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AYURVEDIC CONCEPT OF PREDIABETES/DIABETES MELLITUS & ITS MANAGEMENT: A SCIENTIFIC OVERVIEW

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Abstract

It is one of the oldest diseases recognized since antiquity by medical historians. Diabetes mellitus (DM) is a major challenging health problem of the 21 st century. It refers to a heterogeneous chronic metabolic disorder that shares the phenotype of hyperglycemia. DM is caused by a complex interaction of genetic, behavioral and environmental factors. It results due to impaired Insulin secretion or insulin resistance, decreased glucose utilization, and increased glucose production (Ginsberg, Huang, 2000). The metabolic deregulation associated with DM, causes secondary pathophysiologic changes in multiple organ systems. It imposes a tremendous burden on diabetics and on the health care system. The world today is witnessing an epidemic of Diabetes mellitus. Globally and nationally, DM with its complications has the most important contemporary and challenging health hazards. It is the leading cause of end-stage renal disease (ESRD), non-traumatic lower extremity amputations, and adult blindness. It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the foreseeable future. One decade ago, the US Department of Health And Human Services and ADA on 27th march 2002 gave the term Prediabetes. It is the state in which some but not all of the diagnostic criteria for diabetes are met. It is often, described as the " gray area " between normal blood sugar and diabetic levels (Arun, Nalini, 2002). Globally, numerous terms have been given for prediabetes such as, borderline diabetes, chemical diabetes, touch of diabetes etc. In the early stages of the disorder, glucose tolerance remains near normal, despite insulin resistance, because the pancreatic beta cells compensate by increasing insulin output (Tuomilehto et al., 2001). As insulin resistance and compensatory hyperinsulinemia progress, the pancreatic islets in certain individuals are unable to sustain the hyperinsulinemic state. IGT is characterized by elevations in postprandial glucose. A further decline in insulin secretion and an increase in hepatic glucose production lead to overt diabetes with fasting hyperglycemia. Prediabetes & DM as disease entity has been vividly described in the context of Prameha/Madhumeha in Ayurvedic classics with striking resemblance of its Ayurvedic concepts with latest knowledge on Diabetes mellitus as known in conventional medical sciences. The causes of Diabetes mellitus are comparable to the disease entity Prameha/Madhumeha of Ayurveda. The major categories of the etiological factors are (1) genetic and hereditary factors and (2) lifestyle related errors such as sedentary habit and high calorie diet. The texts also describe the pathogenesis of this disease in an extremely evolved manner, involving the three Doshas (Kapha predominant doshas) and ten Dushyas (ranging from Rasa to
AYURVEDIC CONCEPT OF PREDIABETES/DIABETES
MELLITUS & ITS MANAGEMENT: A SCIENTIFIC
OVERVIEW
Dr. Ajai Kr. Pandey
Assistant Professor, Department of Kayachikitsa, Faculty of Ayurveda, Institute of Medical
Sciences, Banaras Hindu University, Varanasi-221005, E-mail : drajaipandey@gmail.com,
Ph.No. 09452827885
t is one of the oldest diseases recognized since antiquity by medical
historians. Diabetes mellitus (DM) is a major challenging health
problem of the 21
st
century. It refers to a heterogeneous chronic
metabolic disorder that shares the phenotype of hyperglycemia. DM is caused by
a complex interaction of genetic, behavioral and environmental factors. It results
due to impaired Insulin secretion or insulin resistance, decreased glucose
utilization, and increased glucose production (Ginsberg, Huang, 2000). The
metabolic deregulation associated with DM, causes secondary pathophysiologic
changes in multiple organ systems. It imposes a tremendous burden on diabetics
and on the health care system. The world today is witnessing an epidemic of
Diabetes mellitus. Globally and nationally, DM with its complications has the
most important contemporary and challenging health hazards. It is the leading
cause of end-stage renal disease (ESRD), non-traumatic lower extremity
amputations, and adult blindness. It also predisposes to cardiovascular diseases.
With an increasing incidence worldwide, DM will be a leading cause of morbidity
and mortality for the foreseeable future. One decade ago, the US Department of
Health And Human Services and ADA on 27th march 2002 gave the term
Prediabetes. It is the state in which some but not all of the diagnostic criteria for
diabetes are met. It is often, described as the “gray area” between normal blood
sugar and diabetic levels (Arun, Nalini, 2002). Globally, numerous terms have
been given for prediabetes such as, borderline diabetes, chemical diabetes, touch
of diabetes etc. In the early stages of the disorder, glucose tolerance remains near
normal, despite insulin resistance, because the pancreatic beta cells compensate
by increasing insulin output (Tuomilehto et al., 2001). As insulin resistance and
compensatory hyperinsulinemia progress, the pancreatic islets in certain
individuals are unable to sustain the hyperinsulinemic state. IGT is characterized
by elevations in postprandial glucose. A further decline in insulin secretion and an
increase in hepatic glucose production lead to overt diabetes with fasting
hyperglycemia.
