Yoga with a Capital Y

The Benefits of Yoga as a Lifestyle Intervention

Lorenzo Cohen, PhD

of relaxation and meditation. Yoga truly is the union of mind
As a global researcher, Lorenzo Cohen, PhD, has ex- and body, and the practice is about trying to be embodied in
tensively studied the health effects of yoga in people with that realization at all times.
cancer. In 2010, he and his colleagues at MD Anderson
Cancer Center, in Houston, Texas, received the largest Na- Q: What are some of the main health benefits of yoga
tional Cancer Institute (NCI) grant in history for the study that you have come to realize through your research?
of yoga and cancer. Through his expertise, Dr. Cohen has
come to grasp the overarching role of yoga in enhancing Dr. Cohen: Much of the existing yoga research focus is
health, and, in this column, he shares his insights and re- on delivering yoga to people with various medical condi-
search findings. tions. The benefits can be broken down into a few different
categories. One is patient-reported outcomes, which are the
subjective measures of patients’ QoL. Within patient-report-
Q: How did you first become interested in the role of
ed outcomes, we can break that down into symptoms that
yoga and its effectiveness in health and illness?
people could be experiencing, such as fatigue, pain, and sleep
Lorenzo Cohen: My background is in research psychol- disorders, as well as mental health–related issues and physi-
ogy, and I was trained in the area of psychoneuroimmunology, cal functioning. We often measure negative symptoms, and
which is the study of the relationships among psychosocial we are trying to reduce the negative.
factors, hormonal functioning, and immune function. The ori- Then, there are other types of outcomes that are emerging in
gins of the field were in the area of stress response and trying the field of positive psychology, such as positive growth, post-
to understand better the premise that psychologic processes traumatic growth, benefit finding, and meaning making. These
could affect biologic functioning. are the more subjective types of outcomes that patients share
As I moved into the field of oncology, and, in particular, by completing questionnaires. We can also measure outcomes
looking at psychoneuroimmunology, it became clear that we by doing more qualitative research and actually interview-
needed to develop programs to help intervene with respect to ing patients or asking them to write about their experiences.
patients’ stress levels. People with cancer need interventions to Then, there are the more objective outcomes that we monitor
help improve their ability to cope with many of the side-effects in patients, such as heart rate [HR] and blood pressure [BP],
of cancer treatment, as well as improving aspects of their qual- immune function, hormone function, and the balance between
ity of life [QoL] and the psychosocial side of their care. parasympathetic and sympathetic tone by measuring, for ex-
Personally, I was exposed to yoga since childhood through ample, HR variability [HRV].
my grandmother, who was a yoga practitioner and teacher. So, what have we learned from the literature regarding
I watched my grandmother have a truly yogic way of life what improves with yoga? We certainly see that aspects
through her deep yoga practice, her interactions with others, of QoL improve in individuals who are practicing yoga,
and how she led all aspects of her life. whether they are physical functioning, mental health, symp-
Then, in graduate school, I began to read some of the exist- tom control, fatigue, or improvements in sleep disturbances.
ing scientific literature on yoga. Knowing about yoga from a One study by Karen Mustian, PhD, MPH—at the University
personal and scientific perspective, it seemed to me to be a of Rochester, New York—actually showed the benefits of
wonderful approach to bring to patients, because yoga is, in yoga on both objective and subjective measures of sleep
some sense, a quintessential mind–body practice that incor- quality in patients with sleep disturbances at study entry.1
porates many components that other practices do not involve. We also see improvements in benefit finding and meaning
Yoga includes aspects of movement and stretching, a focus on making from participating in yoga programs, and emerging
controlled breathing techniques, and then, importantly, aspects work shows that yoga can also have an effect on more ob-

ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2015.29004.lc • MARY ANN LIEBERT, INC. • VOL. 21 NO. 3
JUNE 2015
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jective measures, including better regulation of stress hor- Dr. Cohen: Some of the yoga research dates back to the
mones, such as cortisol, and a decrease in immune-based early 1980s. However, it was during the past decade that a
inflammatory patterns. lot of this work was performed. Much of the research qual-
ity still falls short in terms of rigorous research design, with
Q: Is there any aspect of what you have just described most studies only comparing yoga to usual care. However,
that is of particular interest to you or perhaps our readers now there are many three-arm studies, such as the one we pub-
in terms of specific physiologic findings related to yoga and lished recently,2 in which there is actually an active control
how it works? group. This is also the case in some of the studies on diabetes
and obesity, in which yoga can be compared with diet against
Dr. Cohen: There are many theories on the benefits of yoga, exercise with diet.
and most look at human beings as biopsychosocial beings and I am actually in the process of co-editing a book with three
view yoga as a stress-buffering and stress resilience–based other scientists/physicians in the field that will be published
model. In other words, the practice of yoga will change how by Hand Spring Publishing. The book is The Principles and
a person responds to stress and perhaps change a person’s set- Practice of Yoga in Health Care. The book is going to have
point from when he or she is at rest. Evidence supports that a about 17 disease-related chapters, broken into many sections
yoga practice may lead to increased HRV, lower systolic and such as mental health, endocrine function, cancer (one for sur-
diastolic BP, a lower HR, and improved insulin and glucose vivors and one for patients undergoing treatment), endocrine
regulation. These are examples of how yoga can change a per- disorders, cardiorespiratory disease, and then some normative
son’s set-point. Then, when a person is confronted by a stres- or special areas, such as women’s health. In reviewing these
sor—and we are constantly confronted with stressors every chapters, in some areas, the breadth and depth of the number
day of our lives—theoretically, he or she now has a different of studies is actually quite surprising.
way of coping with that stressor.
Today, yoga research has focused on medical populations Q: Please talk about the significant $4.5 million grant
who have certain conditions, such as diabetes, cancer, or that you received from the National Cancer Institute [NCI]
heart disease, and teaching people with these conditions how for the study of yoga and cancer.
to do yoga in order to modify outcomes. Again, mechanisti-
Dr. Cohen: We originally conducted a small NCI-funded
cally, the theory is that yoga will buffer the stress response by
R21* in collaboration with colleagues from the Vivekananda
giving the patient a lower set-point and a more adaptive way
Yoga Anusandhana Samsthana [VYASA] in Bangalore, India,
of managing stressors.
to compare yoga against stretching and to compare yoga to a
Among the reasons that people will go to the gym to do their
third, more pure control group of usual care for patients with
yoga is that it makes them feel good and helps them to relax.
breast cancer while they were undergoing radiotherapy.2
However, when yoga is taught and practiced as a comprehen-
There were ~ 50 women in each group. We provided yoga
sive integrated intervention as opposed to simply a form of
3 days a week during the patients’ 6 weeks of radiotherapy,
exercise or stretching, yoga not only helps people feel good and found that benefits were in favor of the yoga group for
or relax but also helps them lead healthier, more fulfilling, and outcomes, such as physical functioning and general health
meaningful lives. This is important, because many people go reports, as well as, importantly, a more objective measure of
through their lives in a very mindless way—mindless eating, cortisol rhythmicity. By the end of radiotherapy, all groups had
mindless work, and mindless relationships. a blunting of their cortisol slopes—the steeper the slopes were,
Whether dietary patterns change in people who are taught a the better the cortisol regulation was. The steepest slope, how-
comprehensive yoga program has not been studied fully. How- ever, was seen in the yoga group, both 1 week after the end of
ever, if we look anecdotally at yoga practitioners, they tend to radiotherapy and 1 month after we stopped delivering the yoga
have a heightened concern about health in all aspects of their program to the patients.
lives, including trying to foster positive relationships and life- Now we are following that up with a study in collabora-
style behaviors such as diet and exercise. tion with VYASA that will be close to 600 patients total and
There is certainly literature about how mindfulness in one that has a very similar design, including patients with breast
area leads to mindfulness in other areas and that a mindful- cancer while they are undergoing radiotherapy. This involves
ness practice will be a good adjuvant alongside, for example, 200 women receiving the comprehensive yoga program;
conventional dietary and exercise practices to help people lose 200 women in an enhanced, active control group, learning
weight. Without the mindfulness component, it is more dif- stretching and relaxation techniques; and 200 women in a
ficult for the practice to have effect, and this is why yoga is usual care group.
being investigated as one component of integrative treatment
plans for a variety of medical conditions.
*An NCI R21 grant is given for “exploratory/developmental research
by providing support for the early and conceptual stages of project
Q: It sounds like there have been great strides in the last development.” Office of Extramural Research, National Institutes of
10–15 years in terms of the amount and quality of yoga Health. Grants and Funding. Online document at: http://grants.nih.
research. Please share your perspective on this. gov/grants/funding/r21.htm Accessed April 21, 2015.

