|Year : 2022 | Volume
| Issue : 1 | Page : 12-17
Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients
Amit Kanthi, Singh Deepeshwar, Chidananda Kaligal, Mahadevappa Vidyashree, Dwivedi Krishna
Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
|Date of Submission||09-Jan-2022|
|Date of Decision||24-Mar-2022|
|Date of Acceptance||26-Mar-2022|
|Date of Web Publication||30-Jun-2022|
Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, No. 19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bengaluru - 560 019, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Poor emotion regulation (ER) is linked to diabetes distress and depression that may contribute to uncontrolled glycemic levels among type 2 diabetes mellitus (T2DM) patients. As ER can adversely affect the physiological and psychological health of patients with T2DM, holistic management of the disease is essential. Yoga therapy is one such method that can positively impact both the mental and physical health of T2DM patients.
Methods: Individuals with T2DM (n = 54) were recruited for the study and were randomly allocated to the intervention (yoga) group and control (conventional treatment) group. Cognitive reappraisal (CR) and expressive suppression (ES) were assessed as ER skills, and mindfulness was evaluated before and after the intervention. The intervention was provided for 3 months.
Results: Participants of the yoga group showed an improved ER ability with increased CR and decreased ES. However, these changes were not statistically significant. ES was significantly reduced (p < 0.05) in the control group. In addition, the yoga group showed significantly increased (p < 0.05) mindfulness and was decreased in the control group.
Conclusion: Yoga therapy positively affects the psychological well-being of T2DM patients.
Keywords: Emotion regulation, mindfulness, Type 2 diabetes mellitus, yoga
|How to cite this article:|
Kanthi A, Deepeshwar S, Kaligal C, Vidyashree M, Krishna D. Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients. Yoga Mimamsa 2022;54:12-7
|How to cite this URL:|
Kanthi A, Deepeshwar S, Kaligal C, Vidyashree M, Krishna D. Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients. Yoga Mimamsa [serial online] 2022 [cited 2022 Dec 5];54:12-7. Available from: https://www.ym-kdham.in/text.asp?2022/54/1/12/348198
| Introduction|| |
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder (T2DM) that results in excessive blood glucose circulation. Individuals with T2DM are at high risk of decreased psychological well-being.,, It inflicts stress, depression, apathy in the absence of depression, or anxiety.,, An international survey of diabetic people across four continents shows that around 13.8% and 44.6% of people reported having depression and diabetes distress (DD), respectively.
Previous studies have focused on the relationship between depression and diabetes., However, sub-syndromal depressive and mild conditions, such as dysthymia, anxiety, stress, and distress, are more prevalent than depressive disorders. Emotion regulation (ER) is one such psychological factor that needs to be addressed as emotions and emotional experiences are associated with health outcomes.,
ER includes extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions to accomplish one's goals. It is defined as “attempts individuals make to influence which emotions they have when they have them, and how these emotions are expressed.” The burden of adherence to restrictive lifestyle and self-care and its relationship to awareness, expression, and modulation of feelings, makes ER an important psychological variable of interest in T2DM management. ER is also important because of its impact on self-help compliance and health behavior in general. Moreover, a recent study reported the contribution of poor ER in increasing DD among type 1 diabetes patients. Thus, it is imperative that psychological constructs such as ER are addressed, and all the possible interventions are explored and developed to improve the psychological health of T2DM individuals.
Yoga therapy is a widely known and accepted intervention method for T2DM across the globe. It is exceptionally beneficial in preventing and managing T2DM.
In addition, the practice of yoga has a multitude of benefits for T2DM patients, including glycemic control, insulin resistance, lipid profile, blood pressure, stress, anxiety, and depression.,,,
One of the ways that yoga might impact the psychological health of T2DM patients is mindfulness, as it is an essential element of the yoga practice. Conceptually, mindfulness contains two elements: awareness of the present moment and the quality of that awareness. In the clinical context, it is described as a nonelaborative and nonjudgmental awareness of present moment experience. Developing the ability of mindfulness is thought to promote objective and adaptive strategies of responding to emotional or cognitive triggers. Consequentially, many researchers have proposed a link between mindfulness and adaptive ER. Moreover, mindfulness has shown to be effective in ER, reducing stress and anxiety., Therefore, it is important to investigate if yoga practice can help in improving ER with increased mindfulness.
