Author’s Accepted Manuscript image

INFLUENCE OF TIME OF YOGA PRACTICE AND

GENDER DIFFERENCES ON BLOOD GLUCOSE
LEVELS IN TYPE 2 DIABETES MELLITUS AND
NORMAL HEALTHY ADULTS

Venugopal Vijayakumar, A. Mooventhan, Nagarathna

Raghuram
www.elsevier.com/locate/bios

PII: S1550-8307(17)30241-0
DOI: https://doi.org/10.1016/j.explore.2017.11.00310.7860/JCDR/2015/12666.574410.1016/j.dsx.2017.
6882-14-
21210.1016/j.aogh.2016.01.00210.1016/j.ihj.2013.03.00210.4103/asl.ASL_178_1610.1093/ecam/n
8210.14131810.1016/j.dsx.2017.04.01010.1007/s10654-015-0056-z10.4103/0975-7406.9010310.1
0018-310.1097/MD.000000000000474910.3109/07420528.2010.48900110.1016/j.jcjd.2013.02.06
Reference: JSCH2280
To appear Explore: The Journal of Science and Healing
in:
Cite this article as: Venugopal Vijayakumar, A. Mooventhan and Nagarathna
Raghuram, INFLUENCE OF TIME OF YOGA PRACTICE AND GENDER
DIFFERENCES ON BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES
MELLITUS AND NORMAL HEALTHY ADULTS, Explore: The Journal of
Science and Healing,doi:10.1016/j.explore.2017.11.003
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Influence of Time of Yoga practice and Gender Differences on Blood Glucose Levels in

Type 2 Diabetes Mellitus and Normal Healthy Adults

Venugopal Vijayakumar,1 A. Mooventhan,2 Nagarathna Raghuram3

1
Assistant Director, Stop Diabetes Movement, VYASA, Bengaluru, Karnataka, India

dr.venu@yahoo.com, +91 949223830.

2
Assistant Professor, Division of Yoga and Life Sciences, Department of Research and

Development, S-VYASA University, Bengaluru, Karnataka, India,

dr.mooventhan@gmail.com, +91 9844457496

3
Director, Stop Diabetes Movement, VYASA, Bengaluru, Karnataka, India,

rnagaratna@gmail.com, +91 9845088086

Corresponding Author:

Dr. A. Mooventhan,

Assistant Professor, Division of Yoga and Life Sciences, Department of Research and

Development, S-VYASA University, Bengaluru, Karnataka, India,

dr.mooventhan@gmail.com, +91 9844457496

ABSTRACT:

Background: Prevalence of type 2 diabetes mellitus (T2DM) is increasing worldwide. Many

studies have demonstrated the effectiveness of yoga in improving glycaemic control, whereas

no studies are available showing the impact of time of practice on glucose levels. The current

study explores the effect of time of yoga practice on glucose levels in community-dwelling

adults with and without T2DM.

Materials and Methods: A total of 189 subjects with T2DM and 121 subjects without

T2DM underwent a 10-day yoga program which includes practical and theory lecture

sessions for 60 minutes every day, either in the morning or evening. Baseline and post-

intervention assessments of fasting plasma glucose (FPG) were measured on day-1 and day-

10 respectively. Data analysis was done using statistical package for the social sciences

(SPSS), version 16.

Results: Results of the study showed that in individuals with T2DM, a significantly higher

reduction in FPG was observed while practicing yoga in the evening sessions than in the

morning sessions. Likewise, a significant reduction in FPG was observed only in women who

practiced yoga in the evening than in the morning, in non-diabetic healthy individuals, while

the reduction was not statistically significant in men.

Conclusion: Results of this study suggest that reduction in FPG level was better while

practicing yoga in evening than morning. Similarly, women had a better reduction in blood

glucose level than men.

Keywords: Gender; Glucose level; Time of practice; Type 2 diabetes mellitus; Yoga.

