18 November 2014

My Letter to Congress about School Lunch Standards

I am writing to ask you to oppose any effort to weaken school nutrition standards through the appropriations process. President Truman first inaugurated the National School Lunch Program, and it has enjoyed a long history of bipartisan support.  I urge you to help Congress return to those bipartisan roots.

For the past two years, schools across the country have been working hard to meet updated nutrition standards for school meals.  As a result, more than ninety percent of schools are serving more fruits, vegetables and whole grains through school lunch. Congress should support that progress, not roll it back.

The U.S. Department of Agriculture is listening and responding to the challenges that some schools are facing as they work to serve healthier meals to kids.  Congress should not micromanage the school lunch program through the appropriations process.  What is being billed as bringing "flexibility" to the school meal programs actually would significantly weaken them and result in more unhealthy food for kids.
Can I count on you to stand up for our kids and oppose efforts to weaken school nutrition?  I look forward to your reply. 

Send your own letter here: https://www.cspinet.org/takeaction/#/47

15 November 2014

Promoting Physical Activity in an Impoverished Population

Promoting Physical Activity in an Impoverished Population

Explanation of the Problem
Manypeople today live in poverty. Poverty creates obstacles for people to achieve their goals and improve their condition. Poverty is associated with a higher prevalence of physical inactivity than those people in higher income populations (R. C. Brownson, Baker, Housemann, Brennan, & Bacak, 2001; C. J. Crespo, Smit, Andersen, Carter-Pokras, & Ainsworth, 2000; Lindstrom, Hanson, & Ostergren, 2001; Yen & Kaplan, 1998). Approximately 13% of the United States reported population is impoverished (Wikipedia contributors, ). Public policy should take an initiative to provide an environment that facilitates physical activity.

Populations Affected / At Risk
The 37 million people living at or below the poverty line are at greater risk for all cause and cardiovascular morbidity, mortality, and physical inactivity than those in higher socioeconomic groups (Johnson-Down, O'Loughlin, Koski, & Gray-Donald, 1997; Lantz et al., 1998; Lindstrom et al., 2001; Wikipedia contributors, ). The children in less affluent school districts have less frequent and less active physical education classes of less quality than more affluent districts (Sallis, Zakarian, Hovell, & Hofstetter, 1996).

Poor people do not have equal access to physical activity. Barriers to physical activity are associated with a lower socioeconomic status of lack of money, lack of transport, illness and disability (Lindstrom et al., 2001). Neighborhood crime also presents a barrier for physical activity with 40% more exposure to crime among low-income groups (R. C. Brownson et al., 2001; Giles-Corti & Donovan, 2002). These barriers represent sociological obstacles because the cultural environment makes it difficult for the individual to become more active.

All these barriers contribute to high levels of physical inactivity among those with less education and those below the poverty line (C. J. Crespo, Ainsworth, Keteyian, Heath, & Smit, 1999). Their children also show high proportions of overweight or obesity (Johnson-Down et al., 1997). Childhood obesity and physical inactivity may set a precedent for the rest of that individual's life. It is important to consider the patterns and habits that people form during childhood to combat the threat of obesity.

Discussion of the Issue
There are several factors to consider when approaching the relationship between poverty and physical activity. The individual has the ultimate choice in the matter but several norms may dictate that individual's choices. High levels of capital, implies a strong sense of being able to influence one's own health, increasing the extent of leisure-time physical activity (Lindstrom et al., 2001). Income may reflect access to medical care resources, good housing, and abundance of food, good working conditions, and more social amenities (C. J. Crespo et al., 1999; C. J. Crespo et al., 2000). Poor social conditions, resulting from low socioeconomic status, may contribute to low levels of physical activity (Lindstrom et al., 2001). The actual and or perceived quality of the neighborhood has an impact on physical activity. Poor quality neighborhood environments provide fewer opportunities and cultural norms for recreational walking (Giles-Corti & Donovan, 2002). Education is important to consider because education influences healthy lifestyle behaviors through exercise, diet, problem solving capacity, and values (C. J. Crespo et al., 1999).

The poor are often stigmatized as lazy failures with no ambition for success. There are several factors to consider. Taking care of children and elders, lack of free time, lack of economic resources, lack of social support and low self-efficacy in exercise may be critical factors in explaining the higher prevalence of leisure time inactivity among those living below the poverty line (C. J. Crespo et al., 2000). It is possible that those living below the poverty line work in occupations requiring more energy expenditure and are not interested in pursuing physical activity (C. J. Crespo et al., 1999).

Impoverished communities face an uphill struggle. Insufficient psychosocial resources in some socioeconomic groups are a part of the differences in leisure time physical activity (Lantz et al., 1998; Lindstrom et al., 2001). The perceived access to indoor and outdoor places to engage in physical activity presents a barrier to people in lower socioeconomic groups (R. C. Brownson et al., 2000; R. C. Brownson et al., 2001). Community policy also presents barriers to physical activity among those in lower socioeconomic strata. Public health policies and interventions that exclusively focus on individual risk behaviors have limited potential for reducing socioeconomic disparities in mortality (Lantz et al., 1998).

Potential Solutions
Local municipalities implement programs to increase physical activity. Environmental and policy approaches to increase physical activity include walking and bicycle trails, funding for public facilities, zoning and land use, facilitating activity in neighborhoods, mall walking programs, policies and incentives promoting physical activity during the workday, and policies requiring comprehensive school health education programs (R. C. Brownson et al., 2000; R. C. Brownson et al., 2001). These are all policies that present an adequate attempt at addressing the situation.

The goal is often to promote the individual's physical activity. Interventions need to consider the environments in which people live. Policies that focus on the individual are often ineffective because they fail to consider the social and environmental obstacles to activity. Improvements of the physical environment are essential. Organizations should offer group exercise as well as community and workplace policies to promote activity (Lindstrom et al., 2001).

It is most important to provide an adequate, supportive and nurturing environment for people to be physically active. Our goal as a society should be modeled after efforts to create healthy communities that provide health promoting information and social support to enable people to develop healthier lifestyles (R. C. Brownson et al., 2001). Walking trails are especially an effective and inexpensive tool. Walking trails can be implemented at an estimated cost of $2000 to $4000 per trail (R. C. Brownson et al., 2000). Even then, local public and private agencies would be willing to donate time and materials toward trail building and maintenance. Implementing this strategy among all neighborhoods and improving the quality of the environment will provide greater opportunity for those in lower socioeconomic strata to become active and positively influence social norms (Giles-Corti & Donovan, 2002).

Conclusion / Summary
Those people in the lower socioeconomic strata face many obstacles to their health and well being. Poverty is associated with a higher prevalence of physical inactivity. This presents more obstacles to health such as childhood obesity and cardiovascular disease. The impoverished must deal with greater obstacles to pursue the benefits of physical activity than those in higher socioeconomic classes. A lack of money, lack of transport, and increased rates of crime are all barriers to physical activity. The environment caters to those with more capital and so the benefits of city planning fall on the shoulders of the wealthy. Social status affects the perception of the built environment in the way that people in lower socioeconomic strata live in areas that are not as conducive to walking for exercise.

The construction of attractive walking trails that provide a nurturing environment for people to become active is an easy and effective way for policymakers to promote physical activity and well being. This will help communities, not necessarily individuals, to pursue the benefits of physical activity in a way that can improve social cohesion. This is an opportunity for public policy to provide an environment where people can be active.

Brownson, R. C., Housemann, R. A., Brown, D. R., Jackson-Thompson, J., King, A. C., & Malone, B. R., et al. (2000). Promoting physical activity in rural communities: Walking trail access, use, and effects. American Journal of Preventive Medicine, 18(3), 235-241.

Brownson, R. C., Baker, E. A., Housemann, R. A., Brennan, L. K., & Bacak, S. J. (2001). Environmental and policy determinants of physical activity in the united states. American Journal of Public Health, 91(12), 1995-2003.

Crespo, C. J., Ainsworth, B. E., Keteyian, S. J., Heath, G. W., & Smit, E. (1999). Prevalence of physical inactivity and its relation to social class in U.S. adults: Results from the third national health and nutrition examination survey, 1988-1994. Medicine and Science in Sports and Exercise, 31(12), 1821-1827.

Crespo, C. J., Smit, E., Andersen, R. E., Carter-Pokras, O., & Ainsworth, B. E. (2000). Race/ethnicity, social class and their relation to physical inactivity during leisure time: Results from the third national health and nutrition examination survey, 1988-1994. American Journal of Preventive Medicine, 18(1), 46-53.

Giles-Corti, B., & Donovan, R. J. (2002). Socioeconomic status differences in recreational physical activity levels and real and perceived access to a supportive physical environment. Preventive Medicine, 35(6), 601-611.

Johnson-Down, L., O'Loughlin, J., Koski, K. G., & Gray-Donald, K. (1997). High prevalence of obesity in low income and multiethnic schoolchildren: A diet and physical activity assessment. The Journal of Nutrition, 127(12), 2310-2315.

Lantz, P. M., House, J. S., Lepkowski, J. M., Williams, D. R., Mero, R. P., & Chen, J. (1998). Socioeconomic factors, health behaviors, and mortality: Results from a nationally representative prospective study of US adults. JAMA : The Journal of the American Medical Association, 279(21), 1703-1708.

Lindstrom, M., Hanson, B. S., & Ostergren, P. O. (2001). Socioeconomic differences in leisure-time physical activity: The role of social participation and social capital in shaping health related behaviour. Social Science & Medicine (1982), 52(3), 441-451.

Sallis, J. F., Zakarian, J. M., Hovell, M. F., & Hofstetter, C. R. (1996). Ethnic, socioeconomic, and sex differences in physical activity among adolescents. Journal of Clinical Epidemiology, 49(2), 125-134.

Wikipedia contributors. Poverty in the united states. Retrieved November 13, 2006, from http://en.wikipedia.org/wiki/united_states_of_america/poverty?oldid=92090167

Yen, I. H., & Kaplan, G. A. (1998). Poverty area residence and changes in physical activity level: Evidence from the alameda county study. American Journal of Public Health, 88(11), 1709-1712.

Effects of Physical Activity on Cerebrovascular Disease

Effects of Physical Activity on Cerebrovascular Disease

Cerebrovascular disease, or stroke, is a devastating illness. A stroke is a type of cardiovascular disease affecting the arteries leading to and within the brain. It occurs when a blood vessel that carries oxygen and nutrients to the brain bursts or is blocked by a blood clot. The result is a loss or impairment of bodily function resulting from the injury or death of brain cells after insufficient blood supply.

