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Lifestyle Interventions to Modify Cardiovascular Disease Risk

Read Time: 9 Minutes

Researchers using whole-body magnetic resonance angiography have found an alarmingly high prevalence of asymptomatic atherosclerosis (49.4% of participants had at least one stenotic vessel and 27% had multiple stenotic vessels) in people considered to be at low to intermediate risk for cardiovascular disease.1 Atheroma develops over time, and subclinical disease is present before clinical symptoms are apparent.1

Atherosclerotic plaque, narrowed vessels, hypertension, and elevated LDL cholesterol are all known risk factors for cardiovascular events,2 the leading cause of death in the US.3 However, with early detection and interventions to address modifiable lifestyle factors, atherosclerosis and cardiovascular disease (CVD) can be slowed or reversed. CVD prevention begins with careful assessment of risk factors, especially those risk factors that can be modified by therapeutic lifestyle change.4

A 2021 prospective study of therapeutic lifestyle change called the Cardiovascular Health Program (CHP) found that therapeutic lifestyle change (TLC), implemented with an integrative, personalized action plan including behavioral prescriptions and supported by an interactive, educational workshop and face-to-face coaching for six months followed by six months of telephonic coaching, resulted in substantial improvements in CVD risk factors.4 Remarkably, up to 50% of participants reverted abnormal findings to normal findings. Furthermore, new medications and increased doses of medications occurred in only a very small proportion of participants, and the effects of medication changes in the study were found to be negligible in relation to the findings.4

In the following video, IFM educator Elizabeth Boham, MD, MS, RD, talks about the importance of functional medicine’s personalized lifestyle factors like diet, exercise, and sleep for at-risk patients:

Elizabeth Boham, MD, MS, RD, is board certified in family medicine and is a registered dietitian.

Food as Fuel: Dietary Approaches

Numerous lines of evidence show that plant-based diets are associated with a reduction in cardiovascular diseases and a prolonged life span.5 A 2010 study suggests that a broader adherence to recommendations for the daily intake of fruit, vegetables, fish, and fatty acid composition may take away as much as 20-30% of the burden of CVD and result in approximately one extra year of life for a 40-year-old individual.6 Observational studies also suggest that healthy eating may affect CVD-related outcomes.7 Beneficial dietary elements may include:

  • Legumes
  • Green tea
  • Mushrooms
  • Plant or marine-based omega-3 fatty acids
  • Vitamin B12 (when dietary deficiencies are present)
  • Fermented foods
  • Seaweed7
  • Spirulina8

What foods should patients avoid? Some evidence has linked added sugar to cardiometabolic and atherosclerotic vascular disease.7 Other foods to limit may include red meat and energy drinks. There is still debate in the literature over the effects of dairy products on CVD;7 however, studies suggest that fermented dairy products have been more convincingly related to lower cardiometabolic disease risk than other forms.9

In prospective cohort studies, the Mediterranean diet has been associated with lower risk for cardiovascular disease.9 In 2017, an international panel concluded that a healthy lifestyle, including the Mediterranean, DASH, Nordic, or vegetarian diet, is crucial for the prevention or delay of the onset of metabolic syndrome, CVD, and type 2 diabetes.10 Compared with a standard Western diet and based on 121 randomized trials with 21,942 patients, a 2020 systematic review and meta-analysis found that most therapeutic macronutrient diets, over six months, result in modest weight loss and substantial improvements in cardiovascular risk factors, particularly blood pressure.11

Western-type diets, which are characterized by a high intake of red meat, processed foods, refined grains, sugars, and saturated fatty acids, have been associated with a higher prevalence of metabolic syndrome in developed and developing countries.12,13 A prospective analysis conducted within the Atherosclerosis Risk in Communities study indicated an 18% greater risk of incident metabolic syndrome for individuals with the highest Western dietary pattern score.14 Furthermore, a study among Asian Indians living in the US suggested that a “Western/non-vegetarian” dietary pattern is associated with an adverse cardiometabolic metabolomic profile.15 The prevalence of metabolic syndrome, obesity, elevated high sensitivity C-reactive protein, and glucose intolerance may increase as diet-related inflammation increases.16

Two long-term observational studies published in 2021 have been added to the research that supports the positive association between plant-based foods and cardiovascular health.17,18 In these two separate studies, which analyze different measures of healthy plant food consumption, researchers found that both young adults and postmenopausal women had fewer heart attacks and were less likely to develop CVD when they ate diets with plant-based foods, particularly a diet called the Portfolio Diet.  The benefits of the Portfolio Diet have been recognized in CVD and diabetes mellitus clinical practice guidelines internationally.17,18

