Complementary and Alternative Approaches in Cardiovascular Disease



Complementary and Alternative Approaches in Cardiovascular Disease


Eleanor F. Bond

Shannon M. Latta



Complementary and alternative medicine (CAM) health care approaches are commonly used by patients with cardiovascular problems to promote health or to treat cardiovascular or other diseases or symptoms. Despite CAM’s substantial influence, much remains unknown about the therapeutic efficacy of CAM methods and interactions with mainstream clinical care. There is a need for systematic investigation of the safety, efficacy, and interactions of CAM with conventional therapies. It is important that scientists consider CAM issues when they design trials of conventional therapies. In the past, U.S. conventional health care profession schools such as nursing schools have given insufficient attention to CAM. This pattern is changing as educators, researchers, care providers, and patients become aware of CAM approaches. It is important that health care providers understand the power and limitations of CAM approaches and integrate this information into their care delivery.

This chapter describes some CAM therapies commonly used to promote cardiovascular health and treat cardiovascular disease. It summarizes the evidence regarding efficacy, untoward effects, and interactions with conventional treatments. Included are suggestions regarding assessing a patient’s underlying health beliefs and CAM use, and also suggestions relating to integration of CAM into clinical nursing management.


CAM DEFINITIONS AND CHARACTERISTICS

The National Institutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM)1 defines CAM as “a group of diverse medicine and health systems, practices, and products that are not presently considered part of conventional medicine.” Conventional health care, in turn, is defined by NCCAM as those practices currently used by medical doctors and other Western health care providers.1 As evidence emerges regarding CAM, these practices and therapies are integrated into conventional Western health care approaches; they are then no longer considered to be part of CAM. Thus, the categorization of practices and therapies as CAM continually evolves. For example, exercise prescriptions, once considered an alternative approach, are now a core element of conventional clinical management of diabetes mellitus, heart disease, arthritis, cancer-related fatigue, and bone health. In a similar way, cognitive-behavioral therapies, once part of CAM, are now a component of allopathic care, for example, for irritable bowel syndrome.

Terms used in discussing CAM include the following:

Allopathic medicine denotes conventional health care approaches as taught in a country’s medical and nursing schools.

Alternative medicine approaches are those used in place of conventional health practices.

Complementary medicine approaches are those used in conjunction with conventional health practices.

Holistic health care approaches emerge from viewing the patient’s physical condition and emotional responses in the context of his environment and support system (family, home, communities). Nursing models are typically holistic.

Integrative health care combines elements of CAM and allopathic health care.

Traditional medicine denotes health behaviors and traditions of people indigenous to a particular region. Traditional health practices are typically based on experience and knowledge accumulated over thousands of years. Traditional medical systems are typically based on cultural perceptions of the universe, religious beliefs, and bodily function. In the United States, “traditional” sometimes is used to refer to allopathic or conventional medicine (although that use will not be applied in this chapter). More commonly in North America the term “traditional medicine” denotes the spiritual and health care practices of American Indians, Alaska Natives, and Canada’s First Nations people.

Whole (or alternative) medical systems are defined by NCCAM as being built on complete systems of theory and practice. Generally, these systems have evolved separately from conventional Western medicine. Some whole medical systems have evolved in other cultures (Traditional Chinese Medicine [TCM], Ayurveda); others have been developed within Western cultures (naturopathy, homeopathy).


CAM DOMAINS

According to NCAAM, CAM practices can be categorized into four major domains: mind-body interventions, biologically based practices, manipulative and body-based methods, and energy medicine. These domains are described in Table 41-1. Whole medical systems typically include treatment approaches from several of the CAM domains.


PREVALENCE OF CAM

In all areas of the world, traditional healing systems compete with the allopathic biomedical model. According to the World Health Organization,2 at least 80% of the developing world uses traditional healing systems as their primary source of health care. While developing countries are striving toward improving health
outcomes by adopting allopathic medicine, the growing trend in industrialized countries is to reclaim traditional healing systems and adopt CAM modalities.








Table 41-1 ▪ CAM DOMAINS























Domain


Definition


Examples


Mind-body interventions


Techniques to facilitate the mind’s capacity to affect bodily function and symptoms


Meditation, hypnosis, prayer and mental healing, biofeedback, yoga, some types of dance, music, or art therapy


Biologically based practices


Natural products


Botanicals, special dietary remedies, aromatherapy, minerals, hormones


Manipulative and body-based methods


Movement or manipulation of the body


Chiropractic or osteopathic manipulation, massage therapy, reflexology.


