The effects of mindfulness training on the level of happiness and blood sugar in diabetes patients

Abstract

Purpose

The present study aimed at investigating the effect of mindfulness training on the level of happiness and blood glucose in diabetic patients in Zarghan city, Iran.

Methods

This quasi-experimental study was conducted in 2018 in Fars province, Iran. 136 diabetic patients who were eligible (had diabetes for more than one year, older than 18 years, willingness to participate in the research, and reside in Zarqan city) were selected based on convenience sampling method. Next the participants were randomly divided into two groups, each comprising 68 individuals. Both of the study samples and statistical analyser were blinded to intervention group (mindfulness training) and control group (without intervention). Before and three month after the intervention the patients’ levels of happiness (based on Oxford Happiness Questionnaire), fasting blood sugar (FBS) and Glycated Hemoglobin test (HbA1c) were measured.

Results

The results indicated that after the sessions, the level of happiness in the Intervention group was significantly higher than the control group (p value <0.001). Also, the level of blood glucose and HbA1c after the sessions was significantly lower in the Intervention group compared to the control group (p value<0.001, p value = 0.004). After the intervention, there was a significant correlation between mean blood glucose levels and mean HbA1c levels in the Intervention group and their level of happiness (p value<0.01 and p value<0.001).

Conclusion

The findings revealed that the mindfulness-based educational intervention can increase happiness in people with diabetes and regulate their blood glucose.

Introduction

Diabetes is a complex metabolic disorder that is characterized by fasting blood glucose levels greater than 120 mg/dl, random blood glucose levels greater than 200 mg/dl (accompanied by excessive fluid intake and frequent urination), two-hour after-meal glucose of equal or greater than 200 mg/dl, or blood sugar of greater than 200 mg/dl after the oral intake of 75 g of glucose. Hyperglycaemia occurs as a result of impaired insulin secretion or insulin action, or both [1]. The prevalence of diabetes has increased dramatically over the past two decades, reaching 285 million people worldwide in 2010. It is estimated that this number will rise to more than 438 million in 2030. Health care costs for diabetes amounted to at least $ 673 billion in 2015. 12% of the total health care spending in the world is related to diabetes care [2].

Research evidence indicates that, about one-third of diabetic patients experience some aspects of mental health problems including nervous tensions, depression [3, 4] and lack of happiness at some stage in their lives [5]. Diabetes may entail other consequences such as irregular use of medication, poor nutrition, poor blood sugar control, higher risk of cardiovascular disease, and lower quality of life [6–8].

Many psychological interventions are used alongside medical interventions to control the disease and its attendant complications. One of these interventions is mindfulness [9]. Mindfulness means paying special and purposeful attention to what is occurring in the present moment, without any prejudice or judgment [10]. In mindfulness, an individual recognizes his/her mode of mind at any moment, and learns the required skills to engage the more effective modes [11, 12]. Research indicates that individuals with higher levels of mindfulness harbour fewer automatic negative thoughts, and believe that they are able to dismiss such thoughts [13, 14].

Segal indicated that Mindfulness-Based Cognitive Therapy is administered to patients with the aim of helping them realize that their thoughts are only “thoughts” and not “reality”. When they are able to view their thoughts as mere thoughts and something separate and external to themselves, they will then be able to have a clearer view of reality and exert greater control over the events. This therapeutic method teaches attention, concentration, and the techniques for practicing this concentration and applying it at all moments in life [15]. Upon the appearance of the first symptoms such as negative mood, negative thoughts, and inefficient processing methods, this therapy enables individuals to bring themselves to the present moment, and by focusing on breathing exercises, physical sensation, and other activities, they can eventually avoid falling in the trap of the “downward spiral” of depression [16].

Much research has been done on the effectiveness of mindfulness on improving mental and physical conditions of diabetic patients. Most of these studies have indicated that mindfulness can have a significant effect on physical outcomes such as; reducing cholesterol [17], body weight [18]; and psychological outcome such as; promoting wellbeing and reducing stress [19, 20] and quality of life [21] in adults with diabetes.

