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Part 1: Yoga, Stress, and Cardiovascular Disease: A Cardiologist's Perspective 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. Part 2: The Role of Yoga in Mental Healthcare: Evidence and Integration We must take stock of the current situation: mental health needs to be improved. Improving mental health means enhancing our social capital. In fact, the World Health Organization recognizes mental health as a component of social capital, so we need to improve it. This has several consequences, including productivity. This year's theme is mental health in the workplace, focusing on its importance for enhancing productivity and caring for workers. The burden produced by mental health issues is enormous. Neuropsychiatric disorders contribute to more than one-third of the burden caused by all diseases. Among them, depression ranks highest in terms of contributing to this burden. The burden includes the number of people needing treatment, medication costs, loss of productivity due to illness, and the consequences of generating or worsening physical illnesses. Estimates indicate neuropsychiatric disorders contribute to a third of the total illness burden in society. In our country, the resources to meet this challenge of mental health and illness are far fewer. We have far fewer mental health professionals trained in allopathic fields compared to developed countries like the USA, UK, or Australia. We have 20 to 25 times fewer professionals per unit of population. This creates a gigantic task. Consequently, there is a huge treatment gap; even among the severely ill, over 75% have not received adequate treatment. This is a challenge we must meet. Can we produce enough psychiatrists? We need to increase their numbers threefold. At the current rate of production, it could take about three decades to reach the expected psychiatrist-to-population ratio. The challenge remains if we depend only on the allopathic system. Therefore, we must integrate. We must also bank on the Āyush systems. In fact, yoga can play a very important role. The descriptions of yoga are for bettering mental health. It has been used extensively and has worked very well in the past, along with Āyurveda. Can we bring it back? If we want to integrate it with the mainstream, there is serious potential. I believe yoga has an important role. To integrate yoga or use it as an alternative system in the care of the mentally ill—at least for some diseases—we need to generate evidence that the mainstream will accept. Even as an allopath, I need good studies to be convinced. We must demonstrate evidence that yoga has a place in mental health. Wherever yoga is referred to, it is concerning improvements in the mind. We heard this morning: yoga is for mental well-being. Today we talk of wellness, mental wellness, and nothing can replace yoga for achieving good mental health. Therefore, yoga must be exploited for investigation, research, and translation into the care of mentally ill individuals in the community, and also for health promotion. I will glance through a few studies where the evidence has been impressive. For depression, a meta-analysis by Kramer shows yoga versus treatment as usual, yoga versus relaxation, and yoga versus exercise. In all three, the evidence favors using yoga as a therapeutic ingredient in depression. We also conducted studies. One published almost two decades ago demonstrated that Sudarśana Kriyā Yoga of the Art of Living was as effective as medicine in treating major depression in hospitalized patients. We also found that adding yoga for people being detoxified from alcohol helped them lose depressive symptoms faster and more robustly than those without yoga. Enthused by these findings, we started the Yoga Center at NIMHANS. I must personally thank Dr. H. R. Nāgendra for the inspiration, and Dr. Basavaraddy. Through the Morārjī Desai National Institute of Yoga, we received a seed grant to start a yoga research center. We realized more people are seeking help for psychiatric disorders. The center now focuses largely on yogāsanas and prāṇāyāma; we have not been able to apply meditation extensively as psychiatrically ill people might have difficulty with meditative practices. Here is some data. As Dr. Basavaraddy mentioned, we need to refer to traditional textbooks and identify āsanas helpful for given syndromal conditions. Experts reviewed textbooks and literature to compile a set of yoga practices for each syndromal description. This was validated by more experts, fine-tuned, and tested in pilot clinical studies. We call them generic yoga modules. Just as we have generic drugs, we believe in generic yoga. We have demonstrated such generic packages for several conditions: schizophrenia, depression, anxiety disorders, obsessive-compulsive disorders, and ADHD. We have developed, validated, and partially published these modules. This graph shows an open trial (not a comparative one) where yoga produced substantial antidepressant effects in outpatient major depressive disorder patients. The other lines represent drug treatment and drug treatment with yoga. I am not asking for a comparison, but it shows yoga produces substantial effects. In schizophrenia, we studied patients attending the outpatient clinic. We invited them to participate in a trial