Integrative Approaches for Health

Doctors give drugs of which they know little, into bodies, of which they know less, for diseases, of which they know nothing at all.

Voltaire

The Epidemic of Lifestyle Diseases

Throughout history, the world has seen severe epidemics of deadly infectious diseases like small pox and the plague. With improved hygiene, sanitation, and better nutrition, coupled with effective antibiotics and vaccines, many such communicable diseases were controlled and eradicated. Now in the twenty-first century, the world is witnessing major epidemics of noncommunicable diseases (NCDs), which are mainly the result of changes in lifestyle and human behavior. These diseases include high blood pressure, heart disease, obesity, diabetes, chronic lung diseases, cancer, Alzheimer disease, and others. Many NCDs, also known as lifestyle diseases, are known to appear as a cluster of diseases resulting in more complex conditions like metabolic syndrome.

A World Health Organization (WHO) report which gives an overview of NCD reveals that more and more countries are adopting strategies to control and monitor known risk factors like unhealthy diet, physical inactivity, tobacco, and the harmful use of alcohol. According to WHO Director General, Dr Margaret Chan, 85% of premature deaths in developing countries are because of NCDs. The challenges presented by these diseases are enormous. Every year, 38 million people die from NCDs, of which about 28 million are from developing countries. Nearly 16 million of these die before the age of 70. Since the beginning of the new millennium, the number of deaths due to NCD has increased worldwide. In 2013, during the World Health Assembly, 194 member countries accepted the WHO Global Action Plan for the Prevention and Control of NCDs. This plan hopes to attain at least a 25% reduction in premature mortality from NCDs by the year 2025.

The challenge to control the present epidemic of NCDs or lifestyle diseases seems to be even more difficult than the battle against communicable diseases. Mainly because of the fact that NCDs cannot be controlled merely by discovering powerful drugs; the root causes of these diseases must be controlled. NCDs cannot be controlled unless healthy lifestyles, and behavioral modifications are adopted by people. Therefore, preventive strategies through governmental policies, and participatory approaches involving communities are required. This may involve promoting healthy eating habits, physical exercise, and avoiding mental stress. Behavioral modifications may involve refraining from use of harmful substances like tobacco, drugs, and alcohol, and strengthening the mind to be able to cope better with adversity. In addition, reducing environmental pollution and enhancing general safety is also necessary.

Lifestyle Modification

Many disorders, diseases, and syndromes have their origin in modern sedentary lifestyle. Due to technological advances and automation, the extent of physical activities and exercise has significantly reduced. Lifestyle diseases can be better managed with healthy lifestyle. Mere medicine will not suffice. Therapeutic interventions through diet, physical exercise, and lifestyle modifications have emerged as important prevention and treatment strategies. A lot of research is underway in various institutions worldwide.

A cluster of diseases involving high blood pressure, high blood sugar level, excess body fat around the waist, and abnormal cholesterol levels are often found together. This condition is now recognized as Syndrome X, or metabolic syndrome, which increases the risk of heart disease, stroke, and diabetes. Metabolic syndrome is considered as a typical outcome of the modern sedentary lifestyle, inadequate physical exercise, and the consumption of unhealthy junk foods. Aggressive life style modifications—improving diet, nutrition, and physical activity—have been shown to play a preventive role. However, what type of diet and exercise is to be adopted needs careful consideration.

Many times vitamins, minerals, and antioxidant supplements are used as preventive or curative agents, however, no substantial evidence to support their use is available. In many studies it has been reported that instead of such dietary supplements and nutraceuticals, consumption of natural foods, fruits, and vegetables has been found to be much better. Similarly, exercise does not mean merely joining a health club, building muscles, burning calories through physical activity, or practicing aerobic and anaerobic exercises. Exercise science is now more advanced, and uses various combinations of physical and mental exercises depending on specific conditions, and individual needs. Yoga practice involving stretching, breathing, and meditation has been shown to be very beneficial. In short, life style modifications involving appropriate diet, nutrition, and exercise is valuable in the prevention and control of metabolic syndrome, and many other associated conditions, including hypertension, ischemic heart disease, diabetes, arthritis, asthma, cancer, and polycystic ovarian syndrome. Nutritional supplementation consisting of vitamins, minerals, and antioxidants can be useful, but do not suffice. More discussions on health supplements are available in Chapter 8. A short review of research on lifestyle and behavior modification provides more insight on this subject.

Body, Mind, Consciousness

The relationship between the mind and brain is still a central philosophical question. Neuroscientists might say that the brain causes mind. But where consciousness arises is still not known in modern science. Many scientists believe that the brain and the mind are different types of entities. The brain is a physical entity, and the mind is mental. The mind–brain relationship is also explained based on a theory of consciousness, which is not fully rejected by science. Many scientists believe that consciousness is created by electrochemical activity within the brain. How the functions of the brain can produce consciousness is not clearly known. The conscious mind can realize human existence.

The brain is not merely a computer. If that were so, near-death experiences, out-of-body experiences, past-life memories, transcendent states, and spirituality would never have existed. However, many of these phenomena have been well documented scientifically. The brain-as-computer approach has been challenged by neuroscientists who attempt to understand the scientific basis for seemingly spiritual mental states [1].

Admittedly, modern science understands the brain better than the mind. Scientists can track brain activities with the help of sophisticated equipment like functional magnetic resonance imaging (MRI) and single photon emission computerized tomography. Advances in psycho-neuro-endocrinology have helped to understand how the brain can control many vital functions of the body. Scientists can measure the levels of neurotransmitters, and relate them to various biological activities affecting body functions. It is easier to measure brain activities, so following the principle of management, it is easier to manage the brain, as opposed to managing the mind.

Not surprisingly, the current focus of discussions about health and disease is primarily on brain and body. This is probably because they are relatively better known to science. Although the importance of mental health is known, our current understanding about it is preliminary. In biomedicine, psychiatric diseases are treated mostly with the help of drugs acting on the brain and nervous system; this is because of a better understanding of neurobiology and endocrinology.

Many chronic, difficult-to-treat diseases involve mental status (psycho), and the physical body (somatic), together—resulting in pathophysiologic changes. Such diseases cannot be treated by addressing the physical body, or mental health, in isolation. Such diseases need holistic consideration involving body and mind. It is normal practice to use the term holistic for many traditional health practices like Ayurveda, Yoga, Sowa rigpa, Traditional Chinese Medicine (TCM), Tai chi, Kampo, and others. This is because these disciplines consider body–mind–spirit as a whole and not in isolation. They might use natural materials such as somatic medicines for body; for psychiatric conditions of mind, meditation can be good medicine; and for spirit, spiritual practices can serve as medicine. In reality, the spirit needs no medicine, still spiritual practices help to maintain the balance of mind and body.

Leon Eisenberg, a leader in psychiatry, and professor at Johns Hopkins and Harvard Medical School, pioneered a study on the effects of stimulants on attention deficit disorder in children. He admits that “during the late twentieth century, psychiatry practice moved from a state of brainlessness, to one of mindlessness.” Eisenberg indicated that earlier, the focus of psychiatry was on Freudian approaches in psychology, and recognized the role of the mind. The current focus is on the physical brain and gives more consideration to the role of neurotransmitters [2]. Psychiatric drugs were discovered through advances in neuropharmacology and brain chemistry, where the focus on mind was greatly compromised. In the process, in clinical settings, psychology was replaced with psychiatry.

