Lifestyle Factors for Cardiovascular Disease In Integrative Medicine
L. Terry Chappell, M.D.
Lifestyle factors recognized by Conventional Medicine (healthy diet, no obesity, regular exercise and not smoking) are a major cause of malfunction, disease, disability and premature death, if not adhered to. They have a greater impact than common interventions, such as drugs and surgery. Paying attention to multiple lifetyle factors has a much greater impact than addressing one or two. Conventional medicine certainly addresses these major lifestyle factors, but should place a greater emphasis on these and other factors. Integrative Medicine puts more emphasis on lifestyle factors, especially dealing with stress, and includes more factors than Conventional Medicine by addressing toxicities and imbalances that occur from interaction with the environment. This paper discusses the importance of making lifestyle changes a high priority and proposes that additional integrative factors be included in the routine assessment and treatment of patients.
CONVENTIONAL LIFESTYLE FACTORS
The first question often asked when evaluating a patient is, “What is your family history for heart attacks, cancer, diabetes and strokes?” The answer gives us an number of clues, but is not completely reliable to assess the risk of cardiovascular and other diseases. Anyone who has a positive family history for cardiovascular diseases, however, should institute an aggressive lifestyle program.
The Institute of Medicine estimates that behavioral and environmental factors cause 70% of avoidable deaths in the United States(1). 435,000 premature deaths are due to tobacco, and 400,000 deaths are caused by obesity and inactivity. Deaths caused by obesity are on the rise, and soon will become our greatest risk factor. In the United States, an estimated 144,000 deaths are caused by poverty. Worldwide, there are 6 billion people. 1.5 billion are hungry and 1.5 billion are obese. Either too much or too little food can be deadly.
Drugs can lower cardiovascular mortality by 5-30%, depending on the severity of the disease and compliance. Attention to five factors (obesity, smoking, inactivity, moderate alcohol consumption and healthy diet) can reduce the death rate by 57-62% (2). Thus risk factor reduction can be twice as effective as medications in reducing cardiovascular mortality.
The Arteriosclerosis Risk in Communities (ARIC) study looked at the same risk factors, excluding alcohol, for primary prevention in patients 45-64 years of age(3). Initially, 8.5% of the study group complied with all 4 risk factors. During the study period, an additional 9.1% of the females and 7.4% of the males switched to a healthier lifestyle, so that they complied with all four of the factors. Those that had full compliance to the healthier lifestyle had a 35% reduction in cardiovascular mortality and a 40% reduction in all-cause mortality. However, those that complied with only 3 of the 4 risk factors had only a 25% reduction in all-cause mortality and no reduction at all in cardiovascular mortality. Clearly, adherence to all four of these major risk factors is far more effective than partial compliance.
Surgical interventions have not consistently been proven to reduce the death rate from cardiovascular disease. The international OAT study disproved the open artery theory(4). It examined the outcomes for stable but high-risk patients who had suffered a recent myocardial infarction. All patients had a persistent totally occluded artery. Patients requiring immedicate surgery within 2 days of their MI were excluded. With a 1-year follow-up looking left ventricular ejection fraction, the patients treated with medications, angioplasties and stents together did no better than those treated only with medications. At four years of follow-up, angioplasty plus stents showed no reduction in death, reinfarction or heart failure. In fact, there was a trend toward a higher incidence of reinfarction.
Many reports have concluded that the death rate from cardiovascular disease has improved only slightly over the last 50 years, and that most of the improvement that has occured can be attributed to lifestyle changes, especially smoking cessation. Coronary artery disease and strokes are still the first and third leading causes of death due to specific diseases. It is apparent that we must do a better job with traditional lifestyle factors, perhaps with coaches or personal trainers and financial incentives. We also must address additional factors. We can do much better by embracing Integrative Medicine.
LIFESTYLE FACTORS IN INTEGRATIVE MEDICINE
Integrative Medicine puts a greater emphasis on the traditional lifestyle factors of diet, obesity, inactivity and not smoking. These are considered almost prerequisites for achieving a healthy lifestyle. With a multitude of mind/body techniques, Integrative Medicine offers patients specific ways to deal with stress, which are often left out of the equation by conventional physicians. Integrative Medicine includes interaction with the environment as a major risk factor. Various techniques are used to assess the toxic load and to detoxify aggressively or to desensitize as needed. Finally, integrative practitioners focus on many ways that various imbalances can occur in the body, most of which are caused by contact with the environment as part of a person’s lifestyle. Bringing the body back into balance is often the goal of integrative practitioners, and there are many techniques available that can detect imbalance and restore balance.
