“The Effect of Religion on Heart Disease, Hypertension & Stroke

March 31, 2011

John K Graham, M.D., D.Min.

The Institute for Spirituality and Healthat the Texas Medical Center,

Houston, TX 77054

Today and Upcoming Thursday Class Schedule

• March 31:  Effect of Religion on Heart Disease & Hypertension (chapters 16-17, HRH)

• April 7:   Effect of Religion on Immune System Dysfunction and Cancer (chapter 19-20, HRH)

• April 14:  Effect of Religion on Longevity and Disability (Chap. 21-22, HRH)

Religion’s Effect on Heart Disease, Hypertension, Stroke

I. Introduction

II. Heart Disease

III. Hypertension

IV. Stroke

V. Summary

I. Introduction:

• Today we are looking at Chapters 16 & 17 of Dr. Harold Koenig, Michael McCullough and David Larson’s book,

• Handbook of Religion and Health (2001)

• published by Oxford University Press, New York.

II. Effect of Religion on Cardiovascular Disease

• Nearly 60 million persons in the US have one or more cardiovascular diseases. It is by far the most common cause of death claiming nearly 1 million lives in 1996 compared to half a million deaths from cancer and 100,000 deaths due to accidents.

• Cardiovascular diseases include heart disease, hypertension, peripheral vascular disease and stroke.

• There are many behavioral, psychosocial, and physiological mechanisms by which religious beliefs and practices may influence cardiovascular function.

II. Risk factors for Coronary artery disease (CAD)

• Among discharges from the hospital in 1996, 2,258,000 had a diagnosis of CAD.

• There is a hereditary component to CAD and those with a family history have increased risk. Likewise, presence of hypertension or diabetes increases the likelihood of atherosclerosis in all arteries, including CAD

• Environmental facts also play a major role in development and progression of CAD. Health behaviors and psychosocial factors that increase the risk of CAD and myocardial infarction:– Cigarette smoking– High cholesterol level– Physical inactivity– Obesity– Alcohol abuse

II. Risk Factos

• In a study by Hasdai et al (1997) Individuals who continue smoking cigarettes have a 76% greater risk of death and 108% greater risk of M.I., than non-smokers.

• A 6-year study of 356,222 middle-aged men showed a strong correlation between level of serum cholesterol and ad-adjusted CAD death rate.

• As to Physical inactivity & Obesity, when compared to smoking and serum cholesterol levels, the evidence is weaker. Katzel et al (1995) concluded that diet-induced weight loss is preferred over aerobic exercise to improve risk of CAD in overweight middle-aged or older men.

II. Risk factors, cont…

• While some studies suggest low levels of alcohol may be protective against CAD (by inhibiting platelet aggregation and by raising HDL cholesterol levels), the opposite is true for high levels of alcohol use.

• A large study by Hanna et al (1997) among 18,323 males and 25,440 females found that heart disease is significantly more common among men who drink more than five drinks per day and in women who drink more than two drinks/day.

• When combined, cigarette smoking and heavy alcohol use leads to and exacerbates hypertension, hypercholesterolemia and diabetes – all contributing to an increased CAD risk.

II. Risk factors, cont….• These cardiovascular risks fail to completely explain the

variations in prevalence and severity of CAD.

• Recent research suggests that infection of coronary arteries by cytomegalovirus, Helicobacter pylori, herpes simplex virus and periodontitis may contribute to as many as 50% of all cases of CAD. The focus of current research is on the association of C. pneumoniae and atherosclerosis.

• There is a gender difference: In premenopausal women, incidence of atherosclerosis and CVD is less than half that of age-matched men. 

• Racial difference: African-Americans who have hypertension are more prone to CAD.

•

II. Depression and CAD

• Depression & heart disease has been studied. Glassman and Shapiro report that nine of 10 studies found increased Cardiovascular mortality among the depressed.

• Several studies followed depressed and non-depressed subjects who were initially free of CAD. Most found an increased risk of ischemic heart disease among those who were depressed.

• Ford, Mead et al (1998) followed 1,190 male medical students from Johns Hopkins for 40 years. The clinical depression rate was 12%. During the study, men with depression were twice as likely to develop CAD and twice as likely to have an MI. Also, depression delayed recovery (were slower to return to work).

II. Psychological Stress and Heart disease• In addition to depression, Psychological Stress is

associated with increased risk of CAD. An evidence our emotions are thought to be related to heart disease is the use of phrases like “Have a heart!” and, “He died of a broken heart.”

• Emotions associated with stress, especially anger and hostility, have long been associated with increased risk for MI.

• Degree of perceived personal control may also affect susceptibility to acute cardiac ischemia.

