Lifestyle changes and heart disease

Precision Medicine in Lifestyle Medicine: The Way of the Future?

Precision medicine has captured the imagination of the medical community with visions of therapies precisely targeted to the specific individual's genetic, biological, social, and environmental profile. However, in practice it has become synonymous with genomic medicine. As such its successes have been limited, with poor predictive or clinical value for the majority of people. It adds little to lifestyle medicine, other than in establishing why a healthy lifestyle is effective in combatting chronic disease. The challenge of lifestyle medicine remains getting people to actually adopt, sustain, and naturalize a healthy lifestyle, and this will require an approach that treats the patient as a person with individual needs and providing them with suitable types of support. The future of lifestyle medicine is holistic and person-centered rather than technological.

Effect of diet composition on insulin sensitivity in humans

Diet composition has a marked impact on the risk of developing type 2 diabetes and cardiovascular disease. Prospective studies show that dietary patterns with elevated amount of animal products and low quantity of vegetable food items raise the risk of these diseases. In healthy subjects, animal protein intake intensifies insulin resistance whereas plant-based foods enhance insulin sensitivity. Similar effects have been documented in patients with diabetes. Accordingly, pre-pregnancy intake of meat (processed and unprocessed) has been strongly associated with a higher risk of gestational diabetes whereas greater pre-pregnancy vegetable protein consumption is associated with a lower risk of gestational diabetes. Population groups that modify their traditional dietary habit increasing the amount of animal products while reducing plant-based foods experience a remarkable rise in the frequency of type 2 diabetes. The association of animal protein intake with insulin resistance is independent of body mass index. In obese individuals that consume high animal protein diets, insulin sensitivity does not improve following weight loss. Diets aimed to lose weight that encourage restriction of carbohydrates and elevated consumption of animal protein intensify insulin resistance increasing the risk of developing type 2 diabetes and cardiovascular disease. The effect of dietary components on insulin sensitivity may contribute to explain the striking impact of eating habits on the risk of type 2 diabetes and cardiovascular disease. Insulin resistance predisposes to type 2 diabetes in healthy subjects and deteriorates metabolic control in patients with diabetes. In nondiabetic and diabetic individuals, insulin resistance is a major cardiovascular risk factor.

Coronary artery disease in offender populations: incarceration as a risk factor and a point of intervention

Coronary artery disease (CAD) is a significant health problem and global burden. Research on antisocial behaviors has identified some groups of offenders as vulnerable to the development of cardiovascular disorders. This article reviews the relationship between criminal offending and CAD, with a particular emphasis on incarcerated populations. Existing research supports this link, with incarceration demonstrating substantial associations with numerous cardiac risk factors, development of cardiac problems, and cardiovascular disease mortality. Comprehensive multicomponent prevention programs, while often available in the community, have received little research attention in prison settings. In addition to clarifying the relationship between incarceration and heart disease, this article reviews various treatment and management responses made by prison officials.

Paleolithic nutrition: twenty-five years later

A quarter century has passed since the first publication of the evolutionary discordance hypothesis, according to which departures from the nutrition and activity patterns of our hunter-gatherer ancestors have contributed greatly and in specifically definable ways to the endemic chronic diseases of modern civilization. Refinements of the model have changed it in some respects, but anthropological evidence continues to indicate that ancestral human diets prevalent during our evolution were characterized by much lower levels of refined carbohydrates and sodium, much higher levels of fiber and protein, and comparable levels of fat (primarily unsaturated fat) and cholesterol. Physical activity levels were also much higher than current levels, resulting in higher energy throughput. We said at the outset that such evidence could only suggest testable hypotheses and that recommendations must ultimately rest on more conventional epidemiological, clinical, and laboratory studies. Such studies have multiplied and have supported many aspects of our model, to the extent that in some respects, official recommendations today have targets closer to those prevalent among hunter-gatherers than did comparable recommendations 25 years ago. Furthermore, doubts have been raised about the necessity for very low levels of protein, fat, and cholesterol intake common in official recommendations. Most impressively, randomized controlled trials have begun to confirm the value of hunter-gatherer diets in some high-risk groups, even as compared with routinely recommended diets. Much more research needs to be done, but the past quarter century has proven the interest and heuristic value, if not yet the ultimate validity, of the model.

