Cardio-vascular disease (CVD) is the leading cause of death and leads the statistics for emergency room (ER) cases. This literature review combines two primary causative agents in CVD: (1) Stress in the workplace, and (2) Middle Age. This review will explore one of the key reasons why the harmful ramifications of stress and middle age can be nullified or, at least, reduced -- through physical activity and exercise. Job stress is defined as harmful physical and emotional responses to job requirements that do not match the abilities, resources, or needs of the worker. Occupational stress is a perceived imbalance between occupational demands and the individual's ability to perform when the consequences of failure are significant (Brehm, 2002) This makes the entire concept of job stress a very personal and psychological matter -- whenever perceptions play an important role. Contemporary magazines like Newsweek, Time, and U.S. News and World Report have run features and cover stories on stress in the workplace and its effect on the average worker.

Work plays a powerful role in people's lives. It exerts an important influence on their well-being. Paid work (in some form since the beginning of time) has occupied an increasing proportion of most people's lives. While employment is challenging for most, it can also be a stressful. As work makes more and more demands on time and energy, individuals are increasingly exposed to both the positive also negative aspects of employment. It is essential to recognize three concepts:

Stress is an interaction between individuals and any source of demand (stressor) within their environment.

A stressor is the object or event that the individual perceives to be disruptive.

Stress results from the perception that the demands exceed one's capacity to cope. The interpretation or appraisal of stress is considered an intermediate step in the relationship between a given stressor and the individual's response to it.

Research has identified many organizational factors contributing to increased stress levels. They range from job insecurity, the vagaries of shift-work and long work hours, physical hazards to interpersonal conflicts with coworkers or supervisors. Reciprocally, elevated stress levels in an organization are associated with increased turnover, absenteeism, sickness, reduced productivity, and low morale. At a personal level, work stressors are related to depression, anxiety, general mental distress symptoms, heart disease, ulcers, and chronic pain. (Sauter and Hurrell, 1999) Any exploration of the relationship between work conditions and personal health must account for sex, age, race, income, education, marital and parental status, personality, and coping methods.

Lack of control over work, the work place, and employment status have been identified both as sources of stress and as a critical health risk for some workers. Employees who are unable to exert control over their lives at work are more likely to experience work stress and are therefore more likely to have impaired health. Studies have found that heavy job demand, and low control, or decreased decision latitude lead to job dissatisfaction, mental strain, and cardiovascular disease. (Israel et al., 1989). Similarly, the researchers concluded that the ability to control or influence work factors (e.g., speed and pacing of production) is linked to incidence of cardiovascular disease as well as to psychosomatic disorders, job dissatisfaction, and depression. Later in this review, reference will be made to an intervention that specifically addresses depression and cardiovascular disease. This depression finds a direct link to job stress.

Assuming that one of the drawbacks of emotional stress from job related problems was CVD, Lazarus (Lazarus, 1991) proposed an intervention with three primary strategies for reducing work-related stress:

Alter the working conditions so that they are less stressful or more conducive to effective coping. This works for large numbers of workers working under severe conditions. E.g., altering physical annoyances such as noise levels, or changing organizational decision-making processes to include employees.

Teaching employees better coping strategies. Intervention strategies could include individual counseling services for employees, Employee Assistance Programs, or specialized stress management programs. (Long, 1989)

Identify the stressful relationship between the individual or group and the work setting. Intervention strategies in these cases would include changing worker assignments to produce a better person-environment fit.

Personal behavior and habits also greatly impact the stress patterns that people experience. What may be stressful and challenging for one person, may be a motivator for another. Such workplace characteristics make it very difficult to set baselines for job-stress. (Gilpin and Gilpin, 2000) Individuals that maintain a good balance between their personal lives and their work, and those that have good social interactions with friends and family, tend to be less affected...