The Effect of mindfulness on happiness and blood glucose reduction in diabetic patients as an emerging paradigm has garnered the attention of researchers. Different studies have indicated that mindfulness can have a significant effect on reducing blood sugar [22–24] as well as increasing happiness [25, 26] in adults with diabetes. Therefore, if mindfulness is considered as a kind of “accepting awareness” free of judgement about what is happening, and if happiness is defined as an overall satisfaction with life, it can be concluded that in most cases mindfulness can bring happiness to people’s lives. Happiness plays a critical role in our lifestyle, including in our choice of food, physical activity and Weight control, all of which affect our physical and mental health and our quality of life [27].

However in other studies, mindfulness had no effect on improving mental and physical conditions of diabetic patients such as; the level of blood sugar and happiness [28, 29]. As can be seen, different and contradictory results have been reported in the effectiveness of this method in the literature. The effectiveness of this method seems to be partly related to the cultural and social contexts of the patients [30].

Given the increasing statistics of diabetes in people and the fact that no study has yet been conducted on this subject in Zarghan city, in the present research we seek to answer the question whether mindfulness training has a significant effect in terms of increasing happiness and reducing blood glucose in diabetic patients in Zarghan city.

Methods

This research is a quasi-experimental study with a two-group pre-test post-tests design, aimed at comparing the effect of mindfulness training on the levels of happiness and blood glucose in diabetic patients attending outpatient diabetes clinics in Zarghan city, Iran, in the year 2018–2019. The statistical population of this study includes all diabetic patients in Zarghan city, Fars providence, Iran in 2018 (N = 336). The sample size was calculated using Cochran formula at a 95% confidence level and 10% drop rate, as shown below:

$$\mathrm{n}=\frac{\mathrm{N}{\mathrm{Z}}^2\mathrm{p}\mathrm{q}}{\left(\mathrm{N}-1\right){\mathrm{d}}^2+{\mathrm{Z}}^2\mathrm{p}\mathrm{q}}$$

Using the above formula, we obtained a sample size of 122 patients. This number was raised to 136 patients to enhance accuracy, especially in view of the 10% drop rate. 136 diabetic patients who referred to the clinic from November 2018 till July 2019 were selected through convenience sampling method. All 136 patients completed the study.

Both of the study samples and statistical analyser were blinded to intervention group (mindfulness training) and control group (without intervention).

Participants

Eligibility criteria for participants

The inclusion criteria for this study were: all diabetic patients who have had diabetes for more than one year, older than 18 years willingness to participate in the research and reside in Zarqan.

Exclusion criteria were: severe psychological illness alongside diabetes, physical defect or deformity, experience of diabetic coma, engagement in other training programs while the mindfulness intervention is in effect. Patients who unwillingness to continue collaboration in the research and not attending the training sessions during the study exclude from the research. Random allocation was performed using random allocation software and study samples were allocated to one of the group based on prepare list.

Intervention

After receiving approval from the Vice Chancellor for Research and Ethics Committee of the University, the qualified subjects were first selected. Then, after explaining the objectives of the study, written informed consent were obtained from the patients. Then the participants individually randomised to one of two “parallel” groups; intervention group (mindfulness training) and control group (without intervention). It should be noted that in order to observe ethical guidelines, the groups are allowed to leave at any stage of the study if they did not wish to continue cooperation. All 136 patients completed the study and the follow-up assessment.

At first, the levels of “happiness skills”, “blood glucose” and “Glycated Hemoglobin test (HbA1c) “were examined in all participants before the training. Then the intervention group underwent eight two-hour sessions of Mindfulness training (Table 1) within eight weeks, and the control group did not receive any training in that period. Three months after the intervention, the levels of blood glucose, HbA1c and happiness of the research samples were assessed again.

Table 1.

