Abstract
Cardiovascular disease is a chronic illness with physiological, behavioral, and psychosocial components implicated in the etiology and course of the disorder. Given its multifaceted nature, management of cardiovascular disease needs to be multidimensional and include attention to all risk factors. Research has indicated that modification of one risk factor (e.g., diet) does not lead to automatic benefits to other risk factors (e.g., exercise) (Prochaska, Nigg, Spring, Velicer, & Prochaska, 2010). Hence, attention needs to be focused simultaneously on both physiological and psychological components. For example, medical regimens need to be augmented by lifestyle changes that include diet and exercise. Psychosocial variables such as depression, hostility, and stress also play a key role in morbidity and mortality associated with cardiovascular disease and need to be independently managed. An explicit focus on techniques that involve concurrent physiological and psychological interventions makes mind-body therapies effective and appealing in dealing with cardiovascular disorders. Mind-body medicine is the most widely used domain of complementary and alternative medicine among the US population for treatment of medical conditions (NIH, 2004). Examples of mind-body medicine include meditation, yoga, relaxation, visual imagery, biofeedback, qigong, cognitive-behavioral therapies, support groups, tai chi, and spirituality. This chapter will focus on the most widely studied and used interventions, specifically, yoga and meditation.
Keywords
- Coronary Heart Disease
- Generalize Anxiety Disorder
- Mindfulness Meditation
- Meditation Practice
- Progressive Muscle Relaxation
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Cardiovascular disease is a chronic illness with physiological, behavioral, and psychosocial components implicated in the etiology and course of the disorder. Given its multifaceted nature, management of cardiovascular disease needs to be multidimensional and include attention to all risk factors. Research has indicated that modification of one risk factor (e.g., diet) does not lead to automatic benefits to other risk factors (e.g., exercise) (Prochaska, Nigg, Spring, Velicer, & Prochaska, 2010). Hence, attention needs to be focused simultaneously on both physiological and psychological components. For example, medical regimens need to be augmented by lifestyle changes that include diet and exercise. Psychosocial variables such as depression, hostility, and stress also play a key role in morbidity and mortality associated with cardiovascular disease and need to be independently managed. An explicit focus on techniques that involve concurrent physiological and psychological interventions makes mind-body therapies effective and appealing in dealing with cardiovascular disorders. Mind-body medicine is the most widely used domain of complementary and alternative medicine among the US population for treatment of medical conditions (NIH, 2004). Examples of mind-body medicine include meditation, yoga, relaxation, visual imagery, biofeedback, qigong, cognitive-behavioral therapies, support groups, tai chi, and spirituality. This chapter will focus on the most widely studied and used interventions, specifically, yoga and meditation.
Epidemiologic Evidence
Mind-body therapies have wide use among patients in the management of cardiovascular disease. According to a recent study, approximately one-third of patients with acute coronary syndrome practice some form of mind-body medicine (Leung, Tamim, Stewart, Arthur, & Grace, 2008). The use of these therapies tends to be more common among nonwhite women with higher levels of education, who exercise regularly, and have a history of smoking and poor mental health (Leung et al., 2008). Mind-body therapies also have a significant impact on risk factors such as insulin resistance which may worsen the disease (Innes, Vincent, & Taylor, 2007).
Introduction: Defining Meditation and Yoga
Meditation (dhyan) and yoga in India and other Eastern cultures have been around by some accounts for several centuries. They are not necessarily considered to be two distinct and separate entities. Collectively, they are considered to be a way of life and a part of daily living. Practice of a yoga and meditation lifestyle is harmony between the mind, body, and spirit, enabling individuals who adhere to their principles to face life with equanimity. Breath (pranayama) is considered to be an essential element of both practices. Committed practitioners of yoga begin their day with 1–2 h of practice which includes yoga, meditation, and breathing exercises. This early morning practice is thought to induce a state of contemplative awareness that is brought to bear on all situations encountered during the day. Practice of yoga is also traditionally augmented by a moderate vegetarian diet that is free of intensive spices that are considered harmful to health and well-being. Spiritually, the practice of yoga also entails the philosophy of Karma or the policy of engaging in right action regardless of provocation and disengagement with reward and benefit calculations associated with action (Jayasinghe, 2004). The Eastern system of medicine, Ayurveda, regularly utilizes principles of yoga, meditation, and pranayama for their therapeutic benefits in treating diseases and achieving optimal health and well-being. It is important to note that the traditional practice of this way of life does not view yoga, meditation, or pranayama as prophylactic treatments but rather views them as a way of optimal functioning.
