International Journal of Research in Medical Sciences

Tiwari VK et al. Int J Res Med Sci. 2020 Apr;8(4):1326-1330

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20201318
Original Research Article

Yoga is an effective technique of stress reduction within the medical

population: a biochemical study in MBBS students of BRD Medical
College, Gorakhpur, Uttar Pradesh, India
Vikash K. Tiwari1, Shashi Pandey1, Ragini Mishra2*

1
Department of Physiology, TS Misra Medical College and Hospital, Lucknow, Uttar Pradesh, India
2
Department of Pharmacology, TS Misra Medical College and Hospital, Lucknow, Uttar Pradesh, India

Received: 22 January 2020

Revised: 02 February 2020
Accepted: 28 February 2020

*Correspondence:
Dr. Ragini Mishra,
E-mail: drvikashkt@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Medicine is a profession with high-stress prevalence. There are many stress markers but cortisol is one
of the commonly used stress marker. Stress begins in the first year of medical carrier and increases with subsequent
years of medical education. There is a decrease in overall academic performance and many health-related adverse
effects due to stress. In this study, yoga was performed in the first year MBBS students of BRD Medical College,
Gorakhpur and the impact of yoga in stress reduction was studied using serum cortisol as stress a marker.
Methods: Study groups, yoga and control contained 26 and 27 subjects including male and female MBBS students.
Yoga group practiced selected yogic asana, pranayama, and yoga nidra for 3 months. The control group as a stress
marker had been kept in touch and allowed to go on their usual activity as before. Morning (8.00 AM to 9.00 AM)
serum cortisol level was used as a stress marker in both group, pre and post-study.
Results: There was a significant reduction in morning serum cortisol level (stress level) in yoga group (p-value =
0.0271) but there was no significant change in morning serum cortisol level of the control group (p-value = 0.8573).
Conclusions: Yoga is an effective stress reduction technique for medical students. Yoga classes should be introduced
in the first year of the medical carrier under the supervision of expert physiologists. This may lead to the implantation
of a healthy lifestyle in our future healthcare providers. Yogic practice by health care providers may have long term
positive impacts on our healthcare system.

Keywords: Cortisol, Medical students, Stress, Yoga

INTRODUCTION aggressive problems, hypo-immune dysfunction, medical

morbidity, structural changes in the CNS, and early
Stress is a mental status when an individual perceives that death.2 A wealth of researches conducted worldwide
environmental demands exceed his or her adaptive shows that doctors have high rates of mental health
capacity. Exposures to chronic stress are most likely to problems. Suicide levels are also high for doctors,
result in long-term or permanent changes in the particularly female doctors. There appear to be high rates
emotional, physiological, and behavioral responses. 1 of mental health issues in young doctors. Recent studies
Exposure to intense and chronic stressors has long-lasting in young doctors suggest that their own health care is
neurobiological effects. Chronic stress exposure puts one poor. The doctors with addiction problems in later life
at increased risk for anxiety and mood disorders, tend to manifest vulnerabilities at medical school.3

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 Tiwari VK et al. Int J Res Med Sci. 2020 Apr;8(4):1326-1330