Several diets have been proposed and studied by Conventional Medicine, including the Mediterranean, LEARN, and DASH diets. The Ornish and vegetarian diets have shown benefit to lower cardiovascular risk. The former even reduced plaque to some degree, but mortality outcomes have not yet been determined. Often, integrative practitioners advocate reduced carbohydrate diets, which are indeed more effective for losing weight, reducing triglyerides, raising HDL’s and lowering high blood pressure than other diets.(5). A low carb diet is also beneficial for patients with a yeast imbalance. Alkaline diets can often be helpful. Patients with multiple food allergies certainly can benefit from an elimination or rotation diet. The message should be clear. No one diet is good for everyone. An integrative doctor must help find the diet that is most suited for the individual patient at that particular time.
Most effective diets have certain recommendations in common. There should be 5-7 servings of fruits and vegetables a day with an emphasis on the latter, and the fresher the better. One should avoid harmful fats, trans-fatty acids, processed foods, and simple sugars. Excessive alcohol is harmful. And maintenance is the most important phase of any diet. Many integrative physicians also recommend dietary supplements.
Moderate aerobic exercise of 150 minutes per week is usually recommended by conventional and integrative practitioners, along with stretching and low-impact weight lifting. There is no doubt that exercise helps people feel and function better, and there is some effect on longevity as well. Exercise can help prevent fractures in the elderly, and it can facilitate detoxification, especially if sweating takes place. But one must be careful to avoid injuries and wear and tear of the joints, especially the ligaments. Joint instability causes cartilage to deteriorate, as well as inflammation and degeneration around joints. This leads to arthroscopic surgery and joint replacements by conventional surgeons, but can often be treated or prevented with prolotherapy by integrative physicians. Prolotherapy is a series of injections to stimulate the regrowth and strengthening of ligaments around one or more joints.
There are many degrees of stress that can occur as a result of lifestyles. Catastrophic stress results from war, poverty and major injuries, sometimes with post-traumatic stress disorder as a complication. High degrees of ongoing stress can occur from work or relationships. Everyday stress is a recuring part of daily life for most people. All forms of stress must be dealt with, one way or another, or there will be consequences in how the body is able to function. The best ways to deal with stress are personal stress coping measures that can be learned and making lifestyle changes that reduce stress to a manageable level.
The ARIC study showed that if anger and excessive stress are present, it is more likely that prehypertension will lead to hypertension, coronary artery disease and cardiovascular deaths(6). Biofeedback has been shown to help, but is not in widespread use. Examples are the RESPeRATE for high blood pressure and Heart Math for heart disease. Mind/body techniques such as yoga, massage, tai chi, meditation, guided imagery, neurolinguistic programing, psych K, and hypnosis are some of the integrative ways to control stress effectively. Deep, slow breathing can help. Regular naps in the elderly might reduce heart-related deaths by a bigger factor than most cardiac drugs. An ample amount of restful sleep is often crucial for getting well, but is not infrequently overlooked as a lifestyle factor. Healthy habits, affirmations, and just taking time for family and fun activities can be very important as well.
Adrenal exhaustion due to excessive stress is almost always overlooked by conventional doctors. Serial measurements of salivary cortisol levels from an integrative lab can be diagnostic of this problem, which usually responds very well to adrenal supplements. Herbals, B-vitamins, amino acids, homeopathics, and acupuncture are frequently utilized to help patients deal with stress, anxiety, and depression. Integrative techniques such as these are safer and carry no risk of dependency, as do tranquilizers and antidepressants, which are commonly used by conventional doctors. The latter can be useful when urgently needed, but should not be routinely prescibed as the initial treatment for stress-related problems.
People who have strong religious beliefs have fewer cardiac events than those who do not. Spirituality is another of the attributes that is often nurtured by Integrative Medicine.
Conventional medical journals have recently published several important articles about the toxicity of low levels of lead and other heavy metals. Blood levels of lead have declined for the past 3 decades, but environmental lead exposures and even low levels of lead in the body remain a “major public health problem.”(7). These levels have been associated with increased mortality from heart attacks, strokes and cancer. Cumulative lead doses, beginning at low levels, have also been associated with cognitive decline (8), osteoarthritis(9), and chronic renal disease(10). Other toxic metals such as cadmium, arsenic, aluminum, antimony, and especially mercury have been associated with a myriad of health problems. Mercury, which is found in coal emmisions, in most fish, and in amalgum dental fillings, is considered to be the most toxic non-radioactive substance we have. Heavy metals do damage by increasing free radicals.
