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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

“I can do almost anything”: The experience of adults with type 2 diabetes with a yoga intervention

Herpreet Thinda,∗, Kate M. Guthrieb, Santina Horowitzc, Matthew Conradd, Beth C. Bockb

a Department of Public Health, University of Massachusetts Lowell, 61 Wilder Street, Lowell, MA, 01854, USA b Psychiatry & Human Behavior, The Warren Alpert Medical School of Brown University, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, 167 Point Street, Providence, RI, 02903, USA c Centers for Behavioral and Preventive Medicine, The Miriam Hospital, 167 Point Street, Providence, RI, 02903, USA d Roger Williams University, Bristol, RI, 02809, USA

1. Introduction

Diabetes mellitus is a complex metabolic disease affecting about 1 in 10 American adults, and between 90 and 95 of these have type 2 dia- betes (T2DM) [1]. The chronic hyperglycemia characteristic of diabetes is associated with several complications, including serious damage to kidneys, eyes, and nerves, and an increased risk of heart disease and stroke [2]. Controlling blood glucose level is critical to the management of T2DM, and typically cannot be achieved by medications alone. The current standard of care for T2DM includes nutrition counseling and recommendations to engage in regular physical activity [3]. Yoga, a mindfulness-based physical activity, may have special relevance for T2DM management. Several mechanistic pathways have been proposed by which yoga may influence outcomes among individuals with T2DM [4]. Yoga practice may reduce activation of the sympathoadrenal system and hypothalamic-pituitary-adrenal axis, enhance para- sympathetic activity, and reduce stress, and may encourage self-care activities [4–6]. Several studies have examined the effect of yoga on glycemic outcomes among adults with T2DM [7–9]. Though promising, results of these studies are limited due in part to methodological con- cerns in study designs. Moreover, nearly all of these studies have been conducted in countries outside the United States, thereby, precluding any firm conclusions about the feasibility, acceptability and efficacy of yoga as a complementary therapy for T2DM for the US population.

Healthy Active and In Control (HA1C) is a pilot study examining the feasibility and preliminary efficacy of yoga for adults with T2DM. In addition to quantitative assessments of glucose management and psy- chological factors associated with diabetes self-care, we used a quali- tative approach to understand the participants' perceptions of practi- cing yoga and its effects. Qualitative research has the advantage of identifying benefits and barriers of the intervention as experienced by the participants, which can be missed in quantitative assessments. Specifically, participants' qualitative response can help to explain why a program had the effect that it did or failed to demonstrate the expected

effect, while providing a more in-depth, experiential perspective on the intervention [10]. In this report, we present participants' experiences with the yoga practice and their perceptions about the intervention and its relationship to any changes in diabetes management.

2. Methods

Participants from this study were enrolled in the Health Active and In Control (HA1C) trial. In that randomized controlled trial, adults with T2DM were randomly assigned to either; (1) a 60-min, 12-week Iyengar yoga intervention given twice weekly, or (2) a twice-weekly 12-week program of 60min of standard exercise (e.g., walking, stationary cy- cling). Both interventions were delivered in group format in two con- secutive cohorts. Quantitative assessments were conducted at program entry (baseline), end of treatment (12-week), and at 3- and 6-months post-intervention. Focus groups were conducted with participants in the yoga arm at the end of the 12-week intervention. Procedures for the overall HA1C trial have been presented in detail elsewhere [11]. This paper reports on the qualitative focus group data collected from the yoga participants. IRB approval for the study was granted by The Miriam Hospital Institutional Review Board.