Prediabetes & DM as disease entity has been vividly described in the
context of Prameha/Madhumeha in Ayurvedic classics with striking resemblance
of its Ayurvedic concepts with latest knowledge on Diabetes mellitus as known in
conventional medical sciences. The causes of Diabetes mellitus are comparable to
the disease entity Prameha/Madhumeha of Ayurveda. The major categories of the
etiological factors are (1) genetic and hereditary factors and (2) lifestyle related
errors such as sedentary habit and high calorie diet. The texts also describe the
pathogenesis of this disease in an extremely evolved manner, involving the three
Doshas (Kapha predominant doshas) and ten Dushyas (ranging from Rasa to
I
94 Scope of Translational Researches in Ayurvedic Medicine
Ojas, specially Meda). The idea of significance of Meda (Adipose tissue) as the
principal Dushya has been recently confirmed also in modern medicine where the
central obesity and dyslipidemia are being considered as the main components of
the basic matrix of this disease. The recent concept of the Metabolic Syndrome
also seems to have been conceived in Ayurveda. Most of the ancient texts
emphasize that all three Doshas are involved in this disease but vitiation of Kapha
Doshas is the main initiating factor. The involvement of a wide range of Dushyas
numbering 10 is of special significance, because such a pathogenic feature of the
disease indicates that Prameha vis a vis prediabetes is a systemic disease
involving the whole body. Prediabetes & Type 2 DM is largely a preventable
disease, while Type 1 DM is generally manageable. However, it is not curable
once it established in the organism.
The most pertinent fact being realized by many diabetologists is the fact
that DM Type-2 is largely a preventable disease through diet and life style
management. However, once it is established in the organism it mostly takes an
incurable course and continues to develop its progressive stage including Type-2
DM & Type-1 DM and its complications including diabetic neruropathy,
nephropathy, cardiomyopathy, carbuncles, etc, a fact that has been clearly
conceived in Ayurveda. Many times the complications continue to progress even
if the blood sugar levels are controlled by medication.
One may find a comprehensive description of drug and non-drug
modalities of treatment for different kinds of Diabetes with a wide range of
herbal, mineral and herbo-mineral formulations for the treatment of Prediabetes &
Diabetes mellitus (Ernst, 2005; Pandey, & Singh, 2000). Seeing this fact it seems
profitable to explore the possibilities of developing an Ayurved- inspired line of
management and medication for contemporary use today. The issues depicted
above can be tackled with the holistic approach of Ayurvedic medicine utilizing
the package of exercise, dietary control and stress management with use of such
Ayurvedic drugs, which may produce Rasayana effect besides the efficacy to
control the dyslipidemia and sugar in the system (Singh, 1998). The Rasayana
drugs of Ayrveda are claimed to produce bio-balancing effect, promoting essential
nutrition and immune enhancing effect. Such a line of management is preferred in
Ayurveda because of the role of Ojas, which is responsible for the immune status
of an individual and is depleted in case of Diabetes mellitus and most of the
diabetics remain in an immune compromised state (Pandey and Singh, 2003).
Because Ojas is considered as one of the major Dushya of Prameha, which can be
controlled by Rasayana Therapy. Such an exercise of 'Reverse Innovation' in the
management of Prediabetes & Diabetes mellitus and its complications is
considered because of the fact that modern management of Diabetes mellitus is
really not satisfactory. When such a disease is really established in the system, it
is difficult to treat because of its deep seated and widespread pathogenic
involvement.
Epidemiology/Prevalence of Prediabetes : According to the Centers for Disease
Control and Prevention, 41 million U.S. adults aged 40 to 74 have prediabetes.
Moreover, the same reports from, the American Academy of Pediatrics show that,
one of every 10 males and one of every 25 females have prediabetes aged from 12
to 19 years. Recent data from the USA indicate that the prevalence of IFG is
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 95
~26% and that of IGT is ~15% in the adult population. Both IFG and IGT
increase in prevalence with age. The prevalence of IFG is similar in men and
women, but IGT is more frequent in women. Although there is some overlap
between IFG and IGT, most studies have shown that these criteria define different
populations at risk for type-2 diabetes and other complications (e.g. CVD).
The worldwide prevalence of DM has risen dramatically over the past two
decades, from an estimated 30 million cases in 1985 to 177 million in 2000. It is
believed that >360 million individuals will have diabetes by the year 2030. The
prevalence of type 2 DM is rising with alarming rate. It is because of increasing
obesity and reduced physical activity in newly industrialized nations. It is
estimated that every year a further 7 million people develop diabetes. In Asian
countries, India has been projected by WHO as the country with the fastest
growing population of diabetic patients and in terms of “Diabetes capital of the
world”. According to the Diabetes Atlas 2006 published by the International
Diabetes Federation, the number of people with diabetes in India currently around
40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive
steps are taken (Mohan, Sandeep, Deepa, Shah, Varghese, 2007).