Western cultures have adopted these Eastern practices as an alternative or complement to allopathic or Western medicine to treat disease and also as a recreational activity, a form of exercise, and a stress management technique. Yoga and meditation are regarded as powerful mechanisms for preventing illness via their beneficial impact on stress. Regardless of the scientific validity of yoga and meditation, overwhelming anecdotal evidence has pointed to this positive, stress-mitigating effect. Still, an important difference to note between Eastern and Western perspectives on yoga and meditation is that Western perspectives have viewed them as supplemental techniques rather than a way of life.
Meditation
The major challenge in operationally defining yoga and meditation is that Western society has popularized many different forms, including mantra meditation, mindfulness meditation, hatha yoga, raja yoga, etc. (Ospina et al., 2008; Innes et al., 2007). For the purposes of this chapter, definitions of two of the most popular forms of meditation are provided: transcendental meditation and mindfulness meditation.
Transcendental meditation (TM): The basis of TM is mantra meditation, which refers to meditation practices in which a repeating mantra (word, sound, symbol) is the main component. The underlying idea is that repetition of the word, symbol, or sound prevents other cognitive activity allowing focused attention. In addition to TM, other forms of mantra meditation include relaxation response (RR), clinically standard meditation (CSM), and Acem meditation (Ospina et al., 2008). Currently, there are many meditation practices used in combination with other relaxation techniques such as progressive muscle relaxation (PMR), autogenic training, and biofeedback.
Mindfulness meditation: Mindfulness is defined as attention on the present moment – observation without judgment. Mindful meditation involves an enhanced awareness or cognizance of the body, thoughts, emotions, and surroundings without questioning or judgment and with acceptance (Baer, 2003). Mindfulness meditation does not restrict attention to a single stimulus such as a word, mantra, or object. Instead, the focus is simply on observing the ongoing stream of internal and external stimuli, nonjudgmentally, as it unfolds, without trying to change, escape, or avoid it (Baer, 2003). For example, a practitioner may focus on the breath, heartbeat, thoughts, proprioceptive sensation, and external auditory and visual stimuli. Mindfulness meditation is the pervasive practice in the USA and is considered to be a secular form of meditation independent of religious and cultural origins.
Mindfulness meditation incorporates guided imagery, breathing exercise, light yoga, and other techniques. The best know therapies that have integrated mindfulness meditation include mindfulness-based stress reduction (MBSR, Kabat-Zinn, 1990), mindfulness-based cognitive therapy (MBCBT, Segal, Williams, & Teasdale, 2002), dialectical behavior therapy (DBT, Linehan, 1993a, b), and acceptance and commitment therapy (ACT, Hayes, Strosahl, & Wilson, 1999). Vipassana meditation and Zen meditation also embody principles of mindfulness meditation (Ospina et al., 2008). Regardless of the modality in which it is used, research on the concept of mindfulness has identified the following components that comprise experience: (a) not reacting to internal experiences (emotions, thoughts, etc.); (b) attention to sensations, perceptions, thoughts, and feelings; (c) awareness of actions/behaviors; (d) description of experiences in the present moment; and (e) not judging experiences (Lutz, Greischar, Rawlings, Ricard, & Davidson, 2004).
Yoga
Yoga is an ancient mind-body discipline that is thought to be a way of life in conjunction with meditation. Throughout history, specifically in countries like India and Tibet, yoga, with its focus on integration of the mind, body, and spirit, has been viewed as a pathway to achieve full human potential and even enlightenment. Yoga couples muscular activity (asanas) with attention focused inward (dhyan) assisted by breathing that is regulated (pranayama) to create a state of contemplation (LaForge, 1997). The idea behind yoga is that over years of practice, this induced contemplative state is maintained as practitioners interact with the world around them (LaForge, 1997). Such a state is crucial in examining the contrast between yoga and other Eastern forms of activity and traditional body-centered aerobic and muscular fitness (LaForge, 1997). The practice of yoga has been rising steadily in Western industrialized countries during recent decades. There are many forms and branches of yoga, but most of them are comprised of different elements of postures, attention, and breath. Of the seven major branches of Hindu yoga, hatha (forceful) yoga, raja (classical) yoga, and mantra yoga are perhaps the best known and most widely practiced forms. Each type of yoga may emphasize different aspects. For example, hatha yoga and raja yoga emphasize specific postures (asanas) which include active and relaxed poses along with breath regulation (pranayama), concentration (dharana), and meditation (dhyan). Hatha yoga is the version most commonly practiced in the Western industrialized world and includes many different styles (e.g., Iyengar, Kundalini, Ashtanga, Integral, and Bikram yoga). It also incorporates mantras or chants, cleansing exercises (kriyas), and specific hand gestures (mudras) (Innes et al., 2007).
