Diabetes Care: Inspiration from Sikhism.

Religion has been proposed as a means of enhancing patient and community acceptance of diabetes and cultural specific motivational strategies to improve diabetes care. Sikhism is a young and vibrant religion, spread across the world and the Holy Scripture Sri Guru Granth Sahib (SGGS) is regarded as the living Guru by all Sikhs. The three key pillars of Sikhism are Kirat Karni (honest living), Vand Chakna (sharing with others) and Naam Japna (focus on God). They can help encourage the diabetes care provider, patient and community to engage in lifestyle modification, shared responsibility, positive thinking and stress management. The verses (Sabads) from the SGGS, with their timeless relevance, span the entire spectrum of diabetes care, from primordial and primary, to secondary and tertiary prevention. They can provide us with guidance towards a holistic approach towards health and lifestyle related diseases as diabetes. The SGGS suggests that good actions are based on one's body and highlights the relevance of mind-body interactions and entraining the mind to cultivate healthy living habits. The ethics of sharing, community and inclusiveness all lay emphasis on the need for global and unified efforts to manage and reduce the burden of the diabetes pandemic.

SIKHISM

Sikhism is a relatively young, yet vibrant religion, with over 30 million adherents spread across the world. Born in Punjab, India, it follows the teachings of the ten Sikh Gurus. The first Guru, Guru Nanak Dev (1469–1539), founded a new philosophy based on:

Kirat Karo: earn an honest, pure, and dedicated living by exercising God-given skills and labor for the improvement of society

Vand Shako: share what you have with those less fortunate in society

Naam Japo: do all of this with the mind focused on God to the extent that you become a part of the creator and you see God in all creation, living or inanimate.

The fifth Guru, Guru Arjan Dev, compiled the teachings of the Gurus and several saints of the Indian Subcontinent including those from Hindu, Muslim and Sikh backgrounds into the Holy Scripture, the Adi Granth. The tenth Guru, Guru Gobind Singh, finalized the compilation by adding teachings of the ninth Guru, Guru Tegh Bahadur and bestowed the Scripture, Sri Guru Granth Sahib (SGGS), Guruship for eternity. SGGS is today considered as the living Guru by all Sikhs. The religion has weathered various challenges and obstacles and endured significant opposition to its growth. Its inbred resilience, however, has allowed it to flourish across the world. Sikhism is an egalitarian philosophy emphasizing that all humans are equal in fundamental worth or social status and encourages its followers to not only develop themselves spiritually but also physically to ensure the welfare of the community and society at large.

DIABETES

One of the challenges facing modern humanity is related to metabolic health. The pandemic of diabetes has spread across regions and races, without respect for borders and boundaries. The Sikh-dominated state of Punjab has an overall prevalence of overweight or obesity of 27.8% in men and 31.3% in women. The neighboring state of Haryana, which boasts of a large Sikh population, reports an obesity/overweight prevalence of 20.0% in men and 21.0% in women.[1]

Diabetes management is a comprehensive and multifaceted process. This includes not only prescription of appropriate therapy but also focuses on ensuring adherence to suggested treatment.[2] This is easier said than done. Adherence to diabetes management plans remains suboptimal, and this in turn leads to below-par clinical outcomes.

RELIGION AND DIABETES MANAGEMENT

Religion has been proposed and used as a means of enhancing patient and community acceptance of diabetes. Incorporation of religion and culture specific motivational and therapeutic strategies improves patient–physician communication and bonding, facilitates appropriate patient-centered care, and provides a framework upon which desired outcomes can be achieved. South Asian diabetology literature has described such approaches in the context of Buddhism, Hinduism, Jainism, and Islam.[3456]

While expert opinion has been published on Sikhism and diabetes management, such literature is scarce and originates from the west.[78910] These pioneering authors have covered significant issues which must be addressed in the field of dietetics and lifestyle. We do note, with satisfaction, that colleagues from other specialties have also explored the interface between Sikhism and their fields of medicine.[11] Existent literature describes the beliefs and practices of Sikhism and also provides evidence that Sikhism-specific interventions are helpful in achieving better outcomes.[1213]