2.1. Participant recruitment

Participants for the HA1C study were recruited through the colla- borating diabetes center and through advertising in the community (i.e. radio, flyers, Craigslist, etc.). Interested individuals calling the study phone line were screened by trained research assistants for eligibility. Inclusion criteria consisted of age>18 years with T2DM for more than 6 months, and HbA1c levels> 6.5. Individuals with serious co-morbid conditions, serious psychiatric disorders, BMI ≥ 42 kg/m2, pregnancy or planned pregnancy were excluded. Individuals were also excluded who had engaged in any mindfulness-based program (e.g., yoga, Tai Chi) or stress management therapy in the past month or attended more

https://doi.org/10.1016/j.ctcp.2018.11.011 Received 29 August 2018; Received in revised form 16 October 2018; Accepted 15 November 2018

∗ Corresponding author. E-mail address: [email protected] (H. Thind).

Complementary Therapies in Clinical Practice 34 (2019) 116–122

1744-3881/ © 2018 Elsevier Ltd. All rights reserved.

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than three such classes in the past six months. Individuals unable to read or write in English were also excluded. We used a revised Physical Activity Readiness Questionnaire (PAR-Q +) [12] to screen for dia- betes-specific complications (e.g., gangrene, foot ulcer, etc.). If one or more items were endorsed on the PAR-Q+, physician consent was re- quired for participation in the study. Eligible individuals were invited to attend an orientation session where the study was described in detail and written informed consent was obtained.

2.2. Yoga intervention

Participants randomized to the yoga group (n=24) attended 60- min, beginner-level Iyengar yoga classes conducted Tuesday and Thursday evenings at 5:30 p.m., weekly for 12 weeks. Classes were led by two certified Iyengar yoga instructors, with over 15 years of ex- perience teaching yoga to individuals with wide range of fitness levels and medical history. Each class consisted of guided meditation and breath-work, active and passive asanas (i.e., postures/positions) in- cluding standing, sitting, twists, backbends, inversions and restorative postures and guided relaxation including Savasana (i.e. corpse-pose). These yoga sessions were designed to emphasize mindfulness (i.e., staying focused on the present moment) and a meditative state (i.e., calming and stilling the mind). Participants were encouraged to prac- tice yoga at home at least twice/week in addition to their supervised sessions. Printed workbooks with photos of the yoga asanas and se- quences were provided to participants along with props (e.g. blocks, straps) and a DVD to aid home practice.

2.3. Qualitative methods

Focus groups were conducted to understand participants' percep- tions and beliefs about the intervention and its relationship to any changes that participants may have experienced in diabetes manage- ment. To explore the potential mechanism of yoga, we wanted to ex- plore its effect on stress and self-care behavior. We also elicited feed- back on the feasibility and acceptability of yoga and the study procedures to help identify any areas needing refinement prior to launching a future larger efficacy trial. A qualitative data collection guide was used to ensure that important topics were covered in the discussion (Table 1). These key topics included the effects of yoga on physical functioning, perceived stress and diabetes management, and logistics of the program likely to affect feasibility. A trained investigator with over 20 years of experience in qualitative research, whom the participants had not previously met, facilitated the discussion and two other members from the research team took notes. Each group lasted about 90min, was audio recorded and transcribed verbatim. Partici- pants received $50 for their time.

Transcripts were reviewed by study research assistants for accuracy and completeness and then de-identified. A coding structure was de- veloped based on the focus group agenda, and then iteratively as more nuanced concepts or emergent constructs were identified from the transcripts. Each transcript was independently coded by two re- searchers who have experience in behavioral interventions and training in qualitative methods. Codes were discussed, and if any discrepancies were found, they were resolved with input from the third investigator, who has over 20 years of experience using qualitative research to de- velop interventions and assessments. Final codes were entered into NVivo qualitative data management software for thematic analysis. Individual codes were reviewed by study investigators and summarized to identify important themes and key concepts within each theme. These data were further interpreted as relevant to the study's primary qualitative research questions and illustrative quotes were extracted.