There are two types of stroke, ischemic or hemorrhagic. An ischemic stroke accounts for 83% of all cases in the United States (American Heart Association, 2006). This occurs as the result of an obstruction in a blood vessel supplying blood to the brain. The principle condition for an ischemic stroke is atherosclerosis, the development of fatty deposits lining the vessel walls. The fatty deposits themselves can cause two types of obstructions, cerebral thrombosis or cerebral embolism. Cerebral thrombosis refers to the blood clot that develops at the clogged part of the vessel. Cerebral embolism refers to a clot that has formed at a different part of the circulatory system. A portion of the clot breaks loose and travels towards the brain through the bloodstream until the blood vessels become so small that the clot becomes lodged, thus obstructing the flow of blood.

A hemorrhagic stroke is where the blood vessel ruptures, causing blood to leak into the brain. This type of stroke accounts for 17% percent of all stroke cases (AHA, 2006). When the vessel ruptures and leaks into the brain the blood accumulates and compresses the surrounding brain tissue. The rupture is a result of either an aneurysm, a ballooning of a weakened blood vessel, or an arteriovenous malformation, a cluster of abnormally formed blood vessels.

Over 273,000 people died from a stroke in the United States in 2003 (AHA, 2006). Cerebrovascular disease kills about 4.4 million people worldwide (Dishman, Washburn, and Heath, 2004). A greater number of women than men die from stroke accounting for 61% of all United States stroke deaths in 2003 (AHA, 2006). Stroke is the leading cause of serious, long-term disability in the United States (AHA, 2006). The estimated cost of stroke for 2006 is $57.9 billion (AHA, 2006).

Stroke has a destructive impact in the United States due to loss of life, loss or impairment of function, and a national economic loss. Identifying risk factors for stroke and taking action to reduce the prevalence of those risk factors in the population will save many lives and the financial savings could be in the billions.

Review of Literature
Surgeon General’s Report: Physical Activity and Health, 1996
In 1996 the Office of the Surgeon General addressed physical activity and health. The main message of the report was that Americans can greatly improve their health and quality of life by including moderate amounts of physical activity in their daily lives. As it relates to cardiovascular disease the report found that regular physical activity or cardiorespiratory fitness decreases the risk of cardiovascular disease mortality. However, the report found inconclusive data regarding a relationship between physical activity and stroke. It indirectly reported that physical activity reduces some of the risk factors for stroke, such as hypertension and atherosclerosis. At the time, stroke was the third leading cause of death in the United States (US Department of Health and Human Services, 1996). The report identified stroke as a major cardiovascular problem in developed countries.

The report found atherosclerosis of the extracranial and intracranial arteries to be the underlying basis of ischemic stroke, hypertension to be a major risk factor for ischemic stroke, and hypertension to be a major determinant of hemorrhagic stroke. The report wrote that physical activity may not affect ischemic and hemorrhagic stroke in the same way because of different pathophysiologies (US DHHS, 1996). In one study cited, inactive men were more likely than active men to have a hemorrhagic stroke and physical activity was associated with a lower risk of ischemic stroke in smokers but not in nonsmokers.

As it relates to hypertension, a risk factor for stroke, it is estimated that those least physically active have a 30 percent greater risk of developing hypertension than their most active counterparts (US DHHS, 1996). Endurance training reduces thrombosis by enhancing the enzymatic breakdown of blood clots and by decreasing platelet adhesiveness and aggregation (US DHHS, 1996). Despite the evidence that an increase in physical activity reduced hypertension and thrombosis, the Surgeon General’s report found no conclusive evidence that physical activity plays a protective role against stroke.

Risk Factors and Mortality in Men and Women in Scotland
The aim of the study was to relate risk factors in middle-aged men and women to stroke mortality over a long follow-up period. This study found that women’s stroke mortality rates were similar to men’s. The study concluded that control of risk factors for reduction of stroke mortality should be targeted at men and women in a similar fashion, particularly with blood pressure control (Hart, Hole, and Smith, 1999).

The study identified hypertension, cardiac disease, age, smoking, and diabetes as major risk factors for stroke. The study population contained men and women, aged 45 to 64 years, in west Scotland. The study found a positive relationship between systolic blood pressure and stroke mortality in both men and women. The stroke mortality rate was approximately 3 times that for men and women in the highest quintile of blood pressure than in the lowest (Hart, et al. 1999).

The study concluded that elevated systolic and diastolic blood pressure were both highly significantly associated with stroke mortality. The study found no relationship between cholesterol and stroke mortality. The study found diabetics had 3 times the risk for stroke than non diabetics (Hart, et al. 1999).

Physical activity is known to reduce blood pressure and could thus reduce the risk for stroke by lowering blood pressure (US DHHS, 1996). Physical activity also reduces the risk for diabetes and therefore contributes to the reduction in risk for stroke (US DHHS, 1996).

Leisure-Time Physical Activity and Risk for Stroke in Men
The objective of this study was to examine the association of leisure time physical activity and pulmonary function with the risk for stroke. The participants in this stuffy were 4484 men aged 45 to 80 years followed for a mean of 10.6 years (Agnarsson, Thorgeirsson, Sigvaldason, and Sigfusson, 1999). The principle findings of the study is that regular continued leisure-time physical activity in middle-aged men offers an apparent protective effect on diminished pulmonary function and on the risk for ischemic stroke. The greatest benefit seemed to be associated with low intensity sports, such as walking or swimming (Agnarsson, et al. 1999). The important factor associated with the protective effect seems to be regular physical activity maintained into ages at which the risk for stroke increases.

The study indicated that physical activity has complex physiologic effects. The study implies that physical activity causes favorable changes in the lipoprotein profile and may reduce potential for thrombosis through enhanced fibrinolytic activity and reduced platelet adhesiveness. The study reports that physical inactivity may be a reason for the increase in stroke mortality in the United States. The study acknowledges a limitation in the specific nature of the inquiry about the level of physical activity in its participants. The study concludes that in men, regular leisure-time physical activity maintained after 40 years age may protect against ischemic stroke.

Physical Activity and Stroke Mortality in Women
This study was conducted to examine the association between different levels of leisure-time physical activity and stroke mortality in women aged greater than or equal to 50 years. The study looked at 14,101 women that participated in the Nord-Trondelag Health Survey in Norway during 1984 – 1986. The study concluded that physical activity was associated with reduced risk of death from stroke in middle aged and elderly women. The study recommends that physical activity should be the primary prevention strategy against stroke in women.

The information was obtained by questionnaires and clinical measurements included in a screening program. Activity among women that exercised less than once per week was classified as low activity; once or several times per week at a moderate intensity was classified as medium activity; and several times per week at a higher intensity was classified as high activity.

The study found that women with a high level of physical activity tended to be younger, leaner, and had lower systolic blood pressure than less active women. The prevalence of coronary heart disease, diabetes, and use of antihypertensive medication decreased with increasing physical activity. In groups aged 50 to 69 and 70 to 79 years, the most active women had an adjusted relative risk of 0.39 and 0.48, respectively (Ellekjær, Holmen, Ellekjær, and Vatten, 2000). In the group aged 80 to 101 years, the most active women had an adjusted relative risk of 0.50 but the study found that it was not statistically significant (Ellekjær, et al. 2000). The overall multivariate-adjusted relative risk was 0.54 (Ellekjær, et al. 2000).

The study also found that women in the least active category were more likely to report ill health and prevalent disease. The study demonstrated a consistent, negative association between levels of physical activity and stroke mortality in women. When compared with inactive women, the most active had almost a 50% lower risk of stroke. The study reported that the negative association between physical activity and stroke mortality may be mediated by decelerating the atherosclerotic process, modifying the structure of arteries, reducing vasospasm, enhancing myocardial electrical stability, or increasing fibrinolysis (Ellekjær, et al. 2000).

This study found evidence to strongly suggest that higher intensity leisure-time activity is a protective measure against stroke in women aged 50 years and greater.

Incidence of Ischemic Stroke in African American and White Men and Women
The purpose of this study was to find an association between white blood cell, WBC, count and incidence of ischemic stroke and mortality in 13,555 African American and White men and women (Lee, Folsom, Nieto, Chambless, Shahar, and Wolfe, 2001). An elevated WBC count is a risk factor for atherosclerotic vascular disease. WBC – derived macrophages and other phagocytes are believed to contribute to vascular injury and atherosclerotic progression. According to the study WBC count is inversely associated with physical activity, high density lipoprotein cholesterol, and family income. The major finding of the study is that elevated WBC count is directly associated with risk of coronary heart disease and stroke incidence and mortality from cardiovascular disease in African Americans.

Since elevated WBC count is a risk factor for ischemic stroke and WBC count is inversely associated with physical activity this study possibly shows that physical activity has an indirect effect on the prevention of ischemic stroke by lowering WBC count.

Physical Activity and Stroke, A Meta-Analysis
The purpose of this study was to examine the overall association between physical activity or cardiorespiratory fitness and stroke incidence of mortality. This study maintains that hypertension and cardiac disease are the primary risk factors for stroke and that physical activity may modify these risk factors and may have more direct effects to lower stroke risk. The study reported that overall, highly active individuals had a 27% lower risk of stroke incidence or mortality than did low active individuals (Lee, Folsom, and Blair, 2003). The study also reported that overall, moderately active individuals had a 20% lower risk of stroke incidence or mortality than did low active individuals (Lee, et al. 2003).

The study concluded, stating that the major finding was that moderately or highly active individuals had a lower risk of stroke incidence or mortality than did low active individuals. Moderately or highly active individuals reduced their risk by 20% and 27%, respectively. The study maintained that physical activity probably reduced stroke risk. The study said that since physical activity questionnaires tend to be imprecise it was possible to have a large measurement error and therefore the relative risk estimates may not be accurate because definitions of low, moderate, and high intensity activity varied widely among the studies reviewed in the analysis.

The study continues by discussing the plausibility that physical activity may decrease stroke risk by reducing hypertension, atherosclerosis, improving blood lipid profiles, and reduces blood viscosity, fibrinogen levels, and platelet aggregability and by enhancing fibrinolysis (Lee, et al. 2003). The study found a distinctive risk reduction caused by physical activity but due to possible errors in physical activity reporting could not claim with supreme confidence that physical activity reduces stroke risk.

Risk of Stroke in Elderly Men
The study examined the relation between high density lipoprotein cholesterol levels and the risk of thromboembolic and hemorrhagic stroke in elderly men. The study found that low concentrations of HDL cholesterol, less than 40 milligrams per deciliter, were more likely to be associated with a future risk of thromboembolic stroke than were high concentrations, greater than or equal to 60 milligrams per deciliter (Curb, Abbot, Rodriguez, Masaki, Chen, Popper, Petrovich, Ross, Schatz, Belleau, and Yano, 2004). The study suggests that stroke risk increases with each unit decline in HDL cholesterol level.

