Hanna Z. Mieszczanska and Gladys P. Velarde (eds.)Management of Cardiovascular Disease in Women201410.1007/978-1-4471-5517-1_18
© Springer-Verlag London 2014
18. A Holistic Integrative Medicine Approach to Cardiovascular Disease
(1)
UCSD School of Medicine, Scripps Center for Integrative Medicine, La Jolla, CA, USA
Abstract
Integrative Medicine by definition is a bridge between conventional Western Medicine and other global healing traditions. The term Holistic refers to treating the whole person: mind, body, emotions and spirit. Holistic Integrative Medicine is not synonymous with Alternative or Complementary Medicine; rather, Holistic Integrative Medicine makes use of the best of conventional medicine combined with techniques from other global healing traditions to prevent and treat chronic disease.
Introduction
Integrative Medicine by definition is a bridge between conventional Western Medicine and other global healing traditions. The term Holistic refers to treating the whole person: mind, body, emotions and spirit. Holistic Integrative Medicine is not synonymous with Alternative or Complementary Medicine; rather, Holistic Integrative Medicine makes use of the best of conventional medicine combined with techniques from other global healing traditions to prevent and treat chronic disease.
Holistic Integrative Medicine is not about the substitution of a supplement for a drug. Rather, it is about treating all of the risk factors for cardiovascular disease (CVD) and getting to their underlying causes. These risk factors are multi-factorial and may include sedentary lifestyle, hypertension, diabetes, dyslipidemia, tobacco use and central obesity. The psychological risks linked to CVD have been well-described and include stress, anxiety, depression and social isolation.
According to Women Heart, 8.6 million women worldwide die from heart disease each year, accounting for a third of all deaths in women. Three million women die from stroke each year. Stroke accounts for more deaths among women than men (11 % vs. 8.4 %), with additional risk for CVD unique to women related to oral contraceptive use in combination with tobacco.
Research points to an infinite number of insults with only a few responses which lead to atherosclerosis. These include inflammation, oxidative stress and immune dysfunction. Although genetics account for approximately 20 % of cardiovascular risk, 70–90 % of chronic disease is related to an individual’s lifestyle and environment. It is this intimate interaction between our genes and the environment that determines health or disease. Although we are born with a certain genetic code, we turn genes on and off by how we live our lives. This is our greatest opportunity for understanding the key steps to the prevention of cardiovascular disease. No field lends itself better to this integration than cardiology, which utilizes the best of technology and mandates the need for aggressive lifestyle change.
While conventional medicine excels at acute care, Holistic Integrative Medicine offers expertise in nutrition, nutraceuticals, exercise and mind-body interventions that are pivotal to CVD treatment and prevention.
Food Is Medicine
From Hippocrates we have learned that food is medicine. Today we also know that food is information. For example, our food choices turn on genes that lead to the formation of anti or pro-inflammatory cytokines. The largest prospective study to look at the benefits of monounsaturated fats and a modified Mediterranean diet is the Lyon Heart study.
This study randomized patients with known CVD to a modified Mediterranean diet or the American Heart Association (AHA) step 1 diet [1]. The modified Mediterranean diet is anti-inflammatory and includes a high consumption of fresh fruits and vegetables; the use of whole-grains rather than refined carbohydrates; low to moderate amounts of dairy, fish and poultry; low amounts of red meat; minimal amounts of processed foods and a low to moderate consumption of wine. The primary monounsaturated fat is alpha-linolenic acid (ALA) enriched canola oil. The experimental group experienced 60 % fewer cardiovascular events and 80 % fewer late diagnoses of cancer. This was further supported in the Indo-Mediterranean Heart study where the Indo-Mediterranean diet group experienced 49 % fewer cardiovascular events, 62 % fewer sudden deaths and 51 % fewer non-fatal myocardial infarctions in comparison to the National Cholesterol Education Program (NCEP) diet group [2]. Both of these diets are high in omega-3 content and are anti-inflammatory. Diets high in saturated fat and refined sugar reduce endothelium–dependent relaxation and increase inflammatory markers such as interleukin-18 and tumor necrosis factor.
The Omni Heart Randomized Trial evaluated the effect of protein, monounsaturated fat and carbohydrate intake on blood pressure and serum lipids [3]. In this study a high carbohydrate (58 %) diet was compared to a protein-modified diet (25 %) and a high monounsaturated fat diet (37 %). Compared with baseline, the 10-year Framingham risk was lowered in each group by 16–21 %. Both the protein and unsaturated fat diets demonstrated greater risk reduction than the high-carbohydrate diet. In addition, the higher-protein diet demonstrated the greatest LDL and blood pressure reductions. These patients were encouraged to have two-thirds of their protein from plant sources such as legumes, grains, nuts and seeds.
Hu and Willet reviewed 147 epidemiological and dietary intervention studies and concluded these nutrition principles for prevention of CVD [4]:
1.
Increase consumption of omega-3 fatty acids from fish, fish oil supplement, and plant sources.
2.
Substitute non-hydrogenated unsaturated fats for saturated and trans fats.
3.
