|Year : 2017 | Volume
| Issue : 2 | Page : 42-47
Role of yoga in prevention and management of lifestyle disorders
Ananda Balayogi Bhavanani
Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Puducherry, India
|Date of Web Publication||7-Dec-2017|
Ananda Balayogi Bhavanani
Director, Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Pillayarkuppam, Puducherry - 607 403
Source of Support: None, Conflict of Interest: None
The modern world is facing a pandemic of lifestyle disorders that require changes to be made consciously by individuals themselves, and as yoga is the best lifestyle ever designed, it has potential in the prevention, management, and rehabilitation of prevalent lifestyle disorders. Yogic lifestyle, yogic diet, yogic attitudes, and various yogic practices help humans to strengthen themselves and develop positive health, thus enabling them to withstand stress better. This yogic “health insurance” is achieved by normalizing the perception of stress, optimizing the reaction to it, and by releasing the pent-up stress effectively through various yogic practices. This review paper summarizes important findings of a recent research on yoga in lifestyle disorders including a series of studies at Puducherry, India, documenting positive effects. The majority of studies on yoga and cardiovascular and metabolic health show positive trends and this augurs well for the future of health care in general and the use of yoga as a part of integrative health care in particular. Major benefits of yoga may occur due to its lifestyle components (healthy diet, activity, relaxation, and positive attitude) as well as psychosomatic harmonizing effects of pranayama and yogic relaxation. Yoga places a great importance on a proper and healthy lifestyle whose main components are achar (healthy activities), vichar (healthy relationships), vichar (healthy thoughts), ahar (healthy food), and vihar (healthy recreation). The basic yogic principles useful in the management of lifestyle disorders are discussed including psychological reconditioning and development of appropriate attitudes; stress management normalization of metabolism; and relaxation, visualization, and contemplative practices.
Keywords: Lifestyle disorders, stress, yoga
|How to cite this article:|
Bhavanani AB. Role of yoga in prevention and management of lifestyle disorders. Yoga Mimamsa 2017;49:42-7
| Introduction|| |
The World Health Organization defines health as “The state of complete physical, mental and social well-being and not merely absence of disease or infirmity.” The yogic way of living is a vital tool that helps attain that “state” of health. We must not forget that it is more important to have both a sense of “being” healthy as well as “feeling” healthy. Hence, the qualitative aspect of health, the spiritual nature of the human life, is rightly considered more important in yoga and other Indian systems of traditional medicine.
The holistic art and science of yoga is the best lifestyle ever designed and is effective in managing prevalent lifestyle disorders such as diabetes and hypertension. Interestingly, modern research has begun to focus on the psycho-physiological beneficial effects of yoga which need to be understood as more than merely a form of physical exercise (Innes, Bourguignon & Taylor, 2005; Innes & Vincent, 2007).
Yogic lifestyle, yogic diet, yogic attitudes, and various yogic practices help humans to strengthen themselves and develop positive health, thus enabling them to withstand stress better. This yogic “health insurance” is achieved by normalizing the perception of stress, optimizing the reaction to it, and by releasing the pent-up stress effectively through various yogic practices. Yoga is a holistic and integral science of life dealing with physical, mental, emotional, and spiritual health of the individual and the society.
| Research Studies on Yoga and Lifestyle Disorders|| |
Comprehensive reviews have suggested that yoga reduces the cardiovascular risk profile by decreasing the activation of sympatho-adrenal system and hypothalamic-pituitary-adrenal axis and also by promoting a feeling of well-being along with direct enhancement of parasympathetic activity (Innes, Bourguignon & Taylor, 2005; Innes & Vincent, 2007). The authors also suggested that yoga provides a positive source of social support that may also be one of the factors reducing risk for cardiovascular diseases. In fact, all the studies reviewed by the authors suggested that yoga improves lipid profile, and as this is an important risk factor for heart disease, such a possibility needs further exploration in greater detail. Their 2005 review covered seventy eligible studies investigating the effects of yoga on risk indices associated with insulin resistance syndrome, cardiovascular disease, and possible protection with yoga, and they reported that most had a reduction of systolic pressure (SP) and/or diastolic pressure.
