The most popular drugs in our country right now are statin drugs used to lower cholesterol. At least 12 million Americans currently take these drugs, and according to industry guidelines another quarter million should be on statins. This section of my site is dedicated to cholesterol/statin related issues. My goal is to educate you as to what cholesterol is and why we have it, the real causes of heart disease, when to consider cholesterol as a risk, the many side-effects of statin use, and ideal treatments using natural medicine that are superior to statin use and build health rather than destroy it.

 What is Cholesterol?

Cholesterol is found in every cell wall in your body and plays a critical role in maintaining cell integrity, without it your cells would not be able to maintain their spherical shape. Many hormones in your body are made from cholesterol. Lowering cholesterol with statin drugs has been linked to depression—probably because of a corresponding disruption of hormonal balance.[i] [ii] Most cholesterol in the human body is manufactured in the liver (some comes from the diet if you eat animal products). Since cholesterol is not water-soluble it must be transported via the blood in particles made of fats and proteins. These particles are called lipoproteins and are classified by their density. Thus HDL is high-density lipoprotein, LDL is low-density lipoprotein, and VLDL is very-low-density lipoprotein. Triglycerides are another type of fat molecule in the blood.

All cholesterol is not the same. HDL cholesterol is often termed “good” cholesterol. This dense particle actually acts as a scavenger, picking up debris from plaques on vessel walls. HDL cholesterol takes this waste back to the liver to be processed. LDL cholesterol is often termed “bad” cholesterol. This is actually a misnomer since LDL is necessary for life. High levels of certain types of LDL cholesterol, however, are correlated with an increased risk of cardiovascular disease. This correlation is not as strong as you might think. In fact, after age 60, increases in LDL cholesterol have little, if any, correlation with heart disease. The observation that 70% of people who have heart attacks have cholesterol levels that are within “normal” limits has prompted researchers to look for other risk factors. Later in this article I will give you a simple method by which you can tell rather your LDL is of the type that is associated with heart disease.

Why Do We Worry About Cholesterol?

In one-third of individuals who suffer from heart disease the first symptom is death. Since heart disease is often asymptomatic until it claims one’s life, screening for the disease is important. Current management of heart disease risk involves screening for and controlling risk factors including blood pressure, cholesterol, blood sugar, homocysteine, and obesity. Unfortunately, despite aggressive drug treatment to modify these risk factors, heart disease is still the leading killer in industrialized countries (responsible for about 40% of all deaths in the United States!).

At this point let’s look at what usually causes a heart attack. Plaque builds up on blood vessel walls (this is called atherosclerosis). This plaque is much more likely to form under “high oxidative stress”.[iii] High oxidative stress results in the oxidation of cholesterol and fats, and there is a relationship between inflammatory states and high oxidative stress.[iv] [v] This plaque itself is relatively harmless as long as the blood vessel walls are healthy and an inflammatory response is not triggered. If this plaque becomes dislodged, however, an overactive inflammatory response can cause a new, larger plaque to cover up the previous plaque quickly. This can occlude the blood vessel and lead to a heart attack. The above scenario is thought to occur in 70-80 percent of heart-attack cases.

There are two points to be made here: first, atherosclerosis is present in many individuals who never have a heart attack. Studies have shown that Japanese people living within their traditional culture, for instance, have levels of atherosclerosis comparable to Americans, but have far fewer heart attacks.[vi]

What about the traditional Japanese lifestyle (and lifestyles of other traditional cultures) is protective against heart disease? Lower inflammation levels and lower oxidative stress. It is usually atherosclerosis in the presence of high inflammatory states that leads to problems, not atherosclerosis itself. We are finding that while high levels of cholesterol are associated with heart disease, keeping inflammatory states low can mitigate this risk. Oxidative stress and inflammation are intimately related. People take antioxidants to lower oxidative stress. I will discuss proper antioxidant use later in this paper. You can also visit my Antioxidant Page.

