A Clinical Study on the Efficacy of a Nutritional Compound In Prameha, Arora Manish T., DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL,HASSAN – 573201, 2006
A Clinical Study on the Efficacy of a Nutritional Compound In Prameha By Arora Manish T. Dissertation Submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES; KARNATAKA, BANGALORE In partial fulfilment of the requirements for the degree of AYURVEDA VACHASPATI (M.D. AYURVEDA) In SWASTHAVRITHA Under the guidance of Dr. Ramana G.V. M.D (Ayu) Prof & HOD. PG studies in Dept of Swasthavritha DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN – 573201 2006
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA DECLARATION BY THE CANDIDATEI hereby declare that this dissertation / thesis entitled “A clinical study on the efficacy ofa nutritional compound in Prameha” is a bonafide and genuine research work carriedout by me under the guidance of Dr. Ramana G.V. Professor, Department of PostGraduate Studies In Swasthavritha, S. D. M. College of Ayurveda and Hospital, Hassan –573 201.Hassan Arora Manish T.
DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201. (Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka) CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A clinical study on the efficacy ofa nutritional compound in Prameha” is a bonafide research work done by “AroraManish T.” under my guidance in partial fulfilment for the degree of AyurvedaVachaspati (M.D. Ayurveda) in Swasthavritha.Date:Hassan Dr. Ramana G V. Professor P. G. Studies in Swasthavritha. S D M College of Ayurveda, Hassan.
DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201 (Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka) ENDORSEMENT BY THE H O D; PRINCIPAL / HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A clinical study on the efficacy of anutritional compound in Prameha” is a bonafide research work done by “AroraManish T.” under the guidance of Dr. Ramana G.V, Professor, Department of PostGraduate Studies In Swasthavritha, S.D.M. College of Ayurveda, Hassan - 573201.Dr. Ramana G.V Dr. Prasanna N RaoProfessor and HOD PrincipalP G Studies in Swasthavritha, S D M College of Ayurveda,S D M College of Ayurveda, Hassan.Hassan.
ACKNOWLEDGEMENT I offer my salution to Lord Bhagawan Dhanvantari and LordManjunatha with whose showering of blessings this task was ventured withoutany hindrances. On this solemn occasion of successful accomplishment of my work, my reverenceand deep sense of gratification is due for my parents Mr. Tirthram Arora & Mrs.Laxmi Devi Arora, who are the architects of my career. The perseverance, discipline andculture, which I could imbibe, is solely because of their painstaking upbringing andstrong moral support I take this opportunity to express my deep sense of gratitude towardsDharmadhikari Pujya Padmabhushana Dr. VIRENDRA HEGDEJI, the founderpresident of SDM Educational Society, who provides me an opportunity of joining in thisesteemed institution. I am very much thankful to Prof. PRASANNA .N. RAO, Principal, whoprovided the necessary facilities & their timely help, inspiration, encouragement,valuable suggestions for the completion of this work. I express my profound gratitude towards my heartiest revered guide Dr.RAMANA G.V. Professor Department of Swasthavritta, S.D.M. college of Ayurvedawho is a back bone of my success and whose valuable guidance, inspiring thoughts andappropriate suggestions helped me in accomplishing my dissertation. I would like to acknowledge Dr. Sajitha K. Asst. Professor Department ofSwasthavritha, S.D.M. college of Ayurveda for her kind assistance and encouragement.
