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Is Religiosity or Spirituality Protective For Heart Disease?

Dsire Lie, MD, MSEd Posted: 04/21/2010

Case
Jorge Delgado is a nonsmoking, healthy, and happily married Hispanic man with a 13-year-old son and a 15-year-old daughter. At his annual physical examination, he is found to have an elevated low density lipoprotein cholesterol level of 170 mg/dL, a high-density lipoprotein cholesterol level of 50 mg/dL, and a total cholesterol level of 230 mg/dL; his blood pressure is 135/85 mm Hg, and his body mass index (BMI) is 28 kg/m2. His fasting blood glucose level is normal. Mr. Delgado has no family history of premature heart disease, but his grandfather was diabetic and died of kidney failure. His physician advises dietary management to reduce weight and exercise by walking 20 to 30 minutes 4 to 5 times weekly, with a goal of reducing his BMI to 25 kg/m2. The physician also discusses the need for a cholesterol-lowering agent and recommends a statin if results of liver function tests are normal. Mr. Delgado responds that he is unwilling to take medications because he feels healthy and that he believes that reducing his weight is not a realistic goal, given his familys cultural values and use of food as an integral part of all social activities. He is proud that his wife and children actively participate in all family events and attend church with him weekly. He has read that being religious and attending church regularly prolongs life and reduces the risk for dying of heart disease. He is willing to increase his church attendance to improve his health. How should his physician respond?

Commentary
Religiosity and spirituality have been variously defined in studies of health and illness, [1] ranging from single questions asking about the frequency of attending religious services to multi-item questionnaires. such as:

The SpREUK[2]; The Ironson-Woods Spirituality/Religiousness Index [3]; The Daily Spiritual Experience Scale[4]; and The Spiritual Wellbeing Scale.[5]

Religious behavior may be assessed through membership in a religious organization, rate of attendance at its functions, frequency of prayer, and involvement in social activities of the organization. Different components of religiosity and spirituality may mediate different health effects. For example, behavioral indicators, such as church attendance, can affect well-being through social integration and support.[6] Spiritual experiences that provide a sense of purpose and meaning may promote hope and affect psychological well-being by influencing depression, marital satisfaction, alcohol use and drug abuse. [7-9] Religious participation may also be a safe haven to avoid stigmatization by society for certain conditions.
Background

The concept that religious behavior or religiosity and spirituality was associated with longevity was observed in the 1990s, when mortality was found to be lower among frequent churchgoers than

among nonattenders.[10-12] In particular, a 2002 study in Alameda County, California, observed that among 6545 residents, infrequent attenders of church compared with frequent attenders had significantly higher rates of death from:[13]

Circulatory diseases (hazard ratio [HR], 1.21); Gastrointestinal diseases (HR, 1.99); and Respiratory conditions (HR, 1.66).

The researchers proposed that religious participation, like socioeconomic status, was a protective factor that promoted health through a variety of pathways. In older adults, religious well-being was found to correlate well with existential well-being and higher scores on psychological well-being measures, as well as healthier behaviors. [14] Church attendance among older adults may also correlate with use of more preventive behaviors, perhaps through a socialization mechanism.[15] Among patients with advanced cancer, survival was observed to be higher among those with higher religiosity or spirituality. [16]
Mechanism of Action: How Might Religiosity Improve Health?

One proposed mechanism for improving mortality among healthy, religious persons is reduced cardiovascular risk, possibly related to lifestyle or other cardioprotective effects of religious behavior. [17] For example, religion has a prohibitive influence on lifestyle risk factors, such as smoking; in fact, studies have documented lower rates of smoking among those with high religiosity or spirituality. [18] Paradoxically, the rate of obesity may be higher among those who attend religious services more frequently. In a study with 8 years of follow-up, 4 dimensions of religiosity (attendance, salience, media practice, and consolation) were associated with higher BMI among women. [19] In terms of weight, however, other researchers have found differential effects depending on religious denomination and sex. For example, high levels of religious media practice and affiliation with the Baptist denomination was associated with increased incidence of obesity in women [20,21] ("Religious media practice" is home practice employing religious television or radio programming, books, magazine, or a combination. Although these practices are not necessarily solitary, they do allow access to food and beverages, which could account for the higher rate of obesity.) [19] Another study found that the effect of religiosity on BMI disappeared when smoking behavior was controlled for, suggesting that the possible association between religious participation and obesity may be a consequence of lower smoking rates among religious persons.[17] A recent study of a multiethnic population that included 5474 white, black, Hispanic, and Chinese participants aged 45 to 84 years measured 3 dimensions of religiosity (frequency of participation, prayer and meditation, and spirituality) and used the 5-item Daily Spirituality Experiences Scale to assess feelings of closeness to God.[22] Overall, this study found no consistent association between religiosity and the presence of subclinical indicators, such as left ventricular function, intima-media thickness, and coronary calcium. Over 4 years of follow-up, no significant difference in cardiovascular events was observed between the religious and nonreligious groups. However, the study confirmed the higher likelihood of obesity and lower likelihood of smoking among those with higher religious and spirituality scores.
Problems in Design of Studies of Religiosity