Therapeutic Mechanisms
Rehabilitation after a cardiac event generally includes diet, exercise, and psychosocial interventions – including stress management interventions – in addition to pharmaceutical managements of the disease. Interestingly, traditional forms of yoga and meditation practice also involve dietary, psychosocial, and physical components – asanas (physical posture), dhyan (meditation), pranayama (breathing exercises), and diet (moderate vegetarian diet). Overall, meditation and yoga are described as multifaceted processes that affect cognitive, sensory, affective, and biological processes (Newberg & Iversen, 2003). Research on yoga and meditation has examined effects on overall well-being as well the effects on patients who have coronary heart disease (CHD), diabetes mellitus, essential hypertension, cancer, etc. Recent literature has also focused on the beneficial impact of these techniques on chronic disease risk factors such as obesity, elevated blood pressure, blood glucose, and cholesterol (Yang, 2007). In addition to physiological factors, research has also indicated links between the practice of yoga and meditation and psychological well-being.
Psychological Pathways
Psychological pathways associated with cardiovascular disorders include depression, anger/hostility, anxiety, and stress. Stress, one of the most prominent risk factors, is a function of psychosocial, behavioral, and physiological factors, including biological and genetic components, that interact throughout the lifespan (McEwen & Gianaros, 2010). Evidence shows that these pathways independently contribute to the risk of developing cardiovascular disease after controlling for traditional risk factors (Figuedero, 2009).
Popular culture frequently points to yoga and meditation as ideal methods for stress relief. The 2008 Yoga in America Study determined that Americans spend $5.7 billion on yoga classes and yoga products such as equipment, clothing, DVDs, books, and magazines. In addition, the amount of people that say they are interested in yoga has nearly tripled in the last 4 years. Many websites such as “yogaawakening.com” and “onlinemeditation.org” advertise yoga and meditation as proven methods to decrease stress and anxiety (Yoga Journal, 2008).
Extant scientific literature confirms the efficacy of yoga and meditation in relieving stress (Rozanski, Blumenthal, Davidson, Saab, & Kubzansky, 2005) to positively impact cardiovascular health. Empirical evidence also points to major depressive disorder (MDD), generalized anxiety disorder (GAD), perceived hostility, and anger as catalysts for both coronary events and CHD. Prevalence of depression has been seen in individuals with CHD (Lett et al., 2004), and depressive symptoms have been found to predict the metabolic syndrome (a constellation of risk factors for CHD) in middle-aged women (Raikkonen, Matthews, & Kuller, 2007). In addition to depression, recent data has shown that anxiety is also associated with CHD. Patients with CHD and a diagnosis of either MDD or GAD are at more than two times the risk for cardiac events (Frasure-Smith & Lesperance, 2007). A study by Goodwin, Davidson, and Keyes (2009) determined that CHD is associated with increased likelihood of any anxiety disorder after adjusting for depressive disorders as well as GAD, panic disorder, or specific phobias. Extant research also links prevalence of hostility and anger to prevalence of CHD and the frequency of recurrent cardiac events (Rozanski et al., 2005). Particularly notable is that all of these aforementioned psychological conditions can be alleviated through yoga and meditation. Thus, it is likely that mind-body therapies may positively impact cardiovascular health via a variety of psychological mechanisms.
Meditation
Transcendental meditation (TM) has been shown to have a beneficial impact on psychosocial stress and anxiety, as well as smoking, and alcohol abuse (Rainforth et al., 2007).
Over the years, mindfulness techniques have often been used to enhance many stress management programs. Mindfulness-based stress reduction (MBSR) was first developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center in 1990. MBSR is a standard 8-week program that combines mindfulness meditation techniques, as well as light yoga and psychoeducational discussions to reduce stress and coping (Olivo, Dodson-Lavelle, Wren, Fang, & Oz, 2009). Research has shown that MBSR reduces symptoms of anxiety, depression, and fatigue (Carlson & Garland, 2005; Carlson, Speca, Patel, & Goodey, 2003; Carlson, Speca, Patel, & Goodey, 2004; Carlson, Ursuliak, Goodey, Angen, & Speca, 2001; Carlson, Speca, Patel, & Goodey, 2003; Speca, Carlson, Goodey, & Angen, 2000). Kabat-Zinn et al. (1992) reported that among patients with GAD and panic disorder (with or without agoraphobia), the 8-week MBSR program resulted in a reduction of anxiety and depressive symptoms. Notably, this reduction in symptoms was maintained over 3 years (Miller, Smith, Turner, Guijarro, & Hallet, 1996).
