Establishing key components of a combined ayurvedic diet and yoga therapy program for weight management in women with polycystic ovary syndrome: a Delphi study

Abstract

Background

Women with polycystic ovary syndrome (PCOS) use Ayurveda and yoga to manage the symptoms, including excess weight. However, heterogeneity in the components of clinical trials limits the quality of current evidence in this area. This Delphi study aimed to address these issues of heterogeneity by developing a list of recommendations of key components for the design of a combined Ayurvedic diet and yoga therapy (AY) program for weight management in PCOS.

Methods

Two rounds of an online Delphi method were used to establish consensus from qualified and experienced Ayurveda and yoga experts. Round one presented a mix of multiple-choice and open-ended questions, allowing experts to individually identify components they considered key to the design of AY interventions. Items that did not reach consensus (≤ 80%) and new items suggested by the experts in the first round were analysed and presented for agreement in round 2. Any statement demonstrating ≥ 75% agreement was determined to have reached a consensus in the second round.

Results

17 experts completed the first round, and 16 completed the second round of this Delphi study. There was a strong consensus that a combined AY intervention would be more effective than Ayurveda diet or yoga alone for weight-related outcomes. The experts reached a consensus on the parameters of the intervention (dosage and setting), provider qualification and training, approach, and components to be included in an AY program.

Conclusions

This study represents the first step in developing a consensus-based AY program for lifestyle management of PCOS. Future studies are needed to confirm the feasibility and acceptability of this program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-025-05130-3.

Introduction

Polycystic Ovary Syndrome (PCOS) is a significant public health concern affecting up to 12% of women globally [1]. It is primarily characterised by hyperinsulinemia and hyperandrogenism [1]. PCOS is associated with irregular periods/anovulation, subfertility, polycystic ovarian morphology, hirsutism, cardio-metabolic disorders, and poor psychological health and quality of life [2]. The international evidence-based guidelines for PCOS recommend lifestyle management through diet, physical activity, and behavioural modification as a first-line treatment strategy for PCOS and to reduce the risk of developing various comorbidities [1, 3]. It further supports the development of culturally appropriate lifestyle methods.

Emerging evidence on women’s preferences supports the exploration of comprehensive lifestyle management that includes non-pharmacological components of culturally relevant traditional, complementary, and integrative medicine (TCIM) therapies targeting the holistic health of the individual [4]. Approximately 70–80% of women with PCOS use various TCIM modalities relevant to their culture and individual preferences [5, 6]. For example, women with PCOS in Australia commonly use naturopathy [5], while Indian women with PCOS are more inclined to use yoga and Ayurveda compared to other TCIM modalities [6]. Given the importance of patient preferences in these therapies, further investigation is needed to explore locally adapted and culturally relevant holistic/whole-person lifestyle treatment strategies before they can be widely recommended.

Ayurveda and yoga are traditional medicinal systems originating from India that have prevailed for several thousand years to assist with disease management and health promotion [7, 8]. Ayurveda emphasises predictive, preventive, and personalised medicine, aiming to actively involve patients in their healing process [9]. This approach enhances self-awareness and promotes positive relationships with others and nature [10]. According to Ayurveda, everyone has a unique constitution, or Prakriti (body constitution), determined by the predominance of one or two Tridoshas (three body regulatory functional factors), namely Vata, Pitta and Kapha [11]. The imbalance in these biological entities leads to various discomforts in the body and mind, causing the manifestation of diseases [12]. Ayurvedic management of an illness includes the clinical assessment of the individual and presenting complaints based on Ayurvedic diagnostic principles such as assessment of the Prakriti, Vikriti (imbalance in the Tridoshas) and Dhatus (body tissues), Agni (digestive and metabolic factors), and Ama (a state of incomplete digestion, transformation, or metabolism), and prescription of the medicines, lifestyle, food items and eating practices that will help balance these entities and alleviate the symptoms [13].

Ayurveda has an elaborate description of various kinds of food, diets and eating practices that aim to create harmony between body, mind, and spirit and promote overall well-being [14]. Ayurveda dietary approach includes the concept of Asta Aharavidhi Visheshayatana (eight Ayurvedic dietary factors) to deliver personalised dietary suggestions [14, 15]. These factors include the consideration of food habitat, classification combinations and quantity, process of cooking, time and seasonal variations, and methods of food intake [15]. Eating habits are equally important in Ayurveda to help promote optimal digestion and absorption of nutrients and reduce stress-induced eating behaviours [16]. These factors are responsible for Pathya and Apathya (wholesome and unwholesome) effects on the body and mind [15]. Therefore, Ayurveda recommends that an individual should consume food after ‘self-assessment’ and consider these factors [15]. Researchers have utilised some of these concepts to understand their efficacy in managing various diseases [17–21]. However, these approaches are not fully understood and explored in women with PCOS [22].

