April 2017 Issue. Yoga in Dietetics Practice By Jennifer Van Pelt, MA Today's Dietitian Vol. 19, No. 4, P. 36

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1 April 2017 Issue Yoga in Dietetics Practice By Jennifer Van Pelt, MA Today's Dietitian Vol. 19, No. 4, P. 36 Learn more about the scientific evidence on yoga's health benefits and how to become a certified yoga instructor and yoga therapist. Over the past five years, interest in yoga as exercise and as therapy has grown significantly. Yoga is now the most studied complementary and alternative medicine (CAM) therapy. Hundreds of research studies and systematic reviews have been published on yoga used alone and adjunctively to treat a range of medical conditions. Recently, textbooks on the medical applications of yoga and how to incorporate yogic principles and practice into health care also have been published.1,2 Growing acceptance of yoga as an evidence-based CAM therapy, coupled with interest in holistic health and a dissatisfaction with pharmaceutical costs and side effects, has resulted in its use with counseling-based fields such as social work, sport psychology, and dietetics. The most well-known integration of yoga and dietetics is probably the Ornish Program, a combination of diet, exercise, and lifestyle changes that have been demonstrated to prevent and even reverse heart disease. The program, by Dean Ornish, MD, a yoga practitioner himself, includes one hour of daily yoga for stress management, along with a low-fat vegetarian diet, additional regular exercise, and group support.2 Yoga is emerging as a new tool for use in a variety of dietetics settings, including hospitals, specialty clinics, and private practice. This article reviews the scientific basis for yoga's therapeutic benefits, discusses how three dietitians are currently integrating yoga and nutrition in their practices, and provides information on yoga therapy certification and the future of yoga in dietetics. The Science of Yoga Ask yoga practitioners why they practice yoga regularly, and many will cite relaxation and stress relief as a primary reason. Scientific studies have shown that yoga poses, breathing techniques, and meditation do in fact affect the body not only by inducing muscles to release and relax but also by influencing the central nervous system and brain.1 A 2015 study demonstrated that yoga protects the brain from age-related neurodegeneration; these study results made media headlines. However, additional study findings weren't as widely reported in the news. A secondary finding from this study was yoga's effect on mood. Magnetic resonance imaging (MRI) found brain volume differences that positively impacted emotional regulation. Long-term yoga practice was associated with increased left orbitofrontal cortex volume, which has been linked to

2 positive mood. The researchers concluded that years of practicing yoga "progressively tunes the brain toward a parasympathetically driven mode and positive affective states."3 This MRI study offers some understanding of how yoga affects the brain, but there's still much to learn. The exact physiologic mechanisms by which yoga reduces stress and enhances mood remain unknown, though researchers are assessing yoga research to try to better understand the science behind yoga's benefits. A 2015 systematic review evaluated 25 randomized controlled trials of yoga that collected physiologic data on blood pressure, heart rate, cortisol, peripheral cytokine expression, and/or structural and functional brain measures related to stress and mood. The evidence suggested that yoga improves regulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal system, which in turn decreases anxiety and depression.4 Additional research suggests that neurotransmitters also play a role. In 2010, a small pioneering study demonstrated that 12 weeks of yoga (one hour, three times per week) increased thalamic gammaaminobutyric acid (GABA) levels and improved mood and anxiety measures more than a walking program. GABA is a neurotransmitter that inhibits nerve transmission in the brain, calming nervous activity. In patients with mood and anxiety disorders, GABA activity has been shown to be reduced; some mood-enhancing and anxiety-reducing medications work by increasing GABA activity. This study was the first to find positive correlations between yoga, increased GABA levels, and improved mood and anxiety measures.5 Anxiety is mediated through the autonomic nervous system, which consists of the sympathetic ("fight or flight") and parasympathetic (rest and relaxation) nervous systems. Hyperarousal the racing thoughts and shallow, rapid breathing caused by the sympathetic nervous system and experienced by those with stress and anxiety can be calmed by yoga poses and breathing techniques, which engage the parasympathetic nervous system and the body's relaxation response. Certified yoga instructors learn that certain yoga poses, such as forward folds, seated twists, legs-upthe-wall, and supported restorative poses, are practiced to help relieve anxiety. Deep yoga breathing, with exhales longer than inhales, slows breathing and heart rates, thereby shifting the body from sympathetic to parasympathetic nervous system dominance. Adding meditation to deep breathing further calms the nervous system by bringing focus to the present moment and away from anxious thinking. Studies also have shown that mindful meditation, a key part of most yoga practices, can reduce psychological stress.6 Yoga Benefits and Nutrition Though the science of yoga isn't yet fully understood, yoga practitioners can attest to yoga's benefits. A small research study that surveyed yoga practitioners who had attributed weight loss success to yoga reported how survey respondents believed yoga helped them. In addition to the physical benefits of yoga as exercise, respondents reported the following: increased sense of mindfulness regarding the circumstances around food consumption and food choices;

