The prevalence of chronic diseases like obesity, hypertension, cardiovascular disease, type 2 diabetes mellitus, and cancer is increasing globally. This has led people with chronic diseases to turn to lifestyle modification programs, which are known to reduce the burden of these diseases. Recent evidence also suggests lifestyle changes aimed at healthy food choices, exercise, behavioral modifications, good sleep, and stress reduction to reverse the adverse impact of chronic diseases. The recommendations from the recent Lifestyle Medicine Research Summit emphasize the need for lifestyle medicine to move beyond biomedical goals (returning to normal biochemical values in chronic diseases) and include sociocultural and environmental factors as important components in the prescription process.
Yoga & naturopathy is one of the most widely used lifestyle medicine approaches across the globe in the management of chronic diseases.[3–6] The foundational principles of yoga & naturopathic medicine emphasize the role of patient education in treating a condition.[7,8] Here, patient education is intended to bring changes in the patient’s physical, mental, and social planes, which is thought to enhance the effectiveness of lifestyle changes. Recent evidence suggests that personality traits may play a role in the prevention and management of chronic diseases. The burden and suffering of chronic diseases are connected to personality qualities like neuroticism and conscientiousness. An earlier study reported personality traits as an important factor in determining the efficacy and adherence to lifestyle interventions. This indicates the need for envisaging plans that can bring about changes at the personality level.
Large-scale evidence supports the efficacy of yoga & naturopathy lifestyle interventions on diabetes mellitus, hypertension, cancer, obesity, musculoskeletal disorders, reproductive disorders, and psychological disorders.[15,16] However, most of these studies used a therapy-centric approach, and the outcome measures of these studies are limited to biochemical and anthropometric changes. A recent study reported that an education-based yoga lifestyle intervention can induce changes in personality and is more beneficial than a therapy-centric yoga program in alleviating abdominal obesity. Barring this 1 study, there are no other reports on the impact of yoga & naturopathic lifestyle medicine programs on personality traits.
Lack of evidence for complementary and alternative medicine (CAM) beyond biochemical normality will confine CAM therapies to merely an adjuvant modality. Hence, it is warranted that CAM systems like yoga & naturopathy explore the utility of their holistic philosophies through robustly designed clinical trials. The present study hypothesized that 10 days of health education-based yoga & naturopathic lifestyle interventions would induce change in personality traits, improve vitality and quality of life (QoL), and increase patient satisfaction compared to a routine therapy-centric approach among patients with non-communicable diseases.
2.1. Trial design
The trial was a single-center parallel group pilot randomized control trial where we determined the effects of offering patients with non-communicable diseases health education-based yoga & naturopathy lifestyle intervention group (HYNLG) compared to therapy-centric yoga & naturopathy lifestyle intervention (TYNLG). This was conducted as a pilot study, as there were no previous studies conducted in this domain and the feasibility of a trial of this kind in Indian CAM settings is unknown. The trial was undertaken at a private medical college hospital in India. The recruitment of the participants commenced in September 2022, and the last enrollment was completed in October 2022. The study was approved by the Institutional Ethics Committee of the study setting and registered as a clinical trial in the Clinical Trial Registry of India. The Consolidated Standards of Reporting Trials flow diagram of the trial is depicted in supplementary file S1, Supplemental Digital Content, https://links.lww.com/MD/I664.
We included participants with non-communicable diseases who enrolled in a 10-day yoga & naturopathy-based lifestyle modification program in the study setting. The study participants were invited to participate in the trial through advertisements in newspapers, social media, and flyers. All the participants, aged between 30 and 70 years, with a known non-communicable disease (pre-diagnosed and documented by their general practitioner) at the time of recruitment were considered eligible to participate in the study. Those participants who are suffering from any known psychiatric conditions, any communicable diseases, are already a part of any other trial, or who did not consent to a 10-day inpatient stay were excluded from the study.
The HYNLG and TYNLG participants received similar yoga & naturopathy-based lifestyle intervention therapies for 10 days, which included hydrotherapy, mud therapy, diet therapy, supervised fasting, sunbathing, acupressure, and massage therapy (see supplementary file S2, Supplemental Digital Content, https://links.lww.com/MD/I665). These therapies were provided under the supervision of licensed yoga & naturopathy physicians. In addition to these therapies, the HYNLG group received a 10-day orientation (1 h/d) on various concepts centered around belief systems, lifestyle changes, and their impact on health.