Here’s how it works; when high inflammatory states exist within your body your blood vessels are easily damaged. In response to this damage your liver creates cholesterol to “patch” the damage. Cholesterol is actually a repair mechanism for blood vessels. Once this repair is done, if inflammation levels remain chronically high, plaques can become disturbed resulting in a heart attack or stroke. If the products that create the plaque are oxidized, the plaque is especially unstable. And so we find that while cholesterol does have an association with heart disease, inflammation and oxidation are the real problems.

We know that lack of physical activity, smoking, poor diet, elevated insulin levels, and chronic stress all lead to higher inflammation levels and higher risk of heart disease. Low inflammatory states allow blood cells to move past plaques and injuries to vessel walls without clotting and adding to plaque formation and disruption. High inflammatory states contribute to and aggravate plaques. You can think of low inflammatory states like fresh oil in you car engine—flowing freely through the engine with little friction. High inflammatory states can be compared to old, dirty motor oil. This oil creates eddies and currents causing parts to wear more quickly. In your body the “parts” are your vessel walls and the plaques upon them. As we learn more about inflammation we are finding that while cholesterol is a piece of the puzzle, it is not the whole enchilada.

Second, these plaques may form, inflame, and dislodge from anywhere in the circulatory system. Stents and bypass surgery keep sections of vessels open around the heart as if these vessels were the sole culprits in heart disease. This approach neglects the fact that a thrombus (a dislodged plaque) can come from virtually anywhere in the circulatory system. For this reason stents and bypass surgery for prevention are falling out of favor (there are circumstances when these surgeries are appropriate). These treatments do not cure any problem, they merely avert a disaster in a couple of centimeters of artery. They do not treat the metabolic disorder that resulted in the disease.

The root of heart disease, stroke, and type 2 diabetes is a loss of metabolic control. Trying to control risk factors like cholesterol and blood pressure with drugs will never cure the problem. Effective treatment must be the re-attainment of proper metabolism!

The Problems With Statins

We are just beginning to realize the many side-effects of statin therapy (the statins are the most common drugs prescribed for high cholesterol). These include compromised liver function, muscle disorders, increased risk of heart failure, a reduction in “good” cholesterol, cancer[vii], cognitive decline[viii], and a depletion of coenzyme Q-10 (CoQ10) (which is associated with an increased risk of heart failure). Statins are also associated with increased rates of depression, violent behavior, and even suicide.i,ii The following is quoted directly from the University of California, San Diego medical web page:

 “In some cases violence, psychosis, and suicide have been reported.  We have published a small case series describing several instances of severe irritability arising on statins, resolving when statins were stopped, and returning when statin use was resumed.”--http://medicine.ucsd.edu/SES/adverse_effects.htm

 The same website continues,

 “Sleep problems, sexual function problems, fatigue, dizziness and a sense of detachment are also reported with these drugs.  Additionally, people have mentioned experiencing swelling, shortness of breath, vision changes, changes in temperature regulation, weight change, hunger, breast enlargement, blood sugar changes, dry skin, rashes, blood pressure changes, nausea, upset stomach, bleeding, and ringing in ears or other noises.”

 As a last blow to the statins, consider the following excerpt from Expert Opinion on Drug Safety, an agency that does systematic, unbiased reviews of drug types for drug research and development:

 “Randomised trial data confirm that lowering cholesterol no longer extends life in the elderly, even those at high risk of heart disease, and no evidence supports the presumption that the impact on all-cause morbidity is any more favourable. These findings increase the importance of statin adverse effects (AEs) in this group. Furthermore, the elderly may be more vulnerable to known AEs, and evidence provides cause for concern that new risks may supervene, including cancer, neurodegenerative disease and heart failure. Physiological evidence regarding the impact of statins on mitochondrial function, and mitochondrial function on ageing, support these concerns. Additionally, the impact of statin AEs (e.g., muscle and cognitive problems) may be amplified in this group. Effects may be misattributed to ageing. Even modestly lower cognitive and physical function in older elderly prognosticates increased disability, hospitalisation, institutionalisation, and mortality. Disability, once present, is less likely to recover. Because the risk for AEs is unattended by evidence of net benefit to the person, the use of statins in the elderly should be undertaken, if at all, with circumspection and close scrutiny for adverse effects.” Expert Opinion on Drug Safety May 2005, Vol. 4, No. 3, Pages 389-397.