The study identified low concentrations of HDL cholesterol to be a risk factor for stroke. Exercise raises HDL levels (US DHHS, 1996). It is therefore possible that physical activity reduces the risk for stroke indirectly by raising HDL levels in elderly men.

Risk Factors for Stroke
This study compared different risk factors for coronary heart disease, stroke, and venous thromboembolism. The results of the study indicated that those that exercised had a relative risk of 0.94 for stroke (Glynn and Rosner, 2005). The study reported that more frequent exercise was associated with decreased risk of coronary heart disease and stroke. The study was limited by its reliance on self reported information for physical activity. The results that this study published indicated a weak correlation with physical activity and risk for stroke.

Metabolic Syndrome and Risk of Stroke
This study examined the relationship of metabolic syndrome with the risk of stroke. The metabolic syndrome is a clustering of disturbed glucose and insulin metabolism, obesity and abdominal fat distribution, dyslipidemia, and hypertension. The study found that metabolic syndrome is a risk factor for stroke through other risk factors, such as hypertension and atherosclerosis. The study urges that early identification, treatment, and ultimately prevention of the metabolic syndrome present a major challenge for health care professionals. Physical activity reduces hypertension, obesity, dyslipidemia, and abdominal fat distribution. This study suggests that physical activity indirectly reduces the risk for metabolic syndrome by reducing the risk and therefore reduces the risk for stroke.

After reviewing some of the literature pertaining to stroke the evidence strongly suggests that physical activity is a preventative measure against stroke. This is biologically plausible. Physical activity reduces blood pressure, reduces atherosclerosis, reduces the risk for diabetes, and increases HDL cholesterol; elevated blood pressure, atherosclerosis, diabetes, and low HDL cholesterol levels are all risk factors for stroke.

Four of the nine articles reviewed did not find sufficient evidence to claim that physical activity is a preventative tool against stroke. One article found that physical activity reduces stroke risk by reducing blood pressure. One article found that physical activity reduces stroke risk by reducing the risk of diabetes. Two articles reviewed strongly recommended physical activity as a preventative measure against stroke. One article suggested that physical activity reduced the risk for stroke by reducing WBC count. One article suggested that physical activity reduced the risk for stroke by raising HDL cholesterol levels.

All of the articles did not conclusively suggest that physical activity can be used as a tool to reduce the risk for stroke; however, all of the articles did show that physical activity could reduce the risk for stroke directly or indirectly by limiting the risk factors associated with stroke. Ultimately, this review will conclude that physical activity does have some preventive effect on the risk for cerebrovascular disease by reducing several of the major risk factors for stroke.

Agnarsson, U., Thorgeirsson, G., Sigvaldason, H., and Sigfusson, N. (1999). Effects of Leisure-Time Physical Activity and Ventilatory Function on Risk for Stroke in Men: The Reykjavík Study. Annals of Internal Medicine. Volume 130. 987 – 990.

American Heart Association. (2006). Heart Disease and Stroke Statistics – 2006 Update. Retrieved April 9, 2006 from American Heart Association Web site: http://circ.ahajournals.org/cgi/content/short/113/6/e85#SEC5

Curb, J. D., Abbott, R. D., Rodriguez, B. L., Masaki, K. H., Chen, R., Popper, J. S., Petrovich, H., Ross, G. W., Schatz, I. J., Belleau, G. C., Yano, K. (2004). High Density Lipoprotein Cholesterol and the Risk of Stroke in Elderly Men: The Honolulu Heart Program. American Journal of Epidemiology. Volume 160. 150 – 157.

Dishman, R. K., Washburn, R. A., & Heath, G. W. (2004). Physical Activity Epidemiology. Champaign, IL: Human Kinetics

Ellekjær, H., Holmen, J., Ellekjær, E., Vatten, L. (2000). Physical Activity and Stroke Mortality Women: Ten-Year Follow-Up of the NordTrondelag Health Survey, 1984 – 1986. Stroke. Volume 31. 14

Glynn, R. J., Rosner, B. (2005). Comparison of Risk Factors for the Competing Risks of Coronary Heart Disease, Stroke, and Venous Thromboembolism. American Journal of Epidemiology. Volume 162. 975 – 982.

Hart, C. L., Hole, D. J., and Smith, G. D. (1999). Risk Factors and 20-Year Stroke Mortality in Men and Women in the Renfrew/Paisley Study in Scotland. Stroke. Volume 30. 1999-2007.

Kurl, S., Laukkanen, J. A., Niskanen, L., Laaksonen, D., Sivenius, J., Nyyssönen, K., Salonen, J. T. (2006). Metabolic Syndrome and the Risk of Stroke in Middle-Aged Men. Stroke. Volume 37. 806 – 811.

Lee, C. D., Folsom, A. R., Blair, S. N. (2003). Physical Activity and Stroke: A Meta-Analysis. Stroke. Volume 34. 2475 - 2482

Lee, C. D., Folsom, A. R., Nieto, F. J., Chambless, L. E., Shahar, E., Wolfe, D. A. (2001). White Blood Cell Count and Incidence of Coronary Heart Disease and Ischemic Stroke and Mortality from Cardiovascular Disease in African American and White Men and Women. American Journal of Epidemiology. Volume 154. 758 – 764.

US Department of Health and Human Services. (1996). Physical Activity and Health: A Report of the Surgeon General. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Atlanta, GA.

Stress Management Final Exam Study Guide

Stress Management

Be able to list and describe using examples the 3 fundamental components of the stress equation.

The stress equation is: Stressor (stimulus) + Individual Characteristics = Stress Response

The stressor is any real or imagined situation, circumstance, or stimulus that is perceived to be a threat. An example of this is seeing a snake directly in the path before you. Individual characteristics describe the past experiences and beliefs of a person. An example is having seen traumatic snake bites on television. The stress response is the release of epinephrine and nor epinephrine to prepare for various organs and tissues for fight or flight. An example is freezing because the person saw the snake, is afraid of being bitten, and stops walking because the path just became dangerous.

Know what the research by Yerkes and Dodson at Harvard University showed about the relationship of stress to productivity

Some stress (eustress) is necessary for health and performance but that beyond an optimal amount both will deteriorate as stress increases.

Be able to list 4 common physical stress reactions, 3 common emotional stress reactions, and 3 common behavioral stress reactions (behavior changes due to stress) from those given in class or in your text.

Physical stress reactions include fatigue, colds/influenza, back aches, and sleep disorders.

Emotional stress reactions include irritable, anger, and frustration.

Behavioral stress reactions include poor concentration, violence, and being accident prone.

Be able to identify the primary organs of the central nervous system (CNS)

The brain and spinal cord are the primary organs of the central nervous system.

Be able to outline the divisions and subdivisions of the peripheral nervous system

The divisions of the Peripheral Nervous System include the Autonomic Nervous System and all other sensory and motor neurons. The Autonomic Nervous System contains the Sympathetic Nervous System and Parasympathetic Nervous System.

Be able to identify the primary functions of each of the following areas of the brain:

The reticular formation connects the brain to the spinal cord. It is a communications link that filters sensory input into the brain.

The brain stem is responsible for involuntary functions of the human body such as heartbeat, respiration, and vasomotor activity.

The limbic system is the emotional control center responsible for pain regulation and emotional processing.

The amygdala is first to register fear and emotional content memory.

The hypothalamus helps to control hunger, thirst, blood pressure, sex drive, heart rate, pain, pleasure, and appetite. It activates the autonomic nervous system, stimulates secretion of adrenocorticotropic hormone, produces antidiuretic hormone, and stimulates the thyroid gland to produce thyroxine.

The cortex assesses physical arousal consciously and subconsciously, and either increases or inhibits the stress response.

Be able to describe how the primary functions of each of the following areas of the brain relate to stress, incorporating examples.

The reticular formation filters information to the brain and can filter out unnecessary information that may lead to stress. An example of this can be sleeping well in a loud city.

The amygdala is first to register fear and initially activates the sympathetic nervous system to deal with the situation even if there is no true danger. An example of this is seeing a snake on the path ahead but realizing that it is only a stick.

Neocortex and cortex deals consciously and subconsciously with sensory information and determines whether a stress response is necessary or unnecessary. An example of this can be consciously changing thought patterns to deal with negative situations.

Be able to identify how neural impulses are transmitted along a neuron, and transmitted from one neuron to another, or from a motor neuron to a muscle.

Stimulation alters permeability of Sodium, Potassium, and Chloride ions creating an action potential. The action potential passes along the nerve fiber and over the surface of the synaptic knob. Synaptic vesicles release their neurotransmitter into the synaptic cleft. Neurotransmitters fit with receptors and cAMP starts up the next neuron.

Chapter 2 of your textbook describes 3 major neuroendocrine axes. These are chain reactions of biochemical messages, and are major components of the stress response in humans that occur as a result of stimulation of a key area in the brain. Be able to name and correctly spell each axis and describe one or more of its effects.

ACTH axis is a physiological pathway whereby a messenger is sent from the hypothalamus to the pituitary, then on to the adrenal gland to secrete a flood of stress hormones for fight or flight. This increases metabolism and blood pressure.

Vasopressin axis is a chain of physiological events stemming from the release of vasopressin or antidiuretic hormone. This regulates fluid loss through the urinary tract. This increases blood pressure to ensure that active muscles receive oxygenated blood.

Thyroxine axis is a chain of physiological events stemming from the release of thyroxine. This increases overall metabolism.

Be able to name at least 2 of the primary glands of the immune system.

The thymus and the spleen are primary glands of the immune system.

Know which type(s) of lymphocytes (immune system cells) help to protect against cancer, and which type(s) of lymphocytes help to protect against infectious diseases, like anthrax.

T-lymphocytes are primarily responsible for cell-mediated immunity. B-cells primarily function to eliminate pathogenic microorganisms that contribute to infectious disease.

The Borysenko Model for the relationship between stress and disease divides the causes of disease into either autonomic nervous system dysregulation or immune system dysregulation. Be able to list 2 examples of specific medical problems resulting from autonomic dysregulation and 2 specific examples from immune dysregulation. According to Borysenko, there are two types of immune system dysregulation. Be able to name them and give examples of each type.

Autonomic dysregulation is associated with migraines and coronary heart disease. Immune dysregulation is associated with viral infections and allergies.

Immune dysregulation overreactions include allergies and arthritis. Underreactions include infections and cancer. Overreactions include arthritis and allergies.

Be able to identify at least 2 of the key concepts of Dr. Candace Pert's research on the relationship between the brain and the immune system.

Pert's model cites research findings linking the nervous system with the immune system because various cell tissues in the immune system can synthesize neuropeptides just as the brain can.

Pert believes that all neuropeptides are really one molecule that undergoes a change at the atomic level brought about by various emotional states or energy thought forms.

