Yoga for Control of Progression in the Early Stage of NCDs

Non-Communicable Diseases

Non-communicable diseases (NCDs) are diseases or body ailments that cannot be communicated or transferred to another person through physical or biological contact. NCDs pose a greater threat to human society more than communicable diseases. NCDs are challenging to treat and are characterized as chronic. However, some chronic diseases, such as cervical cancer, are caused by viral infections as an exception. These diseases have a prolonged course. NCDs usually have complex etiology, and it is difficult to trace the exact cause of these diseases. NCDs can also be called multi-factorial diseases, that is, they have multiple risk factors. NCDs are challenging to diagnose at the early stages of the disease and are generally diagnosed after causing significant damage and at the late stages of the disease. The disease keeps spreading during the latent period. According to the World Health Organization (WHO), nearly 41 million people succumb to the burden of NCDs. Out of all the global deaths, 74% occur because of NCDs. ¹

Classification of NCDs

NCDs are commonly classified as seven types of disorders. These diseases are mostly life-threatening. Diabetes is an NCD that mainly occurs as a result of a sedentary lifestyle. Other types of NCDs are chronic respiratory disease, cancer, cardiovascular disorders (such as stroke and coronary heart disease), musculoskeletal disorders (such as amyotrophic lateral sclerosis and multiple sclerosis)/arthritis, chronic neurological disorders, and unintentional injuries because of certain accidents that result in permanent physical or mental disabilities (Figure 1).

Figure 1. Classification of NCDs.

Status of NCDs in India

It is estimated that chronic NCDs are India’s leading cause of death. Despite the lack of standard methods to estimate NCD data, according to the Sample Registration System (SRS-1998), approximately 32% of deaths are caused by these diseases. ² A series of chronic diseases (chronic disease 3) reported by Reddy et al. estimates deaths (53%) and disability-adjusted life years (44%) due to chronic diseases. It has been reported that there is a 3%–4% prevalence of cardiovascular diseases in rural regions and 8%–10% in urban areas. Data from six cancer centers of the ICMR has reported approximately 800,000 new cancer cases every year. ³ India consists of the largest number of people with diabetes, which was estimated at 19.3 million in 1995 and is estimated to be 57.2 million by the year 2025. ⁴ Hypertension is also increasing among the Indian population drastically, which is a risk factor for many other cardiovascular and coronary diseases. A high prevalence of hypertension among urban adults was reported from 1995 to 2000, which was 30%–37% in Jaipur, 44%–45% in Mumbai, 31%–36% in Thiruvanthapuram, 17%–24% in Rajasthan, 4.5% in Haryana, and 14% in Chennai. Polling of epidemiological studies showed that the prevalence of hypertension was higher, approximately 25% in urban areas and 10% among the rural population. In the ICMR study, hypertension and inactivity were found to be higher in both males and females in urban areas compared to rural areas in Tamil Nadu, Jharkhand, Chandigarh, and Maharashtra. ⁵ It should be noted that this data is an approximation, and the actual number may be higher than this, as indicated by the growing demand for healthcare professionals, hospitals, and allopathy-based treatments.

Economic Burden

Besides individual behavior and lifestyle modifications, several other factors, like economic, social, and political approaches, also act as critical factors for NCDs.⁶⁻⁸ NCDs are more prevalent in developed nations. In comparison, developing nations with middle- and low-income economies face a major challenge as the numbers continue to increase. The low-income economy is directly related to poor health status, which contributes to unhealthy food consumption and expensive treatments. NCDs pose a significant economic burden on the growth and development of a nation. As per the WHO estimates, the average pocket expenditure in India, called out-of pocket expenditure for NCDs, is higher than that in other developing nations. The rate of hospitalization increased from 36.3% (in rural areas) to 43.9% (in urban areas) between 2014 and 2017–2018. During this period, the hospitalization cost due to NCDs also increased by ₹4461. In 2017, 81% of the population in urban areas and 86% of the population in rural areas were covered under different health schemes. There are already several government programs running for the prevention and control of NCDs. The 2017 recommendations by the National Health Policy proposed increasing the expenditure from 1.15% to 2.5% of GDP by 2025. ⁹

Management of NCDs

According to WHO, around 41 million people lose their lives due to these NCDs annually, equivalent to almost 71% of all global deaths. ¹ The critical strategy for reducing the global concern is adequate prevention and related strategies as well as better management. The critical components of management include screening, detection, and treatment. The accessibility of available resources to palliative care for the needy is essential. The primary healthcare system can be strengthened, and timely treatment can be delivered. Reducing the use of modifiable risk factors, like alcohol, tobacco, and unhealthy diets. Also, a lifestyle change, like adopting a balanced diet and engaging in regular physical activity, can reduce the risk. It can significantly prevent NCDs.