Essentially, modern psychiatry uses depressants and stimulants as therapeutic strategies. Mental illness medications were first introduced in the mid-twentieth century, with antipsychotic drugs like chlorpromazine. Since then, many drugs have been developed and used primarily because of their effects on different neurotransmitters. These include new generation blockbuster drugs like Prozac, a selective serotonin reuptake inhibitor (SSRI); typical mood stabilizers, such as lithium carbonate; anticonvulsants like carbamazepine; popular anxiolytics like diazepam; barbiturates; and stimulants like caffeine. Western psychiatry tends to end here.

While these drugs have substantially helped in some of the mental disorders, their side effects and risks of abuse are quite worrying. According to the report from the Citizens Commission on Human Rights, global annual sales of antidepressants, stimulants, anxiolytic, and antipsychotic drugs are estimated to reach over $76 billion. In reports published by this commission, many critics and experts have raised serious questions related to conflicts of interests, and the nexus between industry and professional bodies.

For instance, the American Psychiatry Association gets one-fifth of its funding from the drug industry. According to Robert Whitaker, senior medical writer, and author of a book Anatomy of an Epidemic, in 2009 alone, just one company, Eli Lilly, paid $551,000 to the National Alliance on Mental Illness, $465,000 to the National Mental Health Association, $130,000 to an ADHD patient-advocacy group, and $69,250 to the American Foundation for Suicide Prevention. This example is an eye opener, and explains the intensity of this problem.

Marcia Angel, former Editor-in-Chief of the New England Journal of Medicine has rightly opined that psychoactive drugs are not the only option for the treatment of mental illness or emotional distress. Nonpharmacological interventions like psychotherapy, exercise, relaxation techniques, yoga, meditation, and behavioral and lifestyle medicine were found to be comparably efficacious to drugs for depression. Nonpharmacology interventions are safe and affordable with longer-lasting beneficial effects. However, for obvious reasons, the industry is not interested in promoting such easy, and affordable alternatives. Therefore, instead of supporting nonpharmacology measures, a systematic propaganda campaign asserts that modern drugs are potent and inevitable. According to Marcia Angel, more rigorous research is needed to explore various alternatives to current psychoactive drugs. Proper scientific and factual information about the strengths and limitations of psychoactive drugs need to be a part of medical education [3].

The market for antidepressants is quite large. Debilitating depressive disorders are common in all age groups, from children to senior citizens. Depression can affect individuals, families, societies, and functioning of a professional individual. A systematic review of 10 studies, involving 1235 participants with different severities of disorders does not establish the superiority of antidepressant drugs over psychological therapy [4]. Another systematic review has shown that in patients with chronic low-back pain, the efficacy of antidepressants was almost the same as that of a placebo [5]. In such situation, instead of antidepressants, the use of mind–body medicine involving yoga and mindfulness might be a better, affordable, and safer option.

Emerging Evidence from Research

During the last decade, many clinical trials on lifestyle and behavioral approaches have been published. Powerful tools like meta-analysis, and systematic reviews are being used to synthesize evidence from available research data. A systematic review has concluded that lifestyle modification intervention was effective in the management of metabolic syndrome—with a reduction in blood pressure, fasting blood glucose, triglycerides, and waist circumference [6]. The lifestyle modification interventions involved dietary modifications through the Mediterranean, or dietary approaches to stop hypertension like healthy diet and suitable forms of physical activity.

Type 2 diabetes is a typical disease of lifestyle. A review of eight trials involving 2241 participants who were put on a diet and exercise regime showed a reduced risk of diabetes, as compared with standard treatment group of 2509 participants. This study also reported favorable effects of diet and exercise on weight, body mass index, waist circumference, waist-to-hip ratio, blood lipids, and blood pressure. These interventions decreased the incidence of T2D in high-risk groups [7].

Polycystic ovary syndrome (PCOS) is a common condition affecting women. Overweight women can have reduced ovulation frequency, irregular menstrual cycles, and reduced fertility. Increased levels of testosterone is known to cause acne, and excess hair growth on the body and face. PCOS is known to be associated with hyperinsulinemia, insulin resistance, and abnormal cholesterol levels. PCOS affects quality of life, and can cause psychological conditions such as depression and anxiety. A review of six studies on 164 participants with PCOS has indicated that adopting a healthy lifestyle can reduce testosterone levels, improve insulin resistance, and reduce body weight, and abdominal fat. However, healthy lifestyle did not have a significant effect on cholesterol or glucose levels [8].

Rheumatoid arthritis and asthma are polygenic, immune-pathological, psychosomatic diseases. Diet and lifestyle are considered as one of the causative factors. Suitable modifications might help in the control of these chronic, and difficult-to-treat diseases. However, a systematic review of 14 trials with a total of 837 patients has not shown any conclusive evidence in support of dietary manipulation in rheumatoid arthritis [9].

A study of 38 patients with chronic asthma has shown that a calorie-controlled diet can be beneficial as an adjuvant to drug therapy, with no serious adverse effects. However, the impact of a calorie-controlled diet in the general asthmatic population has not been established [10].

Patients with coronary heart disease can substantially benefit from lifestyle intervention programs. The evidence summarized in a meta-analysis of 23 trials and 11,085 patients confirms that lifestyle modification programs are much better compared to routine clinical care given to coronary heart disease patients [11]. It is known that plasma homocysteine levels are associated with cardiac disease risk. A study reveals that lifestyle interventions, and vitamin B intake might lower homocysteine, and reduce the risk of Cardiovascular Diseases (CVDs) [12].

Lifestyle interventions involving healthy diet, and exercise can be much more effective if they are personalized to individual needs. Personalized lifestyle interventions and advice specific to Prakriti-based classification, with the consideration of time and seasons can be of great value as predictive, and preventive medicine. These concepts are also discussed in Chapters 6 and 11.

Recent reports indicate that about 37% of adults in the United States have neuropsychiatric symptoms, which are difficult to treat with standard treatments. Researchers have examined the usefulness of mind–body therapies in neuropsychiatric symptoms. This large study on 23,393 adults compared the use of mind–body therapy like yoga, meditation, deep-breathing exercises, biofeedback, energy healing, guided imagery, hypnosis, relaxation therapy, qi-gong, and tai chi. The study population was suffering from symptoms like headaches, daytime sleepiness, anxiety, depression, insomnia, memory, and attention deficit. This study concluded that adults with more than one neuropsychiatric symptom tend to use mind–body therapies more frequently [13].

Psychological stress in cancer patients has been identified as a major problem in oncology. Mind–body therapies, including yoga, mindfulness, qigong, tai chi have shown potential to reduce stress, and improve the quality of life of cancer patients and survivors [14]. Researchers from the Mayo Clinic in Rochester have studied the effectiveness of a mind–body therapy involving stress management, and resiliency training (SMART) program on irritable bowel syndrome patients; stress management and SMART showed potential to improve anxiety, life satisfaction, and gratitude [15]. A joint clinical study was conducted by the University of California and University of Washington on 435 patients with low back pain. The study reported that patients who practiced yoga or meditation, and body awareness had better recovery from pain [16]. In an interesting meta-analysis of 1193 papers, involving 58 trials examining the effectiveness of therapies for hot flushes, it was found that yoga, and mindfulness-based behavioral modifications significantly reduced hot flushes, and improved cognitive symptoms, more than exercise alone [17].

