Mind-Body Interventions

Feelings of stress raise blood glucose levels in people with diabetes. This is because of an increased production of stress hormones,7 which reduces insulin action. In addition, patients under perceived stress may find that caring for their diabetes is less of a priority, leading to poor glycemic control, which further exacerbates the situation.

It is therefore important for diabetes health professionals to be aware of and to check with their patients about how stress may be affecting their lives. Health care professionals can then offer advice specific to their patients’ situation. Perhaps some additional lifestyle changes could be recommended for stress reduction. As noted earlier, decreasing stress reactions may lead to better glucose control and improvement in immune system function.

With increased glycemic control, there is always a risk for hypoglycemia. When in a relaxed state, the body metabolizes carbohydrate more efficiently, thereby lowering blood glucose levels.8,9 Patients with type 1 diabetes may potentially develop hypoglycemia following relaxation.9,10 Therefore, such patients should be told of the possibility for low blood glucose levels after relaxation and instructed to promptly treat it as directed by their health care professional.

In published, peer-reviewed research studies featuring diabetes and blood glucose, the most common alternative treatment is relaxation training or biofeedback-assisted relaxation training. Many case and controlled studies using biofeedback-assisted relaxation training with type 1 diabetic patients showed significantly lower average blood glucose levels in experimental groups or at post-test in the instance of case studies.11–13 These differences could not be explained by increased insulin doses.11 It is suggested that stress management be considered as an adjunct to the medical management of people with type 1 diabetes.

In studies of patients with type 2 diabetes, no significant lowering of glycemic levels were observed at post-test.14,15 However, with relaxation training, patients may have experienced other benefits, such as increased self-management abilities, improved sense of well-being, increased coping skills, lowered incidence of depression, and less perceived stress. Some studies have not been designed to provide statistically significant results for more than one or two variables.

Depression is a frequent comorbidity of chronic illness and diabetes.16 People with diabetes who suffer from depression or anxiety struggle more to control their blood glucose levels, even if they are taught biofeedback and relaxation techniques. A small, controlled study followed 18 insulin-dependent diabetic patients with depression.17 Four weeks after the treatment ended, researchers found little difference in the daily blood glucose measurements between patients who were taught to practice relaxation at home and those who were not. Depressed patients often have difficulty executing the self-care activities associated with diabetes. The additional demands of a relaxation treatment plan may have been similarly difficult to follow.

The autonomic nervous system is composed of the sympathetic branch (active in response to stress), and the parasympathetic branch (active during relaxation and digestion). Relaxation, or self-regulation of the sympathetic nervous system activity, can be accomplished in various ways including hand- and foot-warming. In a general way, this may be thought of as quieting the emotions.

When relaxing, the sympathetic nervous system tone is lessened. Muscles relax—not only the large ones, but also the musculature surrounding the capillary blood vessels. This relaxation allows a reduction in blood pressure and improved perfusion to the peripheral blood vessels, thereby increasing blood flow to the extremities.18 With the improved blood flow comes increased oxygenation and nutrition of the tissues.

In the studies of Rice et al.,19,20 this hypothesis was proven valid. A within-subjects design study of 40 people with diabetes19 demonstrated that subjects responded positively to thermal biofeedback-assisted relaxation by increasing peripheral vasodilation. This increased blood flow by an average change score of 22.5% (blood volume pulse [BVP] measured with photoplethysmography). Change scores were expressed as a percentage of the optimal BVP change (100%) as follows for each participant: [(post-BVP score − pre-BVP score)/(100 − pre-BVP score)] × 100. Similarly, for the temperature change score, the optimal value used was 98.6° Fahrenheit. The average increased toe temperature change score was 31.4%, (P < 0.001).

A multi-center, controlled clinical trial of patients with chronic non-healing foot ulcers20 produced significant results in healing. Of participants in the experimental group who were taught thermal biofeedback-assisted relaxation (increased blood flow to the feet), 14 out of the 16 ulcers, or 87.5%, healed. In the control group, 7 out of 16 ulcers, or 43.75%, healed (P < 0.009).

Diabetic peripheral neuropathy affects the sensory nerves in the feet with pain and, later, with loss of feeling. The additional oxygenation and available nutrients to the tissues following the effects of relaxation provide improved sensory function in the nerve fibers that correspond to touch.20 This was shown by measuring the Current Perception Threshold (CPT) levels by electrical stimulation of the great toe. The change in CPT levels pre- to post- intervention indicated a significant difference between the experimental and control groups. A significant improvement (increased sensation in the feet) was noted in the large myelinated nerve fiber functioning in the experimental groups, which used biofeedback-assisted relaxation, compared to the control groups who did not (P < 0.02).