Among adolescents and young adults, a systematic review found that in 43 studies published from 1998 to 2003, 37 distinct religious variables were defined, with unclear frameworks in most studies. [23] The variables ranged from assessing religious importance to religious behaviors of attendance and prayer. However, 8 of the 10 highest-quality studies found evidence of a positive effect of religious participation on health attitudes and behaviors, and protection against:

Substance abuse; Alcohol abuse; Early initiation of sexual behavior; and Smoking.

Case Response
Mr. Delgados physician elicited an understanding of her patients health beliefs using an explanatory model,[24] by first asking him how he believed his condition should be treated and what he believed would help his condition. Given Mr. Delgados religious participation and his family values and culture, his physician would be well placed to negotiate a lifestyle plan using the L-E-A-R-N (Listen, Explain, Acknowledge, Recommend, Negotiate) model,[25] based on these beliefs, as a starting point. Mr. Delgados physician explains to him that religious participation alone was not adequate to protect him from cardiovascular events in the future, citing the most recent evidence. [22] She also shares that the literature demonstrates a positive link between religious behaviors among teens and positive health behaviors, including abstinence from alcohol, drugs, and later sexual debut. The physician congratulates Mr. Delgado on not smoking and being motivated to stay healthy. She expresses understanding of his perspective and acknowledges the culture of food as a "social glue" in Mr. Delgados belief system. She then recommends that Mr. Delgado and his wife meet with the dietician to consider some alternative ingredients for their cooking recipes to incorporate heart-healthy components (such as using canola oil instead of lard and reducing the amount of fat in cooking). The physician negotiates with Mr. Delgado to add family activities around Sunday church attendance that involves brisk walking. She asks if Mr. Delgado is willing to start a heart-healthy social interest group at his church to encourage others to attend to their lifestyle goals, including weight loss. She offers to be a future speaker at such a group. Mr. Delgado is delighted and agrees to pursue the idea. Asked if he would consider taking a baby aspirin to protect his heart, he is agreeable. He will follow-up with his physician in 1 to 2 months for his cardiovascular status. Consideration of other medication, such as statins, will be deferred to that follow-up visit.

Suggested Reading
Dillon M. Handbook of the Sociology of Religion. Cambridge, UK: Cambridge University Press; 2003. Ellison CG, Levin JS. The religion-health connection: evidence, theory, and future directions. Health Educ Behav. 1998;25:700-720. Fetzer Institute/National Institute on Aging Working Group. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. Kalamazoo, Mich: Fetzer Institute; 1999. Kark JD, Shemi G, Friedlander Y, Martin O, Mano O, Blondheim S. Does religious observance promote health? Mortality in secular versus religious kibbutzim in Israel. Am J Public Health. 1996;86:341-346.

Longo DA, Peterson S. The role of spirituality in psychosocial rehabilitation. Psychiatr Rehabil J. 2002;25:333-340. Underwood LG. Ordinary spiritual experience: qualitative research, interpretive guidelines, and population distribution for the Daily Spiritual Experience Scale. Arch Psych Relig. 2006;28:181-218.

References

1.