It gives me pleasure to express my gratitude towards my colleagues, Dr. UdayPatil, Dr. Aditi Bana, Dr. Shrikanth Sajjanar, who provided all the help and supportthrough friendly discussion. I would like to express my gratitude towards all my friends and juniors for theirbrotherly affection & helping hand when ever I needed. All of the patients deserve special mention without whose co-operation the entirestudy would stalemated. I am very much thankful to librarian for his timely help and co-operation at allinstances. I am highly obliged to the staff of Laboratory, Hospital & College for their co-operation. I am ever grateful to those who have helped me directly & indirectly tocomplete this dissertation successfully. Dr. Arora Manish
OtherDr. DoctorProf. ProfessorP.G. Post Graduationi.e. That isDept. DepartmentPb. PublicationRef. Reference In TablesVeg. VegetarianB.T. Before TreatmentA.T. After TreatmentF.B.S. Fasting blood sugarP.P.B.S. Post prandial blood sugarR.B.S. Random blood sugarF.U.S. Fasting blood sugar.S.No. / S.N. Serial Number0,1,2,3 Grades of severity.t Test of significancep ProbabilityS.D. Standard DeviationS.E. Standard Errordif. Difference Symbols used+ Present- Absent% Present< Smaller than> Greater than
ABSTRACTBACKGROUND Diabetes mellitus has emerged as an important public health problem globally. Itis estimated that around 150 million people are suffering from diabetes through out theworld. Majority of which are Type II i.e. NIDDM. Madhumeha is a type of Pramehawhich resembles the clinical picture of Diabetes Mellitus. In India approximately 32million people are suffering from diabetes. The management of Diabetes Mellitus is to be based on three main aspects i.e.diet, exercise and drugs. In Ayurveda, diet is given the foremost place in management of Prameha.Different kinds of Pathya Ahara like Yava, Mudga, Godhuma etc are advised. Here an attempt is made to analyze the efficacy of Pathya Dravya’s mentioned inAyurvedic classics in Prameha.OBJECTIVES 1. To study the effect of various Pathya Ahara in the form of a nutritional compound in Prameha 2. To study the improvement in nutritional status, and over all health status of patients.
METHODSThis is a comparative study with pre-test and post-test design undertaken in two groups.GROUP AConsist of 15 patients who are advised with standard Ayurvedic treatment with AsanadiGana Kashaya 30 ml twice daily before food and Nisha-Amalaki tablet 2 tab twice a dayfor two months and kept as control.GROUP B15 patients of this group were given same line of treatment as in Group A along with thenutritional compound prepared from various Pathya Ahara in 15gm twice daily beforefood along with warm water.RESULTS The overall effect was noted as marked Improvement in 0 % patients in Group Aand 6.66 % in Group B. Moderate improvement in 20 % in Group A and 33.34 % inGroup B. While mild improvement in 60 % in Group A and 40 % in Group B. No reliefwas observed in 20 % patients in Group A and 20 % in Group B.CONCLUSION Statistical analysis reveals that administration of nutritional compound along withAyurvedic treatment was more effective when compared to Ayurvedic treatment alone. Nutritional compound helped in relieving the signs and symptoms of the diseaseand provided feeling of well being.
LIST OF TABLES CHARTS AND FIGURES LIST OF TABLESSr. No. Content Page no. 1 showing different classification of Prameha 07 2 showing General Aharaja Nidana of Prameha 13 3 showing general Viharaja Nidana of Prameha 14 4 showing Specific Nidana of Madhumeha 14 5 Showing Poorva Roopa mentioned in various text 15 6 showing various Pidakas in Prameha as Upadrava 24 7 showing various Pathya Ahara in Prameha 34 8 showing various Pathya Ahara mentioned in classics 35 9 showing Characteristics of oral drugs for diabetes 46 10 showing description of Dravya’s 50 11 showing Nutritional values of the ingredients in supplement 53 12 showing the properties and action of Dravya’s 57 13 Showing Age wise distribution 65 14 showing the sex ratio of both the groups 66 15 shows Religion wise distribution 66 16 showing the marital status 68 17 showing diet patterns 68 18 showing Distribution of patients according to the Prakriti 69 19 Showing patients based on the occupation 71 20 showing Distribution of the patients according to Pipasadhikyata 72 21 showing distribution of patients according to Kshudhadhikyata 73 22 showing Distribution of patients according to Karapada Daha 74 23 showing distribution of patients according to Adhika Mootrata 75 24 showing distribution of 20 patients according to Daurbalya 76 25 showing distribution of patients according to Atisweda 77 26 showing F.B.S. distribution of patients 79 27 showing P.P.B.S. distribution of patients 80 28 Showing F.U.S. Distribution of patients 81 29 Showing P.P.U.S. Distribution of patients 82 30 Showing over all effect of the treatment 84
