Heart disease is the leading cause of death in the United States, ranking above cancer and stroke. Additionally, hypertension, commonly referred to as “high blood pressure,” is the 13th leading cause of death in the U.S. (Kung et al. 2008). It is therefore important for all health and fitness professionals to be informed about the methods available to help support cardiovascular health.
This article will review key mind-body approaches to cardiovascular disease, with particular emphasis on meditation,
relaxation and cognitive skills (mental processes related to perceptions, attitudes and beliefs). Additionally, the article will
describe the field of mind-body medicine, review research on cardiovascular disease and the mind-body connection, and provide practical suggestions for facilitating mind-body awareness.
Mind-Body approaches to health and fitness can be thought of as falling under the umbrella of mind-body medicine. This field encompasses a wide range of methods, including meditation,
relaxation training, tai chi, qigong, yoga, cultivation of optimism, modification of negative thinking, visualization, hypnosis, social support groups and other methods that activate the mind-body connection to reduce stress, improve physical health and enhance mental health (Goleman & Gurin 1993). A comprehensive review of the research literature by Astin et al. (2003) concluded that there is substantial evidence that mind-body therapies can be used as effective adjuncts to standard medical treatment for a variety of medical conditions.
Complementary, Not Alternative
With regard to mind-body methods, it is useful to distinguish between complementary and alternative approaches to health. Methods aligned with mind-body medicine are usually viewed as research-validated practices complementing traditional medicine rather than providing an alternative to medical intervention (Casey, Benson & MacDonald 2004). This distinction reflects the growth of mind-body medicine, whereby what used to be considered alternative (e.g., meditation) is now considered mainstream.
Cardiovascular Disease and the Mind-Body Connection
Decades of research clearly indicate that lifestyle, stress, psychological factors and heredity can significantly contribute to the development and progression of heart disease (Treister 2004; Brotman, Golden & Wittstein 2007).
Stress is a significant risk factor for the development of cardiovascular disease (Brotman, Golden & Wittstein 2007). Stress can be defined as the result of internal and/or external demands that are perceived as exceeding an individual’s resources to cope with them (Lazarus & Folkman 1984). Internal demands or stressors might take the form of illness, pain or negative thoughts and emotions. External stressors might include challenging interpersonal relationships or difficult work conditions. Cardiac risk factors such as hypertension, elevated cholesterol and excessive waist circumference—all components of the metabolic syndrome—have been linked to psychological stressors like
depression, anxiety, tension, anger and perceived stress (Räikkönen, Matthews & Kuller 2002).
Personality Types and Behavioral Patterns: Beyond Type A
Type A behavior has been described as a pattern characterized by competitiveness, muscle tension, ambitiousness, impatience and hostility (Friedman & Rosenman 1974). Past thinking has regarded individuals with this behavioral style to be at greater risk for coronary heart disease (CHD) than other types. However, contemporary research reveals that type A behavior per se does not pose a significant risk for developing CHD; it is the hostility component of type A behavior that creates an increased risk for heart disease (Myrtek 2001). Niaura and colleagues (2002) found that hostility positively predicted the incidence of CHD, and their research demonstrated that hostility was a greater predictor of CHD than more traditional risk factors, such as blood lipid profiles, body mass index and cigarette usage. Williams (1993) notes that “hostility, lack of social support, and high job stress increase the likelihood of developing cardiovascular disease and dying from it prematurely.” Chronic hostility activates the nervous system and distresses interpersonal relationships, and can result in unhealthy behaviors that further increase the risk for developing CHD.
Type D Personality
Research has continued to refine our understanding of the associations between stress, personality, behavior, emotions and risk for developing CHD. The description of a type D personality has emerged from the research on personality style and heart disease (Denollet et al. 1996). Individuals with a type D (distressed) personality are described as having a tendency to experience negative emotions while simultaneously inhibiting self-expression and social interaction. These individuals may be depressed, worried, irritable and distressed, although not inclined to express their feelings or directly seek support from others. Type D personality has been revealed as a significant predictor of death in individuals with a history of CHD, independently of conventional medical risk factors. Elevated cortisol levels may be a significant factor in the relationship between type D personality and increased risk for developing CHD (Sher 2005).
The Role of Social Support, Depression and Sleep
Research has shown that individuals who have a low amount of social support (measured by density and frequency) are at greater risk for developing CHD (Lett et al. 2005).