A meta-analysis of 34 studies from 39 clinical trials involving a total of 2219 participants has shown evidence that mind–body therapies can increase the immune response to vaccination. Mind–body therapies also resulted in a reduction in inflammation markers, and improved virus-specific immune responses [18].

Thus, for psychiatric, psychosomatic, and lifestyle diseases, the role of mind needs to be given predominance over body and brain. The psychological or mental disease is not only in the brain—it might be the case that the mind is involved. The emergence and wide acceptance of mind–body therapy, mindfulness, and behavioral medicine is a clear indication of the growing awareness of this reality. Modern psychiatry must address this issue seriously, and judiciously balance pharmacological interventions involving drugs, and nonpharmacological interventions involving yoga, meditation, mind–body, and mindfulness practices.

Yoga and Meditation

Vedic and Buddhist traditions have given much emphasis to the mind. The role of yoga and meditation to enhance self-awareness and consciousness has been well-recognized in the promotion of mental and physical health. It is possible to train our minds to become more flexible, and adaptable without losing focus on the goal. Yoga suggests the means of controlling the mind through a detached watchfulness of our thoughts. The health tips from yoga for achieving a sound mind suggest refraining from greed, grief, fear, anger, jealousy, attachment, and malice. Ayurveda also reiterates the same concept, and states that behavioral errors may lead to diseases.

Yoga offers various ways to achieve health, increase wellness, and prevent disease at physical, mental, and spiritual levels. Yoga and meditation techniques are becoming increasingly popular worldwide. Yoga is not a quick fix for health. Yoga can benefit those who are ready to put forth effort [19]. The spiritual and biological effects—together with physical and mental benefits—of yogic practices are also important. There is fair evidence supporting the belief that biomedicine and yoga may complement each other. Yoga practices have been shown to be useful in the prevention of several psychological problems, chronic diseases, and musculoskeletal disorders. Yoga has helped scientists to explore new paradigms for obtaining insights into physiological states and mind–body interactions [20]. The study of yoga and meditation, with the help of positron emission tomography, has helped to identify neural networks in brain regions which are active in different states of consciousness. Scientists have shown that systematic breathing exercises can alter cerebral hemisphere activity, neuroendocrine, and autonomic functions [21].

The mind–body relationship is becoming better understood through research on psycho-neuro-endocrinology aspects. The next step appears to be its extension to the deeper understanding of the concept of spirituality. Although, the term spirituality has yet to find a place in the official definition of health, a fairly good number scientific papers suggest a supportive role of meditation and spirituality—especially for cancer patients. A preliminary study published in JAMA has indicated benefits of yoga postures in the treatment of carpal tunnel syndrome [22]. Chanting yoga mantras has been reported to induce psychological and physiological effects [23]. In a randomized controlled study on lymphoma patients, a yoga program was found to be feasible for patients with cancer, and significantly improved sleep-related outcomes [24]. Another prospective, randomized trial has suggested that yoga can be complementary to the conventional treatment of pulmonary tuberculosis [25].

While pharmaceutical drugs are thought of as medicines for disease of the body, meditation can be thought of as a tonic for mind. Yoga places much importance on meditation. Meditation is about various practices and techniques designed to promote peace, tranquility, compassion, love, patience, generosity, and forgiveness. Through meditation, the attempt is made toward relaxation, and to strengthen willpower, and internal energy. Meditation can help improve concentration, and mind activity. Meditation can act as a medicine by enhancing the power of the natural healing force [26].

Meditation is often used to relax the mind, and heal many stress-related diseases like hypertension, anxiety, and depression. Meditation can be done in various ways. According to yoga, one can do meditation through prayers, worshiping, and total devotion; it can be done by extreme dedication, involvement, and commitment to work, or a worthy cause. Meditation actually is an emotional state, which may involve chanting a mantra, and closing the eyes to attempt critical introspection, and sense the inner voice. In short, there are several variants, meanings, perceptions, and prescriptions for meditation. Meditation can be practiced for specific, desired benefits, and also as an attempt to attain ultimate salvation, or nirvana. In general, meditation is an individual or group attempt to train the mind, and to induce a state of consciousness [27].

Many times meditation relates to spirituality, but spirituality has a much broader meaning, which will be discussed later in this chapter. Meditation and spirituality have become a global market. Practically every religion has some form involving chanting, rituals, or practices, which can be considered meditation. Many variants of meditation are promoted by yoga celebrities and spiritual gurus—creating cults, or giving it a mystical aura. Many physicians and scientists have devised easier methodologies for specific purposes, and have given these methods proprietary names such as transcendental meditation, and mindfulness meditation. We will discuss a representative case of mindfulness meditation in the following section.

Mindfulness

The concept of mindfulness has its roots in yoga and meditation practices from Buddhist and Zen traditions. Mindfulness is about maintaining a continuous awareness of our thoughts, feelings, sensations, and external environment. Mindfulness is a wholesome mental state capable of developing deep insight into the nature of reality. More research on neuroscience and consciousness is unraveling the science of mindfulness [28].

Mindfulness is an art that attempts to achieve awareness to individual thoughts and feelings, and to spur the subject to get involved in a process of believing or judging them as right or wrong. A new field known as mindfulness-based interventions is emerging [29]. Yoga, Zen and Buddhist traditions are sometimes linked to particular societies, religions, and cultures so there might be certain inhibitions for their universal acceptance. Therefore, using basic principles from these important traditions, a secular practice of mindfulness has been promoted by Dr Jon Kabat-Zinn, Professor of Medicine at the University of Massachusetts Medical School. In 1979, Dr Jon established the Center for Mindfulness in Medicine, and launched a program known as Mindfulness-Based Stress Reduction (MBSR). Since then, many studies have been conducted on the physical, and mental health benefits of mindfulness. The scientific evidence of benefits from many studies resulted in the growing acceptance of the MBSR programs in various places like hospitals, veterans’ centers, schools, and prisons. The regular practice of mindfulness meditation for a few weeks can lead to many physical, psychological, and social benefits.

The effect of mindfulness training on resilience mechanisms in active-duty marines preparing for deployment showed greater reactivity and enhanced recovery of heart rate, and breathing rate after stressful training; lower plasma neuropeptide Y concentration; and decreased blood-oxygen-level-dependent signal. This study indicates that mechanisms related to stress recovery can be modified in healthy individuals prior to stress exposure. Thus, mindfulness training might have important implications in the prevention of stress, and in effective treatments for better mental health [30]. Participants in mindfulness stress reduction programs showed improvements in worry severity, and improvements in memory. An aging population may have anxiety and mood disorders as common problems, where stress reduction intervention can provide great public health value [31]. In general, there is convincing evidence that mindfulness is safe and therapeutic for psychosis [32].