TM has also been studied in relation to its effect on the psychological correlates of cardiovascular disease. A study by Jayadevappa et al. (2007) showed that TM decreased depressive symptoms in an African-American population living with congestive heart failure. In studies conducted on medical students, nursing students in a graduate program, and premedical students who are all at extremely high-risk stress and stress-related disorders, 1 month of mindfulness meditation training was compared to somatic relaxation. Results showed both groups exhibited less distress and had an enhanced positive mood compared to the control group who did not receive any intervention. However, mindfulness meditation was more effective than somatic relaxation at enhancing positive mood states and reducing distractive thoughts, and was also more effective in reducing ruminative thoughts and behaviors compared to a control condition (Jain et al., 2007; Shapiro, Schwartz & Bonner, 1998). Additionally, among women diagnosed with cardiovascular disorders, 8 weeks of mindfulness meditation led to reductions in anxiety, sadness, and anger compared to women who did not participate in the program (Tacon, McComb, Caldera, & Randolph, 2003).
Collectively, these studies indicate the powerful effect meditation can have on psychological well-being among people who do not have an identified disease and are in chronically stressful situations (e.g., medical school) and among patients that have CHD. Studies using global psychological measures provide evidence that mindfulness improves all aspects of psychological functioning. It appears that mindfulness meditation is as effective as progressive muscle relaxation (a technique for reducing anxiety by alternately tensing and relaxing muscles) or psychotherapy. Finally, it is hypothesized that mindfulness enhances self-regulation of symptoms in the long term (Kabat-Zinn, Lipworth, & Burney, 1985).
Yoga
Yoga promotes feelings of well-being that alleviate the effects of stress. In 2004, West and colleagues conducted a study comparing hatha yoga with African dance using salivary cortisol, a measure for stress levels (West et al., 2004). They found that cortisol levels decreased among individuals participating in hatha yoga, evidencing yoga’s relaxing effects. Treatment for GAD using Ashtanga yoga exercises is remarkably effective, particularly among women experiencing both depression and GAD (Javnbakht, Hejazi Kenari, & Ghasemi, 2009).
The efficacy of the yoga intervention depends on enhanced bodily awareness resulting in being mindful of anxiety and tension (Javnbakht et al., 2009). Enhanced awareness of anxiety and physiological responses leads to deliberate attempts at relaxation, benefiting health and well-being. Research comparing yoga therapies with traditional exercise in areas of focus and concentration found that yoga significantly decreased the time needed to perform certain concentration tasks (Manjunath & Telles, 2001). These research studies further support the notion that yoga exercises allow the participant to identify and attend to their concerns, thereby increasing mindfulness and making health issues easier and more realistic to manage. Thus, yoga’s fundamental nature helps practitioners to lead a psychologically healthy lifestyle that effectively mitigates many risks for cardiovascular problems.
Physiological Pathways
Mind-body therapies act through a variety of physiological pathways to lessen the risk of CHD and improve cardiovascular health. Existing literature suggests that meditation may have a beneficial effect on CHD risk factors, disease markers, and clinical events. It may also decrease myocardial ischemia, carotid atherosclerosis, and mortality rates (Paul-Labrador et al., 2006). Yoga impacts cardiovascular health by reducing activation and reactivity of the sympathoadrenal system of the HPA axis, alleviating the effect of stress and fostering multiple positive effects on neuroendocrine status, metabolic function, and related inflammatory responses (Innes et al., 2007; McEwen & Gianaros, 2010) In summation, an extensive review of extant literature has elicited that yoga and meditation affect cardiovascular health via neurological, biochemical, autonomic, and pulmonary functioning.
