In this month of the “heart” what better opportunity to review each of the determinants of cardiovascular health in order to identify and optimize them in the hope of minimizing the risk of suffering from cardiovascular disease? Being the leading cause of death in the world, cardiovascular diseases (heart attack, stroke, etc.) afflict a significant proportion of the population. Every hour, 12 Canadian adults aged 20 and over with a diagnosis of heart disease die, and this reality affects men more than women. And yet, more than 90% of cardiovascular disease diagnoses could be prevented by adequately controlling certain risk factors resulting from lifestyle habits.
These identified risk factors are those that we are used to hearing from the mouths of our doctors: smoking, high blood pressure, diabetes, being overweight, which manifests itself, especially on the abdominal belt, physical inactivity, a processed food diet low in fruits and vegetables, a disturbed cholesterol balance, etc. But how to explain that certain studies report an abnormally high rate of atherosclerosis (accumulation of cholesterol in the walls of the arteries) in nearly 50% of people who have no symptoms and who are considered at low risk from suffering from heart disease (i.e., who are unlikely to suffer from the risk factors mentioned above)?. Could it be that certain risk factors are underestimated or poorly measured in our usual perception of the progression of cardiovascular disease? This is exactly where the functional medicine approach comes in handy when investigating and addressing the physiological mechanisms that may underlie the progression of atherosclerosis, in a personalized way according to each person’s reality. The action plans developed with an integrative vision and implemented in a sustainable manner through health coaching approaches have been validated and demonstrate surprising effectiveness in the complete reversal of certain metabolic conditions predisposing to the development of cardiovascular disease. It is no longer simply a question of properly “controlling” diabetes, hypertension or a disturbed cholesterol level, but of eliminating the diagnosis, in many cases, thanks to a significant optimization of lifestyle habits.
Beyond “bad cholesterol”
We have often heard the narrative that encourages the development of a negative perception of fat consumption. The fault is easily attributed to “cholesterol” as being the main cause of atherosclerosis and cardiovascular disease. Is this really the case? Let us be reminded that the cells of our body participate in the production of cholesterol, and that this cholesterol molecule is essential for several functions of the body (synthesis of vitamin D and sex hormones, participation in the structural integrity of all cells, etc.). The problem generally lies in the cholesterol carriers which can, by virtue of their constitution, more or less easily undergo a certain degree of oxidation, thus favoring their sequestration in the walls of the arteries by the cells of the immune system. This gradual accumulation of cholesterol transported by the defective proteins, thus promotes the growth of an atherosclerotic plaque until a significant blockage of the arteries is acquired,. The phenomenon of “oxidation” of cholesterol carriers occurs as a result of the production of free radicals when an individual produces too much through unhealthy behaviors, which gradually damages every cell in our body or when there are insufficient reserves of antioxidants to protect the various structures of the body from repeated attacks induced by the free radicals produced. These induced cellular injuries resulting from less than optimal lifestyles can also be the source of many other diseases (cancer, cognitive decline, premature aging, mood disorders, etc.). In fact, it triggers chronic inflammatory processes that serve to both defend and heal the body from continual and incessant attacks caused by unhealthy behaviors while destabilizing the fragile homeostasis of cells. Thus, although very high cholesterol levels (as seen in lipid genetic diseases) have been shown to increase the incidence of cardiovascular disease, the environment in which cholesterol circulates and makes it conducive to oxidation appears to be much greater than the relative amount of cholesterol transporters in a normal individual. Conversely, we even see a significant prevalence of heart disease in individuals with normal cholesterol levels or below the recommended values for prevention. Also, it is important to realize that the amount of carbohydrates ingested in the form of sugar or processed starches (very common in individuals on the diabetes spectrum or suffering from metabolic syndrome), can very negatively affect the type of transporters of manufactured cholesterol, making them prone to oxidation and adversely impacting the progression of atherosclerosis. Since these abnormalities cannot be measured with conventional laboratory tests, it demonstrates the importance of looking beyond the numbers seen on the bloodwork to instead truly understanding the impact of lifestyle habits on physiology. Therefore, let’s review together the most powerful behaviors on cardiovascular health to clean up this environment, both by reducing cellular damage induced by free radicals and by promoting a good reserve of antioxidants in order to preserve a healthy state of balance.
