“Sweet, sweet, sweet poison for the age’s tooth.”
William Shakespeare
Connie was nine years old when she was diagnosed with diabetes. After recovering from the initial shock, and with the loving support of her family and pediatrician, she learned to adapt to her illness. Throughout her teenage years, her blood sugars were kept under good control and she considered her condition more of a nuisance than a disease.
This changed when she started her freshman year in college. It was the first time she had lived away from her family and she found herself frequently feeling anxious. She was keeping up in her classes but was having trouble sticking to her diet. She adjusted her insulin to her erratic eating habits but was having much wider fluctuations in her blood sugars than ever before.
Because she had been snacking while cramming for a midsemester exam, she gave herself an extra dose of insulin before going to bed. The next thing Connie knew she was waking up in the local emergency room being told she had had a seizure due to very low blood sugar.
If during our evolution we had had unlimited access to nourishment, we may not have needed to develop insulin. This remarkable hormone, released when the bloodstream is filled with sugar, moves the basic energy currency of the body into the cells of our tissues and into our liver for storage. Insulin enables us to save carbohydrate packets of energy to be used in leaner times. If we do not produce enough insulin or if despite its presence our cells do not heed its call, sugar molecules overflow from the bloodstream into the urine. We call this real or apparent lack of insulin diabetes mellitus.
Approximately twelve million Americans suffer from this illness.1 The disease is a major cause of disability, including blindness, kidney failure, and nerve damage. It raises the risk of blood-vessel disease throughout the body, including the brain and heart. And, the treatment of diabetes carries a high price tag, estimated at over ten billion dollars each year.2
We now know that the complications of diabetes are directly related to high levels of blood sugar. Recent studies have demonstrated that precise control of glucose levels approaching normal can reduce the complications of diabetes.3 Achieving this control is not easy and requires close monitoring and regulation of blood sugar, diet, and activity.
Although diabetes is primarily a problem of insulin production or responsivity, the regulation of blood sugar is influenced by a dynamic interplay between mind, activity, food, and biochemistry. Besides insulin, other hormones are also involved in blood-sugar regulation, including glucagon and growth hormone. Both of these are often present at high levels in diabetics. Glucagon, which, like insulin, is secreted by the pancreas, elevates blood sugar by causing the breakdown of the complex carbohydrate glycogen into simple sugars. Growth hormone raises blood sugar by antagonizing insulin.
Insulin is a versatile messenger. Within the brain it is an important neurotransmitter, influencing appetite, hunger, and satiety.4 It is found in the cerebrospinal fluid and receptors for it have been identified throughout the central nervous system.5 In addition to its role in eating behavior, insulin has been shown to influence the maturation of nerve cells.
There is a close relationship between insulin, blood sugar, and our emotions. Stress causes the release of adrenaline and cortisol, which have a direct effect on blood sugar and other sugar-regulating hormones. In the initial phase of a stressful challenge, our sympathetic nervous system stimulates the release of stress hormones, which raise blood-sugar levels so our vital organs are assured of available fuel. People with diabetes, however, cannot readily tolerate this sugar challenge because of their impaired production of or insensitivity to insulin.
Stressful events may be a precipitating factor for diabetes in animals or people at risk. For example, certain types of overweight mice will show high blood sugars when put in a stressful environment.6 When rats who have had most of their insulin cells removed are restrained in a tight space, most show elevated blood sugars and almost one in seven will develop permanent diabetes.7
The Native American Pima Indians of Arizona have the highest incidence of diabetes of any ethnic group. Among this culture, men and women are considerably heavier than the average American, and almost 60 percent eventually develop diabetes. When Pimas who have not yet manifested diabetes are subjected to a time-pressured mental math test, more than three out of four will have a rise in blood sugar, compared to only one of eight Caucasians.8
We generally categorize diabetes into two groups. Type I diabetes is characterized by an actual insulin deficiency. Because it occurs in children and adolescents, Type I is called juvenile-onset diabetes, but it can occur at any age. The exact cause of the condition is not clear, but it seems to be an autoimmune disorder that may occur after a viral insult in a person genetically predisposed.
Type I diabetes patients show symptoms of insulin deficiency, including polyuria, polydipsia, and polyphagia—they urinate a great deal, they drink large volumes of water, and they eat a lot—yet they still lose weight. Sushruta, a great Ayurvedic rishi who lived four thousand years ago, described Type I diabetes in a very lyrical way: “Drinking, but always thirsty, eating, but always hungry, the poor patient watches his flesh melt away in a stream of sugary urine.”9
In Type II diabetes there is no deficiency of insulin—in fact, there may be excessive amounts of it in the blood—but Type II patients are insulin resistant. Their receptor sites do not respond adequately to the circulating insulin. Most Type II diabetes occurs after middle age, although in American Indians Type II diabetes is found among the young.