If lead and other toxic metals are such a big problem, why are they virtually ignored by the medical profession? The answer is that doctors don’t test for them, except in young children suspected of chewing lead paint chips. Furthermore, a blood test is often inaccurate, because such metals stay in the blood for only a short time. A challenge test using a chelating agent is much more sensitive. Of course, people should do everything they can to avoid exposure. But this is often not possible in a polluted world. Virtually all patients should be tested for heavy metals. If even low levels of metals are found, they need to be removed with some form of chelation therapy. Widespread screening would reveal the extent of the problem, and would necessitate treatment.
Other toxins permeate the environment as well. Science News reported that virtually everyone has huge chemical cocktails in their various body fluids, consisting of metals, hormones, plastics, pesticides and herbicides(11). It is estimated that 74 million Americans have chemical sensitivities. Thus we have both widespread pollution and increasing sensivity to the chemicals in our bodies. Minimizing exposure helps. Children who eat primarily organic foods have one-sixth as much pesticides as those who do not. Detoxification in the form of exercise, sauna, herbs, colon cleansing and hydrotherapy can be very helpful in ridding the body of this chemical burden. Various desensitization techniques available in Integrative Medicine are effective. Unfortunately, they have been rejected by conventional allergists.
Toxicity is a significant problem that must be addressed by adopting the principles of Integrative Medicine. Ignoring toxicity factors greatly limits our ability to prevent and treat cardiovascular disease. In fact, underlying toxicity and undetected allergies are probably the two most common reasons why patients do not respond to therapies that should otherwise be working well. Some form of detoxification should be done on a regular basis, and more aggressive measures are indicated if high levels are detected.
EDTA chelation therapy has been touted by Integrative Medicine not only for its approved use of removing toxic metals but also to improve circulation throughout the body. Chappell and associates looked at a 3-year follow-up on 220 patients treated with intravenous chelation therapy and routine medications(12). A meta-analysis of comparable groups treated with conventional drugs and surgery predicted that the study group treated with chelation would have 15 MI’s, 6 deaths, 31 new angioplasties, and 16 new bypass procedures during the follow-up period. The chelation group had zero MI’s and no deaths. There were only 2 angioplasties and 6 bypass procedures required. This indicates that chelation therapy is highly effective in preventing cardiac events, probably in large part by removing toxic metals. A large randomized, controlled trial with similar end points, called the Trial to Assess Chelation Therapy(TACT), is in progress.
There are many ways that the body can become unbalanced. The cause is usually an activity of daily living, lifestyle stress, or interaction with the environment. When these factors are treated and brought back into balance, they can have a major preventive or therapeutic effect.
Structural imbalance can usually be treated with chiropractic or osteopathic manipulation, or by massage. Abnormal merideans in the body can be treated with acupuncture or acupressure. Distorted electrical fields can be corrected with bio-electric treatments such as a soft laser, magnetic therapy, or injections of local anesthetics that open interference fields, such as scars. The latter technique is called Neural Therapy and is used widely in Germany. Homeopathic remedies utilize chemical energy fields to restore balance. Bio-identical hormones, as well as thryoid and adrenal supplements can balance the complicated hormonal interactions throughout the body. The immune system gets dysregulated fairly easily and can be brought back into balance with allergy desensitization and/or supplementation. Nerve cell membranes can be activated by providing anti-oxidants like glutathione and good fats like phosphatidyl choline. Neurotransmitters can be increased by giving plenty of the raw materials that serve as precursers, in the form of amino acids. Chinese herbal combinations have complicated interactions that often result in beneficial effects. These have been developed empirically over 5000 years, still without complete understanding. Digestive imbalances are often caused when there is insufficient probiotic bacteria, hydrochloric acid, or pancreatic enzymes.
The body is amazingly good at functioning well enough to survive for quite a while, despite having several systems out of balance. The more of these and other factors that can be brought back into balance, the smoother the body will function. And the less likely that diseases and disability will develop. One definition of health is the degree of survival potential.
WHY DOES INTEGRATIVE MEDICINE WORK BETTER?
Conventional Medicine is more aggressive, in an almost violent way. Drugs tend to block actions of the body and poison enzyme systems. No wonder that side effects are common. Few drugs have only one action in the body. Sometimes scalpels and lasers are called upon to excise parts of the body and put it in position to repair itself. Certainly, emphasizing lifestyle changes is a more gentle approach, and a way to help facilitate normal function.
Integrative Medicine uses multiple modalities to try to enhance normal function and nurture the body, thereby reducing the need for drugs and surgery. That is why integrative techniques are so hard to study, using controlled trials. There are simply too many variables in a comprehensive treatment plan, which is usually required for the outcome to be excellent.
Both Integrative and Conventional Medicine can improve symptoms, but the integrative approach is generally much safer and less likely to cause side effects and complications. Lifestyle changes to enhance normal function are at the core of Integrative Medicine. Conventional Medicine encourages a healthy lifestyle, but tends to bring in lifestyle teaching after the drugs are prescribed and the surgery is done. The lifestyle factors addressed by conventional physicians rarely does much for stress and usually does not look for toxicity, imbalances or interactions with the environment.
