Hula for Heart Health: Using Traditional Dance to Lower Blood Pressure
Shelly Enos, M.P.H., learned the basics of hula, the traditional Hawaiian dance form, when she was a little girl on the island of Oʻahu. She didn’t stick with it, but when she joined a class as an adult, the dance felt familiar. “It’s kind of like riding a bicycle. Once you move that way, it comes back.”
The class was not a standard hula class. All of the students, including Ms. Enos, were Native Hawaiians who had high blood pressure. Many had trouble exercising. The teacher welcomed people at any fitness level. “If you had to stop and rest, it was fine. Nobody made you feel embarrassed about it,” says Ms. Enos.
The dancers were participants in a study on using hula to lower blood pressure. It was one of a series of studies showing that hula can help improve heart health for Native Hawaiians and Other Pacific Islanders. High blood pressure, also known as hypertension, increases your risk of health problems. Although scientists have developed many ways of preventing heart disease, these methods are often developed with White, non-Native people, and the methods do not always work as well in other cultures.
For people who grow up in Hawai‘i, hula is much more than the shows that many tourists see. “Most children growing up in Hawai‘i have learned hula sometime, for their school performances or somewhere,” says Mele Look, M.B.A., co-investigator and Director of Community Engagement for the Department of Native Hawaiian Health at the University of Hawaiʻi at Mānoa.
In hula, each dance has a song, often in the native Hawaiian language. The steps and gestures help illustrate the story of the song, and dancers learn the songs along with the dances. “For me, hula is that connection to culture, to the place I live,” Ms. Look says. “When you learn hula, you study poetry and you study perspectives of life. To be able to recite the song or chant over and over again is very enriching for me. And then you always feel better after the physical movement.”
One day, more than a decade ago, Ms. Look was in a meeting with several researchers, brainstorming ideas for new studies. She had recently gone through a cultural ritual that included a few years of intensive hula training. “It came to my mind because of its very integrated approach to learning and health: mind, body, spirit.” She suggested a study on whether hula helps with heart health. A cardiologist said he had been wanting to do a study related to cardiac rehabilitation, a kind of program to help people recover after heart problems like a heart attack or surgery.
Taking it to the community
In the resulting study, people who had recently had heart surgery attended hula classes for 12 weeks. The researchers found that the exercise was safe and helped people recover from surgery. They also found that it helped participants appreciate and connect to Hawaiian culture and the other people in the class. Strong social ties and a sense of cultural connection helped participants stick with the program, and the classes provided social support, which previous research has established is good for health.1
Part of the university’s research program involves working with the community to find out what its members believe is important to study. In this case, because the community was most interested in prevention, researchers decided to test hula’s ability to reduce high blood pressure. Lowering high blood pressure can reduce the risk of serious health problems such as heart attack, stroke, and aneurysm.
With support from the National Institute of Minority Health and Health Disparities, a research team led by Joseph Keaweʻaioku Kaholokula, Ph.D., one of Ms. Look’s colleagues in the Department of Native Hawaiian Health, conducted a small pilot study. The 45 participants were Native Hawaiians and Other Pacific Islanders who were under a physician’s care for hypertension and had a systolic blood pressure (the top number in a blood pressure measurement) of 140 or more. In addition to a 12-week hula class, participants received education on lowering blood pressure, including avoiding sodium and managing medication.
Three months after the hula class ended, pilot participants’ systolic blood pressure had fallen by an average of 18.3 points—twice as much as for the people in a control group and as big an effect as taking medications.2 Dr. Kaholokula is also examining how taking the hula class made participants feel about their experiences of being discriminated against. He suspects that taking part in such a culturally relevant activity may have strengthened their identity and made them feel more connected to Hawaiʻi and their neighbors.
“Hula is about aloha,” Dr. Kaholokula says. In addition to being used as a greeting, aloha can mean “compassion.” Dr. Kaholokula has toured Japan with a Hawaiian cultural ambassador group and even competed at the Merrie Monarch Festival, the most prestigious annual hula competition in the world. “In the hula school, the other people with you are called hula brothers and hula sisters. When you’re in this group, you extend respect, you extend aloha.”
A larger study
Dr. Kaholokula leveraged the results from the pilot study to get funding from the National Heart, Lung, and Blood Institute for a large 5-year study. The team worked with community partners on the islands of Oʻahu, Maui, and Hawai‘i to set up the classes.
Each group was taught by a hula educator, or kumu hula. The classes started with slow warmups. After some stretching and singing, the students worked on foot patterns to music. Each kumu hula led the study participants in more and more dancing over the 12 weeks. By the end, participants were dancing for 40 minutes, twice a week, well on their way to the recommended 150 minutes of exercise.
Ms. Enos joined the class because she heard of the study as a research coordinator at Waianae Coast Comprehensive Health Center. She liked the class’s pace. “It was very slow-paced, but that’s okay,” she recalls. “We’re not there to dance for the Merrie Monarch. We’re there to exercise and to get back into the cultural way of doing things.”
Although Ms. Enos had to drop out because of scheduling problems, the class inspired her to take further action: She enrolled in a medically supervised weight management program at a local hospital, and her weight and blood pressure are under control now. “Up to that point I thought, ‘What’s the use? Nothing I do is going to make any difference anyway,’” she says. “Sometimes you just need to know that you can do something, to change your belief, and that’s what [the class] helped me do.”
The 5-year study finished last year. The researchers are sharing the results with participants and communities before publishing in a scientific journal but say the results look as good as those in the pilot, with significant drops in systolic blood pressure. Some of the groups have continued studying with their kumu hula, and some even perform.
This work could apply to other indigenous groups, Dr. Kaholokula says. For example, Native American tribes with traditional dances might be able to use those dances to promote health. He also hopes to use hula to promote health for people at risk of other diseases, such as dementia.
That all sounds good to Ms. Enos. “I think people love to dance and to move and to have fun, versus getting on a treadmill and staring at the TV for an hour,” she says. “It has to be done respectfully—that’s the first thing—and this one was.”
- Maskarinec, G. G., Look, M., Tolentino, K., Trask-Batti, M., Seto, T., de Silva, M., & Kaholokula, J. K. (2015). Patient perspectives on the Hula Empowering Lifestyle Adaptation Study: Benefits of dancing hula for cardiac rehabilitation. Health Promotion Practice, 16(1), 109–114. doi:
- Kaholokula, J. K., Look, M., Mabellos, T., Zhang, G., de Silva, M., Yoshimura, S., … Sinclair, K. A. (2017) Cultural dance program improves hypertension management for Native Hawaiians and Pacific Islanders: A pilot randomized trial. Journal of Racial and Ethnic Health Disparities, 4(1), 35–46. doi: 10.1007/s40615-015-0198-4.
Posted September 10, 2019