Emphasis of Yoga in the Management of Diabetes

Objectives: For years, exercise has been considered a cornerstone of diabetes management, along with diet and medication. Growing evidence supports the beneficial effects of yoga in physical and mental health through down regulation of the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system (SNS). The purpose of this article is to provide a scholarly review of the literature of research studies comparing the effects of yoga and exercise in diabetes patients. Methods: This review focuses on published research articles indexed in the PubMed, MEDLINE, Google Scholar, Science Direct and Scopus. Search criteria included research articles written in English with the key words “yoga”, “diabetes mellitus (DM)”, “Type 1 DM”, “Type 2 DM”, “Exercise”. Only clinical or human studies published in English language were included. Exclusion criteria included articles that were not written in English. Conclusion: Exercise can improve glucose uptake by improving insulin sensitivity and reducing body adiposity in both patients of type 1 and type 2 DM. Yoga is an ancient discipline designed to bring balance and health to the physical, mental, emotional, and spiritual dimensions of the individual. Yoga may be an attractive alternate to traditional aerobic exercises and strength training program, as it requires only a little space and needs no equipment and literally devoid of side effects, mainly focusing on relaxation of mind and body. It provides a less strenuous and more pleasurable exercise experience to an individual. Yoga can help the person feel better, both improving the physical fitness and elevating the mood. Numerous studies have shown positive benefits of yoga in the management of diabetes with good impact on glycemic control, lipid profile and cardiovascular status. Further it can alleviate stress. Yoga can be considered as a good alternate for exercise therapy. Emphasis of Yoga in the Management of Diabetes Senthil Raj Thangasami1*, Arati Lal Chandani2 and Thangasami S3 1Department of Medicine, Sree Balaji Medical College, Chennai, India 2Department of Medicine, Gsvm Medical College, Kanpur, India 3Department of General Medicine, Sree Sathya Sai Medical College and Research Institute, Chennai, India *Corresponding author: Senthil Raj, MD, Plt No 26, 27, Concept Homes, Bharathidasan Street, Ags Colony, Ramnagar (North), Madipakkam, Chennai-600091, India, Tel: 9943367902; E-mail: sencon85@yahoo.co.in Received September 17, 2015; Accepted October 06, 2015; Published October 09, 2015 Citation: Thangasami SR, Chandani AL, Thangasami S (2015) Emphasis of Yoga in the Management of Diabetes. J Diabetes Metab 6: 613. doi:10.4172/21556156.1000613 Copyright: © 2015 Thangasami SR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Diabetes mellitus (DM) is a chronic progressive metabolic disorder characterized by hyperglycemia mainly due to absolute (Type 1 DM) or relative (Type 2 DM) deficiency of insulin hormone [1]. The problem of diabetes has grown enormously in the last two decades. In 2014, around 387 million people had diabetes with a prevalence of 8.3%; by 2035 this will rise to 592 million. North America and the Caribbean is the region with the highest prevalence of 11% having 37 million people with diabetes followed by the Middle East and North Africa with a prevalence of 9.2% having 35 million people with diabetes. Western Pacific is the region with higher number of people living with diabetes (138 million); however its prevalence is 8.6%, close to the prevalence of the World. The International Diabetes Federation (IDF) currently states that the top 5 countries with highest amount of diabetic patients are china, India, United States, Russia and Brazil. The number of people with type 2 diabetes is increasing in every country.77% of people with diabetes live in low-and middle-income countries.179 million people with diabetes are undiagnosed. Diabetes caused 4.9 million deaths in 2014 [2]. Primary prevention of diabetes by life style modification is a feasible solution to arrest the rising epidemic of the disease. Government and non-government organizations should create awareness about the disease among public and also teach them way to self-care and benefits of lifestyle modification.
better indicator of the risk of developing diabetes than BMI [8,9]. Even though BMI is important in predicting the risk, distribution of fat plays a major role in assessing the risk of type 2 DM in patients.

Lack of physical activity:
During the last few decades, most of the working population had changed their lifestyle from active working occupations like agriculture to a less demanding works like office jobs. TV, video games too makes the children refrain from regular physical activity. It was observed that the prevalence of diabetes was almost 3 times higher in individuals with sedentary life style compared to those having heavy physical activity (23.2% vs. 8.1%) [10]. It was also noted that prevalence of metabolic syndrome and hypertension were also higher among people with light physical activity. Individuals with light grade physical activity had 2.4 times higher chance of developing coronary artery disease compared to heavy physical activity group [11].

