|
 
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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 2
| Issue : 2 | Page : 47-52 |
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Role of integrative wellness in the care of cardiometabolic disorders
Navjyot Kaur1, KK Talwar2
1 Department of Cardiology, Command Hospital Airforce, Bengaluru, Karnataka, India
2 PSRI Heart Institute, PSRI Hospital, New Delhi, India
| Date of Submission | 17-Apr-2023 |
| Date of Acceptance | 24-Jun-2023 |
| Date of Web Publication | 25-Aug-2023 |
Correspondence Address:
K K Talwar
PSRI Heart Institute, PSRI Hospital, Seikh Sarai, New Delhi 110017
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JCDM.JCDM_2_23
The cardio-metabolic disorders are now the leading cause of morbidity and mortality all around the world. Though genetics play a role, most of these diseases have a causal relationship with smoking, environmental pollution, unhealthy food habits, sedentary lifestyle, and alcohol abuse. Poor mental state, depression, and stress have also been found to aggravate the risk to develop these diseases. These diseases are thus clubbed under diseases related to unhealthy lifestyle. The pathogenesis of these diseases is atherosclerosis or hardening of the blood vessels that occur due to constant inflammatory stress aggravated by the above-said risk factors. Since last decade, every third death is caused by a cardiovascular disease. Apart from high mortality, these are chronic disorders with no permanent cure requiring life-long medication and lifestyle changes. The patients suffering from these diseases not only undergo a decrease in their physical endurance and functional capacity but also suffer from depression, self-pity, and financial burden leading to an unhealthy lifestyle and a vicious cycle. This causes a huge burden on the health care system in the country and hence requires a wholesome approach to the prevention and management of these diseases. The integrated wellness encompasses the best of conventional medicine and evidence-based complementary medicine and lifestyle measures to provide the patient a wholesome management plan. This aims to a better patient-doctor relationship, better compliance, trust, and better lifestyle choices. The center of the integrated wellness remains the patient rather than the disease. Keywords: Cardiovascular diseases, complementary and alternative medicine, health, integrated wellness
How to cite this article:
Kaur N, Talwar K K. Role of integrative wellness in the care of cardiometabolic disorders. J Cardio Diabetes Metab Disord 2022;2:47-52 |
| Introduction | |  |
Cardio-metabolic disorders include various diseases that may accelerate atherosclerosis and can cause acute/subacute events such as coronary artery atherosclerotic disease (CAD), cerebrovascular accident (CVA), peripheral artery disease (PAD), and congestive cardiac failure (CCF).[1] These disorders include diabetes mellitus type 2 (DM type 2), hypertension (HTN), dyslipidemia, and obesity. Since the last three decades, cardiovascular disease (CVD) mortality has increased significantly leading to CVD becoming the leading cause of mortality in both developed and non-developed nations.[2] As per the estimates, every third death was caused by a CVD in 2016 and the estimates were as high as 17.9 million people worldwide.[1] This leads to a very high burden on existing healthcare systems worldwide.[3]
Apart from genetic basis, most of the cardio-metabolic disorders are aggravated by multiple modifiable risk factors that include unhealthy lifestyle, lack of exercise, bad eating habits smoking, alcohol consumption, psychosocial stress, and depression.[1],[4] Even when more than three-fourth of these risk factors can be positively modulated by a healthy lifestyle, the prevalence of cardiometabolic disorders has continued to increase as per the World Health Organization (WHO).[5],[6] Hence, it becomes imperative to prevent these diseases and establish optimal management plans for these patients. The various international associations including American College of Cardiology, American Heart Association, and European Society of Cardiology periodically review the latest evidence and present the updated guidelines to manage these diseases. Apart from the therapeutic options, all the existing guidelines stress on the importance of healthy lifestyle measures such as regular exercise and a balanced diet for the primary prevention of various cardio-metabolic risk factors. To prevent these diseases and treat the already affected patients, an enhanced cooperation and understanding between the medical practitioners, patients, and social surroundings is required.[7],[8]
We all feel an unmet goal of preventing cardio-metabolic disorders and achieving an optimal management plan for most of our patients with CVD. The factors responsible are multiple, which include that these are incurable diseases that require life-long management. During the course of treatment, many of these patients become financially and psychologically drained and a significant percentage of them lack social support. Hence to achieve health: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” as emphasized even by WHO,[9] we need an integrated approach. The concept of integrated wellness is a step to achieve not only physical but also psychological and social well-being. It is best defined as a medicine that combines the best of conventional medicine and the evidence-based complementary and alternative medicine (CAM). The CAM is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.”[10] The NCCAM classifies CAM into five categories: biologically based therapies, mind–body therapies (MBT), manipulative and body-based therapies, whole medical systems, and energy medicine.[11][Table 1] shows the various types of CAM.