This health orientation series was designed based on the naturopathy philosophy, “Doctor as Teacher (Docere)” where the yoga and naturopathy physicians educate their patients and make them a part of the healing process. Instead of simply intervening with therapies, each day of the inpatient stay was used to empower the participant to take their health into their own hands. The orientation program topics are depicted in Figure 1. The TYNLG participants received routine physician consultations. The interventions were developed by the investigators, who have completed a 5.5-year bachelor’s program in Naturopathy and Yogic Sciences and are licensed to practice yoga and naturopathy with A-class medical registration.
The sociodemographic characteristics of the participants were collected at the baseline. The following outcome measures were recorded at the baseline and 10 days after the intervention.
2.5. Primary outcome measure
The primary outcome measure was a change in personality traits, which are considered to be a determinant for better melioration of non-communicable diseases. The change in personality traits (gunas) was measured using a validated 56-item Vedic Personality Inventory, where the qualities of a person are divided into 3 categories named Sattva, Rajas, and Tamas. Sattva personality is characterized as “satisfaction, simplicity, gravity, self-control, and purification.” Rajas personality is characterized as “greedy, always envious, impure, and moved by joy and sorrow,” whereas the tamas personality is characterized as “ignorant, careless, idle, and lazy.”
2.6. Secondary outcome measures
Vitality: Vitality defined as the ability of a person to cope or to be resilient against the odds was measured on a linear visual analog scale of 1 to 10, where “0” represents poor vitality and “10” represents higher vitality.
QoL: The QoL was measured by using a 12-item SF-12 health questionnaire, which assesses the physical and mental QoL using 8 health domains such as general health, physical functioning, role physical, body pain, vitality, social functioning, role emotional, and mental health.
Hamilton Anxiety Scale (HAS): A 14-item HAS was used to quantify the severity of anxiety among the participants. HAS uses a 5-point Likert scale, in which a higher score indicates severe anxiety.
Visit-Specific Patient Satisfaction Questionnaire: Patient satisfaction was measured using a 9-item Visit-Specific Patient Satisfaction Questionnaire instrument, where the responses for each item were averaged together to calculate a final satisfaction score.
Clinical and anthropometric indices: All the participants’ body weight, body mass index (BMI), blood pressure, and pulse rate were measured.
2.7. Sample size
The sample size was calculated using G Power software version 3.1 (Heinrich Heine University, Dusseldorf, Germany). As there were no previous studies available, based on our clinical experience, we assumed a standard large effect size of 0.8, and the level of significance (α = 0.05) and power (β = 80%) were considered as per clinical research standards.[24,25] Based on this consideration, the sample size was calculated as n = 52, however, considering a 6% attrition rate, the final sample size was calculated as n = 56.
2.8. Randomization and blinding
Randomization was performed after baseline assessments using an online computer random number generator. Using the random number generated, the patients were allocated at a ratio of 1:1 to the HYNLG (n = 28) and TYNLG groups (n = 28). The allocation concealment was done by using a sealed envelope. The investigators, statisticians, and participants were not blinded for group allocation.
2.9. Statistical methods
All statistical analysis was performed using Jeffreys Amazing Statistics Program version 0.16.1, University of Amsterdam, Netherlands. The Shapiro-Wilks test was used to assess the normality of the data. Paired T tests and the Wilcoxon signed-rank test were used to compare data within groups, while independent T tests and the Mann–Whitney test were used to compare changes between groups. Pearson’s correlation was used to investigate the association between the variables. P values of 0.05 were considered statistically significant.
The study was completed by all 56 participants. There were no adverse events reported by participants in either group. The baseline characteristics of both groups are outlined in Table 1.
Table 1 -
Baseline characteristics of study participants.
||Experimental group (n = 28)
||Control group (n = 28)
||46.71 ± 18.63
||46.6 ± 14.34
|Average duration of first consultation (in min)
||26.87 ± 10.85
||22.82 ± 5.9
||163.35 ± 10.64
||161.5 ± 8.16
|Body mass index
||28.67 ± 8.2
||27.35 ± 4.7
|Average hospital stay
Musculoskeletal disorders 4
Gastrointestinal disorders 1
Skin disorder 3
Cardiovascular disease 7
ENT disorder 2
Neurological disorder 1
Metabolic disorder 8
Musculoskeletal disorders 6
Gastrointestinal disorders 3
Skin disorder 1
Cardiovascular disease 9
ENT disorder 2
Neurological disorder 1
Metabolic disorder 3
Autoimmune disorder 1
ENT = ear, nose, and throat.