Energy medicine


Manipulation of energy fields originating within the body (biofields) or application of external energy fields to the body.


Tai chi, qi gong, reiki, use of external electric or magnetic fields


In the 2002 National Health Interview Survey (NHIS) of more than 31,000 Americans, more than one third of adults used some form of CAM during the past 12 months (this number excludes the use of prayer for health reasons).3 Similar findings were reported in earlier estimates.4,5 The number of visits to CAM providers increased by nearly 50% from 425 million in 1990 to 629 million visits in 1997. American health care consumers spent between $36 billion and $47 billion for CAM therapies in 1997.4,6 Problems most commonly treated with CAM approaches are back or neck problems, head or chest colds, joint pain and stiffness, anxiety, and depression.3 The most common CAM modalities used are natural products (18.9%), deep breathing exercises (11.6%), meditation (7.6%), chiropractic care (7.5%), yoga (5.1%), massage (5.0%), and diet-based therapies (3.5%).3

Use of CAM modalities is common in other countries as well as the United States. Although many countries have adopted Western health practices, often traditional health approaches persist. In some countries, such as Korea, there has been a resurgence of interest in traditional healing practices. Integration of CAM and Western health approaches vary widely within and between countries. Sometimes the two systems are integrated; sometimes they are separate and parallel. Immigration from countries where CAM therapies are common has increased the demand for equivalent treatments in the United States and Canada.

Several factors contribute to CAM use in North America. Many chronic health problems are only partially managed by allopathic approaches, leading patients to seek alternative care to fill the perceived gap. Most CAM users (59.4%) believe that CAM combined with conventional medical treatment is beneficial to health.3 CAM approaches are appealing to some consumers because they are viewed as less invasive and “drug-like.”7 Patients sometimes express the belief that dietary supplements and herbal products are “natural,” and thus “safe.” Patients sometimes express dissatisfaction with what is perceived to be technologically and disease-focused medicine. Astin et al.5 found that patients report their most powerful motivator in seeking CAM treatment is a desire for a provider approach that more closely matches their personal values, beliefs, and philosophy of health and wellness. The CAM caregiver approach often involves less emphasis on a disease model and more emphasis on healing, overall health, and the patient-caregiver relationship. In CAM venues, that relationship is likely to be more of a partnership than a hierarchical association. CAM approaches may provide the patient with an increased sense of individual responsibility and control over health problems. The trend for the U.S. third-party payers to cover CAM therapies has also contributed to increased CAM use.


CAM Use in Specific Populations

Use of CAM varies by gender, racial and ethnic status, age, geographic region, socioeconomic status, health status, and profession. Surveys have demonstrated that those using CAM are more likely to be female, of Asian or Native American racial background, and older. Also linked with more CAM use are the following factors: Western United States residence, more years of education, higher socioeconomic status, and increased number of chronic health conditions.3,4,8

To characterize the ethnic/racial variation in the utilization of CAM versus conventional Western medicine, Xu and Farrell9 accessed data in the 1996 and 1998 Medical Expenditure Panel Survey of 46,673 respondents, stratified by ethnic group. They found that Native Americans are the most likely to substitute CAM practices for conventional health care; Asian populations also very commonly use CAM methods,8 particularly massage, herbal medicine, traditional Asian medicine, and spiritual healing instead of or in conjunction with conventional health care.9 Hispanic populations use CAM; they are likely to substitute herbal therapies, massage, and spiritual healing for conventional health care. African Americans tend to use spiritual healing, nutritional approaches, and massage to complement conventional medicine.9 Non-Hispanic White populations use chiropractic, acupuncture, and nutritional advice in conjunction with conventional approaches and use spiritual healing, prayer, and other CAM modalities as substitutes. It is not clear that surveys of minority cultures accurately reveal CAM use. Consumption of certain foods, botanical products, and spices for medicinal purposes is a routine dietary practice in many cultures and not identified as CAM; similarly, meditative or structured exercises are not so identified. There is need for culturally sensitive methods to evaluate CAM usage in clinical and research populations.