BACKGROUND

Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycaemia due to

insulin resistance or relative insulin deficiency or both.[1,2] Type 2 diabetes mellitus (T2DM)

is a major global health problem with a prevalence of 387 million in 2014[4] and is projected

to reach 552 million[2,3] by 2030.[2,3] India follows this global trend with a prevalence of 31

million diabetics in 2000,[1,2] 60 million in 2011 and is projected to reach 98 million by

2030.[2,3] The rising burden of diabetes has greatly affected the health care sector and

economy of developing nations like India.[2,4] In recent years, there has been an increase in
the use of non-medical measures in the management of T2DM and its associated

complications.[1,2]

Yoga is an ancient science and a way of life, believed to have originated around 5000 BC in

India and is being increasingly used in the field of therapeutics.[6] Yoga is associated with

reduction in fasting blood glucose, post prandial blood glucose and glycosylated haemoglobin

(HbA1C) levels.[2,5,7] Yoga is a slow static type of muscular exercise, which could be

performed by patients with limited joint mobility, reduced physical fitness due to overweight

and sedentary lifestyle who would otherwise be unable to participate in conventional type of

physical activities like gym-based training and vigorous strength exercises.[8]

Unlike many ‘traditional’ therapies, yoga could be applied to a larger population with T2DM

as it appears to be safe and inexpensive.[9] A community based yoga intervention study has

shown effective reduction in plasma glucose levels of individuals with diabetes and pre-

diabetes, however the dropout rates were reported to be high in the community based

intervention program.[10] It is vital to understand the reason behind these dropouts in yoga

studies, so as to provide better adherence and glycaemic control to the participants.

According to a yoga text, practice of yoga early morning around sunrise and evening around

sunset is encouraged to provide optimum health benefits.[11] In recent decades, many studies

have emerged, demonstrating the effectiveness of yoga in improving glycaemic control and

also the duration and intensity of practice required to provide the desired benefits..[12]

However, no studies have shown the impact of time of practice on blood glucose levels so

far. To our knowledge, the current study is the first ever study to explore the effect of time of

yoga practice on glucose levels in adults with and without T2DM.

MATERIALS AND METHODS

Subjects:

Subjects were participants from various Stop Diabetes Movement (SDM) camps conducted

across five different States of India, namely Gujarat, Karnataka, Maharashtra, Rajasthan, and

Tamilnadu. Adult male and female, above 18 years of age diagnosed with T2DM as per

American diabetes association (ADA) criteria were recruited for the study. Non diabetic

individuals of same age groups were also recruited for the study, to explore the relative

difference in the glucose levels post intervention. Any other forms of diabetes, pregnant

women and individuals with known psychiatric illnesses were excluded from the study. Study

protocol was approved by the institutional ethics committee and a written informed consent

was obtained from each subject.

Study design: This is a comparative study in which subjects were allocated into morning and

evening yoga sessions based on their willingness. Baseline and post assessments were taken

prior to and after the intervention.

Intervention:

All participants received practical yoga sessions and theoretical lectures sessions (on diabetes

and yogic concepts) along with their regular conventional medications. The duration of yoga

(practical) and the theory lecture sessions were 60 minutes/day (Table 1) and 30 minutes/day

respectively for a period of 10 days.

Assessment:

Fasting plasma glucose was assessed using a fully automated bio-chemistry analyser

(Mindray BS-390,China) before (Day-1) and after (Day-10) the intervention.

Data Analysis:

Data were checked for normality using Kolmogorov-Smirnov test. Statistical analysis of

within session was performed using students paired samples-t-test and between sessions were

performed using Independent samples-t-test for data which were normally distributed.

Similarly, for data which were not normally distributed, statistical analysis of within session

was performed using Wilcoxon Signed Ranks Test and between sessions were performed

using Mann-Whitney U test using Statistical Package for the Social Sciences (SPSS) for

Windows, Version 16.0. Chicago, SPSS Inc.

RESULTS:

Details of the demographic variables and baseline FPG of non-diabetic group and diabetic

group are provided in table 2. There was no statistically significant difference at baseline in

the demographic variables (age, height, weight, and body mass index) or in the baseline FPG

levels of male and female participants between morning and evening sessions (table 2). In

patients with T2DM, between group (i.e. morning session and evening session group)

analysis showed a significant reduction in FPG in both male and female who practiced yoga

in the evening, when compared with those who practiced yoga in the morning. In non-

diabetic healthy individuals, only female showed significant reduction in FPG while

practicing yoga in the evening which was not observed in morning session or in the male

participants.