3. Results

Of the 24 individuals randomized to the yoga condition, 22 were

able to attend a focus group discussion. Three focus groups were held between May and December 2017, one with cohort-1 participants and two with cohort-2 participants, allowing 6–9 participants in each group. Over half (59%) of the participants were women. Participant mean age was 58.5 years (SD=5.33, range=51 to 70); 41% were married, 77% were non-Hispanic Whites, 41% had a college or ad- vanced degree, and 27% had annual household income of less than $50 K. Participants were either overweight (23%) or obese (77%) (mean Body Mass Index= 34.16 kg/m2, SD=4.23, range 25.6–40.9). Several themes and important concepts within each theme were iden- tified (Table 2).

3.1. Effect of yoga

3.1.1. Physical benefits A majority of the participants reported improved flexibility after

practicing yoga. Some stated that yoga might have relaxed muscles that were previously tense, and a few felt that yoga increased their muscle strength. Overall, a majority experienced improvement in their body movements not only in class, but also while performing everyday tasks, such as the ability to bend down and get up from the floor without aid, sitting cross-legged, kneeling in church, etc. “I've learned that I can be much more flexible. I can do exercises, do things that make me feel a whole lot better and feel like I can do almost anything.” [Male, 55 years].

Participants also reported that yoga helped them be more mindful of their posture; they were able to attend to poor posture and correct it. One participant mentioned that she used to slouch, but, because of

Table 1 Focus group agenda.

Yoga class experience 1. In one word or phrase describe your experience with the yoga program. 2. Please describe your experience with yoga: Probe for postures, breathing exercise,

meditation 3. Please describe your experience with the postures: Probe for: specific postures,

experience of maintaining the posture and breathing into it, comfort with specific pose(s), with which they felt most/least comfortable, how comfortable or complex each was over time course, which postures are still being practiced; capture rationale for each, after how many classes did they feel comfortable with postures

4. How did you feel after a yoga class? Probe for: effects on body, when did they realize the effects, how long do the effects last, poses associated with those effects, difference in the body since starting the program.

5. What motivated you to practice yoga? describe. 6. What prevented you or discouraged you from yoga practice? Describe Effect of yoga on stress and diabetes management 1. Tell me how your health is different since being in the program, if at all. Probe

for: attributions of the effect being related to yoga experience. 2. What physical changes, if any, have you experienced? 3. What emotional changes, if any, have you experienced as a result of the yoga

classes? Probe for: stress level/stress reduction or an increase in stress, other emotions.

4. Are you doing anything else differently since starting yoga? Probe for: exercise, eating differently, medication adherence.

5. Have there been any other effects of yoga? 6. During class yoga instructor talked about awareness of the body during yoga.

They may have asked you to pay attention to the 4 corners of the feet or to the ‘back body’ during poses. What did you think of those instructions? Probe for: awareness of body, awareness of lifestyle/behaviors.

7. Tell me how your yoga practice has had an impact on your health. Probe for: effect on diabetes, or any co-existing condition

Yoga maintenance 1. Did you do any yoga at home or anywhere else other than study center during the

12 weeks of classes? If yes, where, when, how? Probe for: home practice, other studio

2. Are you currently practicing yoga? 3. Do you plan to continue yoga? If yes, probe for: where, when how. If not, why

not? Program evaluation and conclusion 1. What did you like most about the program? 2. What did you like least about the program? 3. Is there anything else about your experience that we should know?

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Table 2 Focus group themes.

Themes Quotes [age, sex]

Benefits of Yoga Physical benefits

Improved flexibility “I do notice it's easier for me to—because I have a dog, a cat, and a 15-year-old—so when his stuff hits the floor and I notice it's so much easier to bend over and get it. Just little things like that. Yeah. I notice a difference.” [52 years, Female]

Improved posture “Before, you were limited by what you could do … now the posture's good and everything else.” [55 years, Male] Decrease in aches and pain “I used to always have backaches trying to sit up straight and tall, and my back is so much better, so much stronger. I mean, I used to be

all tense in here, gone.” [52 years, Female] Equilibrium/balance “I've been a diabetic for a long time, but as I aged and the diabetes progressed, that's when I would stumble, but taking the Vitamin B12

along with the yoga––the yoga really has strengthened, so it does have something to do with your core––stumbling too, but I think between those two, it has really helped not to lose my balance so much.” [60 years, Female]

