DIABETES, MINDFULNESS AND MEDITATION
A Literature Review
Dr Ian Gawler OAM, BVSc, MCounsHS July 2021
Diabetes is a major global healthcare problem and its prevalence is increasing rapidly.
Diabetes is a chronic, metabolic, multifaceted health problem and is a common cause of death and disability. It has significant effects not only on the body but also on the mind and social functioning of those affected. Peoples’ quality of life, wellbeing, and social relationship can be profoundly affected by diabetes and its side effects.
Diabetes is a complex medical condition whose management requires a diversified approach. This can include drug therapy, diabetes education programs, adherence to medical treatment and active participation in a therapeutic lifestyle program featuring dietary change, exercise and stress management.
THE SCOPE OF THIS LITERATURE REVIEW
This literature review aims to bring together research investigating what mindfulness and meditation can offer to those affected by diabetes. Then, given the times we are in, it also examines the evidence base for online mindfulness and meditation programs.
Diabetes is a generic word used to describe different conditions, so the review includes definitions of the different types of diabetes. However, this review does focus on diabetes mellitus types 1 and 2.
Quite a large body of research has been published in this field, but not surprisingly, it varies in quality. Therefore, while not exhaustive, this review aims to reproduce key research (using many direct quotes from that research) that investigates the efficacy of mindfulness and meditation for people affected by diabetes.
This review includes direct hyper-links to the original scholarly articles as published.
PART A : DIABETES – MELLITUS OR INSIPIDUS? TYPE 1 OR 2? THE DEFINITIONS…
1. DIABETES INSIPIDUS
Diabetes Insipidus (DI) is quite distinct from Diabetes Mellitus. In brief, Diabetes Insipidus is a condition characterized by large amounts of urine (up to 20 litres per day) and increased thirst. Extreme urination continues throughout the day and the night. In children, DI can interfere with appetite, eating, weight gain and growth. Adults with untreated DI may remain healthy for decades as long as enough water is consumed to offset the urinary losses. However, there is a continuous risk of dehydration and loss of potassium.
This condition is not specifically addressed in this review.
2. DIABETES MELLITUS (DM), commonly known as just diabetes, is a group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time.
Symptoms often include frequent urination, increased thirst, and increased appetite. Left untreated, DM can cause many health complications and result in an early death – see below.
There are 3 main types of Diabetes Mellitus, plus some uncommon ones
i) Type 1 Diabetes (T1D)
T1D results from the failure of the pancreas to produce enough insulin (the hormone that regulates blood sugar) due to loss of beta cells. This form was previously referred to as “insulin-dependent diabetes mellitus” (IDDM) or “juvenile diabetes”. The loss of beta cells is caused by an autoimmune response whose cause is unknown. T1D management requires the use of insulin injections, although there is growing evidence lifestyle factors can reduce the dosage needed.
ii) Type 2 Diabetes (T2D)
T2D begins with insulin resistance, a condition in which cells in the body fail to respond to insulin properly. As the disease progresses, a lack of insulin may also develop. This form was previously referred to as “non-insulin-dependent diabetes mellitus” (NIDDM) or “adult-onset diabetes”.
The most common cause of T2D is a combination of excess body weight and lack of exercise.
Prevention and treatment of type 2 diabetes involves adopting a healthy lifestyle based upon maintaining a healthy diet, exercising regularly, avoiding the use of tobacco and utilizing stress management techniques. Care needs to be taken to control blood pressure, along with maintaining proper foot and eye care. Medications such as insulin sensitizers and injections of insulin may be required. Weight loss surgery can sometimes provide an effective measure for those with obesity.
Pre-Type 2 Diabetes
Pre-diabetes describes a condition in which blood glucose levels are higher than normal, although not high enough to be diagnosed with type 2 diabetes. Pre-diabetes has no signs or symptoms. People with pre-diabetes have a higher risk of developing T2D and cardiovascular (heart and circulation) disease. Two million Australians have pre-diabetes and are at high-risk of developing T2D. Risk factors for pre-diabetes are similar to those for T2D.
