CME INDIA Presentation by Dr. Hemant Bhargav, MD, PhD, Asso. Prof., National Institute of Mental Health and Neurosciences (NIMHANS) and Harvard Medical School, Integrative Medicine, Bengaluru & Dr. N.K. Singh, MD, FICP, FACP, FRSSDI, F-Diabetes India, Editor, CME INDIA.

Based on the presentation by authors at RSSDI-Karnataka (2023) and UPDACON-23, Gorakhpur, 2023.

Yoga and Diabetes: Where is the Evidence in 2024?

Definition of Yoga

  • Yogaha Chitta Vritti Nirodhaha (PYS: 1:2) Patanjali Yoga Sutra
  • Yoga is termination of the agitation of the mind
  • Patanjali Yoga Sutra 1.29 (ततः प्रत्यक्चेतनाधिगमोऽप्यन्तरायाभावश्च ॥1.29॥)
  • Tatah: from that (practice of meditation on Aum)
  • Pratyak: individual, turned inward
  • Chetanā: consciousness
  • Adhigama: attainment, realization
  • Api: also
  • Antarāya: obstacle
  • Abhāva: absence
  • Cha: and

Yoga and Diabetes: Where is the Evidence in 2024?

  • Growing evidence indicates that engaging in yoga addresses the pathophysiological mechanisms of diabetes, contributing to better diabetes management and a reduction in associated complications.
  • Yoga practice constitutes a multifaceted intervention encompassing various components, such as cleansing processes (kriya), postures (asana), controlled breathing (pranayama), meditation, relaxation, chanting mantras, yogic diet, a code of conduct, philosophy, and spirituality.
  • Several yoga practices have demonstrated benefits in the management of type 2 diabetes. However, it is advisable to use them judiciously, following a thorough assessment of a patient’s overall health, individual requirements, associated risk factors, and any contraindications.

Yoga and Diabetes: Where is the Evidence in 2024?

Surya Namaskara

  • The regular practice of Surya Namaskar has been observed to have a positive impact on the autonomic function of the body. Additionally, it significantly reduces the oxidative stress in the body, a factor that plays a key role in insulin resistance.
ओम मित्राय नमःPraise be to the One who is the friend of all
ओम रवये नमःPraise be to the One who shines brightly and is filled with radiance
ओम सूर्याय नमःPraise be to the One who eliminates darkness and brings in light
ओम भानावे नमःPraise be to the One who is filled with brilliance and lustre
ओम खगाय नमःPraise be to the One who traverses the entire sky and is all-pervasive
ओम पुष्ने नमःPraise be to the One who provides nourishment and fulfils desires
ओम हिरण्यगर्भाय नमःPraise be to the One with a golden-hued lustre
ओम मरिचये नमःPraise be to the One who shines with the light of innumerable rays
ओम आदित्याय नमःPraise be to the One who is the son of the divine cosmic mother, Aditi
ओम सवित्रे नमःPraise be to the One who gives life
ओम अर्काय नमःPraise be to the One who is worthy of all glory
ओम भास्कराय नमःPraise be to the One who is wise and illuminates the heavenly world

Yoga and Diabetes: Where is the Evidence in 2024?

Pranayam is a practice of controlled breathing

  • Deliberate, slow Ujjayi breathing is known to boost parasympathetic activity and elevate indicators of vagal tone. It reduces chemoreflex sensitivity, enhances baroreflex response, and improves both exercise and stress tolerance. Engaging in Ujjayi breathing imparts a sense of calmness to practitioners.
  • The three-stage pranayama incorporating Ujjayi breath represents an advanced form of pranayama, characterized by precise ratios of inhalation, exhalation, and breath holds, complemented by specific arm positions. This practice exercises control over the autonomic nervous system and modulates heart rate. Moreover, the three-stage pranayama is instrumental in opening all three lobes of the lungs.
  • The bhastrika breathing technique is believed to induce a mild sympathetic stimulation, characterized by excitation, followed by emotional calming with concurrent mental activation and alertness. This process enhances the capacity of the sympathetic nervous system to respond to acute stresses without depleting its reserves rapidly.
  • Kapalbhati involves forceful exhalations and inhalations, aiming to enhance the functional capacities of organs and improve the efficiency of pancreatic β-cells. This technique is thought to massage internal organs, leading to increased blood flow.
  • Om chanting has also been discovered to have positive effects on health. Grounded in a mind-sound resonance technique, it facilitates the removal of negativity and fosters an increase in energy.

Yoga and Diabetes: Where is the Evidence in 2024?

Mechanistic Review

Yoga and Diabetes: Where is the Evidence in 2024?