SIKHISM AND MOTIVATION FOR SELF-CARE

In this communication, we describe aspects of Sikh religion, and motivational verses (shabads) from the Holy SGGS, which can be shared with persons living with diabetes and the community. The teachings of the Gurus can be used to stimulate a discussion on healthy living, prevention of diabetes, and appropriate healthcare seeking and acceptance. These verses, with their timeless relevance, span the entire spectrum of diabetes care, from primordial and primary to secondary and tertiary prevention.[14] Highlighting the wisdom contained in them should stimulate and support efforts to contain the diabetes epidemic in the society.

We take this opportunity to remind our readers that the SGGS is considered the living Guru, and its verses must be accorded the same respect (maryada) that the holy book is. While we have attempted to remain true to the spirit of the Holy Scripture, we seek forgiveness for any unintentional error on our part.

THE PHILOSOPHY OF SIKHISM

For the person living with diabetes and for diabetes care professionals, the three core teachings of Sikhism, Naam Japna (focus of God), Kirat Karni (honest living), and Vand Chakna (sharing with others), can be taken as the three pillars of diabetes self-management.

Naam Japna reflects the advantages of stress management by meditation, mindfulness and positive thoughts. This guidance is equally important for all stakeholders in diabetes, as compassion fatigue and burnout[15] may afflict persons living with diabetes, their family members and care providers as well. Further, the Gurus remind us that one should be absorbed in Naam during routine activities such as eating and should be mindful of our blessings.

“The Lord's name is the sustenance for our soul, as is food of all (thirty six) varieties for the physical body; it gives satisfaction to us.” (SGGS page 593, Guru Amar Das)

Har Naam Hamaaraa Bhojan Shhatheeh Parakaar ǀǀ Jith Khaaeiai Ham Ko Thripath Bhaee ǀǀ

Kirat Karni is a constant reminder to practice hard labor and remain honest with one's efforts at lifestyle modification and disease management. Vand Chakna is a reminder to limit one's consumption of food and share food with the needy and less fortunate ones. This will automatically correct the existing imbalance in calorie intake and expenditure, thus shifting the metabolic fulcrum back to a eubolic state.

In keeping with the spirit of Vand Chakna is the Sikh tradition of “Langar” or free kitchen, which was started by Guru Nanak Dev. The teachings of the Guru, like the food served at the Langar, are always open for all.

“The Langar – the Kitchen of the Guru's Sabad has been opened, and its supplies never run short.” (SGGS page 967, Bhatt Satta and Balwand)

Langar Chalai Gur Sabadh Har Thott N Aavee Khatteeai ǀǀ

In addition to the ideals of equality among all, Langar expresses the ethics of sharing, community, inclusiveness and oneness of all humankind. At an epidemiological level, Vand Chakna would help reduce the dual burden of malnutrition and overnutrition in a population, which seems to be the tragedy of chronic metabolic disorders.

“She distributes the bounty of the Guru's Langar; the kheer – the rice pudding and ghee, is like sweet ambrosia.” (SGGS page 967, Bhatt Satta and Balwand)

Langar Dhoulath Vanddeeai Ras Anmrith Kheer Ghiaalee ǀǀ

The philosophy of Vand Chakna and Kirat Karni extends beyond sharing of material possessions. It also includes, in its ambit, sharing of work and responsibility. For the diabetes care provider, Kirat Karni teaches us to do the best possible for people who seek our care, while working in a patient-centered manner. Vand Chakna reinforces the need to practice shared decision-making with the patient and promote shared responsibility, by involving health-care experts from other specialties and professions where needed.