| Use of Complementary and Alternative Medicine in Cardiovascular Diseases and Review of Existing Evidence | | |
Almost one-third of patients with CVD use CAM.[12],[13],[14] The most common reasons cited for the use of CAM include perceived greater benefit with CAM (15%), treating side effects of conventional medicine (59%), and achieving good health and overall well-being.[15] Although herbal therapies (18%) (garlic, ginkgo biloba, ginseng) and MBT (17%) (deep-breathing exercises and meditation) are the most commonly used CAM,[16] and concomitant use of more than one CAM therapy is also common. Despite one-third of cardiac patients using CAM, the existing evidence on the effectiveness and safety of CAM is less than sufficient. There remain a lot of hurdles: ethical, financial, and technical to conduct large randomized controlled trials (RCTs) on different modalities of CAM. The placebo effect of many therapies such as relaxation and yoga cannot be ignored. Few studies have evaluated the Hatha Yoga and Breathing Awareness Meditation on the prevention of HTN.[17],[18] DuBroff et al.[19] reported improvement in arterial pulse wave velocity and reduction in antihypertensive medications in cardiac patients following 90 days of Ayurveda treatment, which included diet, yoga, meditation, breathing, and herbal supplements. But there are a few trends that are alarming too. Besides having no sound evidence, the use of CAM may also give a false sense of security to the patients leading to non-compliance to evidence-based medicine.[20],[21] Many herbs may interact with the commonly used cardiac drugs and there appears a little awareness about the possible harmful interactions.[22],[23],[24] The physicians’ awareness about their patients using CAM range from 8% to 65%, and the reasons cited are fear of physician’s disapproval of therapy and lack of inquiry by the physicians.[15] Also, many patients tend to use more than one CAM and it further increases the risk of undesirable interactions.[23],[24] This emphasizes the need for an integrated approach for patients with CVD where all the medication and therapies used by the patient need to be reviewed and the best possible treatment plan is reached.
| Biological Based Therapies | | |
A systemic review stated that 26%–42% of cardiac patients use supplements and the concomitant use of dietary supplements and prescription medication is also frequent (16%–64%).[25] The general public people consider these products as healthy and natural and have a sense of security that these are thoroughly regulated by health agencies. But the truth is that any new dietary supplement can be rapidly introduced into the market despite containing new, experimental, or unregulated herbal ingredients.[26]
Omega-3 polyunsaturated fatty acids (PUFA-3), which are known to decrease triglyceride levels, prevent arrhythmias, decrease platelet aggregation, and lower blood pressure (BP), may be included in a healthy diet but there is no evidence that supplementation of PUFAs decreases all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke.[10],[27] Garlic supplementation is frequently used to reduce BP and treat dyslipidemia; however, there is no evidence that it provides a therapeutic advantage in reducing cardiovascular morbidity or mortality.[28],[29] Similarly ginseng and Ginkgo biloba have failed to show any consistent cardiovascular benefits.[30],[31],[32] Hawthorn extract improved exercise tolerance, decreased cardiac oxygen consumption, and improved shortness of breath and fatigue in patients with heart failure.[33] However, it failed to show a significant reduction in cardiac death, nonfatal myocardial infarction, and heart failure hospitalization.[34],[35] Antioxidants, which include beta-carotene, anthocyanins, coenzyme Q10, flavonoids, lipoic acid, selenium, and vitamins C and E, looked to be promising in observational studies; however, a systematic review of large RCTs failed to find any significant beneficial effects of antioxidant supplements for primary or secondary prevention of CVDs. In fact, increased mortality may occur with the use of vitamin A, beta-carotene, and vitamin E.[36] Chelation therapy with ethylene diamine tetraacetic acid (EDTA) has been shown to decrease cardiovascular events in post-myocardial infarction patients[37] and there is an ongoing trial TACT2 in patients with CVD whose results are expected in 2024.