Mystery of Pranayama being revealed

Yoga and Diabetes: Where is the Evidence in 2024?

Kapalbhati is unique

Yoga and Diabetes: Where is the Evidence in 2024?

Effect of Breath

Yoga and Diabetes: Where is the Evidence in 2024?
Yoga and Diabetes: Where is the Evidence in 2024?

An optimal level of AMPK, which commonly declines with age can be reversed with breathing exercises, Pranayama (including kumbhaka)

Yoga and Diabetes: Where is the Evidence in 2024?
Yoga and Diabetes: Where is the Evidence in 2024?

Yoga and T2DM: Current Evidence

Limitations of studies on yoga

  • Numerous gaps exist in clinical trials examining the effects of yoga on health and various diseases. Notably, inadequate control groups, limited patient samples, and brief study durations are significant limitations in investigations into the therapeutic impact of yoga on diabetes. Some studies exclusively focus on blood sugar levels, overlooking potential broader benefits of yoga.
  • The interpretation of these studies is further complicated by issues such as selection bias, the influence of confounding factors, insufficient research methodology, inconsistency in baseline data, and a lack of appropriate statistical analysis. These challenges collectively hinder a comprehensive understanding of the implications of yoga in healthcare.

Important Studies

Diabetes Care journal in 2011 Oct;34(10):2208-10. doi: 10.2337/dc10-2430. Epub 2011 Aug 11.

  • Published Effect of 3-month yoga on oxidative stress in type 2 diabetes with or without complications: a controlled clinical trial.It showed:
  • In contrast to standard care alone, the incorporation of yoga yielded noteworthy reductions in BMI, improvements in glycemic control, and a decrease in malondialdehyde. Additionally, there were observed increases in glutathione and vitamin C. However, no significant differences were found in waist circumference, waist-to-hip ratio, blood pressure, vitamin E, or superoxide dismutase within the yoga group during the follow-up period.
  • In summary, the study suggests that yoga can serve as an effective therapy for reducing oxidative stress in individuals with type 2 diabetes. Furthermore, the addition of yoga to standard care demonstrates benefits such as decreased BMI and enhanced glycemic control in patients with type 2 diabetes

A systemic review and meta-analysis in 2016 (Diabetes Res. 2016;2016:6979370. doi: 10.1155/2016/6979370)

  • An increasing body of evidence indicates that engaging in yogic practices may offer benefits to adults diagnosed with type 2 diabetes (DM2). This systematic review assesses the available evidence from prospective controlled trials, specifically examining the impact of yoga-based programs on key health outcomes relevant to managing DM2. To identify relevant studies, we conducted searches across nine databases and scrutinized bibliographies of pertinent review papers and all located articles. Excluded from consideration were controlled trials that did not target adults with diabetes, focused solely on adults with type 1 diabetes, had a duration of less than two weeks, or lacked quantitative outcome data. The quality of each study was evaluated using the PEDro scale.
  • This analysis encompassed 33 papers presenting findings from 25 controlled trials (13 nonrandomized, 12 randomized), involving a total of 2170 participants. The collective evidence suggests that the practice of yogic techniques may contribute to significant enhancements in various key aspects of DM2 management. These improvements include better glycemic control, favorable lipid levels, and positive changes in body composition. Additionally, more limited data indicate potential benefits such as the reduction of oxidative stress and blood pressure, improvement in pulmonary and autonomic function, mood elevation, enhanced sleep, improved quality of life, and a decrease in medication usage among adults with DM2.

Int J Yoga 2023 Jan-Apr;16(1):27-33. doi: 10.4103/ijoy.ijoy_176_22. Epub 2023 Jul 10. Influence of 24-Week Yoga Intervention on Cardiovascular Risk Factors and Inflammatory Markers in Type 2 Diabetes

  • A 24-week yoga intervention, conducted five days a week, has demonstrated positive effects on various health parameters in individuals with diabetes. The study reveals that engaging in regular yoga sessions has beneficial impacts on BMI, glycemic control, lipid profile, inflammation, and antioxidant levels. These findings establish a scientific basis for advocating the inclusion of yoga in the management of diabetes.
  • The results of the study suggest that individuals with diabetes should be actively encouraged to incorporate yoga into their lifestyle. The observed benefits extend beyond specific aspects of diabetes management and include a positive influence on cardioprotective factors. This underscores the potential of yoga not only as a therapeutic intervention but also as an effective lifestyle approach in the overall care and well-being of individuals with diabetes. The study’s outcomes emphasize the holistic advantages of yoga in addressing multiple facets of diabetes and support its integration into comprehensive diabetes management strategies.

