Do Low Vitamin D Levels Correlate With Osteoporosis?

Do Low Vitamin D Levels Correlate With Osteoporosis?
Shashi Agarwal, MD, FACC, East Orange, NJ; Neil Argarwal, Edison, NJ

INTRODUCTION: Osteoporosis is related to many factors, including a
family history of the disease, tobacco use, steroid use, major preexisting
medical diseases and vitamin D deficiency. This retrospective study was
done to see if low vitamin D levels correlate with the presence of
osteoporosis.

METHODS: We reviewed the records of 101 consecutive
patients who had DXA scans and vitamin D levels done over the period
of one calendar year. Bone mineral density was measured at the hip and
spine by dual-energy X-ray absorptiometry. T scores were considered
normal between +1 and -1, osteopenia between -1 and -2.5 and
osteoporosis if lower than -2.5. Vitamin D was measured as serum 25-
hydroxy vitamin D by the DiaSorin ICMA method. Vitamin D levels were
categorized as: normal levels: 30ng/ml or higher; mild deficiency:
20ng/ml-29ng/ml; moderate deficiency: 10ng/ml-19ng/ml and severe
deficiency: 0ng/ml-9ng/ml.

RESULTS: Of the 101 patients (ages 20 to 88
years) [54 (53.5%) males; 47 (46.5%) females], 19 (18.8%) had normal
vitamin D levels and 82 (81.2%) had low levels. Of the 19 with normal
levels, 6 (31.6%) had normal DXA scan, 8 (42.1%) had osteopenia and 5
(26.3%) had osteoporosis. Of the 82 with low vitamin D levels, 39
(47.6%) had normal DXA scans, 32 (39.0%) had osteopenia and 11
(13.4%) had osteoporosis. Of the 28 with mild deficiency, 12 (42.9%)
were normal, 13 (46.4%) were osteopenic and 3 (10.7%) were
osteoporotic. Of the 50 with moderate deficiency, 27 (54.0%) were
normal, 17 (34.0%) were osteopenic and 6 (12.0%) were osteoporotic.
Of the 4 with severe deficiency, 0 (0.0%) were normal, 2 (50.0%) were
osteopenic and 2 (50.0%) were osteoporotic. The average age of those
who were normal was 52.59 years, those with osteopenia was 56.38
years, and those with osteoporosis was 57.91 years.

CONCLUSION: We
found that approximately one half of the patients with mild or moderate
vitamin D deficiency had evidence of either osteopenia or osteoporosis
on DXA scanning. All patients with severe deficiency were osteopenic or
osteoporotic. Osteoporotic patients tended to be older. However, there
was no diagnostic correlation between low vitamin D levels and the
presence of osteoporosis.

Presented at the Family Medicine Forum 2011, Montreal, November 2011

Vitamin C and the Cardiovasular System: Shashi K. Agarwal, MD

A recent study presented at the American Heart Association’s Annual Meetings in Orlando in November, 2011 showed that there was an inverse relationship between vitamin C levels and an increased risk of development of heart failure. This study examined otherwise healthy 9,187 men and 11,112 women aged 39 to 79 years participating in the “European Prospective Investigation into Cancer and Nutrition”. Their plasma vitamin C concentrations were correlated with incident fatal and non-fatal heart failure events. During a mean follow up of 12.8 years, Dr Roman Pfister and co-researchers from Europe found that for every increase of 20 μmol/L (1 SD) in plasma vitamin C concentration, there was an associated 17% relative decrease in risk for heart failure.

Two previous major studies have found no cardio-protective effect of vitamin C supplementation. In the Physicians’ Health Study II, supplementation with 500 mg of vitamin C every other day in 14,641 US male physicians over the age of 50, was compared with placebo. After 8 years of follow up, vitamin C did not have any beneficial effect on total mortality, heart attacks, stroke or cardiovascular disease death. This study was published in the Journal of the American Medical Association in the November 12, 2008 issue.

In another study involving 8171 women with a mean age of 60, during a follow up of 9 years, no overall benefit from vitamin C was observed for prevention of cardiovascular events. This study was done by Brigham and Women’s Hospital in Boston, with the results published in the August 13, 2007 issue of Archives of Internal Medicine.

Since vitamin C is an antioxidant, there has been great excitement regarding its potential cardio-protective effects. Oxidative stress is closely linked to the development of atherosclerosis and its major complications – heart attacks and strokes. Vitamin C has been primarily used to prevent scurvy. It is also beneficial in preventing gout by reducing serum uric acid levels. Its role in preventing common colds has not been scientifically validated.