Nutrition: A diet rich in processed foods (essentially those that can be found in a form that deviates greatly from their raw state in nature, most of the time wrapped in a cardboard or plastic box…), rich in poor-quality and/or processed red meats, low in vegetables of all kinds (vegetables, fruits, nuts, seeds, etc.), high in sugar, high in low-quality fats (vegetable oils from industrial extraction processes and/or heated to high temperature, fats found in processed products, etc.), and rich in refined carbohydrates (grains that have been processed into flour) is very clearly associated with the development of cardiovascular disease through its negative effects on the increase in blood sugar, insulin, inflammatory markers, and the production of poor-quality cholesterol transport proteins ,,,,. The greater the nutritional density through each bite ingested (by containing several vegetable substances from various sources and a lower quantity of unprocessed and good-quality animal products), the more the food provides the body with a large quantity of antioxidants allowing to accommodate oxidative stress and the prevention of potential damage to essential structures (including blood vessels and cholesterol transporters), as well as the reduction of the phenomenon of chronic inflammation.
Smoking: It’s no surprise to read tobacco again as an established risk factor for cardiovascular disease. But this toxic behavior is not the only one to promote the development of diseases and it is easy to underestimate the impact of others. It has now been shown that the effect of our environment and our interaction with it is very important in the risk of developing chronic diseases such as cardiovascular disease. Indeed, persistent exposure to various chemical products despite being in small quantities (for example: heavy metals, pesticide residues, mold, chemical cleaners, chemical fragrances, etc.) generates a bioaccumulation and the risk of triggering immune and inflammatory dysfunctions and disruption of hormone functioning, are all linked to the development of cardiovascular disease,,,.
Sleep: Quality sleep is an important determinant of cardiovascular health. During recurring periods of frequently interrupted sleep or of a total duration of less than 6 hours, it is possible to negatively influence health through various mechanisms. We see the appearance of poor blood sugar management, inappropriate insulin resistance, production of poor-quality cholesterol transporters and higher levels of stress hormones, all of which are factors favoring the implantation of cardiovascular disease,,,.
Stress: We do not talk about it enough, as a large body of evidence supports the negative impact of stress on the pathogenesis of cardiovascular disease,,,. Whether stress relates to concerns at work, negative emotions, or adverse events experienced at a young age, it is clear that this risk factor has a role to play in the majority of chronic diseases diagnosed in humans. It is hypothesized that the increase in stress hormones usually secreted as a survival reflex on a very occasional basis in an evolutionary perspective of humanity does not have the same effect in the body at all when they are secreted in a chronic manner. In today’s modern era, as everyday life becomes a source of stress in itself, constant exposure to stress hormones causes the appearance of a chronic inflammatory state and a decrease in the body’s defense capabilities. These phenomena accelerate the growth of atherosclerotic plaque in the arteries. It goes without saying that stress relief and meditative methods of all kinds are fundamental in the prevention of cardiovascular disease.
Physical activity: It is well recognized that physical activity practiced on a regular basis prevents the onset of cardiovascular disease. Evidence-based government public health recommendations suggest including 30 minutes a day of moderate-to-vigorous intensity of physical activity for a minimum of 5 days a week. The effects of high-intensity interval training (HIIT) have already been studied and demonstrate superior effectiveness in gaining cardiovascular capacity when compared to moderate and continuous cardiovascular efforts, while being safe, even for individuals who have already experienced a cardiovascular event,.
These recommendations, as beautiful as they may seem on paper, remain a major challenge when it comes time to apply them to daily life. That 2.7% of the population would benefit if their health were supported by lifestyle habits perfectly modeled on the recommendations, according to a study published in 2016 by the renowned Mayo Clinic. If the simple prescription of change were effective, healthy lifestyle habits would certainly be at the top of the list of the most prescribed treatments! Obviously, knowing what to do is one thing, knowing how to do it is quite another matter. This is because change is not an event but a process; a path that sometimes can seem long and winding. Too often, accompanied by our best intentions, we embark on change without thinking too much about it, carried by the hope that this time is the right one! According to studies, it is between 4 to 6 relapses that will have to be crossed in order to successfully integrate a new behavior. So, how do you put your heart into it and achieve your goals without running out of steam?
Change to lose, or change to win?
Losing weight, being less ill, quitting smoking… these are goals often expressed by those around us. These negative goals, or not wanting something anymore, is an awareness that can actually motivate some people enough to initiate a change in their daily lives. However, in the majority of cases, taking the energy to deal with the discomfort of change to lose something rarely leads to success.
Not wanting something anymore is like saying “I don’t like living in Montreal anymore, I want to live somewhere different”, while having no idea of the desired destination. As long as the destination remains unclear, that person is more likely to stay in the same place. You want to lose weight… to gain what? Identifying what we really want to add or improve to our life, looking at what we want to gain, on what has value for us, is key to successful change. To feel fitter to play with my grandchildren, to feel calmer, to resume a passion that once animated me… are positive goals that give meaning and direction to change. A tangible, and therefore positive, destination allows you to channel energy and actions to achieve it in a much more effective way.