Diet:
The amount and quality of dietary fat modifies the glucose tolerance and insulin sensitivity [12,13]. A high fat content in the diet may result in worsening of glucose tolerance by several mechanisms including decreased binding of insulin to its receptors, impaired glucose transport, and decreased glycogen synthase and accumulation of triglycerides in skeletal muscles [14]. The fatty acid composition of the diet affects the tissue phospholipid composition and also insulin action by altering membrane fluidity and insulin signaling.
Stress: Stress is defined as a 'stimulus event of sufficient severity to produce disequilibrium in the homeostasis of physiological systems' resulting from a variety of stressors. The neuroendocrine changes accompanying stress can translate the signals into pathophysiological alterations [15]. The hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) are triggered as a response to a stressor leading to a cascade of physiologic, behavioral, and psychological effects, primarily as a result of the release of cortisol and catechol amines (epinephrine and norepinephrine). Due to repeated firing of the HPA axis and SNS, the system gets de-regulated, leading to diseases such as autoimmune disorders, obesity, diabetes, substance abuse, depression, and cardiovascular disease [16,17]. Stress also plays a role in diabetogenesis. Changes related to stress precipitates hyperglycemia by increasing levels of hormones like glucagon, cortisol, growth hormone, catechol amines, Corticotrophin Releasing Hormone(CRH), prolactin, leptin , neuropeptide Y. Bjorntop postulated that activation of sympathetic nervous system following stress can lead to a series of hormonal changes leading to obesity and hence diabetes. Psychosocial stress may trigger the onset of visceral obesity and metabolic syndrome. HPA has been shown to be more active in pre-menopausal centrally obese women and in centrally obese men. Central android obesity and peripheral gynecoid obesity is associated with differential regulation of HPA and also targets metabolically important tissues such as liver and visceral fat. Chronic psychological stress was correlated with prevalence of type 2 diabetes mellitus and with visceral adiposity. The numbers of stressful events were positively associated with the prevalence of newly diagnosed diabetes [18].
Life style intervention: Diet, medicines (insulin /OAD/other injectable), education and exercise are the mainstay in the management of diabetes. However, exercise is the most neglected part of management. If a proper exercise program accompanies the treatment, it would lead to drastic beneficial effects.

Role of exercise in DM
Physical activity refers to a behavior, specifically a body movement that occurs from skeletal muscle contraction and results in increased energy expenditure above resting metabolic rate. Exercise, or "exercise training," is a specific type of physical activity that is performed with the intention of enhancing components of physical fitness [19]. Physical inactivity can initiate and accelerate the pathogenesis of diabetes and subsequent morbidity and mortality. Conversely, regular physical activity can retard the progression from one stage to another, and it may even reverse the process. Numerous studies have shown that moderate physical activity has decreased the risk of diabetes considerably [20].

