Nalbant, Gamze
(2024)
Yoga for hypertension management in the UK – what is the evidence?
PhD thesis, University of Nottingham.
Abstract
Yoga is an ancient Indian philosophy and way of life that is being used as a means to improve health and well-being. Numerous studies have shown that yoga has positive effects on managing many non-communicable diseases. Moreover, growing evidence suggests that yoga could be used to improve the management of hypertension in addition to current management strategies. Yoga has also become increasingly popular in the world and the UK for improving health and well-being, and previous cross-sectional studies have reported that hypertension is one of the most commonly disclosed health conditions in yoga sessions in the UK. The popularity of yoga has surged globally, including in the UK. However, the term "yoga" encompasses a broad range of concepts and previous systematic reviews included studies from across the world including places where yoga could mean different things. Despite the increasing body of evidence supporting yoga's benefits for hypertension and overall well-being, research specifically focusing on yoga in the UK remains limited. This thesis aimed to bridge this gap by exploring the current landscape of yoga practice in the UK and its potential for managing hypertension. Three studies were conducted for this purpose, aiming to gain a comprehensive understanding of the provision of yoga in the country.
The aim of the first study was to synthesise the content, structure and delivery characteristics of effective yoga interventions used for managing hypertension, and to compare these characteristics with interventions that were not found to be effective. Randomised controlled trials (RCTs) conducted among people with hypertension reporting at least one of the major components of yoga (i.e., asana, pranayama and dhyana and relaxation practices) and comparing them with no intervention, sham intervention, any non-pharmaceutical intervention (such as diet, exercise, or yoga) or pharmaceutical intervention (such as antihypertensive drugs) were eligible. Sixteen databases were searched for published and unpublished studies without any date and language restrictions till March 15, 2021. The literature search yielded 13,130 records. Thirty-four RCTs (evaluating 38 yoga interventions) met the inclusion criteria. Overall, the included studies had low quality mostly due to inadequate reporting of the methodology. Yoga reduced systolic blood pressure (SBP) and diastolic blood pressure (DBP) compared to a control intervention (mean difference (MD −6.49 and −2.78; 95% confidence interval (CI) −8.94 to −4.04 and −4.11 to −1.45, respectively). Eighteen, 14 and 20 interventions were effective in improving SBP, DBP, or either, respectively. 13 out of 20 effective interventions incorporated all the 3 major components of yoga (i.e., asana (yogic poses), pranayama (breathing practices) and dhyana (meditation) and relaxation practices) and allocated similar durations to each component whereas interventions that were not found to be effective were more focused on the asana and duration of asana practice was longer. The most common duration and frequency of effective interventions were 45 min/session (in 5 interventions), 7 days/week (in 5 interventions), and 12 weeks (in 11 interventions) whereas the most common session frequency was 2 days a week (in 7 interventions) in ineffective interventions. Effective interventions were mostly centre-based (in 15 interventions) and supervised (in 16 interventions), and this was similar to interventions that were not found to be effective.
The second study aimed to explore who is providing yoga; what sessions are available, where and at what cost; who attends these sessions in the UK, and whether yoga providers were aware of health conditions in their sessions. A cross-sectional survey was undertaken among yoga providers in the UK. They were approached through four major UK yoga associations. 407 yoga providers participated. Most providers were aged 45-64 years (69%), female (93%), and white (93%). The median number of group sessions and one-to-one sessions delivered per week was four and two, respectively. The most common styles were Hatha (28%), Iyengar (26%), and Vinyasa (15%). Sessions had a varying emphasis on different yogic practices, but 59% of providers allocated most time to yogic poses (asana), 18% to breathing practices (pranayama), and 12% to meditation (dhyana) and relaxation practices. Most (73%) reported that their attendees disclosed their health conditions to them most commonly; mental health issues (41%), hypertension (25%), and heart diseases (9%).
The third study aimed to explore yoga providers’ knowledge, experiences, and attitudes toward delivering yoga to people with hypertension. Semi-structured qualitative interviews were conducted with yoga providers in the UK (n=19). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Eight themes were identified. Yoga providers were generally aware of the health conditions of their attendees, and they had a reasonable knowledge of the causes, signs and symptoms, and management of hypertension. Whilst most had received some information about hypertension as part of their initial yoga teaching training, this was generally felt to be limited. They mentioned the biopsychosocial benefits of yoga on hypertension but also expressed their concerns about the lack of regulation, the wide disparity in what is being delivered under the label of yoga, and the competency of some yoga providers.
In conclusion, despite some mismatches between yoga sessions in the UK and effective yoga interventions, yoga holds promise for hypertension management in the UK as it was an available and accessible practice in the UK, practised by people with hypertension and yoga providers showed willingness to deliver yoga to people with hypertension. Though the current evidence lacks strength in terms of both quality and quantity, it does indicate some consistency in the characteristics of effective yoga interventions. An important implication from this thesis is that the characteristics of potentially effective yoga interventions were in line with the lifestyle recommendations in the hypertension guideline by the ISH. In addition, considering that yoga is an affordable practice and yoga providers were willing to deliver yoga to people with hypertension, yoga could be of some help with managing hypertension in the UK. However, to establish stronger evidence before recommending the integration of yoga into the NHS for managing hypertension, comprehensive investigations involving different study populations, with a focus on validating and improving the identified intervention characteristics, are needed. Therefore, to carry the work done in this review to the next stage, with inspiration from the findings of this systematic review and meta-analysis, a funding application has been submitted to NIHR to develop a yoga intervention that is likely to lead to maximum benefits for people with high blood pressure and to explore the acceptability and accessibility to people with different physical abilities in the UK.
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