Cardiovascular Disease: A Functional Approach

This week in our clinical curriculum course, we talked about: How do we tackle cardiovascular disease from a functional medicine approach?

Time is Key

Of course, we all know that there are a large variety of things out there that might lower cholesterol or help vessels or improve cardiac tone. But how do we put that all together for a patient?

First, understand that a functional medicine approach is really what is expected, even in standard of care, but often there just isn't enough time to fully or immediately deliver necessary actions.

When we looked at what the AMA recommends, they talk about the first-line therapy being diet and exercise, and even Niacin is included as one of the major "go-tos" for lowering cholesterol, and there's also the conversation of Statin. Unfortunately, we know that there's no way to discuss diet, lifestyle, flushing with Niacin, implementing Statins, etc. in a standard 7-minute visit. Even though standard of care recognizes the importance of this analysis, these details are often skipped over and ignored.

Functional Medicine Wins Again

Again we are reminded of why functional medicine is so crucial, especially in a membership model where we really have the time to dig in deeply.

Time and time again, when we think about the root cause of where the patient's symptoms are coming from, we can often see things like cholesterol and prove even if we haven't yet selected a specific supplement that lowers cholesterol. And so when we think about where we would like to start, it's all about the diet and lifestyle situation.

We want to check in and make sure that they are not eating the standard amount of carbohydrates and that we're really lowering the carbohydrates and the processed foods for the patient. We also want to make sure that the patient is getting moderate protein and really focusing on high fiber.  If we are able to get patients to do that alone, we can expect to see a cholesterol shift. We also want to talk to them about exercise-- 30 minutes/five times a week is the gold standard. This is where you really see some of the largest improvements in terms of cardiovascular disease; as you go up, the rate of improvement is not as linear. So you will see lots of improvement up to that 30mins. 5x/week, and then it kind of levels off. This is the point that we really want to hit.

At this time, we are really starting to focus on that stress reduction and sleep management. When there's more insomnia, people show more plaque in the arteries. Also, of course, when people are under more stress, that produces more stress hormones, which means stress to the cardiac tissue.

As you can see, as we do even our most basic functional medicine approach, we can expect to see cholesterol come down from that! Additionally, we're looking back to gut-based inflammation as a reason for many chronic disease, and cardiovascular disease is no different here. Therefore, I detailed a few mechanisms of action which connect what's happening in the gut, to cardiovascular outcomes.

Course of Action and Suggested Mechanisms

First of all, if we have Bacterial Dysbiosis, it creates Lipopolysaccharides. This is what is responsible for Metabolic Endotoxemia -- that low grade inflammation that washes over LDL causing it to become more oxidized and more of a plaque former. The LPS could be damaging the vasculature and even damaging cardiac tissue.

If we have a disrupted microbiome that's going to change the way that we absorb cholesterol, also increasing absorption of it, a healthy microbiome sends signals that increase reverse cholesterol transport, taking cholesterol back to the liver to be broken down and utilized in terms of sent out to the brain or sent out for cell membranes, etc.

A good gut lining helps to create good Pancreatic Enzymes, and Pancreatic Enzymes have been shown to increase HDL cholesterol.

When Lipopolysaccharides remove from the gut, they travel to the portal vein and get dumped right on the liver. Not only do they damage lipids, but they also tell the liver to make more cholesterol and more triglycerides. This must be considered as a reason why there is overproduction.

Also, we know that one of the reasons that that we will make more cholesterol is when the immune system is more lit up and when macrophages are more active in what's called an M-2 state that's more proinflammatory. This is the macrophage that's more likely to uptake oxidized LDL and then plant it in the artery to be a foam cell or plaque and our streak in an eventual atherosclerotic plaque. When we can calm that immune system down, less of this occurs.

Working on gut based permeability is one of the key ways we work to calm down an overactive immune system.

Also, if Zonulin was elevated and telling tight junctions to open, we absorb some of that Zonulin, and it too is a signal to the liver to make more cholesterol and triglycerides.

One last mechanism is short chain fatty acids, like acetate, down-regulate the production of lipids by decreasing genes that are expressed to increase lipid production.

In Conclusion

 A lot of mechanisms for healing that tie gut-based inflammation to cardiovascular disease are evident with a little bit of digging. We must continue to connect cardiovascular risk factors to gut based strategies and recognize how disturbances in the inflammatory pathways lead to cardiovascular disease. We want to get to the root of metabolic endotoxemia. We want to get to the root low-level inflammation that causes cardiac disease, and our gut based approaches are front and center.

As always, we are thankful to digest (pun intended) these topics together. Stay tuned for more glimpses into our discussions here at Origins Incubator.