Treatment of pre-diabetes involves the same lifestyle changes that are recommended for people diagnosed with T2D. For most, this will include regular physical activity, healthy eating and if necessary losing weight. People with pre-diabetes are also at increased risk of heart disease, so controlling blood pressure and blood cholesterol and triglycerides is also important.
Without sustained lifestyle changes, including healthy eating, increased activity and losing weight, approximately one in three people with pre-diabetes will go on to develop T2D within around 5 years, while overall, up to 70% will progress to T2D.
iii) Gestational diabetes occurs when pregnant women without a previous history of diabetes develop high blood sugar levels. The majority of women with gestational diabetes have a healthy pregnancy, normal delivery and a healthy baby.
The need for insulin in pregnancy is 2 to 3 times higher than normal. For women with underlying insulin resistance, the body may not be able to cope with the extra demand for insulin production and the blood glucose levels will be higher resulting in gestational diabetes being diagnosed.
When the pregnancy is over, blood glucose levels usually return to normal and the gestational diabetes disappears. However, this insulin resistance increases the risk of developing T2D in later life for both the mother and the child, so monitoring may well be advised and maintaining a healthy lifestyle is a logical choice.
The treatment is a healthy eating plan, regular physical activity and monitoring and maintaining blood glucose levels
iv) Uncommon Causes of Diabetes
There are some rare forms of diabetes such as the genetic condition Maturity Onset Diabetes of the Young (MODY), while some diseases such as cystic fibrosis and chronic pancreatitis can lead to diabetes.
PART B : THE CONTEXT – WHAT IS THE IMPACT OF DIABETES?
1. HOW MANY PEOPLE ARE AFFECTED?
Diabetes is the 7th leading cause of death globally. In 2019, diabetes resulted in approximately 4.2 million deaths. As of 2019, an estimated 463 million people had diabetes worldwide (8.8% of the adult population). In Australia, around 1.8 million people are diagnosed with diabetes. T2D makes up about 85% of the cases and T1D around 10%. Rates for T1D and T2D are similar in women and men.
The data suggests rates are rising rapidly and will continue to rise. Large numbers of people are affected by silent, undiagnosed T2D which may be causing damage to their bodies. An estimated 2 million Australians are at high risk of developing T2D and are already showing early signs of the condition.
2. WHAT ARE THE RISKS?
Many seem to regard diabetes as a mere inconvenience; something you can live with easily enough. However, the facts are stark.
While diabetes can be managed well, the potential for very unwelcome complications are high and they are the same for type 1 and type 2 diabetes.
According to Diabetes Australia, Diabetes Mellitus:
Is the leading cause of blindness in working age adults
Is a leading cause of kidney failure and the need for dialysis
Increases the risk of heart attacks and stroke by up to four times
Is a major cause of limb amputations
Affects mental health as well as physical health. Depression, anxiety and distress occur in more than 30% of all people with diabetes. Cognitive impairment is a serious risk.
Overall, DM more than doubles the risk of an early death
Early diagnosis, optimal treatment and effective ongoing support and management reduce the risk of diabetes-related complications.
3. WHAT ARE THE FINANCIAL COSTS?
The global economic cost of diabetes-related health expenditure in 2017 was estimated at US$727 billion. In the United States, diabetes cost nearly US$327 billion in 2017. Medical expenditures among people with diabetes are about 2.3 times higher than average.
4. WHAT CAUSES DIABETES?
Type 2 diabetes is a chronic degenerative disease closely related to lifestyle factors. Happily, its successful management is significantly affected by lifestyle changes. According to Diabetes Australia, T2D is one of the major consequences of the obesity epidemic. The combination of massive changes to diet and the food supply, combined with massive changes to physical activity with more sedentary work and less activity, means most populations are seeing more T2D.
PART C : WHAT DOES MEDITATION AND MINDFULNESS HAVE TO OFFER DIABETES?
