Integrating Lifestyle Medicine in Cardiovascular Health and
Disease Prevention 1st Edition
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ISBN: 978-1-032-21386-6 (hbk)
ISBN: 978-1-032-21384-2 (pbk)
ISBN: 978-1-003-26814-7 (ebk)
DOI: 10.1201/b23245
Typeset in Times
by Apex CoVantage, LLC
To my beautiful wife, Stephanie Hart Rippe, and our
wonderful children, Hart, Jaelin, Devon, and Jamie who
inspire me and make it all worthwhile
Contents
Preface.......................................................................................................................ix
Acknowledgments .................................................................................................... xv
Author ....................................................................................................................xvii
PART I Lifestyle Medicine as an Approach
to Cardiovascular Disease
Chapter 1 Overview of Lifestyle Medicine and Cardiovascular
Health and Disease ...............................................................................3
Chapter 2 Epidemiology of Cardiovascular Disease .......................................... 19
Chapter 3 Lifestyle Medicine–Focused History and Physical Examination
for Cardiovascular Disease................................................................. 27
Chapter 4 Lifestyle Medicine, Physical Activity and Cardiovascular
Disease ............................................................................................... 37
Chapter 5 Nutrition and Cardiovascular Disease................................................ 49
Chapter 6 Weight Management and Obesity and Cardiovascular Disease ......... 71
Chapter 7 Lifestyle Medicine: Tobacco Cessation and Cardiovascular
Disease ............................................................................................... 85
Chapter 8 Psychiatric and Behavioral Aspects of Cardiovascular Disease ........ 95
Chapter 9 Sleep and Cardiovascular Disease ................................................... 105
PART II Assessment and Treating Cardiovascular
Risk Factors
Chapter 10 Framework for Assessing Risk Factors .............................................121
Chapter 11 Lifestyle Medicine and Atherosclerosis ........................................... 133
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viii Contents
Chapter 12 Lifestyle Strategies for Managing Dyslipidemia.............................. 141
Chapter 13 Lifestyle Management and Prevention of Hypertension .................. 149
Chapter 14 Peripheral Artery Disease ................................................................ 165
Chapter 15 Ischemic Heart Disease .................................................................... 173
Chapter 16 Approach to the Patient with Chest Pain.......................................... 183
Chapter 17 Carotid Artery Disease and Stroke .................................................. 191
Chapter 18 Diabetes, Prediabetes, Metabolic Syndrome and Cardiovascular
Disease ............................................................................................. 199
Chapter 19 Sedentary Behavior and Cardiovascular Disease ............................207
Chapter 20 Cardiovascular Disease and Optimal Brain Health ......................... 213
PART III Specialized Topics
Chapter 21 Women and Cardiovascular Disease ................................................ 225
Chapter 22 Risk Factor Reduction in Children................................................... 235
Chapter 23 Genetics, Epigenetics and Precision Medicine ................................ 245
Chapter 24 Reversing Heart Disease .................................................................. 253
Chapter 25 The Future of Lifestyle Medicine and Cardiovascular
Disease: Research and Applications ................................................ 261
Index...................................................................................................................... 269
Preface
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortal-
ity in the United States and around the world. Over 37% of deaths each year in
the United States are attributed to cardiovascular disease (1). Many components of
lifestyle practices and habits signifcantly impact risk factors for CVD disease. For
example, the Nurses Health Trial reported that 80%–91% of all incident CVD and
diabetes, respectively, could be eliminated if women would follow fve simple life-
style practices (2). These include
• Participate in regular physical activity (≥30 minutes of moderate-intensity
physical activity each day);
• Maintain a healthy body weight (body mass index between ≥19 and ≤25);
• Follow healthy nutritional practices (more whole grains, fruits and
vegetables);
• Do not smoke cigarettes; and
• If drinking alcohol, consume only one alcoholic beverage/day.
Similar fndings were observed in the U.S. Male Professional Health Study (3). In
fact, if only one of these positive health practices were followed, the risk of CVD was
reduced by up to 50%.
