research papers on yoga for diabetes

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1 Department of General Medicine, Government Medical College, Kozhikode, India.

2 Department of Internal Medicine, Badr Al Samaa Hospital, Barka, Oman.

3 Padma Yog Sadhana, A Unit of Terna Public Charitable Trust, Navi Mumbai, India.

4 Joshi Clinic, Lilavati Hospital and Bhatia Hospital, Mumbai, India.

Copyright © 2018 Korean Endocrine Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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INTRODUCTION

Yoga in type 2 diabetes, duration and frequency of yoga practice, mechanism of benefits and evidence from clinical trials, limitations of studies on yoga, conclusions, article information.

• Yoga originated in India more than 5,000 years ago and is a means of balancing and harmonizing the body, mind, and emotions. Yoga practice is useful in the management of various lifestyle diseases, including type 2 diabetes. Psycho-neuro-endocrine and immune mechanisms are involved in the beneficial effects of yoga on diabetes. Incorporation of yoga practice in daily life helps to attain glycaemic control and reduces the risk of complications in people with diabetes. In this review, we briefly describe the role of various yoga practices in the management of diabetes based on evidence from various clinical studies.
• Keywords : Yoga ; Diabetes mellitus ; Yoga asana ; Pranayama ; Meditation

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

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Showing the mechanisms of benefits of yoga practice in type 2 diabetes. BP, blood pressure; HPA, hypothalamic-pituitary-adrenal; GH, growth hormone.

Some Yoga Practices Beneficial for the Management of Type 2 Diabetes Mellitus

Some of the beneficial effects of yoga practices on type 2 diabetes mellitus, figure & data.

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• Open access
• Published: 23 December 2021

Diabetic yoga protocol improves glycemic, anthropometric and lipid levels in high risk individuals for diabetes: a randomized controlled trial from Northern India

• Navneet Kaur 1 , 4 ,
• Vijaya Majumdar 2 ,
• Raghuram Nagarathna 2 ,
• Neeru Malik 3 ,
• Akshay Anand 4 &
• Hongasandra Ramarao Nagendra 2  

Diabetology & Metabolic Syndrome volume  13 , Article number:  149 ( 2021 ) Cite this article

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Metrics details

To study the effectiveness of diabetic yoga protocol (DYP) against management of cardiovascular risk profile in a high-risk community for diabetes, from Chandigarh, India.

The study was a randomized controlled trial, conducted as a sub study of the Pan India trial Niyantrita Madhumeha Bharath (NMB) . The cohort was identified through the Indian Diabetes Risk Scoring (IDRS) (≥ 60) and a total of 184 individuals were randomized into intervention (n = 91) and control groups (n = 93). The DYP group underwent the specific DYP training whereas the control group followed their daily regimen. The study outcomes included changes in glycemic and lipid profile. Analysis was done under intent-to-treat principle.

The 3 months DYP practice showed diverse results showing glycemic and lipid profile of the high risk individuals. Three months of DYP intervention was found to significantly reduce the levels of post-prandial glucose levels (p = 0.035) and LDL-c levels (p = 0.014) and waist circumference (P = 0.001).

The findings indicate that the DYP intervention could improve the metabolic status of the high-diabetes-risk individuals with respect to their glucose tolerance and lipid levels, partially explained by the reduction in abdominal obesity. The study highlights the potential role of yoga intervention in real time improvement of cardiovascular profile in a high diabetes risk cohort.

Trial registration: CTRI, CTRI/2018/03/012804. Registered 01 March 2018—Retrospectively registered, http://www.ctri.nic.in/ CTRI/2018/03/012804.

Introduction

The rise of diabetes in the developing world poses a threat to meager health budgets. Owing to the strong association between various morbidity and mortality outcomes as complications of this dreaded disease, early detection of diabetes risk through non-invasive parameters is a primary requisite. Observational studies show that the risk reduction for diabetes can be decreased by 58% or 63–65% if risk factors could be controlled [ 1 , 2 ]. Many argue that such experimental strategies for the possible halting of conversion of prediabetes into diabetes must continue to include pharmacological interventions even though the rates have not been compared [ 3 ]. Identification of individuals at increased risk for the disease with invasive measurements of fasting and post challenge (postprandial) blood glucose are costly and time consuming. Hence, it has been advocated that the realistic prevention of diabetes should identify high-risk subjects with the use of the non-invasive risk scores [ 4 ]. Such studies should also target subjects with normoglycemia and prevent their progression to poor glycemic status [ 4 ].

Yoga plays a promising role in minimizing the risk of Diabetes for high-risk individuals with prediabetes [ 5 , 6 ]. It reduces body weight, glucose, and lipid levels, though, most of these studies comply with the guidelines of randomized controlled trials adhered to the CONSORT statements [ 7 , 8 , 9 , 10 , 11 ] whereas majority of studies have not reported as per CONSORT statements [ 12 , 13 , 14 , 15 ]. Several review of published studies, in people with diabetes and prediabetes, have concluded that the practice of yoga may reduce insulin resistance and related cardiovascular disease (CVD) risk factors and improve clinical outcomes [ 16 ]. Specifically, reports suggest that a yoga-based lifestyle intervention reduces body weight, glucose and lipid levels that should reduce diabetes risk. Keeping in view the high transition rates of diabetes in India, we selected a high-risk cohort from Chandigarh, one of the most affluent Union Territories of India with highest reported prevalence of diabetes in order to establish the efficacy of yoga to alleviate the cardiovascular disease. Indian Diabetes Risk Score (IDRS), specific for Indian ethnicity a validated tool was used for identification of the high-risk population [ 17 ]. We developed a national consensus ‘Diabetes Yoga protocol’ based on published reports and classical literature with an aim to stimulate weight reduction by combination of postures and meditation techniques [ 18 , 19 ]. Additionally, cardiometabolic risk reduction has also been recognized as one of the potential outcomes of yoga-based interventions [ 20 ]. Yoga has been shown to be regulating the risk parameters of diabetes, waist circumference (WC), body mass index (BMI), oxidative stress, fasting blood sugar (FBS) and systolic blood pressure (SBP) respectively [ 21 ]. Hence, in this study we tested the efficacy of diabetic yoga protocol (DYP) on alleviation of glycemic and lipid imbalances in individuals at high risk of diabetes.

Materials and methods

Study population.

Under the multi-region survey of Niyantarita Maduhmeha Bharat (NMB-2017) a door-to-door screening was carried out for the identification of high risk individuals among the population of Chandigarh (U.T) and Panchkula (District in Haryana state) on the basis of Indian Diabetes Risk Score (IDRS). The data collection was carried out by well trained yoga volunteers for diabetes management (YVDMs). Written informed consents were taken from every subject during door to door screening as well as at the time of registration. All the experimental protocol, methods and procedures were approved by Ethics committee of Indian Yoga Association (IYA) (ID: RES/IEC-IYA/001). All experiments methods and procedures were carried out in accordance with relevant guidelines and regulations of ethics committee. The study was registered at clinical trial registry of India, CTRI/2018/03/012804 (dated: 01/03/2018).

Study design

The present study is the two-armed randomized controlled trial conducted in the population of Chandigarh and Panchkula regions of northern India. Indian Diabetes Risk Score (IDRS) was used for detection of high risk (≥ 60 score) individuals from the study. Self-declared diabetics and low (< 30 score) and moderate [between 30–50 score] risk individuals were excluded from the study. As evident from the flow of patients presented in the flowchart, out of 1214 eligible subjects, there was approximately 50% loss of sample data due to error in the sampling. Further out of 564, we had to exclude as they were self-declared patients with diabetes and did not further participate in the study. However, this led to final participation of only 184 subjects in the study and allocation of these subjects diminishing the random selection of the study cohort. A cohort of high diabetes-risk cohort consisting of n = 184 participants was randomized into the interventional and control groups (n = 91:93). After excluding the dropouts from the study, based on CONSORT guidelines, the remaining subjects in the DYP and control group were further assessed for selected anthropometric, glycemic and lipid parameters. The intervention group was given the Diabetic Yoga Protocol for three months and control group continued with their daily routine activities. The detailed categorization of the samples is shown in Fig.  1 . The control group was waitlisted for yoga.

Flowchart of study design. PCA   principal component analysis, MIPCA multiple imputations with PCA

Randomization

Simple randomization technique was used to allocate participants into the intervention and the control groups. An independent statistician generated a computer-generated random number sequence and the sequence was given to an external staff who had no involvement in the study procedures. The participants were allocated their consecutive numbers, after baseline measurements. Blinding of the participants was not possible due to the nature of the intervention. However, the outcome assessors were blinded.

Risk assessment

To identify the individuals at high-risk of diabetes, Indian Diabetes Risk Score (IDRS) was administered as proposed by Mohan et al. [ 22 ]. It consisted of two unmodifiable (i.e. age, and family history) and two modifiable (physical activity and waist circumference) risk factors for diabetes, which can predict the level of risk for the development of diabetes in the community. The IDRS is one of the easily accessible and budget friendly questionnaire to be administered. The aggregate score of the unmodifiable and modifiable risk used to probe the level of risk among the population (i.e. High risk > 60, Moderate risk-30–50, Low risk < 30).

Sample size

Sample size estimation for the main Pan India study was focused for prediabetes subjects [ 23 ]. However, for the present pilot scale study we calculated sample size assuming a small effect size 0.3 [ 5 ] of DYP vs waitlist control 0.25, α = 0.80 as 180 (n = 90:90). Further, assuming an attrition rate of 20%, the final sample size was n = 220.

Study outcomes

Changes in the glycemic and other metabolic variables (anthropometric and lipid) over 3 months were documented. The fasting blood sample was withdrawn. For glucose analysis, fasting samples for 10–12 h were taken early in the morning for the estimation of FBS and afterwards 75 g glucose was given to the participants. The blood sampling was repeated after 2 h. for estimation of OGTT.

Biochemical analysis

For the estimation of biochemical parameters viz. FBS (Fasting Blood Sugar, Rxl-Max 500), OGTT (Oral Glucose Tolerance Test), HbA1c (Bio-Rad D-10), Triglycerides, Cholesterol, HDL, LDL, Chol/HDL ratio, HDL/LDL ratio (Rxl-Max 500) and VLDL about 9 ml of blood was drawn and analyzed by phlebotomist of Sisco Research Laboratories (SRL) of Chandigarh. Anthropometric measurements were also obtained (i.e. height, weight, waist circumference) by trained researcher. The waist circumference (WC) was reported in centimeters. The BMI was obtained by using the formula (weight in kg/height (meter) 2 ).

Interventions

The study protocol consisted of Diabetic Yoga Protocol (DYP) approved by the Ministry of AYUSH and Quality Council of India as shown in Table 1 . This is the first protocol to be made specifically for the prediabetics and diabetics. The complete sequence of prayer, yogic postures, breathing and meditative techniques, along with specified time, was shown in previously published paper [ 24 ]. The Yogic practices were performed for 3 months for 60 min. Certified yoga instructors took the yoga classes and they recorded regular attendance. Randomization was done through a computer-generated list of random numbers and allocation was concealed to the participants until the completion of the baseline assessment.

Statistical analysis

For the analysis of data SPSS for Windows (version 22; IBM SPSS Inc., Chicago IL) 0 and R statistical package were used. The normality of data was analyzed using Kolmogorov–Smirnov test. The paired t-test was used to estimate the Baseline and posttest differences of DYP, and control group and the significant level was set at ≤ 0.05. The trial outcomes were analyzed according to the intention-to-treat principle; hence multiple imputation was carried for the missing variables accounting for the loss to follow up. We used absolute change (time and treatment interaction), to estimate intervention effects refers to the difference in the outcome of the intervention and control over different time-points of assessment. Absolute change was determined as follows: absolute change = [(intervention group follow-up) – (intervention group baseline)] – [(control group follow-up) – (control group baseline)]. The percentage change, also called the relative change was determined as relative change = (absolute change / intervention group baseline) × 100%. To evaluate the influence of missing data, we applied multiple imputations to the data using missMDA R package (v1.13) based on the principal component analysis method [ 25 ] from the package, using 5 components to reconstruct the data and over 1000 imputed datasets. One-way multivariate analysis of covariance (MANCOVA) was conducted to compare the effects of the DYP with control group glycemic and metabolic measures, while controlling for the age, gender and baseline values of the covariates.

Baseline characteristics

The data used in this study was collected in (NMB-2017) the northern region of India i.e. Chandigarh and Panchkula. The age range of participants was 3–70 years; [mean age 48.51 (SD 10.08) years]with baseline characteristics of the yoga and control groups as shown in Table 2 . Mean HbA1c of the high-risk cohort was 5.64% (0.38), mean FBS was 97.13 mg/dl (SD 11.10), and mean PPBS were 108.40 mg/dl (SD 28.79). Distributions of age and gender was similar between the intervention and the control groups. The IDRS and anthropometric values were also similarly distributed between the groups. Overall, there was no significant difference in the distribution of demographic, anthropometric, or biochemical parameters between the DYP and the control groups at the baseline.

