|Year : 2019 | Volume
| Issue : 1 | Page : 24-29
The yoga–meditation heart connection: A pilot study looking to improve women's heart health
Sasha De Jesus1, Emily Schultz1, Rachel M Bond2
1 Department of Medicine, Lenox Hill Hospital, New York, USA
2 Department of Cardiology, Lenox Hill Hospital, New York, USA
|Date of Submission||08-Oct-2018|
|Date of Decision||02-Nov-2019|
|Date of Acceptance||06-Nov-2019|
|Date of Web Publication||13-Dec-2019|
Dr. Sasha De Jesus
Department of Medicine, Lenox Hill Hospital, New York
Source of Support: None, Conflict of Interest: None
Background: Stress, anxiety, and depression are nontraditional risk factors for cardiovascular disease (CVD) that are more common in women. For nearly four decades, we have seen a steady decline in the number of deaths in women related to heart disease, especially in those >65 years old. However, recent data suggests there has been a stagnation among women <55 years. With this, it is imperative that we continue to increase awareness, understand, and research the unique pathophysiology of women's CVD, and increase recognition of the prevalence of nontraditional risk factors that are more common in women such as stress, anxiety and depression. Aims and Objectives: Although there is limited understanding of the mechanism behind its benefit, measures such as yoga and meditation may decrease morbidity in patients with CVD. With this in mind, we hypothesize that regular, supervised sessions of chair yoga and meditation can be a complementary measure to decrease the level of anxiety, stress and depression in female patients with or at risk for CVD, as well as increase their likelihood to pursue lifestyle modifications. Methods: Participants of a weekly complimentary chair yoga/meditation workshop supervised by a trained cardiac yoga therapist performed a survey on day 1 and on week 24. A total of 16 and 10 female participants with or at risk for CVD completed the initial and follow-up survey, respectively, which included validated screening tools for depression, anxiety, and stress. Results: The Patient Health Questionnaire-9 from the initial to the follow-up survey showed an increase in the mean score (2.25 vs. 3.2). Despite this, the severity remained as minimal depression. The mean Generalized Anxiety Disorder-7 went from 7 to 4.9 (decreased from mild to no clinical anxiety). Finally, the perceived stress score demonstrated a reduction from 18.25 to 15.2, both remaining as moderate perceived stress. Participants also endorsed a trend toward healthier eating habits, and 37.5% of participants endorsed a 3–9 lbs weight loss. Conclusion: Given the low harm and cost of these measures, they can be done as adjuvants to our standard of care to increase the patient's overall well being by improving the psychological aspect of their lives, which in turn could reflect on their physical health.
Keywords: Heart, meditation, women, yoga
|How to cite this article:|
Jesus SD, Schultz E, Bond RM. The yoga–meditation heart connection: A pilot study looking to improve women's heart health. Ann Clin Cardiol 2019;1:24-9
|How to cite this URL:|
Jesus SD, Schultz E, Bond RM. The yoga–meditation heart connection: A pilot study looking to improve women's heart health. Ann Clin Cardiol [serial online] 2019 [cited 2021 Oct 24];1:24-9. Available from: http://www.onlineacc.org/text.asp?2019/1/1/24/273001
| Introduction|| |
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the United States for women. For nearly four decades, we have seen a steady decline in the number of deaths in women related to heart disease, especially in those >65 years old. Recent data suggest that there has been a stagnation and even an increase in the incidence and mortality of CVD, specifically among younger women (<55 years) in the United States and other countries such as Australia.,
| Materials and Methods|| |
The Institutional Review Board of the hospital where these sessions took place approved the study, and after obtaining informed consent, an anonymous survey was provided to the participants of a complimentary chair yoga/meditation workshop supervised by a cardiac yoga therapist. The 45-min sessions took place at an urban academic hospital in New York City once per week, where the practice of yoga Nidra meditation was performed seated to make it more accessible to all participants. The sessions began in January 2018, where the surveys were distributed and performed on day 1. This was repeated over that period of time on week 24 to assess any changes in their reported level of stress, depression, anxiety, and lifestyle. These surveys consisted of a questionnaire of the patient's baseline characteristics [Table 1], along with validated screening tools for depression, anxiety, and stress, with the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Perceived Stress Scale (PSS).
| Results|| |
A total of 16 female participants with or at risk for CVD and with a mean age of 64 years completed the initial survey. The majority of participants were found to have no to minimal depression with their PHQ-9 for depression assessment mean of 2.25; mild anxiety with their GAD-7 for anxiety assessment found to be a mean of 7; and with a moderate degree of perceived stress with their PSS having a mean of 18.25.