Yoga is a way of life and an integral part of Ayurveda practice [7, 23]. This mind-body therapy encompasses many aspects of healthy living, such as Asana (physical postures), Dhyana (meditation), Pranayama (breathing techniques) and Shadkriyas (six body cleansing procedures) [24]. Yoga therapy is a popular method for cultivating physical and mental well-being, playing a key role in preventing and managing lifestyle-related diseases such as diabetes and cardiovascular diseases [25]. Evidence supports yoga therapy as a simple and effective lifestyle intervention to help induce healthy lifestyle behaviours [26–28], for weight management [29–33], to manage chronic diseases [34] and to improve psychological well-being [35–37]. Despite methodological drawbacks, preliminary evidence suggests it may have a role in managing PCOS-related health outcomes [38].

Our focus group study among Ayurveda doctors managing women with PCOS suggested that they offer culturally-tailored, personalised counselling focused on lifelong dietary and lifestyle regimens, including diet, and yoga with or without the use of pharmacological treatments to support effective PCOS management [39]. We further propose that a combined Ayurvedic diet and yoga therapy (AY) intervention could represent a potential lifestyle program for women with PCOS who are seeking a holistic and culturally relevant approach to health. This integrated approach has been previously studied for weight management among individuals without PCOS and found to be feasible and effective [21, 40]. However, there is a lack of evidence on what should be a standard AY program for women with PCOS to help manage weight. To be able to investigate the effectiveness of a whole-system Ayurvedic diet and yoga therapy intervention for women with PCOS, it is important to understand the key components of AY management and determine if combining these two modalities would benefit women before conducting a clinical trial. A whole-system AY approach indicates that these healing paradigms are implemented in a manner that retains a traditional focus on multivariate diagnosis and multimodal treatment, attending comprehensively to underlying causes while tailoring to the individual [41].

This study aims to gain consensus on the key components of Ayurvedic diet and yoga therapy for weight management in women with PCOS, by drawing upon the cumulative knowledge and experience of qualified practitioners in the field. The objective was to design an AY lifestyle program for women with PCOS and excess weight to be investigated in a future study.

Materials and methods

Study Design

The Delphi method was used to obtain content validity from a panel of experts to gain consensus [42]. This technique has gained popularity in forming guidelines and designing intervention components within the TCIM field [43–46]. The Delphi method is a rigorous process to gain consensus on complex interventions by using content experts who are likely to use the interventions in question [47]. It employs anonymity, iterative processes, and controlled feedback to reach consensus, offering an economical approach free from geographical constraints. By giving equal weight to the perspectives of all participants, it mitigates the risk of any single participant or viewpoint dominating the outcome [48]. Furthermore, this e-Delphi method benefits experts who are likely to utilise the AY intervention. It employs an electronic method for convenience to accommodate busy experts from different locations and time zones, offering a rigorous process to describe complex interventions [49]. The design, conduct and analysis of the Delphi survey was overseen by the study authors who hold diverse expertise in women’s health research, TCIM research and Delphi methodology. The Delphi study was piloted by two AY practitioners to assess relevance, clarity of questions and time involved. No changes were proposed. Ethics approval was obtained from the Western Sydney University Human Research Ethics Committee (H 15187, March 2023).

Sample size

Delphi studies may include anywhere from 4 to 3000 participants [50]. A generally accepted minimum suitable panel size is seven respondents [50]. Considering the dropout rates and to ensure that enough heterogeneity is present within the sample, we determined to analyse a sample of 12–15 participants.

Participants and recruitment procedure.

We purposively recruited experts with diverse expertise in conventional medicines, Ayurveda, yoga, and women’s reproductive/metabolic health. An eligible expert was defined as (i) having a Master’s degree or PhD in both Ayurveda and yoga therapy, (ii) at least five years of clinical experience in Ayurveda and yoga therapy, (iii) being fluent in English, and (iv) considering themselves specialists in PCOS. VR (first author), who is an experienced clinician-researcher in yoga and Ayurveda, compiled a list of potential experts. An email was sent to these experts containing details of the study, a participant information sheet, and a consent form. Interested experts signed an informed consent form before joining the study. Experts were encouraged to forward the study details to other potential experts interested in participating in the study.

Study procedure

Data were collected in two rounds over four months from June to October 2023, where online questionnaires were emailed to experts via a secure electronic link, and responses were recorded utilising Qualtrics XM v10.21 (Qualtrics, Provo, UT, USA). Experts were informed that formal consent was inferred upon survey completion through the participant information sheet, which was provided to them prior to survey commencement via an electronic link. No incentive was offered. Each survey took around 20–30 min to complete and consisted of 32 and 30 questions in round one and round two, respectively. Experts were given two weeks to complete each round, with non-responders being sent two reminder emails. If no response was obtained in round one, these experts were excluded from the subsequent round. All responses to the survey were anonymous.

