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. . Published Ahead of Print a Systematic Review of the Energy . Published ahead of Print A Systematic Review of the Energy Cost and Metabolic Intensity of Yoga D. Enette Larson-Meyer Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY Accepted for Publication: 28 February 2016 ACCEPTED Medicine & Science in Sports & Exercise® Published ahead of Print contains articles in unedited manuscript form that have been peer reviewed and accepted for publication. This manuscript will undergo copyediting, page composition, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered that could affect the content. Copyright © 2016 American College of Sports Medicine Medicine & Science in Sports & Exercise, Publish Ahead of Print DOI: 10.1249/MSS.0000000000000922 A Systematic Review of the Energy Cost and Metabolic Intensity of Yoga D. Enette Larson-Meyer Department of Family and Consumer Sciences, University of Wyoming, Laramie, WY Corresponding Author: Enette Larson-Meyer, PhD, RD, FACSM Department of Family & Consumer Sciences 1000 E University Ave Laramie, WY 82071 (307) 766-4378 [email protected] No funding was received for completion of this project. Results of the present study do not constitute endorsement by the American College of Sports Medicine. CONFLICT OF INTERESTS: None ACCEPTED Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. ABSTRACT Purpose: With the increasing popularity of Hatha yoga, it is important to understand the energy cost and metabolic equivalents (METs) of yoga practice within the context of the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) physical activity guidelines. Methods: This systematic review evaluated the energy cost and metabolic intensity of yoga practice including yoga asanas (poses/postures) and pranayamas (breath exercises) measured by indirect calorimetry. The English Speaking Literature was surveyed via Pubmed using the general terms “yoga” and “energy expenditure” with no date limitations. Results: Thirteen manuscripts were initially identified with an additional four located from review of manuscript references. Of the 17 studies, ten evaluated the energy cost and metabolic equivalents (METs) of full yoga sessions or flow through Surya Namaskar (sun salutations), eight of individual asanas and five of pranayamas. METs for yoga practice averaged 3.3±1.6 (range=1.83 to 7.4 METs) and 2.9±0.8 METS when one outlier (i.e., 7.4 METS for Surya Namaskar) was omitted. METs for individual asanas averaged 2.2±0.7 (range=1.4 to 4.0 METs) whereas that of pranayamas was 1.3±0.3. Based on ACSM/AHA classification, the intensity of most asanas and of full yoga sessions ranged from light-, less than 3 METS, to moderate-aerobic intensity, 3 to 6 METS, with the majority classified as light-intensity. Conclusion: This review suggests that yoga is typically classified as a light-intensity physical activity. However, a few sequences/poses including Surya Namaskar meet the criteria for moderate-to vigorous-intensity activity. In accordance with the ACSM/AHA guidelines the practice of asana sequences with MET intensities above 3 (i.e., >10 min), can be accumulated throughout the day and count towards daily recommendations for moderate- or vigorous-intensity physical activity. Key Words: energyACCEPTED expenditure, yoga asanas, pranayama, metabolic equivalents, oxygen uptake, exercise intensity Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. INTRODUCTION Hatha yoga is an increasingly popular form of physical activity in the United States (4, 18, 21, 40) and may be one of the world’s fastest growing health and fitness activities (4). Yoga originated in ancient India where its practice was intended to help “redirect a person’s search for happiness from external sources to internal ones” and eventually result in life fulfilment, wholeness and enlightenment (8, 29). Hatha yoga is one path that traditionally integrates the physical practice of asanas (holding poses or postures), pranayama (breathing control/exercise), bandhas (muscular contractions), mudras (seals and gestures), kriyas (internal cleansing techniques) and meditation (contemplative thought) along with a spiritually-based philosophical framework (e.g., which includes the nonviolence, truthfulness, non-stealing, etc. Since the 1960’s and 70’s, Hatha yoga has undergone various adaptations in the US and has become a practice believed to promote physical fitness, stress reduction and relaxation (4, 8, 29). Yoga is offered in a majority of US health clubs (8) as well as a growing number of yoga studios and private homes. Classes are typically 60 to 90 minutes in duration and involve flowing through a series of asanas and pranayama. Depending on the style, studio and/or teacher, asanas are held standing, seated or supine for various amounts of time and may involve balance and inversion poses with focus on proper form, alignment and breathing. The rhythmic flow through a