A meta-analysis of 47 trials with 3515 participants indicated that mindfulness meditation programs had moderate evidence of improved anxiety, depression, and pain, and some benefit to mental health-related quality of life. This study concluded that small to moderate reductions of psychological stress can be achieved through meditation programs. Researchers suggested that the clinicians should talk to patients about the positive role of meditation in addressing psychological stress [33]. Mindfulness meditation is shown to reduce cognitive rigidity because it overcomes the tendency to be “blinded” by experience [34]. Studies have also shown that mindfulness was related to the somatic marker circuit of the brain [35].

Another meditation practice similar to mindfulness meditation practice, known as Vipassana, is popular in India, and a few other countries. Based on Buddhist tradition, Vipassana is an introspective practice in which the practitioner tries to develop insight into the true nature of reality. Vipassana practice includes contemplation, introspection, and the observation of bodily sensations. This technique of analytic meditation necessitates silence with no external communication on the part of the practitioner; this triggers a deep internal dialogue, and introspection about the meaning of changes in self-concept, ego defense, life, death, and decomposition. A few studies have shown beneficial neurobiological, and clinical changes following Vipassana meditation [36].

Tai chi chuan (TCC) is a Chinese martial art practice, which is also used for health benefits. A systematic review of seven studies involving 391 participants has shown that fibromyalgia symptoms can be improved by tai chi practice [37]. In another interesting study, compared with controls, TCC practitioners showed significantly thicker cortex in the precentral gyrusin of the right hemisphere, and in the superior temporal gyrus of the left hemisphere [38].

Thus, many scientific studies are indicating the usefulness of meditation—be it through mindfulness, Vipassana, tai chi, Zen, or yoga.

Yoga and Exercise

Yoga breathing techniques, and physical postures are very sophisticated exercises, designed for the whole body. Specific postures are meant to target specific tissues, organs, and systems. There are 84 classical Asana; thousands of their variants are in practice. Again, many proprietary variants of yoga are being promoted in different parts of the world; just to mention a few—iyengar yoga, siddha samadhi yoga, kundalini yoga, and power yoga. On June 21, 2014—which happens to be the longest day of the year—a record number of 11,000 people practiced yoga in Times Square in New York City. The yoga wave can be witnessed all over the world.

In Indian tradition, the sun is given much importance as the source of vital energy. Salutation to the sun is considered a healthy practice. This practice has been cleverly used by sages to create one of the most simple, yet effective exercises for all age groups. This is known as the “Sun Salutation” exercise, or Surya Namaskara; it packages key postures from complicated yogic processes (Figure 6.1). It is actually a set of Yogasana with coordinated breathing patterns. Every day, just 12 or more repetitions according to the stamina of the individual, are recommended as daily exercise. Many studies have concluded that Surya Namaskara can be an ideal exercise to keep oneself in optimum level of fitness [39]. The regular practice of sun salutations as daily exercises is probably the easiest, most convenient, and economical exercise; it can be practiced singly, or in groups, and can help in disease prevention, and health promotion.

Yogasana-based exercise methods like Surya Namaskara are designed to effect the internal organs. Research on Surya Namaskara has revealed its efficacy in controlling bronchial asthma [40]; and its potential to improve pulmonary functions, muscle strength, and endurance, and cardiovascular parameters [41]. In another study, the practice of Surya Namaskara has shown to result in better synchronization of muscular movements with breathing, sympathetic arousal, and muscular exertion [42]. An integrative practice involving Surya Namaskara, along with Pranayama, Yogasana, and meditation, has shown significant improvement in social adaptation, and intelligence quotient—including that of mentally retarded children [43]. The speed of Surya Namaskara performance, and associated breathing patterns have specific effects. The effects of performing Surya Namaskara at a fast pace are similar to physical, aerobic exercises, whereas the slow performance of Surya Namaskara is similar to those of yoga training [41]. The ancient Sanskrit verses (Akal mrutyu haranam sarvavyadhi vinashanam) tell us that the regular practice of Surya Namaskara has the potential to prevent untimely, premature death, and can cure most diseases. Surya Namaskara seems to be the most effective, most easily done, and most inexpensive practice for the protection of health.

Recent studies have demonstrated that even short-term training in techniques like yoga, and exercise programs can influence the sympathetic nervous system, and immune system. Healthy volunteers practicing these techniques have shown profound increases in the release of epinephrine, which leads to increased production of anti-inflammatory mediators [44]. Yoga interventions such as performing gentle postures, breathing exercises, and meditation have definitive advantages over other interventions, such as nature walks, and listening to relaxing music. A comparative study with these two interventions showed that yoga and related practices might provide longer-term physiological benefits, and health protection [45].

Typical Ayurveda treatments include drug, diet, and lifestyle modifications; all help to restore the health of the body, and treat somatic diseases. Yoga focuses on mind and spirit. This helps in the strengthening of mental status. Ayurveda practice has adopted many concepts from yoga, and offered them in easier-to-do, practical procedures. This makes Ayurveda a holistic health science, which considers mind–body–spirit. Ayurveda offers detailed advice, and counseling about avoiding causative factors, diet restrictions, sleep, and digestion, as well as a list of dos and don’ts. Two branches of Ayurveda are particularly relevant to lifestyle and behavioral medicine. Primarily, they provide doctrines for personalized diet, and healthy, lifestyle modifications—which chime with daily routine, seasonal changes, and the purification of body systems. These disciplines, known as Swasthavritta and Panchakarma, are described here as case studies of the preventive and therapeutic potentials of Ayurveda interventions.

Swasthavritta

Ayurveda advocates keys to health promotion through advice on diet and lifestyle. This branch is known as Swasthavritta—it provides dictums to follow for attaining health. Any deviation from the dictums of Swasthavritta may lead to an imbalance in Dosha, resulting in ill-health. Swasthavritta incorporates several dictums pertaining to age, nutritional status, metabolic attributes, and individual tolerance and sensitivity—all in the context of environmental and seasonal variations. There are three main components of Swasthavritta: daily routine, seasonal variation, and behavior. According to Ayurveda, the three Dosha undergo chronobiological changes during the day and night cycle. Dosha are also affected by the pattern of daily routine, foods habits, and behaviors. Ayurveda suggests matching daily food and behavior in such a way that the Dosha are maintained in a balanced state. For example, one should consume food when Pitta Dosha is at the highest peak, exercise when Kapha is increased, and rest when Vata is aggravated. If daily activities are not synchronized with Dosha levels, the resultant imbalance can cause disease. Hence, the history of a patient’s diet and lifestyle is important in the diagnosis. The treatment includes detailed advice about when, and what to eat—according to the attributes of diet which result in keeping Dosha balanced. An asthmatic patient might be advised to drink medicated water before bedtime, in order to avoid the aggravation of Kapha during the night. Sometimes, a useful, therapeutic substance can be harmful if consumed at the wrong time.

The daily routine suggested by Ayurveda aims at protecting body, mind, and senses. Daily activities lead to accumulation of wastes in the internal organs, and to the degeneration of body tissues. There is overuse of some organs and body systems. Ayurveda advocates simple, but effective daily measures for replenishing, and repairing tissues. Many daily routine measures can have protective effects on body and mind. Interestingly, these effects seem to be linked with chronobiology.

