2. ROLE OF YOGA IN PREVENTING AND CONTROLLING TYPE 2 DIABETES Manoj Sharma, MBBS, MCHES, Ph.D., FAAHB Adam Knowlden, MBA, MS, CHES Session 3078, American Public Health Association’s 140 th Annual Meeting Monday, October 29, 2012; 10:30 AM - 11:30 AM

3. Problem of Type 2 Diabetes mellitus Globally diabetes mellitus affects over 311 million people. In the United States, approximately 25.8 million children and adults (8.3% of the population) have diabetes (90% to 95% have type 2 diabetes mellitus) Prevalence rates have doubled from 1990 to 2005 It is estimated that global prevalence would exceed 470 million by 2030

4. Prevention & control of Type 2 diabetes mellitus Type 2 diabetes mellitus is a metabolic disorder characterized by insulin resistance and impaired insulin secretion Number of behavioral interventions have been suggested for preventing and controlling type 2 diabetes mellitus Increased physical activity Diet modification Cessation of smoking Mind-body interventions including yoga

5. Yoga & characteristics of yoga users Yoga is an ancient practice originating in India over 4,000 years ago Yoga has been demonstrated to reduce stress and induce relaxation 2002 National Health Interview Survey (NHIS) found about 5.1% of US population or over 14 million people were yoga users 85% Caucasians 76% females Mean age of 39.5 years A majority of yoga users (61%) felt yoga was important in maintaining health

6. Stages of Ashtangayoga Yama: Techniques for successful living in society Niyama: Techniques for managing and purifying self Asaana: Postures for physical homeostasis & mental balance Pranayama: Breathing techniques for physical homeostasis & mental balance Pratihara: Techniques for developing dispassion toward senses for mental balance and equanimity Dharana: Concentration techniques for mental balance and equanimity Dhyana: Meditation techniques for mental balance and equanimity Samadhi: Universal consciousness

7. Purpose The purpose of this study was to review studies that have used yoga in preventing or controlling diabetes and determining whether yoga is beneficial as an alternative and complementary approach for Type 2 diabetes mellitus.

8. Methods The method used in this study was a systematic qualitative review of interventions obtained from following databases: CINAHL (Cumulative Index to Nursing & Allied Health) MEDLINE AMED (Allied and Complementary Medicine Database) Alt HealthWatch CENTRAL (Cochrane Central register of controlled trials)

9. Inclusion & exclusion criteria for studies Inclusion criteria: (1) interventions targeting the prevention or control of type 2 diabetes mellitus (2) employing any quantitative design (3) published in the English language (4) published between January 1993 and December 2011 (5) employing yoga asanas, or pranayama, or dhyana as intervention (6) with biochemical, physiological, anthropometric, or clinical outcomes. Exclusion criteria: (1) that did not employ a quantitative design (2) did not sample diabetic patients with insulin or glucose levels as outcomes or people individuals at risk for diabetes such as those suffering from metabolic syndrome (3) were not indexed in selected databases

10. Summary of Results A total of 17 studies met the inclusion criteria Of the 17 studies, 11 were conducted in India, four were conducted in the United States, one was conducted in England, and one was conducted in Cuba. Nine of the 11 interventions measuring fasting blood glucose were able to show significant decrease Among the identified studies, five employed randomized controlled design, four utilized quasi-experimental design, and seven used pretest-posttest design 15 of the interventions used yoga asanas, 12 used pranayama, and one each used shatkriyas (cleansing exercises) and yoga nidra (relaxation) The duration of the yoga interventions ranged from 8 days to 24 weeks

11. Interventions…1 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Jain et al. 1993; Pretest- posttest design; n= 149; 45.9 ±9.91 years Shatkriyas (cleansing procedures), asanas (postures), pranayama (breathing exercises) 1.5 hours in the morning and 1 hour in the evening x 40 days  76 subjects (51%) showed good response (normalization of oral glucose tolerance test (OGTT))  28 subjects (19%) showed fair response (OGTT max did not exceed 210 mg/dL) Malhotra et al., 2002a; Pretest- posttest design; n=24; 30-60 years Asanas and pranayama 30-40 min/day x 40 days  Fasting blood glucose decreased from 190.08 ± 90.8 mg/dL to 141.5± 79.8 mg/dL  Post prandial blood glucose decreased from 276.54 ± 101 mg/dL to 201.75 ± 104.1 mg/dL  Glycosylated hemoglobin decreased from 9.03 ± 1.4% to 7.83 ± 2.6%

12. Interventions…2 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Malhotra et al., 2002b; Quasi- experimental design; n=40 divided into 2 groups 30-60 years Yoga asanas30-40 min/day x 40 days  Median nerve conduction velocity in right & left hand in yoga group increased from 52.81 ± 1.1 m/sec to 53.87 ± 1.1 m/sec and 52.46 ± 1.0 to 54.75 ± 1/1 m/sec while in control group it decreased. Singh et al., 2004; Pretest- posttest design; n=24 30-60 years Asanas (postures) and pranayama (breathing exercises) 40 days  After yoga fasting blood glucose decreased from 190.08 ± 18.54 in mg/dL to 141.5 ± 16.3 in mg/dL  After yoga post prandial blood glucose decreased from 276.54 ± 20.62 mg/dL to 201.75 ± 21.24 mg/dL  After yoga glycosylated hemoglobin decreased from 9.03 ± 0.29% to 7.83 ± 0.53%