adding yoga, adding exercise, or being placed on a waitlist. Over three months, more patients who received yoga showed improvements in the negative syndrome subscale—symptoms that are very difficult to treat. These patients had been on long-standing antipsychotic drugs. Yoga provided additional improvement, demonstrating integration. In a randomized clinical trial, yoga versus weight lifting, yoga produced substantial improvement in social cognition in schizophrenia patients—a difficult area to treat that significantly impacts productivity. These publications on yoga as an add-on treatment for schizophrenia have impressed international treatment guidelines. For the first time, yoga has entered the NICE (National Institute for Health and Care Excellence) guidelines in the UK for the treatment of psychosis as an add-on, thanks to studies from NIMHANS. There are many other research studies in anxiety, OCD, ADHD, and autism. However, challenges remain. More evidence is sought. Critics note studies are not double-blind and rely on subjective rating scales. They ask for objective evidence of change. Here are examples from our laboratory demonstrating biological markers of change in yoga-treated psychiatric patients. Depressed people have a lower amplitude of a cognitive event-related potential compared to healthy subjects. After three months of yoga practice (as the only treatment), the amplitude increased to match healthy subjects. Biological change occurred alongside improvement in depression. In another study, cortisol levels—a stress hormone—dropped in people with alcohol dependence. The decrease in cortisol paralleled the decrease in depression scores. We also examined brain-derived neurotrophic factor (BDNF), a neuroplastic element lower in depression. Yoga alone produced significant elevations in BDNF levels. This elevation was associated with an increase in hippocampal gray matter volume after six months of yoga practice in a small sample of elderly subjects—a surprising finding as hippocampal volume typically shrinks with age. In schizophrenia, GABA activity increases. We measured GABA tone via the cortical silent period. After yoga, it widened in healthy subjects. In a randomized clinical trial with schizophrenic individuals, yoga led to improvements in negative symptoms and social cognition, and a longer cortical silent period, indicating enhanced GABAergic tone. The last element is mirror neuron activity, which helps us connect with each other. Yoga should enhance this. In healthy subjects, a four-week yoga program increased mirror neuron activation. A similar effect was observed in schizophrenia subjects given yoga compared to wait-listed controls. Preliminary data suggests yoga enhances mirror neuron activity, possibly linked to increased oxytocin levels. Finally, research shows Oṃ chanting caused deactivation of the amygdala, a brain region associated with stress and cardiovascular risk. Thus, several biological probes demonstrate yoga's role in therapy. The evidence is robust, culturally acceptable, and integration is possible. Efficacy is demonstrated fairly robustly in depression and schizophrenia. I thank the MDNIY, SVYASA, CCRYN, and our institute staff at the yoga center. I thank you for bearing with me and the chairperson for the extended time. Part 3: Strategies for Wellness: Integrating Prevention in Schools, Workplaces, and Communities How can we achieve wellness? This is the central theme of this Congress. How must we proceed? What strategies should we adopt? How do we need to work? The foremost setting for this is our schools. All good and bad habits are formed in childhood. If our children are healthy, the nation will be healthy, and future generations will be healthy. We spend six to eight hours at our workplaces, so these must also be healthy environments. We live as part of a community, so the community should be healthy. We have experience working in all these settings—schools, workplaces, and communities—across northern India. These are considered the three most important settings. Our studies on the effectiveness of school-based NCD interventions in Chandigarh involved two cluster randomized trials of 12- and 20-week multi-component, multi-level lifestyle interventions, which included yoga. After 12 weeks, we found a significant increase in outdoor physical activity, reduced screen time, and improved food consumption. However, while behavioral risk factors changed, there was no change in physiological or biochemical risk factors. We then extended the intervention to 20 weeks. After 20 weeks, compared to the control group, children in the intervention group showed decreases in weight, waist circumference, and triceps thickness, with a significant reduction in the intake of energy, protein, and fat. These interventions proved feasible and effective in the community. We are now working on an accreditation program for health-promoting schools in Chandigarh, developing standards to categorize schools into bronze, silver, gold, and platinum categories. After successful implementation, we intend to upscale it. Regarding workplace interventions, the Ministry of Health asked us to develop an integrated healthy workplace model for the national NCD program. This model has three major components: promoting healthy practices, the physical work environment, and