Many health care providers use CAM therapies to manage their own health. Burg et al.10 surveyed faculty at a major U.S. health science university regarding their personal use of CAM therapies. About half of the respondents indicated that they had themselves used one or more CAM therapies. Highest overall use was by allied health faculty, followed by nursing, dental, pharmacy, and medical
faculty. Fontaine11 suggests that nurses’ CAM use is related to the profession’s emphasis on self-care.


CAM Use for Cardiovascular Health

Patients with cardiovascular disease commonly use CAM approaches to treat their conditions, treat a coexisting noncardiovascular problem, or for health promotion. Saydah and Eberhardt12 evaluated 2002 NHIS data to identify CAM use patterns among chronically ill adults. They found that having a chronic illness diagnosis increased the likelihood that adults would use CAM. Nearly half of adults with cardiovascular disease (46.4%) and more than half of adults with two or more chronic diseases (55%) reported using CAM. Xu and Farrell9 evaluated survey data from 46,673 persons; hypercholesterolemia and hypertension were among the top 10 conditions or diseases of persons using CAM. Using 2002 NHIS data, Bell et al.13 noted that of those with hypertension, less than 10% were using CAM to treat that condition; rather, they sought other health improvements.

In a telephone questionnaire, patients in a Canadian cardiovascular disease registry reported much higher CAM use than has been reported in the United States: 64% of those surveyed used CAM; most commonly used were herbal remedies and nutritional supplements. Acupuncture was used by 12% and chiropractic care by 11% of the patients. Most cardiac patients were using CAM treatments for cardiac or vascular disease, but some were using the treatments for noncardiac conditions such as arthritis or psychological symptoms. Patients generally reported believing that the treatments were safe, proven effective, and that their health was improving because of the treatments.14

Xu and Farrell9 noted that patients with elevated cholesterol commonly used nutritional (33%), herbal (32%), and massage (28%) remedies. Those with hypertension reported using spiritual (31%), herbal (31%), and nutritional (26%) modalities. Another survey revealed that those individuals with hypertension commonly used nutritional supplements (coenzyme Q10, vitamin E), herbal products (hawthorn), and relaxation techniques.4

Ai and Bolling15 conducted a telephone survey of mixed gender middle-aged and older patients on the day before scheduled cardiac surgery to elicit information about CAM use. Of 225 patients, more than 80% used CAM. Most commonly used approaches were relaxation techniques, lifestyle/diet modification, megavitamins, spiritual healing, massage, herbal remedies, and imagery. CAM usage was higher in those with more education and in those with better functional status; men and women used CAM equally. Former cigarette smokers, patients with more comorbidities, and those with heart failure were more likely to use CAM than those with cardiac arrhythmias or coexisting cerebrovascular disease.


Patient Disclosure of CAM Use

Many Americans use CAM, but they often do not inform their primary care providers about their CAM use.3,12 A small study of older people, many with cardiac abnormalities, revealed that 35% had not told their providers about their CAM use.16 Another 40% of the participants reported that their primary care provider was aware of the CAM use, but was not supportive. Montbriand17 reported that most health care providers believe that they are aware of their patients’ CAM use, but in actuality only 50% of their elderly patients had informed their providers. Another study queried nonemergent patients visiting the emergency department of a major metropolitan medical center in the Western United States.18 Most patients were using some type of CAM, but less than half of those patients had mentioned this usage to their primary care provider; this is notable in that the sampling method produced only subjects in the process of seeking conventional health care services. Another study, a survey of adults aged 50 years and older, revealed that only one in five CAM users had discussed their CAM usage with their providers.19

Rationales for nondisclosure of CAM practices include the following: the provider does not need to know; the patient had not seen their provider since starting the CAM treatment; the patient did not think of telling the provider; the provider never asked; the patient perceived that the provider would not take the CAM approach seriously or would disapprove; there was insufficient time during the visit; and the provider lacked knowledge about CAM.18 In the Brown19 study of patients aged 50 years and older, the few who had discussed CAM usage with their providers initiated the topic themselves.

