An Analysis upon the Treatment of Diabetes Mellitus through Yoga Therapy

Diabetes mellitus (DM) is plausibly one of the earliest diseases known to mankind. About 3000 years ago it was reported in Egyptian manuscript. In, the difference between type 1 and type 2 DM was made in 1936. Type 2 DM (non-insulin dependent DM) is the most prevalent form of DM categorized by hyperglycemia, resistance to insulin, and relative deficiency to insulin. The risk determinants of Type 2 DM are interconnected by genetic, environmental and behavioural factors. Type 2 DM is characterized by increased morbidity and mortality; it has an insidious onset and late recognition and leads to premature morbidity and mortality. Type 2 DM acquires pressing clinical and economic significance due to work loss and disability leading to increased expenditures on medicines and hospital stay. Evidently, there is a need to identify cost-effective prevention and management strategies for type 2 DM that address the multiple interrelated factors underlying this increasingly common disorder. There is a strong impact of psychological and social factors on the progression from Insulin Resistance Syndrome to type 2 DM. The mind–body discipline of yoga has been widely used in India for the management of diabetes and related chronic insulin resistance conditions. In adult diabetic patients, yoga therapy has shown more beneficial effects and very few adverse effects. Still, the researches on yoga therapy as a complimentary alternative medicine in patients of diabetes mellitus are few. As yoga is holistic living incorporating social and lifestyle changes which are subjective measurements therefore, studies on the contribution of yoga in preventing and reducing complication of lifestyle diseases like diabetes are even fewer. Yoga offers holistic solution to the management of type 2 diabetes mellitus and its complications. Yogic management of diabetes mellitus involves lifestyle changes encompassing kriyas, various asana, changes in diet, management of stress, meditation and leading a holistic life. The comprehensive yoga, an approach incorporating body postures (asanas), breathing techniques (pranayamas), meditation (affecting the manomayakosa), cleansing (kriyas), beneficial and loyal to its ancient inhabitants. Diabetes Mellitus is one of the major killers of the modern world. It is a disorder which is sparing neither the developing nor the developed nations. It is suggested that the increase in the occurrence of the disease is possibly due to the changing food habits and increasing stressful living habits of the modern society. It is predicted that this will grow to 30 million people by 2030. Throughout the Americas, there was 33 million people with diabetes in 2000 and it is estimated that there will be 66 million people diagnosed with diabetes by 2030. Each year, approximately 1 million people aged 20 or older are diagnosed with diabetes. This paper discusses the use of Yoga to treat diabetes. In particular it focuses on treatment of Type II Diabetes, however the healing aspects of Yoga positively affect all types of diabetes. There are different approaches to yoga including spiritual, therapeutic, and developmental. However, the underlying premise of mind–body exercise modalities like yoga is that the physiological state of the body can affect emotions, thoughts, and attitudes, which in turn have a reciprocal effect on the body. Diabetes mellitus has reached epidemic proportions worldwide as we enter the new millennium. The World Health Organization (WHO) has commented there is ‗an apparent epidemic of diabetes, which is strongly related to lifestyle and economic change‘. Over the next decade the projected number will exceed 200 million. Most will have type-2 diabetes, and all are at risk for the development of complications. Diabetes represents a spectrum of metabolic disorders, which has become a major health challenge worldwide. The unprecedented economic development and rapid urbanization in Asian countries, particularly in India has led to a shift in health problems from communicable to non-communicable diseases. Of all the non-communicable diseases, diabetes and cardiovascular diseases lead the list. Over 30 million have now been diagnosed with diabetes in India. The CPR (Crude prevalence rate) in the urban areas of India is thought to be 9 per cent. In rural areas, the prevalence is approximately 3 per cent of the total population. The population of India is now more than 1000 million: this helps to give an idea of the scale of the problem. The estimate of the actual number of diabetics in India is around 40 million. This means that India actually has the highest number of diabetics of any one country in the entire world. IGT (Impaired Glucose Tolerance) is also a mounting problem in India. The prevalence of IGT is thought to be around 8.7 per cent in urban areas and India is genuinely facing a healthcare crisis. In India, the type of diabetes differs considerably from that in the Western world. Type 1 is considerably rarer, and only about 1/3 of type II diabetics are overweight or obese. Diabetes is also beginning to appear much earlier in life in India, meaning that chronic long-term complications are becoming more common. The implications for the Indian healthcare system are enormous.