• Co-factors: age, sex, income, education, hypertension, cholesterol, smoking, angina, diabetes, family history of CAD, hostility, and Type A behavior.

II. Social factors and heart disease• Social Support may reduce CAD by improving coping,

preventing depression, and counteracting psychological stress.

• Ken (1997) and Anderson et al (1996) concluded that a lack of social ties predicts greater CAD mortality, and strong social support reduces this risk.

• Williams et al (1992) examined the effects of social and economic resources on Cardiovascular mortality among 1,368 patients with CAD. Among the predictors of survival were marital status and presence of a confidant.

• Unmarried without a confidant had a 5-year survival rate of 50% compared to 82% among patients who were married, had a confidant, or both.

II. Why should Religion & CAD be Related?• Considering the risk factors for onset and progression of

CAD that we have reviewed, religious beliefs and behaviors are inversely related to many of those risk factors.

• Religious involvement has been associated with: – lower blood pressure (as we will see ), – less cigarette smoking, – more exercise, – less alcohol use, – less depression and faster recover from depression, – improved coping with stress, – greater well-being, – greater social support.

• So, there are reasons why devout religious beliefs and practices might influence the onset and course of CAD.

II. Research on Religion and CAD• Religious Affiliation – Wardell et al (1963) studied 32 white

male survivors of acute MI and 32 matched controls. The rate of acute MI was nearly four times higher in Protestants than in Catholics.

• They concluded that “Protestants cannot avoid personal responsibility for life’s decisions nor can they assuage feelings of guilt in the confessional.” (p 241)

• Other studies however have found no differences in CAD across religious affiliation.

• • Mormons & Seventh Day Adventist’s have significantly

lower mortality from CAD than the general population (felt due to difference in diet, & smoking and alcohol consumption)

II. Psychosocial and Spirituality Interventions

• A number of studies have evaluated psychological, social, and spiritual interventions to prevent or treat coronary heart disease.

• Frasure-Smith and Prince (1989) studied outcomes of 461 post-MI males during a seven year followup. Subjects involved in a stress reduction program experienced a reduction in cardiac deaths by 50% at one-year.

• Laserman et al (1989) examined the efficacy of the Relaxation Response (RR) -- elicited by meditation or repetitive prayer -- in preparation for cardiac surgery. When compared to controls, the group that practiced RR had a lower incidence of supraventricular tachycardia but there was no difference in systolic or diastolic blood pressures or in heart rate.

Kaplan-Meier Life table demonstrating mortality from CHD among Jewish orthodox believers and non believers (10,059 civil servants)Koenig, page 247.

II. Controversial Report – Annals of Internal Medicine

• The morning before planned electrical cardioversion, an elderly patient with atrial fibrillation summoned her daughters and Baptist minister to conduct a prayer meeting. After direct supplication that “this evil rhythm leave her body,” a nurse with a direct view of the cardiac monitor reported that at that moment the patient reverted to normal sinus rhythm. Atrial fibrillation did not recur.

• Koenig writes, “This remarkable report illustrates the effect that mind and spirit can have on cardiac functioning; it is, however, only a single case.” (p. 249)

• He continues, “Research studies could be designed to test hypotheses suggested by this report.”

II. The controversial Byrd study …• Koenig says, “Perhaps the most extraordinary study in

recent times is the Byrd study. The cardiologist Randolph Byrd (1988) conducted a double-blind trial in the coronary care unity at the San Francisco General Hospital that involved 393 patients randomized to either an intercessory prayer group or a control group.

• Neither patient nor physicians knew which patients were being prayed for and the people praying for the patients did not know the patients.

• Patients in the intercessory prayer group experienced fewer episodes of congestive heart failure, needed fewere diuretics, experienced fewer cardiac arrests, fewer pneumonias and were prescribed fewer antibiotics.

II. Byrd study …• Koenig says, concerning the Byrd study: “This is a

highly controversial study whose results cannot be explained by any known psychosocial or physiological mechanism. Replication of this study is essential before the scientific community can begin to consider the findings more seriously. . .”

II. To summarize • CAD affects more than 7% of persons over age of 20, is

responsible for 2 million hospitalizations a year, and is the leading cause of death in the U.S.

• Risk factors include medical conditions (hypertension and diabetes), family history, and other factors such as cigarette smoking, poor diet, high serum cholesterol, little or no exercise, excessive weight and alcohol abuse.

• When these factors interact, they magnify the risk. Because social factors help prevent depression and relieve stress, group support lowers the risk of CAD.

• And, because of the strong link with religious beliefs and activities and many risk factors for CAD, there is reason to hypothesize an inverse relationship exists between religion and heart disease.