Be able to describe at least 3 detrimental effects of prolonged excess secretion of cortisol (as it occurs with chronic stress).

Cortisol decreases mucous production in stomach lining. Cortisol inhibits new bone formation and uptake of calcium in intestines. Cortisol stops the formation of new lymphocytes in the thalamus.

Be able to identify the key concepts of the Gerber Model with respect to the mind and the brain.

Gerber's model states that the mind consists of energy surrounding and permeating the body. Disease is disturbance in the human energy field, which cascades through levels of the subtle energy to the body via chakras and meridians.

Understand the definition of entrainment in general, and how this principle relates to external power sources that may increase our health risks.

Entrainment is organs or organisms increasing their rate of oscillation to match the stronger rate of oscillation given off by other organs or organisms. Oscillations of a higher frequency are somehow absorbed through the human energy field resulting in alterations to the genetic makeup of cells at the atomic level.

Dr. Kenneth Pelletier cites several types of compelling research evidence dealing with the relationship between thoughts and disease. These are: Multiple personality disorders and placebos. Know how each of these concepts applies to the effects of our thoughts on our health.

Multiple personality disordered individuals may manifest different diseases with different personalities. Stress is thought to be strongly associated with the cause of disease.

Placebos can be as effective as the medicine it is supposed to represent. Healing may occur as a result of the patient's belief or faith that the medicine will work.

According to Dr. Richard Lazarus' "Cognitive Appraisal Model" of stress, there are two appraisal processes continually in play as we interact with our environment. Be able to define and describe each appraisal process.

Primary appraisal is a judgment about whether the stimulus is unpleasant, uncomfortable, threatening, good or bad. Secondary appraisal is a judgment about our ability to successfully deal with the situation and or stimulus.

For each of the two appraisal processes above, be able to name an individual characteristic that affects that appraisal process, and be able to explain why and how it affects that appraisal processes.

Primary appraisal is affected by individual expectations by guiding a person to experience an event in a certain way. It is easier to see something that is wanted than unwanted.

Secondary appraisal is affected by self-efficacy in the way that a person’s confidence directly affects that person’s approach to a solution in an adverse situation.

Be able to list and briefly describe 4 characteristics of Type A Behavior Pattern (TABP).

Time-urgency is a trait of someone who is constantly time conscious.

Polyphasia is a trait of thinking or doing many activities at once.

Ultra-competitiveness is a trait of someone that is very self conscious in that they compare themselves with others of similar social status and strive to be number one at the cost of the quality of the activity.

Hyper aggressiveness is a trait describing someone who has a need to dominate people. People displaying this trait strive to be number one showing little to no compassion in the direction of others.

Be able to briefly describe what gestalt psychologists have discovered about how the structure of the human brain affects the way we perceive the environment, and how that relates to our perception of stress.

Gestalt psychologists have determined that psychological, physiological, and behavioral phenomena are irreducible configurations not derived from the simple summation of parts. This relates to the perception of stress by recognizing that all aspects of life contribute to a person's stress response.

Be able to identify how the prevalence of depression has changed over the past 50 years in America.

Depression is ten times more prevalent today than it was fifty years ago.

Be able to identify the conclusion that Aaron Beck, Martin Seligman, Albert Ellis, and other researchers have come to regarding the true nature of depression.

Beck, Seligman, and Ellis claim that depression is nothing more than symptoms caused by conscious negative thoughts.

Be able to identify what is at the core of depressed thinking, according to Martin Seligman.

According to Seligman, conscious thought patterns are at the core of depressed thinking. These though patterns are an explanatory style to describe events in either a positive or negative way.

Know what research has indicated is the strongest influence on a child’s explanatory style.

Research indicates that a child's explanatory style is most strongly influenced by the mother.

Be able to identify 3 key elements of hostility as Dr. Redford Williams defines it.

Williams identified cynical mistrust, feelings of anger, and aggressive behavior as three key elements of hostility.

Be able to identify at least 3 personality characteristics that are associated with an abnormally high risk for cancer, according to Dr. Caroline Bedell-Thomas.

Three personality characteristics associated with an increased risk for cancer include the tendency to conceal feelings, feeling unloved or unlovable, and feeling a lack of closeness to parents.

Be able to describe 3 key characteristics of the co-dependent personality.

Three key characteristics of the co-dependent personality are dependent on making others dependent on them as a means of self-validation, are perfectionists, and manipulators.

Be able to identify several key characteristics of Learned Helplessness.

Key characteristics of Learned Helplessness include the paralysis of self-motivation, perceptual distortion where perceptions of failure eclipse perceptions of success, a pessimistic explanatory style, chronic depression, and low self esteem.

Know what is the one common denominator is for the 3 major stress-prone personalities.

Low self esteem is a common denominator in stress-prone personalities, as can be seen in Type A, codependent, and helpless-hopeless types.

Be able to identify what the “Seville Statement” of 1986, proclaimed regarding aggression in humans.

The Seville Statement proclaimed that aggression in humans is neither genetically or biologically determined in human beings, it is a learned response.

Know Suzanne Kobassa-Ouellette’s 3 key Stress Hardiness characteristics. Hint: the 3 C’s. Be able to name and describe them.

The three key stress hardiness characteristics are commitment, control, and challenge. Commitment is the dedication to family, self, and work; committed to giving most things the best effort. Control is a sense of influencing the events in one's life rather than a feeling of helplessness. Challenge is the ability to see change and problems as opportunities for growth, rather than threats.

1.      Gary Schwartz, Ph.D. has discovered 3 important stress resistant characteristics that he calls the ACE Factor. The acronym stands for Attention, Connection, and Expression. Know what the terms attention and connection mean in his model, and their relationship to one another.

In Schwartz's ACE Factor model, attention means that people need to pay more attention to their life experiences. Connection means that people need to use their awareness to connect their mind and their body. Attention creates the connection between mind and body eventually leading to wellness.

2.      Know what the philosopher and educator, William James, said is “…our greatest weapon against stress.”

Our greatest weapon against stress is the ability to choose one thought over another.

Know what Viktor Frankl referred to as the “last ultimate freedom”, in his book, Man’s Search for Meaning. Be able to describe the significance of the last ultimate freedom to controlling stress in your life or someone else’s.

The last ultimate freedom is "Response - Ability". It is the ability to choose a response to any given situation.

3.      Know what Dr. Stephen Covey means when he says, “In the last analysis, no one, nothing can hurt us without our consent.”

Dr. Covey means that our consent allows hurt more than what is the reality. A person's true identity or character need not ever be hurt. The character develops freedoms. We can choose our response to either allow the pain or grow the freedom.

4.      Be able to describe the key difference between a proactive and a reactive person, according to Stephen Covey.

A proactive person responds to a situation on the basis of personal values. A reactive person responds to a situation on the basis of feelings or emotions. A proactive person can suppress their impulses and fleeting emotions to be able to respond to the stimulus.

5.      Lou Tice said, “We constantly move toward our dominant thoughts.” Be able to explain the full significance of that statement to stress and well-being.

The significance of the statement is that a person whose mind constantly dwells on the negative aspect of life will actually live in that negative world and experience negative things each day. A person whose mind constantly dwells on the positive aspect of life lives in the beautiful and positive world. This person is propelled through life by their positive thoughts.

6.      Be able to describe what basis Col. Ed Hubbard (Viet Nam POW) had for stating that, “None of us have begun to scratch the surface of our true potential.” Use specific examples to illustrate.

Potential is determined by what you think you can do and how hard you are willing to work to achieve it. A person can do anything that they commit their mind to do. A person may be able to perform hundreds of push ups or sit ups on little more than a couple hundred calories a day if the person puts their mind to it. A person could withstand an amazing amount of torture. A person may recall information that may have been forgotten years ago if the person really tries. A person may learn a language without having previously heard it spoken or seen it written.

7.      Be able to describe how the experiences Col. Hubbard had as a POW in Viet Nam helped him to effectively control his stress for the rest of his life. Use examples.

Colonel Hubbard would leave the horrors behind him, take the positive experiences and enrich the other aspects of his life. He would continue with his life with the commitment to never be shaken by fear again. Fear is only a lack of confidence to surpass an unknown aspect of life. Personal pride is the most important thing that a person can utilize to conquer their challenges.

8.      Martin Seligman has discovered that each of us has a particular explanatory style, a habitual way of explaining the causes of events in our lives. Be able to name and describe each of the 3 dimensions of causal explanations identified by Seligman. Your description may be brief, but should show a complete understanding of each dimension.

The three dimensions of causal explanations are permanence, personal locus, and pervasiveness. Permanence indicates a short term or long term explanation. Personal locus indicates whether or not the person is responsible for the event. Pervasiveness indicates if the event will globally affect many aspects of the person's life or if it will have a specific effect.

9.      You will be given a description of an event (such as getting an A+ on this exam) and asked to identify either how a pessimist or an optimist would explain the causes of the event.

10.  Be able to identify 3 ways that research has indicated flexible optimists do better than pessimists in life.

Research shows flexible optimists do better in school, win more elections, and succeed more at work than pessimists do.

11.  Be able to name each of Martin Seligman’s 3 approaches to (or dimensions of) happiness, and succinctly describe the essence of each.

Seligman’s approaches to happiness are pleasure, engagement, and meaning. The pleasant life is having as many pleasures as possible and having the savoring and mindfulness skills to amplify the pleasures. The engaging life is knowing what your signature strengths are, and then re-crafting your work, love, friendship, leisure and parenting to use those strengths to have more flow in life. The meaningful life is using your signature strengths in the service of something that you believe is larger than you are.

12.  Know which of Seligman’s 3 dimensions of happiness correlates to Plato’s first level of happiness.

Seligman's pleasant life correlates to Plato's first level of happiness, gratification.

Be able to briefly describe 2 ways which positive emotions contribute to happiness and well-being, according to Barbara Fredrickson’s “Broaden and Build Theory” of positive emotions.

Positive emotions contribute to happiness by broadening our intellectual, social, and physical resources building reserves we can draw upon when necessary. Positive emotions render us more like able and help us to cement more friendships, conditions, and social bonds.

13.  Barbara Fredrickson and Marcel Losada discovered a minimum ratio of positive to negative interactions in the workplace in order to be productive. Know what that ratio is.

The minimum ratio of positive to negative interactions in the workplace in order to be productive is 3:1.

14.  John Gottman discovered a “magic ratio” of positive to negative interchanges among couples that predicted marital success 10 years later with 94% accuracy. Know that ratio.

The ratio of positive to negative interchanges among couples predicting marital success over 10 years is 5:1.

15.  Martin E.P. Seligman, and Chris Peterson stated that their 6 core virtues and 24 character strengths, taken together, capture the notion of…. Be able to finish that sentence.