LIST OF CHARTSSr. No. Content Page no.01 Showing Age wise distribution 6702 showing the sex ratio of both the groups 6703 shows Religion wise distribution 6704 showing the marital status 7005 showing diet patterns 7006 showing Distribution of patients according to the Prakriti 7007 Showing patients based on the occupation 7108 showing improvement according to Pipasadhikyata 7809 showing improvement according to Kshudhadhikyata 7810 showing improvement according to Adhika Mootrata 7811 Showing improvement according to Daurbalya 7812 showing improvement according to Atisweda 7813 Showing improvement according to Karapada Daha 7814 showing improvement in F.B.S. of patients 8315 showing improvement in P.P.B.S. of patients 8316 Showing improvement in F.U.S. of patients 8318 showing improvement in P.P.U.S. of patients 8319 showing over all effect of the treatment 84
INTRODUCTION The purpose of human life is the achievements of Chaturvidha Purushartha i.e.Dharma, Artha, Kama and Moksha. Ayurveda advocates that ‘Excellence of health’ is thebasic need for achieving these Purushartha. It aims at preserving and promoting thehealth of an individual as first goal and then to treat the disease. Due to various reasonsand due to negligence of rules and regulation mentioned in Ayurveda for healthy living,man has become a victim to different kinds of diseases. A middle aged person apparently normal may start complaining of weakness,increased frequency of urination, burning sensation in hands and feet, it is very difficultto notice that the person may be suffering from any kind of disease. But on thoroughexamination and investigations the person may be diagnosed as suffering from DiabetesMellitus. Diabetes mellitus has emerged as an important public health problem globally. Ithas become an endemic disease affecting people irrespective of their age, sex, socio-economic status. Diabetes Mellitus is a metabolic disorder characterized byhyperglycemia due to deficiency or diminished activity of insulin. It is a clinicalsyndrome with cardinal features of polyurea, polydypsia and polyphagia. Diabetes mellitus is growing at an alarming rate all over the world especially inIndia. It is estimated that currently around 150 million people are suffering from diabetesthrough out the world. Majority of which are of Type II i.e. NIDDM type of diabetesmellitus. In India at present approximately about 32 million people are suffering fromdiabetes and the future affliction is projected to 80 million by the year 2030.
In Ayurveda Diabetes Mellitus is known to be a ‘rich man’s disease’ which can beunderstood by etiological factors of Prameha mentioned as enjoying the pleasures of lifewith reduced or no physical activity. Madhumeha a type of Vataja Prameha is the nearest resembling condition withDiabetes Mellitus. Prameha is a disease concerned with abnormalities manifested in theurine. Qualitative and quantitative disturbances of urine occur in Prameha. Madhumehabeing type of Prameha is manifested as in which patient passes excessive sweet andastringent urine and exhibits sweetness all over the body. Hence Madhumeha can beentitled clinically with Diabetes Mellitus from the above description. Diabetes is a disease of deficiency or decreased activity of insulin. There is nosuch specification of insulin in Ayurvedic science but the theory that all diseases developfrom Agnimandya i.e. disturbance in metabolism can be understood in pathology of thisdisease. Insulin being one of the metabolic product helps in regulating the amount ofglucose in blood, similarly Bhutagni’s and Dhatvagni are responsible for the maintenanceof normal functioning in the body. Analyzing the etiological factors and pathogenesis mentioned in Ayurveda forPrameha, consuming excessive, irregular and unwholesome food leads to disturbance ofAgni and thereby vitiation of Dosha in manifestation of the disease. The management of Diabetes Mellitus is to be based on three main aspects i.e. management ofdiet, exercise and drugs. These are the three main pillars on which whole management of patient isdependent. Being a metabolic disorder diet plays a major role in management of diabetes.Majority cases of type II diabetes can be effectively managed and controlled just by modification diet andwith regular exercise only. Control of body weight, blood lipids and controlling blood glucose areimportant for reducing the long term complications of diabetes.
