The evaluation of Arkansas Act 1220 of 2003 to reduce childhood obesity: conceptualization, design, and special challenges.

This article describes the evaluation of the Arkansas Act 1220 of 2003, a comprehensive legislative proposal to address the growing epidemic of childhood obesity through changes in the school environment. In addition, the article discusses specific components of the evaluation that may be applicable to other childhood obesity policy evaluation efforts. The conceptual framework for the evaluation, research questions, and evaluation design are described, along with data collection methods and analysis strategies. A mixed methods approach, including both quantitative (surveys, telephone interviews) and qualitative (key informant interviews, records reviews) approaches, was utilized to collect data from a range of informant groups including parents, adolescents, school principals, school district superintendents, and other stakeholders. Challenges encountered with the evaluation are discussed, as are strategies to overcome those challenges. Now in its 9th year, this evaluation has documented substantial changes to school policies and environments but fewer changes to student and family behaviors. The evaluation may inform the methods of other evaluations of childhood obesity prevention policies, as well as inform policymakers about how quickly they might expect implementation of such policies in their own states and localities and anticipate both positive and adverse outcomes.

Creating and using index scores in the analysis of school policy implementation and impact.

BACKGROUND: Epidemic increases in childhood obesity and associated health risks are resulting in efforts to implement school policies related to nutrition and physical activity (NPA). With multicomponent policy efforts, challenges exist in characterizing the extent of policy change across the breadth of NPA policies. METHODS: Aggregated policy indices were created to characterize NPA policy implementation in Arkansas public schools from 2004 through 2009. Index scores are presented by year, domain, and school level. RESULTS: Both mean and median index scores increased over time, with greater changes seen in nutrition than in physical activity policy scores. The composite index score was heavily dependent on the nutrition index score and, thus, is relatively less useful for the purposes of our evaluation. Policy index scores varied by school level, rurality, enrollment size, and percentage of students eligible for federal meal programs. CONCLUSIONS: The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.

Core competencies for doctoral education in public health.

The Association of Schools of Public Health (ASPH) released the Doctor of Public Health (DrPH) Core Competency Model in 2009. Between 2007 and 2009, a national expert panel with members of the academic and practice communities guided by the ASPH Education Committee developed its 7 performance domains, including 54 competencies. We provide an overview and analysis of the challenges and issues associated with the variability in DrPH degree offerings, reflect on the model development process and related outcomes, and discuss the significance of the model, future applications, and challenges for integration across educational settings. With the model, ASPH aims to stimulate national discussion on the competencies needed by DrPH graduates with the new challenges of 21st-century public health practice and to better define the DrPH degree.

Public policy versus individual rights in childhood obesity interventions: perspectives from the Arkansas experience with Act 1220 of 2003.

Childhood obesity is a major public health problem. Experts recommend that prevention and control strategies include population-based policies. Arkansas Act 1220 of 2003 is one such initiative and provides examples of the tensions between individual rights and public policy. We discuss concerns raised during the implementation of Act 1220 related to the 2 primary areas in which they emerged: body mass index measurement and reporting to parents and issues related to vending machine access. We present data from the evaluation of Act 1220 that have been used to address concerns and other research findings and conclude with a short discussion of the tension between personal rights and public policy. States considering similar policy approaches should address these concerns during policy development, involve multiple stakeholder groups, establish the legal basis for public policies, and develop consensus on key elements.

Development and evaluation of the school cafeteria nutrition assessment measures.

BACKGROUND: Foods provided in schools represent a substantial portion of US children's dietary intake; however, the school food environment has proven difficult to describe due to the lack of comprehensive, standardized, and validated measures. METHODS: As part of the Arkansas Act 1220 evaluation project, we developed the School Cafeteria Nutrition Assessment (SCNA) measures to assess food availability in public school cafeterias (n = 113). The SCNA provides a measure to evaluate monthly school lunch menus and to observe foods offered in school cafeterias during the lunch period. These measures provide information on the availability of fruit, vegetables, grains (whole or white), chips (reduced fat or regular), side dishes, main dishes, beverages, à la carte selections, and desserts, as well as information on healthier preparation of these items. Using independent raters, the inter-rater reliability of the measure was determined among a subsample of these schools (n = 32). RESULTS: All food categories assessed, with the exception of the side dish and chip categories, had inter-rater reliability rates of 0.79 or greater, regardless of school type. The SCNA scores encompassed the majority of the possible scores, indicating the ability for the measures to differentiate between school cafeterias in the availability of healthier options. CONCLUSION: These measures allow comprehensive, rapid measurement of school cafeteria food availability with high inter-rater reliability for public health and school health professionals, communities, and school personnel. These measures have the potential to contribute to school health efforts to evaluate cafeteria offerings and/or the impact of policy changes regarding school foods.