Neurological Functioning: HPA-Axis Regulation/Stress Buffering
Responses to stress – both the perception and appraisal of threat and coping physiological and behavioral responses – are controlled by a complicated neurobiological network of brain structures that include the hypothalamus, amygdala, and the prefrontal cortex. Based on developmental history, these structures regulate stress appraisal and physiological/behavioral stress responses. Over a short period of time, these processes are effective in helping the individual adapt to and cope with stress. However, as time progresses, these systems can become maladaptive due to overactivation. This systemic failure due to overuse or “wear and tear” is referred to as allostatic load (McEwen & Gianaros, 2010). Yoga and meditation have a beneficial impact on perceptual and physiological responses to stress, thus reducing the allostatic load or wear and tear on an individual. Data has indicated that yoga helps to regulate the HPA axis, evidenced by a reduction of cortisol and catecholamines (Innes et al., 2007; Kamei et al., 2000; McEwen, 1999). Similarly, meditation/relaxation practices that have a nonexplicit spiritual component (e.g., yoga, TM, or Zen meditation) have been shown to effectively lower stress hormone levels (Seeman, Dubin, & Seeman, 2003). TM practice modulates neurophysiologic, neuroendocrine, and physiologic mechanisms associated with stress and is associated with significantly reduced systolic and diastolic BP similar or greater to effects of other lifestyle modifications, including weight-reducing diet, aerobic exercise, alcohol restriction, and sodium restriction (Rainforth et al., 2007).
Vagal Nerve Stimulation
The vagus nerve, the longest cranial nerve, connects the limbic system to various areas in the body, including the heart. It acts to lower heart rate and calm the body, or deactivate the “fight or flight” response. Vagus nerve stimulation is a procedure that has recently been introduced to improve symptoms of depression and seizure activity in individuals who do not respond to medication. A stimulator is implanted in these individuals in order to improve activity of the left vagus nerve in the neck. Surprisingly, there have been particular mind-body therapies that have shown similar stimulation to the vagus nerve. In 2006, Paul-Labrador and colleagues found a relationship between meditation practice and vagus nerve stimulation, suggesting that meditation produces a cholinergic effect and buffers against the effects of chronic stress (Innes et al., 2007). Similarly, yoga enhances parasympathetic output and shifts the autonomic nervous system balance in favor of the parasympathetic system, leading to increased cardiac-vagal function (Innes et al., 2007). Yoga and meditation may compensate for adverse systematic changes related to cardiovascular disease by buffering the effects of chronic stress and repairing sympathovagal balance, or the autonomic control resulting from sympathetic and parasympathetic activities (Innes et al., 2007).
Brain Anatomy
Current research has focused on utilizing PET and fMRI technology to explore the neurological and neurochemical effects of meditation and yoga. These studies have established a direct relationship between meditation and certain neurological structures. Hippocampal activity (which as aforementioned is directly linked to HPA activation) is found to be significantly increased by meditation practice (Lazar et al., 2000). A study by Lazar et al. (2000) determined that meditation leads directly to increased hypothalamic activity and to increased GABA transmission (Newberg & Iversen, 2003), both of which can help mitigate the risk of cardiac events.
Biochemistry: Hypertension
Hypertension is a term used to describe elevated blood pressure with systolic blood pressure levels greater than 140 mmHg and diastolic blood pressure levels greater than 90 mmHg. It has been established as a major risk factor for cardiovascular disease, with risk increasing significantly even in prehypertensive individuals, who are generally defined as having a systolic blood pressure of 130–139 mmHg and a diastolic blood pressure of 85–89 mmHg (Vasan et al., 2001). Yoga and meditation are effective techniques that lead to significant reductions in blood pressure among adults (Rainforth et al., 2007) and youth (Barnes, Treiber, & Davis, 2001). Compared to the effects of yoga and meditation, other behavioral therapies such as simple biofeedback, relaxation-assisted biofeedback, progressive muscle relaxation, and stress management training did not elicit this same blood pressure effect (Rainforth et al., 2007).
Meditation and Blood Pressure
In studies utilizing TM, results showed decreasing heart rate and resting ambulatory blood pressure in both normal and cardiac at-risk youth (Barnes, Davis, Murzynowski, & Treiber, 2004; Barnes, Johnson, & Treiber, 2004). Three months of consistent TM practice twice a day for 15 min lead to significant reductions in cardiovascular reactivity to stress (a hypothesized marker for CHD) among young people with high-normal BP (Barnes et al., 2001). Even among adult participants, meditation practice leads to lower blood pressure and lower blood pressure reactivity to stress (Seeman et al., 2003). Efficacy of TM in lowering blood pressure has led to its consideration as both a legitimate recommendation for patients with elevated BP to prevent the development of essential hypertension, and as a treatment option among those diagnosed with essential hypertension and CHD (Rainforth et al., 2007).
