ROLE OF YOGA IN NON-COMMUNICABLE DISEASES: A BRIEF REVIEW.

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National Yoga Week-2015
A Mass Awareness Programme for Health, Happiness and Harmony through Yoga
February 12-18, 2015
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Morarji Desai National Institute of Yoga
68, Ashoka Road, Near Gole Oak Khana, New Oelhi-110001
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Yoga for Middle Aged
ROLE OF YOGA IN NON-COMMUNICABLE DISEASES: A BRIEF REVIEW.
Yogacharya Dr Ananda Balayogi Bhavanani
Director, leYER, Puduchery
INTRODUCTION
Yoga as a mode of therapy (yoga chikitsa) has become
extremely popular, and a great number of studies and
systematic reviews offer scientific evidence of its
potential in treating a wide range of psychosomatic
conditions. Yoga understands health and well-being as a
dynamic continuum of human nature and not merely a
'state' to be reached and maintained. Yoga helps the
individual to establish "sukha sthanam", which may be
defined as a dynamic sense of physical, mental, and
spiritual well-being. Yogamaharishi Dr. Swami
Gitananda Giri Guru Maharaj, the visionary founder of
Ananda Ashram at the leYER, Pondicherry
(www.icyer.com) and one of the foremost authorities on
Yoga in the past century exclaimed lucidly, "Yoga chikitsa
is virtually as old as yoga itself, indeed, the return of mind
that feels separated from the Universe in which it exists
represents the first yoga therapy. Yoga chikitsa could be
termed as man's first attempt at unitive understanding of
mind-emotions-physical distress and is the .oldest
wholistic concept and therapy in the world." (1)
To achieve this yogic integration at all levels of our being,
it is essential that we take into consideration the all
- encompassing multi dimensional aspects of yoga that
include the followi~g: a healthy life-nourishing diet, a
healthy and natural environment, a wholistic lifestyle,
adequate bodywork through asana, mudra-bandha and
kriya, invigorating breath work through pranayama and
the cultivation of a healthy thought process through
jnana yoga and raja yoga.
The International Association of Yoga Therapists (IAYT),
USA has taken this idea into account in defining Yoga
therapy as follows'": "Yoga therapy is the process of
empowering individuals to progress toward improved
health and well-being through the application of the
philosophy and practice of yoga." This has been further
elabourated by the IAYT in its "Recommended
"Educational Standards for the Training of Yoga
Therapists", published on 1 July, 2012. (3) This is one of
the best documents on standards in yoga therapy and is
~ Morarji Desai National Institute of Yoga
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a path breaking effort covering comprehensively all
aspects of yoga as a holistic therapy.
The need of the hour is for a symbiotic relationship
between yoga and modern science. To satisfy this need,
living, human bridges combining the best of both worlds
need to be cultivated. It is important that more dedicated
scientists take up yoga and that more yogis study
science, so that we can build a bridge between these two
great evolutionary aspects of our civilization. The
process as well as the goal of yoga is all about becoming
"one" with an integrated state of being. (4)
PROMOTES POSITIVE HEALTH
Healthy life can be considered as a by-product of
practicing yogic techniques since it has been observed
that Yoga practitioners are physically and mentally
healthier and have better coping skills to stressors than
the normal population. Knowledge of inexpensive,
effective and easily administrable yogic techniques by
health professionals will go a long way in helping us
achieve the goal of the World Health Organisation to
provide "physical, mental, spiritual and social health" for
all sections of human society.
Some of the important documented health
promoting benefits of mind-body practices such as
yoga and meditation include:
1. Improvement in cardio-respirato_ry efficiency (5-8)
2. Improvement in exercise tolerance (iJ-12)
3. Harmonious balance of autonomic function (13-16)
4. Improvement in dexterity, strength, steadiness,
stamina, flexibility, endurance, and neuro-musculo-
skeletal coordination (9,17-22)
5. Increase in alpha rhythm, inter-hemispheric
coherence and homogeneity in the brain (23-26)
6, Improved sleep quality (27)
7. Improved cognitive functions (5,28-34)
8. Alteration in brain blood flow and brain
metabolism (35-38)
9. Modulation ofthe neuro-endocrine axis (39-44)
21st
June -International Day of Yoga 53

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Fig1. POSSIBLE FACTORS RESPONSIBLE FOR PHYSICAL PERFORMANCE IMPROVEMENT BY YOGA
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Ray US, Pathak A, Tomer as. Hatha Yoga Practices: Energy Expenditure, Respiratory Changes and
Intensity of Exercise. Evid Based Complement Alternat Med. 2011; 2011: 241294.