Vitamin C is a water-soluble vitamin, with almost 90% of our intake coming from fruits and vegetables, especially citrus fruits, peppers, broccoli, and tomatoes. Kakadu plum, camu camu fruit and rose hips contain extremely high concentration of this vitamin. Vitamin C is also present in some cuts of meat, especially liver and raw oysters. In the United States, vitamin C supplements are widely used. It is available in a variety of forms, including pills, drink mixes and crystals, either naked or in capsules. However a review all the major studies on vitamin C and cardiovascular disease, demonstrates no scientific confirmation that nutritional supplementation with vitamin C is heart protective

Levels of plasma vitamin C correlate consistently with fruit and vegetable intake  and an increased intake of fruit and vegetables is associated with a significant increase in plasma vitamin C concentration. Since studies with vitamin C supplementation provide no support for cardiovascular protection and studies using vitamin C levels as a biomarker for fruit and vegetable intake appear to show distinct cardiovascular benefit, the ‘writing’ is on the wall – do not eat nutrients but eat foods rich in nutrients – namely plenty of fruits and vegetables. The cardiovascular benefits of fruit and vegetable intake may not be limited to vitamin C, as there are many other nutrients in fruits and vegetables, such as potassium and magnesium, that also have positive effects on the heart.

The North American Dietary Reference Intake in 2008 recommended 90 milligrams of vitamin C per day and no more than 2,000 milligrams per day. Toxicity is however rare, as excess intake is not absorbed, and excesses in the blood rapidly cleared in the urine.

ABO Blood Group – A Cardiovascular Connection: Shashi K. Agarwal, MD

Cardiovascular disease is now the number one killer in the world. Although the major risk factors such as hypertension, diabetes mellitus, hypercholesterolemia, obesity, physical inactivity and smoking are well known, some minor risk factors remain relatively unknown. The ABO blood group is one such minor risk factor.

Austrian scientist, Karl Landsteiner earned a Nobel Prize for the discovery of the ABO blood group system in 1901.  Inherited antigenic substances on the surface of the red blood cells allow a classification of the blood into different groups (blood type). Lawyers soon started using this in paternity suits, police in forensic science and anthropologists in the study of different populations. The Japanese, started believing that a person’s blood type is predictive of their personality, character and compatibility with others. Its major impact however, was in preventing fatal reactions to blood transfusions.

If transfusion is given without proper typing and cross-matching, naturally occurring antibodies in the recipients blood can bind to corresponding antigens on the transfused red blood cells resulting in an acute hemolytic transfusion reaction that can cause widespread intravascular blood clotting, shock, acute renal failure, and death.

Another major health impact was understanding the patho-physiology behind the hemolytic disease of the newborn. This dangerous reaction occurs as the anti A and anti B antibodies produced in the O blood group mother cross the placenta and enter the blood stream of her infant with type A or type B blood. However, due to lower number of fetal antigens, the reactions are usually less severe.

Recent reports have noticed an interesting connection of these blood groups with cardiovascular disease. In a presentation at the Annual Scientific Meetings of the American Heart Association in November 2011, researchers from the Harvard School of Public Health reported that men and women in the AB blood group had a  26% higher risk of developing stroke when compared with those with type O blood. Women with type B had a 15% higher risk of stroke, when compared with those with type O blood. They analyzed data from two major studies – the Nurses’ Health Study (NHS) which included 61,973 women and the Health Professionals Follow-up Study (HPFS) which included 27,808 men. The follow up was 26 years and 20 years.

In a study published in the New England Journal of Medicine in the December 9, 1971 issue, researchers investigating  10,000 Israeli male government employees 40 years of age and over as part of the Israeli Ischemic Heart Disease Project (five year duration) found that subjects with blood Groups A, B, and AB tended to have higher incidence rates of myocardial infarction than those with other blood groups. High rates were also noted in A and B subjects for angina pectoris. Subjects in blood Group O tended to have lower rates of infarction and angina pectoris than those of other groups.

Researchers reported a higher incidence of elevated cholesterol levels and ischemic heart disease in non-O group individuals in the British Medical Journal in June 1990. The results emanated from a prospective study of 7662 men with known blood groups. Many other studies have similarly found increased heart attacks in non-O blood group individuals.