Effect of aerobic exercise in type 2 DM
Aerobic exercise is the exercise which improves oxygen consumption and increases the functioning of the cardiovascular and respiratory systems [21]. In non-diabetic persons while performing a moderate intensity exercise, the rise in the peripheral glucose uptake is matched by an equal rise in the hepatic glucose production. While a type 2 DM patient performs a moderate exercise, the blood glucose(BG) utilization by muscles usually rise more than hepatic glucose production, and BG levels tends to decline, the risk of exerciseinduced hypoglycemia is minimal, if there is no use of exogenous insulin or insulin secretagogues [22].
While performing, intense aerobic exercise, plasma catecholamine levels rise markedly producing a surge in the glucose production. Hyperglycemia can result from such activity and persist for up to 1-2 hours, because plasma catecholamine levels and glucose production do not return to normal, immediately with cessation of the activity [23]. Aerobic exercises comprise of swimming, cycling, and treadmill, Structural changes in skeletal muscle ↑ fiber size ↑ percentage of type IIa fibers (Possibly type I fibers) ↑ the capillary density and blood flow Biochemical changes in skeletal muscle ↑ insulin signaling kinetics (1-phosphatidyl inositol 3-kinase and GLUT4 activity) ↑ non-insulin signaling kinetics ( 5'-AMP-activated protein kinase activity) ↑ enzymes related to glucose metabolism [hexokinase, glycogen synthase, and key oxidative enzymes (e.g., citrate synthase, aconitase, succinate dehydrogenase)] ↑ myoglobin Systemic influences of physical activity ↑ oxygen uptake and functional capacity at submaximal and maximal workloads ↑lipoprotein lipase and other key enzymes to improve lipid control ↓ excessive hepatic secretion of glucose and VLDL Improvements in counter-regulatory hormone levels/activity (e.g. Cortisol, IGF-I) Improvements in comorbid conditions (e.g., hypertension, visceral obesity, systemic inflammation, dyslipidemia) Table 1: Potential mechanisms by which exercise enhance glucose homeostasis [21]. vascular endothelial function in people with type 1DM [35]. In multiple studies using animal models of diabetes, aerobic exercise had no effect on the number or size of the insulin-producing beta-cells. However, diabetes caused a decrease in the insulin content per beta cell, which was reversed by aerobic exercise. The increased insulin content per beta cell translated into more insulin per islet in the exercised group along with greater insulin secretion in response to glucose. While these changes within the pancreas were significant, they were not sufficient statistically to reduce blood glucose levels, suggesting that exercise training may have a protective effect against the damage of oxidative stress on beta-cells. In an animal study, the IL-6 induced Glucogon like Peptide-1(GLP-1) release that occurred during exercise improved insulin secretion during subsequent meals. Unfortunately, there are no human clinical studies directly measuring the effect of exercise on the health and function of islets [36].
Exercise improves vascular complications in type 1 DM, by reducing dyslipidemia and also by controlling the oxidative stress induced damage. For people with severe type 1DM associated autonomic neuropathies, exercise should be undertaken with caution. Even lowintensity exercise can significantly increase heart rate variability in type 1DM with early cardiac autonomic neuropathy abnormalities [37].

Benefits of yoga
The word Yoga is derived from the Sanskrit word 'Yuj' meaning union of the body, breath and mind [38]. Yoga is an ancient discipline designed to bring balance and health to the physical, mental, emotional, and spiritual dimensions of the individual. Yoga's primary emphasis is upon gaining general well-being by the way of integration often incorporating three major components: held or sequences of physical postures, breathing exercises and meditation [39].

Yoga practices
Yoga therapy [40,41] consists of graded sets of exercises, including very simple ones, so that all can practice on their own, even after the first lesson, whether or not they have done yoga before. Commencing with gentle stretching and breathing exercises, it varies up to a range of classical asanas and pranayama practices ( Table 2).
The asanas have a variety of effects, including: • relaxation, strengthening and balancing of muscles Asanas relax muscles through holding them in gently stretched positions. Mental relaxation techniques promote relaxation at all levels (muscles, autonomic system and mind), through body awareness, visualizations, etc.
Pranayama harmonizes and links the mind and body. Breathing is controlled by both conscious and unconscious neural pathways, bridging the mind and body. Improving the breathing pattern promotes health and can help in the management of many chronic ailments.
walking, rowing, running and jumping rope [24]. Moderate aerobic exercise leads to maintenance of the blood pressure in diabetic neuropathy patients [25]. Aerobic exercise improves the physiological parameters like fasting blood-glucose level, glycemic control and lipid profile. It reduces the arterial stiffness and can restore the endothelial function, and reduces the risk for developing cardiovascular complications in type 2 DM [26][27][28] and is a valuable therapeutic strategy for type 2 DM. A systemic review of 25 studies with most of them being randomized trials showed that aerobic exercises are beneficial in type 2 DM [21].

Effect of resistance exercise in type 2 DM
Resistance exercise helps to develop proper glucose control and less insulin resistance among type 2 DM. Resistance exercises are exercises that have to be performed against resistance. Example: Weight lifting. Unlike aerobic exercise, resistance exercises are relied on the Equipment. Resistance training has been reported to enhance insulin sensitivity, daily energy expenditure and quality of life [29]. Resistance training increases muscle strength, lean muscle mass, and bone mineral density, which could enhance functional status and glycemic control and assist in the prevention of sarcopenia and osteoporosis [30,31]. In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance exercise, three times a week, targeting all major muscle groups, progressing to three sets of 8-10 repetitions at a weight that cannot be lifted more than 8-10 times.
A combination of aerobic and resistance training may be more effective for BG management than either type of exercise alone. Resistance training will lead to increase in muscle mass and contribute to BG uptake without altering the muscle's intrinsic capacity to respond to insulin, whereas aerobic exercise enhances its uptake via a greater insulin action, independent of changes in muscle mass or aerobic capacity [32].