HOLISTIC APPROACH

“When chanting, austere meditation and self-discipline become your protectors, then the lotus blossoms forth, and the honey trickles out. Bring the 27 elements of the body under your control, and throughout the three stages of life, remember death” (SGGS page 23, Guru Nanak Dev)

J a p Thap Sanjam Hohi Jab Raakhae Kamal Bigasai Madhh Aasramaaee ǀǀ2ǀǀ Bees Sapathaaharo Baasaro Sangrehai Theen Khorraa Nith Kaal Saarai ǀǀ

Diabetes is a multifaceted syndrome, with many etiologic factors, pathogenic pathways, clinical presentations, comorbid associations, and complications. The current approach to comprehensive metabolic management of diabetes is not without its challenges. It places a greater burden upon the prescriber, who has to follow multiple management guidelines, and upon the person with diabetes, who has to adhere to a disciplined lifestyle and self-administer the various injections and tablets suggested to him.

The SGGS reminds us of the various “elements” or constituents of the body and the fact that all are equally important. The most updated psychosocial care guidelines today are based on the transition of various life phases;[16] it is interesting to note that life stages are discussed in the SGGS as well.

HEALTHY HABITS

“Make this body the field, and plant the seed of good actions. Water it with the Name of the Lord, who holds all the world is His hands” (SGGS page 23, Guru Nanak Dev)

Eihu Than Dhharathee Beej Karamaa Karo Salil Aapaao Saaringapaanee ǀǀ

Asian religions are often considered fatalistic, as they subscribe to the view that one's fate or destiny is linked to one's action or Karma, which took place in preceding births. This, however, is not entirely correct. One can perform good actions or Karma and reap their benefit within the same lifespan. This has been proven by the concepts of glycemic legacy or metabolic memory. The rubric of transgenerational Karma[17] goes a step ahead, building upon evidence that maternal actions, before, during, and after pregnancy, can influence the health of unborn offspring.

The SGGS predates these theories, by suggesting that good actions are based on one's body. SGGS highlights the relevance of mind–body interactions and entraining the mind to cultivate healthy living habits. This verse motivates persons with diabetes to take care of their physical body, by accepting timely screening, diagnostic, and therapeutic interventions.

DIET

“Sleep little and eat little; O Nanak, this is the essence of Wisdom” (SGGS page 939, Guru Nanak Dev)

Khanddith Nidraa Alap Ahaaran Naanak Thath Beechaaro ǀǀ8ǀǀ

Nutritional therapy is the cornerstone of diabetes therapy. Supposedly the simplest, it is perhaps the toughest aspect of diabetes care to adhere to. Calorie restriction, in fact, has been found to be the best means of enhancing lifespan in animal species.[18] Many verses of the SGGS remind one to practice moderation in eating.

“False is the tongue which enjoys delicacies and tastes” (SGGS page 269, Guru Arjan Dev)

Mithhiaa Rasanaa Bhojan An Svaadh ǀǀ

“The more one feels hunger for other tastes and pleasures, the more this hunger persists.” (SGGS page 167, Guru Ram Das)

Jithanee Bhookh An Ras Saadh Hai Thithanee Bhookh Fir Laagai ǀǀ

In the modern times of food abundance and easy availability of food, eating is often driven by perceptions of food reward, often in the absence of any metabolic feedback indicating actual reduction of energy reserves.[19] The pleasure from the hedonic value of consuming food leads to nonhomeostatic eating without conscious awareness of it. The SGGS recognizes that unobservant eating causes several inflictions on our body and makes several references to being mindful when eating.

“You are intoxicated with the tastes of the tongue, with greed and pride; countless sins spring from these. You wandered in pain through countless incarnations, weighed down by the chains of egotism” (SGGS page 616, Guru Arjan Dev).

Jihavaa Suaadh Lobh Madh Maatho Oupajae Anik Bikaaraa ǀ ǀ Bahuth Jon Bharamath Dhukh Paaeiaa Houmai Bandhhan Kae Bhaaraa ǀǀ2ǀǀ

“He thinks that his food is so sweet, O Beloved, but it makes his body ill. It turns out to be bitter, O Beloved, and it produces only sadness.” (SGGS page 641, Guru Arjan Dev)

Mithaa Kar Kai Khaaeiaa Piaarae Thin Tan Keethaa Rog ǀǀ Kourraa Hoe Pathisattiaa Piaarae Thin Thae Oupajiaa Sog ǀǀ

These verses can be used to influence behavior change in persons with diabetes. The Gurus clearly encourage us to control our greed.

