Yoga Practice in Diabetes Improves Physical and Psychological Outcomes

Introduction

Diabetes mellitus and insulin resistance are increasing in prevalence, particularly in countries such as India that have limited resources.1 –3 Psychological distress is being increasingly recognized to be a crucial measurement outcome as well as contributing to the cause and course of diabetes.4 ^, 5 Studies in the United States and in India have shown that prevention programs for preventing diabetes are both feasible and cost-effective.6 ^, 7 Yoga is an ancient Indian practice, which incorporates stress-reduction techniques such as meditation, various postures, regulated breathing, and visual imagery.8

The Institute of Yoga and Consciousness was established in 1985 under the auspices of Andhra University in Visakhapatnam, southern India, for training and research in yoga using modern scientific methods. We had conducted a yoga camp for individuals with type 2 diabetes mellitus (T2DM) and evaluated the clinical, biochemical, and psychological outcomes of a 40-day yoga camp. We report the findings of the study here.

Materials and Methods

Individuals with T2DM were invited to participate in the yoga camp through news channels, poster displays, and by word of mouth. Thirty-five subjects participated in the camp held at the Institute of Yoga and Consciousness from June 23, 2008, to August 2, 2008. They were taught a sequence of asanas9 ^, 10 selected from Patanjali Yoga sutras for 10 days, after which they were performed for another 30 days under the direct supervision of the trained yoga teachers of the Institute. Common to all asanas were muscle stretch, awareness of breathing before the posture, awareness of the posture, and awareness of the breath and thoughts. The following were practiced under the supervision of a yoga instructor: hasthachalanam, pada chalanam, tadasanam, pavanmukthasan, utanapadasan, set of 12 suryanamaskars, arthamaschendrasan, bhujangasan, vajrasan, sasankasam jhanu seershasan, paschimuthasan, dharnurasan, jhatara parivruthasan, hamsan, mayurasan, sarvangasan, halasan, masthyasan, udarakasan, katichakrasan, agnisaraka kriya, and pranayam. All asanas were performed every day in the day camp. Subjects had their usual meals at home.

The subjects continued the diet and antidiabetic medicines prescribed by their physicians (5 were on diet and exercise only, 22 on oral hypoglycemic agents, 5 on insulin, 1 on oral hypoglycemic agents, and insulin). No particular yogic diet was prescribed. Physical, biochemical, and psychological evaluation was carried out at the beginning and at the end of the camp. The subjects did not have morbidity and complications that could be potentially jeopardized by following the yoga asanas; a thorough physical examination and detailed review of medical records were carried out. Psychological well-being was assessed by the World Health Organization WHO (Bradley) well-being questionnaire.11 This questionnaire has each of 4 subscales: Depression, anxiety, energy, and positive well-being, and it is useful in determining the incremental benefits to well-being. Written informed consent was obtained from each participant.

Data were analyzed by paired t-test. A P value <0.05 was taken as being statistically significant.

Results

There were 35 subjects (age 50.34 ± 8.38 years, duration of diabetes 5.96 ± 6.1 years; 24 men, 11 women) (Table 1). Twenty individuals did not have any symptoms or previous diagnosis related to organ systems; 2 had related to the cardiovascular system, 2 to respiratory system, 1 to gastrointestinal system, 1 to neurological, and 2 to musculoskeletal system; 6 had symptoms or previous diagnosis related to more than the systems mentioned above. At the end of the study, there was a statistically significant reduction of body mass index (BMI) (26.514 ± 3.355 to 25.771 ± 3.40; P < 0.001) and anxiety (6.20 ± 3.72 to 4.29 ± 4.46; P < 0.05) and an improvement in total general well-being (48.6 ± 11.13 to 52.66 ± 52.66 ± 12.87; P < 0.05) (Table 2).

Discussion

We have shown that a 40-day practice of yoga resulted in decreased BMI, reduced anxiety, and improved well-being using diabetes-specific psychological instruments. Yoga is an ancient Eastern practice that offers an outstanding example of the mind–body connection at work.12 Earlier studies have shown that yoga can rapidly reduce stress,13 decreases depression in the elderly,¹⁴ and improves quality-of-life measures related to energy and sense of well-being.15 ^, 16 An earlier study using yogic breathing and stretch (pranayama) showed that a 30-min program had a markedly “invigorating” effect on perceptions of both mental and physical energy and increased high positive mood.17

A number of studies on the effect of yoga in T2DM showed that yogic practices improved pulmonary function,¹⁸ nerve conduction,19 and glycemic control.20 A series of studies by Sahay et al. have clearly demonstrated the beneficial effects of yoga on decreasing body fat, improved long-term glycemic control, lowering of blood pressure, reduced low-density lipoprotein cholesterol (LDL-C), and very-low-density lipoprotein cholesterol (VLDL-C), and raised high-density lipoprotein cholesterol (HDL-C), along with improved exercise tolerance and reduction of fasting insulin levels.21

To our knowledge, this is the first study evaluating the effects of yoga on diabetic-specific psychological instruments of well-being. Psychological interventions both improve well-being and the quality of life, as well as improve compliance to treatment. In the current study, psychological well-being improved and BMI decreased. Because we did not specifically include it in our protocol, we cannot dissect the independent effects of compliance to treatment and of yoga practice in the beneficial outcomes. Social cognitive factors are crucial to improve self-confidence to undertake physical activity in diabetes mellitus.²² Earlier, we had shown a gender differences in individuals with T2DM and commented on the need for easily accessible, culturally appropriate measures to improve psychological outcomes.5 ^, 23 –25A variety of cognitive behavior correlates showed the beneficial effect of yoga in relieving stress and thereby improving well being.26 ^, 27

In summary, we have shown that a 40-day yoga practice under trained yoga teachers reduced BMI, improved well-being and decreased anxiety in 38 subjects with T2DM who participated in the camp. A follow-up study with a larger sample over a longer period of time is under way, taking particular care to guard against physical injury that may occur on rare occasions from yoga practice.28 This cost-effective, culturally appropriate method can be replicated in larger samples over wider geographic areas to ascertain the acceptability and efficacy found in this study.