Stress increases as MBBS students go in first to second Inclusion criteria

and then subsequent years of study. So the first year of
medical education is the beginning point of stressful • Willing to participate and continue the yoga
medical carrier and it increases with time.4 Factors practice.
contributing to high levels of stress in medical colleges • Physically able to do yoga practice.
could be highly competitive curriculum, intense academic • Normal health status
competition, and excessive demands on coping abilities
in physical, intellectual, emotional, financial and social Exclusion criteria
terms.5 Stress and anxiety along with substance abuse
develop early and may increase with time in the medical • Practicing Yoga in past.
carriers. Until and unless our students themselves practice • History of medical conditions like stroke, seizure,
health promotional measures, they are very less likely to vertigo, hypertension, coronary artery disease,
guide and motivate their patients and the community to congenital heart diseases, history of status
do so.6 asthamaticus, peptic ulcer disease, spondylitis, joint
pain, disc prolapse, CSOM, hernia, physical
There are many hormones used as stress markers. Stress inability to practice yoga, any other disease
hormones are produced by the sympathetic nervous condition
system and the hypothalamic-pituitary-adrenocortical • Any addiction (excluding nicotine).
axis. The sympathetic nervous system stimulates the
adrenal medulla to produce catecholamines and the First-year medical students were counseled and motivated
paraventricular nucleus of the hypothalamus produces for taking part in the study. Both yoga and control groups
corticotropin-releasing factor (CRF), which in turn were informed about the study. Informed consent was
stimulates the pituitary to produce adrenocorticotropin. taken on paper. Each participant was interviewed for
Adrenocorticotropin then stimulates the adrenal cortex to health history and demographic details before the start of
secrete cortisol. the study. The participants (N = 60, including male and
female) were randomized into two groups (yoga group
Together catecholamines and cortisol increase available and control group) by the computer-generated list of
sources of energy by promoting lipolysis and the random numbers. Randomization was done by an
conversion of glycogen into glucose. Energy is then independent assistant with allocation concealment. There
distributed to the organs that need it most. There is an were 30 (20 Male and 10 Female) participants in the yoga
increase in blood pressure and contraction of certain group and 30 (19 Male and 11 Female) in the control
blood vessels while dilation of others depending on the group. The serum cortisol levels of both yoga and control
demand of the concerned organ. Blood pressure is groups were measured a day before the start of the study
increased by either increasing myocardial contraction or in the morning 8.00 AM. Yoga instructor taught yoga
increasing peripheral vasoconstriction.7 group a specific yoga module 1 hour/ day, 6 days a week
for 3 months. Subjects in the control group received no
There is several well-known effects of yoga practice such specific intervention but kept in touch for final
as an enhanced sense of wellbeing, better physical evaluation.
endurance, as well as definite changes suggestive of
stress reduction.8 Practicing yoga and meditation as a All participating medical students were assessed again at
means to manage and relieve both acute and chronic the end of 3 months by measuring morning serum cortisol
stress helps individuals overcome stress and leads to level. Serum cortisol level was measured by
increased quality of life in many populations. Yoga can chemiluminescent microparticle immunoassay (CMIA)
increase relaxation and induce a balanced mental state on ARCHITECT i-system using ARCHITECT cortisol
and improves sleep quality and insomnia. Furthermore, reagent kit (8D15) produced by Fisher Diagnostics USA
participation in yoga classes improved self-reported and distributed by Abbott Laboratories USA. Evaluation
quality-of-life as well as measures of physical function of control and yoga group, pre and post-yoga morning
among an elderly population.9 Thus yoga can be a useful serum cortisol level provide the biochemical support of
tool to reduce the stress among medical students and this change in stress level of subjects. There was 4 dropouts
reduction in stress may be evident by measurement of in yoga and 3 in the control group.
serum cortisol level. Thus this study will pave a path
towards stress reduction techniques for future health care Data was collected in the form of mean±SD of morning
providers, what even now remains minimally touched serum cortisol level. Data of morning serum cortisol level
issue. was compared before and after yogic practices and
analyzed using SPSS V-20. Data related to yoga and
METHODS control groups were compared using t-test and p-value
<0.05 was considered statistically significant. Graph Pad
This study was conducted in the Yoga lab of Physiology Prism V6 was used to prepare figures.
Department, BRD Medical College, Gorakhpur for a
period of 3 months between March and June 2016.

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RESULTS yoga group. Thus there was an overall decreasing pattern

in yoga group. Observed difference in yoga group was
Higher serum cortisol level is associated with high-stress statistically significant (p-value = 0.0271). There were
level. Table 1, Table 3 summarizes findings of yoga 69% (18) participants in yoga group where serum cortisol
group in present study. Pre-study serum cortisol level in decreased from 15.20±4.70 μg/dl to 12.58±4.23 μg/dl
yoga group (N=26) was 13.76±4.69 μg/dl. Post-study (17.24% decrease) while in only 31% (8) participants of
(after 3 months of yogic practices) serum cortisol level in yoga group serum cortisol increased from 10.52±4.31 to
yoga group was 12.41±4.10 μg/dl. There was a 1.35 μg/dl 12.01±4.04 μg/dl (14.16% increase).
(9.81%) decrease in the mean serum cortisol level of

Table 1: Distribution of serum cortisol level (μg/ dl) in yoga group (N = 26).

Yoga group Pre-study (mean±SD) Post-study (mean±SD) Percentage change in cortisol level
Total sample (N=26) 13.76±4.69 12.41±4.10 9.81% decrease
Decreasing pattern (N=18) 15.20±4.70 12.58±4.23 17.24% decrease
Increasing Pattern (N=8) 10.52±4.31 12.01±4.04 14.16% increase

Table 2: Distribution of serum cortisol level (μg/ dl) in control group ((N = 27).

