducing both the mortality and the morbidity from Coronary Heart Disease. - 110 - - 1 1 1 - 6 . Health education should commence at l e a s t a t the kinde- rgarten l e v e l , and should be developed so that i t aims a t a l l ages and sectors of society simultaneously. 7. Various levels of government should be supportive, finan- c i a l l y as w e l l as v e r b a l l y , of h e a l t h education programs. Most people have a desire to remain healthy and have a r i g h t to expect government support i n order to help them do so. 8. The cost of private excess i s now a n a t i o n a l r e s p o n s i - b i l i t y i n terms of taxes and insurance premiums. The i n d i v i d u a l , therefore, has at lea s t a moral o b l i g a t i o n to preserve h i s / h e r own health, and at the same time has a r i g h t to expect f a c t u a l informa- tion on disease prevention and the a v a i l a b i l i t y of proper f a c i l i t i e s to a s s i s t him/ her to make the t r a n s i t i o n to p o s i t i v e l i f e s t y l e be- haviour. The i n d i v i d u a l can either remain the problem or become the solution to i t . RECOMMENDATIONS FOR FUTURE STUDY Since the idea of health education from infancy and through- out l i f e i s a r e l a t i v e l y new approach to the prevention of coronary heart disease, i t would seem appropriate to investigate the long-term effects of such education programs at various levels of society. For -112 - example, the effects of health education as they relate to non-smok- ing , exercise and proper d i e t i n school children at a l l grade l e v e l s could be studied using "treatment" groups and control groups. These studies should continue for several years so that the study groups could be followed i n an attempt to r e l a t e the development of c e r t a i n l i f e s t y l e s with "treatment" or with c o n t r o l . Because I am of the o p i n i o n t h a t proper h e a l t h education holds the key to the prevention of Coronary Heart Disease, I would also recommend that a study or studies be conducted to determine the d e s i r a b i l i t y and/or f e a s i b i l i t y of "developing" a group of s p e c i a l i s t health educators who would, i n association with other teacher specia- l i s t s , develop health education programs f o r schools at a l l grade l e v e l s . Some of these health educators could also be involved i n de- veloping programs for industry. It, would be i n t e r e s t i n g , and probab- l y valuable, to compare the r e s u l t s that these health educators would achieve with their programs i n terms of the development of p o s i t i v e l i f e s t y l e s i n school children, with the r e s u l t s achieved using our current health education programs. B I B L I O G R A P H Y Abraham, S., and Nordsieck, M. "Relationship of Excess Weight i n Children and Adults." 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Journal of P e d i a t r i c s , 84: 527-533 (1974). World Health Organization. World Health S t a t i s t i c s Annual, 1965. V i t a l S t a t i s t i c s and Causes of Death, Vol. 1 (1968). World Health Organization. World Health S t a t i s t i c s Annual, 1967. V i t a l S t a t i s t i c s and Causes of Death, Vol. 1 (1970). World Health Organization. Second Conference on Prevention and Control of Major Cardiovascular Diseases. Summary Report, Brussels (1973). GLOSSARY OF TERMS AHD — A r t e r i o s c l e r o t i c Heart Disease ( a l s o r e f e r r e d to as IHD - ischemic h e a r t disease, and CHD - coronary heart d i s e a s e ) . A r t e r i o s c l e r o s i s of the coronary a r t e r i e s l e a d i n g to a decrease i n oxygen supply to the heart muscle. ANGINA PECTORIS — A disease marked by paroxysmal t h o r a c i c p a i n , with a f e e l i n g of s u f f o c a t i o n and impending death, due, most o f t e n , t o anoxia of the myocardium and p r e c i p i t a t e d by e f f o r t or ex- citement. "Pain i n the chest." ANOXIA -- Oxygen d e f i c i e n c y ; a c o n d i t i o n i n which the c e l l s of the body/organ do not have or cannot u t i l i z e s u f f i c i e n t oxygen to perform normal f u n c t i o n . AORTA -- Main a r t e r y leading from the h e a r t and branching out to a l l p a r t s of the body. ARRHYTHMIA — Any v a r i a t i o n from the normal rhythm of the heart beat; absence of rhythm; i r r e g u l a r i t y . ARTERIOSCLEROSIS — A c o n d i t i o n marked by l o s s of e l a s t i c i t y , t h i c k - ening and hardening of the a r t e r i e s . This u s u a l l y leads to a t h e r o s c l e r o s i s . ATHEROMA — f a t t y degeneration or t h i c k e n i n g of the w a l l of the l a r g e r a r t e r i e s . ATHEROSCLEROSIS — A form of a r t e r i o s c l e r o s i s i n which the l i n i n g of the blood v e s s e l i s c h i e f l y i n v o l v e d , producing, i n the lumen of the v e s s e l s , atheromatous masses which c o n t a i n small drops of f a t ( l i p i d s ) . CHD — Coronary Heart Disease; myocardial damage due to i n s u f f i c i e n t blood supply. (See AHD). CHOLESTEROL — A f a t l i k e , p e a r l y substance found i n the blood as w e l l as other t i s s u e s of the body. I t occurs i n atheroma of the a r t - e r i e s . - 124 - - 125 - CORONARY — E n c i r c l i n g , as the blood v e s s e l s t h a t supply blood d i r e c t l y to the heart muscle. - EMIA — With reference to the blood, e.g., anemia. HYPER — Above normal; an excess o f . HYPERLIPEMIA — A l s o r e f e r r e d to as h y p e r l i p i d e m i a . An excess of l i p i d s i n the blood. HYPERTENSION — Elevated blood pressure. IHD — Ischemic h e a r t disease. (See AHD). INFARCT — An area of coa g u l a t i o n n e c r o s i s i n a t i s s u e due to l o c a l anemia r e s u l t i n g from o b s t r u c t i o n of c i r c u l a t i o n to the area. ISCHEMIA — l o c a l and temporary anemia due to o b s t r u c t i o n of the c i r c u l a t i o n to a p a r t . LESION — A ci r c u m s c r i b e d area of p a t h o l o g i c a l l y a l t e r e d t i s s u e ; an i n j u r y or wound. MORBIDITY — The c o n d i t i o n of being diseased; the s i c k r a t e ; the r a t i o of s i c k to w e l l persons i n a community. MORTALITY — The death r a t e ; the r a t i o of t o t a l number of deaths to the t o t a l p o p u l a t i o n . MYOCARDIAL INFARCTION — Death of h e a r t muscle due to r e d u c t i o n or complete absence of oxygen supply to t h a t area of muscle. MYOCARDIUM — The muscle substance of the h e a r t ; the middle l a y e r of the w a l l s of the he a r t , composed of c a r d i a c muscle. OBESITY — Abnormal amount of f a t on the body. The term i s u s u a l l y not employed unless the i n d i v i d u a l i s from 20 to 30 per cent over average weight f o r h i s / h e r age, sex-, and h e i g h t .

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