It is interesting to note that while the risk of dying of some forms of heart disease decreases with statin therapy, several studies have shown that overall mortality (the risk of death) is the same or increased when compared to individuals not using statins.

 Other studies actually show that what modern medicine considers “high” cholesterol” may be a good thing. For instance, one study found that low levels of cholesterol were associated with a “marked increase in mortality in advanced heart failure”[ix]

When Should I Be Concerned About My Cholesterol Levels?

 As mentioned above, cholesterol is not the cause of heart disease. Cholesterol can, however, be a useful marker of an underlying inflammatory condition or loss of metabolic control. The following guidelines will help you to decide rather or not your cholesterol is indicating such a condition. In the next section I will discuss the root causes of the inflammatory condition, and how to address it naturally.

 A great deal of research supports the notion that the amount of HDL cholesterol compared to the amount of LDL cholesterol is more important than overall cholesterol. Evidence suggests that LDL cholesterol levels should not exceed 4-5 times HDL cholesterol levels. Thus, a person with high HDL levels could have higher than normal LDL levels and not have an increased risk for heart disease. For example, an individual with an HDL level of 70 could have a LDL level of 300 and this could be a healthy level!

The Most Important Part!

But this is not the whole story, as all LDL particles are not equal. There are small, compact LDL particles that can cause problems, and bigger, fluffy LDL particles that do not cause problems.[x] It is very easy to tell what type of LDL particles you have from a routine cholesterol test. Simply divide your triglyceride number by your HDL number. If the number is more than 3.8, it is likely that you have the “bad” type of LDL cholesterol. If it is less than 3.8, it is likely that you have the “good” type of LDL cholesterol.[xi] [xii] [xiii] This ratio is the most important one in your cholesterol panel! This is also the ratio most easily changed by adding fish oil to your diet and decreasing your omega-6 consumption. By consuming fish oil you lower triglycerides and increase HDL. You may see an increase in LDL, but this is the “good” LDL mentioned above.

Heart Disease Risk: Beyond Cholesterol

Keep in mind the other major risk factors for heart disease: insulin resistance, elevated blood pressure, elevated inflammatory levels, and chronically elevated cortisol levels. When several of these risk factors coexist it is called metabolic syndrome. Click here to read more about it. Click here to read about blood pressure.

Perhaps the single most accurate test for metabolic syndrome is this: get completely naked and stand in front of a mirror. If your belly is bigger than your rear-end, it is likely that you have metabolic syndrome. This simple test has been shown again and again to be an accurate predictor of metabolic syndrome![xiv] [xv] To make it more scientific you can get a flexible tape measure and measure your girth around the widest portion of your hips and compare to the girth at the height of your navel.

Ideal Treatment

In my opinion high cholesterol should not be the primary target of treatment. Using the guidelines above, cholesterol can be used to gauge a loss of metabolic control that has led to chronic inflammation and/or high oxidative stress. The goal of treatment, therefore, should be to regain metabolic control; for then inflammation levels will normalize and cholesterol levels will most often fall within the guidelines that I have outlined above.

Ideal treatment of heart disease risk should control abnormal cholesterol levels, oxidative stress, and inflammation without the unacceptable side effects of drug therapy. Ideal treatment should be targeted to every vessel in the body, not just the coronary arteries. Other risk factors to be controlled include blood pressure, smoking, lack of physical activity, obesity, high cortisol levels, and blood sugar/insulin levels. Here we will focus on inflammation, cortisol, cholesterol, and antioxidant status.