The first round of Delphi questions was informed by a literature review and findings from our two focus group studies involving Ayurvedic doctors [39] and yoga therapists (see Additional file 1). Basic demographic details such as qualifications, country of residence, years and setting of practices were collected for all experts. The first round presented 120 items grouped in three sections. The first section asked questions related to Ayurvedic dietary consultation: (i) multiple choice questions related to the Ayurvedic appointments; duration, frequency, mode of delivery, qualification and training requirements for providing the consultation) (ii) open-ended questions related to the Ayurvedic assessment and Ayurvedic diagnosis; (iii) important Ayurvedic concepts to consider when planning dietary suggestions presented on a Likert scale of 1 to 5; and (iv) dietary and behavioural suggestions to include and exclude on a Likert scale of 1 to 5. The second section focused on the components of yoga therapy: (i) multiple choice questions related to the yoga therapy class (duration, frequency, mode of delivery, qualification, and training requirements for providing yoga therapy); (ii) yogic concepts to consider when planning a therapy class presented on a Likert scale of 1–5); and (iii) components to include and exclude presented on a Likert scale of 1–3. In the third section, questions were focused on the most effective approach and expected weight reduction in a month and any expected benefits from a combined AY approach, using a Likert scale of 1 to 5. A free-text question for comments was provided at the end of the survey.

The results of the first survey were analysed upon completion, and findings constituted the questions for the second round of the Delphi survey. The second round Delphi questionnaire consisted of items that could not reach consensus in the first round and some additional questions suggested by the experts in the open-ended question fields. The survey had three sections with questions related to Ayurvedic dietary consultation, yoga therapy class and expected weight reduction from a combined AY approach.

Analysis and consensus

There is no universally agreed-upon percentage of agreement for consensus; however, the literature suggests that a threshold in the range of 70% to 80% is reasonable [51]. In this study, an a priori level of consensus was set at 80% or more for the first round and 75% for the second round. Consensus thresholds in Delphi studies can be adjusted between rounds to reflect evolving agreement and study objectives [42]. This adjustment is consistent with established Delphi practices [42, 47, 52, 53] and supports a balance between rigour and practical considerations, ensuring no potentially important items were excluded prematurely.

In the first round, experts were asked to rate the items to be included in the AY lifestyle program using four formats; a five-point Likert Scale (1, not at all important; 2, slightly important; 3, moderately important; 4, very important; extremely important), a three-point Likert Scale (1, exclude; 2 not sure; 3 include), multiple-choice questions, and a free-text box. Consensus was appraised by compiling the frequency per response category and calculating the percentage of agreement for each rating. The level of consensus was determined by assessing the number of ratings within each response category. If ≥ 80% of responses for an item on a five-point Likert Scale were ‘4, very important’, or ‘5, extremely important, that item was automatically included in the list of Delphi recommendations. Similarly, if ≥ 80% of responses for an item on a three-point Likert Scale were ‘3, include’, that item was automatically included in the list of recommendations. Any item rated as 1, ‘not at all important’ on a five-point Likert Scale or ‘1, exclude’ on a three-point Likert Scale was rejected from the recommendations and removed from the second round. Items that were neither accepted nor rejected were retained for the second round of rating.

For multiple-choice questions, if consensus was not reached for a single option, the two most popular options were combined and presented in the second round. For example, where experts indicated that either up to 30 min or up to 60 min of Ayurvedic consultation was both a potential option, we reworded this for round two as “An adequate amount of time for the first consultation would be 30 to 60 minutes. Do you agree or disagree with this recommendation?” Similarly, open-ended questions were assessed based on the most popular inputs and were presented in the second round for consensus. In the second round, experts were asked to either ‘agree’ or ‘disagree’ with each item presented. If ≥ 75% of responses for an item were in agreement, that item was included in the recommendation. Results are reported as a summary of consensus from both rounds.

Results

Twenty-five potential experts were identified and invited to participate; of these, 20 (80%) expressed an interest in participating (Fig. 1). Of 20 experts, one was not eligible (had less than five years of clinical experience), and two did not respond. Finally, 17 experts (68% of those invited) completed the first round, and 16 completed both rounds of the Delphi. Most were practising in India (n = 16, 94%), in an urban area (n = 12, 71%) with 5–10 years of professional experience (n = 8, 47%) in a private independent clinic/hospital (n = 9, 53%), had completed a Master’s degree (n = 13, 65%), and were seeing a minimum of seven women with PCOS in a week (n = 12, 71%). Table 1 describes the demographics of the experts.

Fig. 1.

Flowchart of participation in the two-round Delphi study

Table 1.

