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Welcome to the house of the Honourable Chairperson. Chairperson, we have already introduced Srimatī Hansājī Jayadev, and co-chairperson, Dr. Sudhir Gupta. He is Additional Director General in the Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare. He is dealing with clinical research. For twenty years, he has been a gold medalist in public health. He has dealt in detail with organ transplantation, the Clinical Establishment Act, cancers, NCDs (non-communicable diseases), and all such types of subjects for the last 20 years. So, such a learned person is with us, and Madam Hansājī Jaidev has already given her glimpses in the morning session. So without much formality, let us start with the first lecture. May I request Professor Dr. B.N. Gangadhar? Director, sorry—yes, Dr. Professor Gautam Sharma jī is to leave for some urgent engagement. He is a professor in the Department of Cardiology and in charge of the Centre for Integrative Medicine, AIIMS, New Delhi. Very briefly about him: he is a visiting professor of S-VYASA University, Bangalore. He did his MD in internal medicine from PGIMER Chandigarh and DM in cardiology from AIIMS. His postdoctoral fellowship was in cardiac electrophysiology from Royal Adelaide Hospital, Australia. He is a senior interventional cardiologist with expertise in complex coronary interventions and radiofrequency ablation for cardiac arrhythmias, his area of interest being atrial fibrillation. He has authored several scientific publications in leading peer-reviewed journals and is a regular speaker at national and international cardiac electrophysiology conferences focusing on atrial fibrillation. He is passionate about integrating yoga and other traditional Indian systems of medicine. May I request him to kindly deliver his speech on yoga, stress, and cardiovascular diseases. Thank you. Thank you for your kind introduction. Good afternoon, chairpersons and dear colleagues. Today is World Mental Health Day, and it’s very appropriate that I’ll be speaking on stress, cardiovascular disease, and yoga. This is a map of the world color-coded to show the magnitude of ischemic heart disease. The gray represents the heart disease, and you can see that from west to east, from north to south, it’s all gray. So the magnitude is such. This again shows the burden of cardiovascular disease. This is from the United States because we have the best data from there. This is showing how the clock is ticking, showing us the burden of cardiovascular disease. As you can see, every 40 seconds somebody dies of cardiovascular disease, every 40 seconds somebody has a stroke, and every 4 minutes somebody dies of a stroke. Cardiovascular disease remains the leading cause of morbidity and mortality, accounting for 31% of all global deaths. What about in India? This is actually a nice picture from the Times of India. It again shows that cardiovascular disease remains the number one killer. This is from an article published in Circulation by my colleague, Dr. Prabhakaran. They analyzed complete data and showed that 37% of the world’s deaths from cardiovascular diseases occur in the developing world, and India tops there. The age-standardized cardiovascular disease death rate is 272 per 100,000 population in India, against a global average of 235. The years of life lost to cardiovascular disease in India have increased by 59 percent from 1990 to 2010. You can see that we remain the world capital of cardiovascular disease in terms of our morbidity and deaths, and we lose a lot of young people to this malady. Now, this is data from the United States of America, arguably the most developed country in the world, especially in terms of medicine and cardiovascular medicine. Despite the numerous advances of CABG, angioplasty, and heart failure devices, cardiovascular disease remains a leading cause of morbidity and mortality. They spend in the U.S. $200 billion every year, and it’s likely to increase two- to three-fold over the next decades. Therefore, there is a need for inexpensive interventions. Despite spending all the money and despite all the advances, it is still a growing disease. Now interestingly, if you talk to the patients—this was a U.S. National Health Interview Survey wherein they actually talked to cardiovascular disease patients—they found that 14 to 24% of Americans with cardiovascular disease have been reported to use or have used some form of mind-body therapy. We are talking about the United States. Even more interestingly, these patients, when they said that, almost 50% of them said they’re ready for any alternative native therapy. So even the patients feel that there is something missing. So what is missing? We all know this. Stress is a cardiovascular risk factor. I would say this statement, just to bring out what I strongly feel, that chronic stress should be treated on par with the other cardiovascular risk factors like hypertension, diabetes, dyslipidemia, and smoking—but we ignore it. I’m a cardiologist, and I ask my patients about all these risk factors. But do I ask them, "Are you stressed out?" or do I give them a questionnaire to assess their stress levels? No. We are missing a lot that we can do to help these patients. You know the physical manifestations of stress: there’s a pro-thrombotic state, there’s inflammation, angiotensin activation, oxidative imbalance, sympathetic overdrive, endothelial dysfunction. All of them have been shown in physiological studies. All of these together, or even each one of them, contribute to atherosclerosis, microvascular apathy, perfusion defects, and, obviously, cardiovascular disease. I wanted to share this very interesting paper; I think Dr. Gaṅgādhar is aware of this. This was a study recently published this year in The Lancet from the Mass General Hospital in Boston. The researchers studied the relation between amygdala activity and cardiovascular events. We know that the amygdala is associated with emotional disturbances and stress, and we know that stress is a cause for cardiovascular mortality and morbidity, but we didn’t know whether there’s a direct link. These researchers wanted to study this. They took individuals who