Morning wake-up time: A person desiring health should get up early. The general suggestion is that one should get up at least 3 h before sunrise. It is also important to note that Ayurveda advises early bedtime, and the avoidance of late-night work. Many proverbs in various Indian languages describe early awakening as one of the healthy practices. Another dictum concerns digestion. One should ensure that food is digested (no heaviness in abdomen), sleep is complete, and the person is feeling energetic. Awakening at proper times is also helpful for bowel movements. Generally, the period before sunrise is Vata dominant, hence it is the best time for elimination of waste. Regular and timely elimination of urine and feces is important to keep systems clean. Proper day–night cycle automatically helps to keep the person healthy. Ayurveda also suggests the relation of sleep with digestion, and the immune system—leading to optimum physical and mental performance.

Sleep: Sleep is one of the important activities. It is known that adequate sleep prevents neurobehavioral deficits, improves memory, and helps to maintain a thoughtful mind [46]. Sound sleep provides nutrition to tissues, and rejuvenates the body. It endows strength, good complexion, growth, and longevity.

Food: The person should consume food only after the digestion of the previous meal, and when experiencing a proper sensation of hunger. The quantity of food should be limited (according to digestive capacity). Food items should vary according to a changing environment (details of food are covered in Chapter 7—Food and Diet).

Oral hygiene: Teeth, gums, and the oral cavity should be cleaned with brushes or powders having bitter, astringent, or pungent tastes. The herbs with these tastes decrease Kapha, and removes wastes (oral secretions and dental coating). The specific herbs indicated for dental cleaning remove tongue coating, open pores of salivary glands, and maintain oral health. Gargling with decoctions strengthen jaw, teeth, and gums; improve the quality of voice, reduce tastelessness, and heal ulcers of the gums. Regular gargling with medicated oils strengthens the jaw and teeth, and heals oral ulcers.

Sensory organs: Specific eye-cleansing lotions are advised to maintain the health of eyes. Oil drops in ear prevent torticollis, lock jaw, and deafness. Medicated oils, and clarified butter drops in the nostrils are helpful in improving respiratory health; to prevent aging; brain degeneration; and to strengthen the head and neck. More information about the nasal administration of medical oil is discussed in Chapter 10—Longevity, Regeneration, and Rasayana.

Skin rub: Ayurveda advocates that after exercise, the body should be massaged with dry herbal powders. The skin rub with such powders helps fat reduction, and provides stability and strength. Interestingly, a skin rub with a dry towel is popular in Japan for preventing respiratory infections; it is a traditional therapy for health promotion known as Kanpu Masatsu. Research on skin rubbing shows striking results in immunological and metabolic variables. After a skin rubdown, pulse rate, body temperature, PO(2), SO(2), pH were increased and rouleaux formation by red blood cells was reduced. Adrenaline and noradrenaline levels increased, indicating sympathetic nerve dominance, with increase in granulocytes. It is suggested that a skin rub with dry towel can have a beneficial effect on the autonomic nervous system, improvement in the immune system, and give benefits such as those obtained with systemic, aerobic exercises [47].

Bath: In addition to skin and hair cleaning, the bath improves metabolism, blood circulation, energy, appetite, sexual vigor, enthusiasm, strength, and longevity. Research on the effect of a sauna bath on human physiological parameters suggested that skin blood flow, and the concentration of oxygenated hemoglobin is improved by a sauna bath. It also significantly reduces muscle fatigue [48]. Taking into account the interpretation of current research trends on massage, skin rubs, and bathing, we can say that sparing a few minutes for exercise, combined with massage, rubbing medicinal powders, and a hot water bath can prevent several metabolic, and infectious diseases. The research trends also hint that innovative discoveries about daily activities are possible if we interpret Ayurveda in terms of modern biology.

Oil massage: Oil massage relieves fatigue, stops aging, and rejuvenates tissues. It also improves the capacity of the body to adapt to stress, and strenuous work, and makes the body able to sustain exercise, trauma, and hard work. Usually, in Indian tradition, any physical exercise is followed by an oil massage. Regular massage reduces drowsiness, fatigue, lethargy, body odor, and lax skin. Massaging feet with oil prevents leg pain, sprains, sciatica, muscle spasms, and cracks. The description of the effect of foot massage includes important effects on eyesight. Ayurveda suggests massaging feet with cow ghee for eye strain, and burning eyes. Head massage is effective in preventing headache, baldness, and early graying of hair. It improves the health of sense organs, and produces sound sleep. Thus, oil massage is one of the important treatments for insomnia, and degenerative and neurological diseases. Regular massage is one of the important secrets of Ayurveda for longevity. Massage is one of the important parts of Indian health traditions.

However, oil application is contraindicated in a state of indigestion, inflammation of the ear, and ear drum perforation. Ayurveda suggests that the ideal timing for massage is in the early morning on an empty stomach (after passing stools), when the body is ready to accept, and digest the oil applied on the skin.

Emerging research on massage is adding various pieces of information. In a pilot study on massage, the participants showed significant reductions in stress with just one session of massage treatment. Reductions in heart rate and blood pressure were also observed [49]. In another study, massage therapy resulted in the reduction of vascular endothelial adhesion molecules 1, and intracellular adhesion molecules 1, in hypertensive women, suggesting its role in the prevention of cardiovascular diseases [50].

Integrative applications of massage have been shown to improve patient satisfaction during hospitalization. In a randomized trial postoperative cardiac surgery patients receiving massage therapy reported significantly decreased pain, anxiety, and tension. These patients showed high levels of satisfaction with massage. According to Dr Brent Bauer from Mayo Clinic in Rochester, massage therapy may be an important component of the healing experience for patients after cardiovascular surgery [51].

A recent meta-analysis reports that massage combined with antihypertensive drugs might be more effective than antihypertensive drugs alone [52]. Massage with aromatic oils applied to middle-aged women with hypertension also showed remarkable benefits in terms of significant reduction in blood pressure, sleep quality, and overall quality of life [53]. Massage therapy was found to be a safe, effective, and cost-effective intervention for controlling blood pressure in prehypertension women [54]. Researchers have tried to assess the duration of massage effects. The beneficial effects of massage on blood pressure may be sustained up to 72 h [55].

Massage has shown remarkable effects in diabetes patients. The diabetic patients, who were treated with gentle massage, showed changes in metabolic markers. They showed improvements in adiponectin, and ratios of adiponectin-to-leptin, and adiponectin-to-HbA1c levels [56].

In India, baby massage is a traditional practice. Massaging in infants results in a higher daily weight gain, and increased potential to fight viruses, and malignant cells [57].

Exercise: Ayurveda emphasizes exercise as a routine. Daily exercise maintains healthy weight and creates a feeling of lightness and strength. It facilitates proper digestion, removes excess fat, and bestows a distinct physique. Everyone except the aged, children, those whose food is not digested, and those having Vata and Pitta diseases should do exercise. One should exercise up to “half of the one’s strength”. The body should be massaged after exercise.

Traditional Indian exercises are quite different to typical aerobic exercise. The aim of exercise is not just to increase the heart rate, blood supply, to dilate vessels, and tone muscles. These exercises are easy to learn and practice. Surya Namaskara is the best example, and has been discussed in earlier sections. These exercises do not require any special gadgets, equipment, or facilities. The exercises are subtle and include specific cycles of stretching, relaxation, breathing, and meditation. They target the entire body—especially abdominal and thoracic organs, and the mind and brain.