Yoga and Blood Pressure
Numerous studies have supported the significant relationship between yoga practice and BP regulation in a variety of populations. Rates of hypertension were significantly lower in a group of yoga-practicing individuals than in a normal exercise control (Murugesan, Govindarajulu, & Bera, 2000). One study determined that 11 weeks of yoga practice for 1 h/day had the same effect as pharmacological therapy in regulating blood pressure in healthy adults between the ages of 33 and 65 (Murugesan et al., 2000). In addition to the beneficial effects of overall yoga practice on blood pressure, specific yoga postures such as the head-up or head-down tilt were found to be especially effective in restoring baroreflex sensitivity, (a reflex triggered by pressure changes), the lack of which is a major cause of hypertension (Selvamurthy et al., 1998; Jayasinghe, 2004). Research also indicates that yoga practice is also useful in managing complications resulting from chronic elevated blood pressure, particularly left ventricular hypertrophy (Jayasinghe, 2004). In a sample of healthy young adults, ages 17–18, 2 weeks of Sarvangasana yoga, a type of yoga where the head is down and the body is up, contributed to a significant decrease in left ventricular volume, an indicator for strong heart muscles (Konar, Latha, & Bhuvaneswaran, 2000). Thus, research suggests that yoga practice has benefit as both a treatment and prevention measure for hypertensive, borderline hypertensive, or healthy individuals.
Lipid Levels
Elevated levels of serum cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglycerides have been identified as primary risk factors for CHD, and improving these risks is associated with CHD prevention (Manninen et al., 1992). While most research leans toward treatment with diet and exercise or prescription medications, yoga and meditation may improve lipid levels in its participants. Manchanda et al. (2000) found that among men with angiographically identified CHD, a 1-year yoga and lifestyle change intervention that included diet and exercise lead to a significant decrease in serum total cholesterol, LDL-C, and triglyceride levels. In fact, it has been suggested that yoga and lifestyle interventions may slow the process of atherosclerosis (Manchanda et al., 2000). In addition to impacting favorably on lipid levels among CHD patients, a brief 8-day yoga intervention showed lowered total triglycerides, lowered LDL-C, and elevations in high-density lipoprotein cholesterol (HDL-C) levels among individuals at high risk for CHD (Bijlani et al., 2005). The 3–4-h intervention in this study included yoga exercises, individualized counseling, and group support and lectures about yoga practices for daily living (Bijlani et al., 2005).
Using a variety of cardiovascular disease markers, Vyas and Dikshit (2002) compared long-term, short-term, and nonmeditators using raja yoga meditation. Individuals’ total cholesterol levels were significantly improved in both long-term and short-term meditators as compared to nonmeditators; however, HDL-C levels were not significantly different among groups. Vyas and Dikshit (2002) suggest that this significant change was due to participants’ ability to cope with stress. Interestingly, while most research suggests diet modification or use of prescription drugs to treat this type of hyperlipidemia, almost all participants in this study were vegetarian, effectively eradicating diet as a potential cause for elevated lipid levels. In 2008, Vyas, Raval, and Dikshit used a similar protocol with postmenopausal women noting similar results with LDL-C and total cholesterol levels.
Blood Glucose Levels
Consistently elevated levels of blood glucose are considered a primary risk factor for heart disease and can lead to the progression of type 2 diabetes mellitus. While much is known about treatment, treatment adherence for improving glycemic control can be difficult for some individuals to maintain. A combination of medical treatment and yoga/meditation may be suggested for both prediabetic individuals and those diagnosed with type 2 diabetes mellitus. In a 40-day yoga intervention designed specifically for individuals with type 2 diabetes mellitus, a yoga lifestyle intervention that included both practices in yoga asanas and pranayama led to reductions in fasting blood glucose as well as postprandial blood glucose levels. Researchers focused on controlled breathing, believing that such practices might influence the mechanism for glycemic control (Singh, Malhotra, Singh, Madhu, & Tandon, 2004). Among healthy adults, Bijlani and colleagues (2005) found lower levels of fasting plasma glucose after individuals participated in a 3–4 h yoga lifestyle intervention study for only 8 days. This further supports the notion that yoga can be used in conjunction with Western medicine to assist with cardiovascular illnesses, via glycemic control improvements in those with type 2 diabetes mellitus.