In another study published in the February 2009 issue of the Journal of Thrombosis and Haemostasis, researchers reported a higher tendency for arterial and venous clotting in patients with non-O blood groups. Several studies have demonstrated the influence of the ABO blood group on plasma levels of von Willebrand factor. VWF is major player in blood clotting.

In summary, non-O blood group individuals suffer a higher risk of myocardial infarction, angina, cerebral strokes and venous thrombo-embolism than those with group O blood. This increased risk, although real, is not very significant. Since your blood group cannot be changed, non-O blood group people should follow heart healthy lifestyles more judiciously, to nullify any increased genetic risk conferred by their blood type.

Vitamin C is good for your heart – but only if taken packaged by nature (in fruits and vegetables).

A recent study presented at the American Heart Association’s Annual Meetings in Orlando in November, 2011 showed that there was an inverse relationship between vitamin C levels and an increased risk of development of heart failure. This study examined otherwise healthy 9,187 men and 11,112 women aged 39 to 79 years participating in the “European Prospective Investigation into Cancer and Nutrition”. Their plasma vitamin C concentrations were correlated with incident fatal and non-fatal heart failure events. During a mean follow up of 12.8 years, Dr Roman Pfister and co-researchers from Europe found that for every increase of 20 μmol/L (1 SD) in plasma vitamin C concentration, there was an associated 17% relative decrease in risk for heart failure.

Two previous major studies have found no cardio-protective effect of vitamin C supplementation. In the Physicians’ Health Study II, supplementation with 500 mg of vitamin C every other day in 14,641 US male physicians over the age of 50, was compared with placebo. After 8 years of follow up, vitamin C did not have any beneficial effect on total mortality, heart attacks, stroke or cardiovascular disease death. This study was published in the Journal of the American Medical Association in the November 12, 2008 issue.

In another study involving 8171 women with a mean age of 60, during a follow up of 9 years, no overall benefit from vitamin C was observed for prevention of cardiovascular events. This study was done by Brigham and Women’s Hospital in Boston, with the results published in the August 13, 2007 issue of Archives of Internal Medicine.

Vitamin C is a water-soluble vitamin, with almost 90% of our intake coming from fruits and vegetables, especially citrus fruits, broccoli, and tomatoes. Since vitamin C is an antioxidant, there has been great excitement regarding its potential cardio-protective effects. In the United States, vitamin supplements, especially vitamin C, are widely used. However a review all the major studies on vitamin C intake and cardiovascular disease, demonstrate no scientific validation that supplementation with vitamin C is heart protective

However, studies have shown that levels of plasma vitamin C correlate consistently with fruit and vegetable intake  and an increased intake of fruit and vegetables is associated with a significant increase in plasma vitamin C concentration. Since studies with vitamin C supplementation provide no support for cardiovascular protection and studies using vitamin C levels as a biomarker for fruit and vegetable intake appear to show distinct cardiovascular benefit, the ‘writing’ is on the wall – do not eat nutrients but eat foods rich in nutrients – namely plenty of fruits and vegetables. The cardiovascular benefits of fruit and vegetable intake may not be limited to vitamin C, as there are many other nutrients in fruits and vegetables, such as potassium and magnesium, that also have positive effects on the heart.

Pomegranate Juice: Cardioprotective

In a recent study presented at American Society of Nephrology Annual Meeting on November 11, 2011 at Philadelphia , regular pomegranate juice intake was associated with an improvement in several cardiovascular risk factors. A group of hemodialysis patients were given 100 ml of pomegranate juice three times a week for 12 months. Their cardiovascular parameters were compared with a similar group who received an equivalent-tasting placebo for the same period of time. At the end of the study, patients receiving the real juice demonstrated a decrease in the damaging triglycerides, an increase in the protective HDL cholesterol and a drop in the systolic blood pressure. None of these beneficial changes occurred in the placebo group.

Although the study was done in hemodialysis patients, there is reason to believe that similar benefits should occur in non-dialysis patients. Pomegranate juice contains several antioxidants, including ascorbic acid and polyphenolic flavanoids. The antioxidant activity of pomegranate juice appears to be stronger than that seen with many other fruit juices, including blueberry, cranberry and orange.  This antioxidant activity may even exceed that found in red wine. The net effect is a decrease in atherosclerosis, and the resultant decrease in heart attacks and strokes. Cardiovascular diseases are the major cause of death and health cost burden worldwide.