In Ayurvedic classics, while explaining the management of Prameha, diet hasbeen given the foremost place. Different kinds of Pathya Ahara like Yava, Mudga,Godhuma etc have been advised to be taken by the patient suffering from Prameha.Along with that various exercises like bare foot long walks, predestrial journeys, digging wellsetc. are indicated to be followed by patients. Apart from Diet i.e. Pathya Dravya’s and exercise variousmedicinal preparations are advised according to the Dosha Avastha and disease condition. In Ayurveda dietetic management has been mentioned under heading of Pathya.And those which are harmful or worsen the disease conditioned are said to be Apathya.All the diet and activities which are beneficial to that patient and which help in pacifyingthe disease are mentioned under Pathya. In Prameha various kinds of Pathya Ahara Dravya’s have been mentioned and areadvised to be used by the patients suffering from Prameha. It is very important to analyzethe do’s and don’ts while treating the disease. Though it is easy to prescribe or advise thedo’s and don’ts to the patients but it is difficult to follow it for the life time. Hence an attempt is made here to analyze the various Pathya Ahara Dravya’smentioned in different Ayurvedic classics and to confirm its efficacy in the managementof Madhumeha or diabetes mellitus.
HISTORICAL REVIEW The disease Prameha is known to mankind since long back. We can find variousreferences regarding Prameha in Vedas, Upanishads and Ayurvedic literatures. Even we get references of pre-Vedic Kala that lord Ganesha too suffered fromthis disease and was treated with Kapitha and Shiva Gutika advised by lord Shiva 1. In Atharvaveda the disease is mentioned under the term ‘Aastravam’ i.e.excessive urination (polyuria) 2. In Garuda Purana it is described as condition in which whole body becomes sweetand it is called Madhumeha3. In various Ayurvedic literatures i.e. Bruhata-trayi and Laghu-trayi, there is detaildescription regarding etiology, pathology, symptomatology prognosis and managementof Prameha in a much elaborated manner. The Egyptian Papyrus Ebers (1500 B.C) described illness associated with passageof excessive urine but did not mention name of the disease. In 2nd century A.D. a Greek physician Aretaeus of Cappodocia named the diseaseas “Diabetes”
In 1674 Willis named the disease as “Diabetes Mellitus” as per his observationthat the urine passed by such patients is like honey and sugar. Thomas Cowley (1781 AD) suggested that pancreas may be the cause of diseasediabetes. Poul Langarhans (1869 AD) Name itself suggests that he described the group ofcells in pancreas. Gusteve Edouard Laguosse (1893 AD) Named after Langerhans as“islets of Langerhans”In 1921 Insulin was discovered. A depancreatized dog is successfully treated with insulin. In 1959 two major types of diabetes were recognized. Type-1 (Insulin dependent)diabetes and Type-2 (Non- Insulin dependent) diabetes. In 1998 the United Kingdom prospective Diabetes Study (UKPDS) resultsidentify the importance of glucose control & blood pressure control in the delay and /orprevention of complications in type 2 diabetes.
ETYMOLOGYIn almost all Samhita, Prameha, a disease concerned with abnormalities in urine has beenmentioned. There are qualitative as well as quantitative disturbances in the urine ofpatients suffering from Prameha.Nirukthi: -Prameha word is derived from combination of“Pra and Miha”Pra + Miha Ksharane + Karane + Ganm 4.The word Meha means to pass urine,‘Pra’ meaning increased intensity.It is the general name for urinary disease 5.Paryaya:-Prameha - - CharakaMeha - - AmarkoshaDefinition:-Prameha means passage of large quantity of urine6.Prameha is defined as the disease characterized by passage of ‘Prabhutavila Mutra’ i.e.large quantity of turbid urine7.