Regaining Metabolic Control: Achieving Optimal Inflammation, Cortisol, Cholesterol Levels and Antioxidant Status Naturally

Stress Reduction

Nutrition

Exercise

Supplements

Stress Reduction

Studies have shown a large reduction in heart disease in individuals who meditate on a regular basis. It turns out that people who meditate regularly have much lower levels of inflammation in their blood vessels than non-meditators.[xvi] Research has shown that regular meditation can actually reverse atherosclerosis![xvii] A very recent study demonstrated that 16 weeks of meditation practice led to a significant reduction in blood pressure and insulin resistance in individuals with coronary artery disease.[xviii] Other research has shown a reduction in cortisol levels in meditators.[xix] People who meditate have healthier cholesterol levels than individuals of similar age and activity level who do not meditate. There are several mechanisms at work including a reduction in stress related hormones, lower inflammation levels, and increased levels of DHEA, a hormone that promotes healthy body weight and cholesterol levels.[xx]

Other methods of stress reduction (prayer, yoga, etc) may also be beneficial, but as of now the best research is with meditation. Be sure to take some time daily, preferably at the same time every day, to practice some method of peace-cultivating stress reduction.

Stress can create havoc in the autonomic nervous system--the part of your nervous system that regulates involuntary bodily functions such as blood flow, digestion, and temperature. Imbalance in this system is associated with elevated cholesterol, elevated blood pressure, and obesity.[xxi] Chiropractic care has been shown to restore balance to the autonomic system[xxii], and I recommend a course of care for anyone dealing with these issues.

An excellent way to find out how stress is affecting your body is to have your cortisol and DHEA levels checked. This is a simple saliva tests that many clinics, including mine, offer. If there are abnormalities in the levels of either of these hormones targeted therapy can begin to address the imbalance. If, for instance, these hormones are low, licorice root can be used for a period to give the adrenal glands a boost (note: people with high blood pressure should not use licorice root).

When thinking along these lines, it is important to note the 2 greatest risk factors for death due to cardiovascular disease: they are not cholesterol, weight, blood pressure, or smoking, they are being unhappy and not loving one’s job![xxiii] This was established in a large, well-done study! Stress reduction techniques may be the most important thing you can do to lower your cardiovascular risk.

Go to scientific paper on stress reduction and heart disease

Go to stress reduction page

Nutrition

Commercial saturated fats from poorly-raised meats contain high levels of arachidonic acid, which promotes inflammation. Omega-3 fatty acids (from fatty fish and flax seed) and monounsaturated fatty acids (olive oil) decrease inflammation levels. Coffee and other stimulants increase inflammation levels through the same mechanisms as stress.

Nutrition can play a large role in determining cholesterol levels. The greatest area of confusion I see in patients is around fats—so here’s the skinny on fat:

Hydrogenated oils (margarine and anything that says “hydrogenated” or “partially hydrogenated”) are the worst type of fat you can eat, and I recommend cutting them from your diet altogether (they have actually been banned in some parts of Europe).

Refined vegetable oils (excepting olive oil) are high in omega-6’s and I do not recommend them. These include oils of sunflower, corn, soy, safflower, canola, and peanut. These should be used on a limited basis, if at all, and offset by appropriate omega-3 use.

Omega-3 fats (fish and flax—see below under the supplementation heading) and monounsaturated fats (olive oil, avocado, and nuts) promote healthy cholesterol levels, as do the special fats (called medium-chain fatty acids) in coconut oil. Fish oil and coconut oil consistently result in lower triglycerides, and higher HDL levels. Remember from the section above that the triglyceride/HDL ratio is the most valuable information in your cholesterol panel pertaining to cardiovascular risk. If your triglyceride/HDL ratio is over 3, I highly recommend taking 3-5 grams of combined EPA+DHA from a quality fish oil per day, and 2 tablespoons of coconut oil 20 minutes before your largest meal of the day.

