Are You Next?

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When Jane Goldman, a 42-year-old legal assistant from Pittsburgh, went to see her doctor because of fatigue she couldn't shake, she was shocked to discover the underlying cause: type 2 diabetes. "I thought I was in generally good health," Goldman recalls. "I was maybe 10 or 15 pounds overweight, but aside from feeling tired, I had no complaints." Like many others surprised by a diabetes diagnosis, Goldman had always associated the chronic illness with people who were either elderly or obese or both: "Several of my great-aunts had it when they were quite old and very overweight." Until her diagnosis, Goldman didn't realize those extra pounds, combined with her genetic history, were enough to trigger the disease.

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Sadly, Goldman's story is increasingly typical. According to the American Diabetes Association, there are 13 million Americans diagnosed with type 2 diabetes and another 5.2 million who are undiagnosed. Even more worrisome is the rate at which the disease is proliferating—the Centers for Disease Control and Prevention report that diabetes diagnoses (types 1 and 2) have increased 61 percent since 1991, and the World Health Organization predicts the numbers will double by 2030. The elderly are not the only ones developing the disease—more children and teenagers are being diagnosed. And it's not just an American problem; countries such as India and China are seeing an increase, making type 2 diabetes a global epidemic.

Type 2 diabetes develops when you have a shortage of insulin or a resistance to it—or typically, a combination of both. (Type 1 is usually an autoimmune disease that causes insulin to cease production altogether. Only 5 percent of the population suffers from type 1.) Insulin is a hormone that allows the energy of glucose (sugar) to be stored in the body for later use. When glucose isn't converted properly, as is the case with diabetics, it builds up in the blood, which damages the vital organs and leads to a long list of life-threatening complications. It's the complications—heart disease, stroke, high blood pressure, kidney disease, and nerve damage that can lead to gangrene and amputation—that make the disease so dangerous.

Although the problem is growing, it's not insurmountable. Unlike type 1 diabetes, which is impossible to prevent, type 2 can be prevented or at least delayed—even in high-risk groups (those with a strong family history, or with a condition known as prediabetes, where blood glucose levels are higher than normal). And the means to do so are within reach: Lose weight by reducing your caloric intake, exercise more, and lower your stress. Ongoing research suggests yoga can help you do all three.

That's what Goldman discovered. When a colleague organized a lunchtime yoga class, Goldman's whole perspective changed. "It was the first time I really breathed fully and was able to relax since my diagnosis. For a few minutes, my mind stopped racing with worries, and I knew I had to continue it if I wanted to stay sane," she says.

know your risk

Genes play a big role in diabetes. Even if you're overweight and sedentary, you won't develop this chronic illness if you don't have the genetic predisposition. But figuring that out isn't always simple. Currently, there's neither a genetic screening test nor a way to know how much weight gain will trigger the disease if you've got the genes. "There are many people with a genetic predisposition to the disease, but it may not show up in their family history because their parents and grandparents took good care of themselves," says Mark Feinglos, M.D., Chief of Endocrinology at the Duke University Medical Center in Durham, North Carolina. "But if the genetic predisposition is there and you do the wrong things, you put yourself at risk." Though most associate type 2 with chronic obesity, Feinglos notes, "if you've got a big dose of the genetic predisposition, it might not take much extra weight to put you over the top." (To help determine your risk, visit www.diabetes.org/risk-test.jsp and take the test you'll see on the site.)

Because of their genetic background, African Americans, Asian Americans, Native Americans (approximately 60 percent of the Pima Indian population develops type 2 diabetes, compared to 5 percent of Caucasians), and Latinos are at a higher risk for diabetes than other ethnic groups.

