Incorporating Complementary Therapies Into Diabetes Care

Abstract

Context

Current diabetes care and education programs and expert clinical diabetes management guidelines focus on diabetes self-care behaviors and have yet to incorporate complementary therapies. Complementary therapies, such as music therapy, yoga, mindfulness, and art therapy, have been used globally for centuries and have positive metabolic and glycemic outcomes. In this mini-review, we describe complementary therapies successfully used in diabetes, identify current evidence-based practice gaps, and provide recommendations for incorporating complementary therapies into diabetes care.

Evidence Acquisition

We thoroughly searched relevant PubMed and Google Scholar studies from 2004 to 2024. Our inclusion criteria were clinical trial studies using the search terms “diabetes self-management” OR “metabolic outcomes” OR “diabetes” OR “type of complementary therapy (music therapy, mindfulness, yoga or art therapy) OR population (type 1 diabetes, type 2 diabetes, prediabetes, diabetes).”

Evidence Synthesis

We synthesized the evidence to determine complementary therapies (music therapy, mindfulness, yoga, or art therapy) that benefit individuals with diabetes. Findings showed that complementary therapies support diabetes-related psychological and cardiometabolic outcomes and enhance the Association of Diabetes Care and Education Specialists 7 Self-Care Behaviors for diabetes self-management, specifically healthy coping, monitoring, reducing risks, and problem-solving. Critical gaps included the lack of large-scale randomized controlled trials in North American diabetes self-management education programs.

Conclusion

Complementary therapies have positive psychological and physiological health benefits for people living with diabetes, yet more randomized controlled trials are needed to assess their effectiveness on a large scale. In the interim, complementary therapies can be integrated into diabetes education, specifically as adjunctive hands-on therapies to enhance self-management behaviors and meet self-management goals.

Of the 38.4 million Americans affected by diabetes (1), a majority do not meet optimal glycemic targets (2). Diabetes self-management education and support (DSMES) programs improve self-care behaviors, problem-solving, well-being, and clinical outcomes for individuals with diabetes (3, 4). The Association of Diabetes Care and Education Specialists (ADCES) ADCES7 Self-Care Behaviors is often used as a framework for providing DSME curriculum and includes healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving (Table 1) (5). To date, there have been few diabetes programs that have incorporated complementary therapy practices into the DSMES curriculum and diabetes care, despite the relevance for enhancing self-care behaviors and known metabolic benefits across chronic disease populations worldwide.

The National Center for Complementary and Integrative Health defines integrative health as combining conventional and complementary therapy approaches in a coordinated way. It emphasizes multimodal or 2 or more conventional health interventions (medication, rehabilitation, physical therapy, and behavioral health therapy) and complementary approaches (yoga, acupuncture, meditation) in various combinations, stressing treating the whole person (6). Complementary therapy approaches have historically been used within chronic disease populations to enhance physical well-being, healing, recovery, and emotional resilience among various patient populations. Complementary therapies come in a multitude of forms, including the mind-body therapies of guided imagery and mindfulness, breath (7) and relaxation techniques, yoga practice, massage, Reiki, and art therapy (8). It has also expanded to include acupuncture, hypnotherapy, aromatherapy, relaxation techniques, meditation, breathing exercises, and homeopathy therapies (7). The National Center for Complementary and Integrative Health classifies complementary health approaches by their primary therapeutic input that fall into psychological, physical, and nutritional domains, all overlapping to support diabetes self-care behavior components (6). Complementary therapies that overlap within nutritional and psychological domains include mindful eating, and those that overlap with psychological and physical domains include mindfulness, meditation, art, music, and yoga. Although we aim to provide integrative therapy to improve the well-being of individuals living with diabetes, individual complementary therapies may best fit into chronic disease self-management support programs.