Their six core virtues and twenty-four character strengths, taken together, capture the notion of good character.

Be able to explain how Plato’s 3rd level of happiness and Seligman’s highest dimension of happiness are similar.

Plato's third level of happiness, Doing Good Beyond Self, and Seligman's dimension of happiness, Meaningful Life, are similar because like Seligman, Plato's work is interpreted to mean that it is important to find meaning and purpose beyond yourself in life.

16.  Be able to name 3 of the 5 character strengths that Peterson and Seligman’s research has indicated have the highest correlation to enduring happiness. You must know the complete name as it is stated on your Strengths handout or on the authentic happiness web site.

Character strengths that Peterson and Seligman's research has indicated have the highest correlation to enduring happiness are curiosity and interest in the world; zest, enthusiasm, and energy; and the capacity to love and be loved.

According to Karen Reivich and Andrew Shatte, there are 7 components of resilience (the RQ Test). Be able to match the name of each component with a description of that component.

The 7 components of resilience are emotional regulation, impulse control, realistic optimism, self-efficacy, accurate causal analysis, empathy, and reaching out. Emotional regulation is the ability to control attention, emotions, and behavior. Impulse control is closely tied to emotional regulation. Realistic optimism is flexible optimism or the hope that things can change for the better. Self-efficacy is the sense that we are effective in the world. Accurate causal analysis is the ability to accurately assess causes of adversity or problems. Empathy is the ability to emotional put yourself in another person's place. Reaching out allows us to increase both pleasure and meaning in life.

17.  Self-efficacy and self-esteem have been identified by many experts as key stress-resistant traits. Our text describes 7 pillars of self-esteem (7 ways we can increase self-esteem). Be able to correctly name and describe any three of those 7 pillars.

Three of the 7 pillars of self-esteem are the focus on action, the practice of living consciously, and the practice of self-acceptance. The focus on action is describing our free will so that we may reach our highest potential. The practice of living consciously is living in the moment rather than confining yourself to past or future events, and being mindful of each activity you are engaged in. The practice of self acceptance is the refusal to be in an adversarial relationship with yourself.

Know the purpose of Progressive Muscular Relaxation (PMR), and be able to describe the process. In other words, how does one do PMR?

The purpose of Progressive Muscular Relaxation is to decrease muscular tension in the body by tensing and then relaxing the body's muscle groups in systematic and progressive fashion. The contraction should be held for five to ten seconds with a relaxation phase of about forty-five seconds. The individual should focus attention on the intensity of the contraction sensing the tension produced. During the relaxation phase of each muscle group, special awareness of the feeling of relaxation should be focused on comparing it to how the muscle felt when it was contracted.

18.  Know the purpose of Autogenic Training, and be able to name two of the primary physiological changes that typically occur during autogenic training.

The purpose of autogenic training is to reprogram the mind so as to override the stress response when physical arousal is not appropriate. Two physiological changes that typically occur during autogenic training are decreases in heart rate and respiration.

19.  Be able to name two of the physical sensations that one should focus on during autogenic training.

Two of the physical sensations to focus on during autogenic training are warmth and heaviness.

20.  Be able to explain the key differences between brain waves produced during meditation and those produced during a normal conscious state.

In a normal state of consciousness the predominant brain waves emitted are rapid and jagged beta waves. Meditation tends to produce slow and almost rhythmical oscillations called alpha waves representing a decrease in sensory input.

21.  Know the key differences between transcendental meditation and mindfulness meditation. In other words how would one practice transcendental meditation, and how would one practice mindfulness meditation, and what would one do differently in each form?

Transcendental meditation is an exclusive meditation where all thoughts are eliminated. Focusing attention on one simple thing like breathing and disregarding or blocking all sensory input helps develop a deep state of calmness, relaxation, and a heightened state of awareness. Mindfulness meditation is where the mind is free to accept all thoughts. All thoughts are invited into awareness without emotional evaluation, judgment or analysis. All thoughts that enter the conscious mind must do so objectively and without judgment or emotional directive.

22.  Be able to describe the essence and significance of each of the following foundations of mindfulness to stress control:

Awareness is the ability to perceive and experience things as if for the first time, a beginners mind.

Living in the moment is to live in the present because it is the only time we have to perceive the world.

Quieting the mind is to reduce the sensory input in order to quit the mind.

Acceptance is to acknowledge where we actually are in the moment. To be able and willing to see the truth about self and life right now. It is seeing things as they actually are.

Non-judging is to observe the environment and our own thought without judging them.

Know what the research says about the difference in the risk of depression between inactive and physically active individuals.

Ross and Hayes reported that inactive people are two times as likely to have symptoms of depression as physically active persons. Paffenbarger reported that physically active men have a 17% to 28% less risk for depression than physically inactive men.

23.  Be able to name and describe 3 psychological benefits of regular physical activity, and be able to identify two probable physiological (physical) bases for those psychological benefits.

Three psychological benefits of regular physical activity are reduced anxiety, temporary mood improvement, and an enhanced self esteem. Two physiological bases for those benefits are the secretion of beta endorphins and enkaphalines and the improved secretion of cortisol during the stress response.

24.  Be able to identify the definition of an affirmation, and correctly identify a short list of guidelines that Lou Tice gives for constructing an effective affirmation.

Affirmations are written goal statements. To effectively write an affirmation, determine areas of desired change and write down 1 or 2 affirmations for each goal. They must be written in the first person, specific, and in the present tense as if they have already been achieved. They must be stated positively using emotional words that convey a vivid image.

Be able to select two of Lou Tice’s guidelines for affirmations and describe what each means using an example.

A good affirmation would be written in the present tense. An example of this would be: I am working efficiently to finish my assignment. A good affirmation must be stated positively. An example of this would be: I am helping others in a significant way when I do community service.

Implementation of the Criminalization of Production and Sale of Tobacco Products

Implementation of the Criminalization of Production and Sale of Tobacco Products

This report looks at the health and economic impact of tobacco production and sale in the United States. A brief summary of several tobacco related diseases and nicotine addiction show how tobacco is a harmful substance. This paper proposes legislation that would eliminate all tobacco sale and production rendering the tobacco market obsolete. The use of tobacco would not be prohibited except in public places. This paper hopes to present a convincing argument for the feasibility of this proposal while presenting a rebuttal that tobacco producers and sellers may offer or have offered in the past regarding municipalities and smoke free ordinances. This paper concludes that if tobacco producers and sellers no longer operated the health and economic condition of this country and it's people would be greatly improved.

Tobacco use is widespread throughout the United States. The main ingredient in tobacco products is tobacco. Tobacco leaves have been used for centuries for making smoking and chewing tobacco (Tobacco, n.d.). Tobacco contains small amounts of nicotine. Nicotine is one of the most heavily used and addictive drugs in the United States and cigarette smoking has been the most popular method of taking nicotine since the beginning of the twentieth century (National Institute on Drug Abuse, 2005). Nicotine is absorbed readily from tobacco smoke in the lungs and when tobacco is chewed. With regular use of tobacco, levels of nicotine are present for 24 hours per day because nicotine accumulates in the body. Nicotine increases the level of the neurotransmitter dopamine, which affects the brain pathways that control reward and pleasure (NIDA, 2005).

Smoking tobacco produces tobacco smoke which is a known harmful substance. Environmental smoke occurs when nonsmokers inhale other people's tobacco smoke. This smoke contains the same chemicals as the smoke smokers inhale. It contains larger amounts of the same toxic and cancer-causing substances than mainstream smoke (American Cancer Society, 2006). Mainstream smoke is the tobacco smoke emitted from a person's mouth after inhaling it.

There are currently thirty-eight of the fifty states, including Puerto Rico, that have some sort of smoke-free legislation enacted to keep environmental smoke out of most public places (Smoke Free World, 2006). There are usually many exceptions which may include bars, restaurants, casinos, or sexually oriented businesses. State laws addressing tobacco control vary in relation to restrictiveness, enforcement and penalties, and exceptions. For example, Arizona has recently passed legislation creating a smoke-free indoor air policy for most commerce sites. Most states, including Arizona, also restrict the sale of tobacco to persons over the age of 18. To restrict young people's access to tobacco, advertising is also restricted and there are excise taxes on cigarettes (Centers for Disease Control and Prevention, 1999). This makes cigarettes less appealing because they are not as visible in the public and are more expensive to purchase.

It is the purpose of this paper to promote the criminalization of tobacco sale and production. It is not the purpose of this paper to promote the criminalization of the use of tobacco. If this were achieved the public's exposure to environmental tobacco smoke would be reduced. It is also of great public benefit to restrict the substance's availability; tobacco is a known health danger (ACS, 2006). Benefits to this proposal include healthier communities and financial savings related to health care costs. The main drawback which may occur would be an economic loss due to the absence of a major market in the United States.

Supporting the Proposal
Health Consequences of Tobacco Use
According to the National Survey on Drug Use and Health 70.3 million Americans aged 12 or older reported current use of a tobacco product, 29.2 percent of the population in that age range (Substance Abuse and Mental Health Services Administration, 2005). Cigarette smoke is a harmful complex mixture of compounds produced by the burning of tobacco and other additives. The smoke contains tar, which is composed of over 4000 chemicals, 60 of which are known to cause cancer (ACS, 2006). Some of these substances cause heart and lung diseases, and all of them can be deadly. The smoke also contains the poisonous gases nitrogen oxide and carbon monoxide. Smoking is known to cause the following cancers: bladder, cervical, esophageal, kidney, laryngeal, leukemia, lung, oral, pancreatic, and stomach (Surgeon General's Report, 2004). Smoking is known to cause the following cardiovascular diseases: abdominal aortic aneurysm, atherosclerosis, cerebrovascular disease, and coronary heart disease (SGR, 2004). Smoking is known to cause the following respiratory diseases: chronic obstructive pulmonary disease, pneumonia, respiratory affects in utero, and other respiratory affects in childhood, adolescence, adulthood (SGR, 2004). Smoking is known to cause fetal death and stillbirths, fertility, low birth weight, and pregnancy complications (SGR, 2004). Lastly, smoking is known to cause diminished health status, hip fractures, low bone density, and peptic ulcer disease (SGR, 2004).

Nicotine and Addiction
Nicotine is a highly addictive substance. It provides an almost immediate "kick" because it causes a discharge of epinephrine from the adrenal cortex (NIDA, 2005). It stimulates the central nervous system and other endocrine glands, which causes a sudden release of glucose. Stimulation is then follow by depression and fatigue, leading the abuser to seek more nicotine (NIDA, 2005). Most smokers, in fact, identify tobacco as harmful and express a desire to reduce their use or stop using altogether (NIDA, 2001). The addiction is so strong it is reported that cigarette smoking is the most difficult thing to quit (Peele, 2005). According to a study done by McGill University, it does not take several years of heavy or daily smoking to become dependent on nicotine, young people become addicted earlier and faster than originally suspected (Gordon, 2005). An estimated 35.3 million Americans aged 12 or older met the criteria for nicotine dependence in the past month based on cigarette use. This represents 14.7 percent of the population (SAMHSA, 2005).