Pomegrante juice is readily available in the United States. Although this study was limited in size and duration, the cardiovascular protective benefits of pomegranate juice appear real. Till studies with larger numbers and of longer duration are available, it appears prudent to integrate regular intake of pomegrate juice in your regimen of cardiovascular interventions, whether they be drug therapy or lifestyle changes or both.

Sugar Intake and Cardiovascular Risk Factors: A Direct Relationship by Shashi K. Agarwal, MD

Cardiovascular disease is the number one killer in the United States, both for men and women. These deaths exceed the number of deaths caused by cancer, accidents, and chronic lower respiratory disease combined. It is estimated that there is one death due to cardiovascular every 39 seconds in this country, amounting to more than 2,200 deaths every day. The major attention has been directed towards the usual risk factors such as cigarette smoking, hypertension, diabetes mellitus, hypercholesterolemia, obesity and physical inactivity. Very little attention has been paid to the adverse impact of increased dietary sugar on cardiovascular disease.

Dietary sugars come in many forms. Simple sugars are monosaccharides and disaccharides. The most common monosaccharide is fructose, which is found in fruits and vegetables. Common disaccharides are sucrose, lactose and maltose. Sucrose is found in sugar cane, sugar beets, honey and corn syrup, lactose is found in milk products while maltose comes from malt. Complex sugars are polysaccharides such as starch. Added sugars are extrinsic sugars such as sucrose or other refined sugars added to soft drinks, fruit drinks and other food products.

The average US sugar utilization per capita was 55 kg (120 lb) per year in 1970, and it reached 68 kg (150 lb) per year in 1995. The consumption of sugar has continued to rise steadily. In 2004, the intake of added sugars was 22.2 teaspoons per day, accounting for 355 calories. This increase is largely due to the advent of modern food-processing methods.

Sugars are carbohydrates and provide daily calories for bodily fuel needs. They also add palatabiity and desiribility to ingested foods. However excessive intake may have harmful effects. These include obesity, hypertension, disturbed glucose homeostasis and abnormal lipid balance.

It is estimated that 56%-85% of the school childrn consume at least one soft drink daily. There is a 1.6 times increased odds ratio of becoming obese with each additional can or glass of sugar sweetened drink consumed daily. Since soft drinks are responsible for the major source of added sugars in the diet, they remain a major culprit for obesity in children and adolescents. Obesity is a leading preventable risk factor for cardiovascular diseases.

The relationship between increased sugar intake and diabetes mellitus has been suggested but not convincingly established. Sugar intake is associated with a high glycemic index – a measure of the rise in glucose induced by the ingestion of a carbohydrate. Foods containing refined sugars have a high glycemic index and put individuals at higher risk of future diabetes. Further, excessive added sugar intake is related to obesity which in turn increases the risk of diabetes mellitus.

An inverse relationship exists between dietary sugar and the good HDL cholesterol. Data from Framingham and PROCAM studies have found for every 1 mg/dl decrease in HDL there is an associated 2-4% higher risk for cardiovascular diseases. Harmful plasma triglycerides are also elevated with diets high in sucrose.Hypertriglyceridemia is an independant cardiovascular risk factor. In a study published in the Journal of the American Medical Association in April of 2010, Welsh and his associates from Emory University reported a statistically significant correlation between dietary added sugars and blood lipid abnormalities in US adults.

Recently, a relationship between excessive sugar intake and high blood pressure has also been found. Forman and his colleagues from Harvard Medical School examined data from three large, prospective studies. These involved 88,540 females from the Nurses’ Health Study I, 97,991 females from the Nurses’ Health Study II, and 37,360 men from the Health Professionals’ Follow-Up Study. The follow up ranged from 16 to 26 years. They found that drinking at least one sweetened beverage a day was associated with a 6% to 20% greater relative risk of hypertension. The risk appears marginally higher in people drinking artificially sweetened drinks when compared to those drinking sugar sweetened drinks. This data was presented at the American Society of Nephrology meetings in November 2011, in Philadelphia.

Recent decades have witnessed a substantial increase in total consumption of sugar in the United States. This has largely come from an increase in added sugars. Added sugars are caloric sweeteners used as ingredients in processed or prepared foods. These include soft and fruit drinks, candies, pastries and cereals with high sugar content. Several studies have also established the negative impact of excessive sugar intake on cardiovascular risk factors. Excessive sugar intake has also been linked to other adverse health conditions including deficiency of essential nutrients and dental caries. Reduction of sugar derived calories to less than 100 calories per day in women and less than 150 calories per day in men should help lower the cardiovascular risk.