Other types of exercises in type 2 DM
Endurance exercise involves the use of several large groups of muscles, which depends on the delivery of oxygen to the muscles by the cardiovascular system. Passive exercise needs to include another person or outside force, or produced by voluntary effort of another segment of the patient's own body [33]. There is paucity of studies on these types of exercise in treating type 2 DM.

Recommendation of exercise duration in type 2 DM
Joint ACSM/American Heart Association Guidelines recommends at least 150 min/week of moderate-intensity aerobic physical activity (40 -60% of VO2max or 50-70% of maximum heart rate) and/or at least 90 min/week of vigorous aerobic exercise (60% of VO2max or 70% of maximum heart rate). The physical activity should be distributed over at least 3 days/week and with no more than 2 consecutive days without physical activity [34].

Effect of exercise in type 1 DM
In Type 1 DM, only fewer reports have focused on the role of exercise, but more recent studies suggest that exercise improves blood glucose regulation, reduces the daily insulin dosage and decreases the risk of diabetes-associated complications in people with type 1DM 36 . There is clear evidence that aerobic exercises decrease the amount of required insulin to maintain glycemic control in people with type 1DM. A meta-analysis of 48 randomized control trials comparing exercise and type 1DM concluded that physical activity improved fitness, decreased insulin requirements, improved lipid levels, and Yoga is now regarded as a complementary for self-management of many stress related disorders like diabetes, Coronary Artery Disease (CAD) etc.

Beneficial Effects of Yoga
Abdominal stretching during yoga exercise causes rejuvenation/ regeneration of cells of pancreas increasing the utilization and metabolism of glucose in peripheral tissues, liver, and adipose tissues through enzymatic process [42][43][44]. Improved blood supply to the muscles and muscular relaxation along with its development enhances insulin receptor expression causing increased glucose uptake and thus reducing blood sugar [45]. The improvement in the lipid levels after yoga could be due to increased hepatic lipase and lipoprotein lipase at cellular level, which affects the metabolism of lipoprotein and thus increase uptake of triglycerides by adipose tissues [46,47]. Yoga postures can lead to improvement in the sensitivity of the β-Cells of pancreas to glucose signal and also the improvement in insulin secretion [48]. Pranayama modified various inflatory and deflatory lung reflexes and interact with central neural element to bring new homeostasis in the body [49].
In an interventional research, involving 98 subjects, fasting blood sugar (FBS), serum total cholesterol, low density lipoproteins (LDL), very low density lipoproteins (VLDL), and the ratio of total cholesterol to HDL-C, and total triglycerides were significantly lower, and HDL-C significantly higher, on the last day of the course compared with the first day of the 8-days course after performing yoga [50].
In a study, 44 Type 2 DM patients were taught yoga (n = 22) and pranayama for three continuous months, 1 hour every day in the morning, by a yoga expert. They had significant decrease in FBS, Postprandial blood sugar (PPBS), glycosylated hemoglobin (HbA1c), triglycerides and LDL of test group with P<0.001, compared with control group (n = 22). The requirement of insulin in the yoga group was also significantly reduced [51].
In a study, 20 patients with type 2 diabetes mellitus were subjected to . At the end of 40 days of performing the asanas, the study participants had a significant decrease in fasting glucose levels, waist-hip ratio and beneficial changes in insulin levels [52].
In a study involving 16 postmenopausal women with more than 36% body fat were divided into yoga group and control group. Yoga group showed improved adiponectin level, serum lipids, and metabolic syndrome risk factors in obese postmenopausal women [53].
In a retrospective study involving 15,550 adults aged 53-57 years, it was found that regular yoga practice for 4 years or more was associated with attenuated weight gain, especially among people who were   [54,55].
Numerous studies have shown yoga to have an immediate effect down regulating the response of SNS -HPA axis to stress. Studies show that yoga decreases levels of salivary cortisol, blood glucose as well as plasma renin levels, and 24-hour urine norepinephrine and epinephrine levels [56].
Most of the works related to yogic practice have been carried out only in type 2 diabetic patients. The associated risk indices have been evaluated in about 25 studies with yogic intervention ranging from 8 days to 12 months. These include decreased blood glucose levels and glycosylated hemoglobin level and also showed improvement in the glucose tolerance test (GTT). A decrease in fasting insulin level, rise in insulin receptors, increased percentage of receptor binding (even before glycemic control) suggests decreased insulin resistance and improved sensitivity [57,58]. There have been reports of weight loss, decrease in body mass index and waist-hip ratio, stress reduction, improvement in mood,self-efficacy and quality of life [59]. Yoga has shown improvement in nerve conduction and cognitive functions in diabetics, a feature, which may prove to be beneficial in management of diabetic complications [60,61]. In a study, Cardiac autonomic functions improved in patients with diabetes on standard treatment that followed the comprehensive yogic breathing program compared to patients who were on standard therapy alone [62,63].
Yoga significantly decreases heart rate, systolic and diastolic blood pressure [64]. Studies suggest that yoga reverses the negative impact of stress on the immune system by increasing levels of immunoglobulin A as well as natural killer cells. Yoga has been found to decrease markers of inflammation such as high sensitivity C-reactive protein as well as inflammatory cytokines such as interleukin-6 and lymphocyte-1B [65,66]. Leptin plays a pro-inflammatory role while adiponectin has anti-inflammatory properties. Adiponectin levels were higher among practitioners of yoga [67]. Yoga could be one such intervention that prevents the occurrence and progression of metabolic deterioration and co-morbidity ( Figure 1).