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An aspect of this study, beyond the sample size, is that be influencing their disease processes. Lifestyle factors play
the design is quite unique in that we have an active control a role in the majority of noncommunicable diseases, such as
group, and, very importantly, we are conducting the study as a cardiovascular disease, diabetes, cancer, and respiratory dis-
blinded trial. So what does that mean? How does one actually eases. Factors, such as smoking, sedentary behavior, obesity,
blind a mind–body study? People will know when they are diet (including alcohol use), and lack of exercise, as well as
doing yoga during the yoga group, and members of the other
group will know that they are in a group that includes stretch-
ing and relaxation techniques. However, people in those two
active groups do not know that the purpose of the trial is to
“ Yoga can be useful for people who
study yoga. It is actually called a “relaxation study,” and, in are experiencing chronic symptoms
the consent form, they are told we are studying two different
forms of relaxation.
that have been difficult to manage
In Group 1, participants will use some stretching, breathing, with conventional care.”
and relaxation techniques. In Group 2, participants will use
some stretching, breathing, and relaxation techniques. However,
one group, of course, will be doing yoga. This will help with chronic stress, all play roles. Yoga would probably be helpful
the few skeptics who still have powerful voices out there who when incorporated alongside the standard of care for many of
believe that the benefits of yoga are simply a result of exercise. I these lifestyle-influenced diseases, such as diabetes, heart dis-
have even had colleagues say that the benefits attributed to yoga ease, stroke, cancer, and obesity.
just comprise a placebo effect. So, if a participant knows that the
purpose of the study is to test yoga and knows they he or she is Q: Yoga practices vary greatly in the United States in
in the yoga group, this is a problem in terms of bias that does not terms of their rigor and pace and whether these practic-
exist in conventional placebo-controlled trials of drugs. es include meditation or spiritual aspects in the teaching.
We have also incorporated cost–benefit analyses, and we are What should clinicians think about when recommending
examining both the indirect and direct care costs that could be yoga to their patients, and what aspects should be included
modified by changing patients’ QoL and the way they respond in the practice from a comprehensive standpoint?
to stress. A number of both objective and subjective measures
will also be collected over time. We are extending follow-up Dr. Cohen: The Western conceptualization of yoga is pri-
beyond 6 months to a full year after the end of treatment, which marily from the Hatha yoga tradition, and the practice here, in
could be relevant for the economic data. Another relevant fac- the United States, typically incorporates postures and breath-
tor is continuing to have patients engaged in the practice after ing exercises, and not as much of the meditation or spiritual
the end of radiotherapy and when the in-person classes end. side. This is, of course, in stark contrast with the origins and
Yoga and, of course, other mind–body practices are not like the purpose of yoga.
taking a course of antibiotics, and, once a 10-day regimen of However, within the studies previously mentioned, research-
such a drug is complete and the bacterial infection is gone, a ers tend to not work a lot with the patients discussing diet,
person simply goes back to living life. The evidence supports exercise, or healthy relationships. As researchers, we focus
instead on the components that were described, such as the
that the more one practices yoga, up to a certain point, the
postures, breathing, meditation, relaxation techniques, and a
greater the benefits will be. The practice needs to be regular in
little bit on the philosophy of the stress response and the use of
order to reap the benefits. After the end of radiotherapy, half
yoga as a coping tool.
of the patients in each of the active groups are randomized to
One aspect of the upcoming book I mentioned is that the
either have maintenance booster phone calls from the thera-
contributors really try to describe what yoga interventions
pists in an attempt to keep the patients on track, and, when
were carried out with participants in the reviewed studies. We
they come back into the hospital, they have booster sessions
are always limited by the level of detail that the authors of the
with the therapists.
scientific articles are willing to include. Some are not very de-
The challenge for us, of course, is that we are a tertiary-
scriptive and may simply say: “We included āsanas and breath-
cancer center. So, most of our patients do not live in the Hous-
ing.” Other researchers have a more comprehensive approach
ton area. This is one alternative to try to keep them engaged in
that may also include meditation. Most do not include an em-
yoga practice.
phasis on spirituality or teaching yoga philosophy. I believe,
however, that these are areas that should be included.
Q: What should prompt clinicians to recommend yoga
My colleagues and I are conducting a comprehensive life-
to their patients?
style study for women with stage-3 breast cancer to investigate
Dr. Cohen: I do not want to be too grandiose and say that if comprehensive lifestyle change can decrease recurrence of
it can be useful for anyone at any time, but, certainly, yoga disease and increase overall survival. When I speak to a yoga
can be useful for people who are experiencing chronic symp- audience, I state that we are examining the effects of yoga
toms that have been difficult to manage with conventional with a capital Y. This is not just the āsanas and the prānāyāma
care. There is also the supposition that lifestyle factors could (breath) and meditation, but also an intensive focus on dietary