Types: -Prameha has been classified into 20 types depending on the constitution of urine anddosha involved 8.All Samhita have classified Prameha into 20 types, out of which 10 types are of KaphajaPrameha, 6 of Pittaja and 4 types of Vataja Prameha.There is a difference between nomenclatures of these 20 types but still the total numberremains same in all Samhita. Though Prameha is a Tridoshaja Vyadhi, the relativepredominance of any one Dosha and Dushya enables its classification in to Vataja, Pittajaand Kaphaja Prameha. 10 Kaphaja and 6 Pittaja Prameha seem to be sub classified basedon the physical characteristics of urine that is Colour, density and volume depending upon the different Gunas of Kapha and Pitta respectively. Vataja Prameha seems to be subclassified in to four types depending up on Dhatu being excreted through urine. Thevarious classifications of Prameha mentioned in the different contexts in the classicaltexts are as follow:Classification of Prameha Table 1 showing different classification of Prameha Prognosis Etiological factor Body Strength Dosha Sadhya Apathyanimittaja Balvana Kaphaja Yapya Pittaja Asadhya Sahaja Krisha Vataja
Avaranjanya and Apakarsanjanya :This type of classification mainly related with etiology and patho-physiology.Avaranjanya pathogenis occurs duet to etiological factors mainly concordant with Kaphaand Pitta but the vitiation of Vata occurs due to Avarana. Apakarshanjanya pathologyoccurs due to depletion of Dhatus because of the Vata vitiated etiological factors 9. Santarpanjanya and Apatarpanjanya : This classification mainly narrated by Charaka when describing the treatment of thePrameha. Classification is mainly based upon the over nutrition and under nutrition10. SoSantarpanajanya Madhumeha can be correlated with Avaranajanya Madhumeha andApartarpanajanya can be correlated with Dhatu-apakarshanajanya Madhumeha.
Madhumeha:Madhu + MehaMadhu: - resembles honey, sweet, juice or nectar of flowers or soma 11.Meha: - derived from the word Miha meaning to pass urine 12. Excess flow of urine 13.Paryaya:-Kshaudra Meha - - SushrutaOjomeha - - CharakaDefinition:-Charaka defines Madhumeha, in which patient passes urine as astringent, sweet, pale andrough 14.Vagbhata classified Madhumeha into two main types DhatuKshayajanya Avaruttajanya
NIDANAThe Nidana (causative factors) of any disease play a major role in manifestation ofdisease. Etiological factors can be classified into Sahaja & Apathyanimittaja15. Prameha Nidana Sahaja (Hereditary) Apathya Nimittaja (Acquired)Sushruta mentioned the Sahaja word showing genetic predisposition in the patho-physiology of the disease MadhumehaCharaka while describing the prognosis of the disease Madhumeha clearly noted that thisis Kulaja Vikara resulting due to defect in the Beeja 16.The three basic causes of any disease are described in Ayurveda as1. Samavayi Karana (material/inherent cause)2. Asamavayi Karana (non-inherent cause)3. Nimitta Karana (instrumental, initiating cause.) Pradhanika Karana.All the body tissues (Dhatu) are Samavayi causes of disease. In Madhumeha the bodytissues or the Dhatu’s i.e. Meda, Mamsa, Kleda, Lasika, Majja, Rasa, Oja, and Pishita arethe Samavayi Karana’s. While the three Dosha’s i.e. Vata, Pitta, and Kapha are the NimittaKarana’s of the disease.