III. The Effect of Religion on Hypertension • Defined: Hypertension is the a sustained or chronic

elevation of blood pressure. Recent studies suggested that systolic pressure should be less than 140 mmHg and dialostic less than 90 mm Hg to reduce the risk of CVD.

• There being no specific symptoms of elevated blood pressure, many people become aware of high blood pressure only on routine physical examines or after a stroke or heart attack.

• Although there is usually no known cause, hypertension can be influenced by a person’s lifestyle (high salt intake, especially in African Americans because of enhanced salt retention by the kidneys).

• HBP has a polygenic, multifactorial origin – hereditary, the renin-angiotensin-aldosterone & the kallikrein-kinin system.

III. Hypertension, factors• Other facts in HBP include: cigarette smoking, heavy alcohol

use, diabetes, and the use of certain medications – oral contraceptives.

• Also, psychological and social stress (job strain, anxiety, depression, emotional distress – (by increasing catecholamines and cortisol release)

• So, hypertension is likely due to the interaction of genetic factors, lifestyle, and environmental factors.

• Hypertension where the cause is unknown is called “essential or primary hypertension” usually begins in the second or third decade of life. “Malignant hypertension” is a form which progresses rapidly and may result in sudden death. “Benign hypertension” progresses very slowly. Another, “Renal” HBP.

III. Religious Involvement and Blood Pressure

• A growing number of studies have found a significant correlation between the degree of religious involvement and blood pressure.

• In general, individuals who report higher levels of religious activity experience a lower risk for hypertension. For example, Scotch (1963) found that frequency of church attendance was negatively correlated with hypertension.

• In the same study, women who belonged to Christian churches had less hypertension than those who were not churchgoers. For men, there was a tendency to have a higher blood pressure. Researchers speculated hypertensive men tended to become church members seeking to find help with their problems.

III. Religion and Hypertension

• T.W. Graham et al (1978) examined the relationship between a variety of sociological factors, including religious involvement and blood pressure in 771 white community-dwelling males.

• They found a consistent association between frequent church attendance and lower systolic and diastolic blood pressure. The finding was also true for smokers and non-smokers, as well as for white-collar and blue-collar workers.

• Larson, Koenig et al (1989) examined the relationship between blood pressure, frequency of church attendance and the importance of religion. For those with high frequency of church attendance and for whom religion was important, diastolic pressures were significantly lower than for those with low attendance and for whom religion was of low importance.

III. Religion and blood pressure …

• One of the largest studies was done by Koenig, George, Cohen, et al (1998) examined 3,963 persons aged 65 years or older.

• Analysis revealed small but consistent differences in measured systolic and diastolic BP between frequent (once a week) and infrequent (less than once a week) attenders.

• Findings also showed lower blood pressures were

observed among those who frequently prayed or studied the Bible (daily or more often).

• These differences were particularly noted in the African-American population.

Relationship between religious activities and average diastolic BP Koenig, George, Cohen, et al (1998), p 254-5 HRH.

III. Religion and Blood pressure . . . worldwide• A lower rate of hypertension among the more religiously

committed has been found in various ethnic populations. Stavig et al (1984) investigated 1,757 Asian and Pacific Islanders who lived in California.

• They found hypertension was positive correlated with

increased consumption of high-calorie, high-fat American food. And, hypertension was also positively correlated with increased alcohol consumption and lower education status.

• In particular, the number of close friends available to provide support was inversely related to hypertension. This was correlated with religious involvement. Hypertension in those without religious affiliation was almost double those with religious affiliation.

III. Religious Involvement of value …

• Religious participation is particularly valuable for enhancing social integration for certain ethic groups. For example, Livingston et al (1991) evaluated the potential role of social integration plays in explaining variations in blood pressure among African Americans.

• Examining 1,420 adults in Maryland, investigators

found that church affiliation was significantly related to lower systolic and diastolic blood pressures in men and in women.

• The investigators concluded that social integration, especially affiliation with a church, contributes to lower blood pressure in African Americans.

III. What about blood pressure in clergy

• If degree of religious involvement is key to the relationship between religion and high blood pressure, one would expect those who make a lifelong commitment to religion to have lower blood pressure compared to general population.

• McCullagh, et al (1960) studied 44 Trappist monks in Kentucky and Massachusetts, 77 % were over the age of 50.

• While the monks had lower serum cholesterol (dietary), they were not protected from either atherosclerotic vascular disease or hypertension. In fact, it appeared high blood pressure was more prevalent among the monks (48%) when compared to general population.