Ayurveda advises specific changes in diet and lifestyle according to various seasons. This is known as Ritucharya. Specific interventions like Panchakarma are also advocated in particular seasons. The guidelines for daily routine, seasonal changes, and treatment regime are specific to Dosha changes, and aim to achieve a dynamic balance of Dosha. The accompanying charts of Dinacharya and Ritucharya are useful in understanding the specificity and richness of Ayurvedic advice for health promotion.

Lifestyle and Behavioral Medicine

The concepts of Swasthavritta overlap with the modern concepts of behavioral medicine, and lifestyle interventions. During the past four decades, behavioral medicine has emerged as an interdisciplinary field. It deals with behavioral, sociocultural, psychosocial, and biomedical aspects—all relevant to health and illness. The systematic use of this knowledge has begun in diagnosis, prevention, and the treatment of disease, and in health protection, promotion, and rehabilitation [58]. The Academy of Behavioral Medicine Research was founded in 1978, by the eminent psychologist, Dr Neal Miller. Around the same time, the Society of Behavioral Medicine was established in the United States to promote interdisciplinary studies on the interactions of behavior with biology, and the environment to improve health and well-being. Today, the International Society of Behavioral Medicine has a membership from 29 countries. The field of lifestyle medicine has grown over the past two decades, mainly because of the efforts of scientists like Dr James Rippe, Professor of Biomedical Sciences at the University of Central Florida, and Dr David Katz, the founding director of the Prevention Research Center at Yale University. The pioneering, scientific work of scientists such as Dr Elizabeth Blackburn and Dr Dean Ornish has also played a key role in drawing the attention of the scientific community to this emerging discipline. In the United Kingdom, the Society of Behavioral Medicine has been set up for behavioral interventions, and research.

Many scientific studies and reviews indicate the benefits from behavioral medicine. A meta-analysis has shown that the psychological preparation of patients undergoing surgery is very important. This can be done by giving procedural information, and behavioral instructions. This simple measure has reduced the use of analgesics, and the length of hospital stay [59]. Behavioral therapy has been shown to reduce chronic pain better, as compared to alternative, active treatments [60]. Behavioral interventions also help in disease prevention. An interesting meta-analysis comparing behavioral interventions such as intensive physical activity, and weight loss, with conventional drug therapy, has shown that the incidence of diabetes was significantly reduced, as compared with the conventional drug metformin [6].

Although behavioral medicine has an important role in the prevention and treatment of many diseases, sadly, it does not get due priority in research, policy, and practice. The nature of medical practice may be responsible for this. The medical school curriculum focuses on pharmacology, use of drugs, and surgery to manage diseases. The role of nonpharmacology measures such as behavioral and lifestyle interventions hardly finds a place in the curriculum. Moreover, the marketing tactics of pharmaceutical industries are very aggressive and attractive.

Although, behavioral and lifestyle interventions are simple and cost-effective, industry and government funding to research such nonpharmacology approaches remains very poor. For instance, in 2003, in the United Kingdom, the pharmaceutical industry spent about £3550 million on the research for drug discovery. This is more than two times the amount spent by the Medical Research Council, and major charities put together. The pharmaceutical industry strongly influences health care delivery strategies. There is reasonable evidence that industry funding can lead to biased results in favor of its products [61]. The WHO has admitted that global health priorities of preventing and managing chronic disease will not be achieved by using drugs and prescription, alone.

Behavioral and lifestyle interventions to improve health may not bring the immediate results to alleviate symptoms, as compared to powerful drugs. But these drugs also bring many side effects, which behavioral interventions do not. Lifestyle intervention benefits might be modest, but they are real, and at much reduced costs, increased empowerment, and autonomy for individual health. Experts are attempting to change hesitant attitudes toward behavioral medicine in science and health policy [62].

According to the American College of Lifestyle Medicine, the use of lifestyle interventions in the treatment and management of disease include diet, nutrition, exercise, stress management, smoking cessation, and many other nonpharmacologic modalities. Increasing scientific evidence indicates that lifestyle intervention is becoming an essential component in the treatment of chronic, difficult-to-treat, psychosomatic disorders, and diseases. Lifestyle and behavioral modifications can be as effective as drugs and medication. In a controlled study, 3234 nondiabetic persons were assigned to either a placebo, metformin, or a lifestyle-modification program. This study concluded that in the prevention and control of diabetes, the lifestyle intervention was more effective than metformin [63]. If used with proper care, lifestyle intervention is safe and devoid of serious side-effects. Lifestyle medicine is the preferred choice for the prevention and treatment of obesity, insulin resistance syndrome, type 2 diabetes, coronary heart disease, hypertension, osteoporosis, cancer, and other chronic diseases.

Salutogenesis

A professor of medical sociology from Israel, Dr Aaron Antonovsky, coined the term salutogenesis as a new approach. The salutogenic model considers relationships between health, stress, and ways of coping. This branch of science studies how and why different individuals respond differently to stress. Dr Antonovsky worked to find out how some people successfully manage stress, and why some people show negative health outcomes due to stress. It was observed that many people survive, adapt, and overcome even the most difficult life-stress experiences. These observations, particularly on women who were in concentration camps, led to Antonovsky’s salutogenic model [64].

Much work has been brought to bear in order to understand the phenomenon of salutogenesis, which is considered as the power of “inner strength,” and a phenomenon of “coping with.” Salutogenesis incorporates concepts of resilience, sense of coherence, hardiness, purpose in life, and self-transcendence—all connected to inner strength. Salutogenesis considers the ability to transcend, and the value of a firm stand, and moral support given by family, friends, society, nature, and spiritual dimensions. Inner strength is also about shouldering responsibility to endure and confidently deal with adversity [65].

Interestingly, the basic philosophies of salutogenesis, lifestyle medicine, and behavioral medicine have drawn substantially from traditional knowledge systems. The concept of salutogenesis draws substantially from yoga. The yogic practices of postures, meditation, and behavioral modifications help to recognize and strengthen inner strength, to cope up, and adapt—countering stress, and other adversaries. Lifestyle and behavioral measures of Ayurveda, and salutogenesis prevention strategies share a common perspective [66].

These new efforts have certainly brought to bear scientific understanding and clarity, and have packaged ancient concepts so that they become acceptable to contemporary cultures. For many psychiatric, psychosomatic, and chronic conditions, behavior medicine, and lifestyle medicine might have an advantage over psychotropic, or other symptom-specific drugs.

Simple interventions through behavioral medicine have been shown to reduce risk factors such as hyperlipidemia, and hypertension. Cardiac rehabilitation programs put a major emphasis on nonpharmacological interventions like yoga, meditation, exercise, and behavioral and lifestyle modifications. Depression is known to be associated with increased mortality, and nonfatal, cardiac events in patients with coronary heart disease. Depression is also associated with heart failure, and coronary artery bypass graft surgery. The standard therapy in such cases includes second-generation antidepressants such as SSRI. However, recent studies have indicated that for depression, antidepressants have marginal benefits as compared with a placebo. Instead, drugs like SSRI, behavioral therapy, and exercise together might play a better role in cardiac disease patients with depression [67].