3 reduction in overeating and stress eating; increased awareness of the effects of certain foods (eg, junk foods and sugar) on their body; decreased food cravings; improved mood and emotional stability; and increased self-esteem and self-acceptance.7 Integrating yoga with dietetics can enhance nutrition counseling and behavioral change. Kara Lydon, RD, LDN, RYT (Registered Yoga Teacher), author of Nourish Your Namaste: How Nutrition and Yoga Can Support Digestion, Immunity, Energy & Relaxation, says, "As a longtime yoga practitioner, I've experienced the benefits of yoga on managing stress and anxiety firsthand." Personally witnessing the healing power of nutrition and yoga together inspired her to integrate yoga into her nutrition practice. "So many of my clients' issues around food are wound up in stress, anxiety, and emotional issues, that I realized that yoga could help them heal their relationship with food," Lydon says. Lydon wrote her book to help readers sift through the mixed messages in the media about yoga and nutrition. "People think that they have to be vegan or eat kitchari all day to be a good yogi," she says. "I wanted to write a book that provides sound, research-based information on how to use nutrition and yoga to improve health and wellness." Lydon says yoga helps support her work with clients around intuitive and mindful eating. "By helping my clients to be more mindful and present through yoga, they can approach eating and food from a more grounded and less judgmental place." With clients who are open to using yoga techniques, she teaches pranayama (breathing exercises) and meditation during counseling sessions. Clients can then practice these techniques at home before a meal or when they're feeling anxious about food. Some of Lydon's clients who have experienced the benefits of her integrated approach include the following: a woman with binge eating disorder who reduced her binge eating episodes by practicing deep breathing exercises when feeling stressed or overwhelmed; a woman with body dissatisfaction and preoccupation with body image who was able to decrease "body bashing" and increase positive statements about her body through mindful movement; and a woman who felt no physical hunger was able to notice hunger and fullness cues through mindfulness meditation. Another nutrition professional using yoga in her practice is Annie B. Kay, MS, RDN, E-RYT500, C-IAYT (in progress), author of Every Bite Is Divine, which discusses yoga and nutrition for healthy weight, and coauthor of Yoga & Diabetes: Your Guide to Safe and Effective Practice (with Lisa Nelson, MD, for the American Diabetes Association), which reviews evidence on safe and effective yoga practice to help manage diabetes. She also has developed "Yoga and Meditation: Tools for Weight Management," a continuing education program. Kay has been practicing yoga since 1993, and immediately noticed how quickly it helped her address body and life issues with which she'd struggled. "Yoga made it easier to eat well and practice self-care, and it shifted the way my mind worked for the better," she remembers. Kay joined the International Association of Yoga Therapists (IAYT) in 2007 to further her knowledge of the