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Q: Can a person start yoga at any age, and is there an op-

To Contact Dr. Lorenzo Cohen timal dose of yoga according to your research knowledge?

Lorenzo Cohen, PhD Dr. Cohen: A person can definitely start yoga at almost
Richard E. Haynes Distinguished Professor any age. My grandmother was doing yoga until her death
in Clinical Cancer Prevention in her 90s, and, in fact, she was practicing right up until the
Director, Integrative Medicine Program
Department of Palliative, Rehabilitation, day she died. There is no maximum age for starting yoga.
and Integrative Medicine An older person may have more challenges and flexibility
MD Anderson Cancer Center may be limited, but again, yoga is about the process and not
1515 Holcombe Boulevard, Box 462 about the product. As soon as a teacher starts focusing on
Houston, TX 77030
Phone: (713) 745-4260 the product, a person should find a new teacher. In terms of
Fax: (713) 745-4286 starting too young, the only real concern is pushing the body
E-mail: [email protected] too hard when bones are still growing. If the practitioner has
Website: www.mdanderson.org/integrativemed experience working with children and/or pediatric popula-
tions, then yoga may be very useful.
counseling, exercise counseling, and an overarching theme of The question about dose is more challenging, as this has
mindfulness across all of those components. not been studied adequately from a conventional medical per-
Importantly, having a guide—in this case, a psychologist— spective. However, in our first study of yoga for patients with
who can help individuals implement and manifest the difficult breast cancer, who were undergoing radiotherapy, we provided
changes needed to make in these people’s lives is a critical yoga twice per week (50–60 minute sessions) and encouraged
component. Of course, changing paradigms takes a while, but the participants to practice every day. In a follow-up study,
one can explore the medical literature and see recent publica- we increased the dose to three times per week. Ideally, a per-
tions and randomized controlled trials on the benefits of yoga. son would be practicing yoga every day, whether that is just a
One would have to be a physician who is either anti-science or 10-minute meditation or 20 minutes of the postures, or a full
a person for whom no amount of data is going to change his 30–60 minutes of practice.
or her mind to not consider the available evidence. Clearly, the Yoga is a lifestyle-based intervention, and, if a patient
literature on the benefits of yoga for a wide variety of medical goes back to an unhealthy lifestyle, then the benefits disap-
populations exists. pear quickly. This is not dissimilar with unhealthy behaviors
The questions that patients typically ask are: “Well, what
kind of yoga should I practice? Is the yoga at the YMCA
good enough?” Ideally, because there are some safety is-
sues, in particular with vulnerable medical populations, one
“ Yoga is a lifestyle-based
wants to make sure that the yoga teacher has worked with intervention, and, if a patient goes
medical populations before or has received special training
for working with those populations. We also want to ensure
back to an unhealthy lifestyle, then
that that the yoga practice is one that is focused on indi- the benefits disappear quickly.”
vidualization and meeting each client’s needs. The teaching
should be based on individual progress, wherein the pro-
cess is more important than the product (e.g., getting into such as smoking. If a person quits smoking for a year, that
a pose). is great, but if that person starts smoking again, then that
What happens when yoga gets exported to the West—maybe patient is going to return back quickly to where he or she
this is happening in India, as well—is that it tends to become was. Using the metaphor of a medication that only works
very competitive: “I can do the posture better than you. If you when it is taken, yoga is like a medication that one needs
cannot get yourself in a full lotus position, then you are not to take frequently. Ideally, a person is also taking yoga off
reaping the benefits. If you cannot touch your toes, then you the mat and out of the studio, and using yoga in all aspects
are not doing it right.” of life, every day in encounters, and bringing mindfulness
However, really, yoga should be more about the process and into daily activities.
going beyond just the calisthenics and stretching aspects of it. Something that is important to advise patients is that there
Yoga should be approached from a more quintessential mind– are many different types of yoga, as, once patients start look-
body perspective. ing, they will realize quickly. Beyond that, there are also many
What is very important, I believe, although we have not different types of mind–body practices. So, the ideal mind–
studied it scientifically, is the relaxation and meditation com- body practice or yoga practice is going to be the one that a
ponent—not just savāsana at the end of the yoga practice, person is willing to do every day or as often as possible.
which is colloquially translated to “corpse pose” and wherein If we were to start testing and comparing practices, I think
the practitioners guide people through relaxation. That is a we would find that there may be a certain posture or a certain
wonderful practice to reground, but is not enough, I believe, exercise that may be better for BP versus another one that may
and a meditation practice is also needed. be better for control of insulin based on baroreceptor reflex or