Integrative Medicine often works better, is cheaper and much safer than Conventional Medicine. Lifestyle factors are the basis for most Integrative Medicine, whereas they are less comprehensive and not emphasized to the same degree in Conventional Medicine. Virtually all physicians agree on weight control, healthy diet, moderate but regular exercise, and not smoking. It is important to realize that one must do all four to be very effective. One or two drinks a day might be helpful, probably because of a relaxing effect. But other techniques to help patients deal effectively with stress are addressed much better with Integrative than Conventional Medicine.
Integrative Medicine seeks to improve function with mind/body techniques and by correcting imbalances and toxicities that have resulted from interaction with the environment. There are a wide variety of integrative practitioners, all with different skills. It is a tribute to the healing powers of the body that not everything that becomes unbalanced needs to be corrected in order for the body to return to essentially normal function.
Our health care system will become more effective when screening and treatment for toxicities and imbalances are incorporated on a much wider scale.
Woolf SH. Potential health and economic consequences of misplaced priorities. JAMA 2007; 297:523-6.
Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation 2006; 114:160-67.
King D, et.al The atherosclerosis risk in communities cohort study. Reported in Family Practice News Feb. 1, 2007, p. 11.
Hochman JS, Lamas GA, Buller CE, et.al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355: 2395-2407.
Volek JS, et.al. Low-carb better than low-fat diet for lipids. Reported in Family Practice News Feb. 1, 2007, p. 11.
Player M, et.al. Stress and anger fuel progression to hypertension. Reported in Family Practice News Dec. 13, 2006; p. 13.
Menke A, Muntner P, Batuman V, et.al. Blood lead below 0.48 micromol/L(10 microg/dl) and mortality. Circulation 2006; 114:1388-94.
Shih RA, Glass TA, Bandee-Roche K, et.al. Environmental lead exposure and cognitive function in community-dwelling older adults. Neurology 2006; 67:1536-7.
Jordan JM, et.al. Blood lead levels linked to osteoarthritis severity. Reported in Family Practice News March 1, 2007, p. 42.
Lin JL, Lin-Tan DT, Chen KH, Huang YL. Low-level environmental exposure to lead and progressive chronic kidney disease. Am J Med 2006; 119: 707.e1-9.
Harder B. Proof of burden: scores of contaminents course through people’s veins. Science News 2003; 163:120.
- Chappell LT, Shukla R, Yang J, Blaha R, Born T, Hancke C, Mitchell W, Olszewer, van der Schaar P, Ventresco J. Subsequent cardiac and stroke events in patients with known vascular disease treated with EDTA chelation therapy. Evidence-Based Integrative Med 2005; 2:27-35.
- Harder B. Proof of burden: scores of contaminents course through people’s veins. Science News 2003; 163:120.
- Lin JL, Lin-Tan DT, Chen KH, Huang YL. Low-level environmental exposure to lead and progressive chronic kidney disease. Am J Med 2006; 119: 707.e1-9.
- Jordan JM, et.al. Blood lead levels linked to osteoarthritis severity. Reported in Family Practice News March 1, 2007, p. 42.
- Shih RA, Glass TA, Bandee-Roche K, et.al. Environmental lead exposure and cognitive function in community-dwelling older adults. Neurology 2006; 67:1536-7.
- Menke A, Muntner P, Batuman V, et.al. Blood lead below 0.48 micromol/L(10 microg/dl) and mortality. Circulation 2006; 114:1388-94.
- Player M, et.al. Stress and anger fuel progression to hypertension. Reported in Family Practice News Dec. 13, 2006; p. 13.
- Volek JS, et.al. Low-carb better than low-fat diet for lipids. Reported in Family Practice News Feb. 1, 2007, p. 11.
- Hochman JS, Lamas GA, Buller CE, et.al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355: 2395-2407.
- King D, et.al The atherosclerosis risk in communities cohort study. Reported in Family Practice News Feb. 1, 2007, p. 11.
- Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation 2006; 114:160-67.
ABOUT THE AUTHOR
L. Terry Chappell, MD, is a Board-Certified Family Physician who is in private practice in Bluffton, Ohio. He is President of the International College of Integrative Medicine. He serves as an advisor for the American Board of Clinical Metal Toxicology and is a member of the American College for Advancement in Medicine and the American Academy of Environmental Medicine. He is a clinical investigator for the NIH-funded Trial to Assess Chelation Therapy. His email address is firstname.lastname@example.org.
I have no financial interest in the modalities discussed in this paper other than their use for patients in my own office.