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Part II: CLINICAL RESEARCH ON THE BENEFITS OF YOGA PRACTICE ON DIABETES

Many studies have reported the beneficial effect of the practice of yoga on diabetes. (10,11,12,13,14, 15,16, 17, 18, 19). Some studies have mentioned up to 65 percent beneficial effect of yogic therapy for diabetes. (11,13,15, 19) K.N. Udupa has even mentioned 5 cases of juvenile diabetes who were completely controlled by yogic treatment. (17) All of these studies have emphasized the possible mechanism of the yogic practices as:

1. Direct influence on pancreatic secretion by rejuvenation of the pancreatic cells, through alternate abdominal contractions and relaxation, during asanas (yogic postures which produce relaxation) and breathing exercises.

2. Reduction in blood sugar due to muscular exercise involved in the asanas.

S.A.A. Ramaiah's study conducted in Washington, D.C. compared the effects of walking, treadmill, static cycling, Amarantha Kokkuasana (Sitting crane), Nindra Kokkuasana (Standing crane) and Vil asana (Bow pose, rocking, especially side to side). The most effective were found to be the latter. it was concluded that the direct stimulation of the pancreas by the postures rejuvenated its capacity to produce insulin.

Several studies have focused upon why the practice of yoga has been more successful than other forms of exercise. M.V. Bhole (20) and K.N. Udupa (18) have measured the effects of yoga on mental stresses. Muhammad (13) has shown the differences between physical exercises and yoga. He has reported how doing the yogic practices without exertion has more benefits.

The mechanism of yogic practices and other exercises is very different. (21) Yogic practices are supposed to change one's attitude towards the situations of life, by developing mental relaxation and balance. One study focused on the practice of the postures in a slow, smooth and non-exerting manner. (22) The postures were maintained comfortably and easily for a length of time and the patients were taught to focus on breathing or on some infinitely vast object like the sky or the ocean while doing the yoga posture. Two thirds of the patients were significantly benefitted by this treatment. The others also showed improvement.

A number of institutions in India offer treatment programs for diabetes (23,24,25,26) Participants generally stay for between two to five weeks, and follow a program of instruction and practice of yoga asanas for at least an hour in the morning and the evening, dietary control, meditation and breathing exercises. They generally become subjects in on going research projects.

Table 2: RECOMMENDATIONS REGARDING THE PRACTICE OF YOGA BY DIABETICS

1. The patient must learn to control and his or her self of diabetes in a wholistic manner, at all levels of your being: physical, emotional, mental, intellectual and spiritual, recognizing the effects of stress, emotional imbalance, and dietary and living habits on the disease condition.

2. Before beginning a program, measure ones exercise toleration. Start with simple movements and positions before progressing gradually to complicated postures.

3. Throughout the program, monitor glucose levels and under the supervision of a physician, and take appropriate medicinal dosages as and when required. After several weeks one may be able to reduce such dosages.

4. Practice in the morning and the evening for 40 to 60 minutes the recommended series of postures according to ones capacity. Practice before meals, but after consuming glucid liquids.

5. Avoid exertion, that is heavy muscular activity. Perform the movements slowly and smoothly, stretching the limbs and joints, and gently compressing the abdomen, without straining. Maintain the postures for a comfortable length of time. The maintenance period of postures should be increased gradually from 5 seconds to one minute, or even longer depending upon the posture and capacity of the patient.

6. Focus on the breath during the maintenance period of the posture, with the eyes closed or focused on one point, as a means of learning to focus the mind and to manage stress and tension in the body.

7. Perform the Shavasana, or complete peace relax pose on the back, systematically relaxing all of the parts of the body, at the end of the session, or after completing several postures, if one begins to feel fatigued.

8.The following postures have been found to be effective in the control and cure of diabetes (sanskrit names; the english and tamil names are in parentheses):

Dhanurasana (Bow pose, Vilasana), Paschimottanasana (Sitting crane, Amarntha kokkuasana), Padangusthansana (Standing crane, Nindra kokkuasana), Bhujangasana (Serpent pose, Paambuasana), Sarvangasana (Shoulder stand), Ardha-matsyendrasana (Spinal twist), Halasana (Plough pose, Kalapoy asana), Yoga mudrasana (Yogic Symbol pose), Supta Vajrasana (Sitting pose of Firmness), Chakrasana (Wheel pose), Shalabhasana (Grasshopper pose, Vittelasana). (19,22)

9. The practice of Udiyana bandam, or the abdominal squeeze has also been fouund to be useful. (22)

10. Regulate the diet throughout the program. Avoid simple sugars such as white sugar, honey, glucose and sweets. And eat complex carbohydrates such as wheat, oatmeal, buckwheat, corn, brown rice and beans. Avoid processed food and eat foods with lots of fibre and nutrients.