Changes in school environments with implementation of Arkansas Act 1220 of 2003.

Changes in school nutrition and physical activity policies and environments are important to combat childhood obesity. Arkansas Act 1220 of 2003 was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity through school-based change. Annual surveys of principals and superintendents have been analyzed to document substantial and important changes in school environments, policies, and practices. For example, results indicate that schools are more likely to require that healthy options be provided for student parties (4.5% in 2004, 36.9% in 2008; P

Overweight children, weight-based teasing and academic performance.

BACKGROUND: School performance of overweight children has been found to be inferior to normal weight children; however, the reason(s) for this link between overweight and academic performance remain unclear. Psychosocial factors, such as weight-based teasing, have been proposed as having a possible mediating role, although they remain largely unexplored. METHODS: Random parental telephone survey data (N=1 071) of public school students collected as part of the statewide evaluation of Arkansas Act 1220, a law to reduce childhood obesity, were used. Overweight status (body mass index > 85th percentile for gender and age) and weight-based teasing were examined as predictors of poorer school performance. RESULTS: Overweight status was a significant predictor of poorer school performance (OR=1.51; 95% CI=1.01, 2.25), after adjustment for gender, school level, free and reduced lunch participation, and race. However, the addition of weight-based teasing to the model (with weight category and covariates) reduced the weight category parameter estimate by 24%, becoming non-significant (OR=1.40; 95% CI=0.93, 2.10) and indicating a possible mediating effect of weight-based teasing on the relationship between weight category and school performance. Weight-based teasing was significantly associated with school performance, with lower odds of strong school performance among weight-based teased children (OR=0.44; 95% CI=0.27, 0.74). CONCLUSION: Psychosocial variables, such as weight-based teasing, should be considered in future research examining the impact of childhood obesity on school performance and in future intervention studies.

Arkansas Act 1220 of 2003 to reduce childhood obesity: its implementation and impact on child and adolescent body mass index.

Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.

No change in weight-based teasing when school-based obesity policies are implemented.

OBJECTIVES: To examine rates of weight-based teasing before initiation of school-based childhood obesity prevention policies (Arkansas Act 1220 of 2003) and during the 2 years following policy implementation, as well as demographic factors related to weight-based teasing. DESIGN: Analysis of consecutive random cross-sectional statewide telephone surveys conducted annually across 3 years. SETTING: Sample representative of Arkansas public school students with stratification by geographic region, school level (elementary, middle, and high school), and school size (small, medium, and large). PARTICIPANTS: Parents of children enrolled in Arkansas public schools and index adolescents 14 years or older. Intervention Statewide school-based obesity policies, including body mass index screening. MAIN OUTCOME MEASURES: Survey items about weight-based teasing, other teasing, body weight and height, and sociodemographic factors, as well as school characteristics obtained from the Common Core of Data of the National Center for Education Statistics. RESULTS: At baseline, 14% of children experienced weight-based teasing by parental report. The prevalence of weight-based teasing did not change significantly from baseline in the 2 years following school-based policy changes. Children and adolescents most likely to be teased because of weight were those who were overweight, obese, white, female, and 14 years or older, as well as those teased for other reasons. Adolescent report of weight-based teasing yielded similar patterns. CONCLUSION: Although the effectiveness of school-based obesity prevention policies remains unclear, policy changes did not lead to increased weight-based teasing among children and adolescents.

Parental recognition of overweight in school-age children.

OBJECTIVE: Examine the accuracy of parental weight perceptions of overweight children before and after the implementation of childhood obesity legislation that included BMI screening and feedback. METHODS AND PROCEDURES: Statewide telephone surveys of parents of overweight (BMI > or = 85th percentile) Arkansas public school children before (n = 1,551; 15% African American) and after (n = 2,508; 15% African American) policy implementation were examined for correspondence between parental perception of child's weight and objective classification. RESULTS: Most (60%) parents of overweight children underestimated weight at baseline. Parents of younger children were significantly more likely to underestimate (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate, nor was inaccuracy associated with parental education or socioeconomic status. African-American parents were twice as likely to underestimate as whites. One year after BMI screening and feedback was implemented, the accuracy of classification of overweight children improved (53% underestimation). African-American parents had significantly greater improvements than white parents (P < 0.0001). DISCUSSION: Parental recognition of childhood overweight may be improved with BMI screening and feedback, and African-American parents may specifically benefit. Nonetheless, underestimation of overweight is common and may have implications for public health interventions.