Remembering Facts of Prediabetes/Diabetes mellitus :
Pre-diabetics have moderate to severe insulin resistance in muscle and/or liver
and impaired β-cell function.
Epidemiologic studies have demonstrated that subjects with isolated IFG and
isolated IGT have a 4% to 6% annual risk for progression to T2-DM
compared with less than 0.5% annual incidence in NGT subjects.
Individuals with combined IFG/IGT have approximately 10% annual risk for
conversion to T2DM.
Numerous clinical trials have demonstrated an approximately 50% increase in
the cardiovascular disease risk, with a somewhat stronger risk in subjects with
IGT compared with those with IFG.
Insulin resistance is an important risk factor for atherosclerosis and
cardiovascular disease.
The worldwide prevalence of prediabetes/DM has risen dramatically over the
past two decades. Worldwide more than 246 million of people suffer from
diabetes mellitus. By 2025 this figures could be expected to be 380 millions.
Although the prevalence of both type 1 and type 2 DM is increasing
worldwide, but the prevalence of type 2 DM is raising with alarming rate.
In 2007, the five countries with the largest numbers of people with diabetes
are India (40.9 million), China (39.8 million), the United States (19.2 million),
Russia (9.6 million) & Germany (7.4million).
By 2025, the largest increases in diabetes prevalence will take place in
developing countries.
Each year a further 7 million people develop diabetes.
Each year 3.8 million deaths are attributable to diabetes.
Every 10 seconds one person dies from diabetic complications.
Every 10 seconds two people develop Type II diabetes.
Diabetes is the fourth leading cause of global death.
At least 50 to 80% of diabetics are unaware of their condition.
96 Scope of Translational Researches in Ayurvedic Medicine
Type II DM is most frequent cause of kidney failure in Western world.
10% to 20% of people with diabetes die of renal failure.
2.5 million People worldwide are affected with diabetic retinopathy.
Chances of heart attack or stroke are twice in Type-II diabetics (Wild, Roglic,
Green, Sicree, King, 2004).
Classification of Prameha: Ancient Indian physicians have tried their level best
to classify the disease in different manner such as-
Doshika classification : Kaphaja- 10, Pittaja- 06 and Vataja- 04.
Aetiological classification : Sahaja (hereditary) another is Apathyanimittaja
(Acquired).
Constitutional classification : Sthula and Krisha Pramehi.
Prognostic classification: Sadhya, Yapya and Asadhya.
Classification of Prediabetes/Diabetes mellitus in Ayurveda:
1. Etiological- 2
(“Dao pramehau bhavatah-Sahajoapathyanimittashcha Su. Ci. 11/3)
(a). Sahaja prameha (patients of Type I DM)
Matripitribeejadoshakrita, i.e. defects in-
1. Bija- sperm/ ovum
2. Bijabhaga- chromosome
3. Bijabhagavayava- genes
(b). Apathyanimittaja prameha (Prediabetes & patients of Type II DM)
It is caused by-
faulty dietary habit
sedentary life style
lack of physical exercise
psychological factors: worry, grief, anger, anxiety etc.
2. Constitutional-2:
Sthula pramehi: patients of Prediabetes & DM with or without insulin
resistance.
Krisha pramehi: malnutrition related diabetes mellitus or Type-I DM.
3. Doshika- 3: Urinary Abnormalities.
Kaphaja-10 types- prediabetes & early stage of type-2 DM .
Pittaja-6 types- acute stage of type-2 DM.
Vataja-4 types- advanced stage of type-2 DM or genetic/hereditary form of
DM.
Prognostic-3:
1. Sadhya: curable (Kaphaja type)
2.
Yapya: palliative (Pittaja type)
3.
Asadhya: untreatable (Vataja type)
The Ayurvedic texts reflect two major categories of Prameha 1. Sahaja
Prameha and 2. Apathyanimittaja Prameha, out of these two, Apathyanimittaja
Prameha is closely resemblance with the contemporary concepts of
Prediabetes/Type-2 Diabetes mellitus. On this basis, Ayurveda has described
Sthula Pramehi, which clearly corresponds to the current concepts of overweight
& obesity and its role in the genesis of Diabetes mellitus. Thus the Ayurvedic
concept of Prediabetes is so advanced than even modern medicine as known
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 97
today. Because the hereditary influence in relation to Prediabetes is still awaited
in modern system of medicine. However, it was well conceived in the Ayurvedic
lexicons in the context of Prameha. According to classical texts of Ayurveda, all
Pramehas have the potential to become incurable (Madhumeha) if left untreated
(Grover, Yadava, Vats, 2002). Kaphaja urinary disorders are curable because the
causative Dosha and the affected tissues (Dushyas) have the same properties, thus
requiring the same type of therapy. Although the Pittaja urinary disorders are
controllable, the resulting disorders may persist for life. Because the causative
Dosha is Pitta, but the tissues and waste products (Dushyas) are different,
requiring a different type of therapy. Vataja urinary disorders are untreatable
because tissues (Dhatus) and bio-immuno-strength (Ojas) undergo deterioration.