For example, 79% of pediatric patients with cystic fibrosis in London noted using complementary therapies, including nutritional/dietary, mind-body therapies such as prayer, visualization, yoga, acupuncture, and massage (9). Complementary approaches continue to be recognized as practical tools in chronic and progressive disease states affecting the muscular, neurological, and renal systems. Muscular sclerosis is an increasingly impairing condition where symptoms often evolve into discomfort physically, as well as increased psychological worry and stress related to disease progression. Between 57.1% and 81.9% of patients with multiple sclerosis use complementary therapies to address their symptoms in the form of diet and relaxation techniques (10). The use of complementary therapies for relaxation and dietary approaches positively impacts individuals with multiple sclerosis, as evidenced by reports of decreased relapse, improved neurological status, and improved quality of life (QOL).

Additionally, across the globe, complementary therapies, including mindfulness (11), yoga (12), music therapy (13), and art therapy (14), are techniques that have been used for centuries to reduce stress, improve healthy coping, and reduce cardiometabolic risk factors such as lipid profiles and blood pressure. Other chronic disease specialties such as oncology (15) and rheumatology (16) have clinical guidelines recommending and advising on incorporating complementary therapies with medical disease therapy to improve chronic disease outcomes. However, complementary therapies are rarely integrated into North American DSMES curriculum, and experts have yet to recommend their integration into diabetes care despite their promise to enhance clinical outcomes.

Evidence-based practices for incorporating complementary therapies into diabetes care and education are critical for person-centered care yet are rarely used in practice. Therefore, an evaluation of the current knowledge of complementary therapies in diabetes management is necessary. In this mini-review, we define and describe these complementary therapies, their efficacy on diabetes self-management outcomes and behavior change, current gaps in evidence-based practice, and recommendations for incorporating them into DSMES and diabetes care to enhance clinical outcomes.

Materials and Methods

A literature search of complementary therapy studies in diabetes in PubMed and Google Scholar was performed. Inclusion criteria were intervention studies published in the previous 20 years (2004-2024). Search terms used were “diabetes self-management” OR “diabetes” OR “type of complementary therapy (music therapy, mindfulness, meditation, guided imagery, yoga or art therapy) OR “population (type 1 diabetes, type 2 diabetes, prediabetes, diabetes).”

Results

The literature review results are displayed in Table 2.

Music Therapy and Diabetes Outcomes

Since ancient times, music has been a therapeutic approach. It is noted that ancient Egyptians described musical incantations as a way of healing the sick.

In his book De Anima, Aristotle (323-373 BCE) described flute music as something that could arouse strong emotions and purify the soul (29). Music therapy is a clinical and evidence-based approach by an established health professional. Music therapists assess an individual's nonmusical needs, provide a therapeutic treatment plan, and use music within a therapeutic context to address physiological and psychological outcomes. Various music interventions such as active music making, songwriting, active/passive listening, and live music listening have been demonstrated through research to lower blood pressure, decrease stress and anxiety perception, and increase quality of life, self-expression, and relaxation.

Research has demonstrated that music therapy can be an effective method in providing a nonpharmacological approach to reducing stress, anxiety, mood modification, depression as well as pain (30) when facilitated by board-certified music therapists (31). Music has shown positive effects on the neurochemical activity of 4 different brain systems, the reward, social, immune, and stress systems (32), allowing our parasympathetic and sympathetic nervous systems to become balanced. Using music interventions such as active music making, improvisation, music-assisted relaxation and imagery, passive music listening, and songwriting can provide and support diabetes management in creating a positive verbal or nonverbal expressive outlet, decreasing body tension, increasing breathing and relaxation, and enhancing quality of life in the perception of self-empowerment and acceptance (33). The music therapist can support an individual living with diabetes in maintaining healthy coping mechanisms, with a focus on physical and psychological outcomes (34). Six studies in this review provided music for diabetes stress management and coping.

Mandel et al (2013) conducted a feasibility randomized controlled trial (RCT) of 199 individuals living with type 1, type 2, or prediabetes who were assigned to either DSMES alone or a music therapy arm. The music therapy intervention used a prerecording composed to meet the patient's preferred style of relaxing and stimulating music accompanied by a script by a board-certified music therapist and live music-assisted relaxation and imagery facilitated by a music therapist to people with diabetes receiving DSMES. Blood pressure, hemoglobin A1c (HbA1c), body mass index (BMI), trait anxiety, state anxiety, and stress were measured as part of study outcomes. Trial findings suggest there was a significant decrease in systolic blood pressure for those with hypertension who participated in a music intervention compared to those enrolled in DSMES alone. The sample size was limited in this study. A larger sample size would provide a quantitative validation of data. Pre- and postnarrative feedback and possible HbA1c pre-post surveys would be recommended with the suggestion of integrating smart technology to support music-assisted relaxation and imagery on a daily or weekly schedule, collecting data of pre- and post-self-efficacy feedback (13).