Training community health workers to reduce health disparities in Alabama's Black Belt: the Pine Apple Heart Disease and Stroke Project.

African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient-provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.

Psychosocial treatment within sex by ethnicity subgroups in the Enhancing Recovery in Coronary Heart Disease clinical trial.

OBJECTIVE: Intervening in depression and/or low perceived social support within 28 days after myocardial infarction (MI) in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial did not increase event-free survival. The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality. METHODS: The 2481 patients with MI (973 white men, 424 minority men, 674 white women, 410 minority women) who had major or minor depression and/or low perceived social support were randomly allocated to usual medical care or cognitive behavior therapy. Total mortality or recurrent nonfatal MI (ENRICHD primary endpoint) and cardiac mortality or recurrent nonfatal MI (secondary endpoint) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression. RESULTS: There was a trend in the direction of treatment efficacy for white men for the primary endpoint (hazard ratio [HR], 0.80; 95% confidence interval, 0.61-1.05; p =.10) and a significant (p <.006, Bonferroni corrected) effect for the secondary endpoint (HR, 0.63; 95% CI, 0.46-0.87; p =.004). In contrast, the HRs for each of the other three subgroups were nonsignificant. The magnitude of differences in treatment effects between white men and the other subgroups remained significant for the secondary endpoint (p =.04) after adjustment for age, education, living alone, antidepressant use, comorbidity score, cardiac catheterization, ejection fraction, history of hypertension, and major depression. CONCLUSIONS: White men, but not other subgroups, may have benefited from the ENRICHD intervention, suggesting that future studies need to attend to issues of treatment design and delivery that may have prevented benefit among sex and ethnic subgroups other than white men.

Knowledge of heart attack symptoms in 20 US communities. Results from the Rapid Early Action for Coronary Treatment Community Trial.

BACKGROUND: Effective treatment for patients with acute myocardial infarction is limited by patient delay in seeking care. Inadequate knowledge of heart attack symptoms may prolong delay. An intervention designed to reduce delay was tested in the Rapid Early Action for Coronary Treatment (REACT) Community Trial. In this report, the impact on knowledge of heart attack symptoms is presented. METHODS: Twenty communities were randomized to intervention or comparison status in a matched-pair design. Intervention strategies included community organization, public education, professional education, and patient education. The main outcome measures were based on information regarding knowledge of symptoms collected in a series of four random-digit-dialed telephone surveys. RESULTS: Knowledge of REACT-targeted symptoms increased in intervention communities. No change was observed in comparison communities. The net effect was an increase of 0.44 REACT-targeted symptoms per individual (P<0.001). The intervention effect was greater in ethnic minorities, persons with lower household incomes, and those with family or spouse history of heart attack (P<0.05). CONCLUSIONS: The REACT intervention was modestly successful in increasing the general public's knowledge of the complex constellation of heart attack symptoms. The intervention program was somewhat more effective in reaching disadvantaged subgroups, including ethnic minorities and persons with lower income. Despite these successes, the post-intervention level of knowledge was suboptimal.

An approach to coordinate efforts to reduce the public health burden of stroke: the Delta States Stroke Consortium.

Stroke is the third leading cause of death and a leading cause of disability in the United States, with a particularly high burden on the residents of the southeastern states, a region dubbed the "Stroke Belt." These five states - Alabama, Arkansas, Louisiana, Mississippi, and Tennessee - have formed the Delta States Stroke Consortium to direct efforts to reduce this burden. The consortium is proposing an approach to identify domains where interventions may be instituted and an array of activities that can be implemented in each of the domains. Specific domains include 1) risk factor prevention and control; 2) identification of stroke signs and symptoms and encouragement of appropriate responses; 3) transportation, Emergency Medical Services care, and acute care; 4) secondary prevention; and 5) recovery and rehabilitation management. The array of activities includes 1) education of lay public; 2) education of health professionals; 3) general advocacy and legislative actions; 4) modification of the general environment; and 5) modification of the health care environment. The Delta States Stroke Consortium members propose that together these domains and activities define a structure to guide interventions to reduce the public health burden of stroke in this region.