Control group Pre-study (mean±sd) Post-study (mean±sd) Percentage change in cortisol level
Total sample (n = 27) 13.01 ± 2.44 13.22 ± 2.50 1.61% increase
Decreasing pattern (n = 10) 14.80 ± 1.86 12.03 ± 2.16 18.72% decrease
Increasing pattern (n = 17) 11.95 ± 2.14 13.94 ± 2.47 16.65% increase

Table 3: Pre and post study pattern of change in participants (69%) in the yoga group as compared to the
serum cortisol level in yoga and control group. control group (37%) where cortisol levels decreased.
There were only 31% of participants in the yoga group
Yoga group Control group where cortisol levels increased while cortisol level
Sample size 26 participants 27 participants increased in 63% of participants in the control group.
Decreasing 69% participants 31% participants Overall there was a statistically significant decrease in
pattern (n = 18) (n = 10) serum cortisol level (p-value = 0.0271) in the yoga group
Increasing 37% participants 63% participants while the observed difference in the control group was
pattern (n = 8) (n = 17) not statistically significant (p-value = 0.8573).
Overall
9.81 % decrease 1.61 % increase DISCUSSION
change in
(p value = 0.0271) (p value = 0.8573)
cortisol level
Potey GG et al, studied the effect of yoga on serum
cortisol level in medical students. They found in their
Table 2, Table 3 summarizes findings of control group in
study that Regular practice of yoga for 3 months
present study. Pre-study serum cortisol level in control
significantly reduced the cortisol level.10 A study
group (N = 27) was 13.01±2.44 μg/dl. Post-study (after 3
conducted by Zivdar Z et al, results of this study
months of their regular life) serum cortisol level in
indicated that yoga training significantly reduced the
control group was 13.22±2.50 μg/dl.
plasma cortisol level.11 In a study conducted by Thirthalli
J. et al they concluded that yoga decreases the cortisol
There was a 0.21 μg/dl (1.61%) increase in mean serum
level in patients of depression and thereby stress. Yoga
cortisol level of control group. Thus there was an overall
may act at the level of the hypothalamus by its 'anti-
increasing pattern in control group. Observed difference
stress' effects and reduces the cortisol.12 Messripour M. et
in control group was not statistically significant (p-value
al, concluded in their one study involving young Iranian
= 0.8573). There were 37% (10) participants in control
women that yoga decreases serum cortisol level.13
group where serum cortisol decreased from 14.80±1.86 to
12.03±2.16 μg/dl (18.72% decrease) and in 63% (17)
Lin SL et al, found that yoga decreases work related
participants of control group serum cortisol increased
stress in mental health professionals in his weekly yoga
from 11.95±2.14 to 13.94±2.47 μg/dl (16.65% increase).
program of 12 weeks.14 Similarly in 2015 Oron G, et al
concluded in his study that yoga decreases stress in
Tables 1, 2, 3 summarize the overall findings of the
women waiting for IVF.15 Multiple studies conducted in
present study. Thus it is clear that there were more

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 Tiwari VK et al. Int J Res Med Sci. 2020 Apr;8(4):1326-1330