4 evidence-based, therapeutic use of yoga; she just submitted her application for the new IAYT yoga therapy certification. How she integrates yoga into client sessions depends on what issues the client has, what type of therapy is needed, the physical ability of the client to do yoga poses, and their openness to new modalities. "I use yoga and a yogic-inspired model of change with every nutrition client. I weave particular yoga breathing techniques into most client encounters," Kay says. She also applies yoga philosophy and certain poses, along with MNT to address structural, psychological, and/or energetic imbalances and misalignments. Examples of clients who have benefited from Kay's integrated yoga/nutrition practice include the following: A woman who lost more than 50 lbs over the course of a year by regularly using Kay's yoga approach. A retirement-aged man who had major cardiovascular surgery, worked seven days per week, and had stress-related health issues, but refused to cut back on work. Kay designed a program that included yoga, 30 minutes of daily meditation, diet, and supplements that support his adrenal and digestive health and help him manage stress. He has reported sleeping better than he has in decades and has lost 20 lbs. Several clients who have resolved constipation with a combination of specific yoga breathing techniques, safe inversion poses, and dietary changes. For dietitians with clinical specialties, such as diabetes, oncology, obesity, geriatrics, and pediatrics, research on the applications of yoga have established its therapeutic benefits.1,2 Another specialty field in which yoga therapy can be applied is in the treatment of eating disorders. Maria Sorbara Mora, MS, RD, CEDRD, PRYT, RYT, cofounder of Aurora Behavioral Health, the first yoga-based eating disorder center in New York City, is certified in Phoenix Rising Yoga Therapy. She has been treating patients with eating disorders with nutrition counseling for almost 20 years and with yoga therapy for almost 10 years. Mora notes that practicing yoga invokes stress tolerance when the muscular stress experienced in holding a yoga pose is combined with using breath to instill awareness, the patient's body learns to tolerate it. "When translated into eating disorder recovery, this stress tolerance enables patients to manage symptoms more successfully. Whether it's riding the wave of a craving or tolerating fullness, those in recovery learn how to push through their discomfort," Mora says. When her patients take their awareness off the yoga mat and apply it to their nutrition habits, they master their recovery with mindful eating and instinctive action. Mora has witnessed several impressive moments when patients have an experience in yoga that transforms their recovery, including the following: a woman struggling with anorexia nervosa who, in a balance pose in yoga, realized how her eating disorder created a life imbalance; a man with body image issues who, during meditation, finally understood that he was his own worst critic; and

5 a woman with binge eating disorder who found her "inner fighter" while in warrior pose, thereby facilitating her recovery. "When patients find their inner wisdom during a yoga practice and use it to fuel the action of change in their eating and their symptoms, it truly exemplifies a holistic and integrative practice," Mora says. Yoga Instruction vs Yoga Therapy For years, in research studies and real-world practice, the term "yoga therapy" has been used loosely to refer to the application of yogic principles (eg, poses, breathing, meditation, and philosophy) for therapeutic benefit, whether yoga was practiced in a class setting, at home, or one-on-one with a yoga therapist. However, as yoga moves toward mainstream acceptance as a health treatment option, a need to distinguish between yoga instruction and yoga therapy has arisen. To avoid confusion, IAYT has been working since 2008 to define and standardize the term "yoga therapy." IAYT is currently the only professional yoga organization worldwide to provide international accreditation for yoga therapists and yoga therapy training organizations. It defines yoga therapy as "the process of empowering individuals to progress toward improved health and well-being through the application of the teachings and practices of yoga." Yoga therapy integrates traditional yoga practices (eg, poses, philosophy, breathwork, and meditation) with modern medical and psychological knowledge; it's considered a holistic or CAM modality. Yoga therapists focus on the needs of individual clients, and begin client interactions with intake and assessment interviews. In contrast, yoga instruction doesn't focus on individual needs. Yoga poses and philosophy may be presented as being therapeutic in a general way, with instructors guiding participants toward self-empowerment. Yoga teacher certification requires 200 hours of instruction with an accredited school, studio, or instructor; generally, no yoga instruction experience is required to begin a teacher certification program. Advanced 500-hour certifications also are available as instructors gain more knowledge and experience. Yoga therapy certification, on the other hand, requires at least a 200-hour yoga teacher certification to enter a training program. And, to become accredited, 1,000 hours of training and client contact are required. (See this month's Focus on Fitness for more information.) Future of Yoga and Dietetics According to a recent survey by the Yoga Alliance, the number of Americans doing yoga increased by 16 million in the last four years. Media reports on scientific studies reporting the therapeutic benefits of yoga will continue to spur interest in practicing yoga. "With this increased awareness and interest in yoga, more and more dietitians will recognize the benefits of integrating yoga into their nutrition practices," Lydon says. "I think dietitians will start to look at yoga as another tool they can add to their tool boxes to help improve care for their clients." Practicing yoga themselves also benefits dietitians, she adds. "Research shows yoga can help health care clinicians and counselors to be better listeners, be more present for their clients, and develop more empathy. Integrating yoga into your nutrition practice might not only benefit your clients but also help you become a better clinician." For nutrition professionals interested in yoga and yoga therapy, it's important to understand the necessary certifications and trainings and their limitations. In January 2016, the Yoga Alliance, an