Employees who also have good and healthy interactions with their co-workers also have better control over the extent that they allow work to affect them. An office environment which fosters honest and open interaction between the management and the worker helps workers relate to their jobs better. It improves their esteem about their work and their role in the organization.
They reported a feeling of being burned out. (Bond, Galinsky and Swanberg., 1998)

The center for disease control (CDC) conducted a study of heart disease and job stress. It found that having increased job control can reduce job stress, was associated with lower incidence of ischemic heart disease. It found no relationship between non-rotating shift work and the risk of heart disease. The 1996 benchmark report Physical Activity and Health: A Report of the Surgeon General brings together findings from decades of research. A major conclusion is that regular physical activity reduces the risk for cardiovascular disease. (CDC.gov, 1996)

Heart attacks and stroke -- the principal "presentations" of cardiovascular disease -- are, respectively, the first and third leading causes of death in the United States. They account for 40% of all deaths. About 950,000 Americans die of heart disease or stroke each year, which amounts to one death every 33 seconds. CVD related symptoms primarily kill the older people. Besides the mortality, consider the morbidity: While 61 million Americans (almost one-fourth of the population) live with the effects of stroke or heart disease; it is also the leading cause of disability in working adults. Six million hospitalizations occur due to CVD and there are 4.5 million survivors of stroke. These ominous findings have far reaching consequences. (AHA.org, Aha Statistics, 2003)

Several years of research have shown that the personal, health and economic consequences can be significantly minimized by employing simple life affirming attitudes: healthier lifestyles, increasing early detection and intervention, e.g. physical activity and enhanced lifestyle. Research done during the 1980s shows that community interventions that change our environment (places where we work, play, learn, or live) are particularly effective in reducing heart disease and stroke throughout the entire community. (ICIHEALTH.org, 2003)

In the U.S.A., New York has led the way in promoting heart healthy policies and environments through the New York Healthy Heart. In 1997, Gov. George Pataki earmarked 4.1 billion dollars to support this effort. The results have been spectacular -- work sites increased their support for heart health by 65%; their programs included more low-fat food choices, smoke-free workplace policies, physical activity breaks, and safer stairwells.

The fact that heart diseases are directly related to work stress is emphasized by knowledge of statistics of developed, industrialized nations. In North America and Western Europe, CVD still represents a significant public health problem - indeed, a pandemic. In the former Soviet Union and other eastern European countries, CVD morbidity and mortality have increased dramatically over the last 30 years (Wrzesniewski et al., 2000). The dominant focus of research and intervention in the medical community has been on individual traits, especially genetic susceptibility and risky behaviors, such as: smoking, over-eating, sedentary lifestyle.

The underpinnings of this explanation of the CVD epidemic lie in the development of powerful engineering models. CVD could be characterized as a disturbance in hydraulic (hemodynamic) and electrical (electrophysiologic) function (Braunwald, 1997). In addition to the biological and anatomical factors, a closer look at the overall public health impact of this traditional medical approach to CVD is in order. Although cardiovascular disease usually becomes evident in middle or older age, progressive harmful conditions (e.g., atherosclerosis) leading to such disease begin in childhood. These underscore the need for developing healthy lifestyles (among them physical activity) as a preventive method. "If you think being physically active at work is helping your heart, think again if you also have workplace stress," proclaimed James H. Dwyer, Ph.D., a professor at the Keck School of Medicine at the University of Southern California, Los Angeles.

Depression is highly prevalent among people with cardiovascular disease (CVD). It has been estimated that anywhere between 20% and 50% of the CVD population suffers from depression. (Carney et al., 1988; Zeigelstein et al., 2000)

Researchers at Stanford (Taylor, Cooke and Roth, 2000) proposed a comprehensive study of seventy nonsmoking men and women, age 55 or greater, at high risk for coronary artery disease -- but who were depressed. Besides medication and the usual care, they proposed a "cognitive-behavioral" intervention. The basic intervention will be cognitive-behavioral therapy for depression. Cognitive therapy would be aimed at symptom removal by identification and correction of the patient's distorted, negatively biased,…