Demographics of the study experts (n = 17)

Characteristics		n (%)
Country of practice	India	16 (94)
	USA	1 (6)
Practice setting	Urban area (Main city and dense population)	12 (71)
	Semiurban areas (Towns that are neither a city nor a village)	5 (29)
Highest qualification	Master’s degree (MD/MS) in Swasthavritta/Streeroga and Prasuti Tantra	11 (65)
	Master’s degree (MD/MSc) in yoga science/therapy	2 (12)
	PhD degree in Swasthavritta or Streeroga and Prasuti Tantra	1 (5)
	PhD degree in yoga science/therapy	3 (18)
Years in practice	More than 20 years	3 (18)
	11–20 years	6 (35)
	5–10 years	8 (47)
Type of clinical practice	Private independent clinic/hospital	9 (53)
	Private college and associated hospital	6 (35)
	Government Ayurvedic college and hospital	1 (5)
	Contractual Government hospital and private practice	1 (5)
Frequency of patients with PCOS	Up to seven cases per week	12 (71)
	Up to 15 cases per week	4 (24)
	Up to 20 cases per week	1 (5)
MD Doctor in Medicine (Ayurveda), MS Doctor of Surgery (Ayurveda), Swasthavritta Ayurvedic master’s degree in Preventive and Social Medicine, Streeroga and Prasuti Tantra Ayurvedic master’s degree in gynaecology and obstetrics, PCOS Polycystic Ovary Syndrome.

Delphi round one

In the first round, consensus was reached on 39 items out of 61 for the Ayurvedic dietary approach, 36 of 47 items for yoga therapy and eight items out of 11 for expected outcomes/benefits of the combined AY approach. Consensus was reached on the Ayurvedic diagnostic concepts to be considered before planning dietary recommendations: Prakriti, Vikriti, Jihwa, Agni, Oksatmyata, and understanding current dietary patterns (Table 2).

Table 2.

Final consensus on ayurvedic dietary consultation and assessments recommended for women with PCOS for weight management

Components of consultation and assessment		Round	n (%)
Minimum Qualification and practical training of the provider	1 year of full-time academic qualification in Ayurveda diet and nutrition, accredited and recognized in the respective country With 3 months of practical training	2	15 (94)
First consultation	30–60 min	2	15 (94)
Follow-up consultation	15–30 days apart	2	16 (100)
	30–45 min	2	13 (81)
Mode of delivery	A mix of online and offline	2	15 (94)
Minimum length of the consultation	3 to 6 months	2	16 (100)
Ayurvedic diagnosis do you associate/correlate with a biomedical diagnosis of PCOS	Depending upon the individual and presenting complaints, the Ayurvedic pathogenesis, and an Ayurvedic diagnosis can be determined in addition to a bio-medical diagnosis of PCOS	2	16 (100)
	There is no single name of the disease that can be correlated to the Ayurvedic term mentioned in the classical textbooks. However, depending upon the clinical representation, a diagnosis can be made such as women presenting with scanty, delayed menstrual cycle with PCOS and weight gain, would be given a diagnosis of Arthava Kshaya or Nastarthava.
Typical Ayurvedic constitutional type (Prakriti) that are likely to develop the biomedical diagnosis of PCOS	Most women diagnosed with PCOS, and excess weight generally have Kapha dominant Tridoshaja Prakriti	2	14 (87)
Typical Ayurvedic doshic imbalance (vikriti) associated with a biomedical diagnosis of PCOS	Most women diagnosed with PCOS, and excess weight generally have Kapha dominant Tridoshaja Vikriti	2	14 (87)
Important factors during clinical assessment	Deha Prakruthi (physical doshic constitution)	1	16 (94)
	Dosha Vikruthi (abnormality of dosha in the body)	1	16 (94)
	Jihwa (inspection of the tongue for toxins and organ function)	1	14 (82)
	Agni (condition of metabolic activity)	1	16 (94)
	Kaala (season/time of the day/age of an individual)	2	15 (94)
	Okasatmyata (the types of foods she has been eating since childhood)	1	15 (94)
	Current dietary/nutritional intake habits	1	17 (100)
	Consideration of a woman’s socio-economic status	2	15 (94)

Most experts agree that it is important to follow certain dietary principles when planning dietary recommendations; Nidana Parivarjana (avoid the food and lifestyle that causes disease manifestation) suggest one recommendation at a time, provide food that helps decrease excess Kapha and Medas, Satvik food, Nityasevaneeya (daily consumables) food, and food that is Srotoshodhaka (unblocks the body channels), Amapachaka (digests the gut toxins), and Deepaka (kindles the digestive fire) (Table 3). Consensus was reached on describing the following behavioural suggestions: eating after the previous meal is digested, food should be freshly prepared, food should be light in quality, eat after self-assessment, eat at home, do not eat in a hurry, do not eat very slowly, eating mindfully, eating with considering the self (thinking in totality if this meal is good for me or not), eating your last meal one-two hours before bedtime, walk a hundred steps after each meal (Table 3). Finally, of 16 Likert items to avoid/reduce, 14 reached consensus in the first round. All experts agreed on the recommendation of avoiding/reducing bakery items, packaged food and Abhishyandi (obstructive/slimy) food (such as curd, especially at night) (Table 4).