the psychosocial work environment. Today is World Mental Health Day, and we were discussing mental health in workplaces. A study of the risk profile in Chandigarh's industrial settings found that 45% of people working in three industries were experiencing stress. Other risk factors like overweight, obesity, hypertension, and a sedentary lifestyle are also very common. A study by the Confederation of Indian Industry across ten industrial settings in India also found very high stress levels. Interventions are needed, and yoga can play a very important role. In community settings, we developed district health promotion models in Hoshiarpur district (Punjab) and Ambala district (Haryana). The focus of this model was on integration and convergence within different national health programs, as well as with AYUSH and sectors like education, social justice, youth, and sports. It emphasized multitasking by health workers, pooling of resources, and multisectoral partnership. We found this health-promoting district model to be effective. India lives in villages and districts; if we can develop health-promoting districts, the entire country can become healthy. A critical question is: are we spending enough on prevention and wellness? An analysis of two progressive states, Punjab and Haryana, shows what proportion of the National Health Mission budget is spent on prevention. In Punjab, it was 0.6%; in Haryana, 1.2%. Most posts were vacant. How can wellness reach the grassroots with such meager funding? Unless we increase funding for the preventive component, wellness will not progress. Our calculations show that if the budget is increased to 4-5% of the total National Health Mission budget for each state, the wellness component can be mainstreamed and strengthened. We have studied the NCD risk profile in Punjab over the last decade. There is a very high prevalence of risk factors. For example, 95% of the population consumes less than five servings of vegetables daily. Despite being a food bowl, people avoid vegetables due to pesticide concerns. Over 90% have raised salt intake. The prevalence of hypertension is 40%, and 40% suffer from overweight or obesity; using waist circumference as a criterion, this figure rises to 60%. Out-of-pocket expenditure for NCDs is very high, with 70% spent on medicines or diagnostic tests. A strengthened system could address this. Our studies prove that health workers are effective in implementing most NCD interventions. This was upscaled in Chandigarh as the Chandigarh Healthy Heart Intervention Project, leading to Chandigarh becoming the country's first smoke-free city in 2017. Significant rural-urban disparities exist in health indicators. We need to strengthen our primary healthcare system. The National Health Policy provides for strengthening sub-centres into Health and Wellness Centres, but this requires functional integration and mainstreaming with yoga, leveraging the substantial workforce at the grassroots level. To achieve this mainstreaming, we need integration policies at national and state levels, strengthened public sector institutions, and active private sector engagement. With 40-60% vacancies in rural areas, adequate manpower is essential. Medicine supply, diagnostics, effective implementation research models, monitoring systems, and multi-sectoral involvement are all crucial. In the sustainable development era, we must focus on other sectors. In summary, for NCDs, we need both population-wide and high-risk strategies, focusing on surveillance and clinical services. Prevention must focus on three main settings: schools, workplaces, and communities. Surveillance is key for mapping risk profiles, and health system strengthening is required. The integration and mainstreaming of AYUSH with the allopathic system is crucial; these systems must work together. Regarding the World NCD Federation, we have a book on public health approaches to NCDs and publish the International Journal of Non-Communicable Diseases. I invite you all to the first World NCD Congress in PGI Chandigarh from 4-6 November, with the theme "Preventing Non-Communicable Diseases and Sustainable Development Goal." There will be a pre-Congress workshop on the role of Āyurveda and yoga in NCDs, led by Dr. Īśvar Vāsavadā and the Morārjī Desai National Institute of Yoga, and sessions on integrated medicine. Part 4: Integrating Traditional and Modern Medicine for Non-Communicable Diseases In addition to aiding in reducing the non-communicable disease burden, the project also aims to establish the effectiveness of Ayurvedic management alongside therapeutic lifestyle and yoga in patients with preclinical, prehypertensive, and borderline high-risk lipid levels. The methodology, as mentioned, involved Information, Education, and Communication (IEC) material. The profile across three districts included 49 community health centers and three district headquarters. We screened more than 113,000 patients, and out of those, 43,000 were enrolled for the different conditions. This is a two-year project to be completed in March 2018, and the data will be analyzed completely after the study's conclusion. Based on the leads we have so far and the analysis I am sharing, changes in blood sugar level, blood pressure, and lipid level at the third and sixth month have been assessed, and promising results