Mindfulness-Based Interventions: Focus on Pediatric Type 1 and Type 2 Diabetes

Abstract

Purpose of Review

Mindfulness-based interventions (MBIs) focus on promoting nonjudgmental, purposeful awareness of the present experience, and they include specific components such as body scan, meditation, and breathing techniques for healthier coping with stress and reduced negative affect. In adult populations with chronic illness (e.g., type 1 diabetes [T1D], type 2 diabetes [T2D], overweight), MBIs have been shown to improve psychosocial outcomes with some improvements in health outcomes as well. Youth with T1D/T2D frequently experience heightened depression as well as diabetes distress, which are associated with less frequent blood glucose monitoring, insulin administration, and nutrition oversight. Thus, MBIs have potential to alleviate psychosocial distress in youth with T1D/T2D and also improve health outcomes. This paper is a review of the literature on potential psychosocial and health benefits of MBIs for youth with T1D/T2D.

Recent Findings

Among youth with T1D/T2D, MBIs have been shown to reduce symptoms of depression and diabetes distress. Improvements in health outcomes, such as A1c, have been inconsistent across studies.

Summary

Although research on the efficacy of MBIs to improve psychosocial and health outcomes in youth with T1D/T2D is promising, this area of study is in its early stages. Future investigation of MBIs in youth with T1D and T2D is warranted, recognizing that these are heterogeneous groups with potential benefit of specifically tailored interventions.

Introduction

Rates of type 1 and type 2 diabetes (T1D/T2D) in adolescents have increased in the US over a 10-year period [1]. Adolescents with T1D/T2D are at heightened risk for negative psychosocial outcomes, such as depression, anxiety, and diabetes-specific distress [2–6]. Importantly, years of data show that worsened psychosocial functioning is strongly associated with poor diabetes management, treatment non-adherence, poorer glycemic control [2, 7], and diabetes complications, such as neuropathy [8] and diabetic retinopathy [9]. As such, developing more effective interventions to reduce negative psychosocial outcomes in youth with T1D/T2D is of utmost importance.

Mindfulness-based interventions (MBIs) may have psychosocial and health benefits for youth with T1D/T2D. Although mindfulness is a multi-faceted construct, a common description is “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” [10]. Mindfulness originated in Buddhist traditions, and it has recently been adopted by Western cultures, with increasing research attention in the last decade [10, 11]. MBIs focus on cultivating intentional and nonjudgmental awareness of the present experience, including internal experiences of the body, thoughts, and emotions, and external experiences, as a means to reduce negative affectivity and stress-related behavior. The current review summarizes MBIs in diabetes, with an emphasis on clinical applications and future directions for research in mindfulness among youth with T1D/T2D.

Mindfulness Intervention Components

Components taught in MBIs include sweeping (“body scans”), mindfulness of breath and other bodily sensations, Hatha yoga postures, and various meditations. Sweeping involves mindfully scanning one’s body from head to toe with a focus on bodily sensations and an awareness of breath [12]. Mindfulness of breath and other breath perceptions refers to activities that cultivate a present awareness of breathing. Hatha yoga postures, while not exclusively a mindfulness exercise, are often used during these programs with an emphasis on mindful movement. Lastly, various meditations are included in MBIs with a range of activities, such as mindfully eating, walking, sitting, or standing, to encourage integration of mindfulness into daily activities.

The first and most prominent empirically supported MBI is mindfulness-based stress reduction (MBSR) for adults with chronic pain [13]. The program focuses on reducing stress by cultivating mindfulness, especially with regard to the body, through meditation practices and mind–body specific practices such as body scans [14, 15]. In one study, single-arm study, more than half of adult participants with chronic pain reported a reduction in pain, medical symptoms, and depressed mood [13].

Mindfulness-based cognitive therapy (MBCT) is an adaptation of MBSR that combines aspects of mindfulness and cognitive therapy, and it parallels MBSR in format and content [15, 16]. However, MBCT deviates from MBSR with the integration of cognitive therapy techniques, especially those relating to decentering one’s thoughts. MBCT teaches detachment of thoughts, with phrases such as “thoughts are not facts” or “I am not my thoughts,” which is derived from cognitive therapy [12]. MBCT was initially developed as a preventative treatment for relapse of major depressive disorder in adults; results showed that MBCT significantly reduced the risk of relapse among adults who had a history of recurrent episodes, referring to three or more previous depressive episodes, compared to treatment as usual over the 60-week study period [16].

