Effect of Breathing and Relaxation Exercises on Serum Cortisol Levels in Type 2 Diabetic Patients
Condition: Diabetes Mellitus; Stress
Study type: Interventional

Summary: 
      Background: Diabetes is a fast-growing health problem in Egypt with a significant impact on
      morbidity, mortality, and health care resources. Aim of the study: To assess the effect of
      breathing and relaxation exercises on serum cortisol levels in type 2 diabetic patients.
      Subject and Methods: sixty, type 2 diabetic patients for more than 5 years were selected from
      the outpatient clinic of the Faculty of Physical Therapy, Cairo University. Their age ranged
      from 40 to 50 years. Serum cortisol and blood glucose tests were done before the start of the
      study and after 6 weeks. The patients were randomly assigned into two equal groups in number
      (30 patients for each group) performed 3 sessions/week for 6 weeks. Group A received aerobic
      exercise in the form of walking on a treadmill, breathing exercise, and mindfulness
      meditation, and group B received continuous aerobic exercise only in the form of walking on a
      treadmill. ( The exercise program included 45 minutes and consist of warming up phase of slow
      walking on the treadmill for 5 minutes, training phase 35 minutes, and cooling down for 5
      minutes) .
    

Detailed description: 
      Diabetes is a metabolic disorder that requires ongoing medical care through multi-factor risk
      reduction strategies in addition to blood sugar control. Continuing education and support for
      diabetes self-management are essential to prevent acute complications and reduce the risk of
      long-term complications. There is a lot of evidence supporting a number of interventions to
      improve diabetes outcomes.

      Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent
      hyperglycemia. This may be due to insufficient insulin secretion, resistance to the
      peripheral effects of insulin, or both. The synergistic effect of chronic hyperglycemia and
      other metabolic abnormalities in diabetic patients can cause damage to various organ systems,
      leading to disabling and life-threatening health complications.

      The global prevalence of type 2 diabetes has increased from 8.3% in 2013 to 9.3% in 2019.
      This increase has been higher in lower- to middle-income countries compared to high-income
      ones. Diabetes treatment includes behavioral and pharmacological approaches. Globally, it is
      estimated that only 23% (30% in Latin America) of people with diabetes have reached the set
      target. However, it is a challenge for treating physicians to choose a treatment that is
      tailored to each patient.

      Egypt is the ninth-largest country in terms of type 2 diabetes mellitus (T2DM) patients,
      according to the International Diabetes Federation (IDF). T2DM patients have increased
      threefold in the last 20 years, with a current prevalence of 15.6 percent among people aged
      20 to 79.

      T2DM is a metabolic disorder that has both microvascular and macrovascular consequences.
      Controlling blood glucose levels is linked to a lower risk of microvascular consequences
      (retinopathy, nephropathy, and neuropathy) as well as macrovascular issues (lower incidence
      of heart attacks, strokes, and better blood flow to the legs).

      The World Health Organisation (WHO) defines diabetes as a "metabolic disorder of multiple
      etiology characterized by chronic hyperglycemia with disturbance of carbohydrate, fat, and
      protein metabolism resulting from defects in insulin secretion, insulin action, or both. "
      The most prevalent form of diabetes is type 2, as an estimated 90% of diabetes patients are
      diagnosed with this form, and the majority of the remaining 10% of patients have type 1
      diabetes (T1D), although there are other rare types. There is a range of effective treatments
      that reduce hyperglycemia in T2D patients, which mediate their effects by improving insulin
      secretion or decreasing peripheral tissue insulin resistance.

      Diabetes is a chronic metabolic disease that can negatively affect the quality of life.
      Psychological stress and negative emotions have a two-way effect on diabetes control. Stress
      increases the risk and severity of diabetes by stimulating the hypothalamus-pituitary-adrenal
      gland (HPA) and sympathetic nerve axis and parasympathetic nerve withdrawal, leading to
      cortisol, epinephrine, norepinephrine, growth hormone, glucagon, catecholamines, Prolactin,
      leptin, and neuropeptide Y. Chronic activation of the HPA axis is related to poor control of
      complications such as diabetes and diabetic neuropathy. Elevated levels of inflammatory
      cytokines lead to insulin resistance in patients with type 2 diabetes. Chronic psychological
      stress can lead to an increased risk of insulin resistance, high blood pressure, and
      cardiovascular events.