More recently, researchers analyzed data from these two major ongoing cohort
studies to estimate the impact of these fve lifestyle practices on life expectancy in
the U.S. population. During up to 34 years of follow-up, adherence to all fve life-
style-related factors signifcantly increased lifestyle expectancy at age 50 years for
“most men and women by 12.2 and 14.0 years, respectively.” The most physically
active cohorts of men and women demonstrated a 78% gain in life expectancy. These
investigators concluded that prevention should be a top priority in the U.S. healthcare
system.
The American Heart Association (AHA) and American College of Cardiology
(ACC) have been leading professional organizations emphasizing the profound
importance of lifestyle habits and actions on cardiovascular health. Clearly, lifestyle
factors modulate multiple risk factors for CVD including abnormal lipids, high blood
pressure, diabetes mellitus, body weight and fat storage.
Recognition of the profound impact of lifestyle medicine on CVD has been
increasingly embraced by the medical community. For example, one Council
of the AHA in 2013 changed its name from the “Council on Nutrition, Physical
Activity and Metabolism” to the “Council on Lifestyle and Cardiometabolic
Health (4).” The most recent Physical Activity Guidelines for Americans (2018)
demonstrated signifcant reductions in the risk of CVD and total mortality for
individuals who engaged in ≥150 minutes of moderate-intensity physical activity
and two musculoskeletal training sessions each week (5). In fact, individuals who
participated in as little as 30 minutes of moderate-intensity physical activity per
week reduced their risk of CVD by 20%. Moreover, it was concluded that being
ix
x Preface
unft warrants consideration as an independent risk factor, and that a low level of
cardiorespiratory ftness increases the risk of CVD to a greater extent than merely
being physically inactive (6).
Only 25% of U.S. adults meet the Centers for Disease Control and Prevention
(CDC) guidelines for physical activity (5). When sedentary individuals are compared
to individuals who engage in regular physical activity, they have a 150%–240%
increased likelihood of developing CVD (7). Thus, individuals who choose to lead
sedentary lifestyles double their risk of heart disease. To put this in perspective,
this is the same increased risk of CVD that individuals accept who smoke a pack of
cigarettes a day. Thus, physical inactivity represents a lifestyle factor that appears as
dangerous as smoking a pack of cigarettes per day with regard to CVD and is four to
fve times as prevalent.
Despite the established links between lifestyle and CVD, few physicians (<40%)
regularly counsel their patients on such issues as nutrition, physical activity, weight
management, smoking cessation, and the avoidance of secondhand smoke (8). This
is a wasted opportunity since over 70% of individuals in the United States see their
primary care physician on at least a yearly basis.
A healthy lifestyle also plays an important role in the primary and secondary
prevention of CVD, even among those taking medications for high blood pressure
or elevated blood cholesterol (9). Moreover, effect estimates show convincingly the
health benefts of adjunctive lifestyle changes in patients with known heart disease,
the magnitude of which are similar to those conferred by cardioprotective drugs after
acute myocardial infarction. Collectively, these fndings and other data suggest that
the effects of lifestyle change and combination drug therapy on cardiovascular risk
reduction appear to be independent and additive.
The American public has also been reluctant to embrace positive lifestyle mea-
sures in their daily lives. As already indicated, the CDC estimates that only 25%
of individuals meet their guidelines for regular physical activity. Less than 15% of
individuals consume the recommended level of fruits and vegetables on a daily basis
(10). Over 70% of the U.S. population is overweight or obese (11), and ~15% continue
to smoke cigarettes (12).
The importance of lifestyle practices is relevant to all aspects of medicine, but
particularly in cardiovascular medicine, where it is increasingly being recognized. In
addition, the American College of Lifestyle Medicine (ACLM) now has over 8,000
members. Its membership has grown over 1,200% since 2003 (13).