13. Interventions…3 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Bijlani et al., 2005; Pretest- posttest design; n=77 20– 74 years Asanas, pranayama, relaxation, meditation, group support, & lectures 3–4 hours each day in an 8-day outpatient course  Fasting plasma glucose decreased from 106.7 mg/dL ±32.6 to 100.2 mg/dL ± 29.7 (p <0.001)  Total cholesterol decreased from 193.2 mg/dL ±36.4 to 185.8 mg/dL ± 32.7(p <0.001) Malhotra et al., 2005; Pretest- posttest design; n=20 30-60 years Yoga asanas and pranayama 30-40 min/day x 40 days  Fasting blood glucose decreased from 208.3 ± 20.0 to 171.7 ±- 19.5 mg/dl  One hour postprandial blood glucose decreased from 295.3 ± 22.0 to 269.7 ± 19.9 mg/dl

14. Interventions…4 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Manjunatha et al., 2005; Pretest- posttest design; n=20 19-31 years Yoga asanas5 days a week x 4 weeks  Serum insulin levels after the asanas were significantly lower than before (p<0.05)  Asanas were responsible for enhanced sensitivity of the B cells of pancreas to the glucose signal Cohen et al., 2008; Randomized controlled design; n=24 Mean age 52 years Brief series of warm-up Stretches, breathing exercises, and 10 asanas that were held for 5–10 minutes each. 15 yoga sessions of 90 minutes each over 10 weeks  Reduced blood pressure (p = 0.07) in the yoga versus control group  Significant increase in energy level (p < 0.009) in the yoga versus control group  Improvement in well-being (p < 0.12) and stress (p < 0.22) in the yoga versus control group

15. Interventions…5 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Chaya et al., 2008; BMI matched control design; n=30 18-35 years Asana for 37 minutes, pranayama for 18 min. & meditation for 23 min. 70 minutes a day for 6 days a week  Yoga group was more insulin sensitive (yoga 7.82 [2.29] vs. control 4.86 [1.97] (mg/[kg.min]) /(μU/ml), (p<0.001) Gordon et al., 2008; RCT; 3 groups with n=231 type 2 diabetics; 77 in each group: hatha yoga, conventional exercise, & control Mean age 64 years Hatha yoga: Pranayama for 20 min, dynamic warm-up exercises for 25 min, asanas for 60 min & shavasana for 15 mins. 2 hours weekly for 24 weeks  Fasting blood glucose in the Hatha yoga and conventional exercise groups after six months decreased by 29.48% and 27.43% respectively (p < 0.0001)  Significant reduction in total cholesterol in the Hatha yoga and conventional exercise groups after six months (p < 0.0001).

16. Interventions…6 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Singh et al., 2008; Quasi- experimental; n= 60 divided in two groups 35-60 years Yoga asanas and pranayama 45 minutes every day x 45 days  In yoga group fasting blood glucose decreased from 172.87±45.55 to 133.77±38.77 (p<0.001)  In yoga group post prandial blood glucose decreased from 260.50±78.60 to 198.90±63.68 (p<0.001) Amita et al., 2009; Randomized controlled design; n=41 35-65 years Practicing of yoga nidra (relaxation) 30 minutes daily for 90 days  Mean fasting blood glucose level decreased from 159 ± 12.27 to 137.7 ± 23.15 (p<0.0007)  Mean post prandial blood glucose level decreased from 255.45 ± 16.85 to 237.5 ± 30.54) (p=0.02)

17. Interventions…7 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Benavides et al., 2009; Pretest- posttest design; n=14 8-15 years; mean 11.7 years Ashtanga yoga sequence: pranayama & meditation. 75 minutes thrice a week for 12 weeks  BMI decreased from 26.4± 6.6 to 25.6 ± 6.2 kg/m2 (p< 0.01) Skoro-Kondza et al, 2009; RCT; n=59 Mean age 60 Yoga asanas & pranayama 24, 90-minute yoga classes x 12 weeks  No change in HbA1c and other outcome measures Kyizom et al, 2010; Age-sex matched quasi experimental design; n=60 35-60 years Yoga asanas & pranayama 45 days: daily for 5 days and then every 7 days  In yoga group fasting blood glucose decreased from 172.87 ±45.55 mg/dL to133.77 ±38.77 mg/dL (p <0.0001)  Improvement in the latency and the amplitude of N200, P300 was found in the yoga group as compared to the control group (p<0.05)

18. Interventions…8 Authors, Design & sample size AgeIntervention modality Intervention dosage Salient findings Yang et al., 2011; Randomized controlled trial; n=23 51.7 ± 4.9 years Yoga asanas and pranayama Sessions twice per week x 3- months  No significant changes in fasting blood glucose levels in yoga group at end of three months Hegde et al., 2011; Randomized controlled trial; n=123 59.8 mean years yoga group; 57.5 mean years in control group Yoga asanas3 months  Yoga resulted in significant reduction in body mass index, glycemic control, and malondialdehyde increase in glutathione and vitamin C

19. Discussion & Conclusions The reviewed interventions did not use behavioral theories. Theory-based frameworks offer the ability to reduce cost, save time, and produce greater behavioral outcomes. Ideally the interventions should be long term (12-18 months) and employ process evaluations to gauge whether participants adhered to yoga or not Yoga was found to be cost-effective approach that is free of negative side effects Yoga-based interventions for the prevention and control of type 2 diabetes mellitus hold promise and must be tested more for efficacy and effectiveness