After a total of 24 weeks of weekly supervised sessions, the surveys were readministered with completion from 10 participants.
Although the absolute numbers, when comparing the average PHQ-9 from the initial session to the follow-up survey [Graph 1], show an overall increase in the score (2.25 vs. 3.2 respectively), this is relatively insignificant as the severity of depression did not change. The numbers remain in the category of none to minimal depression ranging from a score of 0 to 4 (5–9 would be mild depression, 10–14 moderate, 15–19 moderately severe, and >20 severe). Similarly, although the PSS demonstrated a mean reduction from 18.25 to 15.2, this still falls in the same category of moderate perceived stress (0–13 low, 14–26 moderate, and 27–40 severe perceived stress). The area of most notable improvement came from the generalized anxiety scale. Here, the mean GAD-7 was 7 from the initial visit down to 4.9 for the follow-up survey. This showed a decrease in the severity of anxiety from a level of mild to no anxiety (0–4 is minimal to no anxiety, 5–9 mild anxiety, 10–14 moderate, and 15–21 severe anxiety). The statistical significance of these numbers is shown in [Table 2].
|Table 2: Statistical analysis of changes in depression, anxiety, and stress after completing the 24 weeks yoga and meditation program|
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Furthermore, the majority of participants endorsed an improvement in their overall health that was expressed through the reporting of higher levels of energy, an increase in the degree of exercise activity and a subjective decrease in angina. They also endorsed an increase in stress-reducing activities with the use of meditation being the most common one. Although there was no degree of weight gain noted, the majority did not experience a change in their weight, and 37.5% actually had weight loss ranging from 3 to 9 lbs.
As part of our survey, we asked the participants how often they ate foods low and/or high in saturated fat. We defined this by providing a series of examples of both categories (e.g., high being hamburgers, hot dogs, cheese, whole milk, eggs, butter, pastries, and chocolate and low being lean meats, skinless poultry, fish, skim milk, vegetables, and fruits). As shown in [Graph 2], there was a trend toward integrating more low-saturated fat foods after the 24th session.
Baseline characteristics were summarized by the mean and range for continuous variables and by the percentage for categorical variables. Analyses were performed on continuous variables obtained from surveys including scores from the following screening tools: PHQ, GAD, and perceived stress. The data were presented as mean and standard deviation as well as differences between pre- and post-surveys were assessed with two sample t-test. All statistical analyses were performed with StatPlus statistical analysis software (AnalystSoft Inc.) version 6, Walnut, CA, USA.
| Discussion|| |
It is imperative that we continue to increase awareness, diminish gender disparities in the treatment and diagnosis of CVD in women, and research the unique pathophysiology of women's CVD along with the prevalence of nontraditional risk factors unique to or more common in women such as the greater psychological determinants such as stress, anxiety, and depression.
Depression, a common mood disorder that negatively affects how you feel, has a higher incidence in women when compared to men by 1.7 folds. With this, this can confer a 1.64 relative risk for developing CVD. A equally common mental health condition is anxiety, which besides increasing ones risk for CVD, has also been associated with major cardiac events in patients with coronary heart disease (CHD), and has been seen in one out of three women at any point in their lifetimes, compared to only 22% of men. Finally, stress, which when persistent, can have a negative effect on the heart and is also more frequently perceived in women. Due to this, it is imperative that we screen for these common conditions early on and help find ways to manage and cope with them to help decrease our female patient's overall CVD risk.
Studies have shown that yoga and meditation can improve patient's overall levels of depression, anxiety, and stress and possibly decrease CVD risk. A review on the evidence of the effects of meditation on CHD discussed the positive impact meditation had on different aspects of CVD risk, such as hypertension, type 2 diabetes mellitus, dyslipidemia, and high cortisol level.
With this in mind, we hypothesized that regular, supervised sessions of chair yoga Nidra and meditation can be an alternative, complementary measure to decrease the level of stress, anxiety, and depression (primary outcome) in female patients with or at risk for CVD, as well as increase their likelihood to pursue other lifestyle modifications (secondary outcome), such as following a healthy diet and exercising more.