There is a general perception (30%–60% CAM users) that biologically based therapies being natural are safe and have lesser side effects.[15],[26] There is a lack of knowledge (in both patients and physicians) about the herbs’ adverse effects and herb–drug/herb–herb interactions. On average, a patient with CVD daily consumes seven prescribed medications and two vitamin/herbal/mineral products and there may be more than 40 potential drug–herb interactions.[15] For instance, garlic and Gingko Biloba may increase bleeding risk in patients taking antiplatelets and anticoagulants.[26] Gingko Biloba and Ginseng can increase the risk of hypoglycemia in patients on antidiabetic drugs and Ginseng in addition may lead to increased levels of digoxin, and decrease the effectiveness of warfarin.[26] The Hawthorn enhances the coronary vasodilatory effects of nitrates and calcium channel blockers and also augments the effects of digoxin. Echinacea and St John’s wart both may interact with anti-arrhythmic drugs.[26] The review and evidence brings us to the conclusion that most of these medicinal plants contain active elements that may interact with the prescription drugs and modify their action. Hence, physicians must try to gather data from their patients if they use any of these supplements so that the dosage of prescribed drugs can be modified and adverse effects be monitored. The integrated health services and the concept of integrated wellness would help to reach a long unmet goal.
| Mind–Body Therapies | | |
The MBT includes biofeedback, cognitive-behavioral therapies, deep-breathing exercises, group support, hypnosis, guided imagery, meditation, prayer, relaxation, tai chi, and yoga.[11] The prevalence of use of MBT ranges from 2% to 57%, with meditation and deep breathing exercises representing the most commonly used therapies in this category.[15] In contrast to controversial evidence regarding the use of biological therapies, MBT therapies are generally considered safe and have considerable benefits for cardiometabolic health.[16] These tend to encourage a healthy lifestyle. A systemic review has found MBT cost-effective in patients with recent cardiac surgery and with recent acute cardiac events. These therapies are routinely used in cardiac rehabilitation programs for psychosocial support, stress management and coping skills[16] and these form a part of integrated wellness.
| Manipulative and Body-based Therapies | | |
These therapies include acupressure, chiropractic manipulation, massage, osteopathic manipulation, reflexology, Tui na, Trager bodywork, and Rolfing.[11] One study illustrated that deep tissue massage may decrease the mean BP by 7 mm Hg, and the mean heart rate by 10.8 beats per minute[38] but the review of the literature did not support the sustained reduction in BP.[39] Similarly there is a lack of enough evidence that spinal manipulation can significantly reduce the BP.[40] These therapies have a potential to be used in integrated wellness and may help in the relaxation and prevention of cardio-metabolic disorders.
| Whole Medical Systems | | |
The whole medical systems include Ayurveda, homeopathy, naturopathy, and acupuncture.[11] Acupuncture includes Chinese massage, herbal therapy, dietary therapy, and MBT such as Qigong and tai chi.[10] A systemic review revealed that when used along with antihypertensive drugs, acupuncture significantly reduces the BP,[41] reduces weight,[42] and there is some evidence that it may correct hyperglycemia and hyperlipidemia.[43] However given the poor methodology of most of the acupuncture trials, the evidence is still considered to be inconclusive.[41],[43] Similarly there is little evidence that either of any other whole medicine such as Ayurveda, Homeopathy, or Naturopathy can be used to effectively treat a disease in isolation.