have been observed. The comparison between newly diagnosed and already established patients has demonstrated the efficacy of Ayurvedic medicine and yoga in the pre-disease condition. The comparison between patients already established on medicine has provided the inference that the efficacy of Ayurvedic medicine and yoga in the disease condition is encouraging. As the program is ongoing, quarterly monitoring has been conducted to assess progress. During this monitoring, the assessment of the data documented until now showed encouraging results after implementing the integration of the IUSH (Integrative and Unified Systems of Health) component. An interim analysis has revealed that the doses or components of conventional medicine prescriptions were either reduced or discontinued in consultation with and under the supervision of allopathic doctors. After integrating the intervention of Ayurveda, lifestyle, and yoga in patients with diabetes and hypertension, Ayurveda and allopathic integrative healthcare services appear to be a successful attempt at functional integration through delivery in the context of non-communicable diseases. This includes encouraging benefits from stand-alone Ayurveda therapies, as well as benefits as add-on therapies. In conclusion, modification in lifestyle and yoga plays a vital role in the prevention and prognosis of non-communicable diseases. The present integration of IUSH with the NP-CDS program at the grassroots level will be a useful tool for future action plans and for taking appropriate policy decisions for integration to control the disease burden. Strengthening of the Ayush healthcare network by utilizing the services of Ayush doctors can be adopted for the prevention and control of non-communicable diseases through the primary healthcare network. This wellness cannot be adopted without the integration of Āyush and Yoga and Āyurveda and other Āyush systems into the mainstream healthcare system. Rāja Yoga for Stress Management Thank you. It was a very nice presentation, and several aspects of the model are emerging as successful. The main point is that Āyush doctors are almost equal in number to allopathic doctors in the country. If they perform the same functions as other doctors in the public healthcare system, they must engage in joint health promotion, prevention, early detection, and even treatment. In treatment, the patient is often confused about whether to take Ayurvedic medicine or allopathic. Most of the time, they sometimes take both, sometimes one or the other. I think research is required to determine, if both medicines are given, which combinations will be beneficial or harmful. This is an actual real problem at the patient's end, whatever medicines are available. Allopathic medicine has its own set of protocols, like metformin. In Ayurveda, I'm not sure about all treatments, but items like methī (fenugreek) and karelā (bitter gourd) are vegetables with hypoglycemic activity, and similarly for blood pressure. A lot of joint effort is required, and this project is successful. I am sure the manpower, efforts, and expenditure, jointly, can create a synergistic activity beneficial for the country. Āyush by itself, as we have decided, is a joint activity. I would emphasize again that yoga has to be practiced by every individual, every human being. It is a combination of psychology, philosophy, and technology. When Ayurveda talks about lust as the cause of disease, or prajñā-aparādha (intellectual error), that is exactly what Yoga talks very strongly about: mental disease. You cannot separate them. It has to be a combined effort, and we should carry on. One more thing: every human is different. Allopathy may not suit everyone; in somebody, Ayurveda may not suit. Everything should proceed, but the patient should be helped. That’s the whole point. I, respected chairperson and my dear friends, and dignitaries on the dais, have been listening. I am a very small entity in front of them. But one thing I noted: madam was saying "holistic approach" all the time. That is rightly pointed out; everything must be integrated and done jointly. I am really impressed with what has been done here. I have just today come from Mount Abu. Rāja Yoga is basically the teachings of the Mount Abu Brahma Kumarīs, and they have their education and research center. I was there for two days, which is why I greet you with the words "Om Shanti." Om Shanti means "I am a peaceful soul." Just for a second, realize, "I am a peaceful soul." I am talking about Rājayoga for stress management. I think sitting here for two hours listening to everybody must have caused a little stress or tiredness. So, for stress management, just see the person sitting on your right and give a smile, and now see the person on your left and give a smile. That is the remedy for stress. That is a result of Rāja Yoga. If we truly practice yoga, we will always smile, and that is the answer to all questions. Just smile. This is a very important step in any of the yogas, as I learned from Brahma Kumaris Rāja Yoga. A lot has been said about stress. We talk about external stress, whether physical, social, or economic. Basically, we are all sitting here managing stress. The stress is not from outside; it is our response to stress. That begins with Hans Selye's stress response. Everyone has talked