In another study by Fiero et al.,21 it was suggested that diabetic neuropathy might interfere with the ability to self-regulate peripheral temperature and that assessing neuropathic status may be important before prescribing thermal biofeedback. On the other hand, in mind-body therapies, “thinking of warmth” may surpass or be more accurate than “feeling warmth.”

The beneficial effects of thermal biofeedback-assisted relaxation have been demonstrated for several additional vascular disorders, including hypertension,22 migraine,23 and Raynaud’s syndrome.24 

This is a disease process involving inadequate peripheral blood flow. Thermal biofeedback has been tested as a therapy to improve vascular flow and walking tolerance in patients with peripheral vascular disease.25 Improvements were seen in ankle-brachial index, walking distance, walking speed, and stair climbing. Thermal biofeedback provided an improved vascular and ambulatory function for a diabetic patient with claudication.25 

Another case study of a patient with diabetes reported that attacks of intermittent claudication were reduced to zero after 12 sessions of thermal biofeedback. The patient’s daily walking distance increased by about a mile over the course of the treatment.26 Thus, it appears that thermal biofeedback and autogenic training are potentially promising therapies for people with diabetes and peripheral vascular disease.

This modality has been used to help people with eating disorders and those in need of assistance with smoking cessation and other lifestyle changes.27 Adolescents with type 1 diabetes have been reported to have a nonadherence rate of ∼20% to diet, exercise, and other self-care behaviors.28 In a hypnosis study,28 six adolescents served as their own controls, and no changes were made in insulin, diet, or exercise for 6 months. Then hypnosis, administered individually, was added with all of the usual modalities for 6 months. Posttreatment tests showed that average HbA_1c dropped from 13.2 to 9.7%, and average fasting blood glucose (FBG) dropped from 426 to 149 mg/dl.

In yoga, people with diabetes may have found an important “new” tool that is thousands of years old. Research has shown Hatha yoga (physical movements and postures) and meditation to be excellent examples of the mind-body connection at work. Yoga may provide real benefits in stabilizing blood glucose.29 If done properly, yoga also counts as an aerobic exercise.

Jain and associates30 studied the response patterns of people with type 2 diabetes to yoga therapy. Their study showed 70% of participants to have a fair to good response to yoga therapy. After 40 days of yoga, there was a significant reduction in hyperglycemia measured by FBG and oral glucose tolerance test. It has been suggested that yoga, a simple and economical therapy, might be considered a beneficial adjunctive and self-administered therapy to medical treatment.

Regular practice is the most important variable with all these mind-body therapies. They are all inherently noninvasive, inexpensive, and safe. Furthermore, many studies have noted that patients using them experience secondary benefits, such as an increased ability to cope with daily stressors, adherence to prescribed treatments, increased ambulation, and positive outlook on life.13,31–34 

Educational interventions are different from drug therapy and other medical interventions in that patients must accept a much greater personal responsibility for the conduct and success of these treatments. Most of the mind-body therapies involve patient education, supervised practice, and regular practice at home.

Both educator and patient are the beneficiaries of the lifestyle changes and positive attitudes resulting from the mind-body interventions. In addition to providing the education and teaching the techniques, the therapist/educators serve as mentors and human connections to the modality, providing hope and encouragement for patients. Instruction and supervised practice of mind-body skills can be conducted individually or in group settings, which can provide the strength of community.35 

Diabetes educators and other health care professionals have been at the forefront of including proven mind-body therapies in their practices. Continuing education courses and certifications in mind-body interventions are available for health care professionals who want to become familiar with mind-body skills and learn how to instruct patients in these therapies. Table 2 offers a list of resources for reference and training.

Practitioners and providers who want to incorporate mind-body interventions may need to educate their hospital and clinic administrators about these therapies. They need to see and be convinced by positive results when mind-body therapies are used in clinical applications. These therapies could be made available to their patients. Mindfulness meditation36 as a form of stress management therapy has made inroads in many health systems.

For insurance companies, covering mind-body therapies can be financially beneficial because these therapies are cost-effective, nonpharmacological, noninvasive, and safe. Naparstek37 and Rice et al.20 have shown how relaxation and imagery have increased healing in clinical application. Educated clients become more prevention-oriented and stay healthier.