What the science says
Mindfulness-based Interventions (MBIs) can be seen as preventive and complementary interventions in DM, particularly for the relief of symptoms related to depression and anxiety in diabetic patients and also in the management of other factors, including mindful eating, physical exercises and treatment adherence. Mindfulness seems to have beneficial effects on all aspects of diabetes, including incidence, control and complications.
Medina WL et al. Effects of Mindfulness on Diabetes Mellitus: Rationale and Overview. Curr Diabetes Rev. 2017;13(2):141-147.
What common sense says
The mind controls what we eat and drink, along with how much we exercise. If we want to take charge of what we eat and drink, we will benefit from taking charge of what – and how – we think. This is the beauty of mindfulness and meditation; these 2 practices help us to take more control over our own thoughts, our habits and our way of living. Of necessity, they must form the basis of any therapeutic lifestyle program. And they are easy to learn, easy to practice, can be done almost anywhere – and once they are learnt, cost nothing – we can do them for ourselves! And as a side effect, mindfulness and meditation reliably lead to inner peace and contentment…
1. META-ANALYSES and REVIEWS – DIABETES, MINDFULNESS AND MEDITATION
i) Meditation and mindfulness lead to wide-ranging benefits
This study analysed 154 articles examining the potential contribution of mindfulness and meditation to those affected by diabetes. The articles spanned from 1984 to 2017. The review concluded the practice of meditation is associated with reduction in stress and negative emotions and improvements in patient attitude, health-related behaviour and coping skills. There is increased parasympathetic activity with reduction in sympathetic vascular tone, stress hormones and inflammatory markers. Additionally, several studies evaluated the role of mindfulness-based stress reduction in diabetic individuals and demonstrated modest improvements in body weight, glycaemic control and blood pressure.
Mindfulness meditation-based interventions can lead to improvements across all domains of holistic care – biological, psychological and social.
Meditation strategies can be useful adjunctive techniques to lifestyle modification and pharmacological management of diabetes and help improve patient wellbeing.
Priya G, Kalra S. Mind-Body Interactions and Mindfulness Meditation in Diabetes. Eur Endocrinol. 2018;14(1):35-41. doi:10.17925/EE.2018.14.1.35
ii) Mindfulness-based interventions reduce diabetes distress
This meta-analysis examined the evidence and determined the factors influencing the effect of mindfulness-based interventions (MBI) on diabetes distress. A systematic search of nine databases was conducted and randomized controlled trials of MBIs for adults with diabetes that evaluated the effect of the interventions on diabetes distress were retrieved. A total of 10 articles, consisting of eight studies with 649 participants, were included.
MBIs improve outcomes in adults with diabetes who have elevated diabetes distress at baseline, using mindfulness-based stress reduction therapy, using a group format to deliver the intervention, and assigning home practice. MBIs improve diabetes distress significantly more at long-term follow-up compared with short-term follow-up. MBIs could be considered as an adjunct treatment in adults with diabetes to reduce diabetes distress.
Guo J et al. Factors influencing the effect of mindfulness-based interventions on diabetes distress: a meta-analysis. BMJ Open Diabetes Res Care. 2019 Dec 11;7(1)
iii) Mindfulness reduces physiological and psychological symptoms in T1D and T2D
This systematic review examined research published in 5 databases. Eleven studies satisfied the inclusion criteria and they demonstrated Mindfulness-based intervention effectiveness for physiological outcomes (glycaemic control and blood pressure) was mixed. Mindfulness-based interventions appear to have psychological benefits reducing depression, anxiety and distress symptoms across several studies. Some studies’ short-term follow-up periods may not have allowed sufficient time to observe physiological changes or illustrate Mindfulness-based interventions’ potential long-term efficacy. More long-term studies that include a consistent, standardised set of outcome measures are required.