Table 3.

Consensus on ayurvedic dietary approaches recommended to follow for women with PCOS for weight management

Recommendations to follow	Round	n (%)
Focus on Nidana parivarjana (avoid the causative factors)	1	16 (94)
Suggest one or two changes at a time	1	15 (88)
Kaphahara foods (food items that pacify excess Kapha dosha)	1	17 (100)
Dosha-based food suggestion	2	16 (100)
Medohara ahara (food that decreases body fat)	1	16 (94)
Srotoshodhaka ahara (food that purifies body channels)	1	15 (88)
Ama pachaka (food that digests the toxic metabolites)	1	17 (100)
Deepaka (food that kindles the digestive fire)	1	16 (94)
Ruchihkara Ahara (healthy yet tasty food options)	2	14 (87)
Satvik foods (food that calms the mind)	1	14 (82)
Nityaupyogi dravya (food that can be used daily)	1	14 (82)
Shadrasa intake (food items that contain all six tastes)	2	15 (94)
Provide a pathya and apathya food chart (personalised and specified dietary dos and don’ts)	2	16 (100)
Behavioural suggestions
Follow Ayurvedic dietary guidelines (Ahara vidhi)	2	16 (100)
Eat only when the previous food is digested	1	16 (94)
Eat freshly prepared warm foods	1	16 (94)
Cook and eat at home at least 5–6 days a week	1	16 (94)
Don’t eat in a hurry	1	16 (94)
Don’t eat too slowly	1	15 (88)
Eat mindfully without distraction	1	15 (88)
Eat after self-analysis	1	16 (94)
Eat dinner 2–3 h before sleeping	1	16 (94)
Follow langhana (eat light food)	1	15 (88)
Walk 100 steps after a meal	1	16 (94)

Table 4.

Consensus on ayurvedic dietary approaches recommended to avoid for women with PCOS for weight management

Recommendations to avoid in excess	Round	n (%)
Diwaspana (sleeping in the daytime)	1	15 (88)
Eating late at night	1	16 (94)
Excessive intake of water following a meal	1	16 (94)
Snacking in between meals	1	15 (88)
Packaged foods	1	17 (100)
Abhishyandi ahara (sticky foods that clog body channels)	1	17 100)
Eating bakery items	1	17 (100)
Excess physical activity following a meal	1	14 (82)
Trans fats	1	16 (94)
Artificial sweeteners/flavours	1	15 (88)
Eating outside	1	15 (88)
Ultra-processed foods	1	15 (88)
Virudhha ahara (incompatible food combinations)	1	16 (94)
Madhura rasa foods (food items predominant in sweet taste)	1	15 (88)

Most experts agree that yoga therapy can be provided at home or in a yoga centre (Table 5). Consensus was reached for five out of seven yogic concepts to be included in the protocol: history taking, personalising the therapy, yogic counselling, and adding Ashtangayoga (eight limbs of yoga) and Kriyas (yogic body purification techniques). Furthermore, of 33 yoga practice items, 30 items reached consensus in this round. All experts agreed to include a motivational talk at the beginning of the session, and Suryanamaskara (sun salutations) (Table 6).

Table 5.

Final consensus on yoga therapy recommended for women with PCOS for weight management

Session details		Round	n (%)
Location/setting	A mix of home and centre-based classes	1	14 (82)
Mode of delivery	Online and offline methods	2	15 (94)
The minimum length of the yoga therapy program	3 to 6 months	2	15 (94)
An average frequency of yoga therapy	4 to 7 days per week	2	16 (100)
Duration of the yoga therapy session	30 to 60 min	2	16 (100)
Number of participants in a group-based yoga therapy session	2–20 individuals	2	16 (100)
Provider details
Minimum standard for teaching yoga to people with PCOS	Minimum of 500 h of yoga teacher training/qualification, over a minimum of 1 year	2	14 (87)
Important general components of the session to be included	History taking before admission to yoga	1	16 (94)
	Personalising the yogic practices for each individual	1	15 (88)
	Yogic counselling	1	15 (88)
	PCOS-specific yoga therapy	2	15 (94)
	Astanga yoga	1	14 (82)
	Suitable mudras (meditative hand gestures)	2	15 (94)
	Jalandhara, Uddiyana, and Moola Bandha	2	14 (87)
	Kriyas (yogic body purificatory procedures)	1	15 (88)

Table 6.