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the way the posture is moving the anatomy of the body. How- diseases are caused by unhealthy lifestyles. So, we need to
ever, by and large, if one looks at the larger practices overall look at lifestyle-based interventions to prevent and manage
and if one compares these head-to-head, the larger practices these diseases. The conventional focus on “high-tech” and
are going to be quite similar. The key, again, is to find the prac- pharmacologic interventions alone, ignoring the root causes
tice that resonates with the individual and the one that person of the diseases, will come up short for preventing and treat-
will do every day. ing these diseases. n

Q: How confident are you that yoga will become a References

“gold standard” of care in terms of offering it to patients
just like you would a medication for improvement in
1. Mustian K, Sprod L, Janelsins M, et al. Multicenter, randomized con-
their health? trolled trial of yoga for sleep quality among cancer survivors. J Clin Oncol
Dr. Cohen: I am quite optimistic that yoga is becoming part 2013;31:3233–3241.
of the standard of care, and many hospitals already offer yoga 2. Chandwani KD, Perkins G, Nagendra HR, et al. Randomized, controlled
trial of yoga in women with breast cancer undergoing radiotherapy. J Clin
programs for patients, whether these institutions are more gen-
Oncol 2014;32:1058–1065.
eral hospitals or specialized hospitals, such as MD Anderson.
This is happening because of the data and the increased rec-
ognition of the benefits. Much of the data are starting to be
Lorenzo Cohen, PhD, is a professor and director of the Integrative Medicine
examined for yoga as a treatment for different conditions. This
Program at MD Anderson Cancer Center, at the University of Texas, in Hous-
could involve researchers recruiting patients with breast can- ton, Texas. He is also a distinguished clinical professor at Fudan University/
cer who are fatigued, or recruiting patients with cancer who Cancer Hospital, in Shanghai, China.
have chronic sleep issues, and actually using yoga as a treat-
ment versus just offering it to all comers.
The other influential factor is, as I mentioned earlier, that To order reprints of this article, e-mail Karen Ballen at: [email protected]
we now know that most of the chronic, noncommunicable or call (914) 740-2100.

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