Overall, the extant data suggest that MBIs, such as MBCT/MBSR interventions, have been adapted for use among for adults with a variety of medical illnesses (i.e., obesity, cancer, chronic pain, hypertension) and offer psychosocial and health benefits and often address co-morbid psychosocial concerns (i.e., binge eating, anxiety, and depression) [12, 17–21].

Mindfulness Interventions in Adult Diabetes Populations: Psychosocial Outcomes

Research on MBIs has since expanded to adults with T1D/T2D and has demonstrated improvements in diabetes-specific distress [22–28], and general psychosocial outcomes, including depression and anxiety [28–33]. Most intervention studies have implemented MBIs as originally designed, with minimal diabetes-specific modifications. However, in one study, MBSR was tailored for adults with T2D to include examples of diabetes-specific thoughts and feelings; improvements in depressive symptoms and subjective health status were observed 1 year post intervention as compared to the control group receiving treatment as normal; however, HbA1c (A1c) did not significantly improve [30]. Another study evaluated culturally specific adaptations of MBSR for adults with T2D in China, though diabetes-specific modifications appeared to be minimal; participants experienced improvements in diabetes distress, emotional burden, general distress, diabetes self-efficacy, and self-management when compared to a control group receiving regular diabetes education [34].

Mindfulness Interventions in Adult Diabetes Populations: Health Outcomes

In addition to psychosocial outcomes, MBIs have demonstrated improved health outcomes in adults. A review of more than 50 MBI studies concluded that MBIs produce beneficial physiological effects on the body, such as normalizing immune function and decreasing inflammation [35]. However, whether MBIs specifically improve glycemic levels in adults with T1D/T2D is inconsistent. A recent meta-analysis of nine randomized controlled trials examining MBSR/MBCT in adults with T1D/T2D found statistically significant improvements in A1c as well as depression, compared to control conditions [36]; however, few studies showed clinically meaningful decrease in A1c (i.e., > 0.5% reduction) and few studies in this review examined MBI effects on A1c over the long term. Overall, these mixed effects of MBIs on A1c in adults with T1D/T2D mirror the mixed effects on A1c that have been previously shown in cognitive-behavioral therapy (CBT) in this population [37, 38]. Fasting blood glucose (BG) outcomes are also mixed in the limited existing small studies of adults with T2D. Some studies showed more improvements in fasting BG following MBI compared to control [38, 39]. However, another study found no effect of MBIs on fasting BG [40].

Other health indicators that have been examined include cortisol, a stress hormone, and body mass index (BMI). Limited data suggest that MBIs might affect cortisol levels in adults with T2D [39, 40]. Theoretically, MBIs may target physiological systems involved in the regulation of stress, such as the hypothalamic–pituitary–adrenal (HPA) axis. Of note, the association between MBIs and improved BGs in adults with T2D may be partially based on cortisol-mediated pathways [41]. Further, MBIs on their own generally have demonstrated no significant effects on BMI among adults with T1D/T2D [31], which might be anticipated given that many factors affect BMI, such as diet, sleep, and physical activity, that are not directly targeted through MBIs.

Mindfulness Interventions in Adolescents

Adolescence is a developmental stage characteristic of increased social monitoring and concerns for the future. Strategies that provide youth with the skills to cultivate nonjudgmental self-awareness and acceptance may be particularly beneficial for adolescents. Mindfulness practices have been shown to mitigate reactivity, manage strong emotions, reduce stress, and strengthen attention in youth [42]. In fact, a major goal of MBIs is to improve dispositional mindfulness (i.e., the propensity to be present in the moment), which may be a protective factor against negative psychosocial outcomes during adolescence.

Indeed, MBIs have demonstrated improved cognitive and behavioral outcomes in healthy adolescents [43–45]. A few recent meta-analyses, including analysis of 10–30 randomized controlled trials of MBIs in youth, found that, compared to controls, youth in MBI conditions experienced decreases in symptoms of depression [46], symptoms of anxiety/stress [47], and improvements in sleep quality [48].

Mindfulness Interventions in Pediatric Chronic Illness Populations

Navigating a chronic illness during adolescence may be particularly stressful due to frequent doctors’ visits, intensive medical regimens, and lifestyle changes on top of a challenging developmental period. Chronic illnesses are definitionally lifelong, and worries and concerns about chronic illnesses are indeed rational. Thus, MBIs’ focus on acceptance/awareness of and nonjudgmental interactions with one’s thoughts may, in theory, be very relevant for youth with chronic illness in addition to therapies that emphasize changing, fixing, or replacing “irrational” thoughts (i.e., CBT). For instance, the focus on awareness of physical perceptions and support for self-regulation and cognitive control in MBIs may be particularly beneficial to a population of youth with chronic illness.