Yoga can benefit patients in whom exercise has a risk
Risk of exercise in type 1 DM: Physiological, social and emotional benefits of regular exercise and physically active lifestyle are important for diabetic patients regardless of the type of diabetes [68]. Studies evaluating the efficacy of exercise in type1 DM were not encouraging and it may even be detrimental. If the carbohydrate intake and the insulin dosage are not adequate with the exercise of a type 1 DM patient, it can result in metabolic disturbances [69]. Findings from exercise training studies support the concept that moderate intensity aerobic exercise increases the risk of hypoglycemia during the exercise and also several hours after the exercise.
In patients with type I diabetes with severe insulin deficiency, exercise may actually result in a paradoxical rise in both the blood glucose and ketone levels. In this situation, lack of insulin and lipolysis leads to overproduction of glucose and ketoacids that can exceed their rate of utilization [70].
There is no much study regarding the benefits of yoga in type1 DM. yoga may help in reducing the stress and induce physical well-being of patients. Stretching exercises of yoga has been found to improve the regeneration of pancreatic beta cells; it can help in type 1 DM. Further studies are necessitated to assess the benefits of yoga in type 1 DM. Patients suffering from complications like diabetic foot, diabetic neuropathy, denervation, loss of proprioception, all can lead to injuries in a patient while performing exercise or walking. A careful evaluation of blood flow and neurologic status of the lower extremities should be part of any pre-exercise assessment. Careful attention needs to be paid to the selection of proper footwear. Patients with severe disease may need to limit activities, such as jogging to lower impact forms of exercise [71]. Finally, it should be noted that autonomic dysfunction may place some patients at risk for developing post-exercise orthostatic hypotension, particularly during the early phase of an exercise program when autonomic dysfunction is not apparent at rest.  in some circumstances. Evidence suggests that moderately intense exercise does not induce retinopathy and may even have a protective effect [72]. However, in the presence of established proliferative disease; certain types of exercise may predispose the patient to retinal hemorrhage [73]. There is concern about the potential effects of exercise on the progression of diabetic nephropathy. Many patients with no proteinuria at rest will develop protein in their urine for as long as 12-24 hours following a single intensive bout of exercise [74]. The degree of proteinuria is roughly proportional to the rise in systolic blood pressure that occurs during the activity.