The lifestyle medicine movement has also emerged in over 40 countries around
the world (14). The World Health Organization recognizes lifestyle factors in their
initiative to reduce noncommunicable diseases and singles out that reducing the risk
of heart disease and its risk factors is a high priority around the world (15). Similarly,
the AHA in its 2020 Strategic Plan emphasized that lowering the risk of heart disease
and improving cardiovascular health represent top priorities (16).
Finally, failure of the client/patient to take responsibility for their own health rep-
resents the single most important factor affecting the prevention of and recovery
from CVD. Clearly, a greater emphasis needs to be placed on what happens between
an individual’s visits to the physician. Indeed, it is estimated that patients spend
more than 5,000 hours each year outside of healthcare appointments. Accordingly,
Preface xi
self-responsibility (e.g., meeting certain basic health metrics) will become a greater
priority in the contemporary healthcare environment. For example, completing
health habit surveys and/or serial risk factor profles and attaining certain risk factor
goals will be increasingly mandated by insurers and employers, orchestrated in part
by fnancial and other incentives.
With this as background, I felt there was an urgent need to provide an evidence-
based book strongly linking lifestyle habits and practices not only to CVD, but also
cardiovascular health. I am not aware of any other book that specifcally links the
independent and added benefts of lifestyle modifcations to reduction in risk of CVD.
I hope that this book will be valuable in helping physicians to better understand these
multiple linkages and employ them in associated behavioral counseling techniques
(e.g., readiness to change, motivational interviewing, etc.) with more consistency in
the daily practice of medicine.
I also hope that this book will be highly benefcial to nurses who assist in the
practice of cardiovascular medicine as well as nutritionists and exercise physiolo-
gists. These are professions that have an enormous number of members that far
exceed the size of the physician community. For example, there are three times as
many nurses in the United States as there are physicians. I hope and anticipate that
all of these individuals will beneft from an evidence-based compilation of lifestyle
practices that impact cardiovascular health and disease. I hope this book will help
accomplish our goal of strongly linking lifestyle medicine to cardiovascular health
and disease.
This book is divided into three parts. Part I provides a general framework for the
components of lifestyle medicine that are useful in helping to lower the risk of car-
diovascular disease and improve cardiovascular health. These include regular physi-
cal activity, proper nutrition, weight management, tobacco cessation, stress reduction
and healthy sleep.
In Part II, I then move on to specifc ways of addressing and treating cardiovas-
cular disease risk factors. These include atherosclerosis, dyslipidemias, hyperten-
sion, arrhythmias, coronary artery disease, myocardial infarction, stroke, diabetes
and obesity. Chapters are also devoted to overcoming a sedentary lifestyle and using
lifestyle medicine techniques to optimize brain health.
Part III concludes the book with specialized topics including heart disease in
women, stress reduction in children, emerging evidence in genetics and epigenetics,
available data on reversing heart disease, future directions in research and applica-
tions linking lifestyle medicine to cardiovascular disease risk factor reduction and
prevention.
There is no longer any serious doubt that what each of use does in our daily lives
profoundly impacts our short- and long-term health and quality of life. I hope that
this book will encourage practitioners at all levels to emphasize the profound link-
ages between lifestyle and cardiovascular health. This is clearly the future of not
only cardiovascular medicine but also medicine and health, in general. The link-
ages between lifestyle medicine and cardiovascular health and disease prevention
are profound. It will be essential for all individuals who treat aspects of CVD and its
prevention to continue to educate themselves on the linkages between lifestyle habits
and actions to reduce the great burden of CVD around the world. I hope that this
xii Preface
book will assist individuals to continue to gain knowledge and clinical expertise in
the vitally important area of lifestyle medicine and cardiovascular disease.
James M. Rippe, MD
Founder and Director
Rippe Lifestyle Institute
Professor of Medicine (Cardiology)
UMass Chan Medical School
Shrewsbury, Massachusetts
REFERENCES
1. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2021
update: A report from the American Heart Association. Circulation. 2021;143:e254–e743.