The word “yoga” comes from a Sanskrit term that means union. It aims to join body, mind, and the daily challenges of life into a unified experience rather than keep them separate. Beneficial effects of yoga have been reported in multiple chronic conditions including depression, stress, anxiety, chronic pain, and CVD among others.,, Yoga appears to be especially beneficial for the prevention of CVD, likely given the physical activity it involves. This has been shown in a meta-analysis of 44 randomized controlled trials where there was a statistically significant improvement in systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate, cholesterol levels, and waist circumference.
There are different forms of yoga. For our study, we decided to focus on the gentle practice of chair yoga Nidra where the participants achieve a deep state of relaxation when being conscious. This is performed in a sitting position to make it more accessible for everyone with physical limitations. There are studies that focus on how yoga Nidra and meditation in patients with mild to moderate anxiety can be of benefit. A Cochrane review assessed 11 trials and 2 ongoing studies to determine the effects of yoga in the primary prevention for CVD. This review involved different types of yoga, with only one being the practice of Nidra. The conclusion was that although there is limited evidence, yoga can have some favorable CVD benefits which could be explored with caution.
Meditation is a practice that has been present for thousands of years now, which aims to achieve a state of conscious relaxation, but its effects are not limited to feeling at peace and relaxed.
The American Heart Association (AHA) scientific statement on meditation and cardiovascular risk reduction reviewed the association of meditation with different variables related to CVD including, but not limited to, smoking cessation, blood pressure (BP), insulin resistance, metabolic syndrome, and inducible myocardial infarction. The conclusion of the report was that meditation has possible cardiovascular benefits, making it a reasonable adjuvant measure to consider in the reduction of CVD risk. One interesting systematic review conducted in 2007 initially explored this by showing a 5/3 mmHg SBP/DBP reduction with the use of transcendental meditation (TM). TM is a type of meditation where the participant sits comfortably twice daily for 15–20 min and lets the mind focus on a spiritual dimension. As per the basis of the 2013–2014 National Health and Nutrition Examination Services, lowering a patient's BP by just 5 mmHg would mean that 55.3% of US adult will have ideal levels of BP, and this would represent a 21.8% improvement. However, when discussing the previous statement, it is imperative to keep in mind that these numbers may be slightly different now with the 2017 American College of Cardiology/AHA revision to the guidelines for high BP in adults. These updated guidelines were considered as hypertension remains to be a large modifiable risk factor, with CVD risks nearly doubling with readings above 130/80 mmHg. As such, in an attempt to identify more patients with high BP at an earlier stage, the threshold was lowered.
In saying this, and taking into account the AHA's 2020 Impact Goals in reducing the rates of death from heart disease and stroke by 20% through their life's simple 7 initiative, meditation and chair yoga should be considered as a reasonable adjuvant in an attempt to help meet this goal. At this time, we know that this reduction may not be definitive, but these practices are of low risk and can add to our already known and validated measures to decrease CVD rates.
One of the first studies involving meditation track dates back to 1989, where 73 residents (mean age of 81 and 82% were female) within 8 homes for the elderly were randomly assigned to no treatment and three treatments: the TM program, mindfulness training in active distinction making, or a relaxation (low mindfulness) program. Two important outcomes were BP after 3 months and mortality after 3 years. After 3 months, the BP was lower in the TM group, and after 3 years, survival rate was 100% for the TM group, and 87.5% for mindful training (MF) in contrast to lower rates for other groups. The results of this study were then pooled with a similar study, with the objective to evaluate long-term mortality in this group of patients. The conclusion was that in addition to usual care, nonpharmacologic decreases of stress with the TM program may be associated with decreased mortality in older populations with hypertension.
More recently, in 2011, a 5-year prospective analysis was published. It was conducted in 1454 postmenopausal women (with a mean age of 61.3 years at the time of inclusion) where the connection between depression and CVD was assessed. A validated three-question depression screening (yes/no questions being: Do you often get bored? Do you often feel helpless? Do you feel pretty worthless the way you are now?) was distributed, and only 2.1% of the women who did not have a positive depression response developed CHD, when compared to 5.6% of the women who had any degree of a positive depression response (P = 0.002). Furthermore, the more positive depression responses (answering yes to one, two or three of the previously mentioned questions) were associated with a higher prevalence of CHD.