11. Obese patients can start with different asanas, cleansing processes, bhastrika pranayama and relaxation. Lean and thin patients should start with relaxation and pranayama, and practice in a relaxed manner.(20)

12. Meditation practices have been shown to help the endocrine glands through relaxation of the sympathetic nervous system. (27)

Recent studies

Since the writing of this article in 1998, there have been several studies which pertain to this topic.

Regarding the effects of Yoga and Diabetes:

1. In 2007, K.E. Innes and H.K. Vincent performed a comprehensive literature search using four computerized English and Indian scientific databases. The search was restricted to original studies (1970-2006) that evaluated the metabolic and clinical effects of yoga in adults with Type II, non-insulin dependent diabetes. Studies targeting clinical populations with cardiovascular disorders that included adults with comorbid DM were also evaluated. Data were extracted regarding study design, setting, target population, intervention, comparison group or condition, outcome assessment, data analysis and presentation, follow-up, and key results, and the quality of each study was evaluated according to specific predetermined criteria. They identified 25 eligible studies, including 15 uncontrolled trials, 6 non-randomized controlled trials and 4 randomized controlled trials (RCTs). Overall, they concluded that these studies suggest beneficial changes in several risk indices, including glucose tolerance and insulin sensitivity, lipid profiles, anthropometric characteristics, blood pressure, oxidative stress, coagulation profiles, sympathetic activation and pulmonary function, as well as improvement in specific clinical outcomes. They also concluded that Yoga may improve risk profiles in adults with Type II, and may have promise for the prevention and management of cardiovascular complications in this population. However, the limitations characterizing most studies preclude drawing firm conclusions. Additional high-quality RCTs are needed to confirm and further elucidate the effects of standardized yoga programs in populations with Type II. (28)

2. Another study by K.E. Innes and G. Alexander examined the social context of physical activity. Findings from the review indicate that yoga has a positive short-term effect on multiple diabetes-related outcomes; however, long-term effects of yoga therapy on diabetes management remain unclear. The context of the social environment, including interpersonal relationships, community characteristics, and discrimination, influences the adoption and maintenance of health behaviors such as physical activity, including yoga practice. Further research is necessary to determine the extent of this influence. (29)

3. Recent research in India continues to support the beneficial effects of Yoga on diabetes:

In a New Delhi study of 149 Type II diabetics, sixty-nine percent of the respondents showed a fair to good response to yoga therapy. The study authors concluded that yoga was a simple and economical therapy useful for non-insulin dependent diabetics. (30)

In another study from New Delhi on diabetes, researchers tried to find out if yoga asanas (postures) could help diabetes by releasing insulin from the pancreas. Twenty healthy young volunteers were given four sets of yoga postures to perform. The asanas given were:

1) Dhanurasana (bow pose)
Matsyendrasana (seated twist)

2) Halasana (plow pose)
Vajrasana (thunderbolt pose)

3) Naukasana (boat pose)
Bhujangasana (cobra pose)

4) Setubandhasana (bridge pose)
Pavanamuktasana (wind relieving pose)

Each volunteer performed the above sets in random order for five days with a two day interval between consecutive sets of asanas. Based on blood test results, the authors found that performance of yoga postures led to improved "sensitivity of the b-Cells of the pancreas to the glucose signal." They concluded that this improvement in insulin sensitivity was due to the cumulative effect of the volunteers performing the postures. (31)

In a 2005 study, 20 patients with type 2 diabetes were put on a 40 day yoga routine taught by an expert yoga teacher. The postures performed were: Surya Namaskar (sun salutation), Trikonasana (triangle pose), Tadasana (mountain pose), Sukhasana (easy pose), Padmasana (lotus pose), Bhastrika Pranayama (breathing exercise), Pashimottanasana (posterior stretch), Ardhmatsyendrasana (half spinal twist), Pawanmuktasana (joint freeing series), Bhujangasana (cobra pose), Vajrasana (thunderbolt pose), Dhanurasana (bow pose), Shavasana (corpse pose).