Yoga and Diabetes: Where is the Evidence in 2024?

Verma M R, Langade D G, Rao R D, et al. (August 12, 2022) An Observational Study on the Effect of Yoga and Sudarshan Kriya in Type 2 Diabetes Mellitus Patients. Cureus 14(8): e27951. DOI 10.7759/cureus.27951

  • In conclusion this study shows, individuals with diabetes frequently turn to alternative therapies such as yoga for blood sugar level (BSL) control. The findings from a seven-day course of yoga and Sudarshan Kriya (SKY) as part of the “Living Well” program by AOL indicate a significant reduction in both blood sugar levels (BSL) and pulse rate (PR) among patients with type 2 diabetes. Notably, SKY did not demonstrate any notable impact on blood pressure in these individuals.
  • However, it is crucial to note that further large-scale multicenter studies, conducted over an extended duration, are necessary to validate and substantiate the observed beneficial effects of SKY in the context of diabetes management. These additional studies will contribute to a more comprehensive understanding of the potential therapeutic benefits of SKY for individuals with diabetes, providing a stronger foundation for its inclusion as part of diabetes care strategies.

A systematic review and meta-analysis 2023

  • It delivers a strong indication to conclude whether yoga with oral hypoglycemic agent (OHA) has positive effects on insulin resistance and glycemic control compared to the control group (no regular exercise) with taking OHA in patients with T2D.
  • The study conducted in 2023 and published in Clinical Diabetology (Clin Diabetol 2023; 12; 3: 201–208) suggests that regular yogic practice, in conjunction with oral hypoglycemic agents (OHA), yields positive effects on insulin resistance when compared to a control group that did not engage in regular exercise while using OHA. This finding implies that incorporating a consistent yogic practice alongside the use of oral hypoglycemic agents may contribute to better management of insulin resistance in patients diagnosed with type 2 diabetes. The study’s results underscore the potential synergy between yogic activities and pharmacological interventions in addressing insulin resistance in this patient population.

Yoga and Diabetes: Where is the Evidence in 2024?

Yoga T2DM RCT: Study Profile (Bhargav et al, 2022)

Yoga with lifestyle modification as an adjunctive therapy to conventional management

Yoga and Diabetes: Where is the Evidence in 2024?
Yoga and Diabetes: Where is the Evidence in 2024?

  • The integration model proposed by NIMHANS (2022) recommends incorporating yoga into mainstream clinical services as the initial phase of integration. This involves establishing yoga as a formalized clinical discipline with systematic integration. Subsequently, other viable systems of traditional medicine within AYUSH can be gradually integrated in a phased approach, contingent upon clinical practice and evidential support.

Yoga and Diabetes: Where is the Evidence in 2024?

CME INDIA Take-Away

  1. Scientific Mind-Body Practice with a Philosophical Basis: Yoga is not just a physical exercise but a comprehensive mind-body practice deeply rooted in philosophy. It involves physical postures (asanas), breath control (pranayama), meditation, and ethical principles (yamas and niyamas). The philosophical basis of yoga, often rooted in ancient Indian traditions, emphasizes the interconnectedness of the mind and body. Modern scientific research increasingly supports the benefits of yoga, showing its positive effects on mental health, stress reduction, and overall well-being. This combination of ancient wisdom and contemporary scientific validation contributes to yoga’s credibility as a holistic practice.
  2. Multi-dimensional Approach to Addressing T2DM: Type 2 Diabetes is a complex and multi-faceted health condition involving various factors such as insulin resistance, lifestyle, and genetic predisposition. Yoga, with its multi-dimensional approach, can be a valuable adjunct to clinical practice. By incorporating physical postures that promote flexibility and strength, breathing exercises that improve respiratory function, and mindfulness practices that reduce stress, yoga addresses several aspects of T2DM simultaneously. This holistic approach aligns with the idea of treating the individual as a whole, not just focusing on isolated symptoms.
  3. Yoga therapy holds relevance not only for promoting overall well-being but also as a viable approach to managing various health conditions. The most recent scientific findings emphasize the potential of incorporating yoga-based lifestyle modifications in the effective management of type 2 diabetes and its related risk factors. This evidence suggests that the holistic impact of yoga on psychoneuro-endocrine and immune mechanisms plays a crucial role in diabetes control.
  4. Activation of the parasympathetic nervous system, coupled with its anti-stress mechanisms, brings about comprehensive improvements in both metabolic and psychological profiles among patients. This, in turn, leads to heightened insulin sensitivity, improved glucose tolerance, and enhanced lipid metabolism. The diverse array of yoga practices, including cleansing processes, asanas, pranayama, mudras, bandha, meditation, mindfulness, and relaxation, are recognized for their ability to lower blood glucose levels. Moreover, they contribute significantly to managing coexisting health conditions associated with type 2 diabetes mellitus, resulting in positive clinical outcomes.