Yoga continues to remain attractive to researchers due to the fact that it is a simple and safe intervention. Many teachings of yoga are now practiced as behavioral medicine. Yoga interventions can be easily integrated into any medical system. Nonpharmacological approaches from yoga, meditation, mindfulness, mind–body medicine, lifestyle, and behavioral medicine can play a substantial role in the treatment of chronic, psychosomatic, and psychiatric disease. Yoga offers a path for disease prevention, and health protection. More than just health, it advocates a comprehensive approach toward life. This approach changes outlook and behavior, and results in relieving stress, achieving psychological balance, and clarity in thought processes.

Panchakarma

A novel treatment approach for the elimination of vitiated Dosha, leading to physiological purification, and body detox is known as Shodhana. Various ways to attempt the purification of different body systems by removing toxic substances can be attempted with the help of specialized procedures known as Shodhana.

Panchakarma procedures bring a sophisticated confluence of pharmacological and physiological interventions. Panchakarma consists of five main procedures for maintenance of health, and management of disease pathology. Panchakarma procedures are primarily based on physiological processes in the body. Various procedures are included in Panchakarma: therapeutically controlled emesis, or vomiting known as Vamana; therapeutically controlled purgation, known as Virechana; nasal administration of drugs, known as Nasya; medicated enema, known as Basti; and bloodletting using medicinal leeches, known as Raktamokshana. These approaches are used for specific conditions. For example, Vamana is a choice of treatment for vitiation of Kapha leading to respiratory, digestive, and metabolic diseases; Virachana is administered for diseases of Pitta, leading to skin diseases, and acid peptic diseases; Basti is indicated for diseases of Vata, like rheumatic, musculoskeletal, and neurological diseases; Nasya is indicated in diseases of the head, sinus, and sensory organs; Raktamokshana is used for diseases of the blood.

Medicated fats, oils, clear butter, or ghee, are administered before Panchakarma for reliving vitiated Dosha. Fomentation is used to facilitate the expulsion of toxic wastes from Dhatu. Selected herbs are used to prepare hundreds of medicinal oils indicated for specific conditions. Ayurveda describes 13 different types of fomentations, such as local, general, with or without steam, nourishing, and anti-inflammatory. Medicated oils, or ghee can be administered as a steady drip on the center of the forehead. This is known as Shirodhara. Panchakarma procedures are also indicated for healthy people as seasonal therapies. Vamana is indicated after the winter, Virechana is advised before summer, and Basti is suggested in the rainy season to counter adverse effects on Kapha, Pitta, and Vata Dosha. Vamana and Virechana can be used as detox processes for purification—useful in the prevention and treatment of various diseases like asthma, irritable bowel syndrome, and skin diseases.

Each disease stage requires a specific treatment approach. For example, treatment of a malnourished patient requires not only nutrition, but also improved appetite, digestion, absorption, and metabolism. This can be done by the restoration of digestive fire, which can be achieved by specific herbal medicines, and Panchakarma processes.

Panchakarma are very special therapeutic procedures. They require the skills of an experienced physician, who can use appropriate drugs for the season. Experienced therapists to assist the physician, and the patient’s cooperation are also necessary. Improperly performed Panchakarma can cause adverse effects. The beneficial effects of Panchakarma in chronic, and difficult-to-treat diseases are often experienced. Many hospitals, and treatment centers—especially in South India—are known for the classical treatment of Panchakarma.

Ayurveda therapeutics includes preconditioning of the body by processes which revitalize systems, and remove toxins. These interventions can be simple, cleansing procedures, such as medicated oil baths, massage, fasting, and special diet.

Ayurveda has prescribed Raktamokshana as a systematic procedure of bloodletting through venipuncture, medicinal leeches, and drainage of cysts and abscesses. The use of medicinal leeches (Hirudo medicinalis) is one of the important instruments in Ayurveda. Lord Dhanvantari, who is the creator of Ayurveda, is shown holding leeches in one of his hands. This is a symbolic description of the importance of use of leeches in surgical procedures. Leeches are indicated for skin diseases, pain management, infections, wound management, nonhealing ulcers, erysipelas, herpes, abscesses, and tumors. Ayurveda physicians use leeches for symptom management of wounds, pain, inflammation, and paresthesia.

Bloodletting may still be considered as a crude, ancient treatment; however, the use of leech therapy has received the attention of researchers in recent years. Many components having anti-inflammatory, thrombolytic, anticoagulant, and blood and lymph circulation-enhancing properties have been found in leech saliva [68]. The first clinical report on using leeches for reduction of the venous congestion of skin flaps was published in British Journal of Plastic Surgery in 1960 [69]. Venous engorgement, and reduced microcirculation are the most common problems in plastic and reconstructive surgery. A systematic survey of 62 plastic surgery units in the United Kingdom, and the Republic of Ireland, reported the trend of leech use in postoperative wound care [70]. Thus, leech therapy has had a renaissance in reconstructive microsurgery. The animal has become a favorite “instrument” of plastic surgeons.

Leeches have been used in various indications other than plastic surgery. In a trial on osteoarthritis patients, leech therapy showed significant, and sustaining effects [71]. In patients with varicose veins, leech therapy showed the decongestion, reversal of edema, reduction in hyperpigmentation, and healing of varicose ulcers. The surgeons also studied blood gasses of these patients, and found that pO₂ of blood sucked by the leech was similar to that of venous blood. It is suggested that leeches suck venous blood, and facilitate the healing of venous ulcers [72]. The precise mechanisms of leech application are under scrutiny. However, a case report suggests increased perfusion, and hyperemia when studied with bone scintigraphy. It hints at possible vasodilatation effects on superficial veins, after leech therapy [73]. Researchers have studied recombinant hirudin as an anticoagulant therapy for prophylaxis of thromboembolic complications [74]. The topical application of hirudin was reported to heal bruises and hematoma [75].

Use of medicinal leeches was discussed by the General and Plastic Surgery Devices Panel (GPS Panel) of the United States’ FDA, in 2005. The panel unanimously recommended medicinal leeches as nonexempt, Class II medical devices, with special controls [75,76]. After FDA approval, Ricarimpex SAS, a French firm, which has specialized in leech farming since 1835, got permission to market leeches as medical devices in United States [77].

Oil Massage

Body massage with specialized oils can tone muscles, increase blood circulation, and stimulate neuromuscular function, in addition to providing relaxation, and a feeling of well-being. A small, descriptive, observational, clinical study by the Osher Research Center of Harvard Medical School found positive effects of Panchakarma-based intervention in behavioral, and psychosocial measures like adherence to positive lifestyle practices, self-efficacy, and the reduction of anxiety. This study suggests its efficacy in stress-related diseases [79]. A double-blind, randomized clinical trial involving the treatment of hemiplegia patients with nourishing massage and fomentation, suggests improvement in muscle tone and strength, tendon reflexes, range of movement, and functional abilities [80]. Cerebral palsy patients, when treated with massage, fomentation, with a bolus of drugs prepared with boiled rice, and nourishing enema, showed remarkable improvement in motor functions, and memory retention [81].