2. Bassuk SS, Manon JE. Lifestyle and risk of cardiovascular disease and type 2 diabetes
in women: A review of the epidemiologic evidence. Am J Lifestyle Med. 2008;2(3).
3. Manson JE, Nathan DM, Krolewski AS, Stampfer MJ, Willett WC, Hennekens CH.
A prospective study of exercise and incidence of diabetes among US male physicians.
JAMA. 1992;268:63–67.
4. American Heart Association. Council on Lifestyle and Cardiometabolic Health. https://
professional.heart.org/professional/MembershipCouncils/ScientificCouncils/UCM_
322856_Council-on-Lifestyle-and-Cardiometabolic-Health.jsp. Accessed August 10,
2021.
5. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity
Guidelines Advisory Committee Scientifc Report. Washington, DC: U.S. Department
of Health and Human Services; 2018.
6. Myers J, Kaykha A, George S, Lear S, Yamazaki T, et al. Fitness versus physical activ-
ity patterns in predicting mortality in men. Am J Med. 2004;117:912–18.
7. Moore SC, Patel AV, Matthews CE, Berrington de Gonzalez A, Park Y, et al. Leisure
time physical activity of moderate to vigorous intensity and mortality: A large pooled
cohort analysis. PLoS Med. 2012;9(11):e1001335.
8. Rippe JM. Lifestyle Medicine (3rd edition): Physician Health Practices and Lifestyle
Medicine. Boca Raton, FL: CRC Press; 2019.
9. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, et al. ACC/AHA/AAPA/
ABC/ACPM/AGS/AphA/ASH/ASPC/NMA/PCNA guideline for the prevention, detec-
tion, evaluation, and management of high blood pressure in adults: A report of the
American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Hypertension. 2018;71(6):e13–e115.
10. Rippe JM. Lifestyle Medicine (4th edition): Nutrition and Cardiovascular Disease.
Boca Raton, FL: CRC Press; 2023.
11. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of over-
weight among US adults. The national health and nutrition examination surveys, 1960
to 1991. JAMA. 1994;272(3):205–11.
12. National Center for Health Statistics, Health, United States, 2016: With Chart Book on
Long Term Trends in Health. Hyattsville, MD; 2017.
13. American College of Lifestyle Medicine. www.lifestylemedicine.org/. Accessed August
10, 2021.
Preface xiii
14. Lifestyle Medicine Global Alliance. https://lifestylemedicineglobal.org/. Accessed
August 10, 2021.
15. Centers for Disease Control and Prevention. Global Noncommunicable Disease
Programs. Division of Global Health Protection (DGHP). www.cdc.gov/globalhealth/
healthprotection/ncd/about.html#:~:text=CDC%20collaborates%20with%20partners%
20to,improve%20surveillance%20and%20evaluation%20systems. Accessed August 10,
2021.
16. Lloyd-Jones DM, Hong Y, Labarthe D, et al. American Heart Association Strategic
Planning Task Force and Statistics Committee. Defning and setting national goals for car-
diovascular health promotion and disease reduction: The American Heart Association’s
strategic Impact Goal through 2020 and beyond. Circulation. 2010; 121(4):586–613.
Acknowledgments
Textbook writing and editing are collaborative efforts that involve hard work, skill,
and passion of numerous contributors. I am grateful to the many individuals who
over my 30-plus years as a cardiologist have stimulated and infuenced my think-
ing about the interaction between lifestyle and health and the specifc interactions
between lifestyle habits and practices and their role in both preventing and treating
cardiovascular disease.
Numerous individuals have helped guide my thinking and are too many to
acknowledge by name. I would like to particularly thank, however, a few individu-
als who have made substantial contributions to the current book and my career in
cardiology.