INTRODUCTION TO YOGA

Yoga is the term that comes from the ancient sanscrit word ―yuga‖. Yoga discipline originated in India and it dates back 5000 years. Many different interpretations of the word yoga have been given over the centuries .Some of these are ―to unite ‖,to be one with the divine‖ ,and ―a science of self-realization‖. Yoga brings about union of the different bodies-physical, emotional, mental & spiritual. Yoga is not just a series of stretching and strength postures. According to T.K.V Desikachar in his book‖ THE HEART OF YOGA‖,he states that. ‖however beautifully we carry out an asana(posture),however flexible our body may be, if we do not achieve the integration of body,breath,and mind we can hardly claim that what we are doing is Yoga. The purpose of Yoga is to unify the actions. DIABETES-MORDERN VIEW - Diabetes is a chronic metabolic disorder in which the body is unable to make proper use of glucose resulting in hyperglycemia (high blood sugar) and glycosuria (sugar in urine). 1. Type I diabetes 2. Type II diabetes 3. Gestational diabetes TYPE I DIABETES - Type I diabetes is an auto immune disease. The immune system attacks the insulin producing beta cells in the pancreas & destroy them .The pancreas then produces little or no insulin. Individuals with type I diabetes needs to take insulin daily to live. It is not understood what is the exact causal factors that prompts the immune system attack beta cells, however it is believed to be related to genetic, environmental, viral & the autoimmune system. Type I diabetes accounts for about 5%-10% of diagnosed diabetes in the United States. TYPE II DIABETES - It is the most common form.90-95% of total people get affected. Usually develops in adult age 40 & older and is most common in adults over age 55.About 80% of people with type II diabetes are overweight. Type II diabetes is often part of the metabolic syndrome that includes obesity, elevated blood pressure and high levels of lipids Unfortunately as more children and adolescents

common in young people. In type II pancreas is usually producing enough insulin but for some unknown reason, the body cannot use insulin effectively. This condition typically referred to as insulin resistance. After several years, insulin production decreases .The result is the same as for type I diabetes-glucose builds up in the blood & the body cannot make enough use of its main source of fuel. Eventually symptoms of type II diabetes develop .Not as sudden in onset as in type I diabetes. Some people have no symptoms.

YOGA IN TYPE 2 DIABETES

Although yoga has been practised since ancient times, yoga as therapy is still a relatively new and emerging trend in the healthcare field. Extensive research has explored changes in biochemical, electrophysiological, cellular, genetic, neuromuscular, and radiological parameters related to yoga practice. This has facilitated the practical application of yoga in various diseases, and it is now being recognized worldwide as a clinically viable treatment. Traditionally a mind-body practice with the ultimate goal of spiritual enlightenment, yoga is a science of health management, rather than a therapy for treating specific diseases . Dietary management of diabetes with yoga- Yoga is also known to regulate eating patterns, and its potential utility in the management of eating disorders has been advocated. It is believed that the mind-body connection that stems from yoga practice provides opportunities for self-awareness, reflection, and change . Yoga, pranayama, and sudarshan kriya were found to be beneficial in improving dietary practices and medication adherence. Yoga practice and mindful eating- Yoga participation has been correlated with both fruit and vegetable intake, as well as improved eating habits and mindful eating practices . Meditation and ability to heighten mindfulness may be beneficial in controlling binge-eating patterns. Mindful eating in diabetes has shown to facilitate improvements in di-etary intake, modest weight loss, and glycaemic control. Recommended practice based on evidence in diabetes- Yoga practice is a complex intervention with various components, including cleansing processes (kriya), postures (asana), controlled breathing (pranayama), meditation, relaxation, chanting mantras, yogic diet, code of conduct, philosophy, and spirituality. Many yoga practices have been found to be beneficial in the management of type 2 diabetes; careful assessment of a patient‘s overall health, individual requirements, associated risk factors, and contraindications (Table 1). By considering the person as a whole, including physical inactivity and poor health behaviours, yoga practices of high or low intensity may be prescribed . Since most studies have evaluated the effects of yoga practices such as postures, pranayama, relaxation, and meditation, the effects of individual yoga postures or other practices are difficult to interpret. Below, information is presented regarding a subset of yoga practices that are known to have beneficial effects on type 2 diabetes, along with their possible mechanisms of action (Table 2). Cleansing processes- The classical ancient texts Hatha Yoga Pradipika and Gheranda Samhita describe purification/cleansing practices known as shatkarmas. Of these, the practices of vaman dhauti (stomach cleansing with induced vomiting), kapalbhati (frontal brain pu-rification, which is a breathing technique with forceful exhalations and automatic inhalations), and shankhaprakshalana (intestinal cleansing) help to increase the production of insulin and to control blood glucose levels. Regular internal cleansing enhances the functional capacity of the organs.