Mindfulness Training Program Provided to the Intervention Group

Session 1	At the first session, some general principles of group programs are implemented, including orienting people to the class schedule, introducing and familiarizing members with each other, establishing group laws and regulations. Then, a simple exercise called “Raisin Meditation” is performed to familiarize the patients with the concept of mindfulness and how it works. The patients’ experiences in that exercise are then discussed so as to ensure that the concept of being in the moment and focusing on the present activities becomes understandable to the individuals in a tangible sense. After that, the patients undergo a physical examination. At the end of the session, the upcoming tasks for the next week are discussed, and assignments are taught with examples. Finally, The session ends with a “breathing focus” exercise, which is one of the primary therapeutic techniques. Also a pamphlet containing information about mindfulness, prepared by the researcher, was distributed among the participants.
Session 2	The second session includes teaching physical examination techniques and practicing them, reviewing home assignments from previous session, identifying thoughts and feelings and their relationship with patients, and teaching how to record the desirable events of everyday life. It also includes next week’s home assignments focusing on breathing exercises and physical examination, and applying the trained mindfulness to the usual daily activities.
Session 3	This session includes practicing the techniques of “seeing” and “hearing” as well as sitting in a meditative state, awareness of body, breathing and strong physical sensation, and practicing the trained skills. Reviewing home assignments from the previous session as well as breathing exercises are also part of this session. In addition, learning how to pay attention to body movements in a mindful state, mindful walking, creating a table of undesirable events and introducing new home assignments were also included in this session.
Session 4	This session is similar to the previous session in terms of practicing the techniques of “seeing”, “hearing” and sitting in a meditative state for mindfulness of thoughts and sounds. Moreover, the subjects are familiarized with the realm of depression, anxiety and rumination. Breathing exercise is also performed at the end of the session. Also a pamphlet about the above variables, prepared by the researcher, is distributed among the participants. In general, the overall objectives of the first four sessions can be summarized as follows: • Explaining the importance of remaining in the present moment (being here and now), utilizing some techniques to expand on the concept of mindfulness for the members, and learning to perform daily activities by paying attention to them. • Becoming aware of the wandering mind, bringing attention to the body, physical sensation and paying attention to breathing. • Calming down the wandering mind, and learning to stay in the present moment and to observe the turbulence of thoughts without escaping and moving away from these thoughts.
Session 5	In this session, the following activities are covered: sitting in a meditative state and awareness of the body, thoughts and voices, contemplating how we interact with our experiences by reacting to our thoughts, emotions and physical senses, and what difficulties these interactions may cause for us, and how they affect our body. In addition, breathing exercise, reviewing past assignments, and reading poetry with mindfulness content are also part of this session. In the case of Iranian culture, one may explore the rich Persian poetry and literature.
Session 6	In this session, in addition to meditative sitting, whose purpose is to deal with thoughts as mere thoughts (not reality), some exercises are taught for changing thoughts and moods, breaking the defective cycle of mood and thought, and finding a different way of communicating with thoughts rather than responding directly to them.
Session 7	In this session the outlines are as follows: Sitting in a meditative state and reviewing past assignments, performing exercises to explore the links between activity and mood, making a list of pleasurable activities and the activities that help individuals develop their sense of control, and incorporating these activities into the daily programs.
Session 8	In the final session a physical examination exercise is initially performed. Then a review of the entire course is conducted and the group’s learnings and achievements are discussed. There is also some debate over the methods by which these achievements are best preserved, and how to develop what has been learned over the past seven weeks through formal and informal exercises. Some positive and logical reasons for continuing the exercises after the sessions are also suggested. In general, the overall objectives of the sessions 5 to 8 can be summarized as follows: • Comprehensive awareness of thoughts and feelings, and accepting them without judgment and direct involvement. • Changing moods and thoughts by perceiving thoughts merely as thoughts and not reality • Being alert to mental health symptoms and setting up plans to tackle these symptoms • Planning for the future and using the “presence techniques” to continue life, and developing them

Data collection tools

• Oxford Happiness Questionnaire

The inventory consists of 29 multiple-choice items, presented in four incremental levels of response, numbered from 0 to 3. The total score of the respondents ranges from 0 to 87. Using Cronbach’s alpha coefficient, Argyle et al. (2002) reported the reliability of the Oxford questionnaire and its test-retest reliability (over seven weeks) to be 0.9 and 0.78 respectively [31].

