# Exercise as it relates to Disease/Can 'finding our center' help to reduce the size of our center?

This Wikibook page presents a critical appraisal of the research article: “Ashtanga yoga for children and adolescents for weight management and psychological well being: An uncontrolled open pilot study” (Benavides, S. & Caballera, J. 2009)

## What is the background to this research?

* In 2016 the World Health Organisation recorded that more than 340 million children and adolescents aged 5-19 were overweight or obese. This ever increasing prevalence has driven considerable research devoted to identifying non-invasive and non-pharmaceutical treatment methods for childhood obesity and the psychosocial impacts of such interventions.
* Obesity, and the limitations it imposes (i.e. restricted mobility, joint pain and inflammation, social acceptance etc.) yield an unwillingness to participate in conventional physical activity. Therefore, activities which encourage movement and demonstrate positive physiological and psychological outcomes for obese populations are at the forefront of health related research.
* The increasing rate of obesity in minority ethnic groups (Mexican/African Americans, Hispanics etc.) is a relatively unexplored field and is touched upon briefly in this article.
* Yoga, an Indian form of meditative exercise has recently gained international popularity as a recreational activity. Specifically, Ashtanga Yoga uses regulated breathing to reach a meditative state. Numerous studies have investigated the benefits of Yoga on cardiac health, cardiopulmonary function and psychological well-being however little is known about the positive weight management effects of yoga for obese youth.
* The present study aimed to investigate the feasibility of Ashtanga Yoga for weight loss in youth at risk of developing Type 2 Diabetes. Additionally, psychiatric symptoms were observed and measured in response to the intervention.

## Where is the research from?

* Both authors of this study are leading experts in the areas of pharmacy, paediatric obesity, diabetes and obesity related depression.
* The senior author, Dr Sandra Benavides, is an Associate Professor of Paediatrics at Nova Southeastern University Department of Pharmacy Practice. Dr Benavides has published over 70 articles with much of her research devoted to paediatric obesity in Hispanic/Mexican-American populations.
* The supporting author, Dr Joshua Caballero, is a board-certified psychiatric pharmacist with a Doctor of Pharmacy. Dr Caballero's interests and research surround paediatrics, depression and diabetes.
* The research project was funded by the University of Texas, Pan American Faculty Research Grant however the sponsors were not involved in any facet of the study and therefore the results have not been influenced by bias.
* The researched was published in the Complimentary Therapies in Clinical Practice Journal by Elsevier Publishing Company. Complimentary Therapies in Clinical Practice is a longstanding journal which presents high quality peer reviewed research on complementary therapies in an effort to promote safe and effective clinical practice.

## What kind of research was this?

* The research was an uncontrolled prospective pilot study. Uncontrolled studies are conducted in the absence of a designated control group meaning the effectiveness of the intervention cannot be directly compared. Whilst this places limitations on the research, it is not uncommon of pilot studies.
* A Pilot study typically aims to assess the feasibility of future research and obtain guidelines for future full-scale study rather than focusing on the statistical significance of the results.

## What did the research involve?

Fourteen participants aged 8-15 years (11.7 SD 1.5) participated in the study. Eligibility of participants was based on criteria outlined in Table One. Inclusion criteria was type 2 Diabetes risk factors as defined by The American Diabetes Association.
$_{TableOne:ParticipationCriteria}$ :
| Inclusion Criteria (at least one) | Exclusion criteria (any) |
| Overweight First degree relative with Type 2 Diabetes Hispanic / African American descent | Diagnosed as Diabetic Recent infection or condition known to cause inflammation History of / currently smoking Pregnancy Inability to provide assent / consent |
* By opening the eligibility to ‘at least one’ of the inclusion criteria the researchers have somewhat invalidated their conclusion that "Ashtanga yoga may be beneficial as a weight loss strategy in a predominately Hispanic population". Two thirds of the inclusion criteria does not require a subject to be Hispanic nor are the participants required to be overweight or obese, evidenced by baseline Body Mass Index (BMI) data ranging from 16.6-36.2kg/m2. Therefore, a portion of the population were categorised in the underweight (BMI <18.5) and normal weight category (18.5-24.9). In order to develop more reliable results for subsequent studies participants should be screened against a more robust inclusion criteria with a mandated BMI window.
* Additionally, the small same size of 14 participants potentiates skewed results due to the imbalance of age, gender and BMI. Increased recruitment of participants will reduce the standard deviation of results thereby indicating clearer feasibility of subsequent studies in this area.
* The protocol involved three, 1.5-hour yoga sessions per week over 12 weeks. A discretionary attendance saw participants average a total of 33 hours across the whole study (72.9%).
* A number of fasting laboratory analysis tests were conducted at baseline for all participants however these results were not presented in the article and therefore, comment cannot be made with regard to their influence on the intervention outcomes.
* To measure baseline self-concept, symptoms of depression and/or anxiety, participants completed three Beck Youth inventories as shown in Table Two. These were conducted in the absence of parents.
$_{TableTwo:BeckYouthInventories}$ :
| Inventory | Assessment |
| Beck Self-Concept Inventory for Youth (BSCI-Y) | Assesses self-perceptions of competency and self-esteem |
| Beck Depression Inventory for Youth (BDI-Y) | Measures a subjects negative thoughts (i.e. loneliness, sadness) and depressive symptoms. |
| Beck Anxiety Inventory for Youth (BAI-Y) | Evaluates a subjects fears, worries and symptoms of anxiety. |