Autonomic Regulation
Meditation and yoga may affect the cardiovascular system via autonomic pathways. Cardiovascular reactivity may be decreased through calming the sympathetic reaction to stress, and poststress cardiovascular reactivity may be improved by increasing parasympathetic activation. For example, Kubota et al. (2001) have shown that participants who practiced a Zen meditation task requiring sustained attention had an increase in both peripheral sympathetic and parasympathetic activity during the task. Moreover, they found that as frontal midline theta rhythms increased, the sympathetic nervous system slowed. In their 40-day yoga intervention mentioned previously, Singh et al. (2004) noted a decrease in participants’ corrected QT intervals, a test which diagnoses for cardiac autonomic neuropathy. In general, parasympathetic nervous system activation can ameliorate stress responses.
Pulmonary Functioning
Researchers have tested pulmonary levels and exertion rates among individuals participating in meditation and yoga as compared to traditional exercise. In a group of 30 healthy males, Agarwal and Gupta (2006) determined that peak expiratory flow rate improved those practicing TM over both a physical activity and control group. Compared to a normal exercise control, adults who practiced yoga showed significant improvement in terms of vital lung capacity and improved aerobic capacity (Ray et al., 2001). In a study performed with 20 community teens (aged 12–16), half were randomly assigned to a yoga intervention while the others was assigned to a physical activity intervention involving activities in a garden (Telles & Srinivas, 1998). Researchers suggested that garden activities paralleled those in yoga (e.g., stretching and bending), with the exception of the bodily awareness and relaxation that are unique to yoga practice. Results suggest that those individuals in the yoga intervention reduced their breathing rate compared to unchanged breathing patters in the physical activity group.
The following schematic summarizes the physiological and psychological mechanisms by which yoga and meditation impact cardiovascular health (Fig. 11.1).
Clinical Example
The following is the description of a structured 8-week mindfulness meditation course conducted in postoperative cardiac patients. Patients typically met once a week at a group meeting where meditation and mindfulness skills were taught and practiced. The group was located in the same facility where patients received cardiac rehabilitation. The location of the group within the cardiac rehabilitation facility led to increased referrals and attendance among participants. Frequently, patients with chronic and complicated medical histories have difficulty with adherence to any regimen due to problems with transportation, chronic pain, and fatigue. Hence, the convenient location of the group facilitated consistent attendance among group members. Despite the fact that attendance is emphasized, it is helpful to structure the course so that each week offers skills in a noncumulative manner to enhance participation among patients with chronic difficulties who would benefit the most from the intervention. Although the following is a typical, time-limited group format, the content can be modified for use among individuals as well as condensed or expanded in duration.
During the first session, members introduced themselves to each other. They were then educated about the concept of meditation and mindfulness as well as the interaction between stress, affect, and cardiovascular function. They were encouraged to discuss how meditation can be helpful in their own lives, specifically for regulating emotions such as anger and anxiety. A portion of the introduction also included discussion about the importance of practice in the development of mindfulness skills. Many patients become discouraged when first practicing mindfulness, as they are not able to quiet their racing mind or they have a difficult time staying awake. In these cases, patients are reassured that ongoing ruminative thoughts and fatigue are normal processes. Developing mindfulness takes time, and when one falls out of practice, whether it be over the course of seconds or years, one can simply begin in a new moment, with no judgment. The next few sessions consisted of both guided practice and discussion. Initially, it is beneficial for the duration of practice to be a few minutes in length, as many patients are new to mediation. As the weeks progressed, patients improved in their ability to meditate in longer durations.
Exercises conducted during each class included focusing on the breath and describing it objectively. Some patients that also have pulmonary complications find it difficult to deepen their breathing. In these cases, patients were encouraged to not change, rather just focus on their breath. Exercises can also include focusing on heartbeat or pulse sensations. Doing this may cause emotional reactions that need to be discussed. For example, one patient had feelings of anger and frustration toward their cardiovascular system because he perceived that it had failed him and it was diseased. This patient was encouraged to discuss his experience. The use of guided positive imagery with focus on the cardiovascular system also may be helpful in these cases. Following exercises focusing on the breath and emotional reactions, the facilitator expanded the practice to paying attention and objectively labeling external sounds, smells, tastes, and touch as well as to internal sensations such as pain and thoughts. Patients were encouraged to find a visualization that they found helpful in letting go of thoughts, such as ocean waves, a balloon, or clouds. These visual images are generally considered to be inconsistent with stress.
One thing to consider is that some individuals find it difficult or frightening to meditate because they are uncomfortable with losing control. This is especially true among patients with histories of trauma. In these cases, patients have found it helpful to keep their eyes open during meditation to promote feelings of safety.