Refined carbohydrates elevate triglycerides, and over time will elevate “bad” LDL and decrease HDL. Eat only complex whole-food carbohydrates. The fiber present in unrefined forms of carbohydrate lowers cholesterol. Eat plenty of fruits and vegetables. Throw away white flours, sugars, and products containing these, as these refined carbohydrates encourage insulin resistance and raise triglyceride levels. An excellent source of fiber is beans, many of which are extremely high in antioxidants. If your triglycerides are high, limit your carbohydrate intake. Shift to more vegetables, proteins, and fats.

Yogurt and other fermented foods such as tempeh, miso, and kimchee, contain bacteria that break down cholesterol in your gut, causing it to be excreted rather than absorbed into your blood. Eat these in abundance as they have many other health benefits.

 Go to Nutrition/Recipes Page

Exercise

Regular, exercise decreases inflammation levels during daily living.[xxiv] There is, however, a temporary inflammatory response during intense exercise. For this reason it is wise to build intensity over a period of time and to consult with your doctor regarding your exercise program if you are at risk for heart disease.

Regular exercise not only lowers “bad” cholesterol, it is one of the most effective ways to elevate “good” cholesterol, promote healthy blood sugar levels, healthy body weight, and it gives you the energy needed to make changes in your life!

Remember that the number one cause of free radical production in your body is energy production. Be sure to keep your antioxidant and glutathione status high when you are engaged in an exercise program.

 Go to exercise page

Supplements

Many supplements have profound anti-inflammatory and cholesterol lowering capabilities and are very safe at therapeutic levels for long-term use. Here are my favorites, in order:

• Fish Oil (2.5-5 grams/day of combined EPA+DHA: Omega-3 fatty acids feed pathways in your body that guard against excessive inflammation (remember that saturated fats in the absence of omega-3 fatty acids promote inflammation). A recent study in the Archives of Internal Medicine found that Omega-3 supplementation resulted in a 23% reduction in mortality, whereas statin drugs (like lipitor, zocor, and others) resulted in only a 13% reduction in mortality.[xxv] Also read my more complete article on the benefits of fish oil,--this may be the single most important thing you can do for your overall health!
• Policosanol 10-20 mg/day: Not only reduces inflammation better than aspirin, also reduces cholesterol as well as any statin drug while increasing HDL levels. Is beneficial for individuals with intermittent claudication (click for references and more information).
• Chinese Red Yeast Rice: The idea for the statin drugs originally came from this fermented rice product. It produces the same cholesterol lowering effect with far fewer side effects. I highly recommend this product for stubborn LDL levels that are resistant to lifestyle changes. It is also a potent anti-inflammatory (click for references and more information).
• Ginger, Turmeric, and Holy Basil: All of these botanicals lower inflammatory states. They also have a multitude of other benefits; ginger is protective to your stomach and gastrointestinal lining and is cancer protective, holy basil reduces blood sugar in diabetics and reduces the inflammatory effects of stress by regulating cortisol levels, and turmeric has anti-cancer properties, is protective against ulcers, and is a powerful antioxidant. These can be used as spices on your food or taken as capsules. New Chapter makes an effective combination of these herbs called “Zyflammend”.
• Cinnamon: Works especially well for triglycerides. Also helpful in lowering blood sugar levels in people with type-2 diabetes and metabolic syndrome. Take ¼ tsp of organic cinnamon per day, or try this extract.
• Vitamin E: This fat-soluble vitamin promotes healthy platelet function and helps to decrease the inflammatory effects of stress. It is found abundantly in nuts and seeds, whole grains, egg yolks, and leafy green vegetables. If used as a supplement, avoid megadoses that can actually promote heart disease—for this reason I recommend not more than 150 IU per day in supplement form. Ideally you get all you need from eating the above-mentioned foods in abundance.