Researchers attribute this high incidence among certain groups to the "thrifty gene" theory. Postulated by James Neel, Ph.D., in the 1960s, the theory holds that years ago, when societies suffered periods of feast and famine, humans developed genes that allowed them to store more fat during times of abundance so they could survive when food was scarce. Many now carry these thrifty genes, causing them to store fat more easily than others, which can lead to diabetes.

reduce your Stress

If you're diagnosed with type 2, your doctor will typically prescribe a three-pronged approach to treatment—a healthy diet, regular exercise, and medication—in hopes of controlling blood sugar levels and preventing complications. But blood sugar levels can be difficult to maintain. Even if you avoid foods that cause a rapid rise in blood sugar, adhere to your medication regimen, and exercise, you may have trouble keeping your blood sugar levels within a healthy range.

Collin Reynolds, a yoga and Pilates teacher and co-owner of Vitality Studio in Philadelphia, who has had type 1 for 18 years, has found that in addition to being vigilant about his diet and his acupuncture appointments, practicing yoga helps him regulate his blood sugar. Experiences like his and Goldman's support evidence of a growing theory in diabetes research: Reducing the amount of stress in your life can help you maintain healthy blood glucose levels.

For the past 20 years, Richard Surwit, Ph.D., vice chairman of the Department of Psychiatry at Duke University Medical Center, has been researching the effect of stress on blood sugar. The results of his work show that practicing relaxation techniques on a regular basis can significantly control blood glucose levels. "I hope my work encourages doctors to integrate stress management into their general management of the disease," he says. "It can have as big an impact as some oral medications—and that's not an insignificant effect."

In his book The Mind-Body Diabetes Revolution (Free Press, 2004), Surwit explains the physiology behind the stress management–blood sugar connection. When you find yourself in a stressful situation, the sympathetic part of the nervous system switches on, triggering the fight-or-flight response. Your heart begins to race, you're short of breath, your palms sweat. In addition, the stress hormones cortisol and adrenaline are released, which raise blood sugar in order to give you the energy to deal with your threat. This isn't a problem if you have a normal metabolism, but if you're diabetic it's hard to get your blood sugar down once it's up.

Practicing relaxation is an antidote to the fight-or-flight response. When you consciously relax, the parasympathetic nervous system kicks in, stimulating the relaxation response and returning stress hormones to normal levels, which can bring blood sugar back to normal levels as well.

For his studies, Surwit used a technique called progressive muscle relaxation, but he says other approaches that induce the relaxation response should yield the same results. And in addition to the physiological benefits of stress management, there are psychological ones too. After all, a threat doesn't have to be real for us to feel stress; we just have to perceive it as real. Once you learn to consciously relax your body, you can use that skill to deal with everyday stress. "Any kind of calming practice—whether it's yoga, meditation, or progressive muscle relaxation—can significantly lower stress and help diabetics develop long-term mind-body awareness," Surwit says.

This is especially important for diabetics, because managing the disease is stressful in itself. If you have been sedentary or eating poorly for a long time, it may be challenging to change your diet and exercise habits, and if you don't change, the threat of complications looms.

Reynolds, who teaches special classes for diabetics (types 1 and 2), says the stress can become a vicious cycle. "You feel anxious about the changes, which causes blood sugar to rise. Then you feel anxious because you have to lower your blood sugar," he observes. "Youreally have to go inside and explore to figure out how to take care of yourself."

build awareness

Success stories like those of Reynolds and Goldman may become more common if doctors and hospitals begin to embrace yoga and relaxation techniques as part
of a treatment regimen. Already, some Western doctors—like Mark Sandberg, M.D., an endocrinologist at the Hunterdon Medical Center and medical director of the Diabetes Health Center in Flemington, New Jersey—are ahead of the curve. An avid and long-time yoga practitioner himself, Sandberg experienced yoga's benefits firsthand and then decided to start a program at his hospital. "The deep breathing you do in yoga is a stress reliever, and stress definitely contributes to sugar problems with diabetes. Reducing your stress level will improve sugar control," he says.

