It is quite challenging in making lifestyle changes for persons with diabetes. By tailoring treatment and with a focus on metabolic outcomes, medical professionals can help diabetic patients to achieve the metabolic goals [1].

Studies have shown that exercise, along with diet and medication can assist in combatting diabetes. Regular physical exercise may have beneficial effects on metabolic risk factors leading to complications [2-3]. 

According to the International Diabetes Federation diabetes atlas, there were around 425 million people with diabetes.  It is estimated that this figure will rise to 629 million by 2045 [4].   The main cause for the rise will be lack of exercise and unhealthy diet [5]. 

The traditional Yoga of India offers some respite to this problem, as its practice, balances the body, mind, and emotions [6].  Raja yoga meditation is a easy, practicable method of meditation and a behavioral intervention followed in India and worldwide [7]. Researches on Rajyoga meditation have demonstrated increased parasympathetic activity with improved changes in the lipid profile of meditators [8-10]. 

Da Qing DPS, MALMO Feasibility Study, Finnish DPS, United States DPP, Indian DPP, SLIM, and Japanese DPS trials  were conducted  in persons who were  at risk for T2DM (overweight/obese, IGT and/or IFG) . These studies were undertaken to observe the effect of  lifestyle modification measures namely  diet and exercise[10-13]. The findings showed that risk of progressing to T2DM was greatly reduced. Meta-analysis pointed out that compared to other studies, the combination intervention, reduced the risk of progression to T2DM by about 51% [11]. 

In diabetic dyslipidemia there is increased   triglyceride, decreased high-density lipoprotein (HDLand high concentration of small dense low-density lipoprotein (LDL) levels. These lipid changes   are caused due to insulin resistance which further leads to increased flux of free fatty acids [9].            

The  National Health and Nutrition Examination Survey (NHANES) 1999–2000 reports  that  51% (Table 1) of adults  in  the age  group  of 20–59 years, with diabetes have hypercholesterolemia [12,10].  These disturbances in lipid  profile may be due to the sedentary habits , faulty eating and lack of physical activity [12].  Studies have showed that exercise can improve glycated haemoglobin at six and twelve months in T2DM  patients [10].  

Table 1: Age Wise Distribution of Patients in Three Groups

Diabetes Prevention Program in  which exercise  in the form of walking for 30 minutes/day on most days of the week can address this issue [13]. 

Our hypothesis is that these three lifestyle interventions namely Rajyoga meditation, diet and exercise  can have a role to play in slowing down the progress of diabetes in T2DM.

To recruit patients with T2DM and dyslipidemia we used the guidelines of National Diabetes Data Group and the third set of the Adult Treatment Panel of the National Cholesterol Education Program (NCEP ATP IIIa [9,14].  Diabetic patients who were smokers, alcoholics, pregnant, on long-term steroids and those with known retinopathy, nephropathy, coronary artery disease and cerebrovascular diseases were excluded from the study. Ethical clearance was obtained from Institutional Ethical committee.

Study Design: This was a interventional pre and post study

Study Setting: Department of Physiology, Jawaharlal Nehru Medical College, Wardha

Period of Study: 1 ½ years

Study Participants: All diabetic patients in the age group of 30-60years, including both sexes and taking treatment since 5 to 10 years 

Intervention

By random selection 60 diabetic patients were allocated to the intervention group. The study group had 3 subgroups namely 

• Rajyoga meditation(RM) only

• Diet and Exercise only 

• RM, diet and exercise all three combined. Each subgroup had 20 diabetic patients

In the A group i.e Rajyoga meditation only, the person sat upright and concentrated  on a point of white light. These practice of Rajyoga meditation was taught by trained teachers of the local  Brahmakumari  centre. RM was practised daily for 10 min in the morning and 10 min in evening.  The participants were reviewed in the department every weekend for the first 3 months and after every fortnight for the last 3 months.

RM interventions on the same lines were administered to the C group also.

For the   B group, daily  food time table was  the regular diet of the patients supplemented with additional proteins [15].  A project dietician supported facilitators and gave dietary counselling after the RM orientation class. 

Brisk walking for 30 minutes daily at dawn or dusk for 5 days a week for 6 months was advised [13]  for this group.

The same plan of diet and exercise  was implemented for the C  group also.