A research was conducted by Alipoor and Agah to analyse the validity and reliability of the Oxford Happiness Inventory in Iran. The findings of the research indicated that Oxford Happiness Questionnaire has an adequate reliability for measuring happiness in Iranian society [32].

• Glycated Hemoglobin test (HbA1c)

This is a standard method for evaluation and long-term control of blood glucose. When the plasma glucose level steadily increases, non-enzymatic attachment of glucose to hemoglobin also increases. This change is reflective of the change in blood glucose level over the past two to three months. In this research, blood sampling and the blood analysis were performed in the laboratory of the clinic where the research was conducted. The process was supervised by one of the laboratory personnel with adequate knowledge and skills in the field.

Statistical analysis

Data analysis was performed using SPSS software (version 20). Descriptive statistics including mean and standard deviation and descriptive tables were used to survey the demographic characteristics of the research samples. To evaluate the effect of intervention, independent t-test and ANCOVA was performed.

Results

In this study, 68 patients in the control group and 68 patients in the intervention group completed the research process. In terms of gender, the majority of subjects were female (88 people, 65.39%), and the rest were male (46 people, 33.8%). The age distribution indicates that the mean age in the Intervention group was 48.3 years with a standard deviation of 11.8, and in the control group the mean age was 49.5 years and the standard deviation was 8.2. The first objective in this research was to determine whether, in both groups, there was a significant difference between the levels of happiness, blood glucose level and HbA1c level before, and three months after the intervention.

As indicated, there was no significant difference between the mean scores of happiness level, blood glucose level, and HbA1c level in the two groups before the sessions were held (p value>0.05) (Table 2).

Table 2.

Mean and standard deviation of happiness, blood glucose level, and HbA1c level in the control and the Intervention groups, before intervention

Group	Control		Intervention		Test Statistics	p value
Variable	Mean	Standard Deviation	Mean	Standard Deviation
Level of Happiness	47.19	12.94	51.64	15.52	1.8	0.07
Blood Glucose Level	159.8	46.8	162.9	74.9	0.30	0.77
Hba1c	8.1	1.2	7.9	0.9	0.22	0.6

It is shown in Table 3 that, after holding the training sessions, there was a significant difference between the mean scores of happiness in the two groups, so that the level of happiness in the Intervention group was significantly increased (p value <0.001). The blood glucose level (p value <0.001) and HbA1c levels (p value =0.004) after the sessions was significantly lower in the Intervention group compared to the control group, and this decrease is statistically significant.

Table 3.

Mean and standard deviation of happiness and blood glucose level and HbA1c level in control and Intervention groups, after the intervention

Group	Control		Intervention		ANCOVA P value
Variable	Mean	Standard Deviation	Mean	Standard Deviation
Level of Happiness	62.41	11.71	71.25	11.82	<0.001
Blood Glucose Level	144.1	34.4	129.35	48.0	<0.001
HBA1C	8.1	1.2	7.1	0/98	0.004

The other objective of the research was to determine the relationship between; the mean blood glucose level of the intervention group and their level of happiness, and HbA1c level the levels of happiness before, and three months after the intervention (Table 4).

Table 4.

Determining the relationship between the mean blood glucose level and the mean HbA1c level of the research samples and their level of happiness

Happiness	Variable	Group	Pearson’s correlation coefficient	p value
Before the Intervention	Blood Glucose Level	Control	0.14	0.24
		Intervention	−0.22	0.06
	HbA1C	Control	.18	0.25
		Intervention	−.27	0.06
After the Intervention	Blood Glucose Level	Control	−0.12	0.3
		Intervention	−0.3	0.01
	HbA1C	Control	−0.14	0.3
		Intervention	−0.39	0.001

The results of the table show that after the intervention, a significant correlation could be detected between the level of blood glucose in the Intervention group and their level of happiness (p value <0.01(. Also the level of HbA1c after the sessions in the Intervention group was significantly lower than the control group, and this decrease was statistically significant (p value <0.001).