We can say that the Yoga affects every cell of the human
body bringing about better neuro-effector
communication, improve strength, and enhance
optimum functioning of all organ-systems while
increasing resistance against stress and diseases with
resultant tranquillity, balance, positive attitude and
equanimity.
MANAGING STRESS
It is well established that stress weakens our immune
system. Scientific research in recent times has shown
that the physiological, psychological and biochemical
effects of yoga are of an anti-stress nature. A majority of
studies have described beneficial effects of yoga
interventions in stress with an Agency for Healthcare
Research and Quality (AHRQ) report stating that "Yoga
helped reduce stress."?" Reductions in perceived stress
following yoga are reported to be as effective as
therapies such as relaxation, cognitive behavioural
therapy and dance therapy.
Mechanisms postulated include the restoration of
autonomic balance as well as an improvement in
restorative, regenerative and rehabilitative capacities of
the individual. A healthy inner sense of wellbeing
54 21
8t
June -InternatlonalDay otYoga
produced by a life of yoga percolates down through the
different levels of our existence from the higher to the
lower levels producing health and wellbeing of a holistic
nature. Streeter et al recently proposed a theory to
explain the benefits of yoga practices in diverse,
frequently co-morbid medical conditions based on the
concept that yoga practices reduce allostatic load in
stress response systems so that optimal homeostasis is
restored. (46)
They hypothesized that stress produces an:
Imbalance of the autonomic nervous system with
decreased parasympathetic and increased
sympathetic activity,
Under activity of the gamma amino-butyric acid
(GABA) system, the primary inhibitory
neurotransmitter system, and
Increased allostatic load.
They further hypothesized that yoga-based practices i)
correct under activity of the parasympathetic nervous
system and GABA systems in part through stimulation of
the vagus nerves, the main peripheral pathway of the
parasympathetic nervous system, and ii) reduce
allostatic load.
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According to the theory proposed by them, decreased
parasympathetic nervous system and GABAergic
activity that underlies stress-related disorders can be
corrected by yoga practices resulting in amelioration of
disease symptoms. A review by Bhavanani concluded
that heart rate variability (HRV) testing has a great role to
play in our understanding of the intrinsic mechanisms
behind such potential autonomic balancing effects of
yoga. (47) Innes et al had earlier postulated two
interconnected pathways by which yoga reduces the risk
of cardiovascular diseases through the mechanisms of
parasympathetic activation coupled with decreased
reactivity of sympathoadrenal system and HPAaxis. (48)
It is notable that one of the newer applications of yoga
has been in managing the aftermaths of natural
disasters. Studies have shown that yoga significantly
reduces symptoms of posttraumatic stress disorder
(PTSD), self-rated symptoms of stress (fear, anxiety,
disturbed sleep, and sadness) and respiration rate. (49)
CARDIOVASCULAR CONDITIONS
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---
Many studies have tried to explore the mechanisms by
which yoga modifies coronary artery disease risk factors.
Manchanda et al (SO), Ornish et al (51)and Yogendra et al (52)
have conducted prospective, randomized and controlled
trials on angiographically proven coronary artery disease
patients with yoga intervention and demonstrated that
yoga based lifestyle modification helps in regression of
coronary lesions and improvement in myocardial
perfusion. The effect of yogic lifestyle on some of the
modifiable risk factors could probably explain the
preventive and .therapeutic beneficial effect observed in
coronary artery disease.