3.1. Changes in the vitality scores and personality traits
Both the groups have shown significant improvement in the vitality scores; however, the changes were predominant in the HYNLG compared to the TYNLG (P < .001). Similarly, compared to the baseline, there was a statistically significant increase in the Sattva personality and a reduction in the Tamas personality in both groups. Rajas personality has shown a significant reduction in the HYNLG group alone. When compared between the groups, HYNLG has shown a significant increase in the Sattva personality (P < .001) and a reduction in the Rajas (P < .001) and tamas personality (P = .03).
3.2. Changes in the QoL
The mental component summary scores have significantly increased in both HYNLG and TYNLG post-intervention, whereas the physical component summary has shown significant improvement only in TYNLG. HYNLG significantly differed from TYNLG with respect to improvement in the mental component summary (P = .04); however, the changes were not significant between the groups for the physical component summary.
3.3. Changes in the anxiety score
Both groups have shown a significant reduction in the anxiety scores compared to the baseline; however, the reduction was more pronounced in the HYNLG (P = .04).
3.4. Changes in clinical parameters
A pre- and post-comparison within the group revealed statistically significant weight and BMI reductions in both groups. Similarly, we observed a significant reduction in the systolic blood pressure of the HYNLG participants. However, there were no statistically significant differences observed between the HYNLG and TYNLG in weight, BMI, systolic blood pressure, diastolic blood pressure, and pulse rate.
3.5. Patient satisfaction level post-intervention
The HYNLG participants have shown significantly higher satisfaction with the lifestyle program offered when compared with the TYNLG participants (P = .04). The detailed results are tabulated in Table 2.
Table 2 -
Summary of changes before and after the lifestyle program between the groups.
||Experimental group (mean ± SD) within group analysis
||Control group (mean ± SD) within group analysis
||Effect size (95% CI)
P value in-between group analysis
||75.39 ± 18.02
||72.81 ± 17.22‡,∥
||70.97 ± 12.3
||68.94 ± 11.53 §,∥
||28.67 ± 8.27
||27.73 ± 8.02‡,∥
||277.35 ± 4.75
||26.76 ± 6.64 §,∥
|Systolic BP (mm/Hg)
||125 ± 10.68
||121.92 ± 4.97‡,∥
||128.78 ± 20.23
||128.35 ± 15.01§
|Diastolic BP (mm/Hg)
||79.57 ± 6.56
||78.8 ± 11.36‡
||83.5 ± 11.36
||81.71 ± 7.63‡
||75.92 ± 3.04
||75 ± 2.82§
||74.46 ± 3.33
||74.28 ± 2.08§
||6.64 ± 1.19
||7.75 ± 0.64§,∥
||5.92 ± 1.58
||6.82 ± 0.72 §,∥
||44.82 ± 6.58
||47.28 ± 6.35§,∥
||39.89 ± 6.67
||41.35 ± 6.19‡,∥
||30.75 ± 3.03
||29.57 ± 3.06§,∥
||32.71 ± 2.86
||32.67 ± 2.8‡
||24.64 ± 5.04
||23.21 ± 4.92§,∥
||27.6 ± 5.71
||26.28 ± 5.74‡,∥
||42.09 ± 8.006
||43.4 ± 7.04§
||38.83 ± 6.03
||42.92 ± 8.84‡,∥
||47.45 ± 8.53
||51.31 ± 8.11 §,∥
||42.42 ± 8.84
||46.99 ± 7.58 §,∥
|Hamilton Anxiety Score
||13.67 ± 8.76
||8.1 ± 6.08 §,∥
||23.71 ± 13.38
||15.63 ± 11.58 §,∥
||39.67 ± 4.53
||36.03 ± 6.25
BMI = body mass index, BP = blood pressure, CI = confidence interval, SD = standard deviation, VAS = visual analog scale.
