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February 2023, Volume 73, Issue 2

Recent Advances In Endocrinology

Autonomic Hygiene and Diabetes

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, India. )
Saurabh Arora  ( Department of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, India. )
Nitin Kapoor  ( Department of Endocrinology, Diabetes and Metabolism, Christian Medical College & Hospital, Vellore, India. )
Nitin Kapoor  ( The implementation science lab, Victoria, Australia )


Autonomic hygiene is referred to as conditions and practices that help to maintain normal autonomic nervous system health, and prevent the development and spread of autonomic neuropathy and its complications. In this article the authors describe the importance of autonomic hygiene in patients with diabetes. Different methods of practicing autonomic hygiene at the individual, familial and societal level have been described. Its role in preventing and worsening of autonomic neuropathy has been highlighted.


Keywords: Refractory obesity, resistant obesity, person centered obesity care, obesity management, pseudo resistance






Hygiene is defined as “conditions and/or practices that help to maintain health and prevent the spread of disease”.1 Though initially linked to the prevention of infections and infestations, hygiene today is also incorporated even in non-communicable diseases. Mental hygiene, metabolic hygiene and glycaemic hygiene are examples of the use of this term in various spheres of health.2-4 Social hygiene and information hygiene, both modern concepts, demonstrate the applicability of the concept of hygiene beyond the boundaries of infections in medicine.5

In this article, we focus on autonomic hygiene as a means of promoting health and preventing complications, in individuals, as well as the community at large, with specific reference to persons living with diabetes.


Autonomic Dysfunction


To understand the rationale of autonomic hygiene, we should be aware of the causes, clinical presentation and consequences of autonomic dysfunction. Autonomic neuropathy is a common and distressful, complication of diabetes mellitus. It can manifest in various ways, including papillary, pilomotor, sudomotor, cardiac, gastrointestinal or genitourinary syndromes.6 Autonomic dysfunction is also associated with behavioural changes, both at individual and societal level. The emergence of descriptors such as “adrenergic mindsets” and “dopaminergic societies” are testimony to this. Mind-body medicine focuses on autonomic nervous system as a means of achieving holistic health. Along with the higher functions, sympathetic: parasympathetic balance can be viewed as a threshold for risk stratification, a tool for initiating appropriate intervention, a technique for monitoring therapy, and a target to be achieved. The sympathetic: parasympathetic fulcrum is evident in the age-old rubric defined in the Bhagavad Gita as well. A saatvik behaviour is an autonomically balanced one, raajsik personalities are excessively adrenergic, and taamsik individuals exhibit parasympathetic predominance.


Autonomic Hygiene


Autonomic hygiene can be defined as “conditions and practices that help to maintain normal autonomic nervous system health, and prevent the development and spread of autonomic neuropathy and its complication”. Let us analyse this definition in a systematic manner.

Autonomic hygiene is not merely a theoretical, but a pragmatic and practical construct. It lends itself to intervention at both individual (clinical) and public health levels. Maintenance of good nutrition, physical activity and sleep hygiene, while avoiding extremes will promote autonomic nervous system health as well.7 Persons with sympathetic overactivity, for example, may be advised to avoid spices and hot foods, engage in long lasting distance running, as opposed to sprints and combative sports, and ensure regular sleep hours.

At a meso-level, it may be advisable to call for changes in culinary practices (salt reduction, for example), encourage team sports, and facilitate day light saving hours of business. On a large canvas, conditions and practices conducive to autonomic health, such as mind body medicine, mindful meditation and yoga can be promoted.8


Maintenance of Autonomic Nervous Health


Autonomic nervous system is the bridge between the nervous and endocrine systems, both of which ensure the body’s communication within itself and with the outside world.9 The definitions of neuro-transmitters and hormones blur within the autonomic system making it an easy target for disease. However, the same features allow us to use this complex system as an opportunity to ensure hygiene and promote health.

While the ‘conditions and practices’ detailed in the previous section allude to primary prevention, i.e mitigation of risk factor, in this section we correlate autonomic hygienic with secondary prevention, i.e  early diagnosis and  management of disease.

The first sign of cardiac autonomic neuropathy is loss of heart rate variability.6 In general, parasympathetic dysfunction precedes sympathetic damage in diabetic autonomic neuropathy. Autonomic-related  symptoms, such as erectile dysfunction and gastrointestinal motility disorders also make an early appearance in the natural history of uncontrolled diabetes. It is prudent practice, therefore, to screen for symptoms, signs and surrogate laboratory parameters suggestive of autonomic impairment. While batteries of autonomic tests have been described, they are often difficult to perform in busy primary care clinics. There is a need, therefore, to keep a high index of clinical suspicion, and screen for autonomic neuropathy in  individuals at-risk. If the diagnosis is substantiated, autonomic hygiene measures, as detailed in the preceding section, can be instituted and bolstered.


Prevent The Spread and Development Of Disease


In case autonomic neuropathy creates complications, it can still be managed with an aim to limit disability. This would be equivalent to tertiary prevention of disease.8

Specific yogic postures and exercises may be suggested, in conjunction with pharmacological measures, to achieve autonomic balance and hygiene. This prescription will require team work between not only the clinician and physiologist, but the yoga expert and patient as well.




Autonomic hygiene should be addressed as a mass level as well, to handle various societal ills that we face. Impatience, anger and intolerance, which seem to have become hallmarks of contemporary culture, may be attenuated if appropriate autonomic hygiene is inculcated in our citizens. From a diabetes perspective it can help prevent the development and worsening of the morbidity and mortality associated with diabetic autonomic neuropathy.




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7.      Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, et al. Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective. Diabetes Metab Syndr Obes. 2021;14:1703-28.

8.      Kelly BD. Mindful, mindless, or misunderstood? A critical perspective of the mindfulness concept. Ir J Psychol Med. 2022:1-3. doi: 10.1017/ipm.2022.31. Online ahead of print

9.      Kalra S, Kapoor N, Bhattacharya S, Aydin H, Coetzee A. Barocrinology: The Endocrinology of Obesity from Bench to Bedside. Med Sci (Basel). 2020;8:51. doi: 10.3390/medsci804005

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