A review of 70 eligible studies investigating the effects of
yoga on risk indices associated with the insulin
resistance syndrome, cardiovascular disease, and
possible protection with yoga, reported that most had a
reduction of systolic and/or diastolic pressure. However,
the reviewers also noted that there were several noted
potential biases and limitations that made it difficult to
detect an effect specific to yoga. (48)Another literature
review reported significant improvements in overall
cardiovascular endurance of young subjects who were
given varying periods of yoga training. (53)Physical fitness
increased as compared to other forms of exercise and
longer duration of yoga practice produced better
cardiopulmonary endurance. In fact a detailed review of
-
yoga in cardiac health concluded that it can be beneficial
in the primary and secondary prevention of
cardiovascular disease and that it can playa primary or a
complementary role in this regard. (54)
RESPIRATORY DISORDERS
Scientific basis of using yoga as an adjunct therapy in
chronic obstructive pulmonary diseases is well
established with Significant improvements in lung
function, quality of life indices and bronchial provocation
responses coupled with decreased need for regular and
rescue medicinal usage. (55.56)Behera reported perceptible
improvement in dyspnea and lung function in patients of
bronchitis after 4 weeks of yoga therapy that used a
variety of postures and breathing techniques. (57)Yogic
cleaning techniques such as dhautikriya (upper
gastrointestinal cleaning with warm saline or muslin
cloth) and netikriya (warm saline nasal wash) remove
excessive mucous secretions, decrease inflammation
and reduce bronchial hypersensitivity thereby increasing
provocation threshold while kapalabhati through forceful
exhalations improves the capacity to exhale against
resistance.?" A nonspecific broncho protective or
broncho relaxing effect has been also postulated?" while
improved exercise tolerance has been reported following
yoga therapy in patients of chronic severe airways
obstruction. (60)It has been reported that well-performed
slow yogic breathing maintains better blood oxygenation
without increasing minute ventilation, reduces
sympathetic activation during altitude-induced hypoxia
(61)and decreased chemoreflex sensitivity to hypoxia and
hypercapnia (62).These help bring about both objective
and subjective improvem~nts in the condition of patients
with bronchitis. Yoga as a therapy is also cost effective,
relatively simple and carries minimal risk and hence
should be advocated as an adjunct, complementary
therapy in our search for an integrated system of
medicine capable of producing health and wellbeing for
all.
METABOLIC/ENDOCRINE CONDITIONS
A few RCTs have suggested that yoga and meditation
practices act on the hypothalamic-pituitary-adrenal axis
(HPA) axis to reduce cortisol levels in plasma, (63-66)aswell
as reduce sympathetic nervous system tone, increase
vagal activity, (67.68)and elevate brain GABAlevels. (69)
Major systematic reviews of the effects of yoga on risk
indices associated with insulin resistance syndrome and
21st
June - International Day of Yoga 55

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Fig.2. POSTULATED MECHANISMS BY WHICH YOGA CAN HELP REDUCE RISK FOR
TYPE 2 DIABETES MELLITUS AND ITS COMPLICATIONS
Yoga Interveunon:
Pathway 2 ---+
Vagal
stimulation
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Parasympathenc
activation
-.Yoga tntervennou:
Pathway 1
-, « ~ J, Inflammatory cytokines
.!. Heal t I ate. blood prl'Ssnrf'
.j. Perceived stress
.l.Activatioufrfilcti"itv
of sympathondrenal
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Eniumced metatrottc an«
psychological profile
t Insulin sensitivity
i Glucolle tolerance
Improved Upid pr oflie
J, Visceral adiposity
Improved mood
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Reduced rtsk for:
Type 2 diabetes and compllcatious of
'!YIlt 2 Diabetes
Improved coagulation
f fibrinolytic profile
.!. Oxidative stress
i Endothelial function
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Innes KE, Vincent HK. The Influence of yoga-based programs on risk profiles in adults with type
2 diabetes mellitus: A systematic review. eCAM 2007; 4: 469-86.
-.