Two recent systemic reviews reported that MBIs, compared to control conditions, appear to be efficacious for a variety of chronic illnesses, such as ADHD, chronic pain, and sleep [49, 50]. However, the use of MBIs among youth with T1D or T2D were absent from these reviews, suggesting that our understanding of the benefits of MBIs for pediatric diabetes is limited. Further, several disease-specific MBIs have been developed for youth with various chronic illnesses. One mindful yoga intervention for children with asthma was adapted to include treatment components that targeted asthma exacerbations; though heart rate and blood pressure improved, no improvements in lung functioning were noted within this pilot study [51]. Additionally, a martial arts–based therapy including mindfulness strategies was developed for children with cancer to therapeutically target coping with the pain and distress due to cancer treatment; both pain and distress improved among youth [52]. Further, a pilot study found that a general (i.e., non-specific or tailored) MBI, compared to a health knowledge comparison, reduced the propensity to rely on food as a reward at 6-month follow-up and decreased stress-eating at 18-month follow-up among adolescents at risk for adult obesity [53, 54]. It is unclear whether disease-specific modifications are superior to standard MBIs, as no study, to our knowledge, has explored this empirical question, but is a potential area for future study.

Mindfulness-Based Stress Reduction in Youth with T1D

Adolescence is a challenging period for youth with T1D; data have consistently documented a worsening of A1c [55], which is due to both biological (e.g., physiological changes) and psychosocial changes (e.g., T1D management behaviors, independence, reduced parent involvement, increased peer interactions). In youth with T1D, higher general and diabetes-specific stress are associated with worsened glycemic outcomes, self-management behaviors, and quality of life [56]. However, youth with T1D with higher dispositional mindfulness, referring to the propensity for practicing mindful attention, experienced less diabetes-specific distress, greater self-management behaviors, and lower A1c [57].

As such, Ellis and colleagues pilot the comparison of an MBSR intervention to a CBT stress management condition and a T1D support group for T1D health and psychosocial outcomes among 16–20-year-olds with T1D with above target A1cs. Details regarding whether the intervention was adapted to be illness-specific were not provided. The sample characteristics were over 90% Black/African American and 50% female [58, 59]. The MBSR components included meditation, stress reaction awareness, and applying mindfulness to eating, walking, and other daily activities. Results showed that only those in MBSR had a reduction in stress at post-treatment and 3-month follow-up, and only those in the T1D support group experienced a reduction in A1c at post-treatment; however, the T1D support group had the highest baseline A1c (12.7% vs. 11.7% in MBSR vs. 12.3% in CBT stress management), which likely contributed to this result, as the post-treatment and 3-month A1cs became more similar across conditions. T1D adherence behaviors and BG monitoring were not altered by any of the conditions, suggesting that longer term follow-up and a larger sample is needed to detect any effect of improved stress on A1c.

Mindfulness Interventions in Adolescents At-Risk for T2D

To our knowledge, MBI has not been tested in youth with T2D. However, there has been some pilot work on youth at risk for T2D. These at-risk youth are distinct from those with T2D in that they do not have a chronic illness, but work in this population may provide insight on the feasibility and acceptability of MBIs in those who go on to develop T2D. Being at risk for T2D can be challenging/stressful for adolescents for many reasons. These may include seeing family members struggle with this challenging illness and also because a primary risk factor for T2D is a higher weight status. Larger body size in teens is related to increased risk for social challenges, lower self-esteem, and depression or stress [60].The mindfulness intervention targets depression/stress, and the goal is to reduce depression/stress in adolescents, and improve insulin resistance and decrease risk for T2D. In a small pilot study of adolescent females at risk for T2D, an MBI called Learning to BREATHE, a general (i.e., non-adapted) mindfulness curriculum for adolescents [14, 61], was feasible and acceptable [62]. Activities in the MBI condition included core mindfulness practices such as breath awareness, body scanning, mindful eating, sitting meditation, and gentle yoga. Compared to CBT (n = 16), the MBI group (n = 17) had more improvements in depressive symptoms at post-treatment, 6-months, and 12-months, as well as more improvements in insulin resistance at post-treatment and 12 months [62, 63]. In a case report of a 16-year-old White female from the MBI group, increases in dispositional mindfulness and a decreasing pattern of cortisol awakening response generate hypotheses with respect to potential mechanisms of action in MBI, from a preventative lens [64].