Policy and environmental indicators for heart disease and stroke prevention: data sources in two states.

INTRODUCTION: Investigators in South Carolina and Alabama assessed the availability of data for measuring 31 policy and environmental indicators for heart disease and stroke prevention. The indicators were intended to determine policy and environmental support for adopting heart disease and stroke prevention guidelines and selected risk factors in 4 settings: community, school, work site, and health care. METHODS: Research teams used literature searches and key informant interviews to explore the availability of data sources for each indicator. Investigators documented the following 5 qualities for each data source identified: 1) the degree to which the data fit the indicator; 2) the frequency and regularity with which data were collected; 3) the consistency of data collected across time; 4) the costs (time, money, personnel) associated with data collection or access; and 5) the accessibility of data. RESULTS: Among the 31 indicators, 11 (35%) have readily available data sources and 4 (13%) have sources that could provide partial measurement. Data sources are available for most indicators in the school setting and for tobacco control policies in all settings. CONCLUSION: Data sources for measuring policy and environmental indicators for heart disease and stroke prevention are limited in availability. Effort and resources are required to develop and implement mechanisms for collecting state and local data on policy and environmental indicators in different settings. The level of work needed to expand data sources is comparable to the extensive work already completed in the school setting and for tobacco control.

Physical activity patterns among women in rural Alabama.

OBJECTIVE: To explore factors associated with physically active women in a rural community. METHODS: Physical activity patterns were assessed in 585 women in rural Alabama. RESULTS: When combining leisure and nonleisure activities, 68% of women reported > or = 150 minutes per week. Active African American women tended to be younger (AOR 0.97), married (AOR 1.75), less likely to report arthritis (AOR 0.58), or give health (AOR 0.30) or motivational reasons (AOR 0.39) for not being more active; active white women were less likely to report lower health perception (AOR 0.51). CONCLUSION: Ethnic differences in factors associated with higher activity levels need to be considered in physical activity interventions.

Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.

CONTEXT: Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment. OBJECTIVE: To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI. DESIGN, SETTING, AND PATIENTS: Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. INTERVENTION: Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. MAIN OUTCOME MEASURES: Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months. RESULTS: Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients). CONCLUSIONS: The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.

The Depression Interview and Structured Hamilton (DISH): rationale, development, characteristics, and clinical validity.

OBJECTIVE: The Depression Interview and Structured Hamilton (DISH) is a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter clinical trial of treatment for depression and low perceived social support after acute myocardial infarction. The DISH is designed to diagnose depression in medically ill patients and to assess its severity on an embedded version of Williams' Structured Interview Guide for the Hamilton Depression scale (SIGH-D). This article describes the development and characteristics of the DISH and presents a validity study and data on its use in ENRICHD. METHODS: In the validity study, the DISH and the Structured Clinical Interview for DSM-IV (SCID) were administered in randomized order to 57 patients. Trained interviewers administered the DISH, and clinicians administered the SCID. In ENRICHD, trained research nurses administered the DISH and recorded a diagnosis. Clinicians reviewed 42% of the interviews and recorded their own diagnosis. The Beck Depression Inventory (BDI) was administered in both studies. RESULTS: In the validity study, the SCID diagnosis agreed with the DISH on 88% of the interviews (weighted kappa = 0.86). In ENRICHD, the clinicians agreed with 93% of the research nurses' diagnoses. The BDI and the Hamilton depression scores derived from the DISH in the two studies correlated 0.76 (p < .0001) in the validity study and 0.64 (p < .0001) in ENRICHD. CONCLUSIONS: These findings support the validity of the DISH as a semistructured interview to assess depression in medically ill patients. The DISH is efficient in yielding both a DSM-IV depression diagnosis and a 17-item Hamilton depression score.

Use of emergency medical services for suspected acute cardiac ischemia among demographic and clinical patient subgroups: the REACT trial. Rapid Early Action for Coronary Treatment.

OBJECTIVE: Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. METHODS: A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged > or = 30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). RESULTS: The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07-1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18-1.99, and adjusted OR 1.52, 95% CI 1.17-1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS ulse in those who were retired (adjusted OR 1.62, 95% CI 1.29-2.04) or had systolic blood pressure (SBP) at or below 160 mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26-1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88-2.97 for SBP <100 mm Hg). CONCLUSIONS: The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.

Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study.

BACKGROUND: Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates. METHODS AND RESULTS: To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise. CONCLUSIONS: In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.