about the amygdala, hypothalamus, how the autonomic nervous system works, and how the endocrine system works. I will not elaborate further on this or on stress-related diseases—whether stress is the cause or the effect. Any disease will result in stress, and many diseases have stress as a cause. Stress needs to be managed, and I told you a beautiful remedy: smile, smile, and smile. That is the first answer and the first yoga. Why? Because there are more than 100 muscles on the face, and once we smile, these muscles relax, solving many problems in life. One thing I find concerning is when I talk to people. Many say they don't have a job, so there is stress—agreed. They don't have money—stress, agreed. They don't have children—stress, agreed. But people who have jobs and experience job stress—how shameful is that? They have beautiful jobs as executives, doctors, engineers, yet they have stress. We have talked to a number of companies to see stress parameters. If you have a beautiful job and are getting a salary, consider these 10 simple questions. If the answer is positive to three, it indicates stress: 1. Do I feel unhappy many times at the workplace? 2. Isn't the work too boring? 3. Do I feel tired at the end of the day? I have earned money; I should not be tired. 4. Am I sick of my job? 5. Is going to my office all six days in continuity too much? 6. Do I create stories or excuses for my absence from the workplace? 7. Same work every day? Depressing. 8. Do I get stressed out by my boss? (The most common answer is yes.) 9. Is reaching on time difficult? 10. Do I feel stress completing my targets? When we survey executives earning five-figure salaries, 50% answer yes to these questions. This means we need to do something, as has been stressed: integrate with yoga, meditation, a smile, and happiness from inside—not from outside. The stress is not from outside; it is basically something lacking inside. Madam rightly pointed out, and doctors have pointed out, that lust and greed are creating a vacuum inside. For that, we need to be aware of what is happening to us. Stress is not outside; it is in our thoughts, how we think. This thinking results in irritable behavior, anger, fear, jealousy, irritability, suspiciousness, and family problems. This affects our body, mind, emotions, and behavior, filling us with stress. Young, smart, educated people in good jobs see their condition: they cannot manage time, sleep properly, worry constantly, feel tired, sick, have job problems, anxiety, and ultimately develop a condition—not a new one—studied extensively: burnout syndrome. There is a difference between stress and burnout syndrome. Stress means you have multiple engagements, are overactive emotionally, feel urgency, experience loss of energy, and may have an anxiety disorder. But burnout is very difficult to treat and is happening nowadays not only to older people but also to younger people and medical professionals—nurses and doctors. Burnout involves disengagement; they don't want to do anything. It results from overstress, leading to blunted emotions, headlessness, hopelessness, no motivation, detachment, depression, and a feeling that life is worth nothing. Let's prevent it. We have a beautiful tool in our hands: yoga and meditation, which everyone has been focusing on. This needs to be incorporated into our day-to-day life. People talk about stress management, with many resources available online and paid courses. They say: A for Awareness, B for Balance, C for Control. It is easy to say but very difficult to bring into our lives. What awareness? Who am I? What is my job? These awarenesses exist, but how to manage the self? A very important thing is to keep balance: family balance, health balance, friends balance, life balance, career balance. But how to do it? It's easy to guide others, but doing it in our own life is most difficult. We have seen police personnel who want to control others but become out of control themselves. We have given many lectures to police about their family life, personal life, and studies, noting many divorces and family problems because they cannot control themselves. We need meditation and yoga in our life for a balanced life. We should have stress outlets: a family support system, social support system, spiritual support system, and a positive work environment with healthy food. Don't think someone will give this to you; you have to create it. We have to create everything, and for that, we must know ourselves and our level of joy and satisfaction. Let's talk about the self. How many of us know who we are? Nobody teaches us spirituality. There was a time when the home itself taught us—our parents and grandparents. Now, nobody teaches us, "Who am I?" The body is made of five elements, and the soul is made of seven qualities or energies. That is the first lesson of Rāja Yoga: I am a peaceful being. Just think about that and realize the peace in yourself. The second lesson: I am a happy being. Third quality: I am a loveful being. I am a pure being. I am the blissful Ānandam. I am a powerful being. I am a knowledgeable being. Awareness of all these will make me realize who I am. Once I have my self-identity as peaceful, how can I be furious? That means I am not aware of the real fact of who I am, I don't do self-analysis, or I have not recognized