Type II diabetes patients are usually overweight. Treatment becomes much more effective when weight is reduced. Type II diabetes, therefore, is best controlled through diet, weight loss, and exercise. The behavior-modification approaches of mind body medicine are often most effective with Type II patients.
People with diabetes often have difficulty maintaining blood-sugar control during periods of psychological or physiological stress. Both anxiety and stressful life events can raise blood-glucose levels, insulin requirements, and glycosylated (sugar-bound) hemoglobin levels, reflecting poorer diabetic control.10,11,12 In addition to direct effects, people under stress often neglect their eating habits and ignore the need for exercise. In diabetic patients this can worsen the existing condition and possibly precipitate a latent illness.
People facing chronic illness develop a variety of coping styles. Children with diabetes often use avoidant coping strategies such as wishful thinking or detachment, which result in poorer control.13,14 By identifying a person’s response to life stresses, including the stress of dealing with a chronic disease, and teaching the skills to cope more effectively, we can help improve diabetic control.
STRESS AND BLOOD SUGAR
If we feel that our behavior has no relationship to what is happening to us, we learn to feel helpless. Children with diabetes often wish that with good self-care behavior they can eliminate their disease. When they find that there is not such a simple and direct relationship, they begin to lose optimism that their efforts really influence the outcome of their illness. This creates a negative cycle wherein their feelings of helplessness lead to poorer control resulting in more frustration and helplessness.15
Depression is often a feature of both Type I and Type II diabetes and interferes with adherence to diet and medication. In juvenile-onset diabetes, there is an increased incidence of bulimia (self-induced vomiting) and anorexia.16 Abrupt weight changes associated with these eating disorders can be a nightmare for patients, families, and doctors trying to achieve some semblance of stability.
The feedback loop between the stress of dealing with a chronic disease and control of the disease is apparent in people with diabetes. Life stresses, including the stress of having diabetes, result in hormonal changes that worsen blood-sugar control. The emotional distress of having diabetes influences how well people take care of themselves and this influences control of the diabetes. The recognition of this relationship between mind and metabolism has motivated the search for stress-reducing approaches to improve diabetic management.
Over the past several years mind body techniques have been used as complementary therapy for patients with diabetes mellitus. Many, but not all, reports have demonstrated the benefits of relaxation and biofeedback training in helping to stabilize blood sugars. Studies in small groups of people with diabetes show that a stress-management program with relaxation training can improve average blood-sugar levels, improve stability, and reduce insulin requirements.17,18,19 Episodes of insulin-related hypoglycemia (excessively low blood sugar) can also be reduced.20
Although it would be nice to think that specific mind body approaches, including relaxation techniques and biofeedback, are consistently beneficial in diabetes, this complex disease does not surrender so easily to science. Even from the same institution, studies can yield puzzling results. At Duke University, an initial report showed that training people in a relaxation program could improve their blood-sugar control and reduce their stress-hormone levels.21 But, a later report on biofeedback-assisted relaxation could not find a difference between the trainees and controls—they both improved.22 One way to interpret this is that simply in the process of putting their attention on the desire to have better diabetic control, there was some improvement independent of any particular technique. Future efforts will be directed at finding the best ways to enhance the power of attention in this illness. It may be different for different people.
Children with insulin-dependent diabetes are forced to face serious physical and emotional challenges. Concerns expressed by adults with diabetes are magnified in youths, who have to be ever vigilant and responsible. Children are concerned about how they are perceived by their peers and often have control issues with their parents. Mind body approaches in adolescents can improve their ability to cope with the stresses of diabetes.23 Larger studies will be needed to determine if stress-management programs in children also improve blood-sugar control.