Sweetened drinks increase the risk of high blood pressure by Shashi K. Agarwal,MD

Data presented this week (November 2011) at the American Society of Nephrology in Philadelphia suggests that sugar may be sweet for the tongue but bitter for the heart.

Forman and his colleagues from Harvard Medical School examined data from three large, prospective studies. These involved 88,540 females from the Nurses’ Health Study I, 97,991 females from the Nurses’ Health Study II, and 37,360 men from the Health Professionals’ Follow-Up Study. The follow up ranged from 16 to 26 years. They found that drinking at least one sweetened beverage a day was associated with a 6% to 20% greater relative risk of hypertension. The risk appears marginally higher in people drinking artificially sweetened drinks when compared to those drinking sugar sweetened drinks.

In 2004, Americans ate 22.2 teaspoons of added sugars per day. This accounted for 355 calories. Sugar intake has continued to rise since. Previous studies have shown that increased sugar intake is associated with a higher incidence of obesity, diabetes and abnormal lipid levels.

Along with hypertension, these are major risk factors for cardiovascular disease, the number one killer in the United States, both for men and women. Cardiovascular deaths exceed the number of deaths caused by cancer, accidents, and chronic lower respiratory disease combined. It is estimated that there is one death due to cardiovascular every 39 seconds in this country, amounting to more than 2,200 deaths every day.

This recent report should again warn us about the adverse effects of excessive sugar intake on the cardiovascular system. Prudent intake should not exceed 100 calories per day for women and 150 calories per day for men from added sugars.

Alcohol Intake and Increased Breast Cancer Risk by Shashi K. Agarwal, MD

Alcohol intake has long been known to increase the risk of breast cancer in women. A recent study published in the November 1, 2011 issue of the Journal of the American Medical Association, has again confirmed this etiological connection.

In this study, researchers followed  105,986 women as part of the Nurses’ Health Study, from 1980 until 2008. They found that there was a 15 percent increase in the risk of breast cancer in women who consumed three to six drinks a week. The risk increased to 51 percent with consumption of two drinks a day. There was no increase in the risk for breast cancer in women who drank less than the equivalent of three glasses of alcoholic drinks per week. The risk was not related to the nature of the alcoholic drink, when the amount of alcohol in each was considered. Previous studies have reported that breast cancer risk increases by 7%-10% for each 10 g of alcohol consumed per day. Wine has 11 grams of alcohol per 4-ounce serving; beer, 12.8 grams per 12-ounce serving; hard liquor, 14 grams per standard 1.5 oz serving.

Breast cancer is the most common cancer in women following skin cancer. According to the American Cancer Society, about one in eight women will develop breast cancer over their lifetime. Every year, more than 230,000 new cases of breast cancer are diagnosed in the United States, killing about 40,000 women. Alcohol appears to increase the risk of invasive lobular and hormone receptor–positive breast tumors than ductal or hormone-negative breast tumors. Patients with lobular carcinomas have a better survival rate than those with ductal carcinomas, and survival rates for hormone receptor–positive tumors are higher than those for hormone receptor–negative tumors. The 2011 study suggests that stopping or cutting alcohol intake to less than three drinks per week could prevent more than 17,000 breast cancers per year in women.

Cardiovascular Benefits of Yoga

Yoga is an ancient Indian discipline that has been practiced in the East for over 5000 years. It is gaining extreme popularity in the United States. According to the National Health Interview Survey,6.1% of US adults practiced yoga in the months immediately prior to the survey in 2007, compared with 3.7% in 1997 and 5% in 2002. The figures for 2011 are expected to be much higher.

Yoga was first introduced to the West by Swami Vivekananda, who toured Europe and the United States in the 1890s. More recently, Dean Ornish, a follower of Swami Satchidananda, published several studies legitimizing yoga exercises and yogic lifestyle for its cardiovascular benefits.

The Yoga Sutras are foundational texts of Yoga and are attributed to Patanjali, dating back to the 2nd century BC. According to Patanjali, yoga has eight limbs. These are:

1. Yama which encompasses non-violence, honesty, non-coetousness, non-sensuality and non-possesiveness.

2. Niyama which reflects purity, contentment, austerity and surrender to God.

3. Asana which refers to the seated meditation position.

4. Pranayama or controlled breathing exercises.

5. Pratyahara which indicates control of senses.

6. Dharana or concentration.

7. Dhyana or meditation and

8. Samadhi, the ultimate bliss.

This discipline of yoga described by Pantajali is commonly called Ashtanga Yoga. However, over the decades, Yoga has evolved into many different styles and intensities. Most yoga practices in the Western world consist of practice of Hatha Yoga: gentle exercise, stretching poses, controlled breathing and meditation.