When analyzed by multivariate analysis of covariance (MANCOVA), adjusting for age, gender and status of diabetes/prediabetes/normoglycemia, and baseline values of the covariates, yoga intervention was found to have significant influence on few cardinal parameters related to glycemic control (PPBS), and lipid control (LDL-C) as shown in Table 3 . We also observed a significant influence of DPP on waist circumference reduction [relative changes, − 1.94%. Compared to the control, DYP also resulted in significant reductions in LDL-C and, − 0.16% and − 2.81%, for LDL-Cholesterol and post-prandial blood glucose levels from baseline to 3 months [absolute changes, − 0.18% and − 3.08%, respectively and relative changes, − 0.16% and − 2.81%, respectively].

We examined the effect of Diabetic Yoga Protocol on baseline and post (3 months) levels of HbA1c and other glycemic (OGTT and FBS), Lipid (Total cholesterol, triglycerides, HDL-c, LDL-c, and VLDL-c, CDL/HDL, LDL/HDL) and anthropometric parameters (BMI). In the present study, we show the efficacy of DYP in substantial improvement in the waist circumference in a high-risk diabetes population from Chandigarh (relative change of 1.94 cm). We could also demonstrate a significant decline in the worsening of post prandial glucose levels with yoga intervention as compared to the wait-list control group (relative change of 2.82 mg/ml). However, for LDL-c levels, there were clinically significant improvements by 0.16 units. Notably, over 3 months study duration there was an overall increase in the levels of total cholesterol, triglyceride and VLDL means in the study cohort, while HDL levels had decreased. In particular TG levels have gone from normal range to mildly high (> 150 mg/dl) [ 26 ] which draws our attention towards accelerated pace of metabolic dysfunction in the high risk population. These findings comply with Chandigarh being an affluent union territory of India with high per-capita GDP and has been documented to have highest prevalence of diabetes 13.6%, 12.8–15·2 as compared to other Indian states [ 27 ]. As mentioned above, there was a significant influence of DYP on the waist circumference, one of the two important modifiable parameters of Indian Diabetes Risk Score [ 17 ]. The relevance of WC reduction in context of reduced risk of CVD is well established; a 1 cm increase in WC has been associated with a 2% increase in the relative risk of future CVD [ 28 ]. The visceral adipose tissue is a primary source of cytokine production and insulin resistance (IR) [ 29 ]. Given the higher susceptibility towards visceral fat accumulation and insulin resistance in Asian populations as compared to their Caucasian counterparts, the observed influence of DYP on WC is of particular relevance to the metabolically obese phenotype of Asian Indians [ 30 ].

In relation to the glucose metabolism, we could also demonstrate a significant decline in the worsening of post prandial glucose levels with DYP as compared to the wait-list control group (relative change = − 2.81%, P < 0.05); however, no significant influence could be established for fasting blood glucose concentration. These findings could be justified by the phenotypic differences underlying fasting and post-challenge hyperglycemia that represent distinct natural histories in the evolution of type 2 diabetes [ 31 ]. Postprandial glucose disposal is the primary pathogenic manifestation in impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) merely signifies an abnormal glucose set point [ 31 , 32 ]. Our relevance of the study findings is further underlined by the previous results wherein PPG has been reported to contribute more than FBS to overall hyperglycemia and its control was found essential either to decrease or to obtain HbA1c goals of < 7 [ 33 ]. Several epidemiological studies have suggested that increased glycemic exposure, especially post challenge or postprandial hyperglycemia, is an independent risk factor for macrovascular disease with no apparent upper or lower threshold. Our results indicate a significant influence of yoga on glycemic control integrating postprandial glycemic alterations in the high diabetes risk group. Since in the present study the high-risk cohort was selected through A1c based diagnosis, and IGT was not a primary manifestation in the cohort, hence, the overall improvement in postprandial glucose should be specifically tested in an IGT cohort. The findings of the current study with a 3-month intervention of yoga on postprandial measures of glucose at-risk population deserves clinical attention. Increase in the glucose concentration even in the prediabetes stage, manifests as a chronic inflammatory condition and predisposes an individual to the risk of pathogenic infections [ 32 , 34 , 35 ].

The simultaneous reduction in waist circumference observed in the cohort, is also consistent with the observation of an association between abdominal obesity and the risk of IGT. Based on a significant association between IGT and CVD risk [ 32 , 33 , 36 ], we note a significant improvement in lipid concentrations [LDL-c] by the DYP protocol as compared to the control group. These results are consistent with the previously reported overall beneficial effect of yoga in the management of hyperlipidemia [ 36 ]. These results need validation at larger scale and to ascertain the mechanistic insights into the action of yoga, the indices of monocyte chemotaxis, endothelial inflammation, oxidation, nitric oxide production, and thrombosis should also be explored [ 37 ], including animal models, invitro systems and other approaches [ 38 , 39 , 40 , 41 , 42 , 43 , 44 ].

The findings of the present study indicate that identification of high-risk group through IDRS and consequent intervention of Yoga based lifestyle protocol could be an effective strategy to combat the metabolic perturbations associated with diabetes, whose co-morbidity is also being reported to be associated with increasing vulnerability to the emerging viral pandemic of COVID-19. Lifestyle interventions are reported to reduce the risk of Type 2 diabetes in high-risk individuals after mid and long-term follow-up. Information on determinants of intervention outcome, adherence and the mechanisms underlying diabetes progression are valuable for a more targeted implementation. Weight loss is a major contributor in the prevention and management of type 2 diabetes. In many of the earlier lifestyle intervention group of the DPP, weight loss was the dominant predictor of reduced diabetes risk, with a 16% reduction observed for every kilogram of weight loss during the 3.2-year follow-up [ 45 ]. Though we failed to observe a significant weight loss over 3 months of DYP intervention, the significant reductions in WC indicate the plausibility of significant weight loss on longer interventions and follow ups.

Whether Yoga alters the conversion of prediabetics into healthy status and if it helps in maintenance of glycemic index can be assessed by longitudinal studies. There was a significant improvement in the glycemic status of the high risk population at administration of DYP. The analysis shows the aptness of Diabetic protocol which is apparently superior to previous studies where no standardized protocols were used for intervention [ 46 , 47 ]. The findings suggest that there is potential of DYP to manage glucose levels in diabetes patients if public intervention is planned through forthcoming wellness centers in India. There are additional studies showing beneficial effects of Yoga on FBS [ 48 ], PPBS [ 49 , 50 , 51 ], HbA1c [ 50 , 51 ], total cholesterol, LDL [ 50 , 51 ]. The analysis of the yoga protocols used in above said studies reveal the incorporation of some common and important postures in DYP, which seem to be important in managing the disease. It is also the possible that the beneficial effects of mind body techniques are sensitive to mental disposition of subjects and has been characterized by various measures like psychometric analysis [ 52 , 53 ], namely, Tridosha and Triguna scoring [ 54 , 55 ]. These were not analyzed in this study.

Briefly, DYP’s promising efficacy on glycemic and metabolic parameters requires mechanistic insights. This can be examined by further studies, and long term follow up which was not possible in this study. As DYP is a non-pharmacological, cost-effective method to halt the conversion of early diabetes into prediabetes and/or healthy individuals, the success of its integration into public health policy will depend on its wider acceptability and perception of benefits by both public as well as healthcare workers [ 56 , 57 , 58 , 59 ]. Yoga’s benefits in maintaining and regulation of the glycemic status are supported by several other studies [ 49 , 50 ], which might enable its inclusion in the National Ayushman Bharat scheme or as part COVID pandemic management protocol in which a large number of individuals with diabetes and heart disease are falling prey [ 60 , 61 ]. This will further encourage molecular and Ayurgenomic studies which presumably underlie the stated clinical outcome.

Limitations

Moreover, there are some limitations of our study that we only studied in two regions of North India and thus the result of this study cannot be generalized on the remaining population. Further, in this study, the socio economic status and psychological assessments were not carried out. We were not able to control for the dietary habits and psychological status of the study participants. However, the small sample size and absence of long term evaluations limit the strength of the study.

Availability of data and materials

The datasets used during the present study are available from the corresponding author on reasonable request.

Abbreviations

American Diabetes Association

Body mass Index

Cardiovascular disease

• Diabetic yoga protocol

Fasting blood sugar

• Glycated hemoglobin

High density lipid-cholesterol

Indian Diabetes Risk Score

Impaired fasting glucose

Impaired glucose tolerance

Indian Yoga Association

Low density lipid-cholesterol

Niyantarita Maduhmeha Bharat

Oral glucose tolerance test

Postprandial blood glucose

Systolic blood pressure

Very low density lipid-cholesterol

Waist circumference

Yoga volunteers for diabetes management

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Acknowledgements

The authors would like to thank Central Council for Research in Yoga & Naturopathy (CCRYN) for their support for man power, Ministry of Health and Family Welfare (MOHFW) for support the cost of investigations and Indian Yoga Association (IYA) for the overall project implementation. The authors also like to thank to thank Yoga Volunteer for Diabetes Management (YVDMs) for helping in collection of data and also for training participants for yoga.

The Project was funded by Ministry of AYUSH, Government of India (grant number 16-63/2016-17/CCRYN/RES/Y&D/ MCT/).

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NK: writing of manuscript, collection of data. VM: writing of manuscript, analysis. RN: conceptualization of manuscript, supervision and study design. NM: co-conceptualization of manuscript. AA: conceptualization of manuscript. HRN: supervision. All authors read and approved the final manuscript.

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Kaur, N., Majumdar, V., Nagarathna, R. et al. Diabetic yoga protocol improves glycemic, anthropometric and lipid levels in high risk individuals for diabetes: a randomized controlled trial from Northern India. Diabetol Metab Syndr 13 , 149 (2021). https://doi.org/10.1186/s13098-021-00761-1

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RESEARCH DESIGN AND METHODS

Conclusions, acknowledgments, effect of 3-month yoga on oxidative stress in type 2 diabetes with or without complications : a controlled clinical trial.

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Shreelaxmi V. Hegde , Prabha Adhikari , Shashidhar Kotian , Veena J. Pinto , Sydney D’Souza , Vivian D’Souza; Effect of 3-Month Yoga on Oxidative Stress in Type 2 Diabetes With or Without Complications : A controlled clinical trial . Diabetes Care 1 October 2011; 34 (10): 2208–2210. https://doi.org/10.2337/dc10-2430

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To assess the effect of yoga on anthropometry, blood pressure, glycemic control, and oxidative stress in type 2 diabetic patients on standard care in comparison with standard care alone.

The study involved 123 patients stratified according to groups with microvascular complications, macrovascular complications, and peripheral neuropathy and without complications and assigned to receive either standard care or standard care along with additional yoga for 3 months.

In comparison with standard care alone, yoga resulted in significant reduction in BMI, glycemic control, and malondialdehyde and increase in glutathione and vitamin C. There were no differences in waist circumference, waist-to-hip ratio, blood pressure, vitamin E, or superoxide dismutase in the yoga group at follow-up.

Yoga can be used as an effective therapy in reducing oxidative stress in type 2 diabetes. Yoga in addition to standard care helps reduce BMI and improve glycemic control in type 2 diabetic patients.

Oxidative stress has been implicated as the root cause underlying the development of insulin resistance, β-cell dysfunction, diabetes, and its associated clinical conditions such as atherosclerosis, microvascular complications, and neuropathy ( 1 , 2 ). Yoga has been found to be beneficial in reducing oxidative stress in type 2 diabetes ( 3 , 4 ), but there is a lack of controlled trials to demonstrate the same. This report describes the effect of yoga on oxidative stress, glycemic control, blood pressure control, and anthropometry in type 2 diabetic patients with or without complications compared with control subjects on standard care.

This study was conducted at the diabetes clinic of Kasturba Medical College hospital and at four community diabetes clinics offering primary care to diabetic patients in Mangalore, India. A total of 123 type 2 diabetic patients aged between 40 and 75 years, none of whom were alcoholics or smokers, gave written informed consent and were included. Patients with acute macrovascular complications, cancer, pulmonary tuberculosis, and rheumatoid arthritis and those who were unable to perform yoga were excluded. Patients were grouped as 60 for yoga and 63 for control. Stratified sampling was used at the time of allocation to maintain an equal number of patients with uncomplicated diabetes and with microvascular, macrovascular, and peripheral neuropathy in these groups.