First, my long-term editorial director, Beth Grady, who plays a critically impor-
tant role in all of the major writing and editing projects that emerge from my research
organization, deserves special thanks. This book is one of over 53 books that Beth
has managed which have been generated through my organization. In addition to
the current textbook, Beth provides editorial direction to two academic journals that
I edit as well as my major Lifestyle Medicine textbook (Lifestyle Medicine, third
edition, James M. Rippe [editor], CRC Press, 2019) and our major intensive care
textbook (Irwin and Rippe’s Intensive Care Medicine, ninth edition, Wolters Kluwer,
2022). Beth possesses not only superb editorial skills but also an exceptional work
ethic and unfailing good humor to make all of these complex and diffcult projects
possible.
I would also like to express my appreciation to my offce support staff, includ-
ing my executive assistant, Carol Moreau, who seamlessly coordinates my schedule
and travel plans to free up the time necessary for such large writing and publishing
projects and also word-processed many of the chapters in this book. Our editorial
offce assistant, Deb Adamonis, assists all of us in the multiple daily tasks required
to expedite diverse projects in our offce. In addition, she tracked down hundreds
of academic references for the current book. Our chief fnancial offcer, Connie
Martell, make sure that the fnancial processes are in place so that all of our projects
move forward smoothly. The research team at Rippe Lifestyle Institute has always
contributed important insights to clarify my thinking on a number of aspects of
preventive cardiology and lifestyle medicine.
I would also like to acknowledge with gratitude some cardiologists who early in
my career guided me and inspired me initially in invasive cardiology, coronary care
and preventive cardiology. Chief among those is Dr. Joseph Alpert who served as a
mentor and supporter of my career both as a medical student at Harvard Medical
School and subsequently in my faculty career as a cardiologist, both at Umass Chan
Medical School and Tufts Medical School. Also, Dr. Eugene Braunwald supported
and guided my aspirations at Harvard Medical School to not only pursue cardiology
but also establish a research career in this area.
I would like to thank the outstanding editorial team at Taylor & Francis Group/
CRC Press. Randy Brehm, senior editor, has been a key supporter of the multiple
xv
xvi Acknowledgments
textbooks I have published with CRC Press, including the second, third, and fourth
editions of my major academic textbook Lifestyle Medicine. Randy also has been
a strong supporter of the Lifestyle Medicine Series in which this current volume
resides.
Tom Connelly coordinated all aspects of the publication process and provided
important day-to-day leadership and invaluable assistance on multiple issues related
to manuscripts. Venkatesh Sundaram at Apex managed the editing, design and type-
setting of the book with great skill.
Finally, as always, I am grateful to my family, including my loving wife Stephanie
Hart Rippe and our four beautiful daughters Hart, Jaelin, Devon and Jamie who
continue to love and support me through the arduous process of writing and editing
many major textbooks, journal editing and the other diverse professional responsi-
bilities that I juggle, along with my family life.
If there are errors or omissions in Integrating Lifestyle Medicine in Cardiovascular
Health and Disease Prevention, the responsibility is mine. If there is credit due for
this project, it belongs to the numerous people who have made substantial contribu-
tions to my knowledge and performance along the way.
James M. Rippe, MD
Boston, Massachusetts
Author
James M. Rippe, MD, is a graduate of Harvard College
and Harvard Medical School with postgraduate training at
Massachusetts General Hospital. He is currently the Founder
and Director of the Rippe Lifestyle Institute and Professor of
Medicine (Cardiology) at the University of Massachusetts
Chan Medical School.
Over the past 25 years, Dr. Rippe has established and run
the largest research organization in the world exploring how
daily habits and actions impact short- and long-term health
and quality of life. This organization, Rippe Lifestyle Institute
(RLI), has published hundreds of papers that form the scientifc basis for the felds of
lifestyle medicine and high-performance health. RLI also conducts numerous studies
every year on physical activity, nutrition, and healthy weight management. A lifelong
and avid athlete, Dr. Rippe maintains his personal ftness with a regular walk, jog,
swimming, and weight training program. He holds a black belt in karate and is an
avid wind surfer, skier and tennis player. He lives outside of Boston with his wife,
Stephanie Hart—television news anchor—and their four children, Hart, Jaelin, Devon
and Jamie.
xvii