Emotional benefits Increase in confidence “I think this took away a lot of the discouragement that we had. It gave us more encouragement that, ‘Yeah, I'm gonna go back to the

gym, too. I'm paying for it, I'm gonna meet you there’. [Chuckles] It helped a lot.” [55 years, Male] Mindfulness “Toward the end of the yoga sessions, one of the teachers brought up the fact that there's a difference between reacting and responding

and that, if you can, try to scale back on the reacting and do more responding. I noticed in my own life a few real stressful things came up after I heard that, and I reacted all right. It wasn't that I did not react, but I think I scaled it back and went into responding rather than keeping into the reacting or revving up the reacting.” [63 years, Female]

Reduced stress “Totally helped my stress level. Then leaving here, I felt like I did something good for the day. I learned from it. It was helping me. There actually are a couple of changes I've gone through that I can't explain over the past 12 weeks.” [56 years, Male]

Relaxation/Calm effect “I looked forward to each class. I did not miss any classes. I was very fortunate. I did not have any event come up that prevented my attending class. I was so glad to be able to come. And When I would leave class and drive home, I felt very calm.” [63 years, Female]

Effect on diet “What I found was after––because I would come straight from work to here, do the yoga, then go home. I found myself watching what I was eating because I was, okay, I just went through an hour of ‘exercise’. I'm not gonna sit there and order, eat a pizza.” [51 years, Male]

Effect on sleep “I always have a hard time going to sleep and my hours are different and when I come to yoga and I'd go home and I would get––definitely get a good night's sleep on the yoga nights. It surprised me because I would not break a sweat with yoga and you would think that you––but because you're stretching and doing all of that, I think it just kind of like makes your body feel good and I never got cramps anymore in my legs.” [60 years, Female]

Effect on diabetes “It's strong, and the breathing, you're not as stressed out, ‘cause you know when your stress level rises, your cortisone … that rises, and high blood pressure, which is combined with it. It all plays a part in it. If you can get your body to relax and everything else relax—like I said, I came in here one time and I was hungry, headache, stressed out. I left here, I was not hungry. My headache was gone. I wasn't stressed out. I had a good night. That would've never happened without my yoga.” [57 years, Female]

Barriers to Practice and Attendance Medical condition “I did miss two weeks plus a day or two here. I got sick in the middle of it. I got the flu.” [56 years, Male]

“I couldn't do child's pose because I fell last year and damaged the nerve endings in right leg so I couldn't do the child pose.” [60 years, Female]

Traffic “Overall, I loved the class. What I liked least out of everything was [interstate] 95. At that time, really, it's awful.” [70 years, Male] Class timing “Mine would be the timing, I found it difficult the timing.” [56 years, Female] Personal commitments (work, family) “Even for me to not be at home could be stressful for me because of this. My son's on a good medication and hasn't had a seizure now in

a year and a half, but when you have that sort of problem with a child, it's hard to separate. At least it has been for me. This has been huge for me to just be away for a couple––at dinnertime. It probably was the worst timing for me because they're home from school and it's dinnertime. I thought, “Oh that's not gonna work,” but it's worked. I've done it.” [56 years, Female]

Perception of Yoga versus Exercise “I don't even know what the yoga class entails, but I know when I went to the gym and I got on the treadmill, that was exercise. I really, really sweated it out and was breathing heavy. It felt exhausting. I didn't do that here, I just felt relaxed in everything I did.” [57 years, Female]

Group Effect “What I liked most about it was getting to meet all the people that were diabetic like myself that I could talk to and I knew had some of the same issues.” [59 years, Female]