With the increasing cases of T2DM, the risk of associated complications also increases. It is important to utilize therapeutic approaches that benefit the management of both T2DM and related complications. One such approach is yoga therapy, and the present study attempts to assess the efficacy of yoga practice on ER skills and mindfulness in T2DM patients.
| Methods|| |
T2DM patients with ages ranging between 37 and 65 years were recruited from different parts of Bengaluru city. The participants were randomly allocated to the yoga group (n = 27) and the wait-list control group (n = 27). These participants were recruited through newsletter writings and advertisements. The participants included in the study met the following criteria: no presence of complications including neuropathy, nephropathy, retinopathy, and other cardiovascular disorders, absence of neurological or neuropsychiatric disorders, and are familiar with the English language. In addition, none of the participants were advised to stop their conventional medical treatment. The CONSORT flow diagram presents participant selection and allocation details [Figure 1].
The study was approved by the Institutional Ethics Committee (IEC) of Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University (No. RES/IEC-SVYASA-03/020/2016) and was registered in the Clinical Trial Registry (CTRI) of Government of India. The study protocol was informed to the participants and their informed consent was obtained.
The study is a randomized, parallel group design. Recruited participants were T2DM patients who were randomly divided into two groups, i.e., the yoga group with the intervention of recommended common yoga protocol for T2DM patients and the wait-list control group without any form of yoga interventions. Both groups consisted of 27 participants and were assessed on day 1 and day 90.
The yoga intervention protocol adopted in the study was a common yoga protocol recommended for T2DM patients by the Indian Yoga Association, which includes Asanas (yoga postures), pranayama (breathing practice), and relaxation techniques. The duration of the yoga intervention was 60 min and was administered for 5 days a week for 3 months. The detailed protocol of the yoga intervention is provided in [Table 1].
| Outcome measures|| |
Emotion Regulation Questionnaire
Emotion Regulation Questionnaire (ERQ) assesses ER tendencies using two different strategies, reappraisal, and suppression. Reappraisal is an antecedent-focused strategy that involves changing the way one thinks about emotional stimuli in an attempt to alter the emotional response before it is fully activated. Suppression is a response-focused strategy that involves attempts to lessen the emotional impact of events by inhibiting emotionally expressive behavior once the emotional response is in full effect. The 10-item ERQ includes six reappraisal and four suppression items, forming two respective subscales.
Freiburg Mindfulness Questionnaire
The Freiburg Mindfulness Questionnaire (FMI), short form is intended to measure the general factor of mindfulness and is highly correlated (r=0.95) with the long form. It consists of 14 items and is rated on a 4-point Likert scale with answer options ranging from 1 (rarely) to 4 (almost always). Although the scale measures mindfulness as a general context that has some interrelated facets, “Mindfulness presence,” “Nonjudgmental acceptance,” “openness to Experience,” and “Insight” are the tentative factors identified.
Statistical analysis was performed using a statistical analysis software package named SPSS (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. The normality of data was assessed using the Shapiro-Wilk test. Within-group and between-group differences were assessed using paired sample t-test and independent sample t-test, respectively. Pre- and post-mean values were compared for each outcome measure. The results were considered statistically significant if the p ≤ 0.05.
