Meditation Instead of Medication in Type 2 Diabetes?

A recently published meta-analysis suggested that the utilization of mind-body practices in people living with type 2 diabetes can help significantly improve glycemic control. Multiple media outlets extolled the findings that these techniques could lead to a mean A1c reduction of 0.84%, which is similar to or better than what is achieved with many pharmacotherapies developed for the management of diabetes.

Does this mean, then, that we should ask all patients with type 2 diabetes to start practicing yoga and meditation? Let's take a closer look.

Can Alleviating Stress Improve Glycemic Control?

Without a doubt, mental stress can worsen glycemic control. Studies have shown that the physiologic stress response from chronic exposure to stressors, low socioeconomic status, severe mental health problems, or aggressive behavior increases the risk for a new diagnosis of type 2 diabetes. Stress can also lead to worsening of glycemic control in people who already have diabetes.

In the acute phase, stress hormones such as cortisol, epinephrine, norepinephrine, and growth hormone can stimulate hepatic glucose production and lipolysis, leading to an increase in blood glucose and thereby an increase in insulin release. At the same time, insulin resistance is increased, largely due to downregulation of GLUT-4 mediated glucose transport.

Does this mean that alleviating stress can lead to improvement in glycemic control?

A systematic review and meta-analysis found that psychological interventions, including counseling, cognitive-behavioral therapy, and family systems therapy led to an absolute difference of 0.76% in A1c reduction, thereby suggesting glycemic improvement.

Role of Meditation in Diabetes

The practice of meditation is associated with reduction in stress and negative emotions as well as improvements in overall health-related behavior, coping skills, and attitude. Meditation has been linked to an increase in parasympathetic activity and reduction in sympathetic vascular tone, stress hormones, and inflammatory markers.

Mindfulness meditation refers to the state of awareness that arises through paying attention, on purpose, in the present moment, nonjudgmentally.^[1] Mindfulness-based stress reduction (MBSR) has been shown to reduce diabetes distress as well as improve glycemic control, but most studies have been limited by small sample sizes, short durations, and lack of control groups.

Qigong and Diabetes

Qigong is a mind-body integrative exercise intervention originating from traditional Chinese medicine. It typically involves moving meditation, coordinating slow-flowing movement, deep rhythmic breathing, and a calm meditative state of mind.

According to the National Center for Complementary and Integrative Health, qigong may help improve outcomes in some chronic diseases, although the body of evidence to ascertain this is small and with limitations.

When looking specifically at qigong's effects on diabetes, a systematic review of nine clinical trials concluded that currently there is insufficient evidence to suggest any substantial benefits of qigong in glycemic control in type 2 diabetes.

Yoga and Diabetes

Yoga, which originated in India more than 5000 years ago, aims to balance and harmonize the body, mind, and emotions. It is an umbrella term for a practice incorporating various components, including cleansing processes, postures, controlled breathing, meditation, relaxation, chanting mantras, yogic diet, code of conduct, philosophy, and spirituality.

There are over a dozen different types of yoga, ranging from predominantly physical types such as Ashtanga and Hatha to more spiritual types of practice such as Jivamukti and Kundalini. It is thought that different types of yoga can potentially have different benefits on the mind and body.

From the diabetes perspective, yoga is thought to be associated with behavioral, psychological, and physiologic changes that could contribute to an improvement in glycemic control.

Current Guideline/Consensus recommendations

The American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) 2022 consensus report for the management of type 2 diabetes strongly encourages a holistic approach that includes health behavior modification, psychosocial interventions, and social determinants of health, among other components.

It also illustrates the impact of 24-hour physical behaviors on the glycemic control of an individual. It endorses the use of activities such as tai chi and yoga for improving flexibility and balance. This comprehensive outlook toward management of a chronic disease such as type 2 diabetes is paramount if we are to make any specific inroads toward reducing the burden of complications in the long run.

Increased Yoga Sessions Associated With Decrease in A1c

All of this brings us back to the original publication I mentioned earlier. This study has taken the liberty of combining various different mind and body practices, such as MBSR, qigong and yoga, for a meta-analysis. Combining these practices may not be appropriate as different interventions may have different effects on the body.

The authors mention that they decided to assume equal variances, as they felt that there was no evidence to suggest that variances are unequal between the various studies evaluated. Of note, out of the 28 studies used in the meta-analysis, 18 were related to yoga, while substantially lower numbers of studies were included for MBSR (n = 5), qigong (n = 3), and meditation (n = 1). had

They included both randomized controlled trials as well as pre-post studies for the meta-analysis. Only seven studies reported on both A1c and fasting blood glucose (FBG), whereas 13 reported FBG alone.

As studies with different types of yoga were combined together and included, the authors did observe high heterogeneity for the yoga intervention; the i² was 87% for A1c, indicating high heterogeneity in the yoga group, and heterogeneity was much higher in the randomized controlled trials at 89.71% vs 60.12% in the pre-post studies.

The duration of interventions ranged from just 1 week to 3 years of follow-up, with frequency of intervention ranging from once per week to daily. Any patients on insulin therapy or those with cardiovascular/renal complications were excluded in these studies.

The researchers found no statistically significant association between duration of intervention and mean change in either A1c or FBG. Higher numbers of weekly yoga sessions were associated with a bigger drop in A1c but not in FBG.

Also, there is no mention of physical activities outside of the intervention, nor nutritional modifications, adherence to medications, or other crucial parameters to determine whether any confounding variables contributed to the results. All of these factors make the generalizability of the conclusions difficult to substantiate, in my opinion.

It would be especially helpful to differentiate between those interventions that have a significant body of evidence regarding glycemic control (ie, yoga) vs others, and also for clinicians to understand the difference between these various types of interventions and how to best direct patients toward an approach individualized for them.

To summarize, mind and body practices certainly have significant theoretical benefits when it comes to multiple aspects of health, including those related to metabolism. These can be useful adjuncts to nutritional modification, physical activities, and pharmacotherapy.

We still lack formidable data, however, that conclusively ascertain the degree of improvement in glycemic control that one can expect with these approaches in the management of type 2 diabetes. Hopefully, this void can be filled in the future so that healthcare practitioners can add one more tool to their armamentarium to help patients manage their diabetes in a comprehensive, holistic manner.

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