Study Feasibility and Acceptability Reasons for joining study “before I came, I was like, ‘Damn. I've seen my doctor. I don't even want to go see my doctor anymore.’ I was in a—not hopeless kind of

way—but in a, ‘Something's gonna give, because I'm kind of maxed out on meds. I don't want to start shooting up all kinds of more things that I'm doing’.” [56 years, Male]

Feasibility of practicing the poses “there were things that I could push myself to do. It was good. Some things I needed a lot of work on. Some things I may never do, but there were things that I found that I could do and I think that kept me going.” [51 years, Male]

Safety “I just to want to hit on something that she—when you were mentioning when you were doing certain poses and how it hurt after … Well, I can feel that the next day, but in a good sense, because it kind of opened up some—it freed up some muscles that obviously I must have been tense … – but now I was opened up and I was a little bit more relaxed. It's not that it was pain. I felt it, but that was—it was good that I felt it. As the weeks went on, I felt myself being more flexible, being able to bend down farther down and movements, and a lot of that.” [57 years, Female]

Program structure “That actually gave me comfort that somebody was keeping tabs on me and giving me reminders on a weekly basis. Because I have a tendency to forget a lot of things even though they're right in my calendar.” [56 years, Male] “I think that they taught the class at the level that needed to be taught. She gave you a couple of things that pushed you each week––like it was a little something that pushed you a little further but it definitely was at a great pace.” [60 years, Female]

Home Practice and Maintenance “When I go to the gym, I go on the stretch bars, and I do stretches and moves of yoga. I don't do it at home, ‘cause I go to the gym.” [52 years, Female] “I have no space in my house, not enough space, so I can't do many. I try the backwards—the shoulder one, but my chairs are like studio-size chairs, so I can't do it.” [59 years, Female] “I just love it and I do it at home. I go down in the basement. No one bothers me. They leave me alone and I hide. [laughter] No, I don't hide. I just absolutely––I'll do this for the rest of my life.” [70 years, Male]

Recommendations to Improve Yoga Program “I mean, three months is not a long time, because I just think after that you can go back into an old—your old habits. I think if it's a little bit longer, you're more prone to do this again the following year, because you've been at it.” [57 years, Female] “If I could change anything, I would like—I mentioned it earlier, maybe a food aspect, too. Because you can do all the exercise in the world, if you're not eating right, your sugar won't” [54 years, Male]

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yoga, was more aware of her posture. She stated that correcting posture not only made her feel strong, but she also felt proud, “Like a peacock, proud” [Female, 63 years]. Another participant mentioned that correct posture made him feel tall. “I know when I came into it, I was slouching … Then at the end, I felt like I could actually stand up straight. I wonder if that affected my height. I feel like six feet [tall] right now.” [Male, 55 years].

A few participants who had musculoskeletal issues before joining the program, reported a decrease in their aches and pains. “I strength- ened my knees. I stretched my knees at my level and it's really—I mean I went through therapy for months and I have an exercise bike, but what it did for my knees was totally different than what I've done on machines, and so that was really beneficial.” [Female, 56 years] One participant who had backaches reported that her back felt good after yoga class and after home practice of yoga. “I have a bad back. I had a couple of vertebrae fused—put together, and when I leave here, my back feels really good, and I'm able to go home—in the morning, when I get up, I do some exercises that I learned in class. It helps make my back not so tight. I do it durin’ the day, too. It helps me be more flexible.” [Female, 63 years]. Another participant who previously experienced numbness in his leg due to the sciatic nerve problem, reported improvement since starting the program. “I find that I'm more flexible, the joints feel looser. I had a specific problem with sciatic nerve, and at least three or four times a week, I'd have the numbness in my leg. I haven't had that in eight weeks.” [Male, 69 years].

Two participants who had problems with body equilibrium due to past medical conditions experienced improvement in their balance. “This has made my equilibrium, a little bit stronger for me, which it wasn't. It was way off before. I couldn't get down on the floor, and now I can get down on the floor and get back up without having to lean on something. It has helped tremendously with my equilibrium.” [Female, 58 years]. Other participants also reported improvements in the ability to do poses that required balance.