| Results|| |
The demographic characteristics of the patients are given in [Table 2]. The cognitive reappraisal (CR) was increased in the yoga group and decreased in the control group after the intervention. Expressive suppression (ES) was found to be reduced in the yoga group and increased in the control group. None of these changes was statistically significant except ES in the control group (p < 0.05). Mindfulness was significantly improved (p < 0.05) in the yoga group after the intervention, whereas it reduced in the control group. Mindfulness was also correlated positively (r = 0.47, p = 0.01) with CR and negatively (r = −0.48, p = 0.01) with ES in the yoga group. The details of the changes in ERQ and mindfulness are given in [Table 3] and [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Table 3: Changes in emotion regulation questionnaire measures and mindfulness after the intervention|
Click here to view
|Figure 5: Panel a: Correlation between mindfulness and CR in yoga group. Panel b: Correlation between mindfulness and ES) in yoga group. FMI, Freiburg mindfulness inventory; CR, Cognitive reappraisal; ER, Emotion regulation; ES, Expressive suppression|
Click here to view
| Discussion|| |
The present study was intended to investigate the efficacy of yoga practices on mindfulness and ER skills. The ER skills assessed in the current study are CR and ES. Both mindfulness and ER skills were improved after the intervention. Therefore, the findings of the current study exhibit the potential of yoga therapy in the holistic management of T2DM.
The nature of the yoga practice might shed some light on how it helps improve mindfulness and ER skills. Mindfulness, however, is also a core feature of yoga practice and can be defined as a present-focused state where the mind attunes to moment-by-moment sensations rather than “wandering” or dwelling on the past or future. Furthermore, the concentration required to balance and coordinate the movements of a posture synchronizing breath patterns may also facilitate attentional enhancement that eventually might cultivate the habit of being aware of the present moment. This ultimately may contribute to increased mindfulness.
Increased mindfulness has cognitive and psychological effects in terms of improved attention, executive function, reduced stress, and anxiety levels. One of the pathways, mindfulness is thought to yield these psychological benefits is through the facilitation of adaptive ER. Moreover, mindfulness correlated positively with CR and negatively with ES. It indicates that the increase in mindfulness enables an individual to reinterpret an emotion-eliciting situation in a manner that alters its meaning and changes its emotional impact.
Participants in the current study showed improved CR ability than ES after the intervention, suggesting that yoga practice has assisted in improving ER. As mentioned earlier, one must be attentive and be aware while practicing yoga. As a result, the internal distractions are reduced due to continued focus and awareness of the practice, which could be a potential factor contributing to the improved ER.
It is noted that mindfulness affects ER differently at the different stages of practice. Initially, it reduces stress and may subsequently enhance an open experience of emotion that promotes new emotional learning and reestablishes adaptive ER strategies. Webb et al. even categorize mindfulness as a reappraisal strategy suggesting that mindfulness involves a reappraisal of an emotional response.
Some studies report that people with low heart rate variability show greater orientation toward negative emotion and slower attentional disengagement from negative stimuli. It suggests that the worse regulation of cardiac vagal tone negatively interacts with the bottom-up and top-down processing of emotions. Yoga practices have shown to downregulate the sympathetic nervous system activity and hypothalamic-pituitary-adrenal axis response to stress. For example, sympathetic activation and heart rate are found to be reduced after the yoga practice,, In addition, a reduction was reported in anxiety scores that correlated with increased GABA levels and reduced morning cortisol levels post yoga intervention., Similar interesting finding was a positive correlation between melatonin levels and well-being scores in participants receiving 3-month yoga intervention. Notably, melatonin attenuates the sympathetic activity in response to stress. These findings suggest that the yoga practice seems to affect ER through the regulation of autonomic and endocrine systems.
Broadly, these findings are in line with the previous studies demonstrating the psychological benefits of yoga practices. However, the current study also directs the attention toward the psychological constructs underlying yoga practice's benefits. This line of inquiry may open new avenues in thinking about and measuring the impact of yoga practices.
| Conclusion|| |
In the current study, yoga practice has helped T2DM patients in improving ER and mindfulness. However, the increased mindfulness itself might have contributed to the improved ER skills. These results are encouraging as improved ER skills might reduce or prevent DD in T2DM patients that in turn is associated with glycemic control. Furthermore, better ER might enable individuals to improve their health behaviors for the effective management of T2DM. Thus, yoga practice is an effective intervention to improve ER skills and mindfulness in patients with T2DM.