See Supplement Chart  

Important Concepts on Antioxidant Status

Several studies have shown that synthetic antioxidants taken in large amounts have either no effect on health, or actually increase rates of heart disease and cancer! It appears that large forms of single-molecule antioxidants, like vitamin C or vitamin E can actually act as oxidants, rather than antioxidants, in the human body.

 In a natural environment one would never encounter 1,000mg of ascorbic acid (vitamin C), so it makes sense to me that our bodies are not equipped to deal with such high doses of single molecules. For this reason I prefer food-based antioxidants. Research has uncovered a vast array of potent antioxidants that are appropriate for supplemental use under special circumstances. These can be found on my antioxidant page. Most people can get all the antioxidants they need from a healthful diet that is rich in fruits, vegetables, whole grains, and grass-fed organic dairy and meat. New Chapter makes an excellent one-a-day food-based supplement that contains appropriate levels of antioxidants.

 Go to Antioxidant Page

Supplement Chart

Summary

So, what do you do when you find out you have high cholesterol? First of all, re-evaluate your levels-- you may not even have a problem. Is your LDL less than 4-5 times the HDL amount? Are your triglycerides divided by your HDL less than 3.8? If so, talk to a holistic health care provider with knowledge in these areas—you may be worried about nothing!

Second of all consider your lifestyle. People who exercise regularly, eat a diet rich in “good fats”, fruits and vegetables, avoid refined carbohydrates and processed meats, and practice some form of stress reduction have a greatly reduced risk of heart disease regardless of cholesterol levels.

The following chart reviews some of the best strategies for specific cholesterol abnormalities:

References:

[i] Morales K, Wittink M, Datto C, DiFilippo S, Cary M, TenHave T, Katz IR. Simvastatin causes changes in affective processes in elderly volunteers. J Am Geriatr Soc. 2006 Jan;54(1):70-6.

[ii] Vevera J, Fisar Z, Kvasnicka T, Zdenek H, Starkova L, Ceska R, Papezova H. Cholesterol-lowering therapy evokes time-limited changes in serotonergic transmission. Psychiatry Res. 2005 Feb 28;133(2-3):197-203

[iii] Chrysohoou C, Panagiotakos DB, Pitsavos C, Skoumas J, Economou M, Papadimitriou L, Stefanadis C. The association between pre-hypertension status and oxidative stress markers related to atherosclerotic disease: The ATTICA study. Atherosclerosis. 2006 May 25; [Epub ahead of print]

[iv] Annuk M, Soveri I, Zilmer M, Lind L, Hulthe J, Fellstrom B. Endothelial function, CRP and oxidative stress in chronic kidney disease. J Nephrol. 2005 Nov-Dec;18(6):721-6.

[v] Chang CY, Chen JY, Ke D, Hu ML. Plasma levels of lipophilic antioxidant vitamins in acute ischemic stroke patients: correlation to inflammation markers and neurological deficits. Nutrition. 2005 Oct;21(10):987-93.

[vi] Gore I, Hirst AE, Koseki Y. Comparison of aaortic atherosclerosis in the United States, Japan, and Guatemala. American Journal of Clinical Nutrition 1959;7:50-54.

[vii] Newman TB, Hulley SB. Carcinogenicity of lipid-lowering drugs. JAMA. 1996 Jan 3;275(1):55-60.

[viii] Muldoon M, Ryan C, Sereika S, Flory J, Manuck S. Randomized trial of the effects of simvastatin on cognitive functioning in hypercholesterolemic adults. The American Journal of Medicine 2004 Dec 117;11(1):823-829.

[ix] Horwich TB, Hamilton MA, Maclellan WR, Fonarow GC. Low serum total cholesterol is associated with marked increase in mortality in advanced heart failure. J Card Fail. 2002 Aug;8(4):216-24.

[x] Scott M. Grundy, MD, PhD Small LDL, Atherogenic Dyslipidemia, and the Metabolic Syndrome Circulation. 1997;95:1-4.