The goal of this study is the effectiveness of yoga-based therapy as a modality for diabetes management and to examine important factors in the social environment that affect the practice of yoga, leading to a change in life style and health behavior among adults with or at risk for type 2 diabetes mellitus. The Effects of Yoga on Markers of Insulin Resistance- The studies assessing the effects of yoga on insulin resistance markers in patients of type 2 DM have documented considerable improvement in one or more clinical post-intervention measures following the practice of yoga either alone or in combination with other therapies and reported significant improvement post-intervention in indices of insulin resistance relative to baseline values. In patients of diabetes mellitus undertaking yoga therapy the fasting blood sugar levels as well as post prandial blood sugar levels are reduced significantly and glycaemia levels are also maintained better. This finding has been corroborated in many research articles wherein the effect of yoga therapy on diabetes mellitus is studied. Manjunatha et al., , observed decreased insulin resistance with the practice of asanas. Various studies have documented reductions in fasting and fructosamine among subjects receiving a yoga-based intervention versus controls receiving enhanced usual care. The reduction in fasting blood glucose is ranging from 6.1-34.4% in various studies. Decrease in the resistance to insulin and increase in the sensitivity to insulin with increased glucose uptake in patients of diabetes mellitus type 2 undergoing yoga therapy regimen was reported by Sahay . The life style diseases i.e. insulin resistance syndrome, cardiovascular diseases and atherosclerosis which affect the manomayakosha leading to stress causing an activation of sympathetic nervous system and decrease in parasympathetic tone are benefitted with the practice of holistic living of yoga. The Effects of Yoga on Blood Lipid Profiles- Many studies have assessed the potential effects of yoga on blood lipid levels; all proposed that the practice of yoga and yoga-based programs may alter lipid profiles towards betterment. The changes in blood lipid fractions included reductions in cholesterol triglycerides low-density lipoprotein (LDL) and very LDL (VLDL) levels, increases in high density lipoprotein (HDL) levels and reduced LDL/HDL ratio relative to baseline levels and/or control values. Yoga and Anthropometric Measurements- Various studies identified reported declines in body weight, reductions in ratio of waist/hip, following yoga-based interventions ranging from 40 days to 12 months. Littman et al., also reported decrease in weight diameter in randomizes control trial in obese and overweight breast cancer survivors. Sahay and Shirley T et al., also reported considerable decrease in weight, BMI and ratio of waist/hip. Haldar et al., found that Body weight, body mass index and fat% were decreased significantly withhatha yoga. Neck circumference reduced in age group of 40 – 49 years. Chest circumference, back leg and grip strength, and flexibility improved considerably. They concluded that Hatha yoga can improve anthropometric characteristics, muscular strength and flexibility and can also be helpful in preventing and attenuating age related deterioration of these parameters. The Effects of Yoga on Blood Pressure- Schmidt T et al., reported significant improvement in both systolic and diastolic blood pressure as compared to baseline values in patients of type 2 diabetes mellitus who undertook comprehensive residential three month kriya yoga training and vegetarian nutrition. The study interventions emphasized on a yogic vegetarian diet, kriya yoga, stress management and group support. Similar, findings of reduction in systolic and diastolic blood pressure in patients of type 2 diabetes mellitus and coronary heart disease were also endorsed by other practices meditation. The patients of type 2 DM and hypertension also showed remarkable improvements after two to three weeks of yoga practice by a decrease in both systolic and diastolic blood pressure associated with reduction in dose of antihypertensive medication. Influence of Yoga on Other Indices- A three months controlled clinical trial done on type 2 diabetes mellitus patients concluded that Yoga can be used as an effective therapy in reducing oxidative stress in type 2diabetes. The practitioners of Yoga at 3 months achieved significant improvements in basal metabolic index (BMI), HbA1c, malondialdehyde, vitamin and glutathione, as compared to the standard care group. Influence of Yoga on stress and anxiety- An interventional study done on patients who had a history of diabetes mellitus, obesity, psychiatric disorders (stress, anxiety, depression), gastrointestinal tract problems (acid reflux, duodenal ulcers)hypertension, coronary artery disease, revealed that anxiety scores of both types of anxiety i.e. about an event and anxiety level as a personal characteristics were reduced. The yogic intervention involved asanas, pranayama, counselling individually and in groups for lifestyle and attitude modifications, meditation and discussions on philosophy and importance of yoga, satvik diet smooth management of excessive tension and yoga therapy for the relevant disease.The outcome measures were anxiety scores based on State-Trait Anxiety Inventory (STAI), a psychological inventory based on a 4-point Likert scale and consisted of 40 questions, taken on the first and last day of the course and the observations suggested significant reduction in the anxiety scores . Another study done on subjects with type 2 diabetes mellitus with yoga practice for 40 days resulted in reduced BMI, improved well‐being, and reduced anxiety.