Yoga and Diabetes: Where is the Evidence in 2024?

CME INDIA Tail Piece

Yoga and Diabetes: Where is the Evidence in 2024?

References:

  1. Chaya MS, et alAV. Insulin sensitivity and cardiac autonomic function in young male practitioners of yoga. The National Medicalournal of India. 2008; 21(5):217–21.
  2. Mullur RS, Ames D: Impact of a 10 minute seated yoga practice in the management of diabetes . J Yoga Phys Ther. 2016, 6:1000224. 10.4172/2157-7595.1000224 .
  3. Brown RP, Patricia L, Gerbage PL: Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety and depression. Part I: neurophysiologic model. J Alternat Complementary Med. 2005, 11:189-201.
  4. Srivastava S, Goyal P, Tiwari SK, Patel AK: Interventional effect of Bhramari Pranayama on mental health among college students. Int J Ind Psychol. 2017, 4:29-33. 1
  5. Mohanty S, Metri K, Nagaratna R, Nagendra HR: Immediate effect of mind sound resonance technique (MSRT-A yogic relaxation technique) on cognitive functions in type 2 diabetes. Voice Res. 2015, 4:44-5.
  6. Herzig S, Shaw RJ. AMPK: guardian of metabolism and mitochondrial homeostasis. Nat Rev Mol Cell Biol. 2018;19(2):121-135. doi:10.1038/nrm.2017.95
  7. Effects of Yoga Respiratory Practice (Bhastrika pranayama) on Anxiety, Affect, and Brain Functional Connectivity and Activity: A Randomized Controlled Trial.Frontiers in Psychiatry ;11 202010.3389/fpsyt.2020.00467
  8. Raveendran AV, Deshpandae A, Joshi SR. Therapeutic Role of Yoga in Type 2 Diabetes. Endocrinol Metab (Seoul). 2018 Sep;33(3):307-317. doi: 10.3803/EnM.2018.33.3.307
  9. Hegde SV, Adhikari P, Kotian S, Pinto VJ, D’Souza S, D’Souza V. Effect of 3-month yoga on oxidative stress in type 2 diabetes with or without complications: a controlled clinical trial. Diabetes Care. 2011 Oct;34(10):2208-10. doi: 10.2337/dc10-2430. Epub 2011 Aug 11. Erratum in: Diabetes Care. 2012 Apr;35(4):939. PMID: 21836105; PMCID: PMC3177728.
  10. Innes KE, Selfe TK. Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials. J Diabetes Res. 2016;2016:6979370. doi: 10.1155/2016/6979370. Epub 2015 Dec 14. PMID: 26788520; PMCID: PMC4691612.
  11. Sharma S, Bhardwaj S, Gupta A, Katoch VM, Sharma KK, Gupta R. Influence of 24-Week Yoga Intervention on Cardiovascular Risk Factors and Inflammatory Markers in Type 2 Diabetes. Int J Yoga. 2023 Jan-Apr;16(1):27-33. doi: 10.4103/ijoy.ijoy_176_22. Epub 2023 Jul 10. PMID: 37583542; PMCID: PMC10424277.
  12. Verma M R, Langade D G, Rao R D, et al. (August 12, 2022) An Observational Study on the Effect of Yoga and Sudarshan Kriya in Type 2 Diabetes Mellitus Patients. Cureus 14(8): e27951. DOI 10.7759/cureus.27951
  13. Singh, Amit & Tekur, Padmini & Metri, Kashinath & Bhargav, Hemant & Raghuram, Nagarathna & Hongasandra Ramarao, Nagendra. (2018). Effect of a Residential Integrated Yoga Program on Blood Glucose Levels, Physiological Variables, and Anti-Diabetic Medication Score of Patients with Type 2 Diabetes Mellitus: A Retrospective Study. Integrative Medicine International. 4. 181-186. 10.1159/000487947.
  14. Bhargav H, Holla B, Ramakrishna KK, Shivakumar V, Gokulakrishnan K, Varambally S, Gangadhar BN. Yoga and Integrative Healthcare: Lessons from the National Institute of Mental Health and Neurosciences (NIMHANS) in India. Int J Yoga. 2022 May-Aug;15(2):150-157. doi: 10.4103/ijoy.ijoy_56_22. Epub 2022 Sep 5. PMID: 36329771; PMCID: PMC9623895.


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