Within group analysis of patients with T2DM showed a significant reduction in FPG from

baseline, for both genders and sessions. To find the difference in the reduction of FPG in

different practice sessions, the group was further divided into two sub-groups, viz. 1)

Morning session group and 2) Evening session group. A statistically significant reduction in

FPG was observed only in the evening session group and not in the morning session group.
DISCUSSION:

T2DM is a chronic metabolic disorder and is turning out to be a major health problem in

developing countries, probably due to rapid urbanization. There is growing interest amongst

people across the globe towards complementary and alternative medicine (CAM) therapies.

Individuals with diabetes are more likely to use complementary therapies.[13-15]

Yoga is one such widely used CAM therapy for promoting positive health and also a

therapeutic modality for effective management of many non-communicable diseases

including diabetes.[13,16] Many studies are available to understand the effect of various types

of yoga and also duration of practice.[12] To our knowledge, this is the first ever study trying

to understand the impact of ‘time of practice’ of yoga on glucose levels in community

dwelling adults with and without T2DM.

In the current study, Yoga sessions were taught in two batches i.e. 1) morning (5:30 am) and

2) evening (5:30 pm) to mimic the sunrise and sunset timings mentioned in the yoga texts. [11]

Same set of yoga practices (table 1) were taught during both the sessions by the same yoga

therapist to avoid inter individual variability. The dietary changes and physical activity

lectures given to both the groups were exactly same for both the group. Therefore, we assume

that the dietary changes and physical activity were same in both the groups. However, we did

not use any log book during the study to measure the amount of physical activity or dietary

modifications. After ten days of yoga sessions, a significant reduction in FPG was observed

in individuals with T2DM who practiced yoga in the evening session compared with those

who practiced yoga in the morning session. Sub-group analysis showed a better reduction in

women than men. Similarly, a significant reduction in FPG was observed in non-diabetic

women who practiced yoga in the evening session compared to those who practiced yoga in

the morning session.

Modern society, characterized by widespread use of electricity, shift work, prolonged

commute times and multiple leisure time activities have been reported to significantly change

the human sleep patterns. The average self-reported sleep duration decreased from over 8

hours in the 1960’s to approximately 6.5 hours in 2012.[17] In addition to voluntary and work-

related sleep restrictions, a variety of common sleep disorders such as insomnia and

obstructive sleep apnea syndrome contribute to impaired sleep in over 30% adults. [17] In the

community, individuals may prefer to compromise sleep time with watching television or

engage in other modes of entertainment. Sleep-related complaints are also reported to be

common in the community.[18]

Circulating cortisol, catecholamines, pro-inflammatory cytokines and markers of sympathetic

activation were reported to increase along with reduced circulating testosterone, thyroid

stimulating hormone, growth hormone secretion, and adipokines secretion after total or

partial sleep deprivation. Sleep is reported to be causally related to food intake and the

regulation of glucose homeostasis and impaired sleep thus contributes to the rising prevalence

of obesity and T2DM across the globe.[17]

In a study, early start times were reported not to be compensated with earlier bedtimes, and

total sleep time decreased as the work start time has advanced. The study also indicates that

advanced start times were linked with increased fatigue and feelings of not being well rested.

And thus, early start times were reported to be associated with sleep problems and fatigue. [19]

Moreover, early waking, and sleep disturbance often coincide.[20] Sleep disturbance or sleep

restriction has been reported to increase evening cortisol levels, which consequently increase

insulin resistance in the next morning.[21]

In the current study, individuals who were practicing yoga in the early morning were advised

to attend the yoga session by 5:30 am which means they have to get up in the early morning

around 4:30 to 5:00 am to get ready and reach the venue without compensating their normal

routine. This might have possibly altered their normal sleeping hours and a disturbed

circadian rhythm. Getting up early in the morning and getting ready for the yoga sessions

could also possibly be a stressful factor for those who do not have the habit of getting up

early. The chronic psychological stress and negative affective states have been reported to

significantly contribute to the pathogenesis and progression of insulin resistance and glucose

intolerance.[16] Sympathetic activation increases hepatic glucose release and muscle insulin

resistance by affecting lipid and glucose metabolism, through circulating factors as well as

neural innervations of the liver, pancreas, skeletal muscle and white adipose tissue. Adrenal

epinephrine released during sympathetic activation triggers glucose production and impairs

insulin secretion, thereby promoting insulin resistance.[17] Yoga could possibly be

augmenting the impact of reduced cortisol levels observed in evening due to diurnal

variations in cortisol secretion.[22] Thus, the lack of significant reduction of glucose levels in

individuals who practiced yoga in the morning session and a significant reduction in glucose

levels in individuals who practiced yoga in the evening session could be attributed to these

multiple factors.