Recent studies have observed a relationship between the body constitution and
relative amounts of hyperglycemia and insulinemia consistent with Ayurvedic
prognosis. Kapha constitution patients showed the highest level of insulinemia
and the lowest levels of FBS and PPBS. Vata patients showed the lowest level of
insulinemia and the highest levels of FBS and PPBS due to hypoinsulinemia.
Pitta patients were in the middle.
Etiopathigenesis of Prameha/Prediabetes: In conventional medicine, it is also
believed high calorie diet, sedentary habits, and stressors (physical, mental, social
etc.) play an important role in the eiopathogenesis of Prediabetes but its actual
cause is still unknown. Side by side positive familial history, overweight and
obesity are the basic risk factors for insulin resistance and for the development of
type-2 diabetes mellitus. Those patients who were fall in the stratum of IGT or
IFG are at increased risk of cardiovascular disease. (Diabetes Care, 2002).
Ancient scholars of Ayurveda give similar opinion.
Asyasukham svapnasukham dadhini gramyaodakanooparasah payansi. I.
Navannapanam gudavaikritam ca prameha hetuh kaphakéchcha sarvam . II. (C.S.Ci.- 6/4)
Daopramehobhavatah Sahajaoapathyanimittashcha I. ( S.S.Ci.-11/3)
It includes following lifestyle errors: 1. Use of early-ripened Pulses and grains. 2.
Use of sugarcane and its product like-Guda, Khanda, Sharkara, Sugar etc. 3. Use
of milk and its products, Mandaka dadhi. 4. Intake of meats and soups of different
Anupa, Audaka and Gramya animals. 5. Lack of exercise, Laziness, Excessive
sleep during day, alcohol consumption etc. 6. Psychological factors such as
Anxiety, Anger, Worry, Grief etc. have been described to play an important role.
7. Indulging sex / sleep with full belly etc. 8. Excessive consumption of alcoholic
beverages. (Basavaraja -14
th
century A.D.). 9. Person having Medavrittavata. 10.
Person associated with Overweight & Obesity. 11. Person have positive family
history (Sahaja Prameha).
According to Sushruta Madhura Ahara, taken in excess along with day
sleep, and sedentary life style, may convert into fat due to metabolic block (Ama
Rasa). It contributes to the adiposity of the body leading to overweight. So the
present day concept of metabolic syndrome in obese patients where most of the
carbohydrate being converted into fatty acids is well conceived in Ayurveda.
Overweight in prediabetic patients has been observed to be associated with
hyperinsulinemia and increased FFAs level. Due to the increased FFAs level in
the serum, the glucose entry to the cells is hampered, resulting in insulin
resistance and finally diabetes. The FFAs are the soluble form of fat, which are fit
98 Scope of Translational Researches in Ayurvedic Medicine
for utilization in energy metabolism, coming from adipose tissue. So one can
conclude that triglyceride content of Adipose tissue is an example of Baddha
Medas and FFAs may be compared with Abaddha Medas. Hence, sometimes the
Kaphaja type of Prameha is correlated with Type 2 diabetes mellitus with or
without Insulin resistance. The relationship of Ama with psychological factors, as
stated in Charaka Samhita (Sharmā, & Dāsh, 2009; Jadavaji, Acharya, 1992), is
the evidence of relationship of Prameha with mental stress. The emotional factors
enhance the level of counter-regulatory hormones (cortisol, ephinephrine,
norephinephrine) that may alter the carbohydrate, protein and fat metabolism. The
mode of action of these hormones in the genesis of diabetes is through
mobilization of FFAs from TG of adipose tissue. Adrenal hyperactive secretion
causes excess glucose in the blood. On the other hand excess thryroid secretion
causes lipolysis and protein breakdown resulting in muscle wasting. Stress also
increases sympathetic activity which causes increased insulin secretion but the
other glands are predominant that check the insulin response at tissue level.
Risk Factors for Type 2 Diabetes Mellitus :
Family history of diabetes (i.e., parent or sibling with type 2 diabetes)
Obesity (BMI 25 kg/m
2
)
Habitual physical inactivity
Race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)
Previously identified IFG or IGT
History of GDM or delivery of baby >4 kg (>9 lb)
Hypertension (blood pressure 140/90 mmHg)
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level
>250 mg/dL (2.82 mmol/L)
Polycystic ovary syndrome or acanthosis nigricans
History of vascular disease (
Source:Adapted from American Diabetes Association, 2007
).