• Sample Size: 50

• Periods of Recruitment: It was 3 months

• Efforts to Maintain Compliance of Patients: This was done using logbooks of diet charts and exercise charts

• Handling of Lost to Follow Up Patients: This was  addressed by recruiting  extra 1% i.e 6 elligible patients for the study

Outcome measures 

• Primary follow up measure was fasting and postmeal blood sugar and lipid profile estimations. The secondary follow up measure was HbA₁C

• HbA₁C was estimated using morning blood samples by immunoturbidity method

• The fasting blood samples was analyzed for triglycerides (TG), total cholesterol (TC) and high-density lipoprotein–cholesterol (HDL–C). Total cholesterol was estimated by Enzyme end point method. HDL cholesterol was assessed by enzyme direct method. Triglyceride by GPO-PAP  method. LDL cholesterol and VLDL was not separately estimated but calculated. LDL was calculated using  the formula: LDL cholesterol = Total cholesterol – [HDL cholesterol + TG/5)

Statistical Analysis

Statistical analysis was done by using descriptive and inferential statistics using student’s paired t test, one way ANOVA and Multiple Comparison Tukey Test and software used in the analysis was SPSS 24.0 version and p<0.05 was considered as level of significance.

A  significant  finding was  observed  in HbA1C and  HDL values  in Group C and a  significant decrease in LDL level   in Group B.

In our study a significant  finding  was observed  in  HbA1C      values     in      Group C         compared          pre       and  postoperatively  (Table 2-3), which  means  all three  interventions  done together  had  an effect on HbA1c  values.

Table 2: Comparison of Hba1c Level in Three Groups’ Pre and Post Operatively Student’s Paired T Test

Table 3: Comparison of HbA1C level in three groups post operatively Descriptive Statistics

In diabetes mellitus there is the increased glycation of protein. This glycated protein work  as a source of free radicals  and causes increased lipid peroxidation  in T2DM patients [16].

Masaki Asano  et al. conducted a single‐blind randomized controlled trial, where modern diet (MD) was compared with the 1975‐type JD. Their study showed those in the JD group had significantly decreased    glycated    hemoglobin   and   significantly increased high‐density lipoprotein cholesterol levels compared with those in the MD group [17].

Jennie brand-miller et al., performed a metaanalysis of randomized controlled trials to determine whether low-GI diets, compared with conventional or high-GI diets, improved over all glycemic control in  T2DM patients,as assessed by decreased glycated hemoglobin levels. Their result showed low-GI diets decreased HbA1c by 0.43% points (CI 0.72–0.13) (Table 11) as compared to high-GI diets [18].

Normand G. Boulé et al. conducted a meta-analysis of controlled clinical trials study on effects of Exercise on Glycemic Control and Body Mass in Type 2 Diabetes Mellitus. They concluded that  exercise training reduces HbA1c which can further decrease the risk of diabetic complications. They did not find any change in body mass [19,3]. 

In our study when HDL level  was compared in three groups pre and post operatively it was found that Group C finding is significant  (Table 4-9).  This means that all 3 interventions done together affect HDL value.  Our study showed insignificant finding for TC, TG &VLDL.

In contrast to our study A.Sharma, S.  found a statistically significant decrease in TC, TG, LDL, VLDL, and Atherogenic index of plasma (AIP) when they conducted a RCT study  to study the influence of yoga on status of lipid indices in type 2 diabetes mellitus subjects [20].

In  line with  our  study is  the  finding reported  by  K.E. Harno et al. The most frequent lipid abnormality in this study was reduced HDL which is similar to previous research works [15]. In T2 DM patients, low levels of HDL and elevated TG have been reported as tenable cause of CVD [21] (Table 8). This can be due to insulin resistance, which causes diabetic dyslipidaemia and Hypertension [22]. In T2 DM ,increase  in triglyceride levels (TG) occurs due to the combined effect of Lipoprotein lipase (LPL) an insulin dependent enzyme and insulin resistance. HDL levels are decreased in T2DM patients  due to elevated hepatic lipase which catalyzes HDL [15].

Our  study showed  a  significant decrease in LDL level   in Group B when  LDL level   was compared  in three  groups pre and  post operatively (Table 9-10). Normally insulin increases the number of LDL receptors. In diabetes, chronic insulin deficiency decreases the number of  LDL receptors. This leads to increase in LDL-cholesterol value. The abnormal lipid profile seen inT2DM patients can be attributed to defective lifestyle measures [16] (Table 10-12).

Also, a study  by Dalia et al., comprising  of  17 diabetic  patients  in age group  of  32-60 years showed  insignificant post  intervention ( Rajyoga  meditation only)  finding as  regards  to all lipid profile  values.  This showed that Rajyoga  meditation only , had  no effect  on  lipid values [22]. Khursheed Muhammad Uttra et al. studied the pattern of lipid abnormalities in diabetic patients (Table 11-12).  They   observed a high triglyceride in 22 (31%) patients, high LDL in 14 (19%), low HDL in 08(11%) and high cholesterol in 10(14%). The study showed that T2DM patients are more prone to develop hyperlipidemia [23].