Similarly, this is also the first ever yoga study to report a gender difference in reduction of

blood glucose levels after yoga practice. A better reduction observed in the female

participants could be attributed to a better embracing of the lifestyle modifications suggested

during the theory sessions. Women are reported to use CAM therapies and preventive care

facilities more frequently than men.[23, 24] However, this interpretation is only hypothetical

and further studies are required to explore the possible reasons behind this gender differences

observed in the study.

Strength of the study:

With no appreciable side effects and multiple collateral lifestyle benefits, yoga seems to be a

safe practice and could be practiced even by elderly individuals.[16] In the modernised fast-

paced lifestyle, getting up early in the morning and practicing yoga might be one of the top

most reasons for the dropouts especially in the community based studies. In order to avoid

such problems, the feasibility and the efficacy of practicing yoga in the evening should be

explored. The present study explored the feasibility and effectiveness of evening yoga

practices and observed that the effects of evening yoga practise on reducing FPG levels is

significantly higher than the morning yoga practise in this particular sample that was selected.

Limitations of the study:

Number of subjects was not equal in morning and evening sessions. Sample size was less in

evening session group compared to morning session group of both in adults with and without

T2DM which might have influenced the outcome and/or statistical test to get significant

difference. Subjects of the study chose their own convenient timing for the yoga practice and

were not randomised. Lack of varied biochemical outcome variables apart from FPG and

further assessments like quality of sleep, sleep architecture; lack of active control group are

few of the other limitations. Hence, further studies are required with equal number of

participants both in morning and evening yoga sessions with active control group. Longer

duration of intervention and further investigations would help in better understating and

derive robust conclusion on the effect of time of practice on blood glucose levels.
CONCLUSION:

Results of this study suggest that reduction in FPG levels were better in those who practiced

yoga in the evening session than those who practiced yoga in the morning session. Likewise,

better reduction was observed in women than in men. Further studies are required to

substantiate these results.

SOURCE OF FUNDING: Nil

CONFLICT OF INTEREST: Authors declare no conflict of interest

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TABLES:

Table 1: Details of the yoga practices given to the subjects

S.No. Name Practices Duration (Minutes)
1. Opening prayer 1
2. Loosening Practices Pawanmuktasana series & 10
stretching (spinal twists,
chakkichalana, chappathi making,
Bhunamanasana)
3. Instant Relaxation Technique (IRT) 1
4. Surya Namaskara
5. Quick Relaxation Technique (QRT) 3
6. Asanas Ardhakatichakrasana 2
Vakrasana 2
Bhujangasana 2
Pawanmuktasana 2
ArdhaMatsyendrasana 2
Dhanurasana 2
7. Deep Relaxation Technique (DRT) 10
8. Pranayama Slow Kapalbhati (30 Strokes) 1
Nadishudhipanayama 3
Bhramari pranayama 3
9. Cyclic Meditation 15

10. Closing Prayer 1

Total Duration (Minutes) 60

Table 2: Demographic and baseline fasting plasma glucose levels of non-diabetic group (n =

121) and diabetic group (n = 189)

Between Morning

and Evening
Morning Evening
Group Gender Variables Sessions Analysis
Session Session
t/z
p-value
value

Age (years) 51.37±8.45 53.80±9.73 0.608 0.545≠

Height (cm) 167.51±7.70 171.08±5.94 1.005 0.319≠

Weight (kg) 75.60±13.33 69.68±11.88 0.957 0.343≠

Body mass
Male
index 26.76±4.14 23.65±3.39 1.625 0.110≠

Non- (kg/m2)

Diabetic Baseline FPG

90.48±22.35 90.42±21.41 0.005 0.996≠
Group (mg/dl)

Age (years) 47.35±8.54 45.63±9.76 0.699 0.488≠

Height (cm) 158.21±5.92 157.02±6.39 0.711 0.480≠

Female Weight (kg) 71.90±11.85 67.24±13.41 1.373 0.175≠

Body mass
28.54±4.57 27.20±5.23 1.013 0.315≠
index
 (kg/m2)

Baseline FPG
90.83±16.12 89.58±17.79 0.271 0.787≠
(mg/dl)

Age (years) 54.31±11.28 58.64±10.62 1.786 0.077≠

Height (cm) 168.20±6.83 169.19±7.33 1.150 0.250!