Cardiovascular disease is the leading cause of death in the United States for both men and women. It claims more lives each year than cancer, chronic lower respiratory diseases, accidents, and diabetes mellitus combined. According to the CDC, in 2006, 631,636 people died of heart disease in the US. Almost 450,000 of these deaths were attributed to coronary artery disease. It is estimated that almost 800,000 Americans have a first heart attack each year, while another 470,000 who have already had one or more heart attacks have another attack. Heart disease costs over $300 billion each year, which includes the cost of health care services, medications, and lost productivity.

The major risk factors of cardiovascular disease are inactivity, obesity, hypertension, diabetes, abnormal lipid profile and chronic inflammation. Yoga appears to have beneficial effect on all of these. In a review of 37 studies from six countries, 75% of the studies showed improvement in blood pressure with yoga or yoga-based interventions. Overall, these studies demonstrated a 4.9% to 24.2% decline in diastolic blood pressure and a 2.6% to 21.3% decline in systolic blood pressure with yoga. There was also a decrease in resting heart rate and breathing rate. In 18 clinical trials between 1970 and 2004, yoga practice was associated with a 1.5% to 13.6% reduction in body weight. There have been at least 15 international studies demonstrating positive effects on the lipid profile – yoga practice was associated with a 5.8% to 25.2% decrease in total cholesterol, 22.0% to 28.5% reduction in fatty triglycerides, and a 12.8% to 26.0% reduction in the bad LDL cholesterol. Some studies have also demonstrated an increase in the good HDL cholesterol levels. Almost 13 studies have focused on studying the effects of yoga on diabetes mellitus and markers of insulin resistance. On an average, yoga practice was associated with a 5.4 to 33.4% reduction in fasting glucose, 24.5 to 27.0% reductions in postprandial glucose, and 13.3 to 27.3% reduction in glycohemoglobin (HbA1c). Studies have also demonstrated improvement in metabolic syndrome.

Yoga exercises will burn calories to help reduce weight. The mind-body connection benefits of yoga are backed by irrefutable scientific evidence. Yoga techniques improve physical and mental health through down-regulation of the hypthalamic-pituitary-adrenal axis and the sympathetic nervous system. Yoga has been found to decrease markers of inflammation such as high sensitivity C-reactive protein as well as inflammatory cytokines such as interleukin-614 and lymphocyte-1B. There is attenuation of oxidative stress. There is also decreased tendency to clot and brain scans have shown higher levels of GABA (low levels of GABA are associated with anxiety and depression) after an one hour yoga session.

The benefits of yoga extend beyond the cardiovascular system. The gentle stretching exercises improve muscle, ligament and joint function. There is an increase in flexibility, strength and endurance. The body posture is also improved. Chronic conditions such as asthma and arthritis have shown improvement. There is also an anti-depressive and anti-insomnia effect. Overall, most practitioners of yoga claim that they not only feel fitter and energetic, but happier and more peaceful.

The National Institute of Health is actively supporting clinical trials on yoga. An online check regarding clinical trials on yoga revealed 140 trials on the NIH site, clinicaltrials.gov, for a multitude of medical conditions including breast cancer, multiple sclerosis, cystic fibrosis, brain tumors and heart failure. A recent report in the November 1, 2011 issue of the Annals of Internal Medicine reported that yoga practice for 12 weeks in adults with chronic or recurrent low back pain resulted in greater improvement than usual care for up to 12 months.

Yoga is generally considered to be safe in healthy people when practiced appropriately. Studies have found it to be well tolerated, with few side effects. Some yoga ‘inverted’ poses should be avoided by people with disc disease of the spine, glaucoma, retinal detachment, ear problems, severe osteoporosis, or cervical spondylitis. These poses should also be avoided by people with very high or very low blood pressure, risk or history of blood clots and severe atherosclerotic vascular disease. Care should also be taken to avoid certain poses during pregnancy.

Yoga is easy to learn and easy to perform. It can be performed individually at any time and without any constraints due to weather conditions. Further, individuals find that it is easier to stick to yoga than other exercise methods. It is also very safe. It is free of any religious or cultural shackles and can be learnt and performed by everyone.