Micro vascular complications of diabetes could be aggravated
Exercise related hypoglycemia is rare in patients with type 2 diabetes, but may occur in those taking insulin or some of the more potent sulfonylureas. Exercise of the muscles directly underlying an insulin injection leads to a rapid absorption of insulin which in turn can contribute to hypoglycemia. This occurs primarily with short acting insulin and only when the exercise follows the insulin injection within a short period of time. It is easily avoided by selecting injection sites away from the area of exercising muscle. In normal circumstances, exercise results in an acute suppression of pancreatic insulin release and a decrease of serum insulin levels. In the presence of an exogenous insulin depot the normal suppression in insulin levels does not occur, resulting in a relative hyperinsulinemia [75]. In addition, some patients with long standing diabetes may develop deficiencies in glucagon and epinephrine release that could also limit their ability to maintain a normal glucose level during activity.
In a review of comparison studies [56] (Table 3), comparing the effects of yoga and exercise seem to indicate that, in both healthy and diseased populations, yoga may be as effective as/or better than exercise in improving a variety of health-related outcome measures. In this study, yoga showed a better outcome than exercise in all these parameters like HRV, kidney function, menopausal symptoms, psychiatric symptoms, pain, sleep disturbances, stress and lipid profile. Improvement in glycemic status was similar in both exercise and yoga [76]. Main difference between exercise and yoga comes mainly by the influence on the HPA axis. Intense exercise leads to proportional increases in cortisol. The critical level of intensity that leads to release of cortisol is approximately 60% VO2max, with the greater the exercise intensity, the greater the cortisol release [77][78][79][80]. Perhaps this explains why yoga, involving slow and often nonstrenuous activities, positively affects the HPA axis response to stress

Implications to future research
Yoga based therapy has a good scientific background to be applied as an effective intervention in management of both type 1 DM and type 2 DM. However, literature is inadequate in classifying the specific asanas which could benefit in diabetes and also the duration of treatment needed. Further, health administrators should plan about how yoga could effectively be taught as a life style intervention programme among public. More randomized trials in future are needed to compare the benefits of yoga and exercise.

Malhotra V [60]
Pre-post design 20 type 2 DM patients Yoga were performed every day along with medicines in the study group while the control group only with medicines and light excercises.

days
The basal blood glucose, nerve conduction velocity of the median nerve was measured and repeated after 40 days of Yogic regime Control group nerve function parameters deteriorated over the period of study, indicating that diabetes is a slowly progressive disease involving the nerves. Yoga asanas have a beneficial effect on glycaemic control and improve nerve function in mild to moderate Type 2 diabetes with sub-clinical neuropathy.

4-week
Blood samples were collected on days 4 and 5 of each set of asanas for measurement of glucose and insulin levels before the asanas, within 10 min after performing the asanas, and 30 min after ingestion of 75 g glucose, which in turn was ingested immediately after the second blood sample. A standard 75 g oral glucose tolerance test (OGTT) was also done before and after the study. On the days of the pre-study or post-study OGTT, no asanas were done Performance of asanas led to increased sensitivity of the B cells of pancreas to the glucose signal. The increased sensitivity seems to be a sustained change resulting from a progressive long-term effect of asanas. 3

Malhotra V [52]
Pre-post design 20 NIDDM patients 13 specific Yogaasanas were taught in the study group and the study parameters assessed before and after study period.

days
Serum insulin, plasma fasting and one hour postprandial blood glucose levels and anthropometric parameters were measured before and after yoga asanas At the end of 40 days of performing the asanas, the study participants had a significant decrease in fasting glucose levels, waisthip ratio and beneficial changes in insulin levels than the previous levels. 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. 11 Lee [53] Comparison study 16

Conclusion
Yoga is an ancient discipline designed to bring balance and health to the physical, mental, emotional, and spiritual dimensions of the individual. A comprehensive yoga therapy program has the potential to enhance the beneficial effects of standard medical management of DM and can be used in an effective complementary or integrative therapy program. The improvement in various biochemical indices and stress reduction by practicing yoga can enable a person with a better healthy living. 14 V. P.
Jyotsna [63] Randomised control trial 120 patients of diabetes on oral medication along with diet and exercise Study groups were randomized into two groups: (1) Continued to receive standard treatment for diabetes.
(2) Patients administered comprehensive yogic breathing program and monitored to regularly practice yoga in addition to standard treatment of diabetes.

months
Glycemic control, quality of life and cardiac autonomic function tests (CAFT) were repeated after 6 months of intervention and compared with those before randomisation.
sympathetic cardiac autonomic functions significantly improved from baseline in the group practicing comprehensive yogic breathing.