Three months’ yoga included tadasana, padahastasana, vrikshasana, trikonasana, parshvothanasana, vajrasana, vakrasana, gomukasana, paschimotasana, uttanapadasana, pawanamuktasana, bhujangasana, shalabasana, dhanurasana, viparitakarani, sitkari and bhramari pranayama, anuloma viloma, and shavasana poses. The control group at their baseline visit was given general oral and written information about diet and exercise. Compliance with the intervention was defined as attendance for at least 3 days/week at the yoga center for 3 months. Drug dosages with regard to diabetes and blood pressure were kept constant throughout the study period.

Malondialdehyde ( 5 ), glutathione ( 6 ), superoxide dismutase ( 7 ), vitamin C ( 8 ), and vitamin E ( 9 ) were measured to assess the oxidative stress and antioxidant status. BMI, waist circumference, waist-to-hip ratio, blood pressure, fasting plasma glucose (FPG), postprandial plasma glucose (PPPG), and HbA 1c were analyzed.

Data were analyzed using SPSS version 11.0. Paired t test was used to compare the continuous variables from baseline to follow-up. Mann-Whitney U test, a nonparametric test, was used to compare the differences in various parameters before and after intervention between the two groups.

Three participants withdrew from yoga intervention during the first month of the study and were not included in the final analysis. Among these, two moved their residence and one reported illness unrelated to the study. Mean ± SD age was 59.8 ± 9.9 years for the yoga group and 57.5 ± 8.9 years in the control group. There were no significant differences in sex, duration of diabetes, or hypertension between the groups at baseline. Average attendance at the yoga classes was 82–88%.

Yoga practitioners achieved significant improvements in BMI, FPG, PPPG, HbA 1c , malondialdehyde, glutathione, and vitamin C at 3 months compared with the standard care group ( Table 1 ). In the yoga group, the mean percentage reduction in malondialdehyde was 20% (−10.8 ± 1.4 μmol/L) and in HbA 1c 1.4% (−0.1 ± 0.2%). In the control group, the mean percentage increase in malondialdehyde was 3.2% (1.6 ± 1.6 μmol/L) and in HbA 1c 6.25% (0.5 ± 0.3%). Significant reductions in glutathione and vitamin C were seen in control subjects. No significant changes in waist circumference, waist-to-hip ratio, blood pressure, vitamin E, or superoxide dismutase were observed in the yoga group compared with control subjects. No adverse events were observed during the intervention period.

Parameters at baseline and after 3 months

Data are means ± SD. P values are significance values in yoga group compared with the control group.

Yoga practitioners achieved a 20% reduction in oxidative stress, which is similar to the findings of Gordon et al. ( 10 ): 6 months of yoga in type 2 diabetic subjects showed a 19.9% reduction in oxidative stress. Other lifestyle interventions such as aerobic exercise and resistance training are known to increase stress parameters ( 11 , 12 ). Antioxidants like glutathione and vitamin C improved by 15 and nearly 60% compared with standard care. To the best of our knowledge, to date there are no reports of the effect of yoga on glutathione and vitamin status in type 2 diabetes. In this study, yoga improved the antioxidant levels, thereby reducing the oxidative stress in type 2 diabetic patients.

The effect on glycemic control and BMI was marginal compared with results obtained by other lifestyle interventions such as aerobic exercise and resistance training. In the current study, mean percentage reduction in HbA 1c was 1.4% in the yoga group, whereas it increased by 6.25% in the control group. From a clinical perspective, this represents a small change. However, long-term, regular practice of yoga can sustain the improved glycemic control brought about by standard care. Greatest improvements in HbA 1c values after yoga in type 2 diabetes have come from studies in which the sample sizes are small, about 10–30 in each group ( 4 , 13 ) and from studies where yoga was delivered along with exercises ( 14 ).

Skora-Kondza et al. ( 15 ) observed difficulty with adherence of patients to yoga intervention. This was overcome in our study because yoga classes were held at several community centers in the city, which made it easy for the patients to attend the classes; in addition, culturally, Indian patients would accept yoga better than the Western population.

Our study is limited by the fact that the allocation to the groups was not randomized. Random allocation in community settings is difficult. In this study, social and environmental factors during these training sessions may have a beneficial influence on oxidative stress. The strength of our study was the stratification of sample according to complications. Participants with various complications may have increased oxidative stress; stratification made the two groups identical.

In conclusion, yoga can be used as an effective therapy in reducing oxidative stress in type 2 diabetes. Yoga is also beneficial in improving glycemic parameters and BMI and can be administered as an add-on therapy to standard lifestyle interventions. Yoga was not beneficial in reducing the blood pressure or waist circumference in this short-term study. Further studies are needed to confirm that yoga is beneficial in preventing the progression of diabetes and its complications.

Clinical trial reg. no. CTRI/2011/05/001739, ctri.nic.in .

This study was funded by a grant from Manipal University (431/013/2007).

No potential conflicts of interest relevant to this article were reported.

S.V.H. designed the study, acquired and interpreted data, and wrote the manuscript. P.A. developed the protocol, designed the study, interpreted data, and reviewed and edited the manuscript. S.K. analyzed data. V.J.P. acquired data and contributed to discussion. S.D. and V.D. reviewed and edited the manuscript.

The authors thank Laura Prakash, School of Public Health, University of Minnesota, Minneapolis, MN, for her contribution to the study. The authors express appreciation to the participants whose cooperation and dedication made this study possible. The authors also acknowledge International Training and Research In Environmental and Occupational Health (ITREOH) training grant from Fogarty Foundation, which was responsible for their training in medical writing.

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The Effect of Yoga on Health-Related Fitness among Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

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Yoga Programme for Type 2 Diabetes Prevention (YOGA-DP) Among High-Risk People in India: A Multicenter Feasibility Randomized Controlled Trial

• Original Research
• Open access
• Published: 31 March 2023
• Volume 14 , pages 1137–1154, ( 2023 )

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• Kaushik Chattopadhyay   ORCID: orcid.org/0000-0002-3235-8168 1 ,
• Pallavi Mishra 2 ,
• Kavita Singh 2 ,
• Kalpana Singh 2 ,
• Tess Harris 3 ,
• Mark Hamer 4 ,
• Sheila Margaret Greenfield 5 ,
• Nandi Krishnamurthy Manjunath 6 ,
• Rukamani Nair 7 ,
• Somnath Mukherjee 7 ,
• Nikhil Tandon 8 ,
• Sarah Anne Lewis 1 ,
• Sanjay Kinra 9 ,
• Dorairaj Prabhakaran 2 &

YOGA-DP Study Team

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A Publisher Correction to this article was published on 24 May 2023

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Introduction

Many Indians are at high risk of type 2 diabetes mellitus (T2DM). The blood glucose level can be improved through a healthy lifestyle (such as physical activity and a healthy diet). Yoga can help in T2DM prevention, being a culturally appropriate approach to improving lifestyle. We developed the Yoga Programme for T2DM Prevention (YOGA-DP), a 24-week structured lifestyle education and exercise (Yoga) program that included 27 group Yoga sessions and self-practice of Yoga at home. In this study, the feasibility of undertaking a definitive randomized controlled trial (RCT) was explored that will evaluate the intervention’s effectiveness among high-risk individuals in India.

A multicenter, two-arm, parallel-group, feasibility RCT was conducted in India. The outcome assessors and data analysts were blinded. Adults with a fasting blood glucose level of 100–125 mg/dL (i.e., at high risk of T2DM) were eligible. Participants were randomized centrally using a computer-generated randomization schedule. In the intervention group, participants received YOGA-DP. In the control group, participants received enhanced standard care.

In this feasibility trial, the recruitment of participants took 4 months (from May to September 2019). We screened 711 people and assessed 160 for eligibility. Sixty-five participants (33 in the intervention group and 32 in the control group) were randomized, and 57 (88%) participants were followed up for 6 months (32 in the intervention group and 25 in the control group). In the intervention group, the group Yoga sessions were continuously attended by 32 (97%) participants (median (interquartile range, IQR) number of sessions attended = 27 (3)). In the intervention group, Yoga was self-practiced at home by 30 (91%) participants (median (IQR) number of days per week and minutes per day self-practiced = 2 (2) and 35 (15), respectively). In the control group, one (3%) participant attended external Yoga sessions (on Pranayama) for 1 week during the feasibility trial period. There was no serious adverse event.

Conclusions

The participant recruitment and follow-up and adherence to the intervention were promising in this feasibility study. In the control group, the potential contamination was low. Therefore, it should be feasible to undertake a definitive RCT in the future that will evaluate YOGA-DP’s effectiveness among high-risk people in India.

Feasibility Trial Registration

Clinical Trials Registry—India (CTRI) CTRI/2019/05/018893; registered on May 1, 2019.

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Type 2 diabetes mellitus (T2DM) is a complex metabolic disorder with significant health and socioeconomic consequences, and India has the second-largest T2DM population in the world [ 1 ]. An individual at high risk of T2DM has a higher blood glucose level than normal but lower than the level for T2DM, and more than 77 million people in India are at high risk of T2DM [ 2 ]. The chances of developing T2DM and its complications are higher among these people compared to individuals with a normal blood glucose level [ 3 ]. Indians rapidly develop T2DM from the high-risk state and have one of the highest rates across many ethnicities [ 4 ]. The major risk factors for T2DM are physical inactivity and an unhealthy diet, i.e., an unhealthy lifestyle [ 3 ]. A cost-effective and sustainable strategy is to screen individuals at high risk of T2DM and provide a lifestyle intervention that is effective [ 3 , 5 , 6 ]. Effective lifestyle interventions can improve their blood glucose level and can have other health benefits [ 7 , 8 , 9 ]. However, Indians usually have a low physical activity level, and they usually consume an unhealthy diet [ 10 , 11 , 12 ].

Yoga, an ancient mind–body discipline, originated in the Indian subcontinent and incorporates physical activity and a healthy diet [ 13 ]. Various styles of Yoga are practiced, but one style is not necessarily superior or more authentic than another, and all focus on the same important topic, i.e., a healthy lifestyle [ 14 ]. In general, Yoga’s acceptability is high in India as it fits people’s health beliefs and culture [ 15 , 16 ]. A gentle approach is used in Yoga, and it is safe and easy to learn, requires minimal guidance and maintenance costs, and can be practiced indoors as well as outdoors [ 15 ]. People who are old or with comorbidities can practice it [ 14 , 15 ]. Yoga includes low-intensity and moderate-intensity practices (< 3.5 kcal/min and 3.5–7.0 kcal/min, respectively) [ 14 , 17 , 18 , 19 ]. In addition, it is an activity that strengthens the muscles [ 14 ]. Therefore, Yoga can contribute to the goal of routine lifestyle advice which is given to individuals at high risk of T2DM to prevent it.

Yoga’s mechanism of action in T2DM and related conditions has been reported before [ 20 ]. Briefly, its benefits on T2DM-related risk profiles seem to occur predominantly through the following pathways: (1) by decreasing the activation and reactivity of the sympathoadrenal system and the hypothalamic–pituitary–adrenal axis, and by fostering feelings of well-being, it may lessen the effects of stress and promote multiple beneficial downstream effects on the neuroendocrine status, metabolic function, and related systemic inflammatory responses; (2) by directly stimulating the vagus nerve, it may improve the parasympathetic activity and lead to beneficial changes in the cardiovagal function, energy state, mood, and related neuroendocrine, metabolic, and inflammatory responses. Furthermore, Yoga may reduce body mass index (BMI), and the reduction in BMI lowers the risk of T2DM [ 3 ].

Effectiveness systematic reviews suggest the benefits and safety of Yoga in T2DM and related conditions [ 21 , 22 , 24 ]. However, the duration of most of the primary studies was short (≤ 3 months), and these studies often had significant methodological limitations. In addition, the intervention development process was not always reported, and some did not describe the intervention in detail. Even if they did, the interventions were heterogeneous. Therefore, robustly designed studies are needed to evaluate the utility of Yoga for preventing T2DM among high-risk individuals. We systematically developed the Yoga Programme for T2DM Prevention (YOGA-DP) [ 25 ]. Our aim is to conduct a definitive randomized controlled trial (RCT) in the future that will evaluate YOGA-DP’s effectiveness among high-risk individuals in India compared to enhanced standard care. The chances of successful completion of the definitive RCT will improve if the feasibility of its key elements is tested before commencement [ 26 , 27 ]. Therefore, the feasibility of undertaking the definitive RCT was explored in this study.

The feasibility study protocol is published elsewhere [ 28 ].

Study Design

A multicenter, two-arm, parallel-group, feasibility RCT was conducted. The outcome assessors and data analysts were blinded.

Study Setting

We conducted this feasibility study at two Yoga centers in India, namely Bapu Nature Cure Hospital and Yogashram (BNCHY, New Delhi) in north India and Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA, Bengaluru) in south India. These centers are accessed by individuals from a range of socioeconomic backgrounds. We used three languages (English, Hindi, and Kannada) in conducting this feasibility study.