The Dosha-Dushya Sammurcchana is the Asamavayi Karana of thedisease i.e. Interaction between the above said Meda etc. Dhatu’s and Vatadi Dosha’s. Different causes like excessive indulgence in food, consuming excess ofsweet, heavy food, sleeping etc. are the Sahakari Karana’s or the accessory causes whichhave influence on the Dosha’s thereby leading to development of disease or symptoms. In Prameha there is imbalance of all the three Dosha’s but Kapha plays apredominant role in manifestation of the disease. Only Samanya Nidana of Prameha has been enlisted in all Samhita but Charakahas described the specific etiological factors of Madhumeha and that of Vatika Pramehain Nidanasthana 17.General nidana of Prameha 18 Asyasukham Swapnasukham Excessive indulgence in Dadhini i.e. various preparation of curd. Gramya, Audaka, Anupa Mamsa i.e. meat of domestic, aquatic, wet land animals. Payamsi i.e. excessive use of milk & its preparation Navannapanam i.e. new grains & drinks Guda Vaikrutam i.e. various preparation of sugar & jaggery. Other substances which increases Kapha may cause PramehaAccording to Vagbhata, the diet & activities which increase Meda, Mutra & kapha aresupposed to cause Prameha19.
Specific nidana of Madhumeha:The person indulging in food substances having Guru, Snigdha qualities & excessiveindulgence of Amla & Lavana Rasa substances & Navanna Pana, excessive sleep, sittingin a same place for longer duration, avoiding exercises & thinking process & also notperforming the Shodhana process in a proper time 20.Acharya Sushruta has narrated that untreated Prameha in its initial stage, gets convertedinto Madhumeha & becomes incurable 21.According to Acharya Vagbhata, the urine of Madhumehi will be simulating with that ofMadhu. Two type of vata vitiation has been mentioned, one is due to Dhatukshaya &second due to Margavarana.
Table 3 showing general Viharaja Nidana of PramehaViharaAsya Sukham + - - +Swapna Sukham + - - -Diwaswapna - + - -Avyayayama - + - -Alasya - + - -Beeja Dosha + + + + Table 4 showing Specific Nidana of Madhumeha22 Ahara Vihara Excessive intake of - Excessive indulgence in - Guru Nidra Snigdha Asyasukha Amla Tyakta Vyayama Chinta Lavana Sanshodhana Akurvatam Navannapana
POORVA ROOPA Symptoms produced before the manifestation of the disease i.e. when theSthana Samshraya takes place, some predisposing symptoms are manifested. Thesesymptoms can be considered as warning signs of the disease developing in the body. AsMadhumeha is classified under the Vatika type of Prameha, Poorvaroopa of Prameha canbe taken as Poorvaroopa of Madhumeha. Following table elaborates the various PoorvaRoopa seen in Prameha. Table 5 Showing Poorva Roopa mentioned in various text Cha Su. A.H. A.S. Ma. Ni. Kesheshu Jatilibhava + + - + - Asya Madhurya + - + + + Karapadadaha + + + + + Karapada Suptata + - - - - Mukha Talu KanthaShosha + - + + - Pipasa + + - + + Alasya + - - + - Kaye malam + - - + - Kaya Chhidreshu Upadeha + - - + - Paridaha Angeshu + - - - - Suptata Angeshu + -- - + - Shatpada Pipilika + - + + - Mutrabhisaranam Visra sharir gandha + + + + -
Nidra + - - + - Tandra + + - + - Snigdha gatrata - + - + - Pichhila & guru gatrata - + - - - Madhur mutrata - + - - - Sada - + - + - Keshanakhativriddhi + + + - - Sheeta Priyata + - + + - Sweda + - + + - Karapada Daha is due to loss of Ambu which is Sheeta in property and required for Preenanam, failing to which results in Daha. This may also be due to peripheral neuritis. Tandra & Nidra is due to loss of Rasa & Oja. Snigdha, Pichhila & Gurugatrata is due to kapha by corresponding qualities of Snigdha, Pichhila & Guru. Shatpada pipilika mutrabhisaranam is due to presence of Madhurata in the Mutra. Sushruta makes it easy by narrating that a man with slight increase in urine outputalong with the premonitory symptoms should be considered as patient of Madhumeha23.