| Energy Medicine | | |
Energy medicine includes light therapy, healing touch, magnetic therapy, Reiki, Qigong, millimeter wave therapy, and sound energy therapy.[11] It is one of the least studied and utilized categories of CAM. These modalities aim to reduce pain and anxiety, aid in relaxation & stress reduction, improve the sense of well-being and promote wound healing.[44],[45] A trial in 2010 showed that Reiki significantly increased the vagal activity in patients with recent acute coronary syndrome, the magnitude of which is similar to that of propranol in the Beta-Blocker Heart Attack Trial.[46] The healing touch therapies have been shown to reduce the anxiety scores and length of hospital stay after coronary artery bypass surgery.[47]
| Healthy Life Style | | |
Since cardio-metabolic disorders are essentially lifestyle diseases, the healthy lifestyle is important both for the prevention and treatment of these disorders. Despite being linked to most of the cardio-metabolic disorders, lung disorders, and many cancers, smoking still continues to be prevalent in our society, and cessation of smoking remains the cornerstone to prevent and treat CVD diseases.[48] Though moderate alcohol consumption is not considered harmful, excessive alcohol consumption has been linked to HTN and increased cardiovascular events. It also leads to familial disharmony and may lead to social isolation, financial burden, and psychological stress. Hence, any type of addiction including alcohol needs to be tackled for healthy cardiovascular health.
There are guidelines that advocate the optimal lifestyle for the prevention and management of CVDs.[49] The calorie intake should be optimized as per the patient. The Dietary approach to stop hypertension (DASH) and Mediterranean-style dietary pattern (MED) has been recommended to reduce BP and improve dyslipidemia.[49] The DASH diet is rich in fruits, vegetables, whole grains, low-fat dairy products, nuts, fish, calcium, magnesium, and potassium and it is low in sodium, saturated fats, red meats, and sweets. The MED diet is also rich in fruits, vegetables, whole grains, and fish, and uses oils, nuts, and margarines instead of fats and butter. There are macronutrient diet advisories (proportion of carbohydrates, fats, and proteins) for dyslipidemia.[49] The transfat should be avoided as far as possible. No more than 2400 mg of sodium should be taken to prevent HTN. The sodium intake can be further reduced to decrease the BP. There are various resources and information available for dietary advice or the patient may be referred to a dietician for same.[49] processed foods, bakery, fast food, and sweets should be avoided.
Fasting helps to reduce weight, improve dyslipidemia, insulin resistance, and sugar control. In ancient India, fasting (varata) was used for curative and preventive health purposes. During a fast, people eat less, take one meal in a day, and often use fruits/potatoes. They usually consume one-fourth of the calories that they consume daily. The underlying mechanism for the beneficial effect of fasting may be related to reducing oxidative stress, optimization of circadian rhythm, and ketogenesis (intermittent metabolic switching).[50] It has been postulated that if a person fasts, the cells live longer & produce more energy, and also more nitric oxide is produced in the body which helps to rejuvenate the body. In 2016 Prof Yoshino Ohsumi was awarded the Noble Prize in Medicine for his contribution – Fasting for Health and Longevity.