risk profiles in adults with type 2 diabetes have been
done in recent times. (48:0)They reported post-intervention
improvement in various indices but with results varying
by population and study design. Another systematic
review addressed the management of type 2 diabetes
and concluded that the reviewed trials suggest
favourable effects of yoga on short-term parameters
related to diabetes but not necessarily for long-term
outcome.?" The AHRQ cites two studies comparing yoga
versus medication which reported a large and significant
reduction of fasting glucose in individuals with type 2
diabetes in one, and a smaller but still significant
improvement in the other. (45)
A recent systematic review of yoga on menopausal
symptoms reported small effects on psychological
symptoms with no effects on total menopausal
symptoms, somatic symptoms, vasomotor symptoms, or
urogenital symptoms. (72)
56 . 21
st
June -International Day of Yoga
MUSCULOSKELETAL CONDITIONS
A review by Posadzki et al (73)found that 10 of 11 RCTs
reported significantly greater effects in favor of Yoga
when compared to standard care, self-care, therapeutic
exercises, relaxing yoga, touch and manipulation, or no
intervention. Yoga was more effective for chronic back,
pain than the control interventions such as usual care or
conventional therapeutic exercises though some studies
showed no between group differences.'?" Recently two
well-designed trials of yoga for back pain reported
clinically meaningful benefits over usual medical care but
not over an intensive stretching intervention. (75,76)
CANCER
According to the findings of a comprehensive meta-
analysis of role of yoga in cancer, improvements in
psychological health were seen in yoga groups when
compared to waitlist or supportive therapy groups,(77)With
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respect to overall quality of life, there was a trend towards
improvement. To explain the positive outcomes, Smith
and Pukall suggested various complex pathways which
may involve relaxation, coping strategies, acceptance,
and self-efficacy. (78) Kochupillai et al reported increase in
natural killer cells in cancer patients who had completed
their standard therapy after practicing Sudarshan Kriya
Yoga and pranayam breathing techniques. (79)
A systematic review and meta-analysis of RCTs on the
physical and psychosocial benefits of yoga in cancer
patients and survivors by Buffart and colleagues
concluded that yoga may be a feasible intervention as
beneficial effects on several physical and psychosocial
symptoms were reported. (80) They showed that it has
strong beneficial effects on distress, anxiety and
depression, moderate effects on fatigue, general
HRQoL, emotional function and social function, small
effects on functional well-being, and no significant effects
on physical function and sleep disturbances. It was
suggested that yoga can be an appropriate form of
exercise for cancer patients and survivors who are
unable or unwilling to participate in other traditional
aerobic or resistance exercise programs.
IN CONCLUSION
....--
All of the above studies and reviews suggest a number of
areas where mind-body therapies such as yoga may be
beneficial, but more research is required for virtually
every one of them to establish their benefits conclusively.
This is true in the process of introducing any new therapy
into the modern health care system and is not surprising
when we realize that the proper studies on yoga as a
therapeutic modality are not older than a few decades.
Some of the major issues highlighted by these studies
and reviews include:
1. Individual studies on yoga for various conditions are
small
2. Poor-quality trials in general with multiple instances
for bias
3. Substantial heterogeneity with regards to the
populations studied, yoga interventions, duration
and frequency of yoga practice, comparison groups,
and outcome measures.
4. Compliance was not routinely noted, thus
preventing an understanding of the apt 'dosage'
requirements with regard to the mind-body
interventions
5. Yoga requires active participation and motivation
that requires active efforts from both the researcher
as well as the participants.
6. Changes in attitudes and behavior need to be
documented and understood better, especially in
the lifestyle, stress induced psychosomatic
conditions.
7. It is not clear which patients may benefit from the
Yogic interventions, and which aspects' of the
interventions or which specific styles were more
effective than others.
It has been suggested that yoga may help improve
patient self-efficacy, self-competence, physical fitness,
and group support, and may well be effective as a
supportive adjunct to mitigate medical conditions.
Bussing et al concluded that yoga may have potential to
be implemented as a safe and beneficial
supportive/adjunct treatment that is relatively cost-
effective, may be practiced at least in part as a self-care
behavioral treatment, provides a life-long behavioral
skill, enhances self-efficacy and self-confidence, and is
often associated with additional positive side effects. (81)
It is important to develop objective measures of various
mind-body therapies and their techniques while including
them in intervention trials. It has also been suggested
that the publication of specific interventions used in
future studies in manual form can allow reliable
replication and future implementation. It is also important
to develop tools to monitor objectively the participants'
self-practice, compliance, and adherence to the
interventions. Yoga has preventive, promotive as well as
curative potential and a yogic lifestyle confers many
advantages to the practitioner. Since lifestyle related
diseases are alarmingly 011 the rise in our modern
society, yogic lifestyle should be given a special place in
preventing and managing these diseases.
As suggested by Bussing et ai, ."Yoga may well be
effective as a supportive adjunct to mitigate some
medical conditions, but not yet a proven stand-alone,
curative treatment. Larger-scale and more rigorous
research with higher methodological quality and
adequate control interventions is highly encouraged
because yoga may have potential to be implemented as
a beneficial supportive/adjunct treatment that is relatively
cost-effective, may be practiced at least in part as a self-
care behavioural treatment, provides a life-long
behavioural skill, enhances self-efficacy and self-
confidence and is often associated with additional
positive side effects"?"
21st
June -International Day of Yoga 57

National Yoga Week-2015 ~~~-~o,~
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".
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..--
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21'~tJune -Jfiternatlonal Day"'of'Yoga I 59

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ROLE OF YOGA IN NON-COMMUNICABLE DISEASES: A BRIEF REVIEW.

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