Additional sessions focused on other meditation techniques such as focusing on word or mantra, counting, or guided imagery. Facilitators have found it helpful to write copies of their favorite scripts for slow reading, if he or she finds it uncomfortable to improvise.
During discussion, it was helpful for individuals to identify ways they could apply these techniques in their daily lives. For example, one patient spoke about applying the techniques he learned at his place of employment. Although his job caused him great psychological stress, he was unable to consider other options due to familial and financial reason. With assistance from the group, he was able to identify a quiet location that he designated as his place for 60 s of mindful breathing during lunch or particularly stressful moments.
Occasionally, meditation practice elicited distressing emotions and thoughts in patients, and these thoughts were mentioned in discussion. Some common topics included struggles with body image or weight loss, lack of social support, the existence of pain, and marital problems. One particular rumination that surfaced within groups of postoperative cardiac patients somewhat frequently is fear of sudden death. The facilitator encouraged using mindfulness to cope with these thoughts, experiencing the thought as just another transient sensation in the body. However in many cases, the group spent some time discussing these issues as the depression and anxiety associated with these stressors greatly influence cardiovascular function. The group assisted each other in developing insight into the nature of the problem identified ways of coping. If a qualified mental health professional is not present or if the patient needs more intensive treatment, a referral to a qualified professional may be necessary.
Rationale for Treatment Approach
Currently, focus on combating heart disease and promoting heart health has shifted from a pharmacological paradigm toward an emphasis on behavioral modification and an overall healthy lifestyle. The European Prospective Investigation into Cancer and Nutrition (EPIC) study, published in the archives of internal medicine, surveyed 23,153 German individuals to determine that adhering to four simple healthy lifestyle factors – not smoking, having a BMI lower than 30, performing 3.5 h/week or more of physical activity, and adhering to healthy dietary principles – significantly lowered the risk of developing chronic diseases such as myocardial infarction, diabetes, stroke, and cancer (Gonzalez, 1997). Similarly, the INTERHEART study isolated nine risk factors that account for over 90% of the risk of acute myocardial infarction. The nine factors – smoking, lipids, hypertension, abdominal obesity, diet (fruits and vegetables), physical activity, alcohol consumption, diabetes, and psychosocial factors – are consistent worldwide across both sexes and at all ages in all regions. This study also advocated that approaches to prevention should take a behavioral approach and that lifestyle change is the best way to prevent heart attacks (Yusuf et al., 2004).
The strength of mind-body therapies lies not only in empirical support but in logistical advantage. Yoga and meditation programs are appropriate for both men and women of all ages. Empirical support exists for adolescents, adults, and older adults, with positive outcomes found in all three age groups. Yoga and meditation are also both cost-effective and can be used for individuals from lower socioeconomic groups who cannot afford to keep up with potentially expensive medication regimens. In addition, several common cardiovascular medications have unpleasant side effects that are not a risk of mind-body therapy. Furthermore, research suggests that yoga and meditation may positively impact six of the nine INTERHEART factors and therefore are comprehensive treatments as well as effective preventative measures (Tables 11.1, 11.2).
Summary/Conclusions
Various forms of meditation and yoga may be used in conjunction with Western medicine as research suggests powerful benefits among cardiac patients. Although frequency and duration may influence results, both short-term studies of just 8 days (Bijlani et al., 2005) and long-term studies of 5 years (Bharshankar, Bharshankar, Deshpande, Kaore, & Gosavi, 2003) have yielded positive results. However, chronological factors can influence adherence as increased frequency and duration may deter participants from continuing.
There are major empirical limitations in the current research regarding the effectiveness of yoga and meditation in cardiovascular disease. Several meta-analyses indicate a strong need for more rigorous research in this area. In fact, in a notable meta-analysis conducted for the National Center for Complementary and Alternative Medicine, only 10% of studies were considered to be of good quality (Ospina et al., 2008). Specific limitations include selection bias, exposure to multiple interventions, lack of agreement in defining terminology, and few longitudinal studies (Ospina et al., 2008; Rainforth et al., 2007). It is clear however that the psychological and physiological benefits for patients who practice mind-body medicine can have direct and indirect improvement on overall health.
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Suchday, S., Dziok, M., Katzenstein, M., Kaplan, E., Kahan, M. (2012). The Effects of Meditation and Yoga on Cardiovascular Disease. In: Dornelas, E.A. (eds) Stress Proof the Heart. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-5650-7_11
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