Blood-vessel complications of diabetes are associated with major suffering and shortened survival. When blood vessels are damaged there is a real risk of skin ulcers and limb amputation. Since circulation is influenced by stress, it would make sense that influencing blood flow through relaxation training could help in diabetes. Using biofeedback-assisted relaxation training, people with diabetes can learn to increase their skin temperature and improve blood flow to their limbs.24 Some people can increase blood flow to their legs by almost 50 percent just by listening to relaxation tapes that encourage the feeling of warmth and heaviness.25 Learning to relax and let the blood flow can speed up the healing of skin ulcers in people with diabetes.26
Dealing with a chronic illness such as diabetes is taxing to the body, mind, and emotions. The intimate relationship between our mental experience of the world and the neurochemical and hormonal changes in our bodies can be tapped to utilize mind body approaches in a complementary manner for diabetes. In our experience, people with Type I diabetes have not been able to eliminate their need for insulin, but have often demonstrated more stable control using mind body approaches. In addition, the stress-reducing benefits of restful-alertness techniques improve the quality of life of those with diabetes.
Obesity is frequently an issue in Type II diabetes, which has proven to be an extremely challenging problem for Western medicine. Regardless of the approach, the vast majority of patients respond only temporarily before regaining their weight.27
From an Ayurvedic perspective, obesity is most often a hypometabolic or Kapha disorder. From this viewpoint, treatment includes a vigorous exercise program and a diet that reduces foods with sweet, sour, and salty tastes. Body Intelligence Techniques (BITS) can help to develop awareness of internal signals, and to avoid such common problems as eating when one is not really hungry or past the point of satiety. Mind body approaches encourage overweight people to develop a better awareness of their internal signals of hunger and satisfaction and not to confuse emotional needs with nutritional ones.
Occasionally, people with substantial Vata imbalances will become obese as they attempt to pacify their anxiety and agitation with food. They feed their anxieties through food: Whenever they feel restless, they eat something. For these people we recommend a Kapha-pacifying diet but a Vata-pacifying lifestyle.
When we are aware of our internal signals of hunger and satiety, we no longer attempt to fulfill our emotional needs by eating. To create this level of awareness, it is important to take time for silence each day in the form of meditation. This diminishes stress and improves integration between our mind and body. Taking a meal in silence is another very useful technique that helps us get in touch with our internal signals of hunger and fullness and ensures that we take in only the most nourishing foods.
From an Ayurvedic perspective, Type I diabetes is a Vata disorder. Patients are often hypermetabolic, have a tendency to lose weight, and frequently suffer from anxiety or depression. When this is the case, we recommend Vata-balancing exercise and diet programs. Vata-pacifying music, aroma, massage therapy, and yoga are also helpful in treating Type I diabetes.
Type II diabetes, in contrast, is a Kapha disorder. Recommended treatment includes a Kapha-pacifying diet that emphasizes pungent, bitter, and astringent tastes. In correct balance, these can stimulate metabolism and reduce blood sugar. Ayurvedic herbs such as neem (Azadiracta indica) and mehasringi (Gymnesyl sylvestre) are also useful for enhancing sugar metabolism, as is a type of squash called bitter gourd, which is available in oriental groceries. Patients who use these natural substances should closely monitor their blood sugars and make appropriate adjustments in their diabetic medications in partnership with their physicians.
Kapha exercises and a Kapha-pacifying program of sensory modulation through sound, touch, sight, taste, and smell are all recommended for Type II diabetes. Vigorous Ayurvedic breathing exercises such as Kapalabhati (forceful exhalation) and Bhastrika (forceful inhalation and exhalation) are also of value, as they are designed to stimulate metabolic activity.
Although biofeedback-assisted relaxation training is not universally successful, it can be particularly useful when people with diabetes recognize a relationship between their life stresses and elevated blood sugars. Learning to activate the restful-alertness response can have wide-ranging benefits for people facing diabetes.
Facing an illness such as diabetes is a genuine challenge. Fortunately, we are seeing important advances in the scientific understanding and treatment of this problem, resulting in improved quality of life for people with diabetes. Contacting deeper levels of silence and stability through complementary mind body approaches can add real value to the lives of people with diabetes.
1. Follow the Ideal Daily Routine as closely as possible.
2. Practice meditation daily.
3. Practice body awareness—check in regularly with the physical sensations in your body.
4. Use the BITS at every meal.
5. If you tend to be overweight, follow the Kapha-pacifying diet and routine.
6. If you tend to be thin, follow the light Vata-pacifying diet and the Vata-pacifying routine.
7. Favor bitter herbs and vegetables that have a blood-purifying effect. Commonly available bitter culinary herbs include turmeric, cilantro, fenugreek, and rosemary.
8. Ayurvedic herbs traditionally useful in stabilizing metabolism include neem (Azadiracta indica), guggulu (Commiphora mukul), and mehasringi (Gymnesyl sylvestre).
9. Whenever you make any changes in diet or activity, carefully monitor your blood sugars and work closely with your diabetes doctor.