CHAPTER 15

LECTURE EXTENSION

Decline in Deaths from Heart Disease and Stroke

Heart disease has been the leading cause of death in the United States since 1921, and stroke has been the third leading cause since 1938; together they account for approximately 40 percent of all deaths. Since 1950, age-adjusted death rates from cardiovascular disease (CVD) have declined 60 percent, representing one of the most important public health achievements of the twentieth century.

DECLINE IN CVD DEATH RATES
Age-adjusted death rates per 100,000 persons for diseases of the heart (that is, coronary heart disease, hypertensive heart disease, and rheumatic heart disease) have decreased from a peak of 307.4 in 1950 to 134.6 in 1996, an overall decline of 56 percent. Age-adjusted death rates for coronary heart disease (the major form of CVD contributing to mortality) continued to increase into the 1960s, then declined. In 1996, 621,000 fewer deaths occurred from coronary heart disease than would have been expected had the rate remained at its 1963 peak.

Age-adjusted death rates for stroke have declined steadily since the beginning of the twentieth century. Since 1950, stroke rates have declined 70 percent, from 88.8 in 1950 to 26.5 in 1996. Total age-adjusted CVD death rates have declined 60 percent since 1950 and accounted for approximately 73 percent of the decline in all causes of deaths during the same period.

FACTORS CONTRIBUTING TO THE DECLINE IN CVD DEATHS
Reasons for the declines in heart disease and stroke may vary by period and across region or socioeconomic group (for example, age, sex, and ethnic groups). Prevention efforts and improvements in early detection, treatment, and care have resulted in a number of beneficial trends, which may have contributed to declines in heart disease and stroke. These trends include the following:

• A decline in cigarette smoking among adults 18 years or older from approximately 42 percent in 1965 to 25 percent in 1995. Substantial public health efforts to reduce tobacco use began soon after recognition of the association between smoking and CVD and between smoking and cancer, with the first Surgeon General's report on smoking and health published in 1964.
• A decrease in mean blood pressure levels in the U.S. population.
• An increase in the percentage of persons with hypertension who have the condition treated and controlled.
• A decrease in mean blood cholesterol levels.
• Changes in the U.S. diet. Data based on surveys of food supply suggest that consumption of saturated fat and cholesterol has decreased since 1909. Data from the National Health and Nutrition Examination surveys suggest that decreases in the percentage of calories from dietary fat and the levels of dietary cholesterol coincide with decreases in blood cholesterol levels.
• Improvements in medical care, including advances in diagnosing and treating heart disease and stroke, development of effective medications for treatment of hypertension and high cholesterol, greater numbers of specialists and health care providers focusing on CVD, an increase in emergency medical services for heart attack and stroke, and an increase in coronary care units. These developments have contributed to lower fatality rates, lengthened survival times, and shorter hospital stays for persons with CVD.

CHALLENGES FOR THE TWENTY-FIRST CENTURY
Despite remarkable progress, heart disease and stroke remain leading causes of disability and death. During 1985 to 1996, for example, heart disease age-adjusted mortality declined 29 percent among white men, but only 10 percent among American Indian/Alaskan Native women. Persons of lower SES have higher mortality, morbidity, and risk-factor levels for heart disease and stroke than persons of higher SES. In addition, the SES gap in heart disease deaths may be increasing as the rates of heart disease decline faster among higher-SES groups. Geographically, declines in heart disease deaths did not occur at the same time for all communities. Areas with poorer socioeconomic profiles were more likely to experience a later onset of the decline of heart disease.

Although many trends have been positive, trends for some important indicators have not improved substantially, have leveled off, or are reversing. For example, approximately 70 percent of persons with hypertension do not have the condition controlled at levels below 140/90 mm Hg, and death rates for stroke have not declined in recent years. Heart failure has emerged as a health concern for older adults, and adults who survive a myocardial infarction or other hypertension-related diseases remain at increased risk for heart failure. In addition, the prevalence of obesity has increased among both children and adults in the United States. Despite these negative indicators, the overall decline in deaths from heart disease and stroke in the United States is encouraging.

Centers for Disease Control and Prevention (1999). Achievements in public health, 1900-1999: Decline in deaths from heart disease and stroke-United States, 1900-1999. Morbidity and Mortality Weekly Report, 48, 649-656.

LEARNING ACTIVITY

Practicing Stress Management Techniques

Most students will readily agree that they lead stressful lives, especially as the college term progresses. Review with the class the techniques for managing stress found in the Caregiving Concerns table on page 503. Have each class member select one of the suggestions to implement in stressful situations or as a lifestyle change over the next 2 or 3 weeks. Have the students record their use of the selected stress techniques and any changes in reactions to stress that they observe. In small groups, have the students discuss the techniques that they selected, examples of when the techniques were useful (or not useful), and any noticeable changes in their reactions to stress.

Since most students report experiencing school-related stress, this source of stress may be more comfortable to talk about in a group than more personal sources of stress. Students may need to implement the stress management techniques for longer periods of time to achieve noticeable differences in their reactions to stress. At the close of the discussion, suggest that students may want to try other stress management techniques found in the Caregiving Concerns table. Emphasize the importance of not trying to change too many behaviors at once.