Giving a rightful place to the individual and their health
Approaching change in this way, by relying on anchoring in meaning, requires time and reflection. Considering the importance of the impact of lifestyle habits on health and the need to address the meaning of change, a growing number of health professionals and patients are interested in approaches that facilitate change, such as health coaching. This type of support fits perfectly between the recommendations received by the experts and the implementation of these new lifestyle habits in the patient’s daily life. Health coaching is based on the certainty that the patient is the expert in their own life and their well-being, therefore able to identify and implement winning solutions that will lead to the sustainable integration of new behaviors. . The health coach is then an expert in establishing a space allowing not only to create more meaning in actions but also to explore and expand possibilities, facilitate learning through taking action, and continue the development of this inspiring vision of the coachee’s health. More and more studies support that this partnership accelerates the achievement of the objectives set and allows behavioral changes in a lasting way. Five months after the end of the Health Coaching support, the newly integrated behaviors will still be present.
|The Classic Clinical Approach||The Health Coaching Approach|
In conclusion, we realize that the risk factors for cardiovascular disease are numerous and are strongly influenced by daily lifestyle habits. The functional and integrative approach of medicine makes it possible to see beyond the measured values and require strict control, by focusing more on the physiology that gives rise to these different values. Moreover, defining health as a state of physical, psychological, and social well-being, and not just the absence or control of disease opens the door to more health-creating possibilities. Improving one’s health by adopting healthy lifestyle habits, therefore, isn’t just about having good blood test results, or a healthy weight (of course, our doctor will happy!), it is above all the energy that we create, this vitality that drives us and allows us to take action that makes sense to us and awakens our passions. Health is much more than a physical state, it is a resource. Knowing that better health is possible through healthy lifestyles means maintaining an optimistic outlook for the future. With that, let’s keep our hearts set on staying optimistic about our health since it is associated with a 35% lower risk of having a cardiovascular event, and a 14% lower risk of mortality. 
Article originally published in Vitalité Québec Magazine
Anne-Isabelle Dionne, MD
Dr. Dionne has been a general practitioner since 2014 and practices in intensive care at the Honoré-Mercier Hospital in St-Hyacinthe as well as in an FMG on the South Shore of Montreal. In 2018, she founded a preventive medicine center specializing in supporting people suffering from various health problems in improving their daily lifestyle habits through diet, physical activity, stress management, and sleep. Le Centre Axis is an NPO that offers multidisciplinary preventive care to the general population wishing to improve their health and prevent or reverse a known chronic disease while reducing the need for associated medication. The services of Le Centre Axis can be dispensed remotely through telemedicine. To contact us: 514-953-2947 or email@example.com.
Héléna Bureau, Pharmacist, MSc Health Administration
Community pharmacist and FMG, author, entrepreneur, and consultant within the health network, Héléna Bureau holds a bachelor’s degree in pharmacy from Laval University and a master’s degree in health administration from the University of Montreal. Passionate about the health system and patient involvement, she has been exploring for several years the dynamics between the different entities within the system. Her various certifications focused on supporting the patient towards change, obtained at York University and Concordia, among others, as well as at the Mayo Clinic, were a revelation: the role of the patient has never been so crucial. For several years, she has been coaching patients, both in FMGs, at the Centre Axis, and privately, in the establishment of healthy lifestyle habits. In addition, she teaches for Allia, a company she co-founded, coaching skills to health professionals with the goal to support their patients more effectively in achieving their best health.
 Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52. doi: 10.1016/S0140-6736(04)17018-9. PMID: 15364185.
 Lambert MA, Weir-McCall JR, Salsano M, et al. Prevalence and distribution of atherosclerosis in a low- to intermediate-risk population: assessment with whole-body MR angiography. Radiology. 2018;287(3):795-804. doi:1148/radiol.2018171609
 Gao S, Liu J. Association between circulating oxidized low-density lipoprotein and atherosclerotic cardiovascular disease. Chronic Dis Transl Med. 2017;3(2):89-94. Published 2017 May 25. doi:10.1016/j.cdtm.2017.02.008
 Parthasarathy S, Raghavamenon A, Garelnabi MO, Santanam N. Oxidized low-density lipoprotein. Methods Mol Biol. 2010;610:403-417. doi:10.1007/978-1-60327-029-8_24
 Poznyak AV, Nikiforov NG, Markin AM, Kashirskikh DA, Myasoedova VA, Gerasimova EV, Orekhov AN. Overview of OxLDL and Its Impact on Cardiovascular Health: Focus on Atherosclerosis. Front Pharmacol. 2021 Jan 11;11:613780. doi: 10.3389/fphar.2020.613780. PMID: 33510639; PMCID: PMC7836017.