Deshkar et al (2022) observed using culturally significant music for stress management for people with diabetes using heart rate variability. The intervention used ancient healing music of India, called Raga Chikitsa. Music therapy sessions took place using raga-based Bollywood songs to analyze heart rate variability using a cardiac autonomic neuropathy analyzer. Using the Kubios method, data demonstrated a fall in heart rate after (84.71 ± SD 9.13) a music therapy session. The t-test revealed statistically significant differences (t = 2.77 and P < .05) in blood sugar levels before (164 ± 39.8) and after (143 ± SD 23.3) music a therapy session, decreases (t = 3.03 and P < .05) in the sympathetic neurological system index, which is an indicator of sympathetic activity of the body, and a 5% reduction in stress. A randomized control trial on a larger scale is recommended and would benefit from providing more information on the participant selection process and having some comparisons. This study gives the perspective of using culturally appropriate music with healing roots implemented within a clinical setting (17).

Tumuluri et al identified that living with type 2 diabetes (T2D) can cause cognitive deficits and increase stress perception (18). This exploratory study examined the effect of using a case series study design with pre-post evaluation. Music therapy interventions include singing, active music making, and music listening to observe how music affects focused attention, working memory, and stress. Twenty sessions were carried out with 3 participants living with T2D. Pretest and posttest (1 month) measures of serum cortisol, self-reported stress perception, Color Trail Test (1 and 2), and verbal n-back (1 and 2) tests were collected. Participants provided subjective feedback expressing that the music therapy sessions were beneficial. This study highlights that the results varied and were inconsistent because they were limited due to the small sample size. A larger scale RCT study, perhaps involving a music therapist and using patient-preferred music and active music making, would enhance this study's question of using music therapy to affect cortisol levels and perceptions of therapeutic value on cognition, memory, and stress in receiving music therapy services (18).

Using a blinded randomized controlled study, Gelernter et al examined the effect of auditory guided imagery (AGI) on glucose levels, HbA1c, and QOL in N = 13 7- to 16-year-old children with type 1 diabetes (T1D). The study compared the effect of AGI using background music vs solely listening to prerecorded music. In the short phase, patients wore a continuous glucose monitoring system for 5 days, and in the long phase, outcome measures were changes in QOL and HbA1c as participants listened to the AGI recording twice per week for 12 weeks. Results demonstrated that wearing continuous glucose monitors benefited both groups, and those receiving AGI had a more significant decrease in HbA1c. In future studies, it is suggested that an integrative approach in which music therapists cotreat in implementing music for relaxation, with a focus on using preferred music (19).

There is promising early work in music therapy interventions for people with diabetes. Overlapping themes suggest that various music therapy interventions can positively impact stress perception by increasing coping skills to handle the daily demands of living with diabetes. Despite some preliminary studies, it is critical to test music therapy interventions in larger-scale RCTs to further investigate music as a therapeutic tool and an evidence-based integrative approach in diabetes self-management. Common gaps throughout the review of music therapy interventions in diabetes include small sample sizes, lack of RCTs, and a strong focus on the T2D population only. Individuals living with prediabetes, T1D, atypical forms of diabetes, and gestational diabetes can all benefit from receiving music therapy services. Music therapy has the power to enhance well-being in individuals with chronic conditions, and we believe it will greatly impact those living with diabetes.

Mindfulness/Meditation and Diabetes Outcomes

Individuals who live with diabetes persevere through continued use of medications, monitoring, side effects, and complications that may come their way for a lifetime. The unending nature of this process is often fatiguing and can lead to increased incidence of depression, anxiety, and psychological stress. Previous studies have indicated that mindfulness-based stress reduction may be effective in reducing diabetes-related stressors and depression. Mindfulness practice may help improve diabetes management by increasing an individual's ability to recognize emotional stressors brought on by diabetes and assist in coping with the disease from a healthier perspective (24).

