Manoj Sharma, Taj Haider, & Paul Branscum A systematic review of yoga interventions as alternative and complementary treatment in cardiovascular disease. Manoj Sharma, Taj Haider, & Paul Branscum Monday, November 2, 2015; 12:30 pm – 1:30 pm Session 3207; Poster display 143rd American Public Health Association Annual Meeting

Cardiovascular diseases It is estimated that by the year 2030 the number of deaths as a result of cardiovascular disease will reach 23.6 million. Risk factors: Hypertension Hyperlipidemia Hyperglycemia Abdominal and visceral obesity Depression Anxiety Stress

Shortcomings of current therapies Pharmacological therapy for cholesterol, blood pressure, etc.) is cost prohibitive Pharmacological therapy is inappropriate due to deleterious side effects Implantable cardioverter defibrillator (ICD) can also increase anxiety and depressive symptoms – increasing the heart rate of these patients that could lead to heart attack and death. It is estimated that, in some instances, as many as 46% of patients with ICDs experience anxiety and nearly the same percentage experience depression

Role of Exercise & Yoga Exercise has shown favorable changes in cardiovascular disease factors: Improving HDL Decreasing LDL Reducing blood pressure Vigorous-intensity exercise is inappropriate for patients suffering from cardiovascular disease Yoga, a mind-body intervention, consists of low-intensity physical postures that stimulate the parasympathetic nervous system inducing the relaxation response imperative for patients with or at-risk for cardiovascular disease

Yoga for CVD Yoga originated in India as part of the spiritual practice for hundreds of years Path to reduce stress, anxiety, and depression in both healthy and mentally ill adults Combines physical postures with breathing techniques and meditation It is a lifestyle intervention that can result in improved cardiorespiratory fitness Yoga is studied for its efforts to reduce the psychological and physical risk factors associated with cardiovascular disease.

Research Questions Is yoga an efficacious form of therapy to reduce risk factors associated with cardiovascular disease? Are the articles reviewed comprised of valid research studies? Is there sufficient data to draw conclusions about the efficacy of yoga for cardiovascular disease?

Inclusion criteria for studies The inclusion criteria for this review included studies that were: (a) Published in the English language between 2005 and 2015 (b) Indexed in MEDLINE/PubMed, CINAHL, or Alt HealthWatch (c) Employed a quantitative design (d) Applied a yoga intervention

Phase II: Distillation Phase III: Manuscript Review Phase I: Boolean Logic CINAHL, Medline, Alt Health Watch Terms: Yoga AND Cardiovascular disease 1/2005 - 6/2015 Figure: Data Extraction of studies chosen for this systematic review Total Articles Returned: 315 Medline: 257 Atl Health Watch: 37 CINAHL: 21 Duplicate Articles n=33 Review/Discussion/Secondary Data Articles n=169 Study did not incorporate yoga or measure cardiovascular factors or was on hypertension n= 99 Qualitative design n= 1 Phase II: Distillation Total Articles Excluded: 302 Total Articles Included: 13 Phase III: Manuscript Review Total Articles Excluded (n=1) No evaluation results only protocol (n=1) Articles satisfying inclusion criteria, distillation, and manuscript review (n=12)

Results: Interventions 1 & 2 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2005 Bijlani, Vempati, Yadav, Ray, Gupta, Sharma, Mehta, and Mahapatra11 – India Pretest-Posttest design (n=98) of subjects with hypertension, coronary artery disease, diabetes mellitus, and/or a variety of other illnesses 20-74 years Asanas (postures), pranayama (breathing exercises), relaxation techniques Integrate program of 3-4 hours daily of practice and theory for eight days Fasting glucose, cholesterol; Low-density lipoproteins (LDL) and High-density lipoproteins (HDL), and triglycerides were measured Fasting plasma glucose, total cholesterol, LDL, VLDL, triglycerides, and total cholesterol/HDL ratio were all significantly lower (pre vs. post). HDL cholesterol was significantly higher post-test (p<0.001). 2006 Marshall, Vernalis, Remaley, Walizer, Scally, and Taylor6 – USA Pretest-Posttest design (n=96) of adults known to have coronary risk factors or coronary artery disease Adults > 18 years Yoga and supervised exercise From weeks 2-12 (of the three month intervention) subjects had twice weekly yoga and exercise sessions (4 hours) Blood pressure, heart rate, weight, BMI, body composition, LDL, and HDL measurements Fitness level improved (pre to post) by 22% (p<0.0005). Significant decreases in LDL (13%). Significant increases in triglyceride HDL (28%). Largest HDL decrease was in the subgroup that exercised the least, but decreased their fat intake the most