6 organization that accredits yoga teacher training schools and issues the Registered Yoga Teacher (RYT) credential, announced that an RYT doesn't qualify one to do yoga therapy. In the evolving field of yoga and yoga therapy, very few nutrition professionals have the full yoga therapy credentials, an indication of how young the field is, Kay says. As the use of yoga in the dietetics setting increases, it's essential that nutrition professionals also understand the differences between yoga and yoga therapy so they can most effectively serve their clients and best market themselves. Dietitians with an interest in yoga and yoga therapy can start by identifying a yoga teacher training program accredited by the Yoga Alliance. After completion of a 200- hour program, they can then begin teaching yoga. Nutrition professionals who are experienced and certified yoga instructors can apply their knowledge of breathing techniques, meditation, and poses to their work with clients (eg, for stress relief/relaxation) but should be aware of the distinction between yoga and yoga therapy. To best represent their training and the emerging field of yoga therapy, dietitians should avoid using the phrase "yoga therapy" if they have only the yoga teacher certification. To pursue a yoga therapy certification, visit the IAYT website to find an accredited yoga therapy training program. One advantage that dietitians have in pursuing a yoga therapy certification is that they already have the client intake, assessment, counseling skills, and experience that distinguish yoga therapy from yoga instruction. "Each of us is responsible for our own integrity as practitioners. So offer what you are trained in," Kay says. Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area. References 1. McCall T. Yoga as Medicine: The Yogic Prescription for Health and Healing. New York, NY: Bantam; Khalsa SBS, Cohen L, McCall T, Telles S, eds. The Principles and Practice of Yoga in Health Care. Pencaitland, Scotland, UK: Handspring Publishing; Villemure C, Čeko M, Cotton VA, Bushnell MC. Neuroprotective effects of yoga practice: age-, experience-, and frequency-dependent plasticity. Front Hum Neurosci. 2015;9: Pascoe MC, Bauer IE. A systematic review of randomised control trials on the effects of yoga on stress measures and mood. J Psychiatr Res. 2015;68: Streeter CC, Whitfield TH, Owen L, et al. Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study. J Altern Complement Med. 2010;16(11): Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):

7 7. Ross A, Brooks A, Touchton-Leonard K, Wallen G. A different weight loss experience: a qualitative study exploring the behavioral, physical, and psychosocial changes associated with yoga that promote weight loss. Evid Based Complement Alternat Med. 2016;2016:

What Is Yoga Therapy?

What Is Yoga Therapy? All yoga is potentially therapeutic Yoga therapy: Specifically applies yogic tools postures, breathwork, meditation, & more To address an individual s needs physically, mentally,