European Journal of Cardiovascular Medicine

Diabetes mellitus (DM) is a leading cause of death globally. It is a group of diseases with diverse causes, characterized by chronic high blood sugar levels resulting from a combination of environmental and genetic factors [1]. According to estimates from 2019, there were 77 million individuals in India with diabetes, and this frequency is expected to increase by 2045 to an astounding 134 million [2]. It is now widely accepted that diabetes mellitus (DM) is a condition impacted by psychosomatic factors and lifestyle with sedentary behaviours and emotional, mental, and physicalstress playing substantial roles. Lack of physical activity raised diabetes risk by threefold and increased coronary artery disease risk by 2.4 times [3].

The management of type 2 diabetes and associated problems including obesity, hypertension, and dyslipidemia may be accomplished by diet and exercise. Urban life, high-calorie meals, a lack of open space for exercise, contemporary busyness, and motivational problems are common barriers to adherence to these strategies among people with diabetes. Additionally, those with diabetes face barriers to exercise due to factors like excess weight, lack of fitness, sedentary habits, limited joint movement, and complications such as cardiovascular disease, neuropathy, and diabetic foot problems. According to research, non-adherence to food and exercise regimens severely limits the efficacy of non-pharmacological diabetic therapy [4].

Yoga, which originated in India more than 5,000 years ago, aims at balancing and harmonizing the body, mind, and emotions [5]. In light of the fact that yoga is more than simply a physical activity, modern research has concentrated on positive psycho-physiological consequences of the yoga practise [6-8]. Yoga offers a remarkable way of life that stands as a timeless contribution to the global community. This practice aims to achieve a harmonious unity of the mind, body, and soul. The term "yoga" originates from the Sanskrit root "Yuj," signifying the idea of union. In today's fast-paced world, individuals often face the daunting challenges of stress and its associated ailments such as hypertension and diabetes. Those who engage in yoga experience enhanced physical and mental well-being, displaying superior resilience against stress compared to the general population. Within the eight-fold path of Astanga Yoga, many individuals predominantly focus on practicing asanas (firm and comfortable postures) and pranayama (slow, deep, conscious, rhythmic breathing), both of which are often recommended as part of yoga therapy.

Scientific studies have extensively confirmed the significant role of yoga in enhancing overall health, managing and preventing psychosomatic disorders. Yoga therapy holds immense practical value in modern medicine, offering possibilities for promotion, prevention, and treatment. By fostering positive health, vitality, a sense of well-being, and an improved quality of life, yoga provides numerous benefits. The physiological changes induced by yogic techniques are consistent and supported by robust scientific evidence [9]. Incorporating yogic principles into lifestyle modifications yields remarkable improvements and can substantially contribute to the prevention and management of lifestyle diseases [10]. Furthermore, yoga has proven effectiveness in controlling and addressing disorders related to stress, chronic degenerative, age, and lifestyle-related [11]. Studies have examined the impact of yoga-based programs on risk profiles in adults with T2DM, as well as the effects of yoga-based lifestyle interventions on state and trait anxiety. These investigations have shed light on the role of yoga in managing diabetes.

To our knowledge, there aren't many thorough research on the effects of yoga on different physiological and biological parameters in humans. Due to this gap in information, our research aims to address this issue by examining the physiological and biochemical changes before and after yoga practice. The primary objective of our study is to assess the benefits of yoga therapy in improving BMI, blood pressure, postprandial sugar, fasting blood glucose, and HbA1c among individuals with type 2 diabetes. Through this investigation, we aim to shed light on the metabolic alterations induced by yoga and determine whether yoga is effective in bringing about positive metabolic changes.

Selection of subjects: - A total of 100 individuals aged between 40 and 60 years, who had been diagnosed with T2DM for a duration of 0-10 years, were carefully chosen for this study. The diagnosis of Type 2 Diabetes Mellitus was conducted based on the criteria established by the World Health Organization (WHO). The objectives and aims of the study were clearly communicated to all participants, following the ethical principles outlined by the Indian Council of Medical Research in New Delhi, India.

Data Collection: - A comparative study, utilizing a cross-sectional, prospective, and observational design, was carried out at J.L.N Hospital in Ajmer. The study recruited 50 diabetic outpatients who were divided into two groups: the experimental group, where yoga was introduced, and the control group. The experimental group engaged in various yogic asanas, including Surya namaskar, Mandukasana, Vakrasana, Ardha Matsyendrasana, Hamsasana, Mayurasana, Dhanurasana, Pranayama, and Anulom vilom.