Panchakarma treatment may be useful in arresting degenerative changes of the brain. Indian researchers from the National Institute of Mental Health and Neurosciences treated patients of progressive cerebellar ataxia with a typical, holistic Ayurveda treatment composed of Shirobasti, Shirodhara, oil massage and steam bath, and oral medication. They observed improvement in balance within 14 days [82]. The effects of Shirodhara on psychological and physiological response were observed in healthy volunteers. Shirodhara demonstrated reduction in blood pressure, and heart rate, and an increase in alpha rhythm in EEG. The results suggest a wakeful relaxation response, and point to the potential of Shirodhara as a management for anxiety, neurosis, hypertension, and stress mechanisms [83].

The Maharishi Ayurveda Health Center of Norway, studied effects of Panchakarma, and diet and lifestyle modifications in patients diagnosed with fibromyalgia. In this study, 31 patients, were treated for 2 years. The treatment reduced impairment of ability to work, pain, tiredness, morning tiredness, stiffness, anxiety, and depression [84].

Thus, Panchakarma procedures can be used as physiological interventions for health promotion, and in the treatment of several diseases. More intense research is required to understand the underlying mechanisms of these valuable detox procedures.

Spirituality—Beyond Behavior

Lifestyle and behavior in humans is influenced by body–brain–mind, and spirit. New disciplines such as behavior and lifestyle medicine are welcome developments in our current, medicalized society. Lifestyle can influence behavior, and vice versa. Both of them, inter alia, are influenced by the brain and mind, which both produce somatic, and cognitive modulations. Lifestyle and behavioral changes can cause diseases, while their modification in the right direction can prevent, and treat, these diseases too. However, efforts in the area of lifestyle and behavior medicine should not follow the same track that pharmacological drugs have followed. Instead of the focus being on commercialization, the focus should be on empowering people to take their health into their own hands. This can be achieved by devising proprietary, patented modifications in the form of packages which combine traditional knowledge such as Ayurveda and yoga, or cultural practices such as those in Okinawan communities. People should be told about the power of their own mind, brain, and body. The natural potential of healing should be rediscovered. According to eminent Indian physician and cardiologist, Dr B.M. Hegde, occult methods were successfully used for healing in many civilizations. They probably worked by allowing our body to heal naturally [85].

This doesn’t mean the mumbo jumbo should be brought back; it only means that if spiritual practices like prayers can help improve the mental status of people, the least we should do is not ridicule these practices. The commercialization of religions in the name of the god should be condemned. Hippocrates’ statement “nature is the best healer” should not be forgotten.

The use of spirituality in daily life can be one way to empower people. Although the existence of spirit is a debatable question among scientists, during the past few decades, the role of spirituality in health has been recognized by philosophers. Many renowned neuroscientists, including Sir John Eccles and Candace Pert, have formally acknowledged the importance of spirituality in human life—especially for health, tranquility, bliss, and peace. The meaning and concept of spirituality differs in different regions, religions, and cultures. Historically, spirituality relates to religious ideals, and can influence a process of personal transformation. Many god-men, and gurus pose as spiritual leaders. They preach philosophy, and theology. However, since the last century, spirituality has been considered in relation to psychological development. No more is spirituality restricted to religion, but we see now that it relates to any meaningful activity, or blissful experience.

The famous philosopher, Ralph Waldo Emerson, pioneered the idea of spirituality as a separate field. The ethical outlook of having love and compassion for others is considered spiritual. Caring and sharing is spirituality in essence. The purity of thoughts, selfless attitude, respect to others who are around us, and balancing need and greed, are some of the key features of spirituality. Spirituality also induces a process of self-analysis, introspection, and search for meaning and purpose of life. Spiritual practices include meditation, mindfulness, prayer, reading sacred texts, and chanting mantras.

Spirituality is normally explored during end-of-life conditions like terminal cancer, when the reality of death becomes evident. However, the role of spirituality is also relevant in health promotion, and disease prevention. Spirituality may positively influence immunity, and patients’ approach toward disease, hence it should be considered as an important dimension of health. A general tendency to think only of spirituality at the late stages of disease, and in advanced age, limits its advantages during the early, productive years of life.

Integrated medicine approach performed in a clean, and green environment is shown to be potentially useful for the emotional, and spiritual well-being of cancer patients [86]. Another study in end-of-life conditions has suggested that patients who are supported by religious communities are less likely to opt for aggressive medical interventions. They also depend less on hospice care, as compared with those who are treated in usual care, without community support [87]. Daily yogic meditation intervention is shown to reduce stress, inhibit nuclear factor (NF)-κB-related transcription of proinflammatory cytokines, and decrease interferon regulatory factor1-related transcription of innate antiviral response genes [88].

To conclude, the global disease burden is significantly shifting from the dominance of infectious, communicable diseases, to the chronic, lifestyle diseases. Obviously, the earlier strategies of drug-based therapeutics also need to change. Infectious diseases were controllable and treatable with help of vaccines, antibiotics, and chemical agents. However, treating lifestyle diseases requires something more than drugs. This realization has resulted in the development of many new initiatives, and disciplinary branches such as behavioral medicine, lifestyle medicine, and mind–body medicine, in which nonpharmacological approaches are receiving more attention. Today, predominant diseases like diabetes, asthma, obesity, cardiovascular diseases, cancer and many others, are the result of changes in human lifestyle and behavior. Obviously, their prevention, control, and treatment cannot be expected to be achieved by pharmaceutical drugs, unless the root causes are addressed by suitable modifications in lifestyle and behavior. We cannot go on consuming junk food, do less physical work, pollute environments, and in doing so hope to cure obesity, diabetes, and cancer with drugs, alone.

Imagination leads to discoveries and inventions. Today’s ideas become a reality tomorrow. Ideas progress with available information, interdisciplinary environment, resources, dreaming, and desires. It might be dangerous if technology is not used with wisdom. Indian philosophy—led by Ayurveda and yoga—suggests “more responsibility for those who have more capacities.” The concept of Sadvritta suggests compassion with all living beings; sacrifice; controlling body–mind, and speech; and respecting the interests of others as minimum expectations.

The twentieth century mindset of treating disease with drugs is not valid in the twenty-first century, unless it is backed by a healthy lifestyle. Ayurveda calls this Sadvritta, meaning “good behavior.” Sadvritta involves honesty, ethical mindset, respect to others, ability to stay away from greed, the search for truth, and purpose of life. Such pure, moral, and spiritual behavior can keep stressors at bay. We feel the experiential wisdom available from Ayurveda and yoga, integrated with a psycho-neuroendocrinology understanding of biomedicine can provide better avenues to address the serious epidemic of diseases related to lifestyle, and behavior.

Unless a positive change is brought about in lifestyle and behavior, prevention and treatment of many diseases will not be possible. Alone, pharmaceutical drugs and surgeries cannot give health. Health is not a commodity that can be bought in the market. Health naturally occurs within everyone. Health has to be earned, or rather, hard-earned. Doctors are the facilitators; behavior and lifestyle are the real medicine for gaining health. There is a need to systematically translate the lifestyle medicine approach into various levels of health care—from individual to public health. This could be a possible strategy to addressing the present problem of the medicalization of the society.

Compassion with all living beings, sacrifice, controlling activities of body, speech, and mind, and helping others—these are the minimum expectations of good conduct required to maintain health.

Vagbhata

Lifestyle and Behavior

Abstract

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