Samprapti Ghataka:
Dosha Tridosha (specially Kapha Dosha)
Dushya Rasa, Rakta, Lasika, Mamsa, Meda, Kleda, Majja, Oja, Shukra,
Jala (Specially Meda)
Agni Jathharagni, Dhatvagni, Bhutagni (Specially Medoagni)
Ama Aparipakva Ama and Aparipakva dushyas
Srotasa Rasavaha, Medovaha, Mutravaha, Raktavaha, Udakavaha,
Mamsavaha, Majjavaha, Shukravaha (Specially Rasavaha and
Mutravaha srotasa)
Srotodushti Atipravritti, Sanga, vimargagamana
Adhishthana Vasti
Pratyatma lakshana Prabhuta Mutrata & Avila-Mutrata
Sancarsthana Sarvagna Sharira via Rasayani
Roga Marga Abhyantara
Sadhya/asadhyata Kaphaja-Sadhya,
Pittaja-Yapya
Vataja- Asadhya
Vyadhi Svabhava Chirakari
Purvarupas (Prodromal Symptoms) of Prameha : Ayurveda once again
exhibits here its observational supremacy by furnishing prodromal features of
Madhumeha, which covers the pre-diabetic stage or early clinical manifestation or
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 99
subclinical stage of diabetes mellitus. Purvarupas are valuable signs and
symptoms to predict the disease in its early stage & to check its progression
towards Madhumeha and its complications by applying appropriate therapeutic
measures.
Prodromal symptoms Ch. Su. A.H. A.S Ma.
Ni.
Kesheshu Jatalibhava- matting of hairs + + - + -
Asya Madhurya- sweetness in mouth + - + + +
Karapada daha- burning sensation in hands and feet + + + + +
Karapada suptata- numbness in hands and feet + - - - -
Mukhatalu kantha Shosha- dryness in oro-
pharyngeal region
+ - + + -
Pipasa- feeling of thirst + + - + +
Alasya- lethargyness + - - + -
Kaye Malam- accumulation of wastes over the body + - - + -
Paridaha angeshu- burning sensation over the body + - - - -
Suptata angeshu- numbness over body parts + - - + -
Pipilika Mutrabhisaranam- attraction of ants, flies
towards urine
+ - + + -
Mutre cha mutradoshana- changes in the color,
quantity, nature and consistency of urine
+ - - - -
Visra sharira gandha- unpleasant smell from body + + + + -
Sarvakala nidra- desire of excessive sleep + - - + -
Sarvakala tandra- feeling of drowsiness + + - + -
Snigdha gatrata- oiliness over the body - + - + -
Pichchhila guru gatrata- sliminess and heaviness
over body parts
- + - - -
Madhura mutrata- sweetness of urine - + - + -
Shukla mutrata- whiteness and turbidity in urine - + - + -
Sada- always feels lazyness - + - + -
Shvasa- difficulty in breathing - + - + -
Keshanakha Ativriddhi- overgrowth of hair and nails + + + - -
Shita Priyata- likeliness of cold things + - + + -
Hridaya Netra Jihva Sravanopdeha- feeling
unwanted things over heart, eyes, ears and tongue
- - + - -
Sveda- excessive sweating + - + + -
Dehe Chikkanata- greasiness of body - - - - +
Regarding the excessive excretion of Malas in the buccal cavity, one
significant modern observation may be quoted i.e. thickening of vascular wall of
buccal mucosa, especially of gums has been reported in prediabetic condition
(Lozano, Camerini, Avalos, Krall, Marble, 1964). It is now known that the health
complications associated with type-2 diabetes often occur before the medical
diagnosis of diabetes is made. Impaired glucose tolerance is a risk factor for
cardiovascular disease, but not impaired fasting glucose (Choudhary, Umesh &
Pandey, 2013). Therefore, Purvarupa of Prameha may be correlated with the
clinical conditions of (1) Prediabetic stage, (2) Early Stage of Type-2 DM, (3)
Subclinical stage of Type-2 DM.