In 2014, JAMA published a systematic review and meta-analyses to determine the efficacy of meditation programs in improving stress-related outcomes. A total of 47 trials and 3515 participants were included with a mental health/psychiatric condition (e.g. anxiety or stress) and a physical condition (e.g. heart disease and advanced age). However, because stress is of interest in several mindfulness studies, trials that included stressed populations that may not have had an established medical or psychiatric diagnosis were also included. This review showed that at 8 weeks, mindfulness meditation programs had moderate evidence of improved anxiety (0.38 [95% confidence interval: 0.12–0.64]) and depression (0.30 [0.00–0.59]). Although there was low evidence of improvement in stress, the small improvement in anxiety and depression is comparable with what would be expected from the use of an antidepressant, but without the associated adverse effects.,
The male:female prevalence ratio of any anxiety disorder in their lifetime and at 12 months is 1:1.7 and 1:1.79, respectively, and anxiety is a significant risk factor for CVD; hence, women who have these mental health conditions are at increased risk for CVD. In our study, it appeared that the use of chair yoga Nidra and meditation showed a trend toward improving our participants' anxiety scales when compared to their depression or stress scales. This is in line with several other studies. Although not specified on which type of yoga was taught, a study conducted on 50 women (20–50 year olds) who were reportedly healthy homemakers was looked at. The goal of the study was to determine their anxiety levels and the effects of yoga on their anxiety levels after attending a month of yoga camp. Before yoga, the percentage distribution of subjects with mild, moderate, and severe anxiety was 6%, 18%, and 76%, respectively. At the end of the yoga camp, the percentage distribution with mild, moderate, and severe anxiety was 44.24%, 19.23%, and 36.53%, respectively. These results indicate a reduction in not only the severity of anxiety following yoga (statistically significant with P = 0.000), but also their heart rate, SBP, and DBP, going from 82.90 ± 4.25 bpm, 124.84 ± 11.022 mm Hg, and 85.20 ± 10.81 mm Hg at the start of the study to 77.58 ± 3.86 bpm, 117.92 ± 6.76 mm Hg, and 78.68 ± 6.62 mm Hg, respectively.
As previously mentioned, meditation not only helps reduce these nontraditional risks factors, but also traditional risk factors for CVD such as hypertension. This was also proven in an updated systematic review published in 2007 that included 17 trials and 960 participants with hypertension. Methods such as biofeedback, relaxation-assisted biofeedback, progressive muscle relaxation, stress management training, and TM were used. Out of all those programs, the TM program was the one to show a significant improvement in BP (−5.0/−2.8 mm Hg [P = 0.002/0.02]).
In a review of 47 trials involving meditation, although only few reported on harm, no evidence of harm was found on these programs. It is for this reason we decided to explore the effects of chair yoga Nidra and meditation on our female patients with or at risk for CVD. To show statistical significance, a very large study would have to be conducted. Our study demonstrated a trend toward the primary outcome of improvement in these psychological determinants and is very promising. We achieved our goal of a pilot study to show that this should be further investigated and encouraged.
Among the limitations of our study is the fact that we had a small sample size and a 37.5% drop out rate. In addition, the survey was self-administered, which can mean that answers may not be done objectively and could be influenced by the participant's feelings that day. Furthermore, although participants practiced either chair yoga or meditation under the supervision of authorized instructors, their involvement in other activity or practices had not been observed. Finally, the participants were likely a highly motivated group that was willing to volunteer for a research study, and the class was adapted for beginners; therefore, the findings may not be directly generalizable to a typical community. However, our study has several notable strengths including the use of an expert yoga therapist to design a program specifically for women who have or are at risk for CVD.
| Conclusion|| |
With that being said, although more evidence and research is yet to be done to demonstrate a definitive benefit in the use of meditation and chair yoga in CVD risk reduction, given the low harm and minimal cost of these measures, they should be considered as an adjuvant to our standard of care. Because of this, and in an era where death from CHD is falling steeply in the older population, but not in young females (<55 years), we decided to study the effects of yoga in women. Moreover, although our study did not have a large group of women in that age range, we noticed a possible benefit in these practices, and it should be set as an example for larger studies to follow. By doing so, we will increase our female patient's overall well being by improving psychological aspects of their lives which in turn could reflect on their physical health.
We would like to acknowledge and express deep gratitude to Sonja Rzepski, a yoga therapist from the Prema Yoga Institute, as well as her mentees Yuliana Kim Grant, Irina Chernova, Judy Glassman, and Michelle Lauren, for their dedication and time invested in spreading awareness to help improve the health of our women through the practice of yoga and meditation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]