“Where there is greed, there is death. Where there is forgiveness, there is God Himself.” (SGGS page 1372, BhagatKabeer)

Jehaa Lobh Theh Kaal Hai Jehaa Khimaa Theh Aap ǀǀ155ǀǀ

At the other extreme of calorie restriction, prolonged fasting may be associated with metabolic disturbance which can be life threatening at times.[20] While the teachings enjoin us to keep control over our palate, they also specify that we should not fast and torture our bodies as this does not help in the spiritual path.

“Those who do not eat food, they just torture their body (because they don't gain any spiritual benefit from this act). Without the Guru's wisdom, they are not satisfied.” (SGGS page 905, Guru Nanak Dev)

Ann N Khaahi Dhaehee Dhukh Dheejai ǀǀ Bin Gur Giaan Thripath Nehee Thheejai ǀǀ

“Let your mind be content, and be kind to all beings. In this way, your fast will be successful (i.e., this is the real fast).” (SGGS page 299, Guru Arjan Dev)

Man Santhokh Sarab Jeea Dhaeiaa ǀǀ Ein Bidhh Barath Sanpooran Bhaeiaa ǀǀ

PHYSICAL ACTIVITY

Sikhism strongly believes in and encourages physical activity. The second Guru, Guru Angad Dev, took a keen interest in sports and wrestling. He had Mal-Akharas (sports ground) in his compound and encouraged the disciples to participate in exercises after the morning prayers.

“Through sincere efforts, the mind is made peaceful and calm.” (SGGS page 201, Guru Arjan Dev)

Oudham Karath Seethal Man Bheae ǀǀ

Later, the sixth Guru, Guru Hargobind, started the philosophy of Miri-Piri – the balance between the material and the spiritual. He emphasized on the close relationship between Miri (temporal or worldly power) and Piri (spiritual power). A Sikh must be a Saint Soldier – he/she must be prepared to stand up for righteousness and humanity and hence must keep himself/herself physically fit.

Gatka, the dynamic Punjabi martial art of mock battles, is testimony to this. The gatkabaj is expected to be ambidextrous in handling various weapons while ensuring nimble footwork and tactical body positioning. The festival of Hola Mohalla started by the tenth Guru, Guru Gobind Singh, celebrated on the second day of the lunar month, is an occasion to demonstrate daring physical feats such as gatka, horse riding, swordsmanship, and tent pegging. All this calls for strength, stamina, and a supple or flexible body. Such a healthy state is possible only with regular exercise. These facts can be shared to encourage physical activity as a preventive and therapeutic intervention for diabetes.[21]

ALCOHOL AND ADDICTION

“The people are intoxicated (with worldly pleasures); they have forgotten death, and they have fun for a few days.” (SGGS page 15, Guru Nanak Dev)

Mathee Maran Visaariaa Khusee Keethee Din Chaar ǀǀ

“Drinking the wine, his intelligence departs, and madness enters his mind.” (SGGS page 554, Guru Amar Das)

Jith Peethai Math Dhoor Hoe Baral Pavai Vich Aae ǀǀ

Many dietary and lifestyle factors influence glycemic control. One of these is alcohol and substance abuse. Excessive alcohol intake is associated with both hypoglycemia unawareness and hyperglycemia. The SGGS explicitly refers to the hazards of consuming intoxicants such as alcohol, marijuana, or tobacco.

“Kabeer, those mortals who consume marijuana, fish, wine or paan – no matter what pilgrimages, fasts and rituals they follow, they will all go to hell.” (SGGS page 1377, BhagatKabeer)

Kabeer Bhaang Maashhulee Suraa Paan Jo Jo Praanee Khaanhi ǀǀ Theerathh Barath Naem KeeeaeThae Sabhai Rasaathal Jaanhi ǀǀ233ǀǀ

The teachings of the SGGS, which call for abstinence from all intoxicants, are particularly relevant. Believers can be encouraged to avoid the use of stimulatory substances.