Diet- Diet plays an important role in the management of diabetes as it exerts a direct influence on the blood glucose level. The goal of diet therapy is to maintain and prolong a healthy, productive and happy life. Regular small meals complex carbohydrates such as wheat, oatmeal, corn, brown rice and beans, avoid refined food stuffs, junk food simple sugars such as white sugar, honey glucose and sweets. Take lots of green vegetables salads, bitter gourd. Maintain good hydration. Suryanamaskar- Suryanamaskar is very good exercise for people suffering from diabetes, it increases the blood supply to various parts of the body, improving insulin administration in the body, it

rounds. One round of Suryanamaskar consists of twelve postures. It helps to burn out the excessive calorie. If practiced at slow speed, it offers the benefits of asana. Asanas- Asanas are beneficial in the treatment of diabetes. Important aspect of Asanas is stability and comfort experienced in the position. After attaining the position, one needs to relax all the muscles and try to maintain the positions for long. Due to various twists, stretches and strains in the body, the internal organs are stretched and subjected to strain. This increases the blood supply, oxygen supply to the organs, increasing the efficiency and functioning of the organ. Stretching various glands results in increased efficiency of the endocrine system.

Sitting Asana – Dandasana, Vajrasana, Baddhakonasana, Paschimottanasana, Ustrasana, gomukhasana, Ardha matsyendrasana, Janu Sirsasana, Mandukasana Prone – Mandukasana, Bhujangasana, Salabhasana, Dhanurasana, Supine – Navasana, Matsyasana, Suptaveerasana, Sarvangasana, Halasana, Savasana. These asana have positive effect on pancreas and also insulin functioning. But to get this result, one needs to maintain the asana for a longer duration while relaxing the muscles.

Ayurveda addresses diabetes using a multi-pronged approach. The treatment of any disease including diabetes, aims at restoring the balance of doshas and the normal function of dhatu (tissue). If the doshas are only slightly increased, restriction of diet along with increased activity is sufficient as a therapeutic measure. If the doshas are moderately increased, one should administer medicine (herbs) to neutralize the deviant doshas along with dietary restrictions and increased activity. If the dosha's are markedly increased, in addition to diet restriction, exercise and medicines, one should also administer Panchakarma (five actions of detoxification). In a nutshell the practice of Ayurveda can be summarized as the following four practices: 1. Reduction; 2. Detoxification; 3. Nourishing or Tonification; and The following Ayurvedic practices can be recommended in different combinations to treat dosha-specific imbalance and disease specific concerns. Panchakarma - Panchakarma means the five purification practices. Often times the doshas can be out of balance due to toxicity levels in the body. Cleansing practices consists of therapeutic enamas (basti), purgatives (virechana), emetics (vamana), nasal medication (nasya) and blood cleansing (rakta moksha). Prior to beginning the body cleanse the toxins are loosened up by a preparatory practice of oil massage (snehana) and steam therapy (svedana). The practice of panchakarma is more prevalent in the Type II diabetes. Svedana is contraindicated as a preparatory practice for obese diabetics since this will likely aggravate the pitta dosha. The stout or obese diabetic is much more capable of managing other body stresses that occur during detoxification processes and will benefit by reduction therapies. The lean weak diabetic which exhibits excessive vata dosha should avoid panchakarma and focus more on medications and diet which increase the dhatus (rebuilding or tonification). Diet - The treatment of dosha imbalances by using food as medicine is a principle of Ayurveda. Food is more than just calories, protein, fat, mineral, and vitamins. Food has qualities associated with six tastes (rasa), and their associated energy (virya). As food enters the body it signals an immediate heating or cooling response. This factor, which is the active potency of food, is called virya. All pungent, salty and sour foods lend a heating virya. Bitter, sour and sweet foods lend a cooling virya. In addition, each food has certain qualities (gunas) which affect the doshas in certain ways. Exercise - Ayurvedic healers recommend exercise on a daily basis for good health and longevity. The Ayurvedic approach to exercise focuses not only on the physical benefits exercise imparts, but also on its positive influence on mind, heart, senses and spirit when customized to suit individual needs for balance. The Ayurvedic + Yoga approach to exercise aims at the following physical benefits: • Enhanced circulation • Enhanced energy, strength and vitality • Enhanced flexibility and coordination • Good posture • A feeling of lightness in the body • Toned muscles and body • Increased efficiency of the digestive system and a balanced appetite and metabolism • Increased efficiency in eliminating toxins from the body Exercise in Moderation - Exercise done to the point of discomfort tends to be counterproductive. When you work out to the point where you are sore, exhausted and straining to breathe normally, your body is generating free radicals, which have been implicated in disease and premature aging. Excessive free radical build-up in the body tends to lower natural immunity. Also, when you work your body so hard that you have to take a day off to rest it after every three days of exercise, you are increasing wear and tear. Over- xercising can interfere with your metabolism as well, slowing it down. To get the benefits from exercise without the side effects, exercise only as long as you can breathe normally through the nose. When you begin to feel yourself pushing beyond your zone of comfort, slow down and walk until you can resume again without straining. Over time, as your body acclimatizes itself to your new way of working out, you will be able to exercise longer in comfort. Pay heed to your body and it will guide you towards your optimum exercise type and level. Specific Yoga Recommendations - Increased Energy through Breathing Techniques (Pranayama) Kapalabhati Breathing - This breathing technique cleanses the body and pacifies the autonomic nervous system, thereby having a beneficial effect on the blood vessels and various organs of the body. Kapalabhati cleanses the lungs and entire respiratory system. The blood is purified and body gets an increased supply of oxygen to all cells. Digestion is improved. Abdominal muscles are strengthened. Stimulation of the vegas nerve by contraction of the abdominal muscles has a beneficial effect in reduction of depression. Alternate Nostril Breathing - This breathing technique soothes the nervous system and enhances sleep quality. By enabling you to focus your breath and deepening it, your brain will register a message for your nervous system to move from a stressed to a relaxation response. Breathing just through your left nostril (by blocking off your right nostril) can direct oxygen flow and energy into the right hemisphere of your brain, which turns on the parasympathetic nervous system (enabling reiaxation). Alternate nostrii breathing helps balance both hemispheres of your brain, which helps you calm your thinking and be able to rest and relax much more easily. need for oral hypoglycemiants. Meditation - Meditation is an excellent relaxation and calming technique, it is a technique which enables us to realize for ourselves the unity of life within any of the world's great religious traditions, or even if we profess no religion at all. According to June Biermann, author of The Diabetic's Total Health Bookvl1, "Meditation is a generalized unstressing technique that releases you from your thinking machine, from that restless voice inside your head that never lets up on you except when you're asleep or unconscious."