However, we didn’t find any significant prediction factor between happiness and glycosylated haemoglobin in the research samples.

Discussion

The aim of this study was to determine the effect of mindfulness training on increasing happiness and reducing blood glucose in diabetic patients. The results of this study indicated that the level of happiness of the participants was higher in the Intervention group than in the control group. Other studies in this area also emphasize that mindfulness can be effective in reducing stress [33], improving quality of life [34], lowering blood pressure [35], reducing depression [15], dispelling disturbing thoughts [36] and improving sleep quality [37] in patients.

Among them, Dahlgaard et al., revealed in their study that mindfulness training can significantly increase optimism in individuals [38]. Carmody and Baer, also investigated the effectiveness of the Mindfulness method on general aspects of well-being, including the quality of life, and the strategies for coping with pain, anxiety and depression. They concluded that this method leads to significant improvements in the quality of life, and development of strategies for coping with pain and depression [39].

Findings from other studies also suggest that blood glucose levels in research samples decrease after mindfulness training intervention, and thus mindfulness can be used as a means of reducing blood sugar in patients with diabetes mellitus. These findings are consistent with those of Fakhri et al. (2017). They studied the effectiveness of mindfulness on reducing blood glucose in diabetic patients in Sari, Iran. It was found that the post-test level of happiness in the Intervention group was significantly increased as compared to the pre-test level [40]. This finding was also consistent with research by Xiao, showing the positive effect of happiness on reducing blood glucose in diabetic patients. Therefore, mindfulness training programs are an effective means of controlling and reducing glycosylated haemoglobin in diabetic patients [41].

This means that, in addition to their positive psychological effects (increased happiness), mindfulness training programs have been instrumental in improving the physical condition of the body (lowering blood glucose levels).

In order to explain these findings and the effect of mindfulness on patients, one should note that the people who have a higher level of mindfulness should be less anxious, since they are fully aware of their abilities [42]. Individuals with high levels of mindfulness are meticulous in their conduct. They accept only the responsibilities that they are capable of, and are honest with themselves and others. They know why and to what extent they can handle leadership and management tasks. These people are able to use their thoughts to control their emotions, and these factors can directly reduce anxiety [15, 43]. In the intervention sessions, the subjects learned to recognize their inner thoughts and conversations. They learned that many individuals are angry at themselves and blame themselves when they fail to perform a task appropriately. They also learned that our minds are often activated in different life situations, and thus we can conduct internal conversations with ourselves. This conversation can be a positive experience for us, give us courage and inspire us to engage in new activities, which will eventually lead to a decrease in blood sugar and an increase in happiness [29].

In the light of the findings and limitations of this research, it can be concluded that the mindfulness training program can be beneficial in terms of increasing happiness and reducing blood sugar in people with diabetes. The results of this study can be used as a basis for further research on investigating to compare the long term effect of mindfulness training program in boosting happiness and treating diabetes in different cultures and societies.

Limitations

This study was performed only in a single clinic and needs to be implemented on a wider scale for generalization. Also Only short-term effects were studied, there is a need for long-term follow-ups.

Authors’ contributions

KJ and NZ devised the study concept, designed the study, supervised the intervention, data collection and analysis, participated in the coordination of the research, and critically revised the manuscript. LB collected data, ran the study intervention, participated in the study concept, performed the analyses and revised the manuscript. FK and HRS contributed to the design, analysis and interpretation and reporting data, and revising the manuscript critically for important intellectual content, and Final approval of the version to be published. All authors have read and approved the content of the manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Compliance with ethical standards

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All the essential information regarding the goals and methodology of the research was adequately provided to all the subjects before the study. Written informed consent was obtained from the participants and they were assured that their personal information will be considered confidential and only general data and statistics will be made public.

Consent for publication

Not applicable.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Availability of data and material

Data is available by contacting the corresponding author.