*Independent t test. † Mann–Whitney test. ‡Paired t test. §Wilcoxon Signed-rank test. ∥P < .05.
3.6. Association between personality traits, anxiety, and QoL
Further, the duration of consultation has shared a weak positive correlation with Sattva personality (ρ = 0.220) and a weak negative correlation with the Rajas (ρ = −0.230) and Tamas (ρ = −0.138) personality traits as well as with anxiety scores (ρ = −0.182). Likewise, mental QoL had a weak positive correlation with Sattva personality (ρ = 0.363) and a weak negative correlation with Rajas (ρ = −0.188) and Tamas (ρ = −0.367) personality. The correlations are depicted in Figures 2 and 3.
The present study explored if adding a health education component based on yoga & naturopathy philosophies to lifestyle modification programs is more beneficial than therapy-centric lifestyle modification programs. We found that including a health education component in lifestyle modification programs can alter participants’ perceptions and behaviors. HYNLG participants in this study have shown an increase in the Sattva personality trait and a reduction in the Tamas and Rajas traits compared to TYNLG. The dominance of Sattva personality traits and the reduction of Tamas and Rajas traits are associated with increased well-being. Contemporary evidence also suggests personality traits play an important role in the incidence of chronic diseases. This signifies the need for lifestyle interventions to target behavioral changes by inducing changes in personality traits.
Earlier studies reckon health education-based behavioral changes can improve patients’ satisfaction, self-confidence, and ability to recover.[27,28] Yoga and naturopathic interventions have been shown to reduce the burden of non-communicable diseases by improving metabolic and cardiovascular health. Our results reiterate that a health education-based lifestyle intervention produces more significant behavioral modification compared to a routine approach.
In the present study, even though both HYNLG and TYNLG showed positive changes in the clinical parameters assessed, we did not observe any differences between the groups with respect to changes in blood pressure, pulse rate, BMI, weight, or physical QoL. This indicates both modes of approach are clinically effective in managing chronic disorders; however, the health education-based lifestyle intervention remains superior as it fosters changes at the personality level.
The present approach differs from that of the previous lifestyle intervention study in that it acknowledges and tries to enhance the biopsychosocial factors in the health and disease conundrum. Even in the absence of a causal relationship, psychosocial exposure is often associated with a disease. Further, there is an increasing demand for the introduction of biopsychosocial interventions that can provide multi-dimensional care. Building vitality or resilience capacity against diseases or thoughts of illness (infirmity) is thought to be beneficial because it aids in the development of self-help resources that can optimize health seeking.[20,31]
The present study has reported a significant increase in the vitality of the HYNLG participants, which indicates the impact of the health promotion approach over the conventional therapy-centric approach. Earlier studies also reckoned that a heightened vitality status would reduce the incidence of coronary artery disease, reduce the risk of hospitalization, reduce the health care costs, improve interpersonal relationships, reduce depression, addiction, and reduce the risk of cancer.
An earlier randomized control trial found that health education improves life satisfaction and QoL. We observed an improvement in mental QoL in the HYNLG participants, which reflects the influence of a health promotion-based approach on the mental health of the participants. There exists a relationship between personality traits and health-related QoL.Sattva, a personality trait associated with optimal life satisfaction and positivity, could be a plausible explanation for the current study participants’ improved psychological QoL.
Anxiety is a very common co-morbidity among patients with chronic diseases, which warrants substantial attention. In the present study, HYNLG participants showed a significant reduction in their anxiety scores compared to their controls Furthermore, an increase in Sattva personality and a decrease in Rajas and Tamas personalities have been linked to a decrease in anxiety. This reiterates the interplay between personality and mental well-being. Our inference suggests health education-based lifestyle interventions can offer comprehensive care that can promote positive personality change as well as mental health.
The inference from the present study suggests a positive correlation between the duration of the first physician consultation and the change in personality. The patient’s propensity to acquire the sattva personality was observed to be directly proportional to the duration of the consultation. Similarly, a longer consultation time reduced the rajas and tamas personality percentages among the study participants. These findings are unique with respect to personality and they strengthen the findings from previous reports, which suggest a positive association between the duration of consultation and health-related outcomes. The current findings point out the importance of longer face-to-face consultations between the physician and patient to achieve meaningful changes, especially in chronic diseases.