At the end of the 40 days of of performing the asanas, on average the study participants had a decrease in fasting glucose levels, a significant decrease in waist-hip ratio and beneficial changes in insulin levels. (32)

4. In a recent systematic review, Badr Aljasir, Maggie Bryson and Bandar Al-shehri examined five randomized controlled clinical trials (RCTs) with a total of 363 participants comparing yoga practice with other type of intervention or with regular practice or both. Each study was assessed for quality by two independent reviewers. Mean difference was used for summarizing the effect of each study outcomes with 95% confidence intervals. Pooling of the studies did not take place due to the wide clinical variation between the studies. Publication bias was assessed by statistical methods. Five trials with 363 participants met the inclusion criteria with medium to high risk of bias and different intervention characteristics. The authors concluded that the studies’ results show improvement in outcomes among patients with diabetes type II. These improvements were mainly among short term or immediate diabetes outcomes and not all were statistically significant. The results were inconclusive and not significant for the long-term outcomes. No adverse effects were reported in any of the included studies. Short-term benefits for patients with diabetes may be achieved from practicing yoga. They recommended that further research is needed in this area. Factors like quality of the trials and other methodological issues should be improved by large randomized control trials with allocation concealment to assess the effectiveness of yoga on diabetes type II. A definitive recommendation for physicians to encourage their patients to practice yoga cannot be reached at present according to the authors.

5. The United States National Center for Complementary and Alternative Medicine (NCCAM) has completed a four year study "Yoga for Treating People at Risk for Diabetes or With Both HIV and Depression." The results are not yet published. All participant patients practiced specific yoga asanas 3 to 6 days a week for three months, in the study from 2004 to March 2007. It was conducted at the Swami Vivekananda Yoga Anusandhana Samsthana (SVAYSA) in Bangalore, India by Frederick Hecht, M.D. of the University of California at San Francisco Positive Health Program.

CONCLUSION:

Western medical research has focused upon diabetes as only a physical disorder, requiring only physical modalities of intervention. It has been able to confirm that regular physical exercise does have some beneficial effects in diabetics of both types, and that in those who are genetically predisposed to type 2, it could prevent its development. Western studies have recommended exercise of moderate intensity, as a means to adopt a regular diet and insulin dosage, or to control body weight and improve circulation. Research in India has recognized it as a psychosomatic disorder with causative factors being sedentary habits, physical, emotional and mental stress. Many studies there have confirmed that the practice of the postures can rejuvenate the insulin producing cells in the pancreas of diabetics of both types, and that doing the postures in a relaxed manner, without exertion, yogic meditation and breathing help most patients to control the causes of diabetes.

References:

1. Siscovick, D.S., Laporte, R.E., Newman, J.M. "The disease-specific benefits and risks of physical activity and exercise", Public Health Report, March/April 1985, 100, 2: 180-188.

2. Shephard, R.S., "Physical activity and child health", Sports Medicine, May/June 1984, 1: 205-233.

3. Campaigne, B.N. et al., "The effect of physical training on blood lipid profiles in adolescents with insulin-dependent diabetes mellitus", The Physician and Sportsmedicine, Dec. 1985, 13,12: 83-89.

4. Laporte, R.E. et all, "Pittsburgh insulin-dependent diabetes mellitus morbidity and mortality study: physical activity and diabetic complications" Pediatrics, Dec. 1986, 78: 1027-1033.

5. Richter, E.A., Galbo, H., "Diabetes, insulin and exercise", Sports Medicine, July/august 1986, 3,4: 275-288

6. Zinman, B. Vranic, M. "Diabetes and exercise", Medical Clinics of North America, Jan. 1985, 69, 1: 145-157.

7. Richter, E.A., Schneider, S.H., "Diabetes and exercise", American Journal of Medicine", 1981, 70: 201-209.

8. Nadeau, Andre "L'activite physicque chez le diabetique", Federation des medecins omnipraticens du Quebec, Congres "L'omnipraticien et le sport", Quebec, 15 et 16 mai 1986, 12p.

9. American College of Sports Medicine, "Guidelines for exercise testing and prescription, 3rd edition, Philadelphia, Lea and Febiger, 1986, 175 p.

10. Desai, B.P. "Influence of yogic treatment on serum lipase activity in diabetics". Yoga Mimamsa Vol. XXIII, No. 3 & 4, p. 1 to 8, Jan. 1985.

11. Divekar, M.V. and Bhat "Effect of yoga therapy in diabetes and obesity", Clinical diabetes update 1981, Diab. Assoc. India.

12. Koshti et al. "Electrophoretic pattern of serum proteins in diabetes mellitus as influenced by physical exercises (Yogasanas), Journal of the Mysore Medical Assoc. 36; p. 64, July 1972.