Patients who reported speaking to their physicians about CAM asked specific questions. In Brown’s study,19 it was found that only the minority of patients discussed CAM with their providers, but those who did sought specific advice. They sought CAM recommendations and had questions about CAM therapy effectiveness, medication interactions, and safety of a CAM therapy.19 The majority of Brown’s subjects reported that they turned to family or friends for information and advice about CAM use rather than talking to a health care professional.19

The common use of CAM as a complement to conventional health practices, the increased use of multiple prescription drugs, and the reluctance of patients to discuss their CAM practices with their health care providers leaves patients vulnerable to poor health outcomes related to drug interactions, side effects, or other problems.


WHOLE MEDICAL SYSTEMS

Whole medical systems include multiple approaches and use various modalities to maintain or restore health. Some whole medical systems (e.g., Ayurveda, TCM, Traditional Native American Healing, Traditional Korean Medicine) are based on ancient cultural beliefs and practices of a population group; other whole medical systems (e.g., homeopathy, naturopathy, chiropractic) developed concurrently with conventional Western medicine, but are based on different principles and beliefs. Many whole medicine systems incorporate beliefs about the mind-body-spirit connection and are inherently holistic in approach. The following briefly summarizes some features of several common whole medical systems.


Ayurvedic Medicine (AM)

Literally, Ayurveda means “science of life.” This traditional medicine system originated in India thousands of years ago; it is commonly practiced in South Asia and is growing in popularity in the West. Historically, AM was one of the first medical systems to acknowledge the importance of the mind-body connection. The human body is considered a replica of the universe and composed of the same basic matter (earth, water, air, fire, space). Nonmaterial aspects of the person include Sattva (consciousness, intelligence),
Rajas (motion, action), and Tamas (inertia resisting motion, action). Diagnoses are based on history, observation, palpation, and inspection, particularly of the pulse, tongue, eyes, and nails. Therapeutic goals in AM are to maintain or restore harmony between the individual and cosmic forces (mind, body, spirit). This involves increasing Sattva while reducing Rajas and Tamas. The AM approach is holistic; treatments are customized to match the individual’s characteristics (i.e., constitutional type or Prakruti). Appropriate food, sleep, and sexual activity are pillars of good health in AM. Many treatments utilize vegetable-based botanicals such as cardamom, cinnamon, and turmeric. Treatments emphasize mental and physical hygiene and discipline, adherence to moral and spiritual values, massage, exercise, meditation, herbs, sunlight exposure, and controlled breathing. Strict adherence to diet (Yama) and behavior (Niyama) is part of AM. Treatments include accessing pressure regions (Marma), similar to acupuncture. Meditation and yoga exercises are essential components of AM, with stress on the ability to bend, flex, extend, and stretch. Physical fitness from the AM viewpoint involves a capacity to withstand heat, cold, hunger, thirst, and fatigue.


Traditional Chinese Medicine

TCM has been practiced for thousands of years; it relates health to concepts about a person’s energy. The practitioner’s role is to guide the patient toward restored energy balance and, thus, health. Several types of energy are involved. Qi (pronounced chee) is the energy of life. In disease, qi is imbalanced. Related to qi are yin (associated with cold, moist, internal aspects) and yang (associated with heat, dry, external aspects). Yin and yang are constantly interrelated; when imbalanced, illness results (Fig. 41-1). Qi flows along channels called meridians (Fig. 41-2). Disease blocks qi flow and upsets the balance between yin and yang. In TCM, five elements (water, fire, earth, wood, metal) describe a person’s physical and emotional characteristics. TCM assessment involves history taking and physical examination, particularly of the tongue, pulse, and abdomen. Treatments prescribed include acupuncture, the inserting of needles at specific points along the meridians to improve qi flow (Fig. 41-3). Moxibustion treatments involve holding a burning herb to provide heat along a meridian. Cupping treatments involve placing a warmed glass over the skin; as the cup cools, the resulting vacuum pulls blood toward the area. Other TCM treatments include consuming proper foods (nutrition), preparing and ingesting Chinese herbs (herbal medicine), massaging, and exercising the body through prescribed movements such as qi gong and tai chi. Herbs have energies and are characterized as yin or yang. Herbs with cold energy treat hot syndromes; herbs with hot energy treat cold syndromes. For example, anemia or weak pulse might be considered a cold syndrome; treatments would warm the blood and strengthen the energy.