Sample Size

In a feasibility trial, a formal sample size estimation is not usually needed [ 29 ]. It is recommended to recruit at least 50 participants in a feasibility trial [ 30 ]. Thus, we recruited a total of 65 participants in this feasibility trial, after taking into consideration the loss to follow-up.

Screening and Recruitment Strategies

The following strategies were used to inform people about this feasibility study: posters were placed and pamphlets were distributed at several locations (such as in these Yoga centers, health clinics, communities, parks, and religious places) and door-to-door visits were conducted in several communities at different times of the day. Screening camps were organized at several places (such as in these Yoga centers, communities, and religious places) for identifying potential participants. After giving the participant information sheet to potential participants, describing this feasibility study to them, and answering their questions, we requested that those interested in this feasibility trial provide written informed consent. The screening was conducted after receiving written informed consent, i.e., the fasting blood glucose level was assessed using a glucometer (by finger-prick; using either HemoCue Glucose 201 + System or Accu-Chek Active) [ 31 , 32 ]. People with a fasting blood glucose level of 100–125 mg/dL (i.e., potentially at high risk of T2DM) [ 33 ] were requested to visit the Yoga center for eligibility assessment, including a confirmatory venous blood test using the standardized glucose oxidase–peroxidase method. This eligibility assessment was conducted after receiving further written informed consent. Blood samples collected were sent immediately to the accredited laboratories for analysis within an hour. If this was not possible for any reason, the serum was immediately separated by centrifugation and stored in a − 80 °C freezer for analysis on the next day.

Eligibility Criteria

People aged 18–74 years, with a fasting blood glucose level of 100–125 mg/dL (i.e., at high risk of T2DM) [ 33 ], and who were safe to do physical activities (checked using the Physical Activity Readiness Questionnaire (PAR-Q)/clinician) [ 34 ], willing and able to attend the intervention/control sessions on their own, and able to provide written informed consent were included in this feasibility study. The following people were excluded: pregnant women, those with glycated hemoglobin (HbA1c) ≥ 6.5% (i.e., with T2DM [ 33 ]; venous blood test using the high-performance liquid chromatography method) or a serious or uncontrolled medical condition (e.g., cancer), or those who regularly practiced Yoga (i.e., ≥ 150 min/week) or were receiving (or had plans to receive during the feasibility trial period) any related non-pharmaceutical/pharmaceutical intervention (e.g., glucose-lowering medication).

Randomization

A computer-generated randomization schedule was used to randomize eligible participants to the intervention or control group (1:1, block randomization, stratified by sex and site). Sequential random sampling (140/group) was used, with 35 equal blocks generated using STATA V.15. The block size was four and fixed. This central randomization was performed by an independent statistician, based at the Centre for Chronic Disease Control (CCDC), New Delhi, India, and the allocation was accessed by the recruiting site staff by telephone call. There was an exception to this rule to avoid contamination, i.e., people recruited from the same household or who were close relatives or friends were randomized to the same group. Baseline data were collected after randomization. Participants and intervention/control providers were not blinded to group allocation, but the outcome assessors and data analysts were blinded to the feasibility trial assignment.

Interventions

Intervention (yoga-dp).

Intervention details are published elsewhere [ 25 ]. Briefly, YOGA-DP was a 24-week structured lifestyle education and exercise (Yoga) program and included 27 group Yoga sessions and self-practice of Yoga at home using the program booklet and a video. The intervention was delivered by YOGA-DP instructors, qualified and experienced Yoga teachers with formal training received on the program. The program included Shithilikarana Vyayama (loosening exercises), Surya Namaskar (sun salutation exercises), Asana (Yogic poses), Pranayama (breathing practices), and Dhyana (meditation) and relaxation practices. Female instructors were available for women. Group sessions were delivered locally (e.g., at these Yoga centers and community centers). Participants were able to join at their convenience as these sessions were run at different time points of the day (including evening and weekend sessions). We reimbursed participants’ local travel costs to attend these sessions. We also invited a family member or someone close to the participant to join him/her in these sessions. After completing the program, participants were strongly encouraged to use the intervention materials and maintain a healthy lifestyle in the long term.

We ensured intervention fidelity, and YOGA-DP instructors were regularly trained on the basis of an instructor manual. In addition, we regularly observed and evaluated these sessions using a checklist to ensure delivery according to the manual. Structured and instructive feedback was provided to them to improve their performance.

Control (Enhanced Standard Care)

No formal T2DM prevention program is available in India, although some healthcare professionals offer rudimentary advice. Therefore, in the control group, participants received the routine lifestyle advice to prevent T2DM among them in the form of a leaflet, provided by another team member (i.e., different from the YOGA-DP instructor) to avoid contamination.

Study Parameters and Data Collection

We estimated the essential parameters needed for designing the definitive RCT, e.g., participant recruitment and follow-up (for 6 months), adherence to the intervention, potential contamination in the control group, and standard deviations (SDs) of the outcomes. Details are provided in the feasibility study protocol [ 28 ]. Briefly, the following outcomes were assessed: biochemical parameters (fasting blood glucose, HbA1c, total cholesterol, high-density lipoprotein, low-density lipoprotein, very low-density lipoprotein, and triglyceride), physiological parameters (systolic blood pressure, diastolic blood pressure, and heart rate), anthropometric parameters (weight, BMI, and waist circumference), lifestyle (diet, physical activity (the International Physical Activity Questionnaire (IPAQ)-Short was used and categorized into low and moderate/high and vigorous, moderate, walking, and sitting) [ 35 ], tobacco usage, and alcohol consumption), health-related quality-of-life (the EuroQol-5D (EQ-5D) dimensions were categorized into no (level 1; no problems) and yes (level 2 to 5; problems)) [ 36 ], depression, anxiety, and stress (the Depression, Anxiety and Stress Scale (DASS) dimensions were categorized into normal and mild/moderate/severe/extremely severe) [ 37 ], and self-efficacy (for assessing confidence in participant’s ability to practice Yoga) [ 38 ].

Data Analyses and Reporting

For categorical data, numbers and percentages were calculated. For continuous data, summary measures of mean or median and spread were calculated. In terms of the percentage of loss to follow-up and withdrawal, the two groups were compared using the chi-squared test. Being a feasibility trial, it was not powered to find a difference in trial outcomes at 6 months between the two trial arms. However, unadjusted mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI) were reported to indicate initial estimates of effects. Subsequently, we conducted the analysis of covariance (ANCOVA) for four critical outcomes (fasting blood glucose, HbA1c, BMI, and waist circumference), and regression coefficient and 95% CI were reported. In model 1, the respective baseline value was adjusted for; in model 2, the respective baseline value and age were adjusted for. The analysis was based on the intention-to-treat principle. There was no plan to conduct an interim analysis. STATA V.15 was used to analyze the data. The extension of the Consolidated Standards of Reporting Trials (CONSORT) statement for randomized pilot and feasibility trials was used to report the results [ 39 ].

Ethics and Related Issues

The study was conducted in accordance with the Declaration of Helsinki. The research ethics committees of the following institutes gave ethics approval: Faculty of Medicine and Health Sciences, University of Nottingham (UK), CCDC (India), BNCHY (India), and S-VYASA (India). This feasibility study was performed in accordance with relevant guidelines and regulations. We obtained written informed consent from participants. This feasibility trial was registered with the Clinical Trials Registry—India (CTRI) (CTRI/2019/05/018893; registered on May 1, 2019). India’s Health Ministry’s Screening Committee (HMSC) also approved this feasibility study. The independent Trial Steering Committee (TSC) monitored and supervised this feasibility study.

Serious Adverse Events

We planned to collect information on serious adverse events (including hospitalization for at least 24 h and mortality) occurring in the feasibility trial participants that might be attributed to the interventions. An independent clinician was to adjudicate the association of any such event to the interventions on the basis of medical and scientific judgment.

Participant Withdrawal

We planned to withdraw participants from the feasibility trial on the basis of their request or at the discretion of the site investigator, e.g., in case the participant was no longer safe to do physical activities (determined by PAR-Q/clinician) [ 34 ] or was diagnosed with diabetes (and would receive the standard treatment).

Recruitment and Follow-up

In this feasibility trial, participants were recruited from 18 May 2019 to 19 September 2019 (i.e., when the first person was approached to participate and the last participant was randomized, respectively). It took 4 months and 2 days to recruit participants. We approached 727 people to participate. Of these, 711 were screened before eligibility assessment and 160 were assessed for eligibility. Sixty-five participants (33 in the intervention group and 32 in the control group) were randomized, and this excludes deregistered participants who did not meet the inclusion criteria but were recruited or who were recruited late. Five participants were randomized to the same group as the first participant (as either they were from the same household or were close relatives or friends). Fifty-seven (88%) participants were followed up for 6 months (32 in the intervention group and 25 in the control group). There was one (3%) loss to follow-up in the intervention group and six (19%) loss to follow-up in the control group, and the difference was statistically significant ( p  = 0.04). There was no withdrawal in the intervention group and one (3%) withdrawal in the control group, but the difference was statistically insignificant ( p  = 0.31) (see Fig.  1 CONSORT flowchart for details). As a result of the COVID-19 lockdown in India, the follow-up of one intervention group participant was delayed and limited information was collected over the telephone from two intervention group participants and one control group participant.

CONSORT flowchart

Intervention Adherence

In this feasibility study, the group Yoga sessions were continuously attended by 32 (97%) participants, and one participant discontinued because of hospitalization for a few hours for vomiting, high blood pressure, and chest pain (this was not counted as a serious adverse event). The median (interquartile range, IQR) number of group Yoga sessions attended was 27 (3). Yoga was self-practiced at home by 30 (91%) participants, and the median (IQR) number of days per week and minutes per day self-practiced was 2 (2) and 35 (15), respectively.

Potential Contamination in the Control Group

One (3%) participant attended external Yoga sessions (on Pranayama) for 1 week during the feasibility trial period (self-reported). Yoga classes were available outside, but YOGA-DP was not available externally.

Table  1 reports the baseline characteristics of the feasibility trial participants. The mean (± SD) age of participants was 42.1 (7.7) years, and 25 (38%) were female. The mean (± SD) fasting blood glucose was 110.3 (8.3) mg/dL, HbA1c was 5.9 (0.3) %, BMI was 27.6 (5) kg/m 2 , and waist circumference was 93 (13.2) cm. At baseline, the two groups were mostly similar except for a few variables, which could be due to the small sample size.

Table  2 reports the unadjusted outcomes at 6 months.

Biochemical, physiological, and anthropometric parameters—The fasting blood glucose, HbA1c, weight, BMI, and waist circumference were lower in the intervention group compared to the control, but the differences were statistically insignificant. The high-density lipoprotein was higher in the intervention group compared to the control, but the difference was statistically insignificant.

Lifestyle—The percentage of participants reporting no/occasional intake of high-fat/deep-fried food was higher in the intervention group compared to the control. The moderate physical activity time was higher in the intervention group compared to the control, but the difference was statistically insignificant. Sitting time was lower in the intervention group compared to the control, but the difference was statistically insignificant. The percentage of participants reporting no tobacco usage was higher in the intervention group compared to the control. In addition, the odds of tobacco usage were lower in the intervention group compared to the control, but the difference was statistically insignificant.

Health-related quality-of-life—The percentage of participants reporting no problems in all five dimensions of EQ-5D was higher in the intervention group compared to the control. In addition, the odds of problems in the three dimensions (mobility problems, problems in taking self-care, and problems in doing usual activities) were lower in the intervention group compared to the control, but the differences were statistically insignificant. The visual analog scale score was higher in the intervention group compared to the control, but the difference was statistically insignificant.

Depression, anxiety, and stress—The percentage of participants reporting no problems in all three dimensions of DASS was higher in the intervention group compared to the control.

Self-efficacy in Yoga practice—The self-efficacy was higher in the intervention group compared to the control, but the difference was statistically insignificant.

Table  3 reports the adjusted four critical outcomes at 6 months.

Fasting blood glucose, HbA1c, BMI, and waist circumference—After adjustment for the respective baseline value (model 1) and baseline value and age (model 2), BMI was found to be lower in the intervention group compared to the control, and the difference was statistically significant (regression coefficient − 0.56; 95% CI − 1.00 to − 0.11 and regression coefficient − 0.56; 95% CI − 1.02 to − 0.11, respectively). In addition, fasting blood glucose, HbA1c, and waist circumference were lower, but the differences were statistically insignificant.

There was no serious adverse event.

We conducted a multicenter feasibility RCT in India to assess the feasibility of undertaking the definitive RCT in the future that will evaluate YOGA-DP’s effectiveness among high-risk individuals in India. The participant recruitment and follow-up and adherence to the intervention were promising in this feasibility study. There was low potential contamination in the control group. Compared to other T2DM prevention RCTs in India and globally [ 27 , 40 ], the recruitment in this feasibility trial was without any major hurdles. In this feasibility study, the dropout rate was 12% which is consistent with the findings of a systematic review (less than 15–20% in most RCTs on Yoga interventions) [ 41 ]. The only follow-up-related challenge we faced was towards the end of this feasibility trial, and this was due to the COVID-19 lockdown in India. Therefore, it should be feasible to undertake a definitive RCT. This feasibility study provided estimates of important parameters needed for designing the definitive RCT.

In the definitive RCT, the first co-primary outcome will be the incidence of T2DM, indicated by either a fasting blood glucose level of at least 126 mg/dL or an HbA1c level of at least 6.5% at 1-year follow-up [ 3 ]. Repeat testing will be conducted in asymptomatic participants to confirm the diagnosis [ 3 ], and they will only be included as achieving the co-primary outcome if repeat testing of either fasting blood glucose or HbA1c is above the cutoff. The second co-primary outcome will be BMI at 1-year follow-up [ 42 ]. The reduction in BMI lowers the risk of T2DM [ 3 ]. It should be noted that compared to other ethnicities, South Asians are at higher risk of T2DM at equivalent BMI levels [ 43 ]. We expect that the cumulative incidence of T2DM over 1 year will be 18% in the control group [ 44 , 45 ]. In the intervention group, we will be interested in a 50% reduction in the cumulative incidence of T2DM [ 46 , 47 ]. Therefore, in the definitive RCT, we will need to recruit at least 356 participants per group (a total of 712), with 90% power and assuming significance (alpha; two-tailed) of 2.5% to conservatively allow for co-primary outcomes. This sample size will be sufficient for the other primary outcome, considering the mean (± SD) BMI at the baseline was 27.6 (5) kg/m 2 in this feasibility trial and our interest in at least a 5% reduction in BMI at 1 year in the intervention group [ 42 , 48 ].

Initial estimates (as this feasibility trial was not powered for effectiveness) show some beneficial effects of the intervention on many critical outcomes, including fasting blood glucose, HbA1c, BMI, and waist circumference. In the adjusted models, BMI was lower in the intervention group compared to the control and the difference was statistically significant. No serious adverse events occurred. Similar beneficial effects and safety of Yoga on T2DM-related outcomes have been synthesized in several effectiveness systematic reviews [ 21 , 22 , 24 ]. In the future, the adequately powered definitive RCT will be able to provide a clear answer.

In the definitive RCT, if YOGA-DP is found to be effective, it will be a need-sensitive and evidence-based intervention for preventing T2DM among high-risk individuals, not only in India but also globally. Yoga’s popularity is not restricted to India and other South Asian countries, and it is increasingly becoming popular in other nations [ 49 , 50 ]. T2DM and its associated costs are global concerns, and a low-cost intervention to prevent T2DM will be of worldwide interest. More evidence-based choices will be available to people for preventing T2DM. The future burden of T2DM (such as clinical, personal, and economic) on patients, families, health systems, and economies will be prevented. The prevention of T2DM may extend to the prevention of its complications. Individuals will become healthier overall, and the intervention may empower people at the same time for managing their health. The intervention has become even more relevant during the COVID-19 pandemic, as it can be delivered online or in-person (outdoors or indoors by following the social distancing rules), and Yoga can be self-practiced at home.

Semi-structured qualitative interviews (as part of the qualitative process evaluation) were conducted with feasibility trial non-participants, participants, YOGA-DP instructors, and staff to explore trial- and intervention-related barriers and facilitators [ 28 , 51 , 52 ]. The findings will inform decisions on modifying the definitive RCT and intervention to further improve participation and adherence. For example, the intervention duration was 6 months in this feasibility trial, and we intend to deliver a year-long intervention in the definitive RCT. The relatively short-term follow-up was another limitation in this feasibility trial, and we intend to do long-term follow-ups (at least for a year) in the definitive RCT. In terms of glycemic control, this feasibility trial gave some hints about the effectiveness of the intervention, and we intend to assess the cumulative incidence of T2DM in the definitive RCT as a co-primary outcome. We reimbursed participants’ local travel costs for attending the Yoga sessions at BNCHY, and at SVYASA, Yoga sessions were run locally and close to their residence. The reimbursement could have boosted participant recruitment and follow-up in this feasibility trial and adherence to the intervention; however, this would not be available in real-world settings.

The participant recruitment and follow-up and adherence to the intervention were promising in this feasibility study. In the control group, the potential contamination was low. Therefore, it should be feasible to undertake a definitive RCT in the future that will evaluate YOGA-DP’s effectiveness among high-risk individuals in India.

Change history

24 may 2023.

A Correction to this paper has been published: https://doi.org/10.1007/s13300-023-01420-6

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Acknowledgment

The authors would like to thank the funding agencies, participants, and TSC members, namely Prof. Nitin Kapoor (chair), Prof. Mohammed K Ali, Dr. Ajay Vamadevan, and Dr. Dimple Kondal.

The study was funded by the UK’s FCDO/MRC/NIHR/Wellcome Trust Joint Global Health Trials (MR/R018278/1). The funding agencies had no role in designing the study or in writing the manuscript. The publication fee was covered through the UKRI block grant.

Author Contributions

KC wrote the first draft of the manuscript. PM, KavS, KalS, TH, MH, SMG, NKM, RN, SM, NT, SAL, SK, and DP contributed significantly to the revision of the manuscript. All the authors read and approved the final manuscript.

List of Investigators

KC (Principal Investigator) conceptualized and designed the study with the help of Co-Investigators (TH, MH, SMG, NKM, NT, SAL, SK, and DP).

Prior Presentation

The study abstract was selected for presentation at the International Diabetes Federation (IDF) Congress 2021 (held virtually from 6 to 11 December 2021 due to the COVID-19 pandemic) and published in the event material. https://doi.org/10.26226/morressier.617c37317c09fc044a9751b2 .

Disclosures

KC, PM, KavS, KalS, TH, MH, SMG, NKM, RN, SM, NT, SAL, SK, and DP have nothing to disclose.

Compliance with Ethics Guidelines

The study was conducted in accordance with the Declaration of Helsinki. The research ethics committees of the following institutes gave ethics approval: Faculty of Medicine and Health Sciences, University of Nottingham, UK (14-1805); CCDC, India (CCDC_IEC_09_2018); BNCHY, India (BNCHY/IEC/2/2019); and S-VYASA, India (RES/IEC-SVYASA/138/2018). We obtained written informed consent from participants.

Data Availability

The data set generated during the current study is available from the corresponding author on reasonable request.

Author information

Authors and affiliations.

Lifespan and Population Health Academic Unit, University of Nottingham, Nottingham, UK

Kaushik Chattopadhyay & Sarah Anne Lewis

Centre for Chronic Disease Control, New Delhi, India

Pallavi Mishra, Kavita Singh, Kalpana Singh & Dorairaj Prabhakaran

Population Health Research Institute, St. George’s University of London, London, UK

Tess Harris

Division of Surgery and Interventional Science, Institute of Sport, Exercise and Health, University College London, London, UK

Institute of Applied Health Research, University of Birmingham, Birmingham, UK

Sheila Margaret Greenfield

Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India

Nandi Krishnamurthy Manjunath

Bapu Nature Cure Hospital and Yogashram, New Delhi, India

Rukamani Nair & Somnath Mukherjee

Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, New Delhi, India

Nikhil Tandon

Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

Sanjay Kinra

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Corresponding author

Correspondence to Kaushik Chattopadhyay .

Additional information

The original online version of this article was revised due to update in author group.

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Chattopadhyay, K., Mishra, P., Singh, K. et al. Yoga Programme for Type 2 Diabetes Prevention (YOGA-DP) Among High-Risk People in India: A Multicenter Feasibility Randomized Controlled Trial. Diabetes Ther 14 , 1137–1154 (2023). https://doi.org/10.1007/s13300-023-01395-4

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DOI : https://doi.org/10.1007/s13300-023-01395-4

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Scientific Research on Yoga > Disease and Disorders > Diabetes and Endocrine

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Diabetes and endocrine type 1 and 2 diabetes, metabolic syndrome/prediabetes, endocrine conditions.

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Main Research Categories

Review Papers (What's this?)

Effectiveness of Yoga as the Public Health Intervention Module in the Management of Diabetes and Diabetes Associated Dementia in South East Asia: A Narrative Review. Bali P, Kaur N, Tiwari A, Bammidi S, Podder V, Devi C, Kumar S, Sivapuram MS, Ghani A, Modgil S, Malik N, Anand A. Neuroepidemiology. 2020 Feb 19:1-17. [ full text ]

The effect of yoga practice on glycemic control and other health parameters in the prediabetic state: A systematic review and meta-analysis. Ramamoorthi R, Gahreman D, Skinner T, Moss S. PLoS One. 2019 Oct 16;14(10):e0221067. [ full text ]

Therapeutic Role of Yoga in Type 2 Diabetes. Raveendran AV, Deshpandae A, Joshi SR. Endocrinol Metab (Seoul). 2018 Sep;33(3):307-317. [ full text ]

The benefits of yoga practice compared to physical exercise in the management of type 2 Diabetes Mellitus: A systematic review and meta-analysis. Jayawardena R, Ranasinghe P, Chathuranga T, Atapattu PM, Misra A. Diabetes Metab Syndr. 2018 Sep;12(5):795-805. [ abstract ]

The effects of yoga among adults with type 2 diabetes: A systematic review and meta-analysis. Thind H, Lantini R, Balletto BL, Donahue ML, Salmoirago-Blotcher E, Bock BC, Scott-Sheldon LAJ. Prev Med. 2017 Dec;105:116-126. [ abstract ]

A narrative review on role of Yoga as an adjuvant in the management of risk factor, disease progression and the complications of type 2 diabetes mellitus. Mooventhan A. Diabetes Metab Syndr. 2017 Nov;11 Suppl 1:S343-S346. [ abstract ]

The effect of yoga practice on glycemic control and other health parameters in Type 2 diabetes mellitus patients: A systematic review and meta-analysis. Vizcaino M, Stover E. Complement Ther Med. 2016 Oct;28:57-66. doi: 10.1016/j.ctim.2016.06.007. [ abstract ]

Yoga for metabolic syndrome: A systematic review and meta-analysis. Cramer H, Langhorst J, Dobos G, Lauche R. Eur J Prev Cardiol. 2016 Dec;23(18):1982-1993. [ abstract ]

Role of yoga for patients with type II diabetes mellitus: A systematic review and meta-analysis. Kumar V, Jagannathan A, Philip M, Thulasi A, Angadi P, Raghuram N. Complement Ther Med. 2016 Apr;25:104-12. [ abstract ]

Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials. Innes KE, Selfe TK. J Diabetes Res. 2016;2016:6979370. [ full text ]

Psycho-neuro-endocrine-immune mechanisms of action of yoga in type II diabetes. Singh VP, Khandelwal B, Sherpa NT. Anc Sci Life. 2015 Jul-Sep;35(1):12-7. [ full text ]

The benefits of yoga for adults with type 2 diabetes: a review of the evidence and call for a collaborative, integrated research initiative. de G R Hansen E, Innes KE. Int J Yoga Therap. 2013;(23):71-83. [ full text ]

Male reproductive health and yoga. Sengupta P, Chaudhuri P, Bhattacharya K. Int J Yoga. 2013 Jul;6(2):87-95. [ full text ]

Notable Publications (What's this?)