Economic Impact of Public Tobacco Use
Tobacco costs the United States economy billions of dollars each year. Smoking causes more than $167 billion each year in health related costs. This includes the cost of lost productivity due to smoking. Smoking related medical costs totaled more than $75 billion in 1998. This accounted for 8% of personal health care medical expenditures (ACS, 2006). Death related productivity losses due to smoking among workers cost the United States economy more than $92 billion yearly from 1997 to 2001. For each pack of cigarettes sold in 1999, $3.45 was spent on medical care due to smoking, plus $3.73 in lost productivity for a total cost $7.18 per pack (ACS, 2006). So while big tobacco companies may reap the benefits of tobacco sales, the United States is forced to pay the health care costs that are a result of tobacco use.

Tobacco companies argue that smoke free legislation is harmful to the economy but more than 4800 municipalities or 34.7% of the United States population is under a 100% smoke free provision and it is only tobacco funded research that shows any economic loss (ANR, 2004). Smoke free laws have no economic impact on individual businesses. According to the October 2004 edition of Contemporary Economic Policy, smoke free laws add value to establishments (ANR, 2004).

Summary and Conclusion
Tobacco contributes a great deal to our national community. Tobacco increases the rates of several cancers, diseases, and complications. NIDA claims that the use of tobacco products may be the most critical health problem facing our nation today and that tobacco use is the leading preventable cause of death in the United States (2001). It is an even greater concern than obesity. Unfortunately for tobacco users it is not that easy to quit. Nicotine is highly addictive and smoking cigarettes is the most difficult thing to give up. The economic footprint that tobacco leaves on this country is massive. At over $167 billion each year in health related costs, it is a massive footprint.

All of these losses for our country are preventable. By banning the sale and production of tobacco in the United States our country will save $167 billion dollars a year. That is money that can be put to better use funding education, developing a national health care system, and funding a myriad of national health promotion programs. This will create a near smoke free society. Granted, there will still be tobacco use, just as there is illicit drug use, but tobacco use should not be punished with criminal penalties or fines like illicit drug use is punished now. Only the tobacco companies should be punished with extensive over the top fines and criminal penalties. It should be made very clear that tobacco sale and production shall not be tolerated. This is the necessary action needed to save our country from the throws of tobacco related health problems. Restricting access to tobacco products will reduce the number of people that fall victim to the grip of nicotine addiction and it will save our country billions of dollars. Banning the sale and production of tobacco will save lives. A tobacco free society shall result in the decline of the consumption of tobacco products, an increase in the cessation rate among smokers, and a decline in the social acceptability of smoking.

Opposition to the Proposal
Tobacco & Health Concerns
The tobacco industry agrees that extended use of tobacco products has an inherent risk attached. There is even a risk attached to second hand smoke (Health Issues, n.d.). However, it is the choice of an individual to consume or not to consume tobacco. On the topic of second hand smoke, Judge William Osteen, invalidated parts of the 1993 Environmental Protection Agency Report on Secondhand Smoke rendering it ineffective (Americans for Nonsmoker's Rights, 2004). This ruling struck down the EPA's contention that secondhand smoke causes cancer and destroyed a basis for agencies or municipalities to have smoking banned or restricted. The EPA report relies on a threshold model, a method of analysis that assumes a hypothetical threshold below which exposure to secondhand smoke poses no risk (ANR, 2004). Oak Ridge National Laboratory conducted studies that question the science of secondhand smoke (ANR, 2004). In 2003, the British Medical Journal published a study that claims to have found only a weak correlation between secondhand smoke exposure and heart disease and lung cancer (ANR,2004).

Marketing of Tobacco
As it relates to young people and tobacco, the tobacco industry claims that the use of tobacco is clearly marketed towards adults. Philip Morris USA, the nation's market leader of cigarettes, has a policy to advertise in magazines that adults are more inclined to read than children, to advertise at retail stores that adults are more inclined to peruse, and to have corporate sponsorships where a majority of minors will not be present (Marketing Practices, n.d.). Tobacco companies claim to have a responsibility to their customers to maintain attractiveness for their product and do so by legal marketing towards adults.

Economic Impact
The tobacco industry claims to pump billions of dollars into the economy yearly. The tobacco industry reported $16.6 billion in earnings with a profit margin of 9.5% and offering a 29% return on equity (Yahoo! Finance, 2006). This has a tremendously positive effect on the economy. Smoke free laws only hurt those figures. There are many instances where business owners lose money when smoke free air laws go into effect. It is even possible for restaurants to lose up to 50% of their revenue as a result of smoke free air ordinances (ANR, 2004).

Smoking is a Fundamental Right
The tobacco industry claims that it is each individual's choice and right to consume tobacco as long as it does not affect anyone else. By eliminating the sale and production of tobacco those rights are being infringed upon. The choice for tobacco consumption should remain with the individual.

Summary and Conclusion
Although the tobacco industry agrees that tobacco use increases the risk of many diseases there are studies to refute few of those claims. Tobacco is a product allegedly intended for adults and is allegedly marketed only toward adults so the risk of a child's exposure is limited. The impact tobacco has on the economy is massive. By putting $16.6 billion dollars yearly into the national economy tobacco products allegedly increase the revenue of the United States in both sales and tax revenue. Tobacco companies claim smoke free ordinances hurt local business owners and other options for reducing environmental smoke from tobacco should be investigated. It is up to each individual to decide to smoke or not to smoke and the tobacco industry does not believe it should not be left up to the government to decide what a person can or cannot do.

Tobacco is a dangerous and addictive substance. About 15% of the population is already addicted. Drastic and effective action must be taken to curtail this threat. The United States would be far better off without the presence of tobacco. From a financial standpoint, this country would be saving more than $167 billion each year. From a healthy people standpoint, less people would be diagnosed with various types of cancer and disease that go along with chronic and addictive tobacco use. Companies like Philip Morris USA makes a profit off of the suffering of their customers. It is why they target young people so aggressively in their marketing campaigns. Even now, after legislation has been passed preventing their indirect marketing strategies to lure teenagers and children into tobacco use, Philip Morris USA is getting television time by showing anti-tobacco advertisements. This may be an instance where any publicity, even bad publicity, is good publicity.

Tobacco funded studies may claim no links between environmental tobacco smoke and disease but the truth is tobacco smoke is dangerous. Big tobacco may claim that it uses sound marketing practices but young people will always be their target market because of their susceptibility to addiction. Big tobacco may claim that the economic void left behind would be insurmountable. Big tobacco companies claim that businesses would lose clientèle and profits would plummet. There are claims that the tax revenue generated by tobacco products makes

government funded programs possible. These claims are unwarranted and illegitimate. There is no evidence to support that tobacco smoke is not harmful or that the United States economy depends on its production and sale.

Characters like Joe Camel may no longer legally exist but the imprint that tobacco has left on this country is devastating. Tobacco causes about 440 000 deaths in the United States each yeah while the tobacco companies reap the profits (Facts, n.d.). This is unacceptable.

American Cancer Society. February 13, 2006. Questions about Smoking, Tobacco, and Health. Retrieved March 6, 2006 from HTTP://www.cancer.org/docroot/PED/content/PED_10_2x_Questions_About_Smoking_Tobacco_and_Health.asp?sitearea=PED&viewmode=print&

Americans for Nonsmokers' Rights (2004). What to Expect from the Tobacco Industry. Berkely, California

Centers for Disease Control and Prevention (1999). Morbidity and Mortality Weekly Report. June 25, 1999. (Vol. 48 No. SS-3) Retrieved on April 1, 2006 from HTTP://www.cdc.gov/mmwr/PDF/ss/ss4803.pdf

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Finance.Yahoo.com. (2006). Cigarettes Overview: Industry Center retrieved April 12, 2006 from HTTP://biz.yahoo.com/ic/350.html

Gordon, Dianna. (2005) Too Many Kids Smoke. Annual Editions: Drugs, Society, and Behavior Twentieth Edition, 8-9

Health Issues. (n.d.) Philip Morris USA. Retrieved April 15, 2006, from PhilipMorrisusa.com Web site HTTP://www.philipmorrisusa.com/en/health_issues/default.asp

Marketing Practices. (n.d.) Philip Morris USA. Retrieved April 15, 2006, from web site: HTTP://www.philipmorrisusa.com/en/responsible_marketing/marketing_practices.asp

National Institute on Drug Abuse. August 2001. Research Report Series: Nicotine Addiction. (NIH Publication Number 01-4342).

National Institute on Drug Abuse. March 2005. Cigarettes and Other Nicotine Products. Retrieved March 6, 2006 from web site HTTP://www.drugabuse.gove/infofacts/tobacco.html

Peele, Stanton. (2005). The Surprising Truth About Addiction. Annual Editions: Drugs, Society, and Behavior, Twentieth Edition, 37-39

Smoke Free World (2006). Smoke Free USA. Retrieved April 12, 2006 from HTTP://www.smokefreeworld.com/usa.shtml

Substance Abuse and Mental Health Services Administration. (2005). Overview of Findings from the 2004 National Survey on Drug Use and Health (Office of Applied Studies, NSDUH Series H-27, DHHS Publication No. SMA 05-4061). Rockville, MD

Surgeon General's Report (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

Tobacco. (n.d.). West's Enclyclopedia of American Law. Retrieved April 15, 2006, from Answers.com web site HTTP://www.answers.com/topic/tobacco

Development of a Community Based Physical Activity Program

Development of a Community Based Physical Activity Program

Evaluation of the Walk Everyday Live Longer (WELL) Arizona Program


Physical inactivity is a big problem in American society and results in several chronic diseases. Physical activity reduces the risk for cardiovascular disease, diabetes and premature death. It is important to increase the physical activity of the sedentary population because they can receive great benefits.

The program consists of an individual walking program and a local government based intervention aimed at changing current policy and legislation related to physical activity. Social support is an effective tool to help people with their health behavior change and will be implemented within the individual portion of the program. Existing health conscious organizations, once they will be working together, will take the initiative and lobby more fiercely for physical activity legislation.

Once barriers to physical activity are removed it is expected for the general population to increase their current level of physical activity by approximately ten percent.

Problem Definition
Physical inactivity is a pervasive problem within American society. Most of the population does not engage in enough physical activity to maintain or improve their health. Physical inactivity is a risk factor for cardiovascular disease, diabetes, and premature death (Plowman, 2005). In 1999 Blair et al reported that regular physical activity reduces the risk for morbidity and mortality. Figure 1 shows that Pratt and Macera found a significant increase in medical costs associated with physically inactivity (2000). According to their research this is because regularly active people were hospitalized less than inactive people (Pratt & Macera, 2000).