Figure 41-1 Yin-yang symbol. In TCM, yin and yang are constantly interrelated forces; disease results when these forces are imbalanced. Yin is associated with cold, moist, and internal aspects and yang is associated with heat, dry, and external aspects. (From Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. [2004]. Medical surgical nursing: Assessment and management of clinical problems [6th ed.]. St. Louis: Mosby; used with permission.)


Traditional Native American Healing

Native American healing methods are based on the accumulated knowledge and skills from hundreds of generations of traditional healers. The medicine person (traditional healer) holds a place of honor within the tribe; he or she is chosen by their tribe, by an older healer, by a tribal medical society, or as a result of a personal vision quest. Practices are typically not written down. They are handed down verbally from one practitioner to another and not shared with those outside of the group. Mastery of the Native American healing requires many years of training and disciplined spiritual practice. Native American healing practices were illegal in the United States between 1887 and 1978, but traditions were handed down and practiced covertly. Today, Native Americans are more likely to use traditional healing than other ethnic and racial groups.9 The majority of the two million Native American and Alaska Native people consult with traditional healers regardless of whether they live on or off the reservation.9

Tribal groups vary in terms of rituals and ceremonies but, in general, disease is believed to relate to problems of the person’s spirit. The underlying Native American belief system conceptualizes each person as consisting of mind, body, and spirit. Wellness involves harmony between the three components of the inner self and with the outer universe. Illness is attributed to negative mental, physical, or spiritual activity, or to imbalances of the environment; violation of a sacred or tribal taboo could be involved. Interventions are designed to heal the spirit; they include energy field manipulation, sweats, religious ceremony (song, dance), herb lore, and sand painting. In Native American culture, medicine and religion are not separate, but one concept. Most traditional religious ceremonies are also healing ceremonies because spirituality is the cornerstone of healing practices. Typically, each person is believed responsible for his own health care. Healing ceremonies implicitly include family, patient, the traditional healer, and tribal members. The traditional healer may include rituals, prayers, singing, sweat lodge, body manipulation, or herbal remedies as part of the healing process.


Chiropractic Medicine

Chiropracty is the fourth largest health care profession in the United States with 53,000 active practitioners in 2006.20 Chiropractors have 4 to 5 years of postbaccalaureate education including at least 4,500 supervised classroom, laboratory, and clinical hours; they are licensed and regulated in all 50 of the United States and in more than 30 other countries.

Chiropracty focuses on manipulation of the structure of the body to influence the body’s innate ability to restore and optimize health. Special emphasis is placed on spinal alignment. Care is provided by realignment of subluxations through manipulations of joints and vertebrae. Subluxation or a subluxation complex is defined as an abnormal function of a joint and the associated muscles, nerves, tendons, ligaments, and discs. Treatment goals for chiropractic joint realignment include restoration of proper
alignment, control of pain, and, ultimately, restoration of proper body functions.21






Figure 41-2 Meridian flow chart for the heart and the pericardium. In TCM, the Oi, or life energy, flows along meridians. Illustrated are meridians associated with (A) the heart and (B) pericardium. (Adapted from Choi, Y. W. [1973]. The topography of the fourteen meridians. Pasadena, CA: Cunningham Press; with permission.)






Figure 41-3 Person receiving acupuncture treatment. (From Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. [2004]. Medical surgical nursing: Assessment and management of clinical problems [6th ed.]. St. Louis: Mosby; used with permission.)


Homeopathic Medicine

Homeopathic medicine was founded by Samuel Hahnemann, a 19th-century German physician and chemist. Treatments involve prescription of minute doses of plant, mineral, or animal materials. Homeopathy is based on the notion that “like cures like,” that is, a substance that sickens the well will stimulate innate healing powers to cure a patient presenting with a similar disease pattern. Substances used are highly diluted. The belief is that dilute concentrations of a substance given to a healthy person may have an opposite effect in a symptomatic one.


Naturopathic Medicine

Naturopathic medicine is a primary health care system designed around the principle of supporting the patient’s inherent healing capacity. It emphasizes the body’s natural healing powers and personal responsibility for prevention and treatment of diseases.
Treatments are designed to amplify the natural tendency of the body to heal and eliminate toxins from the body.

Naturopathic remedies include diet and clinical nutrition counsel, particularly, use of naturally processed foods and herbs. Other therapies involve application of heat, water, air, or electricity; physiotherapy, acupuncture, or manipulations; homeopathy; and psychotherapy and counseling.

Naturopathic physicians normally provide primary care and do not perform major surgery, dispense pharmaceutical prescriptions (other than botanicals or body-based substances), or use radioactive substances for diagnosis or treatment.


Osteopathic Medicine

Osteopathy was developed by Andrew Taylor Still, a physician who became disillusioned with allopathic medicine after three of his children died in the meningitis epidemic of 1864. His goal was to establish practices to treat disease and promote health, rather than treat symptoms. He developed osteopathic manipulative treatment and established his own medical schools. There are currently about 20 schools of osteopathic medicine in the United States today; their graduates become fully licensed physicians, Doctors of Osteopathy. Three principles guide osteopathy, as follows: (1) the body is a unit designed to move, (2) structure and function are reciprocally interrelated by motion, and (3) the body possesses selfregulatory and self-healing mechanisms which are enhanced by the unrestricted motion of blood and body chemicals.21


MIND-BODY INTERVENTIONS FOR CARDIOVASCULAR HEALTH

There are several types of mind-body interventions used to improve health. Some mind-body interventions are based on a belief that the content of thoughts, beliefs, and emotions affects physical functioning; therapies are thought to improve health by evoking a more positive attitude. Other mind-body approaches promote health by freeing the mind of troubling thoughts or by focusing thought so as to exclude usual mental patterns (e.g., meditation or yoga; prayer, music, dance, or art therapy). Some mind-body therapies involve teaching the patient to control and regulate physical functioning and reduce stress responses (e.g., biofeedback).


Meditation

Meditation involves mental discipline, replacing typical thought patterns with a deeper state of relaxation or awareness. It has been a healing and/or spiritual practice in many cultures and religions for more than 5,000 years.22 Meditation goals sometimes include improved self-awareness, higher levels of consciousness, strengthened mental focus, or more relaxed frame of mind.23 It often involves focusing, centering, and relaxing the mind and body by using techniques such as listening to the breath, repeating a phrase (called a mantra), avoiding thought, or focusing thought. Meditation usually involves focusing on the breath or using a specific breathing pattern. Generally, meditation practices require training to tame, quiet, or focus the mind and achieve a state of detached awareness.23

Meditation has been employed in cardiovascular disease as a method of regulating the stress response and physiological variables, such as blood pressure, heart rate, and peripheral vascular resistance, often linked with cardiovascular problems. Meditative techniques have been recommended to reduce heart rate, lower blood pressure, reduce body weight, or improve the lipid profile. However, it is not clear whether meditation has long-term effects on cardiovascular health. The Agency for Health Care Research and Quality (AHRQ) published a comprehensive review of 817 studies of health applications of meditation published between 1956 and 2005.23

Evidence reviewed in the AHRQ summary suggests that meditation can evoke acute lowering of blood pressure in both healthy adults and in those with hypertension. Zen Buddhist meditation (compared with a blood pressure monitoring group) was associated with lowering diastolic blood pressure by approximately 6 mm Hg. Similarly, Transcendental Meditation was associated with small decreases in systolic (weighted mean difference 4.3 mm Hg) and diastolic (weighted mean difference 3.1 mm Hg) blood pressure when compared to progressive muscle relaxation. Some mind-body interventions also involve energy medicine. Qi gong involves breathing and movements which focus the mind and move qi through channels or meridians in the body. In two trials, hypertensive patients taught qi gong were compared with subjects on a waiting list. The qi gong groups displayed a substantial reduction in blood pressure (average systolic drop 17.8 mm Hg; diastolic 12 mm Hg) compared to those waitlisted. Tai chi is another form of focusing the mind and completing structured movements. Tai chi, yoga plus biofeedback, and yoga alone were each superior to no treatment or health education in decreasing systolic blood pressure; yoga alone and yoga plus biofeedback reduced diastolic blood pressure when compared with groups receiving no treatment.23

Two trials reviewed in the AHRQ analysis (total of 99 participants) demonstrated that tai chi was more effective than another exercise in reducing resting heart rate. In two other studies, yoga was compared with lipid-lowering medications in reducing cholesterol. One study followed patients for 4 months; the drugs were more effective than yoga in reducing total and low-density lipoprotein (LDL) cholesterol. Another study followed patients for a year; the yoga and drug groups had similar reductions in cholesterol.23

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