Because “yoga” has become such a plastic term I’ve learned the hard way that I’d better define it before I say anything about it. In my recent blogs and lectures, I’ve been relying on the Kripalu Research Consortium’s definition of yoga as four “process tools” – ethics, postures and exercises, breath regulation and meditation. This definition becomes increasingly useful in the context of cross referencing research because it allows a broader and more integrated understanding of the fuller effects of these practices. I love to scan the neuroscience, spirituality, meditation, and social work research and synthesize the links (the yoga if you will) which then creates a powerful case for the wide-spread adoption of yoga as a public health strategy.

The other reason a definition of yoga is essential is because what I’m now calling “Public Health Yoga” is not the same thing as fitness yoga or even yoga therapy. Unless and until we draw clear lines in the sand about how we use yoga for health, fitness, recreation, therapy etc., across populations, we will continue to have a lot of difficulty integrating yoga into the healthcare system.

A common public perception is that public health is about things like vaccinations and quarantining Ebola patients. So admittedly, “Public Health” also deserves a definition. According to the Center For Disease Control (CDC), public health aims to improve and protect human health by promoting healthy lifestyles, and researching and preventing infectious diseases. While Ebola and salmonella get more attention than “promoting healthy lifestyles,” the latter is an essential aspect of public health. If you think about Behavioral Health in light of a more public health approach, there are four relevant areas – treatment, prevention, promotion and reclaiming. I’ll talk about these more below and how we can understand yoga in terms of these different arenas.

Fitness yoga has an enthusiastic following – but it shouldn’t be confused with Public Health Yoga because its goals are different. Yoga therapy is also gaining a lot of respect and is a powerful tool. It certainly can be part of Public Health Yoga, but there are some important differences too. For example yoga therapy is often taught in a private context, to individuals or small groups – much like psychotherapy or physical therapy. Public health Yoga is the conceptualization of yoga as a strategy that can be utilized in a broader context to address health issues across larger swaths of the population.

It can be useful to use this Systems Theory Social Ecological model to understand the different realms we are addressing when we offer yoga in different settings:

 

 

 

Fitness yoga and yoga therapy tend to serve on the individual and interpersonal levels. But human beings operate through much broader (and potentially influential) systems as well. Public Health yoga takes into account the organizational, community and public policy levels. If we use a Social Ecology model to think about how yoga can reach larger swaths of the population, then we have to think differently about how it is delivered. In this context, yoga can be geared toward health and wellness as opposed to (or in addition to) fitness. Public Health Yoga aims to provide services through healthcare organizations, schools, companies and community based organizations.

My goal in outlining these ideas is on the one hand, to spark a conversation in the healthcare world about how yoga can become a key player in improving public health and on the other, to encourage the yoga community to better organize ourselves around the idea of Public Health Yoga.

Yoga needs to be positioned to become a key part of Public Health. Why? Here are 7 Key Trends in Healthcare that point in the direction of integrating yoga into Public Health. Though, in reality, these are just the tip of the iceberg.

1. CAM and Integrative Medicine

A 2007 NIH study showed that nearly 40 percent of the US population uses some sort of Complementary and Alternative Medicine (CAM). The healthcare world takes this stuff seriously – if healthcare is to become more effective and efficient (and it desperately needs to) it’s essential to figure out how to integrate these therapies into the healthcare system. A more recent NIH study, which came out earlier this year, showed that the use of yoga has increased to almost 10 percent of all CAMS utilized. And yoga moved up on the list of commonly used CAMS. Besides supplements (which, not surprisingly, are No. 1 by a long shot), categories ahead of yoga include “breathing practices” and “meditation,” – which, the last time I checked, were aspects of yoga.

2. Primary Care Medical Homes

North Carolina is one of the states on the cutting edge of a new trend in delivering healthcare services. The “Medical Home” is a model or philosophy of primary care that is essentially a yoga-ing of healthcare services. Medical Homes aim to be comprehensive, accessible and patient-centered rather than disease based – you go there to take care of you, not your obesity or diabetes or whatever. The idea is that you can lower costs and improve the quality of care. To me, this philosophy sounds like yoga – compassion, connection and helping empower people to address their own needs. Medical Homes have the potential to be an excellent inroad for yoga-based CAM services.