An adult must engage in three to four sessions of vigorous physical activity per week lasting 30-40 minutes each to reduce BP and LDL.[49] Using bicycles instead of motored vehicles, taking walking breaks in between prolonged desk work sessions and using stairs instead of lifts help to maintain a good physical health. Good eating habits, healthy choice of meals, and regular exercise go a long way in preventing the metabolic disorders.[49] Using the traditional spices/herbs just in the right amount without indulgence in supplementation preserves their nutrient values without the risk of any side effects. Understanding of gut microbes in maintaining cardiometabolic health is also gaining importance and the role of a heathy diet, probiotics, and prebiotics is being actively researched.[51],[52]
| Role of Integrated Wellness in Cardiometabolic health | | |
The role of integrated wellness is to combine the evidence-based CAM, a healthy lifestyle, and best of conventional medicine in the management of CVDs. The MBTs such as yoga, meditation, guided imagery, and manipulative therapies like massage help to destress the individual and help reduce anxiety. The spiritual behaviors such as meditation and prayers also release healthy neurohormones, which reduce the mental stress and agony. These therapies also improve the compliance of patients to a healthy life style, to conventional drugs, and help improve the social support when these therapies are administered in groups. The integrated wellness programs may also help and support the individuals in de-addiction. As for as the biological therapies and whole medicine therapies are concerned, none of these therapies can be recommended for treatment in isolation. Integrated wellness also plays a role in breaking the myths such as naturopathy or herbs are natural and can cure anything. The concept of integrated wellness is to include the patient in decision-making by providing him/her with the appropriate information, helping him/her achieve a healthy lifestyle, and prescribing the evidence-based CAM and conventional medicine. It is to help the patient in achieving a good physical, psychological, and social well-being by exposing him/her to MBTs such as yoga and group therapies. This would ensure compliance, and prevent the progression of CVDs and their complications.
| Conclusion | | |
Integrated wellness has an important role to play in patients with cardio-metabolic disorders. Not only it has a role in the prevention of these disorders but would also help in ensuring the compliance with medication and healthy lifestyle in patients with established CVDs. Integrated science also has an important role to play in preventing and counseling patients against leaving the evidence-based medicine in favor of lesser proven biological therapies and against self-medication with supplements.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | World Health Organization. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and Region, 2000–2016. Geneva, Switzerland: WHO; 2018.  |
| 2. | Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation 2013;127:143-52. |
| 3. | Tarride JE, Lim M, DesMeules M, Luo W, Burke N, O’Reilly D, et al. A review of the cost of cardiovascular disease. Can J Cardiol 2009;25:e195-202. |
| 4. | Gyárfás I, Keltai M, Salim Y Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries in a case‐control study based on the INTERHEART study. Orv Hetil 2006;147:675-86. |
| 5. | Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren WM, et al; Comitato per Linee Guida Pratiche (CPG) dell'ESC. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). G Ital Cardiol (Rome) 2013;14:328-92. |
| 6. | Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;74:1376-414. |
| 7. | Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, et al. Core Principles and Values of Effective Team‐Based Health Care. Discussion Paper. Washington, DC: Institute of Medicine; 2012. |