Research has also established the contributive role of clinical depression in the development of CHD (Frasure-Smith & Lespérance 2006). Finally, a recent study has revealed a significant relationship between sleep duration and the cardiovascular risk factor of increased coronary artery calcification (King et al. 2008).
Mind-Body Approaches to Stress and Cardiovascular Health
There is evidence that lifestyle modification programs incorporating mind-body methods can play a significant role in the treatment of cardiovascular disease, reducing risk factors such as body weight and total cholesterol (Rutledge et al. 1999).
The groundbreaking research of Herbert Benson, MD, on the effect of meditation on blood pressure was described in his landmark book, The Relaxation Response (Benson 1975). Benson described a relaxation response that could offset the effects of the fight-or-flight response to stress, which is associated with increased heart rate and blood pressure, among other changes (Benson & Klipper 2000).
The relaxation response is the opposite of the fight-or-flight response, resulting in decreases in heart rate and respiration, blood pressure (if already elevated) and the metabolic rate (Benson & Klipper 2000). Benson and Klipper (2000) describe four basic components that help elicit the
- a quiet environment
- a mental device–a sound, word, phrase or prayer repeated silently or aloud, or a fixed gaze at an object
- a passive attitude–not worrying about how well one is performing the technique and simply putting aside distracting thoughts to return to one’s focus
- a comfortable position
Benson’s work is a cornerstone in the foundation of mind-body medicine, relevant to all who use mind-body disciplines to promote health and wellness, with particular significance for cardiovascular health. Recent research by Dusek et al. (2008) suggests that the relaxation response can change the expression of genes that are normally associated with the damaging effects of stress, essentially “turning off” genes associated with disease!
Benson (1983) notes several mind-body methods that can elicit the relaxation response, including meditation, yoga, tai chi, repetitive prayer, breathing exercises, biofeedback, progressive muscular relaxation, guided imagery and qigong. Meditation, relaxation training and tai chi/qigong are briefly reviewed below, along with cognitive restructuring, which can also help facilitate relaxation.
Although the traditional aim of meditation practice is to increase awareness, wisdom and compassion, meditation can also be used as a method of stress reduction (Kabat-Zinn 1990). There are many forms of meditation. Regardless of the form, three essential ingredients apply to most, if not all, meditation practices: posture, awareness and attitude. In seated meditation, the posture is upright but not rigid, with hands resting on the lap or near the midsection. The eyes can be open or closed. Awareness is directed toward the object of meditation, which might be the breath or a repeated word. Attitudes cultivated in meditation practice include patience, acceptance, letting go, gentleness and even a sense of humor!
Two forms of meditation are mantra meditation and mindfulness meditation. In mantra meditation, the practitioner silently repeats a word or phrase over and over. If awareness strays from the repetition of the mantra, the mind gently returns to it to resume the repetition. Benson’s original research on the relaxation response was based on the cardiovascular benefits of mantra meditation achieved by practitioners of Transcendental Meditation (Benson 1975).
Mindfulness is “awareness, of present experience, with acceptance” (Germer 2005). Mindfulness meditation involves two basic elements: concentration (e.g, on the breath) to focus and stabilize the mind and body; and open, nonjudgmental awareness that observes the passing of thoughts, feelings, images and sensations (Kabat-Zinn 1993). Once concentration is stabilized, the primary emphasis is on opening the field of awareness to the entire range of observed experience, but without analyzing, judging or “holding on” to internal experience. Mindfulness allows practitioners to be aware of the present state of their mind (e.g., calm, judgmental, distracted, excited). Mindfulness-based stress reduction has been found to be a useful approach in the treatment of a wide range of mental and physical disorders, including cardiovascular disease (Grossman et al. 2004).
Tai Chi and Qigong
Tai chi chuan, popularly referred to as “tai chi,” is an ancient Chinese system of meditative movement, exercise and self-
defense. The slow, graceful movements of tai chi promote physical relaxation and mental calmness. According to Benson and Klipper (2000), the benefits of practicing tai chi include improved cardiovascular health, bolstering of immune-system functioning, increased flexibility and muscle strength, and improved coordination and balance. Qigong (pronounced “chee gung”) is another ancient Chinese system of exercise and healing meditative movement that is usually simpler in form and therefore easier to learn than tai chi (Cammarata 2009). Practitioners of qigong experience cardiovascular and immune-system benefits, as well as the physical benefits shared by practitioners of tai chi (Cohen 1997). In fact, when not used for martial arts purposes, the practice of tai chi is considered a form of qigong.