Control of NCDs Through Yoga

As a traditional form of practice, yoga benefits the human body by encouraging physiological and psychological well-being, as well as preventing the development of NCDs. ¹⁰ Yoga can be incorporated as part of a daily lifestyle routine to overcome sedentary lifestyles, one of the main contributors to NCDs. The importance of physical activity for a healthy lifestyle is highlighted in the Global Action Plan on Physical Activity (GAPPA) 2018–2030 with a tagline of “more active people for a healthier world”. They set a target to reduce physical inactivity by at least 15% by the end of 2030 by implementing policies and plans within a period of 12 years. Dance, Yoga, and Tai Chai, along with walking, cycling, and other sports, if done regularly and at a particular intensity, have been recommended by GAPPA for being physically active throughout the day. ¹¹ With the advancement in technology, transportation, economic development, and urbanization, the rate of physical inactivity also increases as lifestyle habits, whether at work or home, become more sedentary. Yoga is the most diverse form of physical activity where not only skeletal muscles but also smooth muscles are involved at different intensities, which can be customized as per an individual’s requirements. Similar or different yoga poses and practices can be practiced by adolescents, adults, and the elderly with varying frequencies from beginning to advance as per their body form and type.

An unhealthy lifestyle, which is the leading cause of the development and progression of NCDs, is a result of both physical inactivity and an unhealthy diet, the prevalence of which is increasing with time. Ashtanga Yoga, a concept given by Rishi Patanjali, includes eight components generally known as limbs of yoga, which make a perfect recipe for a healthy lifestyle if followed conventionally. These components are Yama-restraint, Niyama-observances, Asana-postures, Pranayama-breathing, Pratyahara-senses withdrawal, Dharana-concentration, Dhyana-meditation, and Samadhi-absorption. ¹² Most NCDs are preventable, and these aspects of yoga can help build a strong foundation for the body and mind, which can further prevent many lifestyle disorders, including NCDs, from occurring. One of the crucial ways to reduce the death rate due to NCDs is by controlling the risk factors, which include an inactive lifestyle and consumption of unhealthy food, both of which can be attained by practicing Ashtanga yoga, as discussed previously in the text. Yoga is not only cost-effective but also a feasible form of exercise for individuals of all ages. It can potentially reduce the risk factors responsible for the development of NCDs, such as obesity, impaired glucose metabolism, psychological imbalance, high cholesterol levels, and blood pressure. More strategies are required for risk reduction, prevention, and progression of NCDs, which support healthy aging and lower the premature death rate caused by NCDs. There is a lack of effective treatment for most NCDs, and management is also costly, contributing to the increased economic and global disease burden. ¹³ Being healthy (mentally and physically) prevents the body from becoming a suitable target for NCDs. Different dimensions of mental and physical wellness can be achieved by yoga as follows:

1. Asanas― Asanas are body postures where the body holds specific positions for some duration to increase muscle strength, endurance, and stimulation of organs by increasing blood flow to a particular part of the body.

2. Pranayama―Pranayama is a regulated, controlled breathing technique to increase lung capacity and harmony.

3. Dhayana―Dhayana is meditation for increasing self-awareness and controlling thoughts.

Yoga affects different systematic axes of the body. The pronounced effect of yoga is to decrease the activity of the HPA axis, which gets activated during stress and adverse conditions. ¹⁴ The pranayama practice also shows the potential of yoga in regulating heart rate and the cardiac axis. ¹⁵ The psycho-neuro-immune axis is involved in immune system-related functions such as inflammation and mind-body communication. Yoga helps normalize biomarkers of the neuro-immune axis not only at the molecular level but also at the genetic level. ¹⁶ Metabolic syndrome (MetS) is a cluster of risk factors for most NCDs, such as higher blood pressure levels, increased fasting glucose and triglycerides, central obesity, and a low level of HDL. The Ghrelin axis, which gets upregulated in MetS, has been shown to get modulated after the practice of yoga. ¹⁷ Therefore, based on the above evidence, it can be said that the yoga practice can achieve a standard concept of health and a healthy lifestyle.

Implementation Strategies

The biggest hurdle in implementing strategies and their acceptance among the population after implementation is the need for more evidence-based research. More evidence provides a solid foundation for its implementation. Following are a few preparatory steps that can be kept in mind during the implementation of yoga as complementary and alternative medicine in different policies.