Consume a diet high in fruits, vegetables, nuts, and whole grains, and low in sugar and refined grain products.
Based on the research, nutrition recommendations include:
low glycemic index carbohydrates
organic fruits and vegetables, especially green leafy vegetables
whole grains: quinoa, rye, barley, buckwheat, oats
high-quality fats: avocado, nuts, nut butters, seeds, extra virgin olive oil (first or cold pressed)
omega-3 s from fish such as salmon, herring, mackerel or sardines, or from flaxseed
plant-based protein (nuts, beans and legumes) along with lean meats
free-range organic eggs
fiber (should be slowly increased with the goal being 25–35 g/day)
foods high in antioxidants
less dairy (many people have lactose intolerance)
anti-inflammatory spices like turmeric, cinnamon, oregano and ginger
functional foods: almonds, chocolate, tea, soy, miso, tempeh
viscous fibers: eggplant, oats, and psyllium
tea and chocolate to reduce free radicals (due to high concentration of flavonoids)
In addition, we recommend five cups of green tea daily to reduce cardiovascular mortality as well as to lower cholesterol [5]. Flavonoids, especially those found in green tea, have been shown to have antithrombotic effects [6]. Consumption of black tea is associated with a reduction in acute myocardial infarction [7] and improved endothelial relaxation [8].
Hypertension
Hypertension affects at least 50 million Americans and results from an interaction between genes and the environment. Although the incidence increases with age and is more prevalent among certain ethnic groups such as African Americans, 95 % of what we label Essential Hypertension is lifestyle-related and therefore preventable. Since the release of the 2003 JNC VII report, pre-hypertension is now defined as a blood pressure of 120–130 mmHg systolic and 80–89 mmHg diastolic. Although JNC VII recommends lifestyle change for treating individuals with hypertension and pre-hypertension, their recommendations are limited and do not take supplements, mind-body interventions and vegan/vegetarian diets into consideration [9]. This is unfortunate, since meta-analyses demonstrate that a mean reduction in diastolic blood pressure of 5–6 mmHg is associated with 20–25 % less coronary disease and 35–40 % less stroke [10].
Nutrition Considerations for Hypertension
Our modern-day diet is responsible for a number of nutrition-related diseases. Research has demonstrated that vegetarians have less hypertension and coronary artery disease than non-vegetarians. Vegetarian diets are higher in potassium, fiber and complex carbohydrates. Vegetarians consume more calcium, magnesium, vitamin C and essential fatty acids. In addition, the vegetarian diet contains less saturated fat.
The potassium-to-sodium ratio is one of the keys to the vegetarian diet being associated with less hypertension. The ideal potassium-to-sodium ratio is 5:1. In the typical American diet, this ratio is frequently 1:2. Americans consume more than 5,000 mg of sodium per day. Just eating more fruits and vegetables helps to shift this ratio.
Potassium increases naturesis, improves insulin sensitivity and decreases sensitivity to Angiotensin II and catecholamines. The recommended dietary intake for potassium in hypertensive patients is 4.7 g/day with less than 1,500 mg of sodium. It is important to remind patients that dairy such as cottage cheese may contain high amounts of sodium. Potassium supplementation in foods or through the use of salt substitutes should be monitored closely and reduced in patients with renal impairment and those taking potassium-sparing medications.
The DASH trial was a multicenter, 11-week study that evaluated diet patterns on blood pressure. A total of 459 subjects were divided into three categories: increased fruits and vegetables, control, and a combination diet rich in fruits and vegetables and low in dairy and saturated fat. The combination diet led to a mean blood pressure reduction of −11.4 mmHg SBP and −5.5 DBP [11]. Additional dietary factors that affect blood pressure and are easy to implement include decreasing alcohol consumption, increasing fiber, and adding soy and olive oil. In the Shanghai Women’s Health Study soy protein intake was inversely related to SBP and DBP [12]. Similarly, a meta-analysis of fiber in 25 randomized controlled trials demonstrated significant reductions in blood pressure [13].
Many foods act as natural anti-hypertensive compounds. Foods high in magnesium, such as green leafy vegetables, not only have high fiber but the magnesium competes with sodium for binding sites on vascular smooth muscle cells. In essence, magnesium acts as a calcium channel blocker. Chelated forms of magnesium at 500–1,000 mg/day are well-tolerated. As with potassium, magnesium should be used with caution or avoided in patients with known renal impairment.
Selected Supplements for Cardiovascular Disease
Omega-3 Fatty Acids
Double-blind studies have demonstrated that flax and/or fish oil supplementation is effective in decreasing blood pressure. EPA and DHA competitively inhibit the potent vasoconstrictor thromboxane A2. A meta-analysis of 32 trials demonstrated a 3.4 mmHg drop in systolic and a 2.0 mmHg drop in diastolic blood pressure on consuming 5.6 g/day of fish oil [14].
Coenzyme Q10
Coenzyme Q10 levels have been found to be reduced in patients with hypertension and congestive heart failure. A series of eight small studies has demonstrated average systolic blood pressure decreases of 16 mmHg and average diastolic blood pressure decreases of 10 mmHg [15].