were undergoing FDG PET and studied them longitudinally. They studied amygdala activity, bone marrow activity, and arterial inflammation. These are the results. As you can see from the image above, there was, in this image, a lower amygdala activity compared to the one on the right. Here, this is a left ventricle, and this is the aorta. Comparing these two images, there’s a lot of uptake of FDG here, showing active, very active uptake. Similarly, if they looked at the bone marrow, they showed that there was a lot of uptake. This was very interesting. This is the first study that actually demonstrated that metabolic activity within the amygdala is associated with risk of developing cardiovascular disease. These patients, who had amygdala activity and also had uptake in the aorta, are the patients who eventually had cardiovascular disease when they were followed up clinically. This is the first study, so I’m very excited to share with you that they have actually shown an anatomical link of stress to cardiovascular disease. This is the hypothesis: they presume and hypothesize that this is mediated by arterial inflammation, and that is because of these cells that produce cytokines and inflammatory cytokines from the bone marrow. As you saw, the bone marrow was activated, the aortic vessel wall was activated, and the amygdala was activated. So there’s a link. This is the first study that showed this relation. This is exciting because it actually gives us the first proof that alleviation of stress, beyond the psychological well-being, can actually improve the atherosclerotic milieu. This is very significant; this was what we were presuming all along, but this is the first study to show this. Again, the statement that I shared with you, that chronic stress should be treated as a key risk factor for cardiovascular disease—we all know the benefits of yoga much more than I do, and you and I needn’t go into elaborating on this. Interestingly, there was another study I wanted to share. We all know that you do yoga, you improve the blood pressure, anxiety, quality of sleep, waist circumference, etc. But this is interesting because this is a study published again recently, wherein they looked at gene expression changes. There have been small studies, and this particular meta-analysis of 18 studies was trying to answer the question: what is the molecular signature of mind-body interventions? They looked at 18 studies with different types of mind-body interventions like yoga, quick relaxation response, breath regulation—studies that studied gene expression. What they found is that these practices are associated with a down-regulation of the nuclear factor kappa B (NF-κB) pathway. This NF-κB is a marker of stress. This down-regulation is important to understand: with chronic stress, what happens is an up-regulation of this pathway, leading to bone marrow activity, inflammation, atherosclerosis, and cardiac events. With yoga and the other interventions, there is a down-regulation. It has been shown that there’s a down-regulation, and we presume that this is the mechanism by which the inflammation decreases and the subsequent atherosclerotic milieu improves. This is, again, a landmark study. Now, what about Indian studies? What about the studies that have been done here? There are a couple of studies from my institute which show that there is better management of post-CABG risk factors, and there is a prevention of the progression—in fact, a retardation of coronary artery disease. But these were very small studies with a high dropout rate. There was no blinding. So there were a lot of deficiencies, and nothing conclusive could be got out of them. What do we have? I did a review, and we have a couple of meta-analyses to increase the number of patients studied. This one was published in the International Journal of Cardiology. They looked at yoga’s effect on cardiovascular disease risk factors (not stress). There were 44 RCTs with a total of more than 3,000 patients. They found yoga improved systolic and diastolic blood pressure, waist circumference, cholesterol, and HbA1c. So there was evidence for clinically important effects of yoga. But, despite the first positive sentence, they write "despite methodological drawbacks." There were methodological drawbacks, but they still say yoga can be an ancillary intervention for patients with CVD. In fact, just last week, the AHA brought out a similar consensus statement on meditation and cardiovascular disease, saying meditation can be used as an ancillary method. So all of this is coming from the U.S.; we have to do something fast. This is another meta-analysis studying the effectiveness of yoga in modifying factors for cardiovascular health. They essentially looked at metabolic syndrome across 37 RCTs. They concluded there is promising evidence of yoga improving these metabolic health factors. But again, they say these findings are limited by small trials, sample sizes, heterogeneity, and moderate quality of the RCTs. Every time, this is the Achilles' heel: we don’t have good trials. Even though we believe there’s benefit, and small trials have shown benefit, we don’t have robust scientific data. Here is another one: they did a literature search using "heart disease and yoga" and came across only seven RCTs with 600-odd patients. Four were in coronary artery disease, two in heart failure, and only one in cardiac arrhythmia. They concluded that only weak recommendations can be made for the ancillary use of yoga for patients with coronary heart disease. These weak recommendations are because of the weak studies. What we need today is good, robust data. We need trials with adequate sample size. We need randomized controlled trials. We need an active control to yoga. Most of these trials have just done yoga and followed up with patients, but they don’t have an active arm. Most have been single-center trials; we need multi-centric trials. All this is very important for the world to actually accept what they’re beginning to realize: that yoga is useful. Then there’s a question of the additive value of complex yoga interventions. Yoga is not just physical āsanas, as you know very well. It’s meditation and breathing techniques. Most trials I’ve talked about have looked into just the physical aspect of yoga. What will happen if you introduce the whole yoga as a whole, yoga in its pure form, what it actually is? We don’t have data about that. Another interesting point: most data is from India. Culturally, we accept yoga; it’s our heritage. But are the results going to be the same in the Western population? We presume they will be because humans are the same everywhere, with the same physiology, but we don’t have data. In our own small, humble way at the All India Institute, we have this Centre for Integrative Medicine, started with the help of AYUSH. We are studying integrative medicine. We have a whole lot of trials going on with mainstream specialists—neurologists, pulmonary medicine, cardiologists, etc.