Researchers have also begun to evaluate whether intermittent fasting, a dietary intervention, could also confer cardiovascular benefits.19 Potential mechanisms of this diet involve reducing oxidative stress, syncing with the circadian system, and inducing ketogenesis. Although the exact mechanisms remain to be elucidated, intermittent fasting appears to positively impact multiple cardiovascular risk factors, including obesity, hypertension, dyslipidemia, and diabetes. Furthermore, intermittent fasting has been associated with improved outcomes after a cardiac event.19

Moving to Maintain Heart Health: Exercise Interventions

Sleep, sedentary behavior, and physical activity are each independently associated with cardiovascular health.20 Regular physical activity has been shown to reduce the risk of prevalent diseases such as metabolic syndrome, CVD, and type 2 diabetes.21,22 According to the American Heart Association, moderate and vigorous aerobic activity, muscle strengthening through resistance training, increasing daily movement while decreasing sedentary behavior, and adding intensity to physical activity are among the recommendations for enhancing cardiorespiratory fitness in adults.23 Flexibility and balance training are additional exercise strategies, and the benefits of specific exercise routines and activities, including Pilates, tai chi, and yoga, continue to be studied to determine the impacts of each on prevention and improvement of cardiovascular health.

High-velocity circuit resistance training improved biological markers in a 2018 study, including health-related quality of life and overall CVD risk in adults with cardiometabolic syndrome and CVD risk factors.24 Another study in frail, obese older adults found that lifestyle interventions associated with weight loss improved cardiometabolic risk factors, but continued improvement in insulin sensitivity was only achieved when exercise was added to weight loss.25

Two recent meta-analyses compared the effectiveness of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) in patients with hypertension and within cardiac rehabilitation programs.26,27 A 2020 meta-analysis found that both interventions increased the maximal oxygen uptake (VO2max) for hypertensive patients compared to control groups and promoted a reduction in systolic blood pressure, while HIIT decreased diastolic blood pressure to a greater extent.26 Investigators concluded that overall, HIIT may be more beneficial for improvement of cardiorespiratory fitness in hypertensive patients.26 A second meta-analysis of 17 studies (n=953) echoed this conclusion for those patients in cardiac rehabilitation programs.27 HIIT was superior to MICT in improving cardiorespiratory fitness with a reported standardized mean difference (SMD) of 0.34 mL/kg/min in VO2peak measurements; studies with programs lasting seven to twelve weeks resulted in the largest cardiorespiratory improvements for patients with coronary artery disease (SMD of 0.43 mL/kg/min); and HIIT was reported to be as safe as MICT for this population.27

Sleep Quality & Duration: A Risk Factor for CVD

Much research has accumulated connecting sleep quality/quantity and overall health, including heart health, with epidemiological studies suggesting relationships between sleep deprivation and hypertension, coronary heart disease, and diabetes mellitus. Adequate sleep duration may be important for preventing cardiovascular diseases in modern society. In fact, a 2019 meta-analysis looking at the impact of daylight savings on heart health found that the risk of acute myocardial infarction increases modestly but significantly after the shift to daylight savings time.28 The researchers speculate that the transition to daylight savings may cause a disruption of the circadian rhythm, which in turn induces changes in sleep quantity and quality, together with a predominance of sympathetic activity, an increase in pro-inflammatory cytokine levels, and a rise in heart rate and blood pressure. Acting together, these factors have already been recognized as possible triggers of an increased cardiovascular risk following daylight savings time shifts.28

Associations between sleep variables and measures of abdominal adiposity, glucose homeostasis, blood lipids, blood pressure, and inflammatory markers suggest that inadequate sleep may play a role in cardiometabolic risk later in life for children and adolescents.29 For example, a 2018 study in postmenopausal women suggests that sleep quality is an important correlate of insulin resistance in this population, regardless of whether the individual had metabolic syndrome.30 The study calls for further research to determine whether improving sleep improves insulin resistance in those with an elevated cardiometabolic risk.24 A similar study in children and adolescents from Bogotá DC, Colombia, showed that boys who met the recommended duration of sleep had a decreased risk of elevated blood glucose levels.31 Poor sleep quality was related to lower HDL-c and higher triglyceride levels in girls, suggesting the clinical importance of improving sleep hygiene to reduce metabolic risk factors in children and adolescents.31

An interesting study of 1,654 adults (aged 20-74 years) published in the Journal of the American Heart Association evaluated the connection of short sleep (less than six hours a night, independent of obstructive sleep apnea) with adverse health outcomes.32 Short sleep, which affects approximately 35% of the population, has been identified as a novel contributor to cardiometabolic risk factors (CMRs) and cardiovascular and cerebrovascular diseases (CBVDs). The findings suggest that short sleep duration increases the mortality risk of middle-aged adults with CMRs who have already developed CBVDs. Clinically, these findings further support the inclusion of short sleep duration as a modifiable factor in assessing the prognosis of individuals with CMR and CBVD.3

Conclusion

As IFM educator Elizabeth Boham, MD, states in the video above, “When a patient comes to see me with atherosclerosis, I always focus on those personalized lifestyle factors first and foremost… They form the foundation of health.” IFM’s Cardiometabolic Advanced Practice Module (APM) teaches clinicians new approaches to effective assessments and treatments and how to integrate these lifesaving tools into practice. Clinicians will learn how to evaluate and utilize specific nutrients, phytonutrients, botanicals, pharmaceuticals, dietary plans, stress reduction techniques, and lifestyle interventions to improve the prevention and management of patients with hypertension, cardiovascular disease, metabolic syndrome, and type 2 diabetes.

