MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

prevention

Yoga, it is often claimed, might be a unique method for disease prevention. One website, for instance, states that numerous studies show how yoga can help prevent these diseases: Heart disease, Alzheimer’s, Osteoporosis and Type II Diabetes. 

Cardiovascular diseases (CVD) are responsible for more deaths than any other disease category. Preventing CVD is therefore of prime importance. But are the claims made for yoga really true? What does the reliable evidence tell us?

The aim of our systematic review was to determine the effects of yoga on the primary prevention of CVD. Extensive literature searches were performed to identify all RCTs lasting at least three months, involving healthy adults or people at high risk of CVD. Trials examined any type of yoga and the comparison groups received no intervention or minimal interventions. Outcomes of interest were clinical CVD events and major CVD risk factors. Trials that involved multifactorial lifestyle interventions or weight loss programmes were excluded.

We identified 11 RCTs with a total of just 800 participants. Style and duration of yoga differed between trials. About half of all the trial participants were at high risk of CVD. Most of the studies were at risk of performance bias, with inadequate details reported in many of them to judge the risk of selection bias. None of the studies reported cardiovascular mortality, all-cause mortality or non-fatal events, and most studies were small and short-term.

Yoga was found to produce an average reduction in diastolic blood pressure of 2.90 mmHg. The effect that was small but stable on sensitivity analysis. Triglycerides (-0.27 mmol/l) and high-density lipoprotein (HDL) cholesterol (0.08 mmol/l) were also positively affected. However, these findings were based on small, short-term studies at unclear or high risk of bias. There was no clear evidence of an effect on low-density lipoprotein (LDL) cholesterol. Adverse events, occurrence of type 2 diabetes and costs were not reported in any of the included studies. Quality of life was measured in three trials but the results were inconclusive.

Our conclusion: The limited evidence comes from small, short-term, low-quality studies. There is some evidence that yoga has favourable effects on diastolic blood pressure, HDL cholesterol and triglycerides, and uncertain effects on LDL cholesterol. These results should be considered as exploratory and interpreted with caution.

This systematic review thus offers both good and bad news. The good news is that yoga seems to hold some promise in the prevention of CVD. The bad news, however, is diverse:

  • We cannot be sure what type of yoga is best; yoga can entail anything from regular exercise, to breathing techniques, to a complete and comprehensive change of life style.
  • The effect sizes are far from remarkable.
  • The quality of the research tends to be poor.
  • Once again, we have to note that, by not reporting on adverse effects, alt med researchers are violating fundamental research ethics.

Many systematic reviews conclude by stating that more and better research is required – in the case of yoga, this platitude might actually be true.

In China (and increasingly elsewhere too), the gentle, meditative exercise of tai chi is being promoted and used for disease prevention, particularly for the prevention of cardiovascular disease (CVD). But are these exercises effective? We carried out a Cochrane review to find out.

We searched both English language and Asian electronic databases as well as trial registers and reference lists for relevant studies. No language restrictions were applied. We considered randomised clinical trials (RCTs) of tai chi lasting at least three months and involving healthy adults or adults at high risk of CVD. The comparison groups received no or only minimal interventions. Our outcome measures were CVD clinical events and CVD risk factors. We excluded trials involving multifactorial lifestyle interventions or focusing on weight loss. Two reviewers independently selected trials for inclusion, abstracted the data and assessed the risk of bias of each included study.

We identified 13 trials with a total of 1520 participants and three on-going studies. All of them had at least one domain with unclear risk of bias, and some were at high risk of bias. Duration and style of tai chi differed between trials. Seven studies recruited 903 healthy participants, the other studies recruited people with hypertension, elderly people at high risk of falling, and people with ‘liver or kidney yin deficiency syndromes’.

No studies reported on cardiovascular mortality, all-cause mortality or non-fatal events as most studies were short-term. There was also considerable heterogeneity between studies, which meant that it was not possible to combine studies statistically for cardiovascular risk. Nine trials measured systolic blood pressure (SBP), and 6 of them found reductions in SBP. Two trials found no clear evidence of a difference, and one trial found an increase in SBP with tai chi. A similar pattern was seen for diastolic blood pressure (DBP): three trials found a reduction in DBP, while three found no clear evidence of a difference.

Three trials reported lipid levels and two found reductions in total cholesterol, LDL-C and triglycerides, while the third study found no clear evidence of a difference between groups on lipid levels. Quality of life was measured in only one trial: tai chi improved quality of life at three months. None of the included trials reported on adverse events, costs or occurrence of type 2 diabetes.

From these findings, we drew the following conclusions: “There are currently no long-term trials examining tai chi for the primary prevention of CVD. Due to the limited evidence available currently no conclusions can be drawn as to the effectiveness of tai chi on CVD risk factors. There was some suggestion of beneficial effects of tai chi on CVD risk factors but this was not consistent across all studies. There was considerable heterogeneity between the studies included in this review and studies were small and at some risk of bias. Results of the ongoing trials will add to the evidence base but additional longer-term, high-quality trials are needed.”

These findings are somewhat disappointing. Tai chi might convey many health benefits, but whether a reduction of cardiovascular risk is amongst them seems doubtful. Even if a risk reduction were established beyond doubt, one would need to ask whether its effect size is larger than that achievable through regular conventional exercise. In my view, this is unlikely.

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