myself. Therefore, if I want success in any field—family, relationships, job, anything—for a beautiful life, I need self-realization and to maintain my self-esteem, not ego. Ego will bring anger, but self-esteem—knowing who I am: a peaceful being, a powerful being—enables me to take the right decision and discern what must be done. This is power—not to fight with anybody. I need self-improvement. In this Rāja Yoga meditation study, I have conducted several studies available online. In practical form, we become beautifully organized, develop divine virtues, and bring spirituality into life practically. We are not running from responsibility but are engaged in it. We are very busy, yet our mind is easy; we are cool. People say a boss cannot be cool. Yes, a boss needs to be cool. I came from Mount Abu this morning. All the people there are cool, yet they handle a lot of administration. I invite you to come to Mount Abu. On 26th January, they have a conference. You are all invited to see the practical application: very constructive, very cool. These are examples with our children. We are doing this simple practice of Rājayoga with children, as well as with headache and Parkinson's disease patients. Being in the cardiac neuro center, I meet cardiac and neuro patients. Look at the smile on these children's faces. Just three lessons of Rājayoga were given to them in the hospital premises. See, a child was absolutely dull in the ICU, complaining of pain after heart surgery. Immediately after teaching him, "Who am I? I am very loveful. I am very peaceful," the first lesson, and "I belong to the one who is the ocean of peace. He is my father," this is how to connect the soul to the Supreme Soul. That is called Rāja Yoga—the ruler of our own self. The child starts smiling in the ICU. You can imagine how this improves healing. Rājayoga means just the soul—that is the energy, the live wire. Like a live wire connected to a power source, we get electric power. Similarly, the life in the body is the soul, and the supreme power is the source. The mind is the cable in between. Through the medium of the mind, we connect to the supreme power, and thus we start receiving peace, love, and happiness. It is very easy. There is a meditation room in the AIMS Cardiac Neuro Center where we do this. Our first study was on simple chronic headache patients. The neurologist and I sat together—as madam said, it was jointly done. We taught meditation and assessed them together. Similarly, we see in ourselves that those who start practicing meditation and helping others develop better clarity of mind, decision-making, the art of teamwork and leadership, time management, a cool temperament, a very positive attitude with self-esteem (no ego), and a balanced personality. For that, we need a connection with God. It is not difficult. If you want, I can make you practice here in just one minute. Can you all see me? I will make it a little okay. I will not move anything, but I would like you to sit comfortably. As we command our body, similarly command yourself—the soul, the thinking process, the intelligent process inside. This is called balance and control, the practice of command. Direct your mind to your feet: relax, relax. To your leg muscles: relax, relax. To your knee joint: please relax. Thigh muscles: relax. Hip muscles: relax. The back, all muscles: please relax. See your legs are totally relaxed. You can keep your eyes open or closed; it doesn't matter. Keep giving commands to your body. Relax. Abdominal muscles: relax. Back muscles: relax. Take a deep breath. Release slowly. Again, deep breath. Release slowly. Neck muscles: relax. Shoulders: relax. Both arms: relax. Smile on the face. Face muscles, head muscles: relax. Totally, the body is relaxed. Now tell your mind: "Relax, mind. You are very peaceful. You are very peaceful." Think positive: "I am a peaceful soul. I forgot about it. Now I realize, but when I analyzed, my peace is hardly there. On small things, I become peaceless." A small thing happens, and I become peaceless. So let me go and fill the vacuum of peace from the one who is the ocean of peace. Let's come up with the body, go higher, above the sky. Through the medium of my mind, reach above the sky, and you see orange, reddish, golden light. This light is coming from the supreme power. He is just a supreme soul, not a corporeal being. From there, we feel as if we are in a fountain of peace. Peaceful vibrations are coming on me like a fountain. I feel so comfortable, so filled with peace, absorbing all vibrations of peace. Now, full of peace, I come back to my body, inside the body, in my forehead, and I start giving peaceful vibrations to my whole body. The body is relaxed, the body is peaceful—totally relaxed and peaceful. Vibrations of peace around me, all over me, in the whole world. Very peaceful, very relaxed. You can open your eyes and feel how peaceful and relaxed you are. Are you able to? If you can do this for one minute, you can do it in all situations. It is just a matter of practice. If we say we cannot even practice for a minute a day, that means we are not caring for ourselves. I would like to end here. I have many studies you can see online; a few I mentioned here. I thank the organizer and everybody for this patient hearing and for even improving my knowledge. Thank you so much.