An 8-week program based on body and medication practices, developed to examine the outcomes of the intervention over 5 years, noted that after year 1, individuals practicing mindfulness-based stress reduction meditation had lower levels of depression measured with the Patient Health Questionnaire and improved health status compared to the control group (20). Additionally, the intervention of mindfulness with diabetes has been noted to be effective in reducing pain associated with diabetes. An intervention comparing the 2 modalities of mindfulness-based meditation vs progressive relaxation meditation noted that both forms of mindfulness meditation resulted in reduced neuropathic pain in diabetes patients. Furthermore, mindfulness meditation reduced pain medication use and pain intensity and better patient satisfaction scores (21). Similarly, a randomized trial examining the effects of mindfulness training combined with aerobic exercise in patients with T2D and peripheral neuropathy noted reductions in reports of signs and symptoms of neuropathic pain, improved neurological function, and improved QOL (22).

As the identified benefits of mindfulness in diabetes care are becoming widely known, complementary mindfulness practices have continued to grow in patient care. However, gaps in patient care remain as health care providers' knowledge often lags regarding mindfulness therapies. At some larger institutions, there may be departments of integrative medicine where yoga and mindfulness practices are offered where medical providers may refer patients. In addition, the cost of consults may pose a barrier as insurance companies may or may not cover these services, leaving patients to pay out of pocket or not have the option to receive this care. At this time, we recommend incorporating mindfulness therapies, if available, into diabetes care because of the known benefits.

Yoga and Diabetes Outcomes

Yoga practice has widely been used for the emotional, psychological, and physiological components. The combined practice components contribute to improved cardiovascular health and decreased metabolic risk factors, as well as improved metabolic disease processes. The chronic lifelong state of diabetes often results in fatigue and stress that may lead to decreased engagement with medical management. The practice of yoga incorporates principles of voluntarily controlled breathing and relaxation, concentration, mindfulness/meditation, and self-realization. This principle can be used as a coping mechanism with the ongoing daily stressors common to the chronic nature of diabetes self-management (35).

Yoga practice is both physical and emotional and addresses physical and relaxation components that benefit physiological and psychological diabetes self-management outcomes. Prior studies have also noted that yoga benefits fasting blood glucose, improved glycemic control, and improved lipid values and QOL (23). In a 12-week trial comparing yoga to standard exercise, yoga participants had more significant reductions in HbA1c than the standard exercise cohort. Moreover, reductions in HbA1c were noted at the end of the trial and 6 months’ postintervention (24). A 2-year longitudinal study noted similarities in people with diabetes practicing a yoga intervention, with significant improvements in BMI, fasting blood glucose, low-density lipoprotein (LDL), very LDL, cholesterol, and HbA1c (23).

Similar findings were observed following an 8-week yoga practice intervention, examining the effects of yoga practice on inflammatory and metabolic markers in 30 healthy subjects in China. Markers of inflammation, including risk factors of metabolic syndrome, obesity, abnormal lipid profile, and insulin resistance were noted to decline with yoga practice. Significant reductions were also noted in plasma insulin, total cholesterol, LDL, and endothelial microparticles after 8 weeks of yoga practice intervention. Last, yoga has positively affected metabolic risk factors of increased weight loss and waist circumference. After a 3-month intervention of yoga practice, reductions were noted in weight, total cholesterol, triglycerides, LDL, and improved high-density lipoprotein while also addressing the stress management of diabetes through yoga practice (26). Likewise, an 8-week yoga intervention in individuals at high risk of diabetes was noted to decrease weight-related risk factors, including weight circumference and BMI (25).