—and yoga physicians. We want to generate robust scientific data using contemporary study methodology. With this, I think I’ll end my talk. Thank you for your kind attention. Well, Dr. Gautam Sharma, your concern is very valid. But in yoga, they talk about the heart as a seat of emotion, and when we deal with the heart, first we have to deal with emotions. At the yoga institute, when we did research work on the heart with 100 patients, we found all these things which you are talking about. Right now and here, I always say that the mortality rate of a human being is one, but really what happens is that there is a death of love. That becomes also a death of love. When there is a divorce, when people are fighting and children suffering, all these things affect the heart. There was one lady whose son was taking drugs, and she was following all the āsanas, prāṇāyāmas, meditation, and whatever was told. But she was not improving. Then the whole team went to meet that child who was taking drugs. And when that boy improved, the lady’s heart became perfect. The atherosclerosis was taken care of, blockages had gone, and things improved so fast. So we have to work at that holistic approach to life, and the heart also would be definitely getting affected. Thank you very much for your such a lovely talk. Dr. Gautam Sharma is to leave, so I request the chairperson to kindly honor him with a memento. Thanks, Dr. Gautam Sharma, for a very prestigious talk. The second lecture is from Professor B.N. Gaṅgādhar. He will deliver on yoga for mental health. Professor B.N. Gaṅgādhar is the Director of the National Institute of Mental Health and Neuro Sciences since 2014. He was previously the HOD of the Department of Psychiatry and also the Dean of Life Sciences at S-VYASA Yoga University, Bangalore. He is a D.Sc., Doctor of Science, from S-VYASA. He has more than 350 indexed papers in various national and international peer-reviewed journals and is the investigator and co-investigator for many research projects with ICMR, DST, and others. May I request him to kindly deliver his lecture. Very good afternoon to all of you. Today happens to be the 25th World Mental Health Day. An important occasion—I bring all the best wishes from my colleagues at NIMHANS to all the delegates in this conference. It is very appropriate that this conference has chosen a theme, chosen a talk on mental health to be delivered here, and I am doing the duty of presenting yoga for mental health: some evidence from our research and the importance of mental health in particular. You know that health without mental health is incomplete. Even Āyurveda defines health as prasannātmendriyamanāḥ svāsthyamiti vidyate. So it is important that we keep mental health as a serious concern. Mental health and physical health have serious interactions. Low mental health means low physical health as well. Good mental health means good physical health as well. So it is important that when we are talking about health and yoga, mental health becomes very important. When we are talking of health for all, which means also mental health for all, this is a challenge today. I am sure you must be reading in the papers as to what the difficulties are and where we need to actually exploit the opportunities that the AYUSH provides in mainstream medicine, which is currently using only allopathy. Whether we can integrate Āyurveda, yoga, and other systems into the existing mainstream medicine for the benefit of the mental health of the community. I have given a list of primary, secondary, tertiary prevention, and also health promotion. I believe, having gone through the literature, there is evidence that in all places yoga can play an important role. In fact, in health promotion, yoga alone could be as good. In other places, maybe you have to use some medicines. In some places, medicine can take priority over yoga, and vice versa. But I believe the integration of yoga, like we heard in the previous talk about cardiovascular diseases, has several benefits. So I believe all medical interventions could have an integrative component of yoga, and it is something that is non-invasive and is not going to have interaction with the drugs—unlike if you are going to give Ayurvedic drugs and allopathic drugs. The allopaths say no, and the Ayurvedic people also say no. There are drug interactions, etc., and it goes on. Whereas yoga is something I would call a secular intervention in all treatment; I believe it should happen. What we do when we treat the patient is we make him lose the illness. Would that person become fit enough to work, fit enough to be well? It is not true, and so we have to use the health promotive techniques. One of them is, I believe, yoga. Coming to mental health, I just want to highlight the significance of mental health and the magnitude of the problem. The National Mental Health Survey that NIMHANS conducted just a year ago—we gave the report. In fact, last year on Mental Health Day, this report was released to the public and was available on the net for anyone to see. The numbers are quite staggering. All along, we used to think we don’t have so many mentally ill people in the country. Maybe the West is exaggerating. But having seen this study, having seen the data, we have as many mental disorders as any other country that you may want to name. And interestingly, the urban society has more mental illness than the rural society.