1. Generating More Evidence―Without the available evidence, profound research, and action plan, it is neither safe nor feasible to implement any new strategy (rule, medicine, intervention, and education system). Therefore, the first step in implementing new policies should focus on generating more reproducible, evidence-based research. It can be done by providing resources to the institutes involved in the particular field of interest and providing more financial support, infrastructure, and other required facilities. Besides, quality research should be assured by following good laboratory practices (GLP) so that the evidence produced is reliable and can be implemented. ¹⁸

2. Training of Tutors and Educating Children―A special policy can be made for the training of tutors where teachers are trained in yoga and related techniques, including the benefits, practices, and adaptations in daily routine to make it a lifestyle. It will not only spread awareness, but most of the children will also learn about yoga at a very young age. This will add more value to education and, at the same time, increase awareness at a very early stage of life, which will act as a preventive tool for most lifestyle disorders. Also, even if resources are available, people need to be made aware of the importance of the resources. Therefore, raising awareness at an early stage with the right mentors (teachers at the school and college levels) can make a big difference.

3. Awareness―Unless people are themselves aware and experienced, awareness cannot be spread. There is no reason why yoga cannot be included as a compulsory subject in all educational systems, regardless of whether they are medical or not. The main reason is that medical students who practice medicine can practice yoga, which should be integrated into their curriculum.

The steps mentioned above are of primary importance at the start of an implementation process. Several other steps should be taken before a strategy is planned and can be implemented in all sectors to benefit most of the population.

Status and Potential of Yoga in the Healthcare System in India

A majority of the Indian population lives an unhealthy lifestyle. It is exposed to the risk factors associated with NCDs. Middle-income countries with limited health professionals tend to have a higher prevalence of NCDs, which are not diagnosed at pre- or early disease stages, which places a heavy burden on health systems. Other than allopathy, the AYUSH healthcare system of Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy is being practiced in different parts of India. The AYUSH system of indigenous medicine is not only involved in the treatment but also focuses more on preventive approaches. AYUSH was started by a national rural health mission to help solve the shortage of human resources in the available healthcare system. ¹⁹ The shortage of healthcare professionals can be solved by providing more human resources and promoting a preventive healthcare system through AYUSH personnel, which will spread awareness among people about lifestyle management and ultimately decrease the prevalence of disorders. ²⁰

By preventing NCDs and risk factors with yoga, alternative medicine can potentially reduce the number of patients and the burden on healthcare systems. ²¹ The government of India designed various strategies for mainstreaming the AYUSH system into the existing healthcare system in the country. These strategies include the integration of the Indian system of medicine and homeopathy with the existing healthcare system, establishment of various centers of Indian system medicine, quality research in this field focusing on standardization of interventional research, advocacy for AYUSH, and establishing links of AYUSH in different sectors. ²² AYUSH mainstreaming is still in progress among the general population, but to make this healthcare system available and accessible for all, there is a need for stringent strategies and implementation, along with a robust monitoring mechanism. ²³

Status of Yoga-based Research in India

After the government established resources for yoga-based research, various institutes started producing evidence using different research study designs on varied populations. Some of the studies are given in Table 1.

Table 1. List of Evidence-Based Yoga Studies.

S. No.	Condition	Research Institute	Study Type	Sample Size	Region
1.	Diabetes and pre-diabetes	SVYASA, Bengaluru	Non-randomized controlled trial	896	Karnataka, Maharashtra, Gujarat, Rajasthan, and Tamil Nādu 24
2.	Healthy individuals	Patanjali Research Foundation, Haridwar, Uttarakhand	A cross-sectional survey	3135	North-western state of Rajasthan 25
3.	Pre-diabetic and Type 2 diabetes	Regional Ayurveda Research Institute for Infectious Diseases, Patna	Multi-centric, open-labeled study	3044	Bihar 26
4.	Pain, anxiety, and depression in chronic low back pain	SVYASA, Bengaluru	Randomized control, single-blind active study	80	Bengaluru 27
5.	Pre-diabetes	Srinivas Institute of Medical Science and Research Centre, Mangalore	Randomized-controlled trial	29	Mangalore, Karnataka 28
6.	Cognitive function: pre-dementia	NIMHANS, Bengaluru	Single-blind controlled study	87	Bengaluru 29
7.	Digestive health and sleep	SVYASA, Bengaluru	Randomized-controlled trial	96	Bengaluru 30
8.	Age-related changes in healthy individuals	Defence Institute of Physiology and Allied Sciences (DIPAS), New Delhi	Randomized-controlled trial	104	New Delhi 31
9.	Mild cognitive impairment	SVYASA, Bengaluru	Non-randomized-controlled trial.	88	Bengaluru 32

India has many institutes where research related to effect of yoga on different health conditions and its efficacy as a preventive intervention is being explored. There is a need for new strategies to implement and policies that can spread more awareness and acceptance among the population for the acceptance of Yoga as a preventive and therapeutic intervention for NCDs.