| 8. | Walsh JM, McDonald KM, Shojania KG, Sundaram V, Nayak S, Lewis R, et al. Quality improvement strategies for hypertension management: A systematic review. Med Care 2006;44:646-57. |
| 9. | WHO. Constitution of the World Health Organization. 2006. Available from: www.who.int/governance/eb/who_constitution_en.pd. [Last accessed on 29 Jan 2023]. |
| 10. | National Center for Complementary and Alternative Medicine; 2012. Available from: http://nccam.nih.gov. [Last accessed on 29 Jan 2023]. |
| 11. | Frass M, Strassl RP, Friehs H, Mullner M, Kundi M, Kaye AD Use and acceptance of complementary and alternative medicine among the general population and medical personnel: A systematic review. The Ochsner Journal 2012;12:45-56. |
| 12. | Okoli C, Stacy C, Akuse S, Kelly L, Sullivan K Use of complementary and alternative medicine among people with cardiovascular diseases in Southeast Georgia. J Geor Public Health Assoc 2019;7:24-9. |
| 13. | Anderson JG, Taylor AG Use of complementary therapies by individuals with or at risk for cardiovascular disease: Results of the 2007 National Health Interview Survey. J Cardiovasc Nurs 2012;27:96-102. |
| 14. | Kohl WK, Dobos G, Cramer H Conventional and complementary healthcare utilization among US adults with cardiovascular disease or cardiovascular risk factors: A nationally representative survey. J Am Heart Assoc 2020;9:e014759. |
| 15. | Grant SJ, Bin YS, Kiat H, Chang DH The use of complementary and alternative medicine by people with cardiovascular disease: A systematic review. BMC Public Health 2012;12:299. |
| 16. | Yeh GY, Davis RB, Phillips RS Use of complementary therapies in patients with cardiovascular disease. Am J Cardiol 2006;98:673-80. |
| 17. | Gregoski MJ, Barnes VA, Tingen MS, Harshfield GA, Treiber FA Breathing awareness meditation and LifeSkills Training programs influence upon ambulatory blood pressure and sodium excretion among African American adolescents. J Adolesc Health 2011;48:59-64. |
| 18. | Sieverdes JC, Mueller M, Gregoski MJ, Brunner-Jackson B, McQuade L, Matthews C, et al. Effects of Hatha yoga on blood pressure, salivary α-amylase, and cortisol function among normotensive and prehypertensive youth. J Altern Complement Med 2014;20:241-50. |
| 19. | DuBroff R, Lad V, Murray-Krezan C A prospective trial of Ayurveda for coronary heart disease: A pilot study. Altern Ther Health Med 2015;21:52-62. |
| 20. | Gohar F, Greenfield S, Beevers DG, Lip G, Jolly K Self-care and adherence to medication: A survey in the hypertension outpatient clinic. BMC Compl Alternative Med 2008;8:4-1. |
| 21. | Dal Corso E, Bondiani A, Zanolla L, Vassanelli C Nurse educational activity on non-prescription therapies in patients with chronic heart failure. Eur J Cardiovasc Nurs 2007;6:314-20. |
| 22. | Buettner C, Phillips RS, Davis RB, Gardiner P, Mittleman MA Use of dietary supplements among United States adults with coronary artery disease and atherosclerotic risks. Am J Cardiol 2007;99:661-6. |
| 23. | Yilmaz M, Yontar O, Turgut O, Yilmaz A, Yalta K, Gul M, et al. Herbals in cardiovascular practice: Are physicians neglecting anything? Int J Cardiol 2007;122:48-51. |
| 24. | Chagan L, Bernstein D, Cheng J, Kirschenbaum H, Rozenfeld V, Caliendo G, et al. Use of biological based therapy in patients with cardiovascular diseases in a university-hospital in New York City. BMC Compl Alternative Med 2005;5:4-10. |
| 25. | Bin YS, Kiat H Prevalence of dietary supplement use in patients with proven or suspected cardiovascular disease. Evid Based Complement Alternat Med 2011;2011:632829. |
| 26. | Tachjian A, Maria V, Jahangir A Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol 2010;55:515-25. |
| 27. | Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: A systematic review and meta-analysis. JAMA 2012;308:1024-33. |
| 28. | Ong HT, Cheah JS Statin alternatives or just placebo: An objective review of omega-3, red yeast rice and garlic in cardiovascular therapeutics. Chin Med J (Engl) 2008;121:1588-94. |
| 29. | Stabler SN, Tejani AM, Huynh F, Fowkes C Garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients. Cochrane Database Syst Rev 2012;2012:CD007653. |