It is important to target the currently sedentary population because they can receive the greatest benefit by becoming moderately active. The goal for this population should be to move from a sedentary level of fitness to achieve the recommended level of thirty minutes of moderate physical activity daily (Pate, 1995).

Critical Inputs
Implement a health behavior modification program based on Social Cognitive Theory, capitalizing on self-monitoring, goal setting, and feedback using a pedometer (Tudor-Locke & Chan, 2006). Pedometers are an inexpensive tool to track progress. Pedometers could be used to help individuals monitor their walking. The program should be split into two phases: adoption phase and adherence phase. Adoption phase will consist of a four week period where people will congregate together at a community center once a week and review their steps for that week in a log book. The meetings will encourage participants to reflect on their current steps per day, build on their successes, and set personally realistic steps-per-day goals. The goals are to be recorded in individually kept log books. During the following eight week adherence phase participants shall continue to record their steps per day and shall meet bi-weekly to further discuss progress and review various successes (Tudor-Locke & Chan, 2006).

There is a small but significant difference in walking behavior attributable to the built environment. Residents of sprawling counties are more likely to walk less during leisure time than residents of compact counties (Ewing, Schmid, Killingsworth, Zlot, & Raubenbush, 2003). It is necessary to convince policy makers to support legislation that is supportive of physical activity. It is important to convince urban planners and developers to build communities that support active transportation. Urban planners have a responsibility to plan for active transportation. Urban planners have a responsibility to plan for active transportation to influence the frequency of biking and walking (Hoehner, Brennan, Brownson, Handy, & Killinsworth, 2003). It is important to mandate employers to encourage and facilitate activity among employees during the workday. It is necessary to break down barriers for children to be active at school and in the neighborhoods (Schmid, Pratt, & Witmer, 2006). Finance and budget reform can allow us to fund the necessary changes (Cheadle et al., 2005). Public policy should positively influence and promote physical activity.

Mediating Processes
Social support can be an effective tool to link the policy changes to our desired health outcomes. Social cognitive theory can be used to help build self-efficacy that facilitates physical activity and reduce barriers that hinder it (R. R. Pate et al., 2003). Those with fewer perceived barriers are more likely to engage in physical activity (Ewing et al., 2003). Communities can be utilized to create their own incentives for physical activities. After school programs that promote unstructured activity are a good way to involve children and possibly their parents (R. R. Pate et al., 2003).

Building community capacity for health promotion has three main aspects. First, the mobilization and channeling of existing community assets into productive investments that brings about an increase in physical activity. Second, the enlargement and diversification of a communities existing pool of assets over time. Third, the empowerment of community members to sustain health improvement efforts throughout extended periods through their continuing investments of time, energy, and other resources in pursuit of collectively defined health priorities (Stokols, Grzywacz, McMahan, & Phillips, 2003).

The first process works to bring together the existing community health efforts into a focused productive form. All health conscious community programs or organizations need to collaborate towards changing public administration in a way that is health supportive. The second process facilitates an increase in outside resources and/or a reinvestment of returns on initial investments back into the community’s pool of material or human resources. The third process encompasses active efforts among community members to gain a sense of mastery and actual control over the physical inactivity health problem. Together these processes may allow for a close community empowered to mobilize and enlarge its assets for achieving a greater prevalence of physical activity (Stokols et al., 2003).

The cost of the program is also an important process. Research shows that similar programs result in a cost-benefit ratio of 2.94 meaning that every $1 invested into the program leads to $2.94 in direct medical benefit (Wang et al., 2005).

Expected Outcomes
The intended outcome of a physical activity intervention is to increase the number of people in the moderate activity category and decrease the number of people in the sedentary category. A long term goal is to reduce the incidence of cardiovascular and respiratory diseases, diabetes, and improve the quality of life for people.

The immediate expected effect of the program intervention is to increase the steps walked per day. Figure 2 shows results from the Tudor-Lock & Chan study indicate that an increase of 3000 steps by the fourth week of the program (2006). Results from the Tudor-Lock & Chan study also show that at a period of nine months 25% of the participating population will still report an increase in their walking behavior when compared to baseline (2006).

A possible effect of this community intervention will be an increase in the number of physically active people by 21.0% to 83.8% (Kahn et al., 2002/5). This is the inter-quartile range for an increase in physical activity. A more modest goal of 10% should be attained.

Extraneous Factors
Environment, transportation, social capital, and time are all reported barriers to physical activity (Zlot, Librett, Buchner, & Schmid, 2006). Environmental factors include the presence of parks and sidewalks, crime, traffic, safety, and weather. Social capital includes level of community participation and perceived community involvement and satisfaction with government responsiveness to community issues. Time refers to a perceived amount of free time or not. Transportation factors include the presence and ease of use for public transportation. These perceived barriers can also be enablers to physical activity. Table 1 illustrates how perceived barriers to physical activity increase the odds that a person will not meet recommended physical activity levels (Zlot et al., 2006). Reducing the perceived barriers to physical activity will increase the chances that a person will be able to meet physical activity recommendations.

Implementation Issues
All resources and systems required for program delivery include: funding; trained health promotion personnel; fitness or exercise facilities; outdoor recreational areas; pedestrian friendly streets and neighborhoods; crime control; and an active transportation infrastructure (Schmid et al., 2006). Implementation at the individual level should be carried out primarily through the schools, community centers, and workplaces. Physical activity and health education are necessary to help influence people’s behavior.

Implementing active transportation and other related environmental projects are the responsibility of government officials and city developers. They should be guided by the recommendations of the collaborative efforts of the existing health conscious entities.

Funding can be obtained through state and federal grants and by taxing local and larger businesses and for profit corporations. Personnel can be obtained by offering the needed positions to the health promotion community and selecting the best candidate.

In conclusion there is a need for greater implementation of physical activity promotion programs because of the problem that physical inactivity poses. There is a need for a community wide increase in physical activity but in order for any program to be successful it must have the support of the local leadership. This leadership includes everyone from administrators to city legislators to business owners and church leaders.

At the individual level the use of pedometers and social support groups are great ways for people to come together and be more active. Uses of Social Cognitive Theory by health promotion personnel to help individuals with their physical activity goals will pave the way for active people and communities.

Public policy and environmental development offer the greatest capacity to influence behavior through legislation and urban planning for active transportation. Changing the environment poses a tremendous challenge but once transformed the environment is very capable of providing a means for activity on a community wide level. It will enable people to be active who may not have thought that they could live an active lifestyle. Future development requires that city officials and developers be conscious about constructing or renovating an active environment. It is their responsibility as an elected leadership to provide this for their citizens.

Full implementation of this program may increase current physical activity levels by as much as 80% but it is more likely to see an increase of 10-20%.

Cheadle, A., Senter, S., Procello, A., Pearson, D., Nelson, G. D., & Greenwald, H. P., et al. (2005). The california wellness foundation's health improvement initiative: Evaluation findings and lessons learned. American Journal of Health Promotion, 19(4), 286-286.

Ewing, R., Schmid, T., Killingsworth, R., Zlot, A., & Raubenbush, S. (2003). Relationship between urban sprawl and physical activity, obesity, and morbidity. American Journal of Health Promotion, 18(1), 47-57.

Hoehner, C. M., Brennan, L. K., Brownson, R. C., Handy, S. L., & Killinsworth, R. (2003). Opportunities for integrating public health and urban planning approaches to promote active community environments. American Journal of Health Promotion, 18(1), 14-20.

Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath, G. W., Howze, E. H., & Powell, K. E., et al. (2002/5). The effectiveness of interventions to increase physical activity: A systematic review and. American Journal of Preventive Medicine, 22(4, Supplement 1), 73-107.

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Pratt, M., & Macera, C. A. (2000). Higher direct medical costs associated with physical inactivity. Physician & Sportsmedicine, 28(10), 63.

Schmid, T. L., Pratt, M., & Witmer, L. (2006). A framework for physical activity policy research. Journal of Physical Activity & Health, 3, S20-S29.

Stokols, D., Grzywacz, J. G., McMahan, S., & Phillips, K. (2003). Increasing the health promotive capacity of human environments. American Journal of Health Promotion, 18(1), 4-13.

Tudor-Locke, C., & Chan, C. B. (2006). An exploratory analysis of adherence patterns and program completion of a pedometer-based physical activity intervention. Journal of Physical Activity & Health, 3(2), 210-220.

Wang, G. (., Macera, C. A. (., Scudder-soucie, B. (., Schmid, T. (., Pratt, M. (., Mph), & Buchner, D. (., Mph). (2005). A cost-benefit analysis of physical activity using Bike/Pedestrian trails. Health Promotion Practice, 6(2), 174-179.

Zlot, A. I., Librett, J., Buchner, D., & Schmid, T. (2006). Environmental, transportation, social, and time barriers to physical activity. Journal of Physical Activity & Health, 3(1), 15-21.

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Evaluation of the Walk Everyday Live Longer (WELL) Arizona Program

This paper provides a basic evaluation of the WELL AZ program in Flagstaff, Arizona. The WELL AZ program is a community based physical activity intervention implementing pedometers, log books, and group meetings to increase physical activity behavior. The program currently has a 43% completion success rate. The program makes use of a Par-Q, Baseline Activity Log, and WELL Pre and Post Questionnaires as evaluation tools.

The use of pedometers allows participants to accurately chart their progress in the log books and set realistic goals that enable them to be more physically active. This site lacks digital recordkeeping and the ability to easily implement a statistical analysis to determine the program’s effectiveness at increasing physical activity behavior and reducing the prevalence of chronic disease. An upgrade to digital recordkeeping, physiological data, and statistical analysis would show how effective this program can be.

Executive Summary
The Walk Everyday and Live Longer Arizona (WELL AZ) Program is a community based intervention aimed at increasing physical activity behavior through the use of pedometers, log books, and group meetings. This program is targeted at sedentary individuals. It lasts four weeks and its purpose is to reduce the prevalence of chronic disease. Currently the program is experiencing a completion success rate of 43%. The program is funded by a grant from the Center for Disease Control (CDC) through the Arizona Department of Health Services (ADHS). The program makes use of local resources such as meeting places and other health promotion programs and agencies to present information to its participants and facilitate behavior change through their planned walks.