Specific recommendations to include in the yoga therapy program

	Round	n (%)
Motivational talk at the beginning of the session	1	17 (100)
Laghu shankhaprakshalana (stomach/colon cleanse)	2	13 (81)
Body loosening practices	1	16 (94)
Surya Namaskara (Sun salutation)	1	17 (100)
Bhujangasana (Cobra pose)	1	17 (100)
Shalabhaasana (Locust pose)	1	17 (100)
Dhanurasana (Bow pose)	1	17 (100)
Vyaghrasana (Tiger stretch)	1	16 (94)
Bhadakonasana (Butterfly stretch)	1	17 (100)
Trikonasana (Triangle pose)	1	17 (100)
Partivartit Trikonasana (Twisted triangle pose)	1	17 (100)
Ardha Kati Chakrasana (Half waist wheel pose)	1	17 (100)
Padahastasana ((Hand to foot pose)	1	17 (100)
Naukasana (Boat pose)	1	17 (100)
Baddhakona Asana (Fixed angle pose)	1	17 (100)
Paschimottanasana (Sitting forward stretch)	1	17 (100)
Vajrasana (Warrior pose)	1	17 (100)
Ustraasana (Camel pose)	1	16 (94)
Chakki chalanasana (Mill churning pose)	1	17 (100)
Ardhahalasana (Half plow pose)	1	14 (82)
Padavrttasana (Cyclical leg pose)	1	15 (88)
Nadi Shuddhi (Alternative nostril breathing)	1	17 (100)
Ujjayi pranayama (Victorious breathing)	1	15 (88)
Bhastrika (Bellows breath)	1	17 (100)
Surya Anuloma Viloma (Alternate nostril - right)	1	16 (94)
Kapalabhati (Forceful exhalation)	1	16 (94)
Bhramari (Humming breath)	1	17 (100)
Nadanu Sandhana (A-U-M mantra chanting)	1	15 (88)
Mindful meditation	1	17 (100)
Relaxation techniques	1	17 (100)
Yoga Nidra (yogic sleep)	1	15 (88)

All experts agreed that a combined AY approach would be more beneficial compared to individual therapy (Table 7). Consensus was also reached on seven of nine items that listed benefits of the AY approach; the AY approach will help induce healthy behaviours, self-care, self-efficacy, mental well-being, quality of life, self-esteem, and overall satisfaction with the program. All experts recommended that a combined Ayurvedic diet consultation and yoga therapy program for three to six months would be helpful for PCOS management (Table 7). Depending upon the participant’s involvement in the program and adoption of methods, and allowing for individual variation, a weight reduction of one to five kilograms, with an average of two to four kilograms, was suggested in the first round. Apart from weight reduction, a seven-.

Table 7.

Outcome measures of the combined ayurvedic diet and yoga program

		Round	n (%)
Best approach for weight management in women with PCOS	Ayurvedic diet and yoga therapy combined	1	17 (100)
Expected weight loss in one month of the AY lifestyle program	Up to 4 kg	1	14 (82)
Goals	Induce sustainable, healthy behaviours	1	16 (94)
	Promote self-care	1	15 (88)
	Improve self-efficacy around food intake and exercise	1	16 (94)
	Enhance mental-emotional well-being	1	16 (94)
	Improve the quality of life	1	16 (94)
	Improve Self-esteem	1	15 (88)
	Program Satisfaction	1	14 (82)

Likert item list of other benefits was agreed upon in the first round. Most experts agreed that the AY program would help promote sustainable healthy behaviours, improve self-efficacy around food intake and exercise, and enhance quality of life and mental-emotional well-being (Table 7).

Delphi round two.

The response rate for the second round was 94% (16/17 round-one respondents). A total of 30 items were presented in this round. Of the 17 Ayurveda diet-related items, 14 items reached consensus in this round. Consensus was reached regarding Ayurveda consultation (duration, mode of delivery, frequency), qualification and training requirements of the provider, and factors related to Ayurvedic assessment. The time between appointments was suggested to be 15 days to four weeks apart. All experts agreed that, depending upon the individual and their presenting complaints, the Ayurvedic pathogenesis and an Ayurvedic diagnosis can be determined in addition to a bio-medical diagnosis of PCOS, to provide Ayurvedic dietary recommendations. All participants agreed to provide a Pathya and Apathya food chart (personalised and specified dietary dos and don’ts) to an individual.

Of the 11 yoga-related items that did not reach consensus in the first round, nine items reached consensus in this round. There was a consensus that suitable individually-tailored yoga practice in a group of 2–10 individuals should be suggested for an average of 30–60 min, four to seven times per week, over three to six months, online/offline mode, depending upon the individual’s need. All experts agreed that a minimum of 500 h of yoga teacher training/qualification, or a minimum of one year, should be the minimum standard for teaching yoga to people with PCOS. Most experts agree that it is important to provide PCOS-specific yoga therapy practices rather than general classes to optimise the benefits (Table 6).