[xi] Bhalodkar NC, Blum S, Enas EA. Accuracy of the ratio of triglycerides to high-density lipoprotein cholesterol for predicting low-density lipoprotein cholesterol particle sizes, phenotype B, and particle concentrations among Asian Indians. Am J Cardiol. 2006 Apr 1;97(7):1007-9. Epub 2006 Feb 21

[xii] Hanak V, Munoz J, Teague J, Stanley A Jr, Bittner V. Accuracy of the triglyceride to high-density lipoprotein cholesterol ratio for prediction of the low-density lipoprotein phenotype B. Am J Cardiol. 2004 Jul 15;94(2):219-22.

[xiii] Maruyama C, Imamura K, Teramoto T. Assessment of LDL particle size by triglyceride/HDL-cholesterol ratio in non-diabetic, healthy subjects without prominent hyperlipidemia. J Atheroscler Thromb. 2003;10(3):186-91.

[xiv] Cabrera MA, Gebara OC, Diament J, Nussbacher A, Rosano G, Wajngarten M. Metabolic syndrome, abdominal obesity, and cardiovascular risk in elderly women. Int J Cardiol. 2006 Jun 17; [Epub ahead of print]

[xv] Shen W, Punyanitya M, Chen J, Gallagher D, Albu J, Pi-Sunyer X, Lewis CE, Grunfeld C, Heshka S, Heymsfield SB. Waist circumference correlates with metabolic syndrome indicators better than percentage fat. Obesity (Silver Spring). 2006 Apr;14(4):727-36.

[xvi] Smith, DE, Dillbeck, MC, Sharma, HM. Erythrocyte sedimentation rate and transcendental meditation. Alternative Ther in Clin Practice. 1997;4(2):35-37.

[xvii] Castillo-Richmond, A, Schneider, RH, Alexander, CN, et al. Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke. 2000;31:568-573.

[xviii] Maura Paul-Labrador, MPH; Donna Polk, MD, MPH; James H. Dwyer, PhD ; Ivan Velasquez, MD; Sanford Nidich, PhD; Maxwell Rainforth, PhD; Robert Schneider, MD; C. Noel Bairey Merz, MD Effects of a Randomized Controlled Trial of Transcendental Meditation on Components of the Metabolic Syndrome in Subjects With Coronary Heart Disease Arch Intern Med. 2006;166:1218-1224.

[xix] Walton, KG, Pugh, ND, Gelderloos, P, Macrae, P. Stress reduction and preventing hypertension: Preliminary support for a psychoneuroendocrine mechanism. J of Alternative and Complimentary Medicine. 1995;1(3):263-283.

[xx] Walton, KG, Pugh, ND, Gelderloos, P, Macrae, P. Stress reduction and preventing hypertension: Preliminary support for a psychoneuroendocrine mechanism. J of Alternative and Complimentary Medicine. 1995;1(3):263-283.

[xxi] Kimura T, Matsumoto T, Akiyoshi M, Owa Y, Miyasaka N, Aso T, Moritani T. Body fat and blood lipids in postmenopausal women are related to resting autonomic nervous system activity. Eur J Appl Physiol. 2006 Jun 9; [Epub ahead of print]

[xxii] Zhang J, Dean D, Nosco D, Strathopulos D, Floros M. Effect of chiropractic care on heart rate variability and pain in a multisite clinical study. J Manipulative Physiol Ther. 2006 May;29(4):267-74.

[xxiii] Coelho R, Ramos E, Prata J, Maciel MJ, Barros H. Acute myocardial infarction: psychosocial and cardiovascular risk factors in men. J Cardiovasc Risk. 1999 Jun;6(3):157-62.

[xxiv] Ford, ES. Does exercise reduce inflammation? Physical activity and C-reactive protein among U.S. adults. Epidemiology. 2002;13(5):561-568.

[xxv] Studer M, Briel M, Leimenstoll B, Glass T, Bucher H. Effect of Different Antilipidemic Agents and Diets on Mortality. Arch Intern Med. 2005;165:725-730.