MBSR for Type 2 DM: Does Reducing Stress Reduce Complications?
MBSR for Type 2 DM: Does Reducing Stress Reduce Complications?
Abstract and Commentary
By Nancy Selfridge, MD, Associate Professor, Department of Integrated Medical Education, Ross University School of Medicine, Commonwealth of Dominica, West Indies. Dr. Selfridge reports no financial relationships relevant to this field of study.
Synopsis: The first results of a 5-year study of the effects a mindfulness-based stress reduction program on medical complications and psychosocial outcomes in patients with type 2 diabetes show prolonged reduction in psychological distress and depression compared to usual care.
Source: Mechthild H, et al. Sustained effects of a mindfulness-based-stress-reduction intervention in type 2 diabetic patients. Diabetes Care 2012; DOI 10.2337/dc11-1343.
The heidelberger diabetes and stress study (hei- DIS-Study) is a 5-year prospective, randomized, controlled trial created to evaluate the effects of a mindfulness-based stress reduction (MBSR) program on complications and psychological distress in patients with type 2 diabetes. The report summarizes this study's preliminary data at the end of the first year of follow-up. Prior research on MBSR suggests that it may be helpful in reducing stress and depression in patients with chronic disease, as well as improving diabetic control.1,2 The authors previously have shown that psychological stress is linked to activation of pro-inflammatory factors involved in late diabetes complications.3 Thus, a stress-reducing strategy for diabetic patients may have long-term beneficial effects on target end organ disease.
Methods
A total of 110 type 2 diabetic patients fulfilling inclusion criteria were randomized into a control group (n = 57) and an intervention group (n = 53). To be included in the study, all patients were between 30-70 years old, had diabetes for more than 3 years, and had microalbuminuria > 20 mg/L in two separate spot urines. All patients were provided medical treatment-as-usual by a single physician according to diabetes management guidelines in an outpatient clinic. After enrollment, the intervention group completed an 8-week MBSR program4 in groups of 6-10 participants who met weekly, followed by a "booster" session after 6 months. MBSR was facilitated by a psychologist and a resident in internal medicine. The MBSR intervention was adapted from the original program created by Kabat-Zinn by including practices for difficult thoughts and feelings related to diabetes. Primary outcome was albuminuria progression, and secondary outcomes were psychological distress, subjective health status, mortality, blood pressure, cardiovascular events, and activation of pro-inflammatory transcription factors. Albuminuria was measured in 24-hour urine collections over 3 consecutive days. Blood pressure was determined with a 24-hour measurement. The Patient Health Questionnaire (PHQ), a validated self-report survey for use in primary care, was used to detect and quantify depression, anxiety and eating disorders. Patients reported subjective health status using the SF-12, a peer-reviewed, validated, and reliable instrument for monitoring physical and mental health. Covariate analyses were subjected to intent-to-treat and per-protocol analyses. Nine persons in the intervention group did not attend the full MBSR training as required (at least five sessions). The reasons cited included illness, death of a family member, lack of interest in group and having to provide caregiving in home. In the control group, six individuals were lost to follow-up.
Results
Baseline differences between the two groups showed no statistical differences, nor was there any significant effect on any outcomes immediately after the MBSR intervention. However, at the 1-year follow up, while there was no significant difference between groups on progression of albuminuria, there was a significant improvement in the MBSR group on the PHQ depression score (P = 0.007), subjective mental health status on the SF-12 (P = 0.033), and diastolic blood pressure (P = 0.004) with intent-to-treat analysis. Per protocol analysis resulted in even greater effect sizes for these measures and also significant reduction in the PHQ stress score (P = 0.023).
Commentary
Because psychosocial stress activates pro-inflammatory transcription factors, which mediate micro- and macrovascular disease, the authors continue to hope to show that long-term stress reduction will demonstrate a beneficial effect on the progression of diabetic complications. The preliminary data from this study support the conclusions of existing research on MBSR for reducing psychological distress. MBSR programs are normally not offered free of charge, though some insurance products offer rebates to participants who complete the course. Completion of the course requires significant motivation and time commitment from participants and the dropout rate in this study points to this fact. However, MBSR appears effective for reducing perceived stress and is a low-risk intervention, making it a potentially useful adjunctive therapy for diabetics. Though the number of participants is small in this study, it will be interesting to see over time if microalbuminuria, an established risk factor for cardiovascular and microvascular disease, is reduced. Slowly but surely, the effects of stress and difficult emotional states on cell biology are being elucidated, providing the opportunity to potentially alter the natural history of chronic disease with stress reduction strategies. The authors are applauded for their efforts and excitement awaits future outcomes of this long-term study.
References
1. Grossman P, et al. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004;57:35-43.
2. Rosenzweig S, et al. Mindfulness-based stress reduction is associated with improved glycemic control in type 2 diabetes mellitus: A pilot study. Altern Ther Health Med 2007;13:36-38.
3. Bierhaus A, et al. Multiple levels of regulation determine the role of the receptor for AGE (RAGE) as common soil in inflammation, immune responses and diabetes mellitus and its complications. Diabetologia 2009;52:2251-2263.
4. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, Delacorte, 1990.
The first results of a 5-year study of the effects a mindfulness-based stress reduction program on medical complications and psychosocial outcomes in patients with type 2 diabetes show prolonged reduction in psychological distress and depression compared to usual care.Subscribe Now for Access
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