 Sachdeva A, Cannon CP, Deedwania PC, Labresh KA, Smith SC Jr, Dai D, Hernandez A, Fonarow GC. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009 Jan;157(1):111-117.e2. doi: 10.1016/j.ahj.2008.08.010. Epub 2008 Oct 22. PMID: 19081406.
 Adiels M, Olofsson SO, Taskinen MR, Borén J. Overproduction of very low-density lipoproteins is the hallmark of the dyslipidemia in the metabolic syndrome. Arterioscler Thromb Vasc Biol. 2008 Jul;28(7):1225-36. doi: 10.1161/ATVBAHA.107.160192. PMID: 18565848.
 Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu FB, Willett WC. Dietary patterns, insulin resistance, and prevalence of the metabolic syndrome in women. Am J Clin Nutr. 2007;85(3):910-918. doi:1093/ajcn/85.3.910
 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
 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
 Meltzer GY, Watkins BX, Vieira D, Zelikoff JT, Boden-Albala B. A systematic review of environmental health outcomes in selected American Indian and Alaska Native populations. J Racial Ethn Health Disparities. Published online January 23, 2020. doi:10.1007/s40615-020-00700-2
 Chowdhury R, Ramond A, O’Keeffe LM, et al. Environmental toxic metal contaminants and risk of cardiovascular disease: systematic review and meta-analysis. BMJ. 2018;362:k3310. doi:10.1136/bmj.k3310
 Berg ZK, Rodriguez B, Davis J, Katz AR, Cooney RV, Masaki K. Association Between Occupational Exposure to Pesticides and Cardiovascular Disease Incidence: The Kuakini Honolulu Heart Program. J Am Heart Assoc. 2019 Oct;8(19):e012569. doi: 10.1161/JAHA.119.012569. Epub 2019 Sep 25. PMID: 31550966; PMCID: PMC6806025.
 Balali-Mood M, Naseri K, Tahergorabi Z, Khazdair MR, Sadeghi M. Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. Front Pharmacol. 2021 Apr 13;12:643972. doi: 10.3389/fphar.2021.643972. PMID: 33927623; PMCID: PMC8078867.
 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
 Pulido-Arjona L, Correa-Bautista JE, Agostinis-Sobrinho C, et al. Role of sleep duration and sleep-related problems in the metabolic syndrome among children and adolescents. Ital J Pediatr. 2018;44(1):9. doi:1186/s13052-018-0451-7
 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
 Cohen S, Janicki-Deverts D, Doyle WJ, et al. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. Proc Natl Acad Sci U S A. 2012;109(16):5995-5999. doi:10.1073/pnas.1118355109
 Miller GE, Cohen S, Ritchey AK. Chronic psychological stress and the regulation of pro-inflammatory cytokines: a glucocorticoid-resistance model. Health Psychol. 2002;21(6):531-541.
 Su S, Jimenez MP, Roberts CTF, Loucks EB. The role of adverse childhood experiences in cardiovascular disease risk: a review with emphasis on plausible mechanisms. Curr Cardiol Rep. 2015;17(10):88. doi:10.1007/s11886-015-0645-1
 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
 Hannan AL, Hing W, Simas V, et al. High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis. Open Access J Sports Med. 2018;9:1-17. doi:2147/OAJSM.S150596
 Paul D. Loprinzi, Adam Branscum, June Hanks,,Ellen Smit,Healthy Lifestyle Characteristics and Their Joint Association With Cardiovascular Disease Biomarkers in US Adults, Mayo Clinic Proceeding, February 21, 2016
 Prochaska J, DiClemente C, Norcross J. In search of how people change: Applications to addictive behaviors. American Psychologist. 1992;47(9):1102.
 Oliveira JS, Sherrington C, Amorim AB, et alWhat is the effect of health coaching on physical activity participation in people aged 60 years and over? A systematic review of randomised controlled trialsBritish Journal of Sports Medicine 2017;51:1425-1432.
 Yeon-Hwan Park, Sun-Hee Moon, Ji-Yeon Ha, Min-Hye Lee, The long-term effects of the health coaching self-management program for nursing-home residents, Clinical interventions in aging, 2017; 12: 1079–1088.
 Juneau M, L’optimisme réduit le risque de maladie cardiovasculaire et de mortalité, 2020 (Website – Prevention Observatory – consulted November 2021)