Last, a laughter yoga technique has also been used in individuals with diabetes to improve glycemic outcomes. A 12-week laughter yoga intervention improved glycemic control as evidenced by reductions in HbA1c. The weeklong laughter yoga intervention group had a decline in HbA1c from 7.07% to 6.82%, whereas HbA1c increased from 7.19% to 7.26% in the control group (P = .008) (27). Reductions in these areas noted the positive impact on yoga, decreasing hallmarks of metabolic disease and, therefore, noting the effect of metabolic risk factors with incorporating yoga practice.

The daily demands of living with diabetes often induce diabetes distress. Yoga adds psychological and emotional benefits such as improved QOL, and changes within the sympathetic neurological system and the hypothalamus-pituitary-adrenal axis, influencing the parasympathetic system and decreasing stress responses associated with diabetes distress psychological stressors (25). Many types of yoga can be implemented into practice to assist individuals with diabetes in healthy coping, preventing risks, and staying physically active.

Art Therapy and Diabetes Outcomes

The American Art Therapy Association defines the field of art therapy as a mental health profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship (36). In particular, an individual's verbal expression may fail them when experiencing adversity or chronic condition symptoms. Art therapists assist individuals with chronic conditions in expressing themselves during difficult moments in ways beyond words or language. Art therapists have psychology and art training and can assist clients by integrating metaphors and nonverbal clues via the creative process. Art therapy supports individuals of all ages and diversified populations who have or are experiencing a variety of physical, mental, behavioral health, and trauma concerns.

For decades, art therapy has been proposed as a means of coping with emotions related to diabetes and a catalyst in diabetes self-management. Because art is tangible, the person living with diabetes can solidify and abstract an emotion from a distance, allowing them to take control over their diabetes-related emotions. The art can then be kept as a visual diary for the diabetes-related emotions and feelings expressed, giving the person with diabetes permission to do art in negative emotional situations, enabling the development of confidence and self-esteem (37).

A mixed-methods study assessed group art therapy for N = 16 adolescents and young adults with T1D and T2D transitioning to adult diabetes care. The intervention was 12 weekly, 90-minute group art therapy sessions, run by an art therapist, that looked at one's experience of living with diabetes. Many theoretical practices were used, such as existentialism and cognitive behavior theories that stressed transformative thinking processed through a decolonizing lens (a framework of practice to seek, recognize, and deconstruct the impacts of colonization and discrimination of First Nations, Inuit, and Métis peoples and to empower and inform people in their healing journeys), and elements of phenomenological-based talking and dialoguing with the artwork (38). There was a 57.14% reduction in diabetes distress, measured by the Problem Areas in Diabetes Scale, from pre- to postintervention. The participants found the art therapy intervention highly beneficial and enjoyable and a good distraction from general life stressors (28).

In children with T1D, art and related therapies are known to have benefits. Sketching and creative expression improved children's understanding of their diagnosis and self-management treatment (39). Additionally, stress levels decreased by 57%, increasing emotional well-being and addressing barriers to diabetes self-management behaviors, especially decreasing anxiety about needles and carbohydrate counting requirements (39). However, this was a brief literature review, and it is crucial to recognize the need for more quantitative assessments of the benefits of art therapy for diabetes self-management.

To date, most research related to art therapy and diabetes coping and self-management surrounds expressive therapy modalities such as play, music, and exercise in children. Child Art Psychotherapy, along with multisystem therapy, are positive interventions for children younger than age 11 years with suboptimal diabetes self-management outcomes (40). Additionally, after an individual art therapy session, a significant reduction in HbA1c of 0.79% was observed in children in Israel with suboptimal diabetes self-management outcomes (41).

Although art therapy has promising benefits for people living with diabetes, many gaps remain. Much of the literature includes theoretical, early, or pilot studies focusing on children and adolescents. However, art therapy has the potential to benefit adults living with diabetes because it aids in verbal and written communication, provides a sense of control over diabetes, and allows for a better understanding of diabetes treatments needed for longevity. Art therapy can also assist in decreasing stress and depression, allowing for the exploration of feelings, self-efficacy, and the need for social support among peers. Overall, art therapy practice is a promising therapy to complement diabetes management, but many research gaps remain.