| 30. | Park BJ, Lee YJ, Lee HR, Jung D-H, Na H-Y, Kim H-B, et al. Effects of Korean Red Ginseng on Cardiovascular Risks in Subjects with Metabolic Syndrome: A double-blind Randomized Controlled Study. Korean J Fam Med 2012;33:190-6. |
| 31. | Brinkley TE, Lovato JF, Arnold AM, Furberg CD, Kuller LH, Burke GL, et al; Ginkgo Evaluation of Memory (GEM) Study Investigators. Effect of Ginkgo biloba on blood pressure and incidence of hypertension in elderly men and women. Am J Hypertens 2010;23:528-33. |
| 32. | Kuller LH, Ives DG, Fitzpatrick AL, Carlson Michelle C, Mercado C, Lopez OL, et al; Ginkgo Evaluation of Memory Study Investigators. Does Ginkgo biloba reduce the risk of cardiovascular events? Circ Cardiovasc Qual Outcomes 2010;3:41-7. |
| 33. | Pittler MH, Guo R, Ernst E Hawthorn extract for treating chronic heart failure. Cochrane Database Syst Rev 2008;1:CD005312. |
| 34. | Koch E, Malek FA Standardized extracts from hawthorn leaves and flowers in the treatment of cardiovascular disorders--preclinical and clinical studies. Planta Med 2011;77:1123-8. |
| 35. | Tassell MC, Kingston R, Gilroy D, Lehane M, Furey A Hawthorn ( Crataegus spp.) in the treatment of cardiovascular disease. Pharmacogn Rev 2010;4:32-41. |
| 36. | Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2008;2:CD007176. |
| 37. | Escolar E, Lamas GA, Mark DB, Boineau R, Goertz C, Rosenberg Y, et al. The effect of an EDTA-based chelation regimen on patients with diabetes mellitus and prior myocardial infarction in the Trial to Assess Chelation Therapy (TACT). Circ Cardiovasc Qual Outcomes 2014;7:15-24. |
| 38. | Kaye AD, Kaye AJ, Swinford J, Baluch A, Bawcom BA, Lambert TJ, et al. The effect of deep-tissue massage therapy on blood pressure and heart rate. J Altern Complement Med 2008;14:125-8. |
| 39. | Moraska A, Pollini RA, Boulanger K, Brooks MZ, Teitlebaum L Physiological adjustments to stress measures following massage therapy: A review of the literature. Evid Based Complement Alternat Med 2010;7:409-18. |
| 40. | Mangum K, Partna L, Vavrek D Spinal manipulation for the treatment of hypertension: A systematic qualitative literature review. J Manipulative Physiol Ther 2012;35:235-43. |
| 41. | Lee H, Kim SY, Park J, Kim YJ, Lee H, Park HJ Acupuncture for lowering blood pressure: Systematic review and meta-analysis. Am J Hypertens 2009;22:122-8. |
| 42. | Cho SH, Lee JS, Thabane L, Lee J Acupuncture for obesity: A systematic review and meta-analysis. Int J Obes (Lond) 2009;33:183-96. |
| 43. | Liang F, Koya DA is it effective for treatment of insulin resistance? Diabetes Obes Metab 2010;12:555-69. |
| 44. | Anderson JG, Taylor AG Biofield therapies in cardiovascular disease management: A brief review. Holist Nurs Pract 2011;25:199-204. |
| 45. | Rindfleisch JA Biofield therapies: Energy medicine and primary care. Prim Care 2010;37:165-79. |
| 46. | Friedman RS, Burg MM, Miles P, Lee F, Lampert R Effects of Reiki on autonomic activity early after acute coronary syndrome. J Am Coll Cardiol 2010;56:995-6. |
| 47. | MacIntyre B, Hamilton J, Fricke T, Ma W, Mehle S, Michel M The efficacy of healing touch in coronary artery bypass surgery recovery: A randomized clinical trial. Altern Ther Health Med 2008;14:24-32. |
| 48. | Dai X, Gil GF, Reitsma MB, Ahmad NS, Anderson JA, Bisignano C, et al. Health effects associated with smoking: A burden of proof study. Nat Med 2022;28:2045-55. |
| 49. | Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):3027-3028]. J Am Coll Cardiol 2014;63:2960-84. |
| 50. | Dong TA, Sandesara PB, Dhindsa DS, Mehta A, Arneson LC, Dollar AL, et al. Intermittent fasting: A heart healthy dietary pattern? Am J Med 2020;133:901-7. |
| 51. | Tang WH, Kitai T, Hazen SL Gut Microbiota in cardiovascular health and disease. Circ Res 2017;120:1183-96. |
| 52. | Novakovic M, Rout A, Kingsley T, Kirchoff R, Singh A, Verma V, et al. Role of gut microbiota in cardiovascular diseases. World J Cardiol 2020;12:110-22. |
[Table 1]
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