Finally, consensus was reached in the second round for the percentage of expected benefits of an Ayurvedic diet alone, a yoga therapy alone or a combined AY approach. 62% (n = 10) of participants stated that more than 80% of improvement can be obtained with combined AY therapies (Fig. 2).

Fig. 2.

Expected benefits from Ayurvedic dietary and yoga therapy individually or in combination

Discussion

While we acknowledge that Ayurveda and yoga therapy need to be tailored to suit individual health needs, we explored common suggestions that are provided to women with a biomedical diagnosis of PCOS and excess weight. This two-round Delphi study describes the key components of the Ayurvedic diet and yoga therapy for weight management in women with PCOS. The key components included a 54-item list of the Ayurvedic dietary approach and a 46-item list of yoga therapy, and reflect the views of 17 experts who are qualified and experienced in the field of Ayurveda and yoga. In this study, consensus was reached for characteristics of Ayurvedic consultation, yoga therapy sessions, program provider, Ayurvedic assessment, Ayurvedic dietary and lifestyle approach, and important components of the yoga therapy program.

Ayurveda and yoga are Indian sciences with shared principles and precepts and are often learned and practised together. Similar to the recommendations made by researchers for managing non-PCOS metabolic disease [54–58], all the study experts agree that a combined approach of Ayurvedic diet and yoga would have more benefits than a single modality on its own, although yoga therapy alone can cause a reduction in body mass index by 1.38 kg/m² compared to exercise in women with PCOS over three months [38]. Moreover, experts suggested that weight loss of up to 4 kg in 3 months can be achieved with the combined AY approach, which aligns with previous trials in which AY interventions demonstrated statistically significant weight loss in individuals with excess weight [21, 40]. This supports the ongoing efforts of integration across TCIM modalities, in particular Ayurveda and yoga [9, 59]. Considering the importance of lifestyle management in PCOS, studies exploring the combined approach of Ayurvedic diet and yoga are needed to generate more scientific evidence for integrative lifestyle treatment protocols.

Our findings indicate that Ayurveda doctors, like many TCIM practitioners [60, 61], follow patient-centred holistic practices, discussing various lifestyle aspects during consultations and focusing on patient-reported outcomes. In general, longer consultations can strengthen the patient-provider relationship by creating a safe space for open communication, knowledge sharing, and incorporating patient preferences in decision-making [61, 62]. This is evident from the consensus on 30–60-minute consultations in our study, which allow for a full case history, exploration of patients’ complex needs, and an individualised treatment approach. Similarly, Kessler et al. [20] found that the Ayurvedic conversational and counselling techniques provide more opportunities for patients to describe their problems and allow physicians to offer patient-centred practices and resource-oriented recommendations compared to biomedical nutritional counselling.

Although a common prescription of Ayurveda contains advice on Ayurvedic medicines as well as diet and lifestyle, we aimed to explore non-pharmacological aspects of Ayurveda consultation, that is, the Ayurvedic diet and lifestyle approach in particular. Providing suggestions on diet and daily routine is one of the major treatment components of Ayurveda [63]. One of the most highly recommended components was the dosha-based dietary approach, which has been explored in previous studies demonstrating potential for weight loss [21, 64]. However, evidence reports several variations in Ayurvedic assessments in the trials and recommends developing and utilising standard clinical assessment tools to investigate the full potential of Ayurvedic interventions [65, 66]. For example, standard tools to assess dosha [67, 68] and Agnibala (metabolic strength) [69] can be utilised in future studies to overcome discrepancies related to Ayurvedic assessments. Moreover, there is a need to develop and validate Ayurveda assessment tools for PCOS, as previously done for gynaecological disorders [70] and anxiety [71].

Ayurvedic diet emphasises the balance of three fundamental bodily doshas: Vata, Pitta, and Kapha [63]. The principal Ayurvedic dietary approach to weight reduction includes foods that reduce excess Kapha and Medas in the body, as utilised in previous studies for weight reduction [21, 64]. It is important to note that not all women with PCOS and excess weight are automatically advised to follow Kapha and Medas-reducing dietary modifications. The suggestions depend on the clinical presentation and Ayurvedic assessment. If the Ayurvedic doctor makes a diagnosis of predominantly Pitta imbalance, then pitta-reducing foods will be suggested. However, in clinical practice, elevated Kapha and Medas are typically associated with a PCOS diagnosis, thus Kapha and Medas-reducing foods are suggested often for women with excess Kapha dosha and abnormal Medas presenting with excess weight, and absence/delayed menstrual cycle [22].