Effect of an Integrated Naturopathy and Yoga Program on Long-Term Glycemic Control in Type 2 Diabetes Mellitus Patients: A Prospective Cohort Study. Bairy S, Rao MR, Edla SR, Manthena SR, Tatavarti NVGD. Int J Yoga. 2020 Jan-Apr;13(1):42-49. doi: 10.4103/ijoy.IJOY_32_19. [ full text ]

Randomized Controlled Trial of A 12-Week Yoga-Based (Including Diet) Lifestyle vs. Dietary Intervention on Cardio-Metabolic Risk Factors and Continuous Risk Score in Indian Adults with Metabolic Syndrome. Yadav R, Yadav RK, Khadgawat R, Pandey RM, Upadhyay AD, Mehta N. Behav Med. 2020 Jan-Mar;46(1):9-20. [ abstract ]

Efficacy of a Validated Yoga Protocol on Dyslipidemia in Diabetes Patients: NMB-2017 India Trial. Nagarathna R, Tyagi R, Kaur G, Vendan V, Acharya IN, Anand A, Singh A, Nagendra HR. Medicines (Basel). 2019 Oct 11;6(4). [ full text ]

Partitioning of radiological, stress and biochemical changes in pre-diabetic women subjected to Diabetic Yoga Protocol. Singh AK, Kaur N, Kaushal S, Tyagi R, Mathur D, Sivapuram MS, Metri K, Bammidi S, Podder V, Modgil S, Khosla R, Sharma K, Anand A, Malik N, Boroiah V, Nagarathna R, Nagendra HR, Anand A. Diabetes Metab Syndr. 2019 Jul - Aug;13(4):2705-2713. [ abstract ]

Comparative efficacy of a 12 week yoga-based lifestyle intervention and dietary intervention on adipokines, inflammation, and oxidative stress in adults with metabolic syndrome: a randomized controlled trial. Yadav R, Yadav RK, Khadgawat R, Pandey RM. Transl Behav Med. 2019 Jul 16;9(4):594-604. [ full text ]

Effectiveness of Adjuvant Yoga Therapy in Diabetic Lung: A Randomized Control Trial. Balaji R, Ramanathan M, Bhavanani AB, Ranganadin P, Balachandran K. Int J Yoga. 2019 May-Aug;12(2):96-102. [ full text ]

"I can do almost anything": The experience of adults with type 2 diabetes with a yoga intervention. Thind H, Guthrie KM, Horowitz S, Conrad M, Bock BC. Complement Ther Clin Pract. 2019 Feb;34:116-122. [ full text ]

Feasibility of yoga as a complementary therapy for patients with type 2 diabetes: The Healthy Active and in Control (HA1C) study. Bock BC, Thind H, Fava JL, Dunsiger S, Guthrie KM, Stroud L, Gopalakrishnan G, Sillice M, Wu W. Complement Ther Med. 2019 Feb;42:125-131. [ full text ]

Effect of Ayurveda intervention, lifestyle modification and Yoga in prediabetic and type 2 diabetes under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)-AYUSH integration project. Sharma R, Shahi VK, Khanduri S, Goyal A, Chaudhary S, Rana RK, Singhal R, Srikanth N, Dhiman KS. Ayu. 2019 Jan-Mar;40(1):8-15. [ full text ]

One Year of Yoga Training Alters Ghrelin Axis in Centrally Obese Adults With Metabolic Syndrome. Yu AP, Ugwu FN, Tam BT, Lee PH, Lai CW, Wong CSC, Lam WW, Sheridan S, Siu PM. Front Physiol. 2018 Sep 20;9:1321. [ full text ]

Influence of Time of Yoga Practice and Gender Differences on Blood Glucose Levels in Type 2 Diabetes Mellitus and Normal Healthy Adults. Vijayakumar V, Mooventhan A, Raghuram N. Explore (NY). 2018 Jul - Aug;14(4):283-288. [ abstract ]

Multidimensional Improvements in Health Following Hatha Yoga for Individuals with Diabetic Peripheral Neuropathy. Van Puymbroeck M, Atler K, Portz JD, Schmid AA. Int J Yoga Therap. 2018 Nov;28(1):71-78. [ abstract ]

Effect of 12 Weeks of Yoga Therapy on Quality of Life and Indian Diabetes Risk Score in Normotensive Indian Young Adult Prediabetics and Diabetics: Randomized Control Trial. Keerthi GS, Pal P, Pal GK, Sahoo JP, Sridhar MG, Balachander J. J Clin Diagn Res. 2017 Sep;11(9):CC10-CC14. [ full text ]

Effect of yoga and aerobics exercise on sleep quality in women with Type 2 diabetes: a randomized controlled trial. Ebrahimi M, Guilan-Nejad TN, Pordanjani AF. Sleep Sci. 2017 Apr-Jun;10(2):68-72. doi: 10.5935/1984-0063.20170012. [ full text ]

A Randomized controlled trial of the effect of yoga and peer support on glycaemic outcomes in women with type 2 diabetes mellitus: a feasibility study. Sreedevi A, Gopalakrishnan UA, Karimassery Ramaiyer S, Kamalamma L. BMC Complement Altern Med. 2017 Feb 7;17(1):100. [ full text ]

Yoga for Risk Reduction of Metabolic Syndrome: Patient-Reported Outcomes from a Randomized Controlled Pilot Study. Sohl SJ, Wallston KA, Watkins K, Birdee GS. Evid Based Complement Alternat Med. 2016;2016:3094589. [ full text ]

Impact of individualized yoga therapy on perceived quality of life performance on cognitive tasks and depression among Type II diabetic patients. Satish L, Lakshmi VS. Int J Yoga. 2016 Jul-Dec;9(2):130-6. [ full text ]

Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism: A pilot study. Nilakanthan S, Metri K, Raghuram N, Hongasandra N. J Complement Integr Med. 2016 Jun 1;13(2):189-93. [ abstract ]

Effects of a 12-Week Hatha Yoga Intervention on Metabolic Risk and Quality of Life in Hong Kong Chinese Adults with and without Metabolic Syndrome. Lau C, Yu R, Woo. PLoS One. 2015 Jun 25;10(6):e0130731. [ full text ]

Effects of 1-year yoga on cardiovascular risk factors in middle-aged and older adults with metabolic syndrome: a randomized trial. Siu PM, Yu AP, Benzie IF, Woo J. Diabetol Metab Syndr. 2015 Apr 30;7:40. [ full text ]

Completion report: Effect of Comprehensive Yogic Breathing program on type 2 diabetes: A randomized control trial. Jyotsna VP, Dhawan A, Sreenivas V, Deepak KK, Singla R. Indian J Endocrinol Metab. 2014 Jul;18(4):582-4. [ full text ]

Effect of restorative yoga vs. stretching on diurnal cortisol dynamics and psychosocial outcomes in individuals with the metabolic syndrome: the PRYSMS randomized controlled trial. Corey SM, Epel E, Schembri M, Pawlowsky SB, Cole RJ, Araneta MR, Barrett-Connor E, Kanaya AM. Psychoneuroendocrinology. 2014 Nov;49:260-71. [ full text ]

A yoga intervention for type 2 diabetes risk reduction: a pilot randomized controlled trial. McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH, Hecht FM. BMC Complement Altern Med. 2014 Jul 1;14:212. [ full text ]

Restorative yoga and metabolic risk factors: the Practicing Restorative Yoga vs. Stretching for the Metabolic Syndrome (PRYSMS) randomized trial. Kanaya AM, Araneta MR, Pawlowsky SB, Barrett-Connor E, Grady D, Vittinghoff E, Schembri M, Chang A, Carrion-Petersen ML, Coggins T, Tanori D, Armas JM, Cole RJ. J Diabetes Complications. 2014 May-Jun;28(3):406-12. [ full text ]

Effect of regular yogic training on growth hormone and dehydroepiandrosterone sulfate as an endocrine marker of aging. Chatterjee S, Mondal S. Evid Based Complement Alternat Med. 2014;2014:240581. [ full text ]

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A Comprehensive Review of Yoga Research in 2020

Affiliations.

• 1 Advanced Yoga Research Council, AAYM, Germantown, TN, USA.
• 2 Department of Research, Government Yoga and Naturopathy Medical College, Chennai, India.
• 3 Department of Cardiology, NRS Medical College, Kolkata, India.
• 4 Department of Yoga, Central University of Rajasthan, Ajmer, India.
• 5 Department of Yoga, Manipur University, Imphal, India.
• 6 Department of Cardiology, Memphis VA Medical Center, Memphis, TN, USA.
• 7 School of Public Health, The University of Memphis, Memphis, TN, USA.
• 8 Integrative Cardiology, All India Institute of Medical Sciences, Rishikesh, India.
• PMID: 35099279
• DOI: 10.1089/jicm.2021.0420

Objectives: Accumulated evidence garnered in the last few decades has highlighted the role of yoga in health and disease. The overwhelming mortality and morbidity mediated by noncommunicable epidemics such as heart disease and cancer have fostered a search for mechanisms to attenuate them. Despite overwhelming success in acute care, the efficacy of modern medicines has been limited on this front. Yoga is one of the integrative therapies that has come to light as having a substantial role in preventing and mitigating such disorders. It thus seems trite to analyze and discuss the research advancements in yoga for 2020. The present review attempts to distill recent research highlights from voluminous literature generated in 2020. Methods: This review was conducted on the articles published or assigned to an issue in 2020. The authors searched the PubMed database for clinical studies published in the English language, using yoga (including meditation) as the intervention, and having an adequate description of the intervention. Then, they extracted data from each study into a standardized Google sheet. Results: A total of 1149 citations were retrieved in the initial search. Of these, 46 studies met eligibility criteria and were finally included. The studies were predominantly on mental health and neuropsychology, addressing various issues such as anxiety, postural balance, migraine, academic performance, and childhood neglect. Anxiety, stress, and depression were other common denominators. Eight studies were on cardiorespiratory systems, including exercise capacity, cardiac rehabilitation, myocardial infarction, and hypertension. Three studies were on diabetes, evaluating the effect of yoga. Five studies focused on cognition, health status, and autonomic regulation and few others included cancers, infertility, ulcerative colitis, urinary incontinence, restless leg syndrome, rheumatoid arthritis, chronic pain, and metabolic syndrome. Finally, most studies were on noncommunicable diseases with one exception, human immunodeficiency virus; two randomized controlled trials were dedicated to it. Conclusions: Yoga has been studied under a wide variety of clinicopathological conditions in the year 2020. This landscape review intends to provide an idea of the role of yoga in various clinical conditions and its future therapeutic implications.

Keywords: clinical research; meditation; trials; yoga.

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Yoga for Type 2 Diabetes: Scientific Rationale and Clinical Research Evidence

By Nikhil Rayburn and Sat Bir Singh Khalsa, Ph.D. 

Type 2 Diabetes Mellitus (DM2), also called adult-onset diabetes, is a metabolic disease that was formerly only diagnosed in midlife but is now impacting younger adults and even children. This disorder is characterized by defects in insulin production and action, resulting in elevated blood glucose levels, which can lead to serious medical consequences. Long-term complications from diabetes account for more adult cases of vision loss, end-stage kidney disease, and amputations than any other disease. In addition, diabetes significantly increases the risk of cardiovascular disease and may be linked to cancer.

DM2 is largely a lifestyle disease caused by inadequate physical activity, diets rich in highly-processed foods and refined sugars, and elevated levels of life-stress. Twenty-eight million people in the United States have DM2, and more than 80 million are considered to be at high risk of developing it, a state called prediabetes or metabolic syndrome. Worldwide, more than 350 million people are estimated to have DM2, a disease affecting many developing countries with limited resources. The high cost and relatively low effectiveness of conventional treatment have resulted in an economic burden estimated to total $322 billion annually in the United States. Conventional treatment aims at controlling glucose levels through medications, education, and behavior change schemes. However, behavior change is notoriously hard to enact because the same environmental and social conditions that gave rise to the disease-causing behavior are still in place. Pharmaceutical treatment drawbacks include dependency, resistance, and adverse long-term effects. Consequently, there has been a concentrated search for non-pharmaceutical treatment and preventative measures. Behavioral treatments such as lifestyle interventions addressing the risk factors of obesity and sedentary activity reduce the development of diabetes by as much as 58% and decrease the need for medications. However, current conventional behavioral lifestyle interventions have limited effectiveness; this is a factor that may likely be improved with yoga. 

Yoga interventions address several DM2 risk factors and bring a much-needed holistic approach to DM2 treatment. In yoga, physical exercises are linked to lifestyle and behavioral changes that include diet, relaxation, and stress management. A lesser-known aspect of yoga is the social support that a yoga class or community provides and social support is strongly linked to improved diabetes self-care and clinical outcomes. Yoga is better known for increasing fitness and physical function, thereby improving both glucose metabolism and psychological health. At the same time, yoga promotes and supports weight loss and thereby addresses obesity which is a major cause of DM2 onset and complications. Finally, the two most beneficial and consistent outcomes of yoga are an increase in mind-body awareness and stress-coping ability. This leads to a host of positive downstream effects including improvements in healthy behaviors, avoidance of unhealthy behaviors, better sleep cycles, balanced neuroendocrine status, improved metabolic function, and reduced inflammatory responses.

There is convincing research that shows that yoga improves mindfulness and mind-body awareness, and this may well encourage individuals to gravitate to healthy behaviors such as exercise and healthy food choices, and away from unhealthy habits such as consuming junk food. This is all due to their enhanced experience of the positive effects of these behaviors. Evidence suggests that stress may play a major role in the development of diabetes, which is why relaxation techniques, such as are found in yoga, could serve as a very effective complement to other lifestyle modifications. Therefore, there is every reason to believe that yoga should be efficacious in preventing and treating DM2. 

Metabolic Regulation  

Studies evaluating yoga interventions in patients with DM2 found that yoga normalized metabolic functions which resulted in increased insulin sensitivity, glucose tolerance, and improved lipid profiles. These beneficial effects of yoga on glycemic control are well documented. A recent review in the International Journal of Yoga Therapy looked at the evidence for the benefits of yoga in adults with DM2. Peer-reviewed studies published between 1970 and 2006 looked at the effects of yoga on diabetes and diabetes risk factors in a broad range of outcomes, such as insulin resistance, glucose intolerance, elevated blood pressure, and excess body weight. Each of these factors is strongly implicated in the development and progression of DM2.