Registrants will also receive a 30-day access to IFM’s Toolkit, with more than 430 downloadable clinician resources that can be accessed and used in practice immediately after the course, including intake forms, patient handouts, and assessment questionnaires. As the research behind modifiable factors like diet and sleep continues to develop, clinicians are seeing new opportunities for safer and more effective interventions to prevent and reverse cardiometabolic disease. Learn more below.

Learn More About Cardiometabolic Function

When to Suspect Metabolic Syndrome

Clinical Pearls on Cardiometabolic Treatment

Understanding the Oral-Systemic Connection

 

References

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  2. Bhatt DL, Eagle KA, Ohman EM, et al. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA. 2010;304(12):1350-1357. doi:1001/jama.2010.1322
  3. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38-e360. doi:1161/CIR.0000000000000350
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  8. Serban MC, Sahebkar A, Dragan S, et al. A systematic review and meta-analysis of the impact of spirulina supplementation on plasma lipid concentrations. Clin Nutr. 2016;35(4):842-851. doi:1016/j.clnu.2015.09.007
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  11.  Ge L, Sadeghirad B, Ball GDC, et al. Comparison of dietary macronutrient patterns of 14 popular named dietary programmes for weight and cardiovascular risk factor reduction in adults: systematic review and network meta-analysis of randomized trials. BMJ. 2020;369:m696. doi:1136/bmj.m696
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  14.  Lutsey PL, Steffen LM, Stevens J. Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Circulation. 2008;117(6):754-761. doi:1161/CIRCULATIONAHA.107.716159
  15.  Bhupathiraju SN, Guasch-Ferré M, Gadgil MD, et al. Dietary patterns among Asian Indians living in the United States have distinct metabolomic profiles that are associated with cardiometabolic risk. J Nutr. 2018;148(7):1150-1159. doi:1093/jn/nxy074
  16.  Mazidi M, Shivappa N, Wirth MD, et al. Dietary inflammatory index and cardiometabolic risk in US adults. Atherosclerosis. 2018;276:23-27. doi:1016/j.atherosclerosis.2018.02.020
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  18.  Glenn AJ, Lo K, Jenkins DJA, et al. Relationship between a plant-based dietary portfolio and risk of cardiovascular disease: findings from the Women’s Health Initiative Prospective Cohort Study. J Am Heart Assoc. 2021;10(16):e021515. doi:1161/JAHA.121.021515
  19.  Dong TA, Sandesara PB, Dhindsa DS, et al. Intermittent fasting: a heart healthy dietary pattern? Am J Med. 2020;133(8):901-907. doi:1016/j.amjmed.2020.03.030
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  23.  American Heart Association recommendations for physical activity in adults and kids. American Heart Association. Reviewed April 18, 2018. Accessed November 2, 2021. https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
  24.  Robertson KB, Potiaumpai M, Widdowson K, et al. Effects of high-velocity circuit resistance and treadmill training on cardiometabolic risk, blood markers, and quality of life in older adults. Appl Physiol Nutr Metab. 2018;43(8):822-832. doi:1139/apnm-2017-0807
  25.  Bouchonville M, Armamento-Villareal R, Shah K, et al. Weight loss, exercise or both and cardiometabolic risk factors in obese older adults: results of a randomized controlled trial. Int J Obes. 2014;38(3):423-431. doi:1038/ijo.2013.122
  26.  Leal JM, Galliano LM, Del Vecchio FB. Effectiveness of high-intensity interval training versus moderate-intensity continuous training in hypertensive patients: a systematic review and meta-analysis. Curr Hypertens Rep. 2020;22(3):26. doi:1007/s11906-020-1030-z
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  30.  Kline CE, Hall MH, Buysse DJ, Earnest CP, Church TS. Poor sleep quality is associated with insulin resistance in postmenopausal women with and without metabolic syndrome. Metab Syndr Relat Disord. 2018;16(4):183-189. doi:1089/met.2018.0013
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  32.  Fernandez-Mendoza J, He F, Vgontzas AN, Liao D, Bixler EO. Interplay of objective sleep duration and cardiovascular and cerebrovascular diseases on cause-specific mortality. J Am Heart Assoc. 2019;8(20):e013043. doi:10.1161/JAHA.119.013043

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