Most lifestyle disorders adversely impact functioning of the autonomic nervous system (ANS) and hence research on yoga focusing on this aspect is noteworthy. Studies have shown that central nervous system processing is also affected in diabetes mellitus and that a comprehensive 6-week yoga therapy program produces a significant shortening in auditory reaction time in diabetic patients (Madanmohan, Thombre, Das, Subramanian & Chandrasekar, 1984; Madanmohan, Bhavanani, Dayanidy, Sanjay & Basavaraddi, 2012). It has also been reported that yoga improves nerve conduction (Malhotra et al., 2002) and biochemical profile (Gordon et al., 2008) in patients of diabetes mellitus.
It has been reported that even a short lifestyle modification and stress management education program based on yoga reduces risk factors for cardiovascular disease and diabetes within a period of 9 days (Bijlani et al., 2005) while a systematic review of 32 articles published between 1980 and 2007 found that yoga interventions are effective in reducing body weight, blood pressure (BP), glucose level, and high cholesterol (Yang, 2007).
Yogic practices may have a role in the prevention and management of diabetes and in comorbid conditions such as hypertension and dyslipidemia (Sahay, 2007). Long-term yoga practice is associated with increased insulin sensitivity and attenuation of negative relationship between body weight or waist circumference and insulin sensitivity (Chaya et al., 2008).
The cardiovascular health-promoting benefits of yoga have been studied in a literature review that reported significant improvements in overall cardiovascular endurance of young participants who were given varying periods of yoga training (Raub, 2002). Physical fitness increased as compared to other forms of exercise and longer duration of yoga practice produced better cardiopulmonary endurance. Another detailed review of yoga in cardiac health concluded that yoga is beneficial in the primary and secondary prevention of cardiovascular disease and that it can play a primary or a complementary role in this regard (Jayasinghe, 2004).
Other prominent studies (Ornish et al., 1990; Manchanda et al., 2000; Yogendra et al., 2004) conducted prospective, randomized controlled trials on angiographically proven coronary artery disease patients with yoga intervention and demonstrated that yoga-based lifestyle modification helps in regression of coronary lesions and improvement in myocardial perfusion. The effect of yogic lifestyle on some of the modifiable risk factors could probably explain the preventive and therapeutic beneficial effect observed in coronary artery disease.
A series of studies conducted at Puducherry, India (Bhavanani, Sanjay & Madanmohan, 2011; Bhavanani & Ramanathan, 2012; Bhavanani, Madanmohan & Sanjay, 2012; Bhavanani, Madanmohan, Sanjay & Basavaraddi, 2012; Bhavanani, Madanmohan & Sanjay, 2012; Bhavanani, Madanmohan, Zeena & Vithiyalakshmi 2012; Madanmohan, Bhavanani, Sanjay, Vithiyalakshmi, & Dayanidy, 2013), have documented the immediate effects of various pranayamas in hypertension where yoga has been shown to be an effective adjunct therapy. Different pranayamas were studied in patients of hypertension and postulated mechanisms behind healthy reductions in heart rate, SP, diastolic pressure, mean pressure, and BP indices such as rate–pressure product and double product were determined. Beneficial immediate results of sukha (inhalation = exhalation), savitri (6:3:6:3 rhythm for inhalation: held in: exhalation and held-out breath in sitting and supine positions), chandra nadi (exclusive left nostril breathing), and pranava pranayamas (using audible AUM chanting during prolonged sequential exhalation in sitting and supine positions) were reported. These changes were attributed to a normalization of autonomic cardiovascular rhythms as a result of increased vagal modulation and/or decreased sympathetic activity and improved baroreflex sensitivity along with an augmentation of endogenous nitric oxide production. The prolonged exhalation phase of pranava pranayama was hypothesized to mimic Valsalva maneuver, resulting in decreased venous return, cardiac output, and SP. These findings have potential therapeutic applications in day-to-day as well as clinical situations where BP needs to be brought down at the earliest. These simple and cost-effective techniques may be added to the management protocol of hypertension in addition to regular medical management.