3. The Rise of Neuroscience

Unless you’ve been living in a wi-fi free underground bunker for the past 10 years, you have witnessed the rise of interest in neuroscience. With the breakthrough technology of functional MRI neuroimaging, scientists have been prolific in releasing studies on how the brain works. Because neuroplasticity is now well understood, the search is on for how to use it to make positive changes in the brain. I was speaking at the American Mental Health Counselors Association annual conference early this summer about yoga, but what was buzzing among conference goers was neurofeedback. It’s great technology – and it’s also what yoga does, without the gadgets and expense.

One of the stellar benefits of yoga practice is its evidence based capacity to regulate the nervous system and train the relaxation response. A small but growing body of research focused on asanas, meditation, pranayama and spirituality is clearly demonstrating its positive effects on recruiting neuroplasticity to this end.

Last year, an article outlining a theoretical framework for the neurobiology of how yoga improves mental health was published by a consortium of researchers.  And if you don’t have the time or patience to slog through the whole thing, I wrote a bunch of blogs on it earlier this year. Also, there are researchers like Sara Lazar and Richard Davidson who’ve looked at how meditation creates more gray matter in certain areas of the brain related to attention networks and executive function. Additionally, Lisa Miller at Columbia showed that valuing spirituality seems to produce a similar effect and is remarkably neuroprotective against depression.

Other research shows how asanas can improve a range of physical and mental/emotional challenges. Research on breathing has demonstrated a link between breathing practices and better respiratory and psychological health.

A meta-analysis published last year that looked at the array of neuroscientific research on meditation concluded that “these results suggest…that meditation techniques could be adopted in clinical populations and to prevent disease.” So how do you go about adopting these techniques in clinical populations?  In my opinion, those of us with expertise in straddling the fields of yoga and healthcare need to create systems through which that adoption can happen smoothly, effectively and with a strong evidence base.     

4. How the Yoga Puzzle Piece fits into Integrated Care

Something in the range of 60-70 percent of all healthcare visits are related to mental health issues. Additionally, one in four people have a diagnosable psychological disorder – mostly anxiety or depression. Healthcare necessarily includes mental healthcare and addiction treatment – but it has often been provided by people who have little to no training in those fields. I wrote a blog about the Integrated Care trend and yoga that goes into this topic in greater detail. Basically, primary care is realizing the need to bring in appropriate mental health diagnosis and treatment.

Annual healthcare expenditures are pushing $3 trillion. But less than 6 percent of that goes to mental health treatment. And if 60-70 percent of all healthcare visits are related to mental health issues – well, it’s not rocket science. We are a nation in a big mental health crisis that is not being adequately addressed. Part of the problem is that we can’t expect primary care docs to treat mental health issues and that’s essentially what is happening right now. But what we can do is offer more empowering patient self-management solutions – especially to milder mental health challenges. Yoga is an excellent strategy here.

One of the most promising studies about how yoga can benefit depression was published in 2013. The evidence is so convincing that the study’s author wrote:

“The search for improved treatments, including non-drug based, to meet the holistic needs of patients is of paramount importance. If the promise of yoga on mental health was found in a drug, it would be the best-selling medication worldwide.”

When I read statements like that I get a bit excited and dysregulated. So I started writing this article (rather than having a Netflix binge with my cat on the couch) because I can’t sit back and watch the transformative potential of yoga being accessed only by the privileged few.

5. Treatment and Prevention – Dean Ornish’s baby

Here’s the story behind our country’s shocking medical bill: 75 percent of the $3 trillion plus we spend per year goes to chronic, preventable diseases. Diabetes, obesity, heart disease – these issues cost our society dearly. Yet research shows if we spent $10 per person per year in community based prevention programs we could save more than $16 billion a year. And again, that’s just the tip of the potential of prevention. Prevention and lifestyle modification is such a sorely underutilized strategy that we really can’t envision its full potential. Yet prevention is the future of healthcare.