The current recommended dose is 60–120 mg taken with food. CoQ10 levels can be measured and higher doses may be indicated. Patients taking coumadin should be monitored as it has been reported that CoQ10 can decrease coumadin levels. Side effects include nausea, anorexia, and diarrhea and epigastric discomfort.
Q-SYMBIO is now the largest trial to date of CoQ10 in heart failure in the modern era. Mortensen presented results from 420 patients with class III or IV HF who were randomized to CoQ10 three times daily or placebo. After 2 years there was a significant reduction in the incidence of major adverse cardiovascular events in the CoQ10 group: 14 % (29 patients) in the CoQ10 group versus 25 % (55 patients) in the placebo group (hazard ratio 2.0, CI 1.3–3.2, p = 0.003). Mortensen also reported a significant reduction in overall mortality: 9 % (18 patients) in the CoQ10 group versus 17 % (18 patients) in the placebo group (HR 2.1, CI 1.2–3.8, p = 0.01) There were also significant reductions in cardiovascular mortality (p = 0.02) and HF hospitalizations (p = 0.05) [16].
Magnesium
An inverse correlation exists between magnesium levels and blood pressure. In the Nurses Heart Study and Honolulu Heart Study low magnesium correlated with hypertension [17, 18]. Women taking 300 mg/day had less hypertension than those on less than 200 mg/day. I recommend chelated magnesium at 250 mg twice per day. Patients are advised to monitor their bowel habits as magnesium can cause soft stool. Adverse side effects include diarrhea and renal stones. As with potassium, magnesium should be monitored closely or avoided in patients with renal insufficiency.
Potassium
As noted above, improving the potassium to sodium ratio is a key to improving blood pressure. A meta-analysis of 19 studies has demonstrated a significant reduction in blood pressure in patients taking oral potassium; −8.2 SBP, −4.5 DBP [19]. Potassium is best taken in food and in salt substitutes. Potassium should be avoided in patients with renal insufficiency and those on potassium-sparing medications.
Vitamin C
One of the many effects of vitamin C is that it induces a sodium diuresis. There is an inverse correlation between vitamin C level and blood pressure. In a study of elderly patients with refractory hypertension, 600 mg of vitamin C lowered the blood pressure 20/16 mmHg. Those with the lowest ascorbate levels had the best response [20].
Vitamin D
Vitamin D levels are also inversely related to blood pressure. Levels lower than 30 ng/ml result in elevations of the plasma renin angiotensin system. In a study of 148 women with low vitamin D3 levels, the administration of 800 IU of D3 and 1,200 mg of calcium reduced SBP 9.3 % [21]. The same effect was not noted with calcium alone.
Aged Garlic Extract
In a randomized placebo-controlled trial with 50 patients, 900 mg of aged garlic extract with 2.4 mg of S-allylcysteine daily for 12 weeks reduced SBP 10 mmHg in patients with hypertension [22]. Four cloves of garlic are required to decrease blood pressure. This contains approximately 10,000 mcg of allicin.
Aged garlic extract has also been found to slow vascular calcification. Sixty individuals were randomized to a daily capsule of placebo vs. Aged Garlic Extract-S inclusive of aged garlic-extract (250 mg) plus vitamin-B12 (100 μg), folic acid (300 μg), vitamin B6 (12.5 mg) and l-arginine (100 mg). Participants underwent coronary artery calcium (CAC) scoring and wEAT(white adipose tissue) and bEAT(brown adipose tissue) measurements at baseline and 12 months. CAC progression was defined as an annual increase in CAC > 15 % from baseline to 12 months. There was a strong correlation between increase in wEAT and CAC (r2 = 0.54, p = 0.0001). At 1 year, the risks of CAC progression and increased wEAT and homocysteine were significantly lower in AGE-S to placebo (p < 0.05). In addition, bEAT was higher in AGE-S as compared to placebo (p < 0.05). Maximum beneficial effect of AGE-S was noted with an increase in bEAT/wEAT ratio, and lack of progression of homocysteine and CAC. The authors concluded AGE-S is associated with increase in bEAT/wEAT ratio, reduction of homocysteine and lack of progression of CAC [23].
Tea, Coffee and Cocoa
Black tea and green tea have been shown to decrease blood pressure in humans. Dark chocolate (100 g) and cocoa are high in polyphenols. A meta-analysis of 297 hypertensive patients given cocoa for 2 weeks had a 4.5/2.5 mmHg drop in blood pressure [24]. Likewise, polyphenols, chlorogenic acid (CGAs) and di-hydrocaffeic acids decrease blood pressure. CGAs are found in coffee bean extract. At 140 mg/day, green coffee bean extract has been shown to decrease SBP and DBP [25].
However, the results on coffee are conflicting. Coffee contains other compounds such as hydroxyhydroquinone, which antagonizes the beneficial effect of CGA. In addition, it is important to note that slow metabolizers of caffeine have a much higher risk of developing hypertension than fast metabolizers. In this group, caffeine should be reduced or avoided.
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