“Those who do not use intoxicants and overcome their lust for worldly pleasures are true; they dwell in the Court of the Lord.” (SGGS page 15, Guru Nanak Dev)

Sach Miliaa Tin Sofeeaa Raakhan Ko Dharavaar ǀǀ1ǀǀ

SMOKING AND TOBACCO

“Those who eat betel nuts and betel leaf and put cigarette in mouth, but do not contemplate the Lord, Har-Har – the Messenger of Death will seize them and take them away and they will remain in the cycle of birth and death.” (SGGS page 726, Guru Ram Das)

Paan Supaaree Khaatheeaa Mukh Beerreeaa Laaeeaa ǀǀ Har Har Kadhae N Chaethiou Jam Pakarr Chalaaeeaa ǀǀ13ǀǀ

The Sakhi of Guru Gobind Singh mentions an episode when his horse abruptly halted in front of a field planted with tobacco, and he asked his soldiers to take a much longer route. When asked why, the Guru replied that his horse had stopped as it had caught the scent of tobacco and refused to walk through such an unclean space. He emphasized that while alcohol destroys one generation, tobacco destroys many. He commanded the Sikhs not to expose themselves to such pollution. Likewise, smoking and other substance abuse are strictly prohibited by the Sikh code of conduct.

YOGA AND MEDITATION

Meditation is a state of contemplation, concentration, and reflection that improves spiritual and emotional well-being. Yoga has been recommended by the Indian national guidelines for psychosocial management of diabetes and has been shown to have a beneficial effect on metabolic parameters.[22]

“Practice such Yoga, O Yogi. As Gurmukh, enjoy meditation, austerities and self-discipline.” (SGGS page 970, BhagatKabir)

Aisaa Jog Kamaavahu Jogee ǀǀ Jap Thap Sanjam Guramukh Bhogee ǀǀ1ǀǀ Rehaao ǀǀ

The Gurus emphasized that one does not need to become an ascetic saint to meditate and that such efforts should be practiced while living day-to-day life and fulfilling one's responsibilities toward family and society. The scripture emphasizes the need to remain fully awake in a sea of worldly attachments. There is great emphasis on meditation – Jaap (reciting the name of God, Waheguru) and Simran (remembrance).

“You may perform exercises of inner purification, and fire up the furnace of the Kundalini, inhaling and exhaling and holding the breath. Without the True Guru, you will not understand; deluded by doubt, you shall drown and die.” (SGGS page 1343, Guru Nanak Dev)

Nivalee Karam Bhuangam Bhaathee Raechak Poorak Kunbh Karai ǀǀ Bin Satgur Kishh Sojhee Naahee Bharamae Bhoolaa Boodd Marai ǀǀ

However, SGGS reiterates that physical exercises of yoga alone will fail to achieve the desired results without meditation and inner awareness. Meditation on the naam is the key to eternal bliss.

“O Nanak, in just the same way, vibrate and meditate on the Lord, single-mindedly, with one-pointed consciousness.” (SGGS page 1428, Guru Tegh Bahadur)

Nanak Eih Bidhh Har Bhajo Eik Man Hue Eik Chith ǀǀ45ǀǀ

STRESS MANAGEMENT

“When you are plagued by great and excessive anxiety and suffer from disease.” (SGGS page 70, Guru Arjan Dev)

Jaa Ko Chinthaa Bahuth Bahuth Dhaehee Viaapai Rog ǀǀ

Diabetes has a strong psychosocial component, which cannot be underestimated. It is noteworthy that suggestions contained in “modern” recommendations on psychosocial management of diabetes[22] have been penned down several centuries ago by the Gurus.