Results: Interventions 3 & 4 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2009 Howie-Esquivel, Lee, Collier, Mehling, and Fleischmann3 – USA Pretest-Posttest design (n=12) of patients with heart failure 30-74 years A modified yoga program (with a focus on pranayama – breathing) for patients with past injuries Eight weeks of three times weekly one hour yoga classes and a CD for at-home practice Physical function measures, endurance tests, Quality of Life assessment, Beck Depression Inventory, and the Kentucky Inventory of Mindfulness Skills Quality of Life symptom stability sub-scale significantly improved (p=0.02). 2010 Pullen, Thompson, Benardot, Brandon, Mehta, Rifai, Vadnais, Parrott, and Khan9 – USA Randomized control design (n=40) of patients with ischemic or non-ischemic etiology of heart failure randomized to a yoga or control group 31-76 years Low-intensity yoga One hour yoga sessions twice weekly for a total of 16 sessions Living with Heart Failure Questionnaire, EKG tests, plasma sampling, and a Quality of Life assessment Significant increases in treadmill time (p=0.002) and maximum oxygen uptake (p=0.003) for yoga group compared to pretest. Plasma serum levels of Interleukin 6 (IL-6), and C Reactive Protein (CRP) decreased significantly in the yoga group (pre vs. post-test).

Results: Interventions 5 & 6 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2011 Pal, Srivastava, Tiwari, Verma, Narain, Agrawal, Natu, and Kumar12 – India Randomized control design (n=154) of patients with coronary artery disease randomized to yoga or control groups 40-75 years Medication + Yoga 35-40 minutes/day five days of week for six months of yoga practice Body fat, Body mass index (BMI), fat mass, and cholesterol levels were measured Significant decreases in fat percentage, BMI, fat free mass, systolic and diastolic blood pressure, heart rate, total cholesterol, HDL and, LDL among yoga group (pre to post). 2013 Pal, Srivastava, Narain, Agrawal, and Rani13 – India Randomized control design (n=258) of patients with coronary artery disease randomized to yoga and non-yoga groups. 35-82 years 18 months of five days a week 35-40 minute yoga sessions. Autonomic functions, heart rate, blood pressure, and isometric strength were measured BMI, waist: hip ratio, heart rate, Systolic and Diastolic BP decreased significantly in yoga vs. control group (p<0.01).

Results: Interventions 7 & 8 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2013 Sarvottam, Magan, Yadav, Mehta, and Mahapatra14 – India Pretest-Posttest design (n=30) overweight or obese male subjects (BMI ≥ 23 to < 35 kg/m2) 18-55 years Unspecified yoga Two hours daily for ten days of yoga practice and theory and a nutrition awareness program Body weight, BMI, height, blood pressure, and lipid profiles Significant weight loss for participants (p<0.001) resulting in significant reduction in BMI (p<0.001). Reduction in pulse rate (p=0.02) and systolic BP (p=0.042). Clinically meaningful improvement in serum lipid profile (n.s.) Toise, Sears, Schoenfeld, Blitzer, Marieb, Drury, Slade, and Donohue5 – USA Randomized control design (n=46) of implantable cardioverter defibrillator (ICD) recipients randomized to standard medical (control) or yoga groups Adults >18 years Unspecified Yoga program Eight weekly sessions of 80 minute yoga and a 30-minute at home yoga CD to be performed 3x a week Florida Shock Anxiety Scale, Center for Epidemiologic Studies Depression, Positive Health Expectation Scale, State-Trait Personality Inventory, etc. Yoga group had significantly fewer device-treated ventricular (DTV) events than the control group. Yoga group had a 32% lower risk relative to control of experience DTV events. Anxiety also decreased significantly in the yoga group (pre to post intervention) while it increased significantly for the control group.