specific sequence of 12 asanas with controlled breath, termed Surya Namaskar (sun salutations), are often incorporated into many styles/classes and are thought to promote cardiorespiratory fitness (23). Classes typically end in a supine posture called Savasana (corpse pose) and many incorporate meditation. ACCEPTEDSpecific styles of yoga such as Bikram (4, 7) and hot power yoga (4) have also separated from traditional Hatha practice. Both styles—although distinctly different-- incorporate set sequences of basic Hatha poses but are conducted in a hot and humidified room. Practice in Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. this environment is believed to loosen joints, muscles and tendons and help students push themselves, providing a gratifying sense of progress (4). Yoga has even emerged as a component of the new-generation active computer games (13, 22) with WII Fit plus software containing at least 18 modes of yoga (22). Recent data suggests that as many as 20.4 million Americans (8.4% of the US population) practiced yoga in 2012, up from 15.8 million in the previous 2008 survey, with an additional 44.4% expressing interest in trying yoga (40). With the increasing popularity of Hatha yoga, it is important to understand the energy cost and intensity of yoga and its various asanas and pranayamas within the context of the public health and exercise prescription guidelines recommended by the American College of Sports Medicine (ACSM) (2, 10, 12, 16) and the American Heart Association (AHA) (16). To promote and maintain health and reduce disease risk, the ACSM/AHA guidelines encourage 30 minutes of moderate-intensity aerobic physical activity five days per week or vigorous-intensity aerobic activity for a minimum of 20 minutes three days per week. The public health guidelines define absolute intensity in terms of metabolic equivalents (METs) (16) rather than estimates of relative intensity that are more commonly used for individual exercise prescriptions. These typically include percentages of maximal heart rate (%HRmax), heart rate reserve (%HRR), maximal oxygen uptake (%VO2max) or maximal oxygen uptake reserve (%VO2R) (see Table 1)(12). METs are useful for expressing the energy cost and intensity of physical activity as a ratio to metabolic rate at rest, standardized as 3.5 ml/kg/min. in a manor comparable among persons of different weights and physical fitness. Moderate- and vigorous-physicalACCEPTED activity are defined as an intensity between 3 to 6 METs and greater than 6 METs, respectively (16). Current physical activity guidelines also emphasize that combinations of moderate and vigorous-intensity activity are likely to have similar health benefits as Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. continuous activity and can be combined in shorter bouts of at least 10 minutes throughout the day to meet guidelines. The goal is to achieve 450 to 750 MET minutes per week (i.e., METs X daily min accumulated X number of times per week) (16). The purpose of this paper is to twofold: 1) provide a systematic review and evaluation of the literature concerning energy cost and intensity of yoga asanas and yoga practice according to the current ACSM and AHA guidelines (12, 16); and 2) evaluate the quality of published studies measuring the energy cost of yoga asanas, pranayama and complete practice via indirect calorimetery. Although a small handful of studies have measured the metabolic cost of individual yoga asanas and full yoga sessions, a summary of the energy cost and intensity of yoga is not currently available for yoga as it is for other sports (1). This information may prove useful to the exercise, nutrition and medical professional prescribing yoga as a fitness activity or recommending yoga practice for weight loss and/or weight maintenance (10). It may also be useful for yoga teachers and practitioners. METHODS The English Speaking literature was surveyed via Pubmed and cross checked with Web of Science using the general terms “yoga” and “energy expenditure” with no date limitations. To be included, articles had to use indirect calorimetry to calculate energy expenditure from measures of oxygen uptake and carbon dioxide production. Key variables of interest, including absolute and relative oxygen uptake, energy expenditure, MET values, heart rate, respiratory rate and rate of perceivedACCEPTED exertion (RPE) were evaluated and summarized from each identified article and the references scanned for additional manuscripts not identified in the initial literature search. Energy expenditure, METs and relative heart rate (i.e., as a percentage of actual or Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. estimated max) were calculated from available data if values were not reported by the authors using an assumed 5 kcal/liter of O2 consumed, a MET value of 3.5 ml/kg/min and an estimated maximal heart rate of 220 minus average age.
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