Clinical feature of Prediabetes or diabetes mellitus: Ayurveda has described
20 subtypes of Prameha as different clinic-pathological conditions, which is
outcome of interaction of specific Doshas and Dushyas at different level that
may lead to gross urinary characteristic and clinical manifestations. Vagbhata
100 Scope of Translational Researches in Ayurvedic Medicine
seems to have paid much attention in diagnosing the disease in its early stage
explaining the following in his treatise Rasaratna samucchaya. (1) Asvasthyam
sarva gatreshu–persisting & vague uneasiness in the body. (2) Shoshah
Asyasosha- feeling of dryness in the body and dryness in the mouth. (3) Taapo
angah-burning sensation in the body. (4) Bahumootrata-increased frequency of
micturition. (5) Karshyam-emaciation. The above conditions alarm us to
understand their observational supremacy. In advanced stage urinary changes
become more prominent such as- Prabhootamutrata-excessive urination. (a)
Avilamootrata-turbidity in urine. (b) Madhviva mehati-passes urine similar to
Madhu. (c) Madhuryacha tanoratah-patient’s body starts yielding sweet smell
and taste. (d) Mootreabhidhavanti Pipeelikashcha-ants, flys etc are attracted
towards urine & body parts. Beside the common symptoms of Prameha,
following features are specific to diabetes mellitus, which indicates the
observational supremacy of ancient sages. (1) Urine is astringent, sweet, pale
and ununctuous (C.Ci.4/44). (2) Urine is just like Ksaudra (honey) in taste and
color (S.Ni.6/14). (3) Whole body becomes sweetened (A.H.Ni.10/18-27). (4)
Ojas (immune strength) is diminished, the person becomes timid, week, wearied,
having disordered of senses, loss of luster, neurasthenic, dry and emaciated
(C.Su.17/43). (5) Diabetic patients prefer sedentary life style. (S.Ni.6/28).
Possible mechanism of diabetic complications in biomedical science
Hyperglycemia
Intracellular Glucose
AGEs
Sarbltol
DAG
Abnormal
protein
function
Altercations in
osmolalty
myoinositol, and
rodax potential
PKC activation
Circulating
AGEs
Altered
cell
function
Altered cell
function
Altered
gene
axprassion
Renal, vascular
connective
tissue effects
Cytokines
growth factors
Altered
enzyme
function
(cPLA
2
, Na, K-
ATPase)
Growth
factors
Complications
of diabet
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 101
Possible mechanism of diabetic complications in Ayurveda
Apathyaja prameha--Bija dosha --Obesity --Stress
Prameha/Madhumeha (prolong duration)
(Hyperglycemia & dyslipidimia in plasma i.e. Increased sugar & FFAs level
Impaired Pitta component i.e- Dhatvagni and Bhutagni vyapara; i.e cellular biofire
(Formation of unwanted, antigenic & auto-toxic products)
Disturbance of Dhatus parinama and activities of Dhatus
Dhatukshaya + Ojokshaya + Vyadhisvabhava itself
Resulting impairment of Vyadhikshamatva
Vata and Pitta prakopa
(Impaired Psycho-neuro-humoral mechanism)
Alter the form of Kapha dosha i.e- bioprotective factor
Deranged function of Vatavaha srotasa
(Impaired the sensory and motor functions of nerve\ nervous system as a whole)
Diabetic complications
Diagnostic Criteria for Diabetes mellitus: Historically, Ayurvedic diagnosis of
DM was primarily based on the sweetness of urine that was identified by a swarm
of flies and ants over the urine. Ayurvedic texts give the signs and symptoms of
10-Kaphaja, 6-Pittaja and 4-VÁtaja Pramehas for diagnosis, which is based on
physico-chemical characteristics of urine. However, on this basis physician is
unable to reach the final diagnosis. So the newer diagnostic tools and techniques
should be be utilized as an aid for diagnosis and assessment of prognosis, until a
still better and simple method is introduced in Ayurveda. Prediabetic/diabetic
diagnosis can broadly divided into two groups-
I. In asymptomatic undiagnosed individuals:
1. Testing of all individuals at the age of 45 years and if it is normal, it should
be repeated at 3 years intervals.
2. Testing should be carried out more frequently in individuals, who—
are obese (BMI >=27 kg/mt2)
have a first degree relative with diabetics.
are a member of a high risk ethnic population.
are hypertensive (>=140/90 mmof Hg)
have HDL level < 35 mg/dl &/ or triglyceride level 250 mg/dl.
on previous testing has IGT or FPG.
II. In symptomatic individual having Prediabetes: Prediabetes is usually
diagnosed with a blood test:
Fasting blood sugar (glucose) level of:
110 to 125 mg/dL (6.1 mM to 6.9 mM) - WHO criteria (Choi et al.,
2002)
102 Scope of Translational Researches in Ayurvedic Medicine
100 to 125 mg/dL (5.6 mM to 6.9 mM) - ADA criteria (Choi et al.,
2002)
Two-hour glucose tolerance test after ingesting the standardized 75
Gm glucose solution the blood sugar level of 140 to 199 mg/dL (7.8 to 11.0
mM).
Glycosylated hemoglobin between 5.7 and 6.4 percent.
III. In symptomatic individual having Diabetes mellitus: Diabetes is diagnosed
(ADA-2000) by measuring blood glucose levels. It is diagnosed by three ways
and each must be confirmed on subsequent day. They are-
Classical symptoms of diabetes + casual glucose concentration > 200 mg/dl.
Fasting plasma glucose (FPG) 126 mg/dl.
2 hour plasma glucose (PPG) 200 mg/dl.