Williams DR. The measurement of religion in epidemiologic studies: problems and prospects. In: Levin JS, ed. Religion in Aging and Health: Theoretical Foundations and Methodological Frontiers. Thousand Oaks, Calif: Sage Publications; 1994. 2. Bssing A, Ostermann T, Matthiessen PF. Role of religion and spirituality in medical patients: confirmatory results with the SpREUK questionnaire. Health Qual Life Outcomes. 2005;3:10. 3. Ironson G, Solomon G, Balbin E, et al. The Ironson-Woods Spirituality/Religiousness Index is associated with long survival, health behaviors, less distress, and low cortisol in people with HIV/AIDS. Ann Behav Med. 2002;24:34-8. Abstract 4. Underwood LG, Teresi JA. The Daily Spiritual Experience Scale: development, theoretical description, reliability, exploratory factor analysis, and preliminary construct validity using health-related data. Ann Behav Med. 2002;24:22-33. Abstract 5. Ellison CW. Spiritual well-being: conceptualization and measurement. Journal of Psychology Theory. 1983;11:330-340. 6. Ellison CG. Religious involvement and subjective well-being. J Health Soc Behav. 1991;32:80-99. Abstract 7. Ferraro K, Albrecht-Jensen C. Does religion influence adult health? J Sci Study Relig. 1991;30:193-202. 8. Larson DB, Sherrill K, Lyons J, et al. Associations between dimensions of religious commitment and mental health reported in the American Journal of Psychiatry and Archives of General Psychiatry: 1978-1989. Am J Psych. 1992;149:557-559. 9. Matthews DA, McCullough ME, Larson DB,. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med. 1998;7:118-124. Abstract 10. Strawbridge WJ, Cohen R, Sherma S, Kaplan G. Frequent attendance at religious services and mortality over 28 years. Am J Public Health. 1997;87:957-961. Abstract 11. Koenig HG, Hays J, Larson D, George L, Cohen H, McCullough M, Meador K, Blazer D. Does religious attendance prolong survival? A six-year follow-up study of 3968 older adults. J Gerontol A Biol Sci Med. 1999;54:M370-M376. 12. Hummer RA, Rogers R, Nam C, Ellison C. Religious involvement and US adult mortality. Demography. 1999;36:273-285. Abstract 13. Oman D, Kurata JH, Strawbridge WJ, Cohen RD. Religious attendance and cause of death over 31 years. Int J Psychiatry Med. 2002;32:69-89. Abstract 14. Lawler-Row KA, Elliott J. The role of religious activity and spirituality in the health and wellbeing of older adults. J Health Psychol. 2009;14:43-52. Abstract 15. Benjamins MR. Religion and preventive health care use in older adults [Abstract]. Dissertation Abstracts International, A: The Humanities and Social Sciences. 2005;65:3171A. 16. Breitbart W. Spirituality and meaning in supportive care: spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Support Care Cancer. 2002;10:272280. Abstract

17. Kim KH, Sobal J, Wethington E. Religion and body weight. Int J Obesity Relat Metab Disorders. 2003:27:469-477. 18. Roff LL, Klemmack D, Parker M, Koenig H, Sawyer-Baker P, Allman R. Religiosity, smoking, exercise, and obesity among Southern, community-dwelling older adults. J Appl Gerontol. 2005;24:337-354. 19. Cline KM, Ferraro K. Does religion increase the prevalence and incidence of obesity in adulthood? J Sci Study Relig. 2006;45:269-281. 20. Ferraro KF. Firm believers? Religion, body weight, and well-being. Rev Relig Res. 1998;39:224-244. 21. Ellis L, Biglione D. Religiosity and obesity: are overweight people more religious? Pers Individ Dif. 2000;28:1119-1123. 22. Feinstein M, Liu K, Ning H, Fitchett G, Lloyd-Jones DM. Burden of cardiovascular risk factors, subclinical atherosclerosis, and incident cardiovascular events across dimensions of religiosity. The Multi-Ethnic Study of Atherosclerosis. Circulation. 2010;121:659-666. Abstract 23. Rew L, Wong YJ. A systematic review of associations among religiosity/spirituality and adolescent health attitudes and behaviors. J Adolesc Health. 2006;38:433-442. Abstract 24. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258. Abstract 25. Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 1983;39:934-938. Available at https://www.thinkculturalhealth.org/cc_legislation.asp Accessed March 10, 2010.

Authors and Disclosures

Author(s)
Dsire Lie, MD, MSEd

Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development and Research, UCI Medical Center, Orange, California Disclosure: Dsire Lie, MD, MSEd, has disclosed no relevant financial relationships.
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