Patient satisfaction levels were higher among the HYNLG participants, which should be viewed as another significant finding. An earlier finding suggests that increased patient satisfaction levels can significantly lower inpatient mortality rates and improve adherence to treatments. Further, higher patient satisfaction is an indicator of high-quality health care. This could be due to the increased attention and awareness offered through patient education to the HYNLG participants.
4.1. Strengths and limitations
This is the first randomized control trial to investigate the usefulness of incorporating a health education-based component into lifestyle modification programs. Further, this study offers a framework that can be readily integrated with existing models of lifestyle programs. The results from the present study may encourage yoga & naturopathy physicians to use patient education as an integral part of their prescription-making. There are some limitations to the current study. The study included participants with varying comorbidities. These comorbidities and their associated medications may have some influence on the outcome measures, as the burden induced by different clinical conditions may not be indistinguishable.
Additionally, it would have been beneficial to check the role of patient education on other biomarkers of inflammation and disease-specific clinical parameters. This may be considered another limitation of this study. The results reported here are limited to the inferences of a 10-day residential program. The investigators did not follow up with the patients, which limits the authors’ ability to report on the sustainability of the changes. For more conclusive recommendations, future studies may consider including patients with identical characteristics and disease-specific outcome measures.
4.2. Implications for policy, and/or practice
Yoga & naturopathy philosophies preach the importance of patient education and the role of the doctor as a teacher, but this largely remains a textbook philosophy. Our results reflect the necessity of a health education that is largely patient-centric and suggest the importance of decentralizing the responsibility for health from the physicians to the patients. Yoga & naturopathy physicians should consider educating the patients about the rationale of the interventions provided and their perceived benefits. This may make the lifestyle programs more enthralling, comprehensive, and holistic.
Integrating health education into lifestyle modification programs has been found to influence personality traits, improve QoL, reduce anxiety, and enhance patient satisfaction compared to a routine therapy-centric approach. Future studies are warranted to examine the sustainability of the changes reported in the present study.
Conceptualization: Gulab Rai Tewani, Karishma Silwal, Dinesh Yadav, Ayush Maheshwari, Varsha Vijay Nathani, Vakeel Khan, Hemanshu Sharma, Pradeep M.K. Nair.
Data curation: Karishma Silwal, Sucheta Kriplani, Deepika Singh, Pradeep M.K. Nair.
Formal analysis: Karishma Silwal, Pradeep M.K. Nair.
Investigation: Gulab Rai Tewani, Karishma Silwal, Dinesh Yadav, Aarfa Siddiqui, Sucheta Kriplani, Ayush Maheshwari, Varsha Vijay Nathani, Deepika Singh, Kunal Gyanchandani, Rukmani Iyer, Vakeel Khan, Piyush Dubey, Hemanshu Sharma, Pradeep M.K. Nair.
Methodology: Gulab Rai Tewani, Karishma Silwal, Dinesh Yadav, Sucheta Kriplani, Ayush Maheshwari, Varsha Vijay Nathani, Deepika Singh, Kunal Gyanchandani, Rukmani Iyer, Vakeel Khan, Piyush Dubey, Hemanshu Sharma, Pradeep M.K. Nair.
Project administration: Gulab Rai Tewani, Dinesh Yadav, Aarfa Siddiqui, Sucheta Kriplani, Ayush Maheshwari, Varsha Vijay Nathani, Deepika Singh, Kunal Gyanchandani, Rukmani Iyer, Vakeel Khan, Piyush Dubey, Hemanshu Sharma, Pradeep M.K. Nair.
Resources: Gulab Rai Tewani, Kunal Gyanchandani, Rukmani Iyer, Piyush Dubey, Hemanshu Sharma, Pradeep M.K. Nair.
Software: Pradeep M.K. Nair.
Supervision: Hemanshu Sharma, Pradeep M.K. Nair.
Writing – original draft: Pradeep M.K. Nair.
Writing – review & editing: Gulab Rai Tewani, Karishma Silwal, Dinesh Yadav, Aarfa Siddiqui, Sucheta Kriplani, Ayush Maheshwari, Varsha Vijay Nathani, Deepika Singh, Kunal Gyanchandani, Rukmani Iyer, Vakeel Khan, Piyush Dubey, Hemanshu Sharma.
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