13. Mohammad U. et al. "glucose tolerance and insulin therapy after yoga in diabetes mellitus", Dept. of Medicine and Diabetology, Govt. Stanley Hospital, Madras. (unpublished)

14. Patel C. H., "Yoga and Biofeedback in the management of hypertension", The Lancet Nov. 10, p. 1053-1055, 1973.

15. Rugmini, P.S. and Sinha, R.N. "Effect of yoga therapy in Diabetes mellitus", Seminar on yoga, Science and man, C.C., R.I. M.Hl, p. 175-189, 1976.

16. Sahay, B.K. et al. "The effect of yoga in Diabetes" in Bajay, J.S. "Diabetes mellitus in developing countries", New Delhi, Interprint 1984, 379-381.

17. Tulpule, T.H. "Yogic exercises and diabetes Mellitus (Madhumeh), Journal of Diab. Assoc. India Vol. 17, April 1977.

18. Udupa, K.N. "Stress and its management by yoga", p. 305-320.

19. Ramaiah, S.A.A., "Yoga Therapy for Diabetes: Washington, D.C. Study", International Conference on Traditional Medicine, 1986, Madras. Published by Siddha Medical Board, Govt. of Tamil Nadu, Madras, India.

20. Bhole, M.V. "Therapeutic applications of yoga techniques", Yoga Mimamsa, Journal Kaivalyadhama, Vol. XXIII, No. 3 & 4, p. 29, Oct. 1984.

21. Gore, M.M. "Anatomy and Physiology of Yogic practices", p. 74-96, Ed. 1985 by Kanchan Prakashan Kaivalyadhama, Lonavla.

22. Gore, M.M. "Yogic Treatment for Diabetes", Yoga Mimamsa Vol. XXVI, no. 3& 4 pp. 130 to 145 Oct. 1987, Jan. 1988.

23. Bihar School of Yoga, Munger, Bihar, India under the direction of Dr. Shankardevananda MBBS.

24. Vivekananda Kendra Yogas, Eknath Bhavan, no. 19, Gavipuram Circle, Bangalore, 560019, India. Tel. 0091-80-6597347 or 660.8645; fax: 0091-80-66-8645 or 667.3446 or 661.0666 email: vkyogas@bir.vsnl.net.in

25. The Yoga Institute, Prabhat Colony, Santacruz, (East) Bombay 400055.

26. Kaivalyadhama Institute, Lonalva, India 410403 27. Shankardevananda, Dr. Swami, MBBS, "Yogic Management of Asthma and Diabetes", Bihar School of Yoga", Munger, Bihar, India pg. 76, 163-167.

27. Shankardevananda, Dr. Swami, MBBS, "Yogic Management of Asthma and Diabetes", Bihar School of Yoga," Munger, Bihar, India pg. 76, 163-167.

28. Innes, K.E., Vincent, H.K., "The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: a systematic review,"Evidence Based Complement Alternat Medicine. 2007 Dec;4(4):469-86. Center for the Study of Complementary and Alternative Therapies and Department of Physical Medicine and Rehabilitation, University of Virginia Health Systems, Charlottesville, VA, USA.

29. Alexander, G., Taylor, A., Innes, K.E., Iulbok, P., Selfe, T., Snyder, A.,"Contextualizing the Effects of Yoga Therapy on Diabetes Management: A Review of the Social Determinants of Physical Activity," Family & community Health, July/September 2008 volume 31, number 3, pages 228-239.

30. Jain SC, Uppal A, Bhatnagar SO, & Talukdar B,. "A study of response pattern of non-insulin dependent diabetics to yoga therapy." Diabetes Research and Clinical Practice, Jan:19(1)(1993): 69-74.

31. Manjunatha S, Vempati RP, Ghosh D, Bijlani RL, "An investigation into the acute and long-term effects of selected yogic postures on fasting and postprandial glycemia and insulinemia in healthy young subjects." Indian Journal of Physiology and Pharmacology, 2005 Jul-Sep;49(3):319-24.

32. Malhotra V, Singh S, Tandon OP, Sharma SB, "The beneficial effect of yoga in diabetes." Nepal Medical College Journal, 2005 Dec;7(2):145-7.

33. Badr Aljasir, Maggie Bryson and Bandar Al-shehri, Yoga Practice for the Management of Type II Diabetes Mellitus in Adults: A systematic review," of the University of Ottawa, Canada, in the Oxford Journal of Evidence-Based Complementary and Alternative Medicine.

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