Glycosylated Hb (HbA1c- < 6.5% in normal individual)
Blood urea, Serum creatinine, Lipid profile, Serum cholesterol, CRP, NCV etc
are needed to assess the complications.
Prevention & Management of Prediabetes & diabetes mellitus: No doubt, the
knowledge of prediabetes/diabetes mellitus in conventional system of medicine is
so advanced. Side by side, several drugs were also developed to tackle different
aspects of the pathogenic steps. Modern medicine have been developed α-
glucosidase inhibitors to manage post prandial hyperglycemia at digestive level, it
has sulphonylurea to enhance glucose uptake through multiple pathways at
tissue/cellular levels, in order to tackle the problems of insulin resistance, it has
biguanides and insulin sensitizers glitazones. However, its management remains
unsatisfactory and challenging because of danger of complications, drug
hypersentivity, drug intolerance, fear of hypoglycemic episode with sulphony-
lureas and resistance to insulin are the major. Recent evidences suggests that
consuming a heart-healthy diet, losing excess weight, staying active and by
adopting mental relaxation can reverse prediabetes progression to type-2 diabetes
mellitus. It is believed that Prediabetes is likely to have full-blown diabetes within
5 to 10 years. By exercising regularly and losing weight, the risk of diabetes can
be lowered by 60 percent. In this concern, Ayurveda emphasizes the role of
environmental factors, daily routine, seasonal changes, lifestyle, diet, regular
exercise and Rasayana for maintaining good health in general. The management
of DM/Prameha emphasizes dietary and lifestyle recommendations, herbal,
herbo-mineral and mineral preparations in accordance with the aetiopathology
and psychosomatic constitution. Charaka and Sushruta have strongly emphasized
the first and foremost principle of prevention as well as the treatment of any
disease is to protect oneself from causative factors i.e.-Sanksepatah kriyayogo
nidanam parivarjanam (C.Ci.6\53, S.U.1\25). Caraka has divided the diabetics
into two groups, i.e. Sthula pramehi (obese diabetics) and Krisha pramehi (lean
and thin diabetics) on the basis of vitality, constitution and etiology of the disease.
This warrants different lines of management for the two types of diabetics. In
Sthula pramehi (Prediabetics & type-2 diabetics) biopurificatory measures and
lightening measures are advocated, such as- Sthulah pramehi balavanihaikah
krsastathaikah paridurbalasca.I Sambrmhanam tatra krsasya karyam
samsodhanam dosa baladhikasya. II (C.Ci.6\15.). At present, the goal of
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 103
Prediabetic treatment is not only to normalize the blood glucose level within the
range but also to improve the Ojas status, Agni status & improve the quality of
life.
1. Abstinence from etiological factors: “Nidana Parivarjana is firmly
advocated in Ayurveda for the management of diseases. Prediabetes is a clinical
entity in which lifestyle modification can reverse Prediabetes and check its further
progression to Type-2 diabetes mellitus. Food enriched with any type of
fermented material, excessive water intake, milk, oil, ghee, sugarcane & its
products, newly cultivated graims, soups and meat of aquatic and near aquatic
animals should be avoided to the patients of Prameha.
2. Ahara (Diet and dietary rule): Diet is the first line defense against
Prediabetes. The Ashta Aharavidhivishesha Ayatanas are kept in mind while
prescribing diet. Yava is considered as the best diet for Pramehi. Charaka opines
that Yava first given to animals and then remaining parts collected from the dung
of that animals to be consumed by Pramehi. Old Shali, Shashtika (Variety of
rice), Yava, pulses like Chanaka, Adhaki, Mudga and Kulattha are advised by
Sushruta in Prameha. In this context, Sushruta wants to convey the role of less
intake of carbohydrate rich food for the management of Prameha. The quantity
and quality of the diet should be decided based on Agni Bala and vital power of
the body. Contemporary dietary guidelines are given below.
Reduce high calories intake will improve insulin sensitivity and lower blood
sugar.
Reduce total fat and saturated fat will improve body ability to use the insulin..
Avoid high fat foods include fast food burgers and cheese, ground meats like
sausage and many convenience foods like frozen pepperoni pizza and chicken
pot pie.
Increase intake of good sources of omega-3 fatty acids such as salmon, herring,
trout, sardines, flax seeds, flax seed oil, and walnuts. Because omega-3 fatty
acids may improves the insulin sensitivity in the body tissues.
Eat the right amount of carbohydrates from unprocessed and unrefined foods as
much as possible. Examples include vegetables and fruit, dried beans and whole
grain breads, cereals, and pasta.
Eat 20 to 35 grams of fiber every day. A high fiber diet improves insulin
sensitivity by slowing down digestion of carbohydrate digestion Good sources
of fiber are beans, lentils, vegetables, whole fruits, oats, bran, whole-grain
breads, and cereals
Limit alcohol intake: If you do not currently drink alcohol, do not start up for
the sake of preventing diabetes.