The Affordable Care Act has allotted more than $15 billion to prevention. The benefits of yoga practice and lifestyle are well researched by key players like Dean Ornish who I’ve heard speak on several occasions. He likes to emphasize that yoga is both prevention and treatment, and his extensive research, specifically on recovering from heart disease, carries this out.

6. Health Promotion and Reclaiming

As I mentioned in the intro to this article, public health is not only about vaccinations and Ebola containment, it’s also about promoting healthy lifestyles. Treatment and Prevention are focused on reducing negative outcomes. But Reclaiming and Health Promotion are about optimizing positive outcomes. Again, these intervention areas were originally conceptualized in terms of mental or behavioral health models, but now they are being applied to all healthcare issues – which makes sense since mental health is such a huge chunk of healthcare in general.

According to the World Health Organization, “Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions.” The Institute of Medicine suggests that health promotion should occur across the spectrum of prevention, treatment and reclaiming.

After people are on the other end of a scary health situation – whatever it is – a heart attack, bout of depression or addiction – they have the opportunity to transform, change their lives and self-actualize. This is reclaiming – and it’s recognized as an important part of integrated healthcare outcomes. Perhaps it sounds a bit familiar? Like maybe what you or your yoga friends have talked about in terms of your own experience finding yoga? For me the question is how can we help people access this kind of yoga experience for themselves in their own terms, without sectarianism or fear, and use it as a tool for self-actualization?

For yoga professionals, the issue is not simply around defining the difference between yoga teachers and yoga therapists, we should also be looking at where our best services lie – treatment, prevention, health promotion or reclaiming?

7. Patient Self-Management – Becoming empowered

I’ve had numerous conversations with healthy yoga practitioners over the years about the healthcare crisis and invariably, the argument that health is a matter of personal choice and people are just too lazy to do it is voiced. But individual responsibility for health is largely a white, middle class myth. According to a study conducted by the Robert Wood Johnson foundation, up to 70 percent of the reasons why people are unhealthy are determined by external forces – social, economic, and access to resources, access to care. Only 30 percent of health outcomes are directly connected to individual health behaviors. Here’s a chart explaining these statistics:

 

 

Those percentages might seem bleak, but there’s lots of hope! Patients who are actively involved in their own health have better outcomes. So how do you get people motivated?

What yoga practice can do very well is help people increase and internalize their locus of control. Yoga is empowering – you get to make yourself feel better. It can help people take back the direction of their own health and make mindful choices that help them break out of the social, economic, and environmental bondages which create lousy health. Healthier people are more active people – physically and socially. And more active people, especially those who have come out of difficult health situations, are more motivated to help others and begin to make changes in the systems.

Look at yourself? If you are still reading, you are the kind of person who understands the transformative power of yoga. You’re not alone, yoga practice does this to lots of people. If you feel like your health is mostly in your own hands, good. And then think about how other people will start to feel once they have experienced that shift. Other people you don’t know, people who would never set foot into yoga studio.

What does Public Health Yoga look like? It’s happening. Yoga professionals are interfacing with healthcare organizations all over the country. Healthcare professionals are recommending yoga to their patients. But what if we drilled down deeper into this connection?  What would a yoga informed healthcare center or rehab look like? What would it look like to refurbish a yoga studio into an affordable yoga health center? What could yoga therapists do on a Primary Care Medical Home team? What can Public Health Yoga look like in schools, hospitals and organizations?

What I don’t doubt is that this stuff is happening organically. What I would encourage is that is becomes more intentional, systematic, mindful and integrated – which is to say, yogic.

Kristine Kaoverii Weber is the founder of Subtle®Yoga and the director of the Subtle®Yoga Training for Behavioral Health Professionals at the Mountain Area Health Education Center (MAHEC) in North Carolina. She conducts workshops and trainings internationally and online with YogaUonline.com. She lives in the Asheville with her husband, son and neuroprotective cat. Find out more about her work at www.subtleyoga.com.