Despite considerable variability in design, clinical measures, and target populations, most trials reported positive changes in at least one of the outcomes related to DM2 and in clinical outcomes as well. The most recent review of research on yoga therapy for DM2 was published this year by Kim Innes of West Virginia University in the Journal of Diabetes Research. Researchers found 33 papers reporting findings from 25 controlled trials (12 of them RCTs) representing 2170 participating research subjects and concluded that “collectively, the findings suggest that yogic practices may promote significant improvements in several indices of importance in DM2 management, including glycemic control, lipid levels, and body composition.

More limited data suggest that yoga may also lower oxidative stress and blood pressure; enhance pulmonary and autonomic function, mood, sleep, and quality of life; and reduce medication use in adults with DM2.” 

Improved Sense of Well-Being  

In a pilot study conducted by Shanti Shanti Kaur Khalsa and Guru Parkash Kaur of the Guru Ram Das Center for Medicine and Humanology (founded by Yogi Bhajan in Espanola, New Mexico to apply the practices of Kundalini Yoga for therapeutic populations), they applied 3 questionnaires to evaluate the effectiveness of an 8-week Kundalini Yoga and lifestyle intervention program in diabetic patients. One of these was the Audit of Diabetes Dependent Quality of Life, which measures individuals’ perception of the impact of diabetes on their quality of life. Improvement in quality of life was measured in 9 of 11 participants.

The second scale was the Profile of Mood States which consists of subscales measuring the following moods: anger, confusion, depression, fatigue, anxiety, and vigor. There was a statistically significant improvement in all of the above mood states following participation in the diabetes program. The third measure was the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being, which measures a faith factor as well as a meaning-and-peace factor. There was a statistically significant improvement in spiritual well-being following participation in the diabetes program as measured by this scale.

The evaluation showed that most participants found the components of the program extremely helpful especially in the areas of mood, stress management, quality of life, and ability to relax. Although such findings support the efficacy of yoga as a therapeutic intervention to improve quality of life and stress management, larger randomized control trials are required to substantiate the results. 

Assist Controlling Glucose Levels  

There is now a growing number of studies with larger sample sizes showing that yoga can have a positive impact on diabetes. For example, an Indian study from 2015 highlights the efficacy of yoga in controlling blood glucose levels in patients with DM2. The study was conducted at the Department of Physiology and Diabetic clinic of a teaching hospital over a period of two years. The subjects were 30 middle-aged male diabetic patients and an equal number of non-diabetic volunteers made up the control group. The significant decrease in blood glucose levels after yoga in both the experimental and control groups indicates the potential role of yoga as preventive and treatment strategies for DM2. In addition, there is some reason to believe that yoga may rejuvenate or regenerate beta cells of the pancreas which can normalize insulin production.

Given its positive effects on metabolic regulation, physical well-being, and mental health, yoga can be considered as a cost-effective and non-invasive adjunct therapy for treating DM2. With few exceptions, the studies document beneficial changes in yoga program participants and suggest improvements in several risk indices mentioned previously such as glucose tolerance, insulin sensitivity, lipid profiles, blood pressure, oxidative stress, and pulmonary function. However, several of the current studies have small sample sizes which prevent the generalization of findings. The therapeutic potential of yoga in the face of a worldwide epidemic of diabetes warrants additional research, which will require more funding from our public health institutions. This would likely prove to be a valuable investment given that conventional pharmaceutical treatment comes with a number of side effects and limited efficacy. Yoga is potentially a highly cost-effective protocol to treat and prevent DM2 since it addresses the underlying causes along with symptoms. 

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research. 

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and  The Principles and Practice of Yoga in Health Care  and author of the Harvard Medical School ebook Your Brain on Yoga.

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Diabetic yoga protocol improves glycemic, anthropometric and lipid levels in high risk individuals for diabetes: a randomized controlled trial from Northern India

Navneet kaur.

1 Department of Physical Education, Panjab University, Chandigarh, 160014 India

4 Department of Neurology, Neuroscience Research Lab, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India

Vijaya Majumdar

2 Division of Life Sciences, Swami Vivekananda Yoga Anusandhana Samsathana, Bengaluru, Karnataka 560106 India

Raghuram Nagarathna

Neeru malik.

3 Dev Samaj College of Education, Sector 36B, Chandigarh, 160036 India

Akshay Anand

Hongasandra ramarao nagendra, associated data.

The datasets used during the present study are available from the corresponding author on reasonable request.

To study the effectiveness of diabetic yoga protocol (DYP) against management of cardiovascular risk profile in a high-risk community for diabetes, from Chandigarh, India.

The study was a randomized controlled trial, conducted as a sub study of the Pan India trial Niyantrita Madhumeha Bharath (NMB) . The cohort was identified through the Indian Diabetes Risk Scoring (IDRS) (≥ 60) and a total of 184 individuals were randomized into intervention (n = 91) and control groups (n = 93). The DYP group underwent the specific DYP training whereas the control group followed their daily regimen. The study outcomes included changes in glycemic and lipid profile. Analysis was done under intent-to-treat principle.

The 3 months DYP practice showed diverse results showing glycemic and lipid profile of the high risk individuals. Three months of DYP intervention was found to significantly reduce the levels of post-prandial glucose levels (p = 0.035) and LDL-c levels (p = 0.014) and waist circumference (P = 0.001).

The findings indicate that the DYP intervention could improve the metabolic status of the high-diabetes-risk individuals with respect to their glucose tolerance and lipid levels, partially explained by the reduction in abdominal obesity. The study highlights the potential role of yoga intervention in real time improvement of cardiovascular profile in a high diabetes risk cohort.

Trial registration: CTRI, CTRI/2018/03/012804. Registered 01 March 2018—Retrospectively registered, http://www.ctri.nic.in/ CTRI/2018/03/012804.

Introduction

The rise of diabetes in the developing world poses a threat to meager health budgets. Owing to the strong association between various morbidity and mortality outcomes as complications of this dreaded disease, early detection of diabetes risk through non-invasive parameters is a primary requisite. Observational studies show that the risk reduction for diabetes can be decreased by 58% or 63–65% if risk factors could be controlled [ 1 , 2 ]. Many argue that such experimental strategies for the possible halting of conversion of prediabetes into diabetes must continue to include pharmacological interventions even though the rates have not been compared [ 3 ]. Identification of individuals at increased risk for the disease with invasive measurements of fasting and post challenge (postprandial) blood glucose are costly and time consuming. Hence, it has been advocated that the realistic prevention of diabetes should identify high-risk subjects with the use of the non-invasive risk scores [ 4 ]. Such studies should also target subjects with normoglycemia and prevent their progression to poor glycemic status [ 4 ].

Yoga plays a promising role in minimizing the risk of Diabetes for high-risk individuals with prediabetes [ 5 , 6 ]. It reduces body weight, glucose, and lipid levels, though, most of these studies comply with the guidelines of randomized controlled trials adhered to the CONSORT statements [ 7 – 11 ] whereas majority of studies have not reported as per CONSORT statements [ 12 – 15 ]. Several review of published studies, in people with diabetes and prediabetes, have concluded that the practice of yoga may reduce insulin resistance and related cardiovascular disease (CVD) risk factors and improve clinical outcomes [ 16 ]. Specifically, reports suggest that a yoga-based lifestyle intervention reduces body weight, glucose and lipid levels that should reduce diabetes risk. Keeping in view the high transition rates of diabetes in India, we selected a high-risk cohort from Chandigarh, one of the most affluent Union Territories of India with highest reported prevalence of diabetes in order to establish the efficacy of yoga to alleviate the cardiovascular disease. Indian Diabetes Risk Score (IDRS), specific for Indian ethnicity a validated tool was used for identification of the high-risk population [ 17 ]. We developed a national consensus ‘Diabetes Yoga protocol’ based on published reports and classical literature with an aim to stimulate weight reduction by combination of postures and meditation techniques [ 18 , 19 ]. Additionally, cardiometabolic risk reduction has also been recognized as one of the potential outcomes of yoga-based interventions [ 20 ]. Yoga has been shown to be regulating the risk parameters of diabetes, waist circumference (WC), body mass index (BMI), oxidative stress, fasting blood sugar (FBS) and systolic blood pressure (SBP) respectively [ 21 ]. Hence, in this study we tested the efficacy of diabetic yoga protocol (DYP) on alleviation of glycemic and lipid imbalances in individuals at high risk of diabetes.

Materials and methods

Study population.

Under the multi-region survey of Niyantarita Maduhmeha Bharat (NMB-2017) a door-to-door screening was carried out for the identification of high risk individuals among the population of Chandigarh (U.T) and Panchkula (District in Haryana state) on the basis of Indian Diabetes Risk Score (IDRS). The data collection was carried out by well trained yoga volunteers for diabetes management (YVDMs). Written informed consents were taken from every subject during door to door screening as well as at the time of registration. All the experimental protocol, methods and procedures were approved by Ethics committee of Indian Yoga Association (IYA) (ID: RES/IEC-IYA/001). All experiments methods and procedures were carried out in accordance with relevant guidelines and regulations of ethics committee. The study was registered at clinical trial registry of India, CTRI/2018/03/012804 (dated: 01/03/2018).

Study design

The present study is the two-armed randomized controlled trial conducted in the population of Chandigarh and Panchkula regions of northern India. Indian Diabetes Risk Score (IDRS) was used for detection of high risk (≥ 60 score) individuals from the study. Self-declared diabetics and low (< 30 score) and moderate [between 30–50 score] risk individuals were excluded from the study. As evident from the flow of patients presented in the flowchart, out of 1214 eligible subjects, there was approximately 50% loss of sample data due to error in the sampling. Further out of 564, we had to exclude as they were self-declared patients with diabetes and did not further participate in the study. However, this led to final participation of only 184 subjects in the study and allocation of these subjects diminishing the random selection of the study cohort. A cohort of high diabetes-risk cohort consisting of n = 184 participants was randomized into the interventional and control groups (n = 91:93). After excluding the dropouts from the study, based on CONSORT guidelines, the remaining subjects in the DYP and control group were further assessed for selected anthropometric, glycemic and lipid parameters. The intervention group was given the Diabetic Yoga Protocol for three months and control group continued with their daily routine activities. The detailed categorization of the samples is shown in Fig.  1 . The control group was waitlisted for yoga.

Flowchart of study design. PCA   principal component analysis, MIPCA multiple imputations with PCA

Randomization

Simple randomization technique was used to allocate participants into the intervention and the control groups. An independent statistician generated a computer-generated random number sequence and the sequence was given to an external staff who had no involvement in the study procedures. The participants were allocated their consecutive numbers, after baseline measurements. Blinding of the participants was not possible due to the nature of the intervention. However, the outcome assessors were blinded.

Risk assessment

To identify the individuals at high-risk of diabetes, Indian Diabetes Risk Score (IDRS) was administered as proposed by Mohan et al. [ 22 ]. It consisted of two unmodifiable (i.e. age, and family history) and two modifiable (physical activity and waist circumference) risk factors for diabetes, which can predict the level of risk for the development of diabetes in the community. The IDRS is one of the easily accessible and budget friendly questionnaire to be administered. The aggregate score of the unmodifiable and modifiable risk used to probe the level of risk among the population (i.e. High risk > 60, Moderate risk-30–50, Low risk < 30).

Sample size

Sample size estimation for the main Pan India study was focused for prediabetes subjects [ 23 ]. However, for the present pilot scale study we calculated sample size assuming a small effect size 0.3 [ 5 ] of DYP vs waitlist control 0.25, α = 0.80 as 180 (n = 90:90). Further, assuming an attrition rate of 20%, the final sample size was n = 220.

Study outcomes

Changes in the glycemic and other metabolic variables (anthropometric and lipid) over 3 months were documented. The fasting blood sample was withdrawn. For glucose analysis, fasting samples for 10–12 h were taken early in the morning for the estimation of FBS and afterwards 75 g glucose was given to the participants. The blood sampling was repeated after 2 h. for estimation of OGTT.

Biochemical analysis

For the estimation of biochemical parameters viz. FBS (Fasting Blood Sugar, Rxl-Max 500), OGTT (Oral Glucose Tolerance Test), HbA1c (Bio-Rad D-10), Triglycerides, Cholesterol, HDL, LDL, Chol/HDL ratio, HDL/LDL ratio (Rxl-Max 500) and VLDL about 9 ml of blood was drawn and analyzed by phlebotomist of Sisco Research Laboratories (SRL) of Chandigarh. Anthropometric measurements were also obtained (i.e. height, weight, waist circumference) by trained researcher. The waist circumference (WC) was reported in centimeters. The BMI was obtained by using the formula (weight in kg/height (meter) 2 ).