## What were the basic results?

Overall results for both weight loss and psychiatric symptoms were diverse and are summarised in Table Three:
$_{TableThree:ResultsSummary}$ :
| Objective | Outcome |
| Weight Loss | Average loss of 2kg. Two individuals experienced weight gain. It should be noted that these figures do not account for changes in the participants fat mass and are simply a measure of the weight of each individual. |
| Self-Concept | Of the five individuals with low baseline self-concept, four improved and two declined. |
| Depression | Two individuals had mild increases in depressive symptoms. |
| Anxiety | All participants either maintained or reduced their baseline levels. |
* These varied results complicate the findings of the study and limit the ability of the authors to make conclusive statements. However again, this is not uncommon of pilot studies and simply stands to direct future research in this area.

## What conclusions can we take from this research?

* These findings are consistent with similar projects evaluating the efficacy of physical activity interventions on overweight youth however other studies have presented more promising results pertaining to self-concept and depression. Therefore, this article does not place yoga favourably ahead of alternative childhood obesity interventions but rather poses an interesting premise for future studies.
* Further research, employing more robust parameters of inclusion and methodology is recommended in order to accurately assess the effect of yogic practices on childhood psychiatric symptoms (i.e self-esteem, depression and anxiety).

## Practical advice

This article provides both clinical and research guidance and advice.
* This research postulates that a relationship exists between yogic exercise and lowered anxiety scores. However, due to limitations typical of pilot studies (i.e. small sample size, voluntary participation, restricted budget and duration) the results do not convincingly tie yoga with the other assessed parameters of weight loss, self-concept and depression. The study also attempts to link the alleged weight loss benefits of yoga with Hispanic ethnicity, however, without a control group for comparison there is insufficient evidence to support this.
* This pilot study has laid the foundation for further inquisition and future research. However, the absence of robust methodologies, consistent population demographics and adherence to the intervention highlights the impact these factors can have on forming strong conclusive research. Therefore, a larger controlled study prescribing yoga to participants categorised as either overweight or obese, for a longer duration, measuring fat mass and additional metabolic responses would be a more appropriate design.
* Locally, this study presents a space for future research on whether indigenous Australians have a varied physiological and psychological response to exercise when compared to non-indigenous Australians.

## Further information/resources

* Early Childhood Measurement and Evaluation Tool Review
* Facts and figures on childhood obesity
* Fact Sheet 1 - Yoga for Children
* Beyond Blue - Depression in Children
* Beyond Blue - Anxiety in Children
* Kids Help Line

## References

* 1 2 3 4 5 6 7 8 Benavides, S. & Caballera, J. Ashtanga yoga for children and adolescents for weight management and psychological well being: An uncontrolled open pilot study. Complement Ther Clin Pract. Edinburg, The University of Texas. 2009: 15;110-114.
* ↑ World Health Organisation (2018). "Obesity and Overweight." Accessed from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
* ↑ Jyotsna, V.P. Prediabetes and type 2 diabetes mellitus: Evidence for effect of yoga. Indian J Endocrinol Metab. 2014; 18(6): 745–749. doi: 10.4103/2230-8210.141318. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4192976/
* 1 2 Jayasinghe, S.R. Yoga in cardiac health (a review). Eur J Cardiovasc Prev Rehabil. 2004; 11(5):396-75. doi: 10.1097/01.hjr.0000206329.26038.cc. Accessed from: https://www.ncbi.nlm.nih.gov/pubmed?db=PubMed&cmd=Retrieve&list_uids=15616408
* 1 2 Jarry, J.L., Chang, F.M. & La Civita, L. Ashtanga Yoga for Psychological Well-being: Initial Effectiveness Study. Mindfulness. 2017; 8(5):1269-1279. Accessed from: https://link.springer.com/article/10.1007/s12671-017-0703-4
* ↑ Nagarathna R, Nagendra H. Yoga for bronchial asthma: a controlled study. Br Med J (Clin Res Ed). 1985;291(6502):1077-9. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1417003/pdf/bmjcred00470-0011.pdf
* 1 2 Benavides Caballero, S. Sandra Benavides. 2014. Accessed from: https://pharmapps.nova.edu/PAD/Faculty/Portfolio/Documents/CV/sbenavid/sbenavid_CV.pdf
* ↑ Caballero, J. Curriculum Vitae; Joshua Caballero, PharmD, BCPP (n.d.) Accessed from: https://pharmapps.nova.edu/PAD/Faculty/Portfolio/Documents/CV/jcaballe/jcaballe_CV.pdf
* ↑ Rankin-Box, D. (n.d.) Complementary Therapies in Clinical Practice. [place unknown], Elsevier Publishing. https://www.journals.elsevier.com/complementary-therapies-in-clinical-practice
* ↑ Nahler G. (2009) uncontrolled study. In: Dictionary of Pharmaceutical Medicine. Springer, Vienna. Accessed from: https://link.springer.com/chapter/10.1007/978-3-211-89836-9_1432
* ↑ S.E.F.O (2011) Different types of clinical trials [publisher unknown] Accessed from: https://www.scientific-european-federation-osteopaths.org
* ↑ Riebe, D. (2018) ACSM’s Guidelines for Exercise Testing and Prescription. (10th Ed). Baltimore: Lippincott, Williams & Wilkins