The program currently lacks the capacity to easily analyze its data because it is not in digital form. There was not any readily available statistical data to confirm the efficacy of the program at increasing physical activity behavior or at decreasing the prevalence of chronic disease. A needs assessment could provide the Program Coordinator with relevant information about the direction the program should take. Physiological data taken at baseline and at the conclusion of the program would provide information into the program’s efficacy at reducing the prevalence of chronic disease. Statistical analysis of the physical activity behavior taken at baseline and at the program’s end would allow insight into whether or not the increased physical activity behavior is truly a result of the intervention. A long term follow up could also show whether the program is effective at reducing the risk for chronic disease.

Program Description
The WELL AZ Program is a four week community based intervention aimed at increasing the physical activity levels of sedentary Arizona residents. Pedometers and log books are tools used in the program for monitoring and motivating people to increase physical activity. There are weekly group meetings to discuss strategies and goal setting for each week. There is also a group walk each week of the program. Coconino County sometimes adds educational sessions to the group meetings. This program is sponsored and funded by the ADHS Division of Public Health Services (DPHS). The CDC provides grant money to ADHS. The Coconino County Health Department Heartbeat Physical Activity Program is responsible for promoting, implementing and evaluating the program. To receive the grant money the WELL AZ program must be implemented. This program is in an ongoing stage of implementation beginning every other month.

The mission of the WELL AZ program is to reduce the prevalence of chronic disease such as cardiovascular disease, diabetes, osteoporosis, and some types of cancer by increasing the number of Arizonans who get 30 to 60 minutes of moderate to vigorous intensity physical activity on most days of the week by walking. The target population is all sedentary people from high school to older adults. The program serves the general public that is looking to start or increase their current activity level.

WELL AZ was first implemented in 2003 by the Coconino County Health Department. The program is on a four week timeline. The first phase of the implementation of the program is to recruit participants. The second phase includes the four weekly meetings and involves establishing baseline data. The final phase includes an evaluation by the participants.

ADHS has tested this program through several counties and they have concluded that program goals and objectives have been reached. ADHS negotiates with each county about the number of participants that should be reached. The past two years Coconino County has been charged to reach 60 to 80 participants for the grant year. For the past two years Coconino County has reached 100 to 130 participants. There is no data readily available for the first two years of the program’s implementation.

During the last two years of the program, 225 have signed up and 97 have successfully completed the program and received completion certificates. This is a success rate of approximately 43%. Of the 225 that have signed up, 53 participants have dropped out. This is an attrition rate of approximately 24%. There have been three people that have dropped out and returned to complete the program. This is a rate of 6%. There have not been any adverse effects associated with program participation and the program meets the needs of the community by providing an easy an affordable way to be more physically active.

Program Objectives
The goal of the WELL AZ program is to help increase an individual’s daily steps. Objectives of the program are to enable participants to keep track of their steps using a pedometer, to be able to set step goals by using the WELL log book, and to become aware of their physical activity level by the use of materials, log book, and pedometer.

Program Resources
The program currently records all of its participants data in log books provided ADHS. Currently Coconino County has only hard copies of records, not in digital form. WELL AZ makes use of the several evaluation tools. The Par-Q (Appendix A), Baseline Activity Log (Appendix B), WELL Pre and Post Questionnaires (Appendix C & D, respectively), a Procedural Handbook (Appendix E), and the ADHS log book. WELL AZ. The grant funding allows the program to temporarily supply pedometers to participants, and calculators and timers to group facilitators. The log books are supplied by ADHS. The program purchases replacement pedometers at $225 each, calculators at $10, and timers at $5. Other budgeting information was not available at this time.

Other resources utilized by the program include the Northern Arizona University Skydome concourse. This provides a safe and comfortable are to walk since weather in Flagstaff can be unpredictable in the fall, winter, and spring. The program also makes use of other health promotion programs to do educational presentations during group meetings. Presentations include nutritional information, injury prevention, and a tobacco cessation program.

Participants are given evaluations about program operations and knowledge gained through participation. The Program Coordinator collects evaluations and enters data to help with program improvement within their community.

Evaluability Assessment Findings
The WELL AZ program is a good program that, according to ADHS, is successful at increasing physical activity in a sedentary population. The use of pedometers allows participants to accurately chart their progress in the log books. The use of log books allows the Program Coordinator to suggest or make changes to the implementation of the program. The mission of the program is to reduce the prevalence of chronic disease but there is currently no data to keep track of this progress. There is no readily available data based on participation of the program to indicate that the prevalence of chronic disease is being reduced. There is data, by looking at the log books, and the population that has completed the program to indicate that participants in the program are indeed increasing their physical activity behavior.

A lack of electronic data entry hinders the programs ability to be fully evaluated. It would be far easier to keep track of information and population progress if a digital system were in place. This would allow for quick statistical analysis to determine if changes in physical activity behavior are actually a result of participation in the program instead of random chance. For the four years that the program has been implemented there is only two years of data readily available. That hinders a longer term analysis of the program’s effectiveness. In addition, a needs assessment has not been conducted recently.

Participant evaluations provide an opportunity for the Program Coordinator to examine the effectiveness of the program in increasing physical activity behavior. This is an important aspect of program evaluation that allows participants to voice concerns and make suggestions.

Literature Review
Available literature shows that pedometers are a useful tool to increase physical activity in populations that have little to no interest in formal exercise programs (Tudor-Locke, Bell, Myers, Harris, Ecclestone, Lauzon, et al., 2004). The use of pedometers in a physical activity intervention program may be so effective that it increases physical activity by an average of 3000 steps per day (Chan, Ryan, & Tudor-Locke, 2004). Current public health agencies recommend at least 30 minutes of physical activities most days of the week. Research shows this to be approximately 3000 to 4000 steps (Tudor-Locke & Bassett Jr, 2004). Pedometer determined physical activity may be classified in the following categories: <5000 steps per day is sedentary; 5000-7499 steps per day may be classified as low active; 7500-9999 steps per day may be classified as somewhat active; >9999 may be classified as active; and >12500 may be classified as highly active (Tudor-Locke & Bassett Jr, 2004). One article suggests that health promotion programs should focus on accumulating 30 minutes of moderate intensity physical activity instead of simply having a universal step goal (Le Masurier, 2004). This is because there is not a step per day number that the available research has proven beneficial and any step per day recommendation is far to general to be easily applied to any population.

A review of the literature indicates that an active support system promotes physical activity behavior and increases adherence to physical activity programs (Tudor-Locke et al., 2004). Participation in some physical activity programs is associated with small reductions in waist and hip girths but is not associated with improved cardiovascular fitness (Tudor-Locke et al., 2004). A lifestyle intervention is as effective at producing beneficial changes in physical activity, cardiorespiratory fitness, blood pressure, and percentage of body fat at 24 months. This especially applies to sedentary persons who have many barriers to physical activity, such as a lack of time or a negative attitude towards structured exercise (Dunn, Marcus, Kampert, Garcia, Kohl, & Blair, 1999).

Program attrition is a documented problem. In one physical activity program, full program adherence dropped from 100% in the adoption phase of the program to 58% during the adherence phase of the program (Tudor-Locke et al., 2004). Self monitoring is useful in promoting short term adherence. The process of record keeping can be implemented to improve fitness walking adherence rates (Konradi & Lyon, 2000). One study recommends the use of a fitness walking log consisting of multiple weekly grids and one distance measure (Konradi & Lyon, 2000).

Behavior change models may be used as an effective tool to change behavior. One intervention used Social Cognitive Theory (SCT) and the Stages of Change (SC) model. Ten cognitive and behavioral strategies to help people progress through their behavior change journey are aimed at ways of things and at increasing specific behaviors (Dunn et al., 1999). The use of group leaders helps participants learn to set realistic goals, monitor their physical activity progress, and provides reinforcement. In a specific intervention, participants that failed to attend at least one session per week were contacted and encouraged to return to a regular schedule of exercise. Groups met for one hour once a week for the first 16 weeks. Groups met biweekly for weeks 17 through 24. Meetings consisted of activities and discussions aimed at addressing and increasing physical activity (Dunn et al., 1999).

Proposed Evaluation Plan
This evaluation shall make a few suggestions. The first is to create digital entries of all records. This makes it easier for statistical analysis and has the potential to reduce the amount of physical paperwork that the program needs to maintain. Conducting a needs assessment would provide greater insight into the current needs of the community and could strengthen the need for the program. Most importantly, recording some sort of physiological data of the program participants would allow for a more thorough evaluation into the effectiveness of the program’s ability to reduce the prevalence of chronic disease in the population. Simple measures of blood pressure, heart rate, height, and weight taken at baseline and at the conclusion of the program could strengthen the need for the program in the community. One possible problem with recording physiological data in this program is that the program lasts only four weeks and that may not be enough time for physiological changes to occur. Another drawback to recording a person’s weight is that it may create the expectation for an individual to attempt to lose weight. This goes against a new paradigm of health at every size and may create an environment of unrealistic expectations.

This evaluation proposes that the program implement the ability to record physiological data. Tools needed for this would be sphygmomanometers, scales, and height rods. Analysis of the data should be done regularly. Once the data is digital any statistical software would be easily implemented to determine whether differences in behavior or physiological improvements are really due to involvement in the program.

A longer term follow up should be conducted to determine if there is an impact on chronic disease and physical activity behavior. This will provide more information about the effect that the program has on chronic disease.

All of these suggestions could be readily implemented as long as there is money. This evaluation foresees that this would increase the financial needs of the program. More tools and devices would need to be purchased. Personnel may need to be hired to do the data entry. Statistical software can be quite expensive.

While these suggestions would improve the evaluability of the program they are not completely necessary. One of the goals of the program is to increase physical activity and as long as the community actively participates in the program, physical activity behavior should increase. Reference List

Chan, C. B., Ryan, D. A. J., & Tudor-Locke, C. (2004). Health benefits of a pedometer-based physical activity intervention in sedentary workers. Preventive Medicine, 39(6), 1215-1222.

Dunn, A. L., Marcus, B. H., Kampert, J. B., Garcia, M. E., Kohl III, H. W., & Blair, S. N. (1999). Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: A randomized trial. The Journal of the American Medical Association, 281(4), 327-334.

Konradi, D. B., & Lyon, B. L. (2000) Measuring adherence to a self-care fitness walking routine. Journal of Community Health Nursing, 17, 159-169.

Le Masurier, G. C., M, & S. (2004). Walk which way? ACSM'S Health & Fitness Journal, 8(1), 7-10.

Tudor-Locke, C., Bell, R. C., Myers, A. M., Harris, S. B., Ecclestone, N. A., Lauzon, N., et al. (2004). Controlled outcome evaluation of the first step program: A daily physical activity intervention for individuals with type II diabetes. International Journal of Obesity & Related Metabolic Disorders, 28, 113-119.

Tudor-Locke, C., & Bassett Jr, D. R. (2004). How many Steps/Day are enough?: Preliminary pedometer indices for public health. Sports Medicine, 34, 1-8.