This study was primarily funded by Ministry of AYUSH, Government of India. (Sanction number - Z.28015/209/2015HPC [EMR]-AYUSH). The authors express deep gratitude to the research fellows and Anvesana Research Laboratories for their consistent support to accomplish this project.
Financial support and sponsorship
The funding source is reported.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hall PA, Rodin GM, Vallis TM, Perkins BA. The consequences of anxious temperament for disease detection, self-management behavior, and quality of life in Type 2 diabetes mellitus. J Psychosom Res 2009;67:297-305.
Robertson SM, Stanley MA, Cully JA, Naik AD. Positive emotional health and diabetes care: Concepts, measurement, and clinical implications. Psychosomatics 2012;53:1-12.
Rane K, Wajngot A, Wändell PE, Gåfvels C. Psychosocial problems in patients with newly diagnosed diabetes: Number and characteristics. Diabetes Res Clin Pract 2011;93:371-8.
Anderson RJ, Grigsby AB, Freedland KE, de Groot M, McGill JB, Clouse RE, et al.
Anxiety and poor glycemic control: A meta-analytic review of the literature. Int J Psychiatry Med 2002;32:235-47.
Katon WJ. The comorbidity of diabetes mellitus and depression. Am J Med 2008;121 11 Suppl 2:S8.
Padala PR, Desouza CV, Almeida S, Shivaswamy V, Ariyarathna K, Rouse L, et al.
The impact of apathy on glycemic control in diabetes: A cross-sectional study. Diabetes Res Clin Pract 2008;79:37-41.
Sagui SJ, Levens SM. Cognitive reappraisal ability buffers against the indirect effects of perceived stress reactivity on Type 2 diabetes. Health Psychol 2016;35:1154-8.
Nicolucci A, Kovacs Burns K, Holt RI, Comaschi M, Hermanns N, Ishii H, et al.
Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med 2013;30:767-77.
Park M, Katon WJ, Wolf FM. Depression and risk of mortality in individuals with diabetes: A meta-analysis and systematic review. Gen Hosp Psychiatry 2013;35:217-25.
Baumeister H, Hutter N, Bengel J. Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression. Cochrane Database Syst Rev 2012;12:CD008381.
Das-Munshi J, Stewart R, Ismail K, Bebbington PE, Jenkins R, Prince MJ. Diabetes, common mental disorders, and disability: Findings from the UK National Psychiatric Morbidity Survey. Psychosom Med 2007;69:543-50.
Gonzalez JS, Fisher L, Polonsky WH. Depression in diabetes: Have we been missing something important? Diabetes Care 2011;34:236-9.
Beveridge RM, A Berg C, J Wiebe D, L Palmer D. Mother and adolescent representations of illness ownership and stressful events surrounding diabetes. J Pediatr Psychol 2006;31:818-27.
Gullone E, Hughes EK, King NJ, Tonge B. The normative development of emotion regulation strategy use in children and adolescents: A 2-year follow-up study. J Child Psychol Psychiatry 2010;51:567-74.
Gross JJ. The Emerging Field of Emotion Regulation : An Integrative Review. Review of General Psychology. 1998;2:271-299.
Rasmussen NH, Smith SA, Maxson JA, Bernard ME, Cha SS, Agerter DC, et al.
Association of HbA 1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 diabetes mellitus. Primary Care Diabetes 2013;7:213-21.
Fisher L, Hessler D, Polonsky W, Strycker L, Guzman S, Bowyer V, et al.
Emotion regulation contributes to the development of diabetes distress among adults with type 1 diabetes. Patient Educ Couns 2018;101:124-31.