With the help of diabetes educator Carolyn Swithers, Sandberg instituted weekly classes at Hunterdon. The teacher, Lynne LaSpina, takes a gentle Kripalu-oriented approach and emphasizes mindfulness. "With diabetes, you have to learn to be very aware of what's going on in your body. Most times, that awareness is not there yet." LaSpina builds awareness by starting class with a few minutes of meditation and Pranayama (breathing techniques) and inviting students to be more fully present by observing their thoughts and sensations. "I ask them to look at how they're feeling in this moment, but not get caught up in it," she says. "As we begin our sequence, I promise them that if they put their problems aside, they will probably have a different perspective at the end of class." By doing this, LaSpina helps her students see that they have a choice about how they want to respond to stress.

LaSpina then leads them through a class that includes a standing sequence, seated poses, and balancing poses, with chairs available for modifications. She ends with a long, deeply relaxing Savasana (Corpse Pose), where she often guides students through the body organ by organ, asking them to visualize each organ as healthy.

Some of Sandberg's patients who have attended LaSpina's classes now report feeling more energetic in general, and some even say they've been able to decrease their medication. But both Sandberg and LaSpina say it's difficult to get people with type 2 diabetes in the door and keep them coming consistently. "It's a hard sell," says Sandberg. "I mentioned yoga to a patient today and she thought I was from Mars."

find the right class

Reynolds reports similar problems, which he attributes to two things—people with type 2 often need a class that offers modifications and those classes can be hard to find, and when they do find a class that's gentle enough, they might not feel or see results immediately. He recommends starting with private sessions to learn the pose modifications and to gain the stamina, endurance, and confidence to join a group class.

Like LaSpina, Reynolds (who contributed the sequence of poses in this article) takes a gentle approach with his students: He begins with breathing and ends with a long Savasana. He also does three or four variations for most poses, like the Paschimottanasana (Seated Forward Bend). First he has students sit on a chair, then on the floor on a bolster, and then use the wall for support until they can safely fold forward with a long, straight spine on their own.

In his classes, Reynolds teaches simple poses that focus on the various movements of the spine to help encourage spaciousness and strength where it might be missing—in the central axis and core of their bodies. In a pose like Bhujangasana (Cobra Pose), he'll have students take their hands off the floor, which forces them to use their upper back muscles rather than relying on their legs or arms. He'll do the same for a seated twist. Rather than having his students lean into the back hand, which can make the upper back slump, he'll have his students bring their arms out to the side, which forces them to use their abdominal muscles.

He incorporates detailed instruction to help students build physical and mental awareness. For example, in a simple twist, Reynolds asks his students to lengthen in the spine while at the same time finding Savasana in the pose. "If they can balance strength and relaxation in a pose that's difficult for them, they'll be able to leave the studio and face things that could potentially stress them out, but stay calm and centered in their breath," he explains.

Inversions are also recommended, because they help soothe the nervous system and may help with early stages of peripheral neuropathy—a complication of diabetes that manifests as numbness and pain in the hands and feet. Reynolds reversed his own minor neuropathy after having numbness in his big toes for years. His practice includes rigorous Headstand and Shoulderstand variations, but Viparita Karani (Legs-up-the-Wall Pose) has similar effects for those who find the other poses too difficult. His only warning: You might experience cramping after an inversion. When the blood circulates back to your feet, it can feel tingly like it does after your foot has fallen asleep.

In addition to decreasing stress, lowering blood sugar, and reducing peripheral neuropathy, yoga can help diabetics with joint pain. "Yoga helps ease joints and ligaments stiffened from the toxic buildup of sugar," explains Sandberg.

Besides all the physical benefits yoga imparts, it also gives you the sense of being in control of your own healing. Instead of feeling helpless, you feel connected with your inner self, the part of you that is more than your illness. "We all have limitations and great strengths in our physical bodies, but we all have perfect souls," says LaSpina. "To share that with each other in yoga practice is a great joy." Go to The Diabetes Epidemic: How you can beat the odds to read more about diabetes.