The efficacy and cost effectiveness of integrative medicine: a review of the medical and corporate literature

Data supporting the efficacy and cost effectiveness of an integrative approach to healthcare comes from three sources: medical research conducted at universities, studies carried out by corporations developing employee wellness programs, and pilot projects run by insurance companies. The integrative approaches being studied place the patient at the center of the care and address the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person's health. Most importantly, they promote prevention by engaging the whole person in the attainment of a personalized lifestyle that supports health. A review of the medical, corporate, and payer literature reveals that, to start, immediate and significant health benefits and cost savings could be realized throughout our healthcare system by utilizing three integrative strategies: (1) integrative lifestyle change programs for those with chronic disease, (2) integrative interventions for people experiencing depression, and (3) integrative preventive strategies to support wellness in all populations.

Autonomic denervation and the origins of chronic Western diseases

Many chronic Western diseases result from lifestyles that include refined diets, poor bowel habits, limited physical exercise and suboptimal patterns of childbirth. Western diets result in reduced stool weights, increased bowel transit times and persistent physical efforts during defaecation. Prolonged physical efforts during defaecation and childbirth cause latent, or direct, injuries to branches of the cardiac (thorax), coeliac (abdomen) and hypogastric (pelvis) plexi. Injuries to autonomic nerves result in impaired visceral function including visceral dysmotility, tissue hypoplasia and hyperplasia, increased susceptibility to infection, and, aberrant reinnervation with sensitisation of the central nervous system (CNS). These unrecognised injuries are vulnerable to the long list of causes of autonomic Dysfunction, e.g. stress, alcohol, drugs, infection, trauma, cancer, etc. Specific injuries at different anatomical locations in midline autonomic pathways give rise to a wide range of Western diseases from infancy to old age, through diverse and cumulative mechanisms.

A program in contemplative self-healing: stress, allostasis, and learning in the Indo-Tibetan tradition

This paper reviews current behavioral health interventions and introduces a self-healing program based on the Indo-Tibetan tradition. While most work on behavior change emphasizes cognition and motivation, this review highlights stress-reactivity as a rate-limiting resistance to learning. Surveying cognitive-behavioral theories, it finds these limited in modeling stress-reactivity. Reviewing current interventions that address stress by integrating relaxation, mindfulness, imagery, or movement with cognitive-behavioral education, it attributes their limited effectiveness to the limits of their model of stress and their strategy of eclectically mixing techniques. Next, the article explores the Indic model of stress-cessation and self-healing assumed by mindfulness practice, concluding that it more fully reflects current findings on stress and learning. It reviews the theory and practice of mindfulness and of two less known contemplative "vehicles" preserved in Tibet, using more advanced techniques and insights better suited to lay lifestyles and secular cultures. It suggests that the Tibetan tradition of integrating all three vehicles of contemplative insight and skill in one self-healing practice should maximize coherence and effectiveness while minimizing confounding variables caused by eclecticism. Finally, the paper introduces an intervention that integrates mindfulness with techniques of cognitive analysis, affect modulation, motivational imagery, and reinforcing breathing, tailored over centuries into a complete, threefold path of self-healing. A pilot study of this intervention in women treated for breast and other gynecologic cancers suggests that the whole spectrum of Indo-Tibetan mind/body practices can be readily mastered and effectively used by Westerners to reduce stress and enhance learning and quality of life.

Long-Term Effects of Integrated Rehabilitation in Patients with Advanced Angina Pectoris: A Nonrandomized Comparative Study

OBJECTIVES

An evaluation of Integrative Rehabilitation (IR) of patients with angina pectoris with respect to death rate, the need for invasive treatment, and cost effectiveness.

DESIGN

A report from a clinical database. Death rates were compared to those of the general Danish population matched for age, gender, and observation period, as well as with data from the literature concerning medical and invasive treatments.

SETTING

The treatment was carried out as an ambulatory treatment in a private clinic.

SUBJECTS

One hundred and sixty-eight (168) patients with angina pectoris, of whom 103 were candidates for invasive treatment and 65 for whom this had been rejected.