Yoga may be able to have a positive influence in even a single session and a retrospective review from Centre for Yoga Therapy, Education and Research (CYTER) (Bhavanani, Ramanathan & Madanmohan, 2013) analyzed clinical data to determine cardiovascular effects of a single yogic session in 1896 normal individuals as well as patients of different medical conditions. The CYTER team found a healthy reduction in heart rate, BP, and derived cardiovascular indices following a single yogic session. The magnitude of this reduction depends on the preexisting medical condition as well as the yoga therapy protocol adopted. These changes were attributed to enhanced harmony of cardiac autonomic function as a result of coordinated breath–body work and mind–body relaxation due to yoga.
| Role of Yoga in Modulating the Stress Response|| |
Stress plays a vital role in inducing, precipitating, or worsening all lifestyle disorders and hence it is imperative to understand that we can manage it better through yoga. Streeter et al. proposed a theory to explain the benefits of yogic practices in diverse, frequently comorbid medical conditions based on the concept that yogic practices reduce allostatic load in stress response systems such that optimal homeostasis is restored (Streeter, Gerbarg, Saper, Ciraulo & Brown, 2012).
They hypothesized that stress induces an:
- Imbalance of the ANS with decreased parasympathetic and increased sympathetic activity
- Underactivity of the gamma aminobutyric acid (GABA) system, the primary inhibitory neurotransmitter system, and
- Increased allostatic load.
They further hypothesized that yoga-based practices (1) Correct underactivity of the parasympathetic nervous system and GABA systems in part through stimulation of the vagus nerves, the main peripheral pathway of the parasympathetic nervous system and (2) reduce allostatic load.
According to the theory proposed by Streeter et al., the decreased parasympathetic nervous system and GABAergic activity that underlie stress-related disorders can be corrected by yogic practices, resulting in amelioration of disease symptoms.
| Yogic Management of Lifestyle Disorders|| |
Basic yogic principles that are used in the management of lifestyle disorders include the following (Giri, 1976; Bhavanani, 2013):
- Psychological reconditioning and development of appropriate attitudes such as yama-niyama, chaturbhavana, and pratipaksha bhavanam
- Stress management through counseling, jathis (loosening techniques), asanas (postures), kriyas (systematic rational breath–body coordination movements), and pranayama (breath–energy harmonizing techniques)
- Helping normalize metabolic activity through physical activity such as surya namaskar, asanas, kriyas, and pranayama
- Relaxation, visualization, and contemplative practices to induce a sense of inner calmness and well-being.
According to Swami Kuvalayananda, founder of Kaivalyadhama, positive health does not mean mere freedom from disease but is a jubilant and energetic way of living and feeling that is the peak state of well-being at all levels – physical, mental, emotional, social, and spiritual (Kuvalayananda & Vinekar, 1971). Accordingly, one of the aims of yoga is to encourage positive hygiene and health through development of inner natural powers of body and mind. In doing so, yoga gives special attention to various eliminative processes and reconditions inherent powers of adaptation and adjustment of body and mind. Thus, the development of positive powers of adaptation and adjustment, inherent to the internal environment of humans, helps them enjoy positive health and not just mere freedom from disease. He emphasizes that yoga produces nadi shuddhi (purification of all channels of communication) and mala shuddhi (eradication of factors that disturb balanced working of body and mind).
According to Swami Kuvalayananda (Kuvalayananda & Vinekar, 1971), yoga helps cultivation of positive health through three integral steps as follows:
- Cultivation of correct psychological attitudes (maitri, karuna, mudita, and upekshanam toward those who are sukha, duhkha, punya, and apunya)
- Reconditioning of neuromuscular and neuroglandular system – in fact, the whole body – enabling it to withstand stress and strain better
- Laying a great emphasis on appropriate diet conducive to such a peak state of health, and encouraging the natural processes of elimination through various processes of nadi shuddhi or mala shuddhi.