Procedure: - The participants in the study were divided into two distinct groups: Group I and Group II. Group I comprised of individuals with Type 2 Diabetes Mellitus (T2DM) (n=50, Male=23, Female=27), who were allocated to the Yoga group. All patients gave informed written permission once the procedure was explained, the college's ethics committee approval was obtained, and the procedure was then carried out.

These patients underwent various yogic asanas for a duration of 24 weeks, in addition to following a diabetic diet and taking prescribed medications. The yoga sessions, including asanas and pranayama, were performed for approximately 30 minutes per day, under the supervision and guidance of a qualified yoga expert. Group II (n=50, Male=19, Female=31) comprised the control group, consisting of T2DM patients who followed a regular diet and received standard medical treatment. After the 24-week intervention period, blood samples were collected from all subjects and analyzed to assess the biochemical and physiological changes associated with the impact of yoga on diabetes management.

Biochemical Analysis: - The biochemical analysis, including measurements of Postprandial Blood Glucose (PPS), Fasting Blood Glucose (FBG), and Glycosylated Hemoglobin (HbA1C), was conducted using the following procedure: Blood (5 ml) was collected in a biochemical tube containing a polyacrylamide gelatine separator. The samples were then analyzed using a fully automated analyzer (COBAS 400 PLUS) manufactured by Siemens. The HbA1C levels were determined using the indirect ELISA method.

Statistical Analysis: - The findings were expressed as the mean ± standard error of the mean (SEM). Statistical analysis was conducted using SPSS 25.0 software (SPSS, Inc., Chicago). A t-test was employed to compare the control and the experimental group, with P values below 0.05 indicating statistically significant differences between the pre- and post-intervention data.

Table 1 represents the distribution of studied population based on their gender and age group.

In both groups, there are 50 diabetes patients. There were 31 females and 19 males in group I (Experimental) while 27 females and 23 males were there in the group II (Control). The control group included 24 people aged between 40-50, and 26 aged between 51-60, while the experimental group had 17 participants aged between 40-50, and 32 aged between 51-60. Most of the patients in the both the groups were between the age group of 51-60 (52 percent) and 51-60 (64%) respectively.

The comparison is done regarding a control group in addition to examining the different parameters of data before and after yoga intervention. The difference between control and experimental groups were shown in Table 4.2.

The table 2 depicts the pre- and post-test data of physiological and biological parameters included. In control group, no major differences in BMI of the participants was observed between pre- and post-test levels in control group (24.68 kg/m2 to 24.83 kg/m2), whereas a decrease was observed in the experimental group in post-test (24.08 kg/m2 to 21.96 kg/m2) (Figure 1a). A reduction in FBS was also observed in experimental group (122.13 mg/dL to 108.11 mg/dL) as compared to the control group (122.08 mg/dL and 121.06 mg/dL) (Figure 1b). A decrease in blood pressure (Systolic, 130.32 mmHg to 119.84 mmHg and diastolic, 83.86 mmHg to 80.66 mmHg), PPs (226.76 mg/dL to 144.86 mg/dL) and Hb1Ac (7.27 mmol/mol to 6.69 mmol/mol) levels were also observed in group I as compared to group II (Figure 1c-f).

Figure 1. Pre- and post-test level of physiological and biochemical parameters, a) BMI, b) FBG, c) systolic, d) diastolic, e) PPs, f) Hb1Ac

The differences in average BMI levels of the participants both in the control and the experimental groups were represented in table 3. In control group, the recorded mean difference was 0.153 indication an increase in the BMI levels in post-test whereas in experimental group, a mean value of -2.117 indicates a decrease in the levels of BMI in post-test as compared to pre-test levels. Statistically a significant difference was also observed in the average BMI levels of the experimental group (P<0.05) as compared to the control group (P>0.05).

Table 4 represents the paired differences of studied biochemical parameters between pre-and post-test of control and the experimental group.

The level of biochemical parameters was recorded both before and after yoga intervention. In control group (without yoga intervention), non-significant differences

were observed between pre- and post-test levels of FBS, Systolic and Hb1Ac levels (P>0.05), whereas diastolic and PPS showed statistically significant differences between them (P<0.05).

In experimental group, a significant decrease was observed in the FBS, systolic, diastolic, PPS and Hb1Ac levels of experimental group (P<0.05). It was found that after yoga therapy, the experimental group showed significant decrease in BMI, fasting glucose levels, blood pressure, post prandial sugar and HB1Ac. It can be concluded that the yoga therapy had a significant impact on health of diabetic patients.