Two useful forms of relaxation training are progressive relaxation (Jacobson 1938) and autogenic training (Schultz & Luthe 1959). Progressive relaxation involves the identification of muscular tension and the systematic reduction of that tension through the intentional, progressive tensing and relaxing of the body’s major muscle groups. For example, when the arms are purposely tensed (by making tight fists) and the tension is held for 10 or more
seconds before it is released, the arm muscles—with practice—become relaxed, and the practitioner becomes more adept at distinguishing tension from relaxation.
Autogenic training is the oldest known Western system of self-regulation (Sadigh 2001). It is a powerful, straightforward method that involves body awareness and the repeating of relaxing phrases, such as “My left arm is heavy,” to induce a state of mind-body relaxation. These self-administered phrases induce feelings of heaviness and warmth, regulated heart and respiratory functioning, and other physiological alterations associated with deep relaxation. The basic requirements for attaining autogenic relaxation include reducing environmental stimulation, maintaining a detached attitude about reaching a specific outcome, establishing mental contact with a body part or function, mental repetition of the specific phrases and daily practice (Sadigh 2001). Autogenic training is effective in treating irregular heartbeat, high blood pressure and headaches, and in reducing the experience of stress and pain (Davis, Eshelman & McKay 2000).
Cognitive restructuring is a method of identifying and changing dysfunctional and stressful thoughts and perceptions. A cognitive framework views stress as a result of how one thinks about and perceives situations; that is, of how one’s thinking is structured in relation to various situations (Beck 1984). Although challenging situations in life cannot always be changed, our thoughts about them can be changed. When we are distressed or depressed, our thoughts and perceptions can function like a lens through which we negatively interpret our self, our world and the future (Beck et al. 1979).
Consistent with the cognitive approach, a relatively new field called “positive psychology” asserts that positive emotions—such as hope and optimism—are associated with greater longevity and health (Seligman 2002). While not directly eliciting the relaxation response in the same way as the methods described above, cognitive restructuring can derail stressful thoughts and thereby counteract the fight-or-flight response, easing access to the relaxation response. This method is therefore in alignment with other mind-body approaches aimed at promoting cardiovascular health.
Beyond Technique: A Way of Being
Practices that reduce stress and elicit the relaxation response are useful methods of supporting cardiovascular health, especially when they are applied consistently over time. When these practices are integrated into one’s life, they can become a natural way of being. For example, mindfulness can be applied to any situation, not just when formally practicing mindfulness meditation. Mindfulness can be used to observe the workings of the mind when facing stressful situations, allowing for a healthy “disentanglement” from the situation. The martial arts aspect of tai chi teaches the practitioner to relax and soften when facing an opponent. In the language of tai chi, “Soft conquers hard.” This philosophical stance has significant implications for cardiovascular health. Within the stress management context, “hard” refers to the challenging, stressful circumstances and people that we encounter in life. If we harden (i.e., become hostile, tense or oppositional) to these situations, we become more distressed. If, on the other hand, we “soften” to these situations, we can potentially breathe with ease, relax, clear our mind and respond in a skillful, effective manner without wasting energy.
The technique of cognitive restructuring reminds us to question our own thinking and perceptions whenever we feel distressed. It just might be our negative thinking that is the cause of our stress! When integrated into the body-mind, the present-centered awareness of mindfulness, the relaxation facilitated by disciplines like tai chi and yoga, and the rational attitude promoted by cognitive restructuring can support cardiovascular health in a way that is not dependent on formal technique.
Facilitating Mind-Body Awareness
Mindfulness encompasses the mind-body experience by including awareness as a key ingredient to optimal fitness, health and well-being. Mindfulness, or mind-body awareness, allows your clients to know the state of their mind, body and emotions in the present moment.
Chances are that you have facilitated an enhanced state of mindfulness for your clients without even knowing it! The yoga teacher’s essential well-timed instruction to “breathe” will make a big difference for the yoga practitioner, as will the tai chi instructor’s reminder to “relax your shoulders.”