To live a healthy life, it is important to do healthy things and follow a healthy lifestyle. The modern world is facing a pandemic of lifestyle disorders that require changes to be made consciously by individuals themselves. Yoga places a great importance on a proper and healthy lifestyle whose main components are as follows (Giri, 1976; Bhavanani, 2013):
- Achar – Yoga stresses the importance of healthy activities such as exercise and recommends asanas, pranayamas, and kriyas on a regular basis. Cardiorespiratory health is one of the main by-products of such healthy activities
- Vichar – Right thoughts and right attitude toward life is vital for well-being. A balanced state of mind is obtained by following the moral restraints and ethical observances (yama-niyama). As Mahatma Gandhi said, “there is enough in this world for everyone's need but not enough for any one person's greed”
- Ahar – Yoga emphasizes the need for a healthy, nourishing diet that has an adequate intake of fresh water along with a well-balanced intake of fresh food, green salads, sprouts, unrefined cereals, and fresh fruits. It is important to be aware of the need for a satwica diet, prepared and served with love and affection
- Vihar – Proper recreational activities to relax body and mind are essential for good health. This includes proper relaxation, maintaining quietude of action-speech-thoughts, and group activities, wherein one loses the sense of individuality. Karma Yoga is an excellent method for losing the sense of individuality and gaining a sense of universality.
| A Yogic Approach to Prevention and Management of Lifestyle Disorders|| |
Cultivation of right attitudes
The most important part of tackling lifestyle disorders is the cultivation of right attitudes by the development of yogic attitudes toward every part of life. This is vital to reduce the stress that is more often an inner over-reaction than the response to any external stimuli. The attainment of clarity of mind (chitta prasadhanam) through the attitudes extolled by Maharishi Patanjali (maitri, karuna, mudita, and upekshanam) is to be inculcated by the therapist. The therapists need to stress the importance of the individual taking the opposite view toward negative thoughts and actions (pratipaksha bhavanam) as well as emphasis on the cultivation of Karma Yoga, Raja Yoga, and Bhakti Yoga principles in daily life.
Healthy heart-friendly diet
It is important to have a diet that is of a healthy nature. Meals should be taken regularly and there should be adequate amounts of green vegetable salads, sprouts, fenugreek, turmeric, bitter gourd, and neem. There should be the minimum possible amount of salt in the diet and it should have adequate potassium and calcium that are present in fruits and low-fat dairy products. It is important to maintain good hydration, and therapists need to stress that a loss of a few kilograms of body weight will help reduce the BP and enhance insulin sensitivity. Some good pointers are: eat when hungry and after the previous meal has been digested, take regular small meals with complex carbohydrates, and avoid refined foodstuffs and junk foods.
Breath–body movement coordination practices
Practices that enhance mind–body harmony through the use of “breath-linked movements” should be emphasized. Sukshma vyayama and sheetalikarana vyayama practices as well as the enjoyable jathis of the Gitananda tradition are useful in this regard. The surya namaskar when done slowly with breath awareness can also produce psychosomatic harmony and the postures can be held without strain for a short period with meditative awareness of the surya mantras (names of the sun).
Modified versions of the following asanas as per physical condition and other associated health problems of the patient may be used. Standing postures such as tada asana, trikona asana, padottana asana, hasthapada asana, padangushta asana, and mehru asana are useful. Prone postures that are of benefit include bhujanga asana and ardha shalaba asana while useful sitting postures include vakra asana, gomukha asana, ushtra asana, shashaha asana, and yoga mudra asana. The supine postures include matsya asana, pavana mukta asana, and eka and dwipada uttanpada asana. Topsy turvy postures may help in resetting baroreceptor reflex mechanisms that regulate BP. This may also be achieved by “head-below-heart” postures that do the same if the patient cannot do postures such as sarvanga and sethubanda sarvanga asana.
Vibhaga and pranava pranayama are beneficial as also chandra bhedana and chandra nadi pranayamas help reduce sympathetic overactivity. Savitri, nadi shuddhi (aloma viloma in the Gitananda tradition), and bhramari pranayama are excellent practices to reduce stress. Pranayamas such as sheetali and sitkari also produce a sense of relaxation.
Kriyas to cleanse the toxins
For patients who are able to do them, cleansing practices such as kunjal, nauli, kapalabhati, agnisara, shanka prakshalana may be done as deemed fit for the individual predisposition.