Results: Interventions 9 & 10 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2014 Krishna, Pal, Pal, Balachander, Jayasettiaseelon, Sreekanth, Sridhar, and Gaur4 – India Randomized control design (n=130) patients with heart failure randomized to a yoga or standard medical therapy groups Yoga: 49.34±5.70 Control: 50.14±4.54 Modified yoga focusing on pranayama breathing techniques 12-weeks of three times weekly 60 minute yoga sessions Heart rate, blood pressure, heart rate variability, and RPP (measurable index of myocardial oxygen consumption and load on the heart) Significant decrease in HR, RPP, systolic BP, and diastolic BP, and HRV (low frequency) for yoga group (pre vs. post). Yadav, Magan, Yadav, Sarvottan, and Netam15 – India Pretest-Posttest design (n=238) of Indian adults 38.81±11.40 Integral Health Clinic yoga program with asanas and pranayamas Two-weeks of 10 total two hour yoga sessions followed by an interactive lecture on stress management and nutrition Lipid profile, BMI, blood pressure, and blood glucose Significant increase in HDL, significant reduction in blood pressure and BMI (pre vs. post)

Results: Interventions 11 & 12 Year Authors/ Country Design, Sample & Setting Age Intervention Modality Intervention Dosage Outcome measures Salient Findings 2015 Siu, Benzie, and Woo7 – China Randomized control design (n=182) of adults diagnosed with Metabolic Syndrome randomized to either a yoga or health status assessment questionnaire (control) group 56±9.1 Hatha yoga Year-long thrice weekly 60-minute Hatha yoga sessions Systolic and diastolic blood pressure, fast glucose, waist circumference triglycerides, HDL-c, and depression Significant decreases in waist circumference and blood pressure (yoga vs. control group posttest) (p<0.005) Yadav, Singh, Singh, and Pai16 – India Randomized control design (n=80) of patients with coronary artery disease randomized to a yoga or conventional medicine (control) group 45-65 Yoga regimen of yogasanas and pranayamas Three-month six days a week of 60-minute yoga practice followed by lectures/group discussions regarding life style change, weight management, stress, anxiety, and diet followed by ten weeks of at-home practice. Pulmonary function measurements – slow vital capacity, forced expiratory volume, and maximum voluntary ventilation Significant improvement in almost all pulmonary function measurements (yoga group pre vs. post). No significant improvements for control (pre vs. post)

Discussion…1 Of the 12 interventions, seven took place in India, four took place in the United States, and one took place in China Of the 12 studies, all measured significant improvements in some component of cardiovascular disease, including both physical and mental factors: Body Mass Index (BMI), blood pressure, cholesterol, anxiety, depression, quality of life, weight, and pulmonary function

Discussion…2 In this review, five studies utilized pretest-posttest design while the remaining seven implemented randomized control trials (RCTs). The duration of studies ranged from eight days to one year. Similarly, the dosage of the intervention ranged dramatically: Higher dosage may play a role in improving cardiovascular risk factors

Limitations of interventions No study offered any type of quality assessment tool of the instructors: Terms like “yoga experts,” & “supervised sessions” were used in some studies Different schools of yoga so difficult to compare Small sample sizes Not all RCTs

Recommendations Only seven interventions utilized randomized control design which should be used in all studies Only three interventions addressed the psychosocial components of cardiovascular disease which should be done in all studies Standardization of techniques, duration, & dosage is needed Need to have an in-home component Need to have behavioral theories guide the intervention