Introduction
Diabetes affects approximately 300 million people throughout the world and is on an increasing trend because of change in life style, with excessive calorie intake, reduced physical activity and increased stress. Obesity is the most common nutritional disease in developed countries. It is often associated with type 2 diabetes mellitus which increases the mortality rate. However, the death rate can be reduced by proper management of obesity. Obesity is particularly responsible for insulin resistance and glucose intolerance. Regular exercise and physical training can enhance insulin sensitivity. Poor glycemic control is associated with higher levels of stress in both adolescents as well as in adults.Different studies have clearly demonstrated that the changes in life style chiefly dietary modification, physical exercise and stress relaxation have an important role in the management of diabetes. Exercise training increases the proportion of insulin sensitive fibers in muscle as also increases fat oxidative enzyme activity, and both these changes favor the utilization of fat as the fuel. Physical training increases muscle GLUT-4 content and insulin sensitivity in subject with type 2 diabetes mellitus and HbA1c may fall by 1.0-1.5% after 6 weeks of training.Cross sectional and prospective data suggest that regular exercise can reduce the probability of development of type 2 diabetes mellitus. Population studies have clearly demonstrated that the glucose tolerance is better in physically active persons than in inactive persons.Joslin medal displays a troika with three horses (diet, exercise and insulin) as the major means of diabetic control but unfortunately more emphasis is directed towards the use of drugs, however the diet and exercise are equally important and cost effective. Yoga has always been an essential part of life in traditional system of treatment, so we have tried to elucidate the influence of yoga in diabetic patients with specific aims and objectives. The present study was designed to assess the effects of strict but "user friendly" intervention using yoga life style methods (which include yogic exercises, dietary management, moderate aerobic exercise and stress management) in achieving glycemic control and improvement in various risk factors like BMI, W/H ratio, lipid profile along with quality of life in diabetic patients.
Material and methods
This prospective randomized case control study was conducted in associated group of hospitals, attached to Sardar Patel Medical College, Bikaner in North West Rajasthan, India.200 patients were randomly selected from diabetic clinic, out of which 154 completed the study (group-1 n=72 and group-2 (yoga group) n=82). 46 patients were excluded due to non compliance with treatment or had complications viz IHD, infection and refusal to participate. Patients suffering from disorders like liver disease, pulmonary tuberculosis, malabsorption, thyrotoxicosis, alcoholism, and non-cooperative patients were excluded from the study. Approval from ethical committee and consent from patients were taken before starting the protocol.Baseline parameters - BMI, W/H ratio, fundus, fasting blood glucose, glycosylated hemoglobin, lipid profile, renal functional test, neurological examination, diabetes quality of life score and doses of OHA and insulin were recorded in all the patients in the beginning of study.Patients in the control group (n=72) were managed on conventional medical therapy or usual unsupervised exercise protocol at home while those in the yoga group (n=82) were advised strict life style modification and yogic exercises at "Dhyan Center" of the hospitals. At the end of one month all the patients were reevaluated for the above parameters except lipid profile and glycosylated hemoglobin. Doses of OHA and insulin were titrated according the results of glycemic control every week. At the end of three months, besides above parameters the glycosylated hemoglobin and lipid profile were also estimated. Quality of life score were assessed by psychological questionnaire self evaluation questionnaire and diabetes quality of life questionnaire in the beginning and at the end of the study in all the patients.
Yoga Lifestyle Intervention Programme
The patients were asked to come daily or at least five days a week for continuous 3 months duration. They were put on strict diabetic diet. The yogic lifestyle intervention program consisted of-
1.Health rejuvenating exercises (5 min) - A set of movements for improving the general tone of body and to improve coordination.
2.Asanas - Yogic postures for stretch relaxation.
a. Surya namaskar/parmeshwar vandana (3 min)
b. Paschimottanasana (3 min)
c. Ardhamatsyasana (3 min)
d. Uttanpadmasana (3 min)
e. Sarwangasana (3 min)
f. Matsyasana (3 min)
3.Abdomen exercises (7 min)
4.On every alternate day either
a. Relaxation exercises (Kayotsarga) (30 min) - A method of complete relaxation to prepare the body and mind for meditation or
b. Preksha meditation (Preksha means seeing deeply within) including pranayama (breathing exercises)and Anupreksha (reflection on moral value for 30 min)
Results
Initially 200 patients were randomly selected but 28 patients in group-1 and 18 patients from group-2 (study group) were excluded from the study because of poor compliance or refusal to participate. Hence study was conducted only in 154 patients (group-1 n=72 and group-2 n=82). The demographic parameters of both groups were similar in respect to mean age, sex, weight, duration, BMI, W/H ratio, glycemic control, lipid profile, renal function and quality of life.At the end of 3 months, the yoga group showed significant improvement in glycemic control i.e. HbA1c(mean change 0.79 vs 0.32%, p<0.005),>.
Discussion
The prevalence of diabetes is high in Indians as a whole and is rising very rapidly due to urbanization and westernization. Recent national survey showed that the prevalence of diabetes in urban adults is 12.1%. A number of factors are related to this phenomenal increase directly or indirectly. We have tried to identify association of life style modification with includes diet and yoga in this study, because a number of reports have shown favorable outcome on patients of coronary artery disease using this maneuvers. However there is a paucity of studies showing such a relationship in patients of diabetes and their complications.We observed improvement in glycemic control in patients who had undertaken yogic interventions. Earlier, Sahay (1994) reported significant beneficial effect of six month yoga therapy in diabetic patients. BMI decreased from 24.02 to 23.05 kg/m2; observed statistically significant improvement in lipid profile along with weight reduction-6.8±8.2% (p=0.0019) after yogic life style intervention in coronary atherosclerotic patients.Calle-Pascual et al (1991)observed reduction in BMI from 34.2±0.8 kg/m2 to 30.6±1.1 kg/m2.Thus from the favourable changes observed using different parameters in this study we found that yoga life style intervention have several beneficial effects, in the form of improvement in glycemic control, reduction in body weight and favorable alteration in lipid profile parameters. There was also a favorable response on various risk factors like BMI, W/H ratio and quality of life. The present study shows that adjunctive use of yoga life style interventions significantly improves glycemic status and various risk factors. There was also a significant reduction in doses of OHA and insulin. Being a traditional and cost effective life style management maneuver it can be used as an alternative therapy in the patients of diabetes mellitus.