Noordali F., Cumming J., Thompson J. L. Effectiveness of mindfulness-based interventions on physiological and psychological complications in adults with diabetes: a systematic review. Journal of Health Psychology. 2017;22(8):965–983. doi: 10.1177/1359105315620293. [PubMed]
2. INDIVIDUAL RESEARCH PAPERS
i) Mindfulness meditation improves glycemic control and mental health
Stress and mental illnesses adversely affect glycemic control. In most patients, a multidisciplinary approach including physical activity, healthy diet, and stress management is required for glycemic control. Mindfulness-based stress reduction (MBSR) is a structured group program that reduces emotional distress through self-awareness and assuming the responsibility for individual choices, and results in increased effective health behaviours. This randomized clinical trial study involved 108 patients with T2D randomised into a 12 weeks MBSR program or routine care.
The means of haemoglobin A1C (HbA1C), fasting blood sugar (FBS), and depression, anxiety, and stress scores improved significantly after intervention in the MBSR group. Except FBS levels, all outcome variable scores’ mean change was significant between the two groups.
In general, this study revealed that mindfulness meditation could be helpful in improving the quality of mental health and lowering glycemic control indices in patients with T2D.
Nikkhah Ravari O, Mousavi SZ, Babak A. Evaluation of the Effects of 12 Weeks Mindfulness-Based Stress Reduction on Glycemic Control and Mental Health Indices in Women with Diabetes Mellitus Type 2. Adv Biomed Res. 2020 Oct 30;9:61.
ii) MBSR demonstrates a remarkable improvement in emotional wellbeing and glycemic control
Sixty patients with T2D were recruited for this outpatient-based randomized controlled trial. The intervention group participated in 8 sessions of MBSR, and the control group continued treatment as usual. All the assessments were performed at baseline and after 8 weeks and 3 months as follow-up.
In comparison with the control group, the MBSR intervention group showed a significant reduction on all outcome measures including FBS, HbA1C, Hamilton Anxiety Rating Scale (HARS), and Hamilton Depression Rating Scale (HDRS) scores.
The researchers concluded MBSR had a remarkable improvement on emotional wellbeing and glycemic control of patients with T2D.
Armani Kian A et al. The Impact of Mindfulness-Based Stress Reduction on Emotional Wellbeing and Glycemic Control of Patients with Type 2 Diabetes Mellitus. J Diabetes Res. 2018;2018:1986820.
iii) Innate mindfulness associated with less obesity, less diabetes
Dispositional mindfulness, or trait mindfulness refers to an individual’s innate capacity to pay and maintain attention to present-moment experiences with an open and nonjudgmental attitude. (Brown & Ryan, 2003).
This study examined 399 people with median age 47 years from the New England Family Study, a prospective birth cohort. Dispositional mindfulness was assessed using the Mindful Attention Awareness Scale (MAAS).
People with high versus low MAAS scores were significantly more likely to have normal plasma glucose levels and were not significantly associated with T2D when adjusted for age, sex, race/ethnicity, family history of diabetes and childhood socioeconomic status.
Mediation analyses provided evidence of mediation via obesity and sense of control, where indirect effects were prevalence ratios.
The authors concluded dispositional mindfulness may be associated with better glucose regulation, in part because of a lower likelihood of obesity and greater sense of control among participants with higher levels of mindfulness. They suggest findings need to be replicated by prospective studies to establish causality and to evaluate potential implications for mindfulness-based interventions to reduce risk of T2D.
Loucks EB et al. Associations of Mindfulness with Glucose Regulation and Diabetes. Am J Health Behav. 2016;40(2):258-267. doi:10.5993/AJHB.40.2.11
iv) Mindfulness and yoga improve quality of life
Many studies reveal the incidence of depression and anxiety is higher among patients with T2D. This study examined an 8 session group mindfulness-based stress reduction program that included conscious yoga. The data demonstrated a significant difference between experimental and control groups in terms of the quality of life level. The mindfulness-based stress reduction program was associated with a significantly increase in the quality of life in the participants of the experimental group.