3. Vihara (Exercise and Yoga):
Physical exercise: Physical activity is the lifestyle factor most consistently
reported to improve insulin resistance. Insulin moves sugar from the bloodstream
into the cell where it is burned for energy. Exercise promotes sugar burning in the
cell, the same as insulin. Exercise has such a strong impact on blood sugar that it
can improve prediabetes even without other lifestyle changes. Aerobic exercise is
particularly recommended for pre-diabetes. The American Diabetes Association
recommends exercising at least 30 minutes a day, five days a week, for a total 150
104 Scope of Translational Researches in Ayurvedic Medicine
minutes or more. Examples of aerobic exercises include- brisk walking, biking,
swimming, low impact aerobics, and some team sports like basketball or football.
Thousand years back Sushruta has recommended exercise and diet for the
management of poor and rich patients. Poor patients should move from one to the
other village and earn his living by begging. For rich patients he has also
described that persons who eats Shyamaka, fruits of Amalaki, Tinduka,
Ashmantaka, live along with animals, and breaking the stones, becomes free from
Prameha within one year.
Mental relaxation: Meditative Asanas such as Shvasana, Pamdmasana,
Siddhasana, Vajrasana is found beneficial for mental relaxation. Anuloma-
viloma, Bhramari Pranayama is helpful for the removal of mental stressors.
Yoga and Asanas: Yama and Niyama is performed in daily life. Asanas like-
Mayurasana, Bhujangasana, Pashchimottanasana, Gomukhasana, Halasana etc
are helpful by promoting peripheral glucose utilization and by improving insulin
sensitivity at target level.
4. Aushadhi (Medicines): Pharmacological approach is only indicated to those
patients in which lifestyle modification failed or is not sustainable and who are at
high risk for developing Type-2 diabetes. Metformin and Acarbose help to
prevent the development of frank diabetes, and have a good safety profile (Lilly,
Godwin, 2009; The Diabetes Prevention Program Research Group, 2002). In
Ayurvedic classics, a number of herbal and herbo- mineral drugs are advocated
for the treatment of Prameha in general. Drugs having Katu (pungent), Tikta
(bitter) and Kashaya (astringent) Rasa are indicated in all types of Prameha such
as- Vijayasara, Nisha, Amalaki, Mamajjaka, Mamajjaka, Jarula, Jamboo,
Bilvapatra, Tejapatra, Nimba, Karvellaka, Pippali. Gudoochi, Khadira,
Kramuka, Bhoomyamalaki, etc.
1. Promotion of Agni status (promote metabolism): drugs having Deepana, and
Pachana properties such as Pippali, Shunthi, Maricha, Chitraka etc.
2. Promotion of Ojas status (promote immune status): drugs having Rasayana,
Jivaniya & Pramehaghna properties, such as Nisha, Amalaki, Guduchi, Shilajatu
etc.
Conclusion: Prediabetes was well known clinical entity since antiquity. The
feature described in Ayurvedic classics seems very contemporary and scientific.
Ayurveda considers lifestyle errors play a major role in the diathesis of
Prediabetes/ Prameha. Scholars and researchers of biomedical sciences have
recently conceived the idea of Medas as the principal Dushya of Ayurveda, opines
that central obesity and deranged lipid metabolism are considered as the main
pathogenic component of the basic matrix of Prediabetes and Type-2 Diabetes
mellitus (Sharma, Hari, Chandola, 2011). The recent concept of the Metabolic
Syndrome also seems to have been conceived in Ayurveda. In accordance with
the these centuries old Ayurvedic descriptions about prediabetes/diabetes
mellitus, conventional system of medicine also recognizes that diabetes mellitus is
strongly associated with disglycemic state, where metabolic homeostasis of
carbohydrates, proteins and lipids is deranged by insulin and other governing
factors. Therefore, if this inappropriateness in metabolic homeostatic disturbance
is not managed properly and on time, prolonged hyperglycemia results, further
aggravation may lead to cellular damage and ultimately being responsible for the
Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management
……. 105
early and late diabetic complications (Pandey and Singh, 2012). The recent
scientific understanding of cause, types, course of development of disease, and
consequently its complications are in fact not different from Ayurveda. It seems
likely therefore, that therapeutics described in Ayurvedic lexicons may also find
relevance in the management and treatment of the cause and course of diabetes as
a whole. Similarly, evaluation of diabetes described in Ayurvedic classics, reveals
the fact that they are amazingly relevant even today and have the capabilities to
take global care of it. It seems that issues depicted above can be tackled with the
holistic approach of Ayurvedic therapeutics by utilizing the package of exercise,
dietary control, Rasayana drugs and bio-purificatory measures of Ayurveda,
which may not only control the lipid and sugar metabolism in the system but also
control its progression to Type-2 DM.
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