INTERVENTIONS

Integrated rehabilitation consists of acupuncture, a self-care program including acupressure, Chinese health philosophy, stress management techniques, and lifestyle adjustments.

OUTCOME MEASURES

Death rate from any cause, the need for invasive treatment, and health care expenses.

RESULTS

The 3-year accumulated risk of death was 2.0% (95% confidence limits: 0.0%-4.7%) for the 103 candidates for invasive treatment, 6.4% for the general Danish population, 5.4% (4.7%-6.1%), and 8.4% (7.7%-9.1%) for patients who underwent percutaneous transluminal balloon angioplasty and coronary artery bypass grafting, respectively, in New York. For the 65 inoperable patients the risk of death due to heart disease was 7.7% (3.9%-11.5%), compared to 16% (10%-34%) and 25% (18%-36%) for American patients, who were treated with laser revascularization or medication, respectively. Of the 103 candidates for invasive treatment, only 19 (18%) still required surgery. Cost savings over 3 years were US 36,000 dollars and US 22,000 dollars for surgical and nonsurgical patients, respectively. These were mainly achieved by the reduction in the use of invasive treatment and a 95% reduction in in-hospital days.

CONCLUSIONS

Integrated rehabilitation was found to be cost effective, and added years to the lives of patients with severe angina pectoris. The results invite further testing in a randomized trial.

Diet, nutrition and the prevention of excess weight gain and obesity

OBJECTIVES

To review the evidence on the diet and nutrition causes of obesity and to recommend strategies to reduce obesity prevalence.

DESIGN

The evidence for potential aetiological factors and strategies to reduce obesity prevalence was reviewed, and recommendations for public health action, population nutrition goals and further research were made.

RESULTS

Protective factors against obesity were considered to be: regular physical activity (convincing); a high intake of dietary non-starch polysaccharides (NSP)/fibre (convincing); supportive home and school environments for children (probable); and breastfeeding (probable). Risk factors for obesity were considered to be sedentary lifestyles (convincing); a high intake of energy-dense, micronutrient-poor foods (convincing); heavy marketing of energy-dense foods and fast food outlets (probable); sugar-sweetened soft drinks and fruit juices (probable); adverse social and economic conditions-developed countries, especially in women (probable). A broad range of strategies were recommended to reduce obesity prevalence including: influencing the food supply to make healthy choices easier; reducing the marketing of energy dense foods and beverages to children; influencing urban environments and transport systems to promote physical activity; developing community-wide programmes in multiple settings; increased communications about healthy eating and physical activity; and improved health services to promote breastfeeding and manage currently overweight or obese people.

CONCLUSIONS

The increasing prevalence of obesity is a major health threat in both low- and high income countries. Comprehensive programmes will be needed to turn the epidemic around.

Behavioral medicine in the prevention and treatment of cardiovascular disease

Cardiac behavioral medicine is the application of behavioral and psychosocial principles to the prevention and treatment of heart disease. Most biomedical cardiovascular risk factors (e.g., high blood lipids, high blood pressure, diabetes) require behavioral and medical interventions. Other risks, including obesity, high-fat eating pattern, smoking, and inactivity, clearly require lifestyle change. Behavioral medicine screening and intervention have been applied to psychosocial risk factors such as depression, hostility, and social isolation. Appropriate assessment of risk factors is essential because research has demonstrated successful prevention of heart disease and reduction of morbidity and mortality in patients with existing disease. Behavioral interventions have been beneficial in improving cardiac outcomes by enhancing compliance with medication taking and dietary/exercise recommendations. Future needs include the study of psychosocial factors in women and ethnic minorities with heart disease and the integration of behavioral medicine with newer medical technologies designed to detect subclinical biomarkers of heart disease.

Effects of exercise and cardiac rehabilitation on cardiovascular outcomes

Comprehensive cardiac rehabilitation for coronary patients includes a systematic approach to the measurement and treatment of coronary risk factors, along with the better-known exercise training component. Studies of exercise and nutritional interventions in patients with coronary heart disease have documented improved primary outcomes of decreased morbidity and mortality, decreased symptoms, and fewer cardiac rehospitalizations. Quality of life, depression scores, and physical functioning are improved after rehabilitation.