III. Blood pressure in clergy

• Another study reported different findings, (Locke & King, 1980) examining the cause of death for 5,207 male clergy in the American Baptist denomination.

• This investigation found a significantly lower rate of mortality due to hypertension and heart disease than men of the general population (the disparity was almost 40%).

• Similar findings were reported by Timio et al (1988), who conducted a 20-year study of blood pressure in 144 nuns who belonged to a secluded monastic order (compared with 138 controls). Blood pressure began at the same levels for both groups but gradually increased only for the lay order.

III. Mechanism of blood pressure control

• Levin and Vanderpool (1989) reviewed 20 studies on the relationship between religion and hypertension postulating the healthy life-style and the proposed a salutary effect of religion on blood pressure might be due to a combination of biological, social, psychological, and behavioral factors including:

• Promotion of beneficial healthy lifestyle behaviors• Hereditary predisposition in particular groups• Healthful coping and social support effects of religious

practice• Beneficial psychodynamics of particular religious belief

systems, religious rites, and faith.

III. Religious practices and reduction of hypertension

• Meditation – Blackwell et al (1976) studied seven hypertensive patients who were give standard antihypertensive medication in addition to learning transcendental meditation (TM).

• After 12 weeks of TM, six subjects showed psychological changes and reduced anxiety scores. More importantly, six of the seven patients had significant reductions in their blood pressure.

• In another study, Patel and North (1975) compared yoga relaxation methods plus biofeedback to general relaxation control group. Both groups showed reduction in blood pressure but the yoga group was greater. The control group was then trained in yoga and their blood pressures dropped to the same level as the other group.

III. Religious Communities as sources of Hypertension Control

• Church-based interventions have long been considered effective in the treatment of chronic illnesses that affect African Americans (A-A), primarily because of the role the church plays in A-A social support networks

• Given the high rate of high blood pressure among A-As, there has been increasing interest in the effectiveness of churches a blood pressure control centers.

• Kumanyika et al (1992) analyzed data from the Baltimore Church High Blood Pressure Program and concluded that such church-based programs may help initiate long-term behavioral changes that positively influence weight and blood pressure, especially among A-As and possibly others, as well.

IV. Religion and Stroke

• The brain is the center of human thought, personality, emotion, feeling and will, and mediates all sensory impulses and motor activity. I.e., everything we think, fell and do has its origin in our brains (including spirituality experiences).

• For this reason, it is important to explore the relationship between religious beliefs, experiences, and brain function, both normal and abnormal.

• Transient ischemic attacks, stroke, and vascular dementia are the most common types of CVD in the brain. Strokes are the leading cause of long-term disability in the U.S. Of the more than 4.4 million stroke victims who are live today, over 1 million have severe disability.

IV. Psychological Factors related to Stroke• Given the link among psychological stress, risk factors for

stroke, and the occurrence of stroke, it is possible that a relationship between religious beliefs and activities and stroke may also exist. The reasons for this hypothesized relationship:

• Religious beliefs and activities are associated with – lower B.P.– Less CAD– Lower rate of cigarette smoking– Lower alcohol and drug use– Improved coping skills and better adjustment to stress– Lower rates of anxiety– Less depression and less hopelessness

• However, Koenig says only six published studies have examined this relationship at the time his book was published (p. 269 HRH)

IV. A Miraculous Cure of Stroke• J. Wassersug (1989) reported an 86-year-old man in Mass.,

who suffered a massive stroke, right hemiplegia, leaving him bedridden, unable to move right arm and leg. The cause was due to hypertension, with little chance of recovery. Yet, the man and his wife spoke frequently of God during his hospitalization, convinced God would heal him.

• On the fifth day of hospitalization, the patient greeted his doctor with the story he had dreamed that night that an angel stood at the foot of his bed and told him that he would be able to move his arms and leg when he awoke. With that, the patient raised his right arm and leg off the bed.

• Koenig, says this is the only case he could locate in the literature of a religious healing of a stroke victim.

IV. Religion and Stroke conclusions…

• Colantonio et al (1992) reported on the relationship between level of religiousness and stroke a seven-year followup of 2,812 patients with stroke. His analysis showed that those with a high religious attendance was a predictor of fewer strokes.

• Only five other studies have examined the relationship between religion and stroke and focus primarily on religious affiliation, not on level of religiousness.

• In summary, some evidence links religiousness to lower rates of cerebrovascular disease and stroke. More research is needed to examine this association.

Next Thursday’s Class

• April 7:   Effect of Religion on Immune System Dysfunction and Cancer (chapter 19-20, HRH)

• April 14:  Effect of Religion on Longevity; and, Religion and Disability (Chap. 21-22, HRH)