Weight (kg) 74.52±11.18 71.51±19.20 1.781 0.075!

Body mass
Male
index 26.33±3.85 24.95±6.39 1.368 0.174≠

(kg/m2)

Baseline FPG
131.34±48.45 135.56±50.77 0.376 0.707!
Diabetic (mg/dl)

Group Age (years) 54.91±10.67 57.45±11.23 1.013 0.314≠

Height (cm) 155.70±7.26 153.81±5.72 0.877 0.381!

Weight (kg) 63.53±11.50 60.26±10.95 1.259 0.212≠

Body mass
Female
index 26.42±5.04 25.51±4.68 0.806 0.423≠

(kg/m2)

Baseline FPG
120.49±32.74 142.49±62.54 1.225 0.221!
(mg/dl)

Note: All values are in Mean ± Standard deviation. ≠ = Independent samples-t-test; ! =

Mann-Whitney U Test. FPG = Fasting Plasma glucose

Table 3: Baseline and post-test assessments of non-diabetic group (n = 121) and diabetic

group (n = 189)

Within

Session
Sampl
Sessio Analysis
Group Gender e size Pre FPG (mg/dl) Post FPG (mg/dl)
n t/z
(n) p-
valu
value
e

Both 121 90.46±19.35 88.37±16.92 1.20 0.232

M&E 2 *

M 97 90.63±19.74 89.19±16.94 0.70 0.486

Both 0 *

Gender E 24 89.76±18.09 85.07±16.78 1.73 0.082

s 8 ¶
Non-
Between z= p= z= p=0.079
Diabeti
Sessions 0.127 0.899! 1.759 !
c
Analysis
Group
Both 59 90.47±22.09 88.74±20.29 0.67 0.502

M&E 5 *

M 54 90.48±22.35 88.96±20.47 0.54 0.587

Male
7 *

E 05 90.42±21.41 86.34±20.13 0.82 0.459

0 *
 Between t=0.00 p=0.996 t=0.27 p=0.785

Sessions 5 ≠ 4 ≠

Analysis

Both 62 90.45±16.51 88.02±13.10 1.02 0.311

M&E 2 *

M 43 90.83±16.12 89.47±11.26 0.43 0.667

4 *

Female E 19 89.58±17.79 84.74±16.40 1.55 0.121

0 ¶

Between t=0.27 p=0.787 z= p=0.041

Sessions 1 ≠ 2.048 !

Analysis

Diabeti Both Both 189 131.39±48.68 124.53±40.11 2.60 0.010

c Gender M&E 5 *

Group s M 128 127.61±43.86 127.20±38.08 0.14 0.888

1 *

E 61 139.31±57.08 118.91±43.88 3.72 0.000

5 ¶

Between z= p=0.303 z= p=

Sessions 1.031 ! 2.004 0.045!

Analysis

Male Both 112 132.39±48.84 128.34±43.33 1.23 0.220

M&E 4 *
 M 84 131.34±48.45 130.91±40.79 0.12 0.904

1 *

E 28 135.56±50.77 120.66±50.22 1.93 0.053

4 ¶

Between z= p=0.707 z= p=0.124

Sessions 0.376 ! 1.539 !

Analysis

Female Both 77 129.92±48.72 118.97±34.42 2.52 0.014

M&E 2 ¶

M 44 120.49±32.74 120.13±31.49 0.07 0.943

2 *

E 33 142.49±62.54 117.43±38.44 3.26 0.001

1 ¶

Between z= p= z= p=

Sessions 1.225 0.221! 0.788 0.431!

Analysis

All values are in mean ± Standard deviation. * = Students paired samples-t-test; ¶ =

Wilcoxon Signed Ranks Test; ≠ = Independent samples-t-test; ! = Mann-Whitney U Test. BMI

= Body mass index; FPG = Fasting Plasma glucose; M = Morning session; E = Evening session.