Most of the previous yoga trials are predominantly group-based [72]. Some researchers suggest having one-on-one sessions with the therapist, for example, in individuals with mental health disorders [45]. According to data from the Delphi process, there was consensus that a suitable individually tailored yoga practice in a group setting of a maximum of 10 participants would be beneficial. This may be because the group-based approach helps with motivation and social engagement [73], which is important for weight management [74] and long-term PCOS management. Similar to previous evidence [44], experts in this study recommended supervised home practice, which may improve adherence and safety. Further research to consider the relative effectiveness of each approach for PCOS management is recommended.

The consensus-based recommendation for a yoga practice frequency and duration of four to seven times per week, 30–60 min per day, over a minimum period of three months of yoga class, reflects commonly recommended parameters in previous trials of yoga studies in women with PCOS and individuals with excess weight [29, 38]. Aligned with traditional yoga practices, this study supports developing flexible intervention guidelines. These should be non-prescriptive, integrated, and individualised, allowing for tailored, multi-dimensional combinations suited to each person. While this may differ from what is considered typical best practice, practitioner training, and standardised, replicable research interventions emphasised in biomedicine, it reflects the need for a balance between evidence-based standardisation and individual needs to achieve optimal patient outcomes. Such approaches are consistent with causal understandings in the holistic medical sciences and have been used previously for complex interventions, for example, manualization used in clinical trials of acupuncture and yoga therapy [75].

In this Delphi study, the use of hatha yoga, dynamic postures, meditation, heating Pranayamas and relaxation techniques were the primary components of the program. These suggestions align with previous research conducted using these techniques among non-PCOS individuals with obesity [29, 31, 76]. Experts proposed the use of dynamic postures, which may yield higher energy expenditure. This could be due to the fact that several yoga techniques have been shown to elicit an equal or lower energy expenditure than aerobic exercise [77, 78]. While aerobic exercise is an evidence-based treatment for managing weight in women with PCOS, structured yoga therapy may bring added benefit via its holistic, positive, psycho-somatic approach to managing complex PCOS symptoms in the long term.

Previous studies have highlighted that yoga offers diverse behavioural, physical, and psychosocial benefits targeted at cultivating sustainable healthy lifestyle behaviours, making it a valuable tool for weight management [28, 74, 79]. Role modelling and social support from the yoga community can be particularly helpful for those struggling to lose weight [74]. Similarly, experts in this study supported the fact that in addition to weight management, there are several benefits that yoga therapy could offer to improve self-efficacy, quality of life and psychological well-being.

Strengths and limitations

This study’s strengths include moderate recruitment and high completion rates, participants’ significant expertise and experience, flexibility in recommended interventions, and the reproducible Delphi method. The contents of our Delphi study were informed by previously conducted focus groups studied among different experts in the field. Additionally, our strict eligibility criteria helped us to gather the right information from experienced and qualified experts in the field with a high response rate.

Some limitations of the study are also noted. Although participants were selected to represent a diversity of professions and expertise, they may not represent the full set of views held by individuals in the profession. Experts were selected based on the first author’s personal or professional network. This introduces the potential for selection bias, limiting the diversity of perspectives and possibly overrepresenting certain viewpoints or disciplines. Moreover, experts were largely from India, which limits the views of Ayurvedic doctors and yoga therapists practising outside India. However, it is important to note that our eligibility criteria were developed to include highly qualified and expert clinicians in the study, and the standard of education and practice for Ayurveda and yoga are comprehensive in India. Future studies involving various degrees of professionals might provide different cultural and professional views from different parts of the world. Finally, while the Delphi method is a powerful tool for synthesising expert opinion, its results must be interpreted with caution, particularly given the risks of bias in expert selection and the potential conflation of agreement with accuracy.

Conclusion

This Delphi study produced a consensus recommendation for a combined Ayurvedic diet and yoga therapy program. This program is presented as a potential holistic lifestyle management tool for women with PCOS and excess weight, which needs to be evaluated in future clinical research for its feasibility. This study also highlights the importance of developing consensus on prioritizing common elements and approaches that can be standardized in otherwise individualised TCIM approaches such as yoga and Ayurveda.

Authors’ contributions

V.R., Conceptualization, Investigation, Methodology, Analysis and Interpretation, Writing – original draft, Writing – review & editing; M.A., Conceptualization, Methodology, Supervision, Writing – review & editing; J.R., Investigation, Writing – review & editing; A.M., Investigation, Writing – review & editing; B.S.C., Conceptualization, Supervision, Writing – review & editing; C.A.S., Conceptualization, Writing – review & editing; C.E., Conceptualization, Methodology, Supervision, Writing – review & editing. All authors have read and approved the final version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethics approval was obtained from the Western Sydney University Human Research Ethics Committee (H 15187, March 2023). The study was conducted in adherence to the Declaration of Helsinki. Written and verbal informed consents were obtained from all the participants. Participants were appropriately informed about the content and purpose of the study. Participation was voluntary.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests. As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies, and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute.