Adapted from "Beyond Cholestrol" by Elaine Ferguson, M.D., which appeared in Alternative Medicine, Issue #32, November 1999.

Although heart disease, the leading cause of death in the Western world, has been studied for many years, scientists are now finding that beyond the known risk factors--smoking, obesity, high cholesterol levels, hypertension, a sedentary life style, and diabetes--subtler psychosocial factors such as hostility, isolation, and depression, are also responsible for coronary artery disease

For many years, the "Type A" personality--always in a hurry, quick to anger, and highly competitive--was touted as a principal contributor to heart attacks. But as research became more common in this area, studies refined the behavioral profile of potential heart attack victims, and the Type A personality did not consistently predict the development of heart disease.

Redford Williams of Duke University Medical Center found, for example, that a cynical mistrust of others, the overt expression of this cynicism, and hostility expressed in aggressive behavior accounted for higher mortality related to heart disease. "Hostility flares like a beacon, a risk factor that needs to be tempered," Williams wrote in his book, "Anger Kills."

But while it may be critical to one's health to recognize unrelenting anger as a toxic, health-damaging personality trait, it is equally important to know that it can be modified with behavioral therapy and a commitment to change. An international study conducted in Canada, the United States, and Israel, "The Short-Term Effects of Hostility-Reduction Intervention on Male Coronary Heart Disease Patients," which was published in Health Psychology (July 1999), evaluated the effectiveness of an intervention aimed at reducing hostility in patients with coronary artery disease. The project found that heart patients who released at least some of their hostility were able to significantly reduce their blood pressure.

Still the effects of hostility are manifold. One study conducted by the Massachusetts Department of Public Health in 1972, found that, in individuals age 50 and younger, unhappiness was the greatest predictor of heart disease and heart attacks. In his book, Williams connects hostility to unhappiness. He cites a study, "Cynical Hostility at Home and Work: Psychosocial Vulnerability Across Domains," conducted by Timothy Smith, a University of Utah researcher and his colleagues and published in the Journal of Research in Personality (December 1988), which found that college students, who score high on a hostility questionnaire, a part of the Minnesota Multiphasic Personality Inventory (MMPI), a standard psychological test, reported more hassles and negative life events, along with less social support. Williams also points out that hostile people had more marital problems and conflicts in their families. Thus, hostility led to another contributor to heart disease: isolation.

Family Ties

Much has been written about dysfunctional families, but the bonds among family members can also enhance one's health. A most fascinating long-term study was conducted by Stewart Wolf, M.D., in Roseto, Pennsylvania. The researchers sought to explain the very low incidence of heart disease and concluded that the supportive, interactive, and close-knit nature of the town's primarily Italian-American population created their "immunity" to heart disease. A special March 1998 Newsweek issue on health dubbed this phenomenon in Roseto the "Pennsylvania Paradox" because although residents' diets included food generously prepared with lard, they had almost no heart disease. What stood out as a critical variable was the fact that residents held on to the Old World values--drinking wine with meals and maintaining very strong social and familial ties.

Wolf's findings had a counterpart in the French Paradox, a study conducted by Boston University Department of Medicine epidemiologist, Dr. Curtis Ellison, in which the drinking of red wine positive correlated with low heart disease among the French despite a high cholesterol and high fat diet.

Dr. Wolf, who with John G. Bruhn co-authored the 1979 book "The Roseto Story" and the 1993 follow-up book "The Power of Clan," forecasted that when the researchers returned in the mid-1970s they would find increased mortality from heart disease. When Wolf first arrived in Roseto the town's families lived in tidy homes on a tightly packed avenue, their kitchens were often filled with neighbors who they also met with in the streets after leisurely dinners. Slowly and subtly, however, things changed. Traditionally the men worked in salt quarries, the women in the numerous textile mills, but as education became more important, their children became professionals. The younger people were very respectful of the Roseto spirit and attitudes but didn't want it for themselves. Since maintaining links to the past, which included behaviors that seemed to ward off heart disease, became less important than material success, Dr. Wolf accurately predicted that Roseto would lose its relative immunity to coronary heart.

Researchers then predicted that national cholesterol education programs and other public health measures would decrease the incidence of heart disease during the 80's. But when they returned in 1985, they found that despite decreasing fat intake and smoking rates, the rate of heart disease continued to climb. They concluded that the new way of life was preventing the expected decline in heart disease.

Another study focusing on the effect of community on health was conducted by Dr. George Kaplan of the University of California Medical School in San Francisco. This research project followed thousands of residents of Alameda County, California, for several years, and found social isolation to be a significant risk factor for all diseases including heart disease. Another study conducted in 1993 of patients recovering from heart attacks also found that those with lower amounts of emotional support were nearly three times as likely to die in six months as those with higher levels of emotional support. On the other hand, the Japanese, known for their high degree of social connectedness, evince a low rate of heart disease not only in their native country but also among Japanese-Americans, who retain their traditional culture.

A research project, conducted at the University of California, San Diego, found that depression is inversely associated with the size of the person's network of social support, and a recent CNN.com health study, "Depressed men twice as likely to develop heart disease," also reported that depressed men are twice as likely to develop heart disease.

In the "Rescuing the Depressed Heart," published in the Duke University Research Magazine 1997-98, Richard Merritt profiles a self-described strong and independent woman struck down by a heart attack who had never been to the hospital except to give birth to her six children. Once out of immediate danger, she became angry, full of fear, with little self-esteem, classic signs of depression. Follow up cognitive-behavior therapy helped her address her symptoms.

Williams also identifies loneliness as a psychological factor that ranks as great a risk for heart disease as high cholesterol levels. Socially isolated people are four times more likely to fall victim to sudden cardiac death as people not socially isolated.

Though known primarily for his strict cholesterol-reducing diet and exercise program, Dr. Dean Ornish's Program for Reversing Heart Disease, Dr. Ornish agrees. "The real epidemic in our culture," he writes, "is not only physical heart disease, but also what I call emotional and spiritual heart disease--that is, the profound sense of loneliness, isolation, alienation, and depression that are so prevalent in our culture with the breakdown of the social structures that used to provide us with a sense of connection and community."

Beyond Body and Mind

A recent and intriguing study, reported at the American Heart Association's annual meeting in 1998, was conducted by Dr. Mitch Krucoff, M.D, another Duke University cardiologist. Called "Monitor and Actualization of Noetic Trainings (MANTRA)," this double-blind study randomly divided 150 angioplasty patients into 30-person groups. Three of the groups received relaxation, guided imagery, or touch therapies. The names of the fourth group were inserted in the Western Wall in Jerusalem and given to Buddhist monks in Nepal, Carmelite nuns in Baltimore, and to groups of Moravians and Christian fundamentalists to pray for them by name. The fifth group received only standard medical care. Patients who received either touch therapy, stress relaxation, or guided imagery showed a 30 to 50 percent trend of improved outcomes during hospitalization compared to patients who didn't receive such therapies.

Although the study of 150 patients was too small to offer statistically significant comparisons, the results "are highly intriguing, and not what most traditional physicians would have expected," concluded Dr. Krucoff. "Our data show beneficial trends. Our goal was to conduct as scientifically rigorous and reasonable a trial as has ever been undertaken to look at what else, besides pills and procedures, might help us treat patients." A larger 1,500-patient trial is expected to start soon.

Prescriptions for a Healthy Heart

These studies and others indicate the importance of emotional and spiritual health in maintaining a healthy heart. In addition to exercise, proper nutrition, nutritional supplements, and relaxation techniques, here are a few other tips:

1. Live in the here and now. Let the past go. Put it in its proper context and look at what you've survived. We are not life's victims. Life is a gift that was meant to be enjoyed and we can do that only when we thrive.

2. Forgive yourself and others. Perhaps the most important part of letting go of the past is forgiving. Carrying around toxic memories from our past is very similar to transporting old, rotting garbage in our cars.

3. Develop life-sustaining relationships with yourselfand others and leave the rest behind. Our social support systems mirror the way we truly feel about ourselves. If we are in unhealthy, damaging relationships, something within us is out of order with our highest good. It is best to minimize or terminate those relationships that do not truly honor who we are.

4. Have faith in yourself as a part of a higher power. Regardless of what we may call the Supreme Being, God, Yahweh, Allah, Great Spirit, Jehovah, or any other divine name, that state of awareness brings forth healing in every area of our lives, if we allow it to act on our behalf.

5. Pray in accordance with the pure intents of your heart. The true heart we all possess is a life-giving organ always accessible to our innermost thoughts and desires. Live in that truth.

6. Take time to listen to your inner voice and follow its instructions. Become internally focused rather than externalized. The simple fact is that we only have to release the negative thoughts and constant chatter we create and let the soft inner voice whisper to our willing ears.

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