Interventions

The study protocol consisted of Diabetic Yoga Protocol (DYP) approved by the Ministry of AYUSH and Quality Council of India as shown in Table ​ Table1. 1 . This is the first protocol to be made specifically for the prediabetics and diabetics. The complete sequence of prayer, yogic postures, breathing and meditative techniques, along with specified time, was shown in previously published paper [ 24 ]. The Yogic practices were performed for 3 months for 60 min. Certified yoga instructors took the yoga classes and they recorded regular attendance. Randomization was done through a computer-generated list of random numbers and allocation was concealed to the participants until the completion of the baseline assessment.

Diabetic yoga protocol (DYP)

Statistical analysis

For the analysis of data SPSS for Windows (version 22; IBM SPSS Inc., Chicago IL) 0 and R statistical package were used. The normality of data was analyzed using Kolmogorov–Smirnov test. The paired t-test was used to estimate the Baseline and posttest differences of DYP, and control group and the significant level was set at ≤ 0.05. The trial outcomes were analyzed according to the intention-to-treat principle; hence multiple imputation was carried for the missing variables accounting for the loss to follow up. We used absolute change (time and treatment interaction), to estimate intervention effects refers to the difference in the outcome of the intervention and control over different time-points of assessment. Absolute change was determined as follows: absolute change = [(intervention group follow-up) – (intervention group baseline)] – [(control group follow-up) – (control group baseline)]. The percentage change, also called the relative change was determined as relative change = (absolute change / intervention group baseline) × 100%. To evaluate the influence of missing data, we applied multiple imputations to the data using missMDA R package (v1.13) based on the principal component analysis method [ 25 ] from the package, using 5 components to reconstruct the data and over 1000 imputed datasets. One-way multivariate analysis of covariance (MANCOVA) was conducted to compare the effects of the DYP with control group glycemic and metabolic measures, while controlling for the age, gender and baseline values of the covariates.

Baseline characteristics

The data used in this study was collected in (NMB-2017) the northern region of India i.e. Chandigarh and Panchkula. The age range of participants was 3–70 years; [mean age 48.51 (SD 10.08) years]with baseline characteristics of the yoga and control groups as shown in Table ​ Table2. 2 . Mean HbA1c of the high-risk cohort was 5.64% (0.38), mean FBS was 97.13 mg/dl (SD 11.10), and mean PPBS were 108.40 mg/dl (SD 28.79). Distributions of age and gender was similar between the intervention and the control groups. The IDRS and anthropometric values were also similarly distributed between the groups. Overall, there was no significant difference in the distribution of demographic, anthropometric, or biochemical parameters between the DYP and the control groups at the baseline.

Baseline characteristics of the participants in the intervention and control group

Continuous variables are represented as mean (SD) and compared using independent t-test. Categorical variables are represented as number (percentages) and compared using chi-square test. P value < 0.05 were considered significant. FBS fasting blood sugar, PPBG postprandial blood glucose, HbA1c glycated hemoglobin, HDL-c high density lipid-cholesterol, LDL-c low density lipid-cholesterol, VLDL very low density lipid-cholesterol, IDRS Indian diabetes risk score

When analyzed by multivariate analysis of covariance (MANCOVA), adjusting for age, gender and status of diabetes/prediabetes/normoglycemia, and baseline values of the covariates, yoga intervention was found to have significant influence on few cardinal parameters related to glycemic control (PPBS), and lipid control (LDL-C) as shown in Table ​ Table3. 3 . We also observed a significant influence of DPP on waist circumference reduction [relative changes, − 1.94%. Compared to the control, DYP also resulted in significant reductions in LDL-C and, − 0.16% and − 2.81%, for LDL-Cholesterol and post-prandial blood glucose levels from baseline to 3 months [absolute changes, − 0.18% and − 3.08%, respectively and relative changes, − 0.16% and − 2.81%, respectively].

Comparative assessment of influence of DYP on biochemical and weight related variables with the control group

Absolute change = [(intervention group follow-up) – (intervention group baseline)] – [(control group follow-up) – (control group baseline)]. Relative change = (absolute change / intervention group baseline) × 100%; p value for difference between the intervention and the control groups by MANCOVA adjusting for age, gender, status of diabetes/prediabetes/normoglycemia baseline values of glycemic and lipid variables, length of time having had prior exposure of yoga

We examined the effect of Diabetic Yoga Protocol on baseline and post (3 months) levels of HbA1c and other glycemic (OGTT and FBS), Lipid (Total cholesterol, triglycerides, HDL-c, LDL-c, and VLDL-c, CDL/HDL, LDL/HDL) and anthropometric parameters (BMI). In the present study, we show the efficacy of DYP in substantial improvement in the waist circumference in a high-risk diabetes population from Chandigarh (relative change of 1.94 cm). We could also demonstrate a significant decline in the worsening of post prandial glucose levels with yoga intervention as compared to the wait-list control group (relative change of 2.82 mg/ml). However, for LDL-c levels, there were clinically significant improvements by 0.16 units. Notably, over 3 months study duration there was an overall increase in the levels of total cholesterol, triglyceride and VLDL means in the study cohort, while HDL levels had decreased. In particular TG levels have gone from normal range to mildly high (> 150 mg/dl) [ 26 ] which draws our attention towards accelerated pace of metabolic dysfunction in the high risk population. These findings comply with Chandigarh being an affluent union territory of India with high per-capita GDP and has been documented to have highest prevalence of diabetes 13.6%, 12.8–15·2 as compared to other Indian states [ 27 ]. As mentioned above, there was a significant influence of DYP on the waist circumference, one of the two important modifiable parameters of Indian Diabetes Risk Score [ 17 ]. The relevance of WC reduction in context of reduced risk of CVD is well established; a 1 cm increase in WC has been associated with a 2% increase in the relative risk of future CVD [ 28 ]. The visceral adipose tissue is a primary source of cytokine production and insulin resistance (IR) [ 29 ]. Given the higher susceptibility towards visceral fat accumulation and insulin resistance in Asian populations as compared to their Caucasian counterparts, the observed influence of DYP on WC is of particular relevance to the metabolically obese phenotype of Asian Indians [ 30 ].

In relation to the glucose metabolism, we could also demonstrate a significant decline in the worsening of post prandial glucose levels with DYP as compared to the wait-list control group (relative change = − 2.81%, P < 0.05); however, no significant influence could be established for fasting blood glucose concentration. These findings could be justified by the phenotypic differences underlying fasting and post-challenge hyperglycemia that represent distinct natural histories in the evolution of type 2 diabetes [ 31 ]. Postprandial glucose disposal is the primary pathogenic manifestation in impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) merely signifies an abnormal glucose set point [ 31 , 32 ]. Our relevance of the study findings is further underlined by the previous results wherein PPG has been reported to contribute more than FBS to overall hyperglycemia and its control was found essential either to decrease or to obtain HbA1c goals of < 7 [ 33 ]. Several epidemiological studies have suggested that increased glycemic exposure, especially post challenge or postprandial hyperglycemia, is an independent risk factor for macrovascular disease with no apparent upper or lower threshold. Our results indicate a significant influence of yoga on glycemic control integrating postprandial glycemic alterations in the high diabetes risk group. Since in the present study the high-risk cohort was selected through A1c based diagnosis, and IGT was not a primary manifestation in the cohort, hence, the overall improvement in postprandial glucose should be specifically tested in an IGT cohort. The findings of the current study with a 3-month intervention of yoga on postprandial measures of glucose at-risk population deserves clinical attention. Increase in the glucose concentration even in the prediabetes stage, manifests as a chronic inflammatory condition and predisposes an individual to the risk of pathogenic infections [ 32 , 34 , 35 ].

The simultaneous reduction in waist circumference observed in the cohort, is also consistent with the observation of an association between abdominal obesity and the risk of IGT. Based on a significant association between IGT and CVD risk [ 32 , 33 , 36 ], we note a significant improvement in lipid concentrations [LDL-c] by the DYP protocol as compared to the control group. These results are consistent with the previously reported overall beneficial effect of yoga in the management of hyperlipidemia [ 36 ]. These results need validation at larger scale and to ascertain the mechanistic insights into the action of yoga, the indices of monocyte chemotaxis, endothelial inflammation, oxidation, nitric oxide production, and thrombosis should also be explored [ 37 ], including animal models, invitro systems and other approaches [ 38 – 44 ].

The findings of the present study indicate that identification of high-risk group through IDRS and consequent intervention of Yoga based lifestyle protocol could be an effective strategy to combat the metabolic perturbations associated with diabetes, whose co-morbidity is also being reported to be associated with increasing vulnerability to the emerging viral pandemic of COVID-19. Lifestyle interventions are reported to reduce the risk of Type 2 diabetes in high-risk individuals after mid and long-term follow-up. Information on determinants of intervention outcome, adherence and the mechanisms underlying diabetes progression are valuable for a more targeted implementation. Weight loss is a major contributor in the prevention and management of type 2 diabetes. In many of the earlier lifestyle intervention group of the DPP, weight loss was the dominant predictor of reduced diabetes risk, with a 16% reduction observed for every kilogram of weight loss during the 3.2-year follow-up [ 45 ]. Though we failed to observe a significant weight loss over 3 months of DYP intervention, the significant reductions in WC indicate the plausibility of significant weight loss on longer interventions and follow ups.

Whether Yoga alters the conversion of prediabetics into healthy status and if it helps in maintenance of glycemic index can be assessed by longitudinal studies. There was a significant improvement in the glycemic status of the high risk population at administration of DYP. The analysis shows the aptness of Diabetic protocol which is apparently superior to previous studies where no standardized protocols were used for intervention [ 46 , 47 ]. The findings suggest that there is potential of DYP to manage glucose levels in diabetes patients if public intervention is planned through forthcoming wellness centers in India. There are additional studies showing beneficial effects of Yoga on FBS [ 48 ], PPBS [ 49 – 51 ], HbA1c [ 50 , 51 ], total cholesterol, LDL [ 50 , 51 ]. The analysis of the yoga protocols used in above said studies reveal the incorporation of some common and important postures in DYP, which seem to be important in managing the disease. It is also the possible that the beneficial effects of mind body techniques are sensitive to mental disposition of subjects and has been characterized by various measures like psychometric analysis [ 52 , 53 ], namely, Tridosha and Triguna scoring [ 54 , 55 ]. These were not analyzed in this study.

Briefly, DYP’s promising efficacy on glycemic and metabolic parameters requires mechanistic insights. This can be examined by further studies, and long term follow up which was not possible in this study. As DYP is a non-pharmacological, cost-effective method to halt the conversion of early diabetes into prediabetes and/or healthy individuals, the success of its integration into public health policy will depend on its wider acceptability and perception of benefits by both public as well as healthcare workers [ 56 – 59 ]. Yoga’s benefits in maintaining and regulation of the glycemic status are supported by several other studies [ 49 , 50 ], which might enable its inclusion in the National Ayushman Bharat scheme or as part COVID pandemic management protocol in which a large number of individuals with diabetes and heart disease are falling prey [ 60 , 61 ]. This will further encourage molecular and Ayurgenomic studies which presumably underlie the stated clinical outcome.

Limitations

Moreover, there are some limitations of our study that we only studied in two regions of North India and thus the result of this study cannot be generalized on the remaining population. Further, in this study, the socio economic status and psychological assessments were not carried out. We were not able to control for the dietary habits and psychological status of the study participants. However, the small sample size and absence of long term evaluations limit the strength of the study.

Acknowledgements

The authors would like to thank Central Council for Research in Yoga & Naturopathy (CCRYN) for their support for man power, Ministry of Health and Family Welfare (MOHFW) for support the cost of investigations and Indian Yoga Association (IYA) for the overall project implementation. The authors also like to thank to thank Yoga Volunteer for Diabetes Management (YVDMs) for helping in collection of data and also for training participants for yoga.

Abbreviations

Authors' contributions.

NK: writing of manuscript, collection of data. VM: writing of manuscript, analysis. RN: conceptualization of manuscript, supervision and study design. NM: co-conceptualization of manuscript. AA: conceptualization of manuscript. HRN: supervision. All authors read and approved the final manuscript.

The Project was funded by Ministry of AYUSH, Government of India (grant number 16-63/2016-17/CCRYN/RES/Y&D/ MCT/).

Availability of data and materials

Declarations.

Written informed consents were taken from every subject during door to door screening as well as at the time of registration. All the experimental protocol, methods and procedures were approved by Ethics committee of Indian Yoga Association (IYA) (ID: RES/IEC-IYA/001). All experiments methods and procedures were carried out in accordance with relevant guidelines and regulations of ethics committee.

Not applicable.

The authors declare that they have no competing interests.

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