The authors concluded the result of this study suggests mindfulness-based stress reduction program can be an appropriate therapeutic method for improving quality of life in patients with T2D.
Rahmani S., Zahirrodin A., Moradi M., Hoveida S., Nejati S. Examining the effectiveness of mindfulness-based stress reduction program and conscious yoga on quality of life in patients with diabetes type 2. Iranian Journal of Diabetes and Obesity. 2014;6(4):168–175.
v) More mindfulness, less stress and depression, better quality of life
Twenty to forty percent of outpatients with diabetes are affected by emotional distress. This study of 139 outpatients examined the effectiveness of group therapy with Mindfulness-Based Cognitive Therapy (MBCT), relative to usual care with regard to reducing emotional distress and improving health-related quality of life and glycemic control.
Compared with control, MBCT was more effective in reducing stress, depressive symptoms, and anxiety and more effective in improving quality of life. No significant effect was detected on HbA(1c) or diabetes-specific distress, although patients with elevated diabetes distress in the MBCT group tended to show a decrease in diabetes distress compared with the control group.
van Son J et al. The effects of a mindfulness-based intervention on emotional distress, quality of life, and HbA1c in outpatients with diabetes (DiaMind): a randomized controlled trial. Diabetes Care. 2013;36(4):823–830. doi: 10.2337/dc12-1477.
vi) More meditation, less worry
This pilot study tested a six-week meditation and mindfulness intervention in people (n = 40) with diabetes mellitus and coronary heart disease. The intervention was highly acceptable, with 90% completing ≥5 sessions. Meditation and mindfulness skills led to improved sleep, greater relaxation, and more-accepting approaches to illness and illness experience. At the end of the six-week meditation course, worry, and thought suppression were significantly reduced.
Keyworth C et al. A mixed-methods pilot study of the acceptability and effectiveness of a brief meditation and mindfulness intervention for people with diabetes and coronary heart disease. Behav Med. 2014;40(2):53-64.
vii) Mindfulness in adolescents – well accepted; reduces depression and insulin resistance
This study explored a brief mindfulness-based intervention (MBI) on clinical outcomes in adolescents at-risk for T2D. Participants were 12–17yo girls with overweight/obesity, elevated depression symptoms, and T2D family history participating in a randomized, controlled pilot trial of a six-session MBI vs. cognitive-behavioural therapy (CBT) group.
One-year retention was 71% in MBI; 81% in CBT. At 1-year, depression decreased and IR decreased in adolescents randomized to MBI compared to those in CBT. There were no significant between-condition differences in mindfulness, adiposity, or BMI.
The authors concluded One-year outcomes from this randomized, controlled pilot trial suggest that brief MBI may reduce depression and insulin resistance in at-risk adolescents. They suggested replication and exploration of mechanisms within the context of a larger clinical trial are necessary.
Shomaker LB et al. One-Year Follow-Up of a Randomized Controlled Trial Piloting a Mindfulness-Based Group Intervention for Adolescent Insulin Resistance. Front. Psychol., 08 May 2019
viii) Mindfulness meditation shows even greater diabetes related pain reduction than Progressive Relaxation (PR)
Chronic pain, the most common complication of diabetes, is treated with medication often to no avail. This study compared the use of mindfulness meditation (MM) and PR to reduce chronic pain in 109 older females with diabetes.
Groups MM and PM experienced significant reduction in average daily pain compared to baseline (28.7% and 39.7%, respectively). Group MM had more significant reduction of pain compared to control. Groups MM and PM showed significant improvement in patients’ impression at study end. In Group MM, patient satisfaction scores increased significantly by week 12.
The authors concluded Integrative therapies such as mindfulness meditation can be part of a comprehensive pain management plan. Benefits include reduction of pain-related medication consumption, better treatment outcomes, improvement in comorbid conditions such as anxiety and depression as well as no risk of addiction or abuse.