      Psychological stress has been linked to the development of type 2 diabetes. Meditation
      exercise can be viewed as a combination of mindfulness intervention and physical activity.
      This may partly explain why meditation exercises have a more positive effect on type 2
      diabetes than other active and non-exercise exercises. A large number of studies have shown
      that meditation exercise is effective for blood sugar control in patients with type 2
      diabetes.

      Meditation interventions were shown to have a significant effect on changing cortisol levels
      assessed from blood samples.

      Mindfulness meditation-based strategies are simple, easy to grasp and practice, and do not
      incur an additional cost. Meditation-based therapies may offer immediate positive benefits in
      such individuals.

      Deep breathing has been shown to have a positive impact on various factors like stress,
      anxiety, and negative aﬀect in numerous studies.

      Breathing exercises, also known as "diaphragmatic breathing" or "deep breathing", are defined
      as effective comprehensive training of the body and mind to deal with stress and physical and
      mental conditions. Diaphragm breathing involves the contraction of the diaphragm, the
      expansion of the abdomen, and the deepening of inhalation and exhalation, thereby reducing
      the respiratory rate and maximizing the amount of gas in the blood. The benefits of
      diaphragmatic breathing have been studied in conjunction with meditation.

      Physical activity is a broad term that applies to any physical movement or activity that
      requires energy consumption by skeletal muscles. Aerobic exercise is a specific subcategory
      of physical activity. It is characterized by the rhythmic and continuous exercise of a large
      number of muscles, which mainly relies on the energy production process produced by oxygen
      metabolism. The main goal of aerobic exercise is to improve or maintain cardiorespiratory
      fitness, that is, the ability of the circulatory system and respiratory system to supply
      oxygen during continuous exercise

      Exercise as a regular physical activity is found to be an efficient influencer that would
      switch back most of the known type 2 diabetes mellitus factors toward healthier positions.
      Exercise is proven to have clinical benefits, such as improved insulin sensitivity,
      reductions in glycosylated hemoglobin (A1C), and increased peak oxygen consumption (VO2peak)
      which are definitely preventive toward diabetes. Exercise improves blood glucose control in
      type 2 diabetes, reduces cardiovascular risk factors, and regulates body weight by reducing
      body fat percentage and enhancing lean mass.

      Aerobic exercise consists of continuous, rhythmic movement of large muscle groups, such as in
      walking, jogging, and cycling. The most recent ADA guidelines state that individual sessions
      of aerobic activity should ideally last at least 30 minutes per day and be performed 3 to 7
      days of the week. Moderate to vigorous (65%-90% of maximum heart and rate) aerobic exercise
      training improves VO2max cardiac output, which is associated with substantially reduced
      cardiovascular and overall mortality risk in patients with type 2 diabetes.

      According to a study published in "Psycho-neuroendocrinology", there is a clear link between
      the stress hormone cortisol and high blood sugar levels in patients with type 2 diabetes
      mellitus (T2DM) The researchers explained that in healthy people, cortisol naturally
      fluctuates throughout the day. This natural fluctuation usually peaks in the morning and
      falls at night. However, patients with type 2 diabetes have lower levels of cortisol during
      the day and higher levels of glucose higher serum cortisol levels are a risk factor for
      future incidence of diabetes.

      Cortisol is a glucocorticoid produced by activating the hypothalamic-pituitary-adrenal axis.
      It is called the "stress hormone" because it plays a major role in the body's response to
      stress. The activation of the HPA axis and the increase in cortisol secretion are important
      and adaptive parts of the human stress response, which can promote survival. However, when
      the stressor is activated for a long time, the HPA axis will become dysregulated, causing
      abnormal cortisol secretion and negatively affecting the body. Cortisol inhibits inflammation
      and allergic reactions, has an immunosuppressive effect, and also affects metabolic processes
      through gluconeogenesis (the release of amino acids from proteins in skeletal muscle and
      bone), glycogenolysis, and lipolysis

      This study was conducted to investigate the effect of breathing and relaxation exercises on
      serum cortisol levels in type 2 diabetic patients.
    

Intervention name(s): Aerobic exercise; breathing exercise; Relaxation training
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): continuous aerobic exercise on a treadmill; continuous aerobic exercise plus breathing exercise (Mindfulness); continuous aerobic exercise plus relaxation training
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Treatment