Table 4: Comparison of TC Level In Three Groups’ Pre and Post Operatively. Student’s Paired T Test

Table 5: Comparison of TC Level in Three Groups Post Operatively Descriptive Statistics

Table 6: Comparison of TG Level In Three Groups Pre and Post Operatively. Student’s Paired T Test

Table 7: Comparison of TG Level in Three Groups Post Operatively Descriptive Statistics

Table 8: Comparison of HDL Level In Study Group Pre and Post Operatively. Student Has Paired T Test

Table 9: Comparison of HDL Level in Three Groups Post Operatively Descriptive Statistics

Table 10: Comparison of LDL Level In Three Groups Pre and   Post Operatively. Student’s Paired T Test

Table 11: Comparison of LDL Level in Three Groups Post Operatively Descriptive Statistics

Table 12: Comparison of VLDL Level in Three Groups Post Operatively Descriptive Statistics

Our study concludes that RM, diet & exercise all three combined significantly affects  HbA1C level in type -2 diabetic patients.  Also exercise and diet has significant effect on LDL level in T2DM patients.  It  can be inferred that  all three lifestyle modification measures  can be used in the management of T2DM  in conjugation with routine antidiabetic therapy.

1. Franz, M.J. “Lifestyle modifications for diabetes management.” Endocrinology and Metabolism Clinics of North America, vol. 26, no. 3, 1997, pp. 499–510.

2. Joslin, E.P. et al. The Treatment of Diabetes Mellitus. Lea & Febiger, 1959.

3. American Diabetes Association. “Diabetes mellitus and exercise.” Diabetes Care, vol. 20, 1997, pp. 1908–1912.

4. International Diabetes Federation. IDF Diabetes Atlas. 8th ed., International Diabetes Federation, 2017, pp. 40–59.

5. Thangasami, S.R. et al. “Emphasis of yoga in the management of diabetes.” Journal of Diabetes and Metabolism, vol. 6, no. 613, 2015, p. 2.

6. Liu, X.C. et al. “Effects of yoga training in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis.” Journal of Thoracic Disease, vol. 6, no. 6, 2014, pp. 795–802.

7. Yoga, E.R. Prajapita Bramhakumaris, Ishwariya Vishwa Vidyalaya, 1981, p. 825.

8. Desiraju, T. and S. Telles. “Autonomic changes in Brahmakumari’s Rajayoga meditation.” International Journal of Psychophysiology, vol. 43, 1993, pp. 218–224.

9. Vyas, R. and N. Dikshit. “Effect of meditation on respiratory system, cardiovascular system and lipid profile.” Indian Journal of Physiology and Pharmacology, vol. 46, 2002, pp. 487–491.

10. Vyas, R. et al. “Effect of Raja yoga meditation on the lipid profile of post-menopausal women.” Indian Journal of Physiology and Pharmacology, vol. 52, 2008, pp. 420–424.

11. Thomas, G.N. et al. “A systematic review of lifestyle modification and glucose intolerance in the prevention of type 2 diabetes.” Current Diabetes Reviews, vol. 6, no. 6, 2010, pp. 378–387.

12. Nield, L. et al. “Dietary advice for treatment of type 2 diabetes mellitus in adults.” Cochrane Database of Systematic Reviews, no. 3, 2007, CD004097.

13. Mayer, J. “Diabetes control with physical activity and exercise.” Nutrition in Clinical Care, vol. 6, no. 2, 2003, pp. 89–96.

14. National Diabetes Data Group. “Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance.” Diabetes, vol. 28, no. 12, 1979, pp. 1039–1057.

15. Harno, K.E. et al. “Study on lipid disorders.” Diabetologia, vol. 19, 1980, pp. 281–285.

16. Suryawanshi, N.P. et al. “Study of lipid peroxide and lipid profile in diabetes mellitus.” Indian Journal of Clinical Biochemistry, vol. 21, no. 1, 2006, pp. 126–130.

17. Asano, M. et al. “Japanese diet: A randomized controlled trial.” 1975, https://doi.org/10.1002/oby.22448.

18. Brand-Miller, J. et al. “Analysis of randomized controlled trials.” Diabetes Care, vol. 26, 2003, pp. 2261–2267.

19. Boulé, N.G. et al. “Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: A meta-analysis of controlled clinical trials.” JAMA, vol. 286, no. 10, 2001, pp. 1218–1227.

20. Sharma, S. et al. “Influence of yoga on status of lipid indices in type 2 diabetes mellitus subjects.” International Journal of Diabetes in Developing Countries, vol. 40, no. 3, 2020, pp. 410–415.

21. Miller, M. “The epidemiology of triglyceride as a coronary artery disease risk factor.” Clinical Cardiology, vol. 22, suppl. 2, 1999, pp. II-1.

22. Biswas, D. et al. “Effect of Rajyoga meditation on lipid profile in type-2 diabetic patients.” International Journal of Current Research, vol. 11, no. 12, 2019, pp. 8752–8755.

23. Khursheed, M.U. et al. “Lipid profile of patients with diabetes mellitus (A multidisciplinary study).” World Applied Sciences Journal, vol. 12, no. 9, 2011, pp. 1382–1384.