Regardless of your specialty, the general principle for facilitating mind-body awareness in a client is to ask a question or make a statement that increases his or her awareness of the present moment. Ask yourself, “What would I like this client to focus on in this session/class/exercise?” Then, pose a direct question, such as, “Are you paying attention to your abs right now?” Alternatively, you might pose an indirect question, such as, “Where is your attention right now?” Using the above example, you might also choose to make a direct statement, such as, “Focus on your abs right now.”
Mindfulness-oriented communications can also focus on your client’s thoughts or general state of awareness, but without analysis. For example, in response to a client who is distracted by extraneous matters, you might say, “I encourage you to let go of your concerns during our time together and to fully focus your mind on this movement that we’re reviewing.” In response to clients who have a difficult time “letting go,” I usually tell them, “Let your concerns ‘be’; let them be if you can’t let them go.”
Skillfully using the various forms of mindfulness questions and statements involves your awareness of the client’s communication style (e.g., receptive or defensive), knowledge of the technical aspects of your discipline and the intention to integrate mind-body awareness into your work.
Now, more than ever, health and fitness professionals have information, technology and methods at their disposal to assist their clientele in maintaining the highest degree of cardiovascular health possible. Cultivating the healing potential of mindfulness, relaxation and an optimistic attitude will likely to a longer, healthier and more satisfying life!
Increase Your Effectiveness by Staying Informed and Updated About the Benefits of Mind-Body Methods. Knowing the benefits of mind-body practices prepares you to explain how these methods can help. Clear information, combined with supportive encouragement, can motivate clients to make healthy changes.
Practice What You Preach. As an old provocative saying goes, “Nothing worth learning can be taught.” Experience yoga, tai chi, meditation and other mind-body methods for yourself. This will allow you to involve both mind and body in the learning process!
Become Trained to Teach Mind-Body Practices Such as Tai Chi and Yoga. There is a growing need for competent teachers to help the aging population prevent cardiovascular disease.
Know Your Limits, and Share Resources. Health and fitness professionals are responsible for working within the scope of their license or role. When the limits of your expertise are reached, it’s advisable to keep a list of resources (e.g., health professionals, books, websites, class schedules) available to share.
Stay Balanced by Acknowledging That Stress, Negativity and Hostility Are Equal Opportunity Diseases. It may very well be easier to perceive your clients’ stress and negativity than your own. Recognize the cardiovascular risk factors of stress, hostility and lack of social support in your life as well as the lives of your clients.
- Practice being fully present (a state of alertness and concentration) wherever you are.
- When facing challenging people and situations, relax and breathe mindfully.
- Befriend yourself by letting go of self-judgments and criticism.
- Cultivate gratitude, optimism, appreciation and kindness.
- Remember that you have the ability to make peace with yourself, right now, regardless of your situation. If you’re not at peace, ask yourself, “With what am I at war?” Are you willing to establish a truce?
- Stop trying to control things (and people) that can’t be controlled.
- Accept reality on reality’s terms, even if you don’t like it (for example, you may be unhappy about a recent breakup, and accepting that fact will ultimately reduce your stress about the reality of the situation).
- Practice being patient while waiting in lines or stuck in traffic.
- When stressed about any situation, explore how you can think about the situation in a nonstressful way.
- Sit in a chair, maintaining a straight spine, head upright, with your hands resting comfortably upon your legs, eyes closed or open and cast downward.
- Breathe quietly through your nose.
- Continually focus on the flow of breathing at the level of your diaphragm.
- If you’re a beginner, silently repeat the words “rising, falling” or “in, out” to correspond with the inhalation and exhalation of the breath.
- After your awareness of breathing has become more established, let go of the repeated words and observe the breath without internal commentary.
- If you notice your mind wandering, accept the distraction and gently return your awareness to the sensation of breathing.
- Return your awareness, over and over again, to the breath.
- Bring patience, nonjudgment and kindness to your practice.
- Breathe, relax and smile!
Autogenic training is the oldest known Western system of self-regulation (Sadigh 2001). It is a safe and effective way of inducing mind-body relaxation that involves body awareness and the repeating of relaxing phrases, such as “My left arm is heavy,” to induce a state of mind-body relaxation.
Author Larry Cammarata, PhD, has created an online autogenic training audio program that can be found on the IDEA website at www.ideafit.com/autogenic-training-audio. Take a few minutes to try it or share it with clients.
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