Discussion

Our literature review identified multiple ways music therapy, mindfulness, yoga, and art therapy improve psychosocial and metabolic diabetes self-management outcomes. Additionally, we identified ways complementary therapies support the ADCES7 Self-Care Behaviors,⁵ specifically healthy coping, empowerment, and increasing self-efficacy related to monitoring, reducing risks, and problem-solving. However, many gaps were identified, including a lack of adequately powered RCTs, trials conducted outside of North America, and a lack of diversity in the types of diabetes included in trials. Larger-scale interventional trials are critical to understand better how these promising complementary therapies can support self-care behaviors and metabolic outcomes in people with diabetes across the lifespan. In the interim, we encourage allied healthcare team members who care for people with diabetes to integrate complementary therapies into practice.

Recommendations for Integrating Complementary Therapies Into Diabetes Care

In Table 3, we provide recommendations for integrating complementary therapies to support the ADCES7 Self-Care Behaviors⁵ behaviors based on our review of the current literature.

Case Study

We encourage other diabetes teams to integrate complementary therapies into DSMES programs. For example, our group DSMES retreat integrates complementary therapies to support the ADCES7 Self-Care Behaviors.⁵ We introduced individuals living with prediabetes, diabetes, and related metabolic disorders to yoga and mindfulness. We begin with having short moments of meditation where the focus is on becoming comfortable with stillness. In this light, the concept of working with moving thoughts is introduced and the approach to working with these thoughts is to transition into a still meditative state. We discuss how these actions may be practiced daily as an approach to reconnecting with oneself and as a restorative practice that may be incorporated throughout the day.

The benefits of the mindfulness practice are discussed with the group. Different types of meditation are introduced and discussed, including body scanning, focused attention, resting awareness, reflection, noting of thoughts, and visualization. A guided imagery visualization mindfulness moment is incorporated after the discussion about mindfulness practice, and all group members participate in this activity. We have incorporated the yoga practice into the physical activity component of the retreat. The groups practice yoga together with a certified yoga instructor. The yoga practice is 20 minutes long and begins with yoga breathwork. Then, it moves into stretching through beginner yoga poses (Asanas) while seated in a chair. Chair yoga poses are then introduced, often including seated extended mountain poses, folds, seated spinal twists, and warrior 2. Finally, the group practices a half sun-A and ends with practice together in silence and the traditional Namaste, a greeting in Sanskrit of “I bow to you.” These exercises are encouraged at home to support healthy coping and reduce long-term diabetes risks.

Conclusions

In conclusion, complementary therapies, including music therapy, mindfulness, yoga, and art therapy, can support diabetes self-management behaviors and outcomes. It is critical to continue supporting people with diabetes as they cope with the daily demands of living with diabetes. Although we need further research to assess the large-scale effects of complementary therapies on diabetes populations, we can begin to enhance care by integrating these therapies alongside traditional DSME education.

Supplement Sponsorship

This article appears as part of the supplement “Guidebook for Providers on Comprehensive Diabetes Care,” sponsored by the University Hospitals Mary B. Lee Chair in Adult Endocrinology endowment, and by the Ratner Family Fund.

Funding Support

B.H., Deborah and Ronald Ratner fund and University Hospitals, Mary B. Lee Chair in Endocrinology.

Disclosures

J.E.B. consults for Insulet Corporation and Embecta and receives grant support from The Leona M. and Harry B. Helmsley Charitable Trust (04/2023-04/2026) and National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) (09/2023-06/2028). B.H. received support as the study site principal investigator (08/31/23-08/31/26) from Jaeb Center for Health Research, Inc.; and support as the study site principal investigator (04/18/2024-04/30/2027) from Diasome Pharmaceuticals. F.P., B.N.D., and R.L.K. have nothing to declare.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

References

Abbreviations

 
• ADCES

  Association of Diabetes Care and Education Specialists

 
• AGI

  auditory guided imagery

 
• BMI

  body mass index

 
• DSMES

  diabetes self-management education and support

 
• HbA1c

  hemoglobin A1c

 
• LDL

  low-density lipoprotein

 
• QOL

  quality of life

 
• RCT

  randomized controlled trial

 
• T1D

  type 1 diabetes

 
• T2D

  type 2 diabetes