Yoga therapy is relevant for wellness, as well as for illness. The latest scientific evidence suggests the potential role of yoga-based lifestyle modifications in the management of type 2 diabetes and its associated risk factors. It is suggested that psycho-neuro-endocrine and immune mechanisms have holistic effects in diabetes control. Parasympathetic activation and the associated anti-stress mechanisms improve patients‘ overall metabolic and psychological profiles, increase insulin sensitivity, and improve glucose tolerance and lipid metabolism. Yoga practices such as cleansing processes, asanas, pranayama, mudras, bandha, meditation, mindfulness, and relaxation are known to reduce blood glucose levels and to help in the management of comorbid disease conditions associated with type 2 diabetes mellitus, resulting in significant positive clinical outcomes. To conclude, many studies including the stop diabetes movement by yoga therapy suggest that yoga therapy has a beneficial effect in patients of type 2DM in terms of reducing the blood sugar levels and insulin resistance and increasing the sensitivity to insulin. Yoga also has a positive effect on lipid profile, management of weight and blood pressure in type 2 DM. In adults with diabetes data indicates that yoga may improve coagulation profiles and pulmonary function, reduces oxidative damage, and decrease sympathetic activation. The effect of yoga therapy on reducing the dose of drug required for management of hypertension and other cardiovascular complications in patients of type 2 diabetes mellitus has also been documented in a few studies. Yoga therapy is effective in promoting health and management of diabetes and yields manifold benefits with very few adverse effects. However, any single intervention is not adequate to ascertain long-term behavior change. Environmental and social factors, yoga, and other lifestyle changes are also important for optimal management of diabetes. However high-quality randomized control trials are needed to

programs in patients with type 2DM. The practice of yoga regulates body physiology through control of posture, breathing, and meditation. Hence, Yoga helps in enhancing health and sense of well-being. There are several asana suggested in Yoga that actively works upon the human body to help to achieve a perfect balance between body requirements and energy produced. By balancing the hormonal production and organ functioning, yoga helps in healing several diseases and optimum healthy life.

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M.A. in Yoga Science, Department of Physical Education, MDU, Rohtak