Current Directions and Disease-Specific Adaptations

Drawing on the extant data of possible psychosocial and health benefits of MBI in diabetes, ongoing work (R34 AT011035–01) from our own team is currently underway to refine and tailor MBI content and delivery for adolescents with T1D using an iterative and mixed methods approach, based on the ORBIT model, with the Learning to BREATHE MBI curriculum [14, 61, 65]. First, we employed qualitative interviews with three clinician stakeholders and three adolescents with T1D regarding their experiences with negative affect, maladaptive eating behaviors, social relationships, T1D management, and MBIs or mindfulness practices. Using the information provided, small adaptations, primarily to the examples provided in Learning to BREATHE as real-life applications of mindfulness-based practices, were implemented. This adapted content was then presented to four additional adolescents with T1D and the same clinician stakeholders for their feedback, resulting in a revised manual (BREATHE-T1D) appropriate for use with adolescents with T1D (see Table 1 for components of BREATHE-T1D).

Table 1.

BREATHE-T1D intervention components

Session title	Key mindfulness objective	Example activity	T1D tailoring
B — Body	Pay attention to body cues and practice awareness of breath and body	Body scan: a guided body scan designed to help participants relax and pay attention to how their body feels	Discussion on how diabetes can affect bodily sensation (e.g., What do you already recognize about your body when you are starting to feel symptoms of highs or lows?)
R — Reflections	Observe thoughts and letting them go	My Mind is a Cast of Characters: designed to demonstrate how thoughts can impact emotions. A participant completes a math task while other group members repeat a thought (e.g., “I’m not good at math”) out loud	Added diabetes-specific thoughts, for example: “What if my blood sugar goes low right now?”
E — Emotions	Understand how emotions vary and how to manage them mindfully	How Does It Feel: designed to help participants understand the impact different situations have on their emotions. Situations are listed and participants discuss how they feel in those scenarios	Added diabetes-specific situations, for example: “How does it feel when people in public stare at your CGM or pump?”
A — Attention	Bring mindful awareness to stressors in life	Case Study: an activity designed to help participants understand different types of stress (i.e., chronic vs. acute) and discuss coping strategies. The case study is a story of a teenager with stressors at school and at home	Added diabetes stressors including disclosing diagnosis to peers, sports, and relationships with parents
T — Tenderness	Connect mindfulness practice to self-care and cultivate the mind to support health, wellness, and inner strength	Ways We Care For Ourselves: an activity designed to generate ways we practice kindness and meanness to ourselves. Participants are asked to generate a list of ways we care for ourselves and a list of ways we do not care for ourselves	Added to discussion diabetes-specific examples, such as: What are some examples of things you do to care for yourself related to diabetes?
H — Habits	Identify ways to incorporate mindfulness into daily life and develop a personal mindfulness practice	Mindful Quilt: an activity that allows participants to reflect on the mindfulness group program overall by drawing or writing their response to reflection questions	Added diabetes-specific reflection question: How will I use what I learned to take care of diabetes?

The next phase of this research is to conduct a pilot feasibility and acceptability trial of BREATHE-T1D as compared to a health education condition, recruiting 40 adolescents with T1D across three cohorts in order to conduct iterative tailoring based on cohort feedback to maximize acceptability and feasibility. Regarding delivery method, recent literature has examined alternative options for delivering MBIs, including telehealth methods. Given that youth commonly use technology to connect with peers, adolescents may be more comfortable with digital communication platforms, and telehealth may increase engagement in MBIs among youth [66]. In our ongoing trial, BREATHE-T1D is being delivered via telehealth.

Conclusion

Although the extant literature on MBIs in youth with T1D is very limited, to date, and there is no research on MBIs in youth with T2D, there are sufficient positive signals to suggest the benefit of more rigorous testing of mindfulness-based strategies with these groups of youth dealing with the chronic stress of specific diabetes-related stressors. Given theoretical and empirical data pointing to the strong value of adapting behavioral interventions for the unique needs of target groups, there is much room to develop MBI adaptations for youth with T1D/T2D. Further, research is needed to investigate the pragmatic nature and feasibility of incorporating MBIs into diabetes management practices for youth, as ultimately our interventions will only be so useful as they are designed for and capable of effective dissemination. It will also be important to understand the mechanisms of action of reduced psychological distress and improved health via MBI, as such an understanding will guide further MBI development for youth with T1D/T2D. If our own pilot work (R34 AT011035–01) proves feasible and demonstrates preliminary efficacy, there will be a new virtually delivered T1D adapted MBI available for further study and potential clinic integration.