Raveendran AV, Deshpandae A, Joshi SR. Therapeutic role of yoga in type 2 diabetes. Endocrinol Metab (Seoul) 2018;33:307-17.
Balaji PA, Varne RS, Ali SS. Effects of yoga-pranayama practices on metabolic parameters and anthropometry in type 2 diabetes. Int Multidiscip Res J 2011;1:01-4.
Hegde S, Adhikari P, Kotian S, Pinto VJ, D'souza S, D'souza V. Effect of 3-month yoga on oxidative stress in type 2 diabetes with or without complications A controlled clinical trial. Diabetes Care 2011;34:2208-210.
Sharma M, Knowlden AP. Role of yoga in preventing and controlling type 2 diabetes mellitus. J Evid Based Complement Alternat Med 2012;17:88-95.
Singh VP, Khandelwal B, Sherpa NT. Psycho-neuro-endocrine-immune mechanisms of action of yoga in type II diabetes. Anc Sci Life 2015;35:12-7.
Bishop SR. Mindfulness: A Proposed Operational Definition. Clinical Psychology: Science and Practice; Autumn 2004;11.
Kang Y, Gruber J, Gray JR. Mindfulness and de-automatization. Emot Rev 2013;5:192-201.
Roemer L, Williston SK, Rollins LG. Mindfulness and emotion regulation. Curr Opin Psychol 2015;3:52-7.
Bamber MD, Schneider JK. Mindfulness-based meditation to decrease stress and anxiety in college students: A narrative synthesis of the research. Educ Res Rev 2016;18:1-32.
Goldin PR, Gross JJ. Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion 2010;10:83-91.
Nagarathna R, Rajesh SK, Amit S, Patil S, Anand A, Nagendra HR. Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a nationwide multicentric trial on the effect of a validated culturally acceptable lifestyle intervention for primary prevention of diabetes: Part 2. Int J Yoga 2019;12:193-205.
] [Full text]
Harald Walach K, Feldman G, Tschacher W, Walach H, Buchheld N, Buttenmü ller V, et al
. Measuring mindfulness - the Freiburg Mindfulness Inventory (FMI). Personality and Individual Differences. 2006;40:1543–55.
Froeliger B, Garland EL, McClernon FJ. Yoga meditation practitioners exhibit greater gray matter volume and fewer reported cognitive failures: Results of a preliminary voxel-based morphometric analysis. Evid Based Complement Alternat Med 2012;2012:821307.
Khoury B, Lecomte T, Fortin G, Masse M, Therien P, Bouchard V, et al.
Mindfulness-based therapy: A comprehensive meta-analysis. Clin Psychol Rev 2013;33:763-71.
Hayes AM, Feldman G. Clarifying the Construct of Mindfulness in the Context of Emotion Regulation and the process of change in therapy. Clinical Psychology: Science and Practice. 2004; 11:254-62.
Webb TL, Miles E, Sheeran P. Dealing with feeling: A meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychol Bull 2012;138:775-808.
Park G, Van Bavel JJ, Vasey MW, Thayer JF. Cardiac vagal tone predicts attentional engagement to and disengagement from fearful faces. Emotion 2013;13:645-56.
Ross A, Thomas S. The health benefits of yoga and exercise: A review of comparison studies. J Altern Complement Med 2010;16:3-12.
Kiecolt-Glaser JK, Christian L, Preston H, Houts CR, Malarkey WB, Emery CF, et al.
Stress, inflammation, and yoga practice. Psychosom Med 2010;72:113-21.
Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, et al.
Effects of Hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. J Altern Complement Med 2004;10:261-8.
Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR, Rekha M, Vanitha N, et al.
Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: A randomized controlled trial. Integr Cancer Ther 2009;8:37-46.
Streeter CC, Whitfield TH, Owen L, Rein T, Karri SK, Yakhkind A, et al.
Effects of yoga versus walking on mood, anxiety, and brain GABA levels: A randomized controlled MRS study. J Altern Complement Med 2010;16:1145-52.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]