The current study demonstrated the beneficial impact of yoga on individuals with diabetes. Significant differences were observed in various parameters, including BMI, blood pressure, postprandial glucose levels, hemoglobin A1c, and fasting glucose, between the control group and the group that underwent yoga intervention in both the pre-test and post-test assessments.

Our study showed significant reductions in BMI and blood pressure (diastolic and systolic) among diabetic patients of experimental group in both the pre-test and post-test measurements (P<0.05). A study conducted by Mohan et al. in 2016 reported a notable decrease in body fat after 12 weeks of yoga practice. Participants who engaged in a high level of yoga practice over time experienced a decrease in body fat percentage [12]. Another study by Braunstein in 2004 demonstrated that incorporating yoga into conventional treatment led to lower BMI and improved glucose control in participants with T2DM [13]. In Subramanian et al.'s study conducted in 2011, it was observed that all three intervention groups experienced a notable decrease in blood pressure, whereas no significant changes were observed in the control group [14]. Additionally, a study by Rao et al. in 2011 found that initiating a nonpharmacological therapy regimen consisting of yoga and naturopathy resulted in a reduction in mean diastolic blood pressure from 91.2 to 86.1 and systolic blood pressure (SBP) from 139.6 to 129.6 [15]. Furthermore, Sahay et al. reported that type 2 diabetic patients exhibited substantial reductions in body fat and increases in lean body mass following yogic intervention [8]. Our results also demonstrated a significant difference in HbA1c, fasting glucose, and postprandial glucose levels (P<0.05). The study's findings conducted by Kumar 2012 indicated that patients with diabetes experienced reductions in fasting and postprandial blood glucose levels following yogic intervention [16]. Similar findings were reported in studies conducted by Singh et al. [17] and Chimkode et al. [18]. Raveendran et al. concluded that the decrease in postprandial glucose levels, HbA1c, and fasting blood sugar suggests improved glycemic control and potentially reduced requirements for anti-diabetic medication [19]. Manjunatha et al. provided evidence that yoga aids in diabetes treatment by enhancing insulin release from the pancreas. They found that yoga asanas improved the pancreatic β-cells sensitivity to glucose signals [20]. Previous studies comparing yoga to physical exercise have yielded varying results. Some studies have suggested a greater decrease in FBS and PPBS in the yoga group compared to the physical exercise group. Conversely, alternate studies have reported no substantial distinction between both the groups. While some studies have reported a substantial reduction in HbA1c and fasting blood glucose levels, an exploratory trial conducted in the United Kingdom found only a modest decrease in HbA1c. Our study revealed a significant decrease in both diastolic and systolic blood pressures in the experimental group (P<0.05). Cohen et al., (2011) also reported notable reductions in both diastolic and systolic blood pressures at 12 and 24 weeks among those who completed the treatment [21]. Subramanian et al. (2011) found that regular exercise is more beneficial compared to reducing salt intake or practicing yoga [14]. Ahte et al. showed that individuals with hypertension experienced a significant decrease in their diastolic blood pressure [22]. Rao et al. also reported similar findings [15]. In a study conducted by Wolf et al., (2013), the impact of yoga on diastolic blood pressure and self-reported quality of life was examined. The results showed that participants who practiced yoga at home experienced a decrease in both systolic and diastolic blood pressures compared to the control group [23].

The clinical studies conducted to determine how yoga affects health and different diseases have several gaps. Trials investigating yoga's ability to manage diabetes have mostly been hindered by insufficiently controlled groups, limited sample size, and short research duration. It is difficult to differentiate between the particular effects of yoga and medical therapy since individuals were also taking regular hospital medicines at the same time. Nevertheless, because the patient's symptoms stabilized and the medical care protocol stayed the same, we may rationally attribute the extra benefits to the yoga therapy program. Future randomized control studies are advised to confirm these results and provide a deeper understanding of the underlying processes.

Yoga is widely acknowledged for its positive impact on physical well-being. Our study demonstrated significant improvements in physiological and biochemical parameters among diabetes patients who underwent a 24-week yoga therapy training program in group I (P<0.05), in contrast to the control (P>0.05). The results indicated that yoga had a positive effect on reducing fasting glucose, postprandial glucose, and HbA1c levels in diabetic patients. Additionally, it showed significant effects on weight and BMI reduction. Moreover, there was a notable decrease in blood pressure (both systolic and diastolic). These findings suggest that a yoga therapy program can enhance the benefits of standard medical management for diabetes and serve as an effective integrative or complementary therapy. However, further clinical trials are necessary to explore the precise effects of yoga, and additional studies employing rigorous methodologies are needed to investigate the health benefits associated with different types of yoga

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