Viparita karani, shanmuki mudra, and brahma mudra are all useful in various ways. Viparita karani helps by virtue of being “head-below-heart” and also has a profound effect on the psycho-neuro-endocrine axis. Shanmuki mudra produces a sense of inner calm while brahma mudra by virtue of working with breath and vibration (nada) induces a sense of relaxation and reinvigoration in the head and neck region that reduces stress and normalizes reflex mechanisms.
Hatha Yoga relaxation practices that can be done from shavasana include spandha nishpandha kriya (alternate tension and relaxation), marmanasthanam kriya (part-by-part relaxation), and kaya kriya (dynamic body relaxation). Jnana Yoga relaxation practices such as anuloma viloma kriya and yoga nidra can help reduce stress levels and create psychosomatic harmony. Even simple makara asana offers an excellent antidote to stress and benefits the patients of all psychosomatic disorders.
Dharana and dhyana
Concentrative practices that induce a state of meditation include the popular om japa and ajapa japa. Chakra dhyana is another useful practice while mandala dharana may be done on all chakras with special emphasis on anahata chakra to harmonize prana vayu that is based in the heart region and on the navel center to harmonize the samana vayu at manipura chakra.
This is a vital component of Yoga Chikitsa when dealing with any lifestyle disorder as yoga is basically a preventive life science (heyam dukhkam anagatham - Yoga Darshan II: 16). The counseling process is not a “one off” matter but is a continuous process that starts from the very first visit and continues with every session at different levels.
| Conclusion|| |
Yoga has a great potential in preventing and managing lifestyle disorders and diseases, and yogic lifestyle can make an appreciable contribution to improvement of health of our masses. Yoga has the potential to prevent progression of the disease and if started early, maybe even possibly manifest a cure.
The majority of studies on yoga and cardiovascular health show positive trends and this augurs well for the future of health care in general and the use of yoga as part of integrative health-care system in particular. The major benefits of yoga may occur due to its lifestyle components (healthy diet, activity, relaxation, and positive attitude) as well as the psychosomatic harmonizing effects of pranayama and yogic relaxation. According to tradition, yoga implies both the process as well as the attainment of a state of psychosomatic, harmony, and balance (samatvam yoga uchyate - Bhagavad Gita) and this restoration of physical, mental, emotional, and spiritual balance may be the prime factor behind the changes seen across all short- and long-term studies.
It has been aptly stated that with no appreciable side effects and multiple collateral benefits, yoga is generally safe, simple to learn, and can be practiced by even ill, elderly, or disabled individuals. It has also been recommended that it should be considered as a beneficial adjuvant for patients of such disorders as it is a safe, simple, and economical therapy (Jain, Uppal, Bhatnagar & Talukdar, 1993).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhavanani, A. B. (2013). Yoga Chikitsa: The Application of Yoga as a Therapy
ed.). Pondicherry: Dhivyananda Creations.
Bhavanani, A. B., & Ramanathan, M. (2012). Immediate cardiovascular effects of savitri pranayama in sitting and supine positions in female volunteers. Yoga Mimamsa, 44,
Bhavanani, A. B., Madanmohan, & Sanjay, Z. (2012). Immediate effect of Chandra nadi pranayama (left unilateral forced nostril breathing) on cardiovascular parameters in hypertensive patients. International Journal of Yoga
Bhavanani, A. B., Madanmohan, & Sanjay, Z. (2012). Suryanadi pranayama (Right Unilateral Nostril Breathing) may be safe for hypertensives. Journal of Yoga & Physical Therapy, 2
Bhavanani, A. B., Madanmohan, Sanjay, Z., & Basavaraddi, I. V. (2012). Immediate cardiovascular effects of pranava pranayama in hypertensive patients. Indian Journal of Physiology and Pharmacology, 56
Bhavanani, A. B., Madanmohan, Zeena, S., & Vithiyalakshmi, L. (2012). Immediate cardiovascular effects of pranava relaxation in patients with hypertension and diabetes. Biomedical Human Kinetics, 4,