3.1.2. Increase in self-confidence Many participants reported apprehension about their ability to do

yoga poses, but as the classes progressed, their body flexibility im- proved, and they were able to do poses more effectively. They felt a sense of accomplishment after being able to do the poses they initially considered too difficult. “My favorite [part of the study] was learning that I could do what I didn't think I could do.” [Female, 60 years] Their overall self-confidence increased, which in turn motivated them to complete the program and to engage in physical activities outside of the class, e.g. joining a gym. Participants felt they had learned something new about themselves and their own potential. “Even the confidence it gave to me though, ‘cause I didn't have the confidence before. That's what the yoga gave me. I said, ‘All right. Yeah, you can do it.’ … I'd always find an excuse why I can't bend and get that, my weight or something else like that. It showed me that I could do it.” [Male, 55 years].

3.1.3. Mindfulness Participants' description of their experience with yoga indicated that

they had become more mindful. “The total change in how I feel about almost everything. It's so totally different it's unreal. It's like I go home and it's just, I can—I know how to take myself out of the stressful situations. It gave me things to be able to respond to those issues and gave me the con- fidence that I know now that I don't have to react. I can just respond to everything.” [Female, 58 years].

Participants mentioned that while practicing the different poses, they were asked by the instructors to pay attention to their body parts, whether they felt weak or tense, and how their bodies responded to yoga. Each session also included the ‘body scan’ technique to increase awareness and focus on the present moment. Participants reported that doing this over time helped them to become mindful of their body and their emotional state. Breathing in and out during poses also had a soothing effect and helped them to work through discomfort to execute the poses. “It also made you aware of different parts of your body … ‘Cause before … you just didn't really even think about it, but this makes you think

about how different … your body feels when you're sitting in the position. Well, maybe your left side feels different from your right side. They [in- structors] would make you notice that. It helps out immensely, because then you can focus on that side that might be hurting more than the other. They would tell you to take your breath to that area and try and make the change. It did. It helped.” [Female, 58 years].

3.1.4. Emotional effects A majority of participants reported feelings of reduced stress after

practicing yoga. “The classes have been kind of a haven from the stress of the work day, somethin’ to really look forward to.” [Male, 63 years] Each class would start with the relaxation practices to free the mind of the stressors of the day and allowed participants to let go of everything and focus. Most reported feeling relaxed physically and emotionally after yoga class. For some, this effect lasted for several days after the class. This feeling of relaxation further motivated them to continue with the yoga practice. “Just the level of stress that was way up here and at the start of yoga, came all the way down. I felt better. I had had a headache. The headache was gone. I wasn't hungry. I think it was one of the—being hungry because I had a headache, because I was stressed out. I wasn't hungry anymore. That's what yoga does for me or did for me then and probably what it will do if I continue down this path.” [Female, 57 years].

As alluded to above, the perceived benefits of yoga were not re- stricted to class practice. Participants noted that yoga gave them a tool to deal with stress in their routine lives. Participants found themselves responding to situations with acceptance where previously they would have felt stressed, for example, in traffic, or when dealing with stressful situations at work. They reported using breathing exercise to ‘stay in the moment and relax’, and learned to apply the concept of ‘responding instead of reacting’ to stressful life situations, feeling that they could handle situations calmly. “People at work that could get right on my last nerve, tend to not bother me [now]. I found a way and I believe part of it is … because when you're in this class and she's teaching you, she's like ‘ … Bring yourself back to center. Get rid of all the outside chatter … ’ I gotta say, this was better than going to a therapist and cheaper.” [Female, 60 years].

Yoga was perceived by most participants to be helpful for emotional well-being. One participant mentioned that she used to take medication for panic attacks, but since joining the study had used breathing tech- niques instead of relying on medication. Another participant indicated significant improvement in managing anger. “This has seriously helped me to calm myself down. As she said, not to react but to res