“The Name of the Lord is the medicine to cure all diseases; with it, no disease afflicts me.” (SGGS page 814, Guru Arjan Dev)

Aoukhadhh Har Kaa Naam Hai Jith Rog N Viaapai ǀǀ

The SGGS strongly endorses meditation. Mindfulness-based stress reduction has been shown to improve symptom management, overall quality of life, and health outcomes in individuals with chronic disease.[23]

“Suffering, pain, terrible disease and Maya do not afflict them.” (SGGS page 522, Guru Arjan Dev)

Dhookh Dharadh Vadd Rog N Pohae This Maae ǀǀ

“While laughing, playing, dressing and eating but remaining free from vices, he is liberated.” (SGGS page 522, Guru Arjan Dev)

Hasandhiaa Khaelandhiaa Painandhiaa Khaavandhiaa Vichae Hovai Mukath ǀǀ2ǀǀ

Several verses can be utilized to promote stress management as a means of overcoming diabetes distress, psychiatric disorders such as anxiety and depression, and diabetes-related burnout and compassion fatigue. This is important not only for persons living with diabetes and their family members but also for their health-care professionals, too.

POSITIVE ATTITUDE

“The hot wind does not even touch one who is under the Protection of the Supreme Lord God. On all four sides I am surrounded by the Lord's Circle of Protection; pain does not afflict me, O siblings of Destiny.” (SGGS page 819, Guru Arjan Dev)

Thaathee Vaao N Lagee Paarabreham Saranaaee ǀǀ Chougiradh Hamaarai Raam Kaar Dhukh Lagai N Bhaaee ǀǀ1ǀǀ

“Keep faith in the One Lord within your mind. All disease, O Nanak, shall then be dispelled.” (SGGS page 288, Guru Arjan Dev)

Eaek Aas Raakhahu Man Maahi ǀǀ Sarab Rog Nanak Mitt Jaahi ǀǀ1ǀǀ

A diagnosis of complication or intensification of therapy is often accompanied by distress and despair. The role of psychosocial and professional support and counseling is important in such situations. For religious persons, religion provides the much-needed scaffold with which to climb seemingly unsurmountable barriers.

“The Naam is the panacea, the remedy to cure all ills.” (SGGS page 274, Guru Arjan Dev)

Sarab Rog Kaa Aoukhadh Naam ǀǀ

“The physicians meet together in their assembly. The medicines are effective, when the Lord Himself stands in their midst.” (SGGS page 1363, Guru Arjan Dev)

Vaidhaa Sandhaa Sang Eikathaa Hoeiaa ǀǀ Aoukhadh Aaeae Raas Vich Aap Khaloeiaa ǀǀ

The SGGSs teachings provide an attitude of positive thinking, which can help impart the requisite coping skills in overcoming adverse health-related issues in persons with diabetes and their caregivers.

“Thus says Nanak: by meeting the True Guru, the wandering soul becomes steady, and comes to dwell in the home of its own self.” (SGGS page 441, Guru Amar Das)

Eio Kehai Nanak Sathigur Miliai Dhhaavath Thhanmihaaa Nij Ghar Vasiaa Aaeae ǀǀ4ǀǀ

CONCLUSION

This is a small effort from the authors of this article to understand the concept of prevention and management of diabetes in the context of teachings from SGGS. The Holy Scripture provides an armamentarium of a holistic approach toward health and lifestyle-related diseases such as diabetes.

The Sikh Ardas, a prayer given by Guru Gobind Singh, concludes with a prayer for positivity and well-being of all:

“Nanak, with Naam comes an eternally positive and blissful state, and with your blessings, peace, prosperity and welfare of everyone.”

Nanak Naam Chardikala, Tere Bhaane Sarbat da Bhalaaǀǀ

The attitude of “Chardikala” refers to an eternally positive, buoyant, ever progressive, and blissful state of mind and allows one to sail through the ups and downs of life, including but not limited to, health, and disease. A positive spirit and an acceptance of His (God's) will provide the necessary scaffold for everyone involved in diabetes care, the patient, the family, and the health-care provider, in overcoming barriers in disease prevention and management. “Sarbat da Bhalaa” in an invocation of the well-being of everyone and can help emphasize that we need global efforts to reduce the burden of the diabetes pandemic worldwide.