Bhavanani, A. B., Ramanathan, M., & Madanmohan. (2013). Immediate cardiovascular effects of a single yoga session in different conditions. Alternative & Integrative Medicine, 2,
Bhavanani, A. B., Sanjay, Z., & Madanmohan. (2011). Immediate effect of sukha pranayama on cardiovascular variables in patients of hypertension. International Journal of Yoga Therapy, 21
Bijlani, R. L., Vempati, R. P., Yadav, R. K., Ray, R. B., Gupta, V., & Sharma, R., … Mahapatra, S. C. (2005). A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus. Journal of Alternative and Complementary Medicine, 11
Chaya, M. S., Ramakrishnan, G., Shastry, S., Kishore, R. P., Nagendra, H., & Nagarathna, R., … Kurpad, A. V. (2008). Insulin sensitivity and cardiac autonomic function in young male practitioners of yoga. The National Medical Journal of India, 21
Gordon, L. A., Morrison, E. Y., McGrowder, D. A., Young, R., Fraser, Y. T., & Zamora, E. M., … Irving, R. R. (2008). Effect of exercise therapy on lipid profile and oxidative stress indicators in patients with type 2 diabetes. BMC Complementary and Alternative Medicine, 8,
Innes, K. E., & Vincent, H. K. (2007). The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: A systematic review. Evidence-Based Complementary and Alternative Medicine: eCAM, 4
Innes, K. E., Bourguignon, C., & Taylor, A. G. (2005). Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: A systematic review. The Journal of the American Board of Family Practice, 18
Jain, S. C., Uppal, A., Bhatnagar, S. O., & Talukdar, B. (1993). A study of response pattern of non-insulin dependent diabetics to yoga therapy. Diabetes Research and Clinical Practice, 19
Jayasinghe, S. R. (2004). Yoga in cardiac health (a review). European Journal of Cardiovascular Prevention and Rehabilitation
Kuvalayananda, S., & Vinekar, S. L. (1971). Yogic Therapy: Its Basic Principles and Methods.
India, New Delhi: Central Health Education Bureau, Ministry of Health.
Madanmohan, Bhavanani, A. B., Dayanidy, G., Sanjay, Z., & Basavaraddi, I. V. (2012). Effect of yoga therapy on reaction time, biochemical parameters and wellness score of peri and post-menopausal diabetic patients. International Journal of Yoga, 5
Madanmohan, Bhavanani, A. B., Sanjay, Z., Vithiyalakshmi, L., & Dayanidy, G. (2013). Effects of a comprehensive eight week yoga therapy programme on cardiovascular health in patients of essential hypertension. Indian Journal of Traditional Knowledge
Madanmohan., Thombre, D. P., Das, A. K., Subramanian, N., & Chandrasekar, S. (1984). Reaction time in clinical diabetes mellitus. Indian Journal of Physiology and Pharmacology, 28
Malhotra, V., Singh, S., Tandon, O. P., Madhu, S. V., Prasad, A., & Sharma, S. B. (2002). Effect of yoga asanas on nerve conduction in type 2 diabetes. Indian Journal of Physiology and Pharmacology, 46
Manchanda, S. C., Narang, R., Reddy, K. S., Sachdeva, U., Prabhakaran, D., & Dharmanand, S., … Bijlani, R. (2000). Retardation of coronary atherosclerosis with yoga lifestyle intervention. The Journal of the Association of Physicians of India, 48
Ornish, D., Brown, S. E., Scherwitz, L. W., Billings, J. H., Armstrong, W. T., & Ports, T. A., … Gould, K. L. (1990). Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 336
Raub, J. A. (2002). Psychophysiologic effects of hatha yoga on musculoskeletal and cardiopulmonary function: A literature review. Journal of Alternative and Complementary Medicine, 8
Sahay, B. K. (2007). Role of yoga in diabetes. The Journal of the Association of Physicians of India, 55
Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical Hypotheses, 78
Giri, G. S. (1976). Yoga: Step-by-Step
. India, Pondicherry: Satya Press.
Yang, K. (2007). A review of yoga programs for four leading risk factors of chronic diseases. Evidence-Based Complementary and Alternative Medicine, 4
Yogendra, J., Yogendra, H. J., Ambardekar, S., Lele, R. D., Shetty, S., & Dave, M., … Husein, N. (2004). Beneficial effects of yoga lifestyle on reversibility of ischaemic heart disease: Caring heart project of International Board of Yoga. The Journal of the Association of Physicians of India, 52