different population by different researchers like Serpa 3. Brooks SK, Gerada C, Chalder T. Review of
JG. et al, Gard T. et al, Brown RP. et al proved the literature on the mental health of doctors: Are
efficacy of yoga practices in stress reduction.16-18 specialist services needed? J Mental Health.
2011;20(2):146-56.
Emotions, mood, anxiety, stress, and fear can all alter 4. Sharma N, Bhargava M, Chahar BK, Parakh R,
ANS output. The autonomic nervous system is activated Mishra AK, Sharma D. Perceived stress and coping
mainly by centers located in the spinal cord, brain stem, strategies amongst undergraduate Indian medical
hypothalamus, and limbic cortex.19 Hypothalamus students. Indo Am J Pharm Res. 2014;4(06):2785-
coordinates autonomic function with many physiological 90.
variables like feeding, thermoregulation, circadian 5. Malathi A, Damodaran A. Stress due to exam in
rhythms, water balance, emotions, sexual drive, medical students-role of yoga. Indian J Physiol
reproduction, motivation, etc. Thus hypothalamus plays a Pharmacol. 1999;43(2):218-24.
dominant role in the integration of higher cortical and 6. Bansal R, Gupta M, Agarwal B, Sharma S. Impact
limbic systems with autonomic control. So the of short term yoga intervention on mental well-
hypothalamus is the major integrative center for stress being of medical students posted in community
response. Suppression of the HPA axis at the medicine: a pilot study. Indian J Commu Med.
hypothalamic level may be the key effect of yoga in the 2013;38(2):105-8.
case of perceived stress.20, 21 7. Llabre MM, Klein BR, Saab PG, Mccalla JB,
Schneiderman N. Classification of individual
Strength differences in cardiovascular responsivity. The
contribution of reactor type controlling for race and
All subjects of the study were staying within the hostels gender. Int J Behav Med. 1998;5:213-29.
of college. They all were 1st-year MBBS students with an 8. Telles S, Bhat R. Yoga: physiology and application
age range between 18 to 22 years. Subjects with any in therapy and rehabilitation. In: Tandon OP,
confounding factor were not included in the study. The Tripathi Y, editors. Best and Taylor's physiological
study was started almost after 6 months of their entry into basis of medical practice. 13th ed. Gurgaon:
medical college, thereby in equilibrium with medical Lippincott Williams and Wilkins. 2012:1217.
college life. Thus, all subjects were almost similar and 9. Woodyard C. Exploring the therapeutic effects of
were facing similar social and academic stress within Yoga and its ability to increase quality of life. Int J
college premises. Yoga. 2011;4(2):49-52.
10. Potey GG, Verma R, Rajak C, Rampalliwar S,
Limitation of the study was the sample size and duration Mahapatra SP. Effect of yoga practices on
of the study were small. The cortisol level was measured examination stress induced changes in serum
only at the start and end of the study, so the trend of cortisol level and cardiovascular parameters in
change during study cannot be predicted. young healthy medical students. World J Pharm
Pharm Sci. 2016;5(6):1902-15.
CONCLUSION 11. Zivdar Z, Zivdar B. The effect of yoga exercise on
secretion of cortisol in women. Int J Sport Studies.
Stress is very common in the medical professionals. As 2014;4(10):1262-5.
stress adversely affects the work outcome, so medical 12. Thirthalli J, Naveen GH, Rao MG, Varambally S,
professional needs some basic stress reduction Christopher R, Gangadhar BN. Cortisol and
techniques. Here in this study, there was a significant antidepressant effects of yoga. Indian J Psychiatry.
decrease in serum cortisol level in the yoga group; it 2013;55(3):405-8.
concludes that yoga may be instituted as basic stress 13. Messripour M, Shohreh S. Psycho-biological
reduction techniques in health care professionals. correlation of yoga exercise in young Iranian
women. J Neurosci Behavioural Health.
Funding: No funding sources 2012;4(2);13-4.
Conflict of interest: None declared 14. Lin SL, Huang CY, Shiu SP, Yeh SH. Effects of
Ethical approval: The study was approved by the yoga on stress, stress adaption, and heart rate
Institutional Ethics Committee variability among mental health professionals--a
randomized controlled trial. Worldviews Evid Based
REFERENCES Nurs. 2015;12(4):236-45.
15. Oron G, Allnutt E, Lackman T, Arnon ST, Holzer
1. Cohen S, Deverts DJ, Miller GE. Psychological H, Takefman J. A prospective study using Hatha
stress and disease. JAMA. 2007;298(14):1685-7. Yoga for stress reduction among women waiting for
2. Schneiderman N, Ironson G, Siegel SD. Stress and IVF treatment. Reprod Biomed Online.
health: psychological, behavioral, and biological 2015;30(5):542-8.
determinants. Annu Rev Clin Psychol. 2005;1:607- 16. Serpa JG, Taylor SL, Tillisch K. Mindfulness-based
28. stress reduction (MBSR) reduces anxiety,

International Journal of Research in Medical Sciences | April 2020 | Vol 8 | Issue 4 Page 1329
 Tiwari VK et al. Int J Res Med Sci. 2020 Apr;8(4):1326-1330

depression, and suicidal ideation in veterans. Med 20. Boron W, Boulpaep E. Medical physiology: a
Care. 2014;52(12):19-24. cellular and molecular approach. 2nd ed.
17. Gard T, Brach N, Hölzel BK, Noggle JJ, Conboy Philadelphia, PA: Elsevier Saunders. 2012;364-367.
LA, Lazar SW. Effects of a yoga-based intervention 21. Hall JE. Guyton and Hall Textbook of medical
for young adults on quality of life and perceived physiology. 12th ed. Philadelphia, PA: Elsevier
stress: The potential mediating roles of mindfulness Saunders; 2011:734-738.
and self-compassion. J Positive Psychol.
2012;7(3):165-75.
18. Brown RP, Gerbarg PL. Sudarshan kriya yogic Cite this article as: Tiwari VK, Pandey S, Mishra R.
breathing in the treatment of stress, anxiety, and Yoga is an effective technique of stress reduction
depression: part I-neurophysiologic model. J within the medical population: a biochemical study
Alternative Complem Med. 2005;11(1):189-201. in MBBS students of BRD Medical College,
19. Preston RR, Wilson TE. Lippincots’s illustrated Gorakhpur, Uttar Pradesh, India. Int J Res Med Sci
review of physiology. 1st ed. Baltomore, MD. 2020;8:1326-30.
Lippincott Williams and Wilkins; 2013:77-90.

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