Hussain N, Said ASA. Mindfulness-Based Meditation Versus Progressive Relaxation Meditation: Impact on Chronic Pain in Older Female Patients With Diabetic Neuropathy. Journal of Evidence-Based Integrative Medicine. January 2019. doi:10.1177/2515690X19876599
ix) Mindfulness Meditation improves glycaemic control and quality of life in T1D
While Mindfulness Meditation (MM) is known to improve glycemic control and enhance the quality of life (QoL) in T2D patients, to date the role of meditation in T1D has not been studied extensively. Therefore, this randomised study of 32 people examined the effect of MM on the glycemic control and QoL in people living with T1D.
Significant improvement was recorded in the glycemic control and quality of life of the patients practicing MM. Also, the authors concluded MM certainly plays an important role in attaining peace of mind and helps patients to channel their energy in a positive direction.
Shukla R, Gupta M, Agarwal N, Bajpai A. Mindfulness Meditation as Adjunctive Therapy to Improve the Glycemic Care and Quality of Life in Patients with Type 1 Diabetes. Medical Sciences. 2021; 9(2):33.
x) Mindfulness offers help to T1D in adolescents
This small study examined the acceptability and feasibility of Mindfulness-Based Stress Reduction (MBSR) to reduce stress and improve illness management among urban, older adolescents, and young adults with poorly controlled T1D.
Satisfaction with MBSR was high based on both quantitative and qualitative data. Preliminary evidence was found to suggest that MBSR reduced stress and improved blood glucose levels. The authors suggested additional testing in adequately powered controlled clinical trials appears warranted.
Deborah A. Ellis, April Carcone, Richard Slatcher & Erica Sibinga (2018) Feasibility of Mindfulness-Based Stress Reduction for older adolescents and young adults with poorly controlled type 1 diabetes, Health Psychology and Behavioral Medicine, 6:1, 1-14.
3. ONLINE MINDFULNESS AND MEDITATION PROGRAMS FOR PEOPLE WITH DIABETES
i) Online programs and their benefits – a meta-analysis
The aim of this meta-analysis of 15 randomised controlled studies was to estimate the overall effects of online MBIs on mental health. Results showed that online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness. The largest effect was found for stress, with a moderate effect size.
For stress and mindfulness, analysis demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, effect sizes for stress were significantly moderated by the number of intervention sessions.
The researchers concluded their findings indicate online MBIs have potential to contribute to improving mental health outcomes.
Spijkerman MPJ et al. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review Vol 45, 2016, 102-114
ii) App use decreases depression, improves mental health
There is evidence that depression can be prevented; however, traditional approaches face significant scalability issues. Digital technologies provide a potential solution. This randomized controlled trial involving over 2,000 people, evaluated a new smartphone app designed to reduce depression symptoms and subsequent incident depression amongst a large group of Australian workers.
Prevalence of depression over the 12-month period was 8.0% and 3.5% for controls and HeadGear recipients, respectively. Scores for workplace performance, resilience and wellbeing had improved. The authors concluded the trial demonstrates that a smartphone app can reduce depression symptoms, and such interventions may have a role in improving working population mental health.
“This is the first time researchers have ever been able to achieve reductions in depression incidence using an app alone,” claimed the lead author Dr Mark Deady.
Deady, M et al. (2020). Preventing depression using a smartphone app: A randomized controlled trial. Psychological Medicine, 1-10. doi:10.1017/S0033291720002081
PART D : CONCLUSION
There is a solid evidence base for mindfulness and meditation being used to help people affected by diabetes. Both the cause and management of diabetes are directly related to lifestyle factors and the evidence is clear that regular mindfulness and meditation is associated with a healthier lifestyle. These same interventions can play a part in prevention and they can reduce the associated symptoms of diabetes such as stress, anxiety and depression, as well as assist in recovery.
Also, there is good evidence online mindfulness – based programs have positive benefits and that these benefits are increased with the support of an on-line guide or mentor. Further, the evidence concludes that increasing the number of guided sessions increases the measured benefits.