ROOPA According to Sushrutacharya, the person should be diagnosed as Pramehi whencomplete or partial prodromal symptoms of Prameha accompanied by polyuria getmanifested. These are characteristic of Vyakta Avastha of a Vyadhi 24. From, above description, it can be postulated that the prodromal symptoms alongwith main symptoms continues as disease progresses.General Symptomatology:(1) Prabhuta Mutrata (Quantity): This is the cardinal sign of Prameha described by all Acharyas.(2)Avila Mutrata (Turbidity): Patient passes urine having hazy consistency.(3)Pichhila Mutrata (Consistency): Acharya Sushruta has described two types of Prameha along with theirmanifestations as follows:(i) Sahaja Pramehi (Krisha-) Ruksha (Dry body ) Alpashi(consumes less food) Bhrish Pipasa (Voracious thirst) Parisarpansheelata (Restless, always desires to wander)
(ii) Apathyanimittaja (Sthula-Obese) Bahuashi (Voracious eater) Snigdha (Unctuous body texture) Shayyasanswapnasheela (Like to sit down & sleep always)Acharya Kashyapa has described the symptoms listed here.(a) Akasmata Mutra Nirgama: Child excretes urine suddenly without any intention.(b) Makshika Akranta Mutra: Flies get attracted towards the urine.(c) Shweta & Ghana Mutrata: Child passes urine having shweta colour & turbidity(d) Gaurava (Heaviness of the body), Baddhata (tightness) & Jadata (Steadiness, Laziness).Specific Symptomatology of Madhumeha: Madhumehi passes urine having Kashaya & Madhura taste, Pandu Varna &Ruksha quality25. Chakrapani opines that Vayu, because of its Prabhava convertsMadhura Oja into Kashaya Oja. According to Sushruta, the urine of Madhumehi resembles with that of honey, asdescribed above. Similar description is found in Ashtanga Hridaya & AshtangaSamgraha. The special manifestation related to behavioral pattern is depicted by Sushrutathat, Madhumehi prefers standing to walk, sitting to stand, lying down to sit, & sleepingto lying down 26.
SAMPRAPTI Prameha is considered as a type of Santarpanajanya Vikara. Charaka inNidanasthana gives the detailed explanation of Nidana and other Samprapti Ghataka indetail. Charaka has explained elaborately that how this disease develops in the body. For the establishment of any disease in the body the important three factorsconnected are Nidana, Dosha and Dushya under the influence of Prakruti, Desha, Kala,Bala & Linga. When these three factors are not interconnected properly, the disease willnot occur. The Nidana, Dosha (Vatadi Tridosha), Dushya (Rasadi Dushya) areresponsible for the production and manifestation of any disease in the body. When Sadhya Roga changes into Krichrasadhya or Asadhya it can be called asVidhi Samprapti. It commonly occurs in the untreated condition. As far as Madhumeha isconcerned, we can partly include it in Vidhi Samprapti. Acharya Sushruta explains it as ifall the Prameha are not treated first, they will gradually pass to stage of Madhumeha. Acharya Charaka has described Madhumeha vividly. Vagbhattacharya dividesMadhumeha into two types, according to Samprapti. The Madhumeha is included inVataja type. If Vataprakopa occurs due to Sarvadhatukshya, it is calledDhatukshayajanya Madhumeha. And if Vataprakopa manifests as result of Vatavarana, itis called Avaranjanya Madhumeha. Acharya Sushruta explains it as if all the Prameha arenot treated first, they will gradually pass the stage of Madhumeha.
SAMPRAPTI OF MADHUMEHA: The pathogenesis of Madhumeha is explained in Charaka Samhita, Nidanasthana4th chapter. Due to causative factors in the person susceptible for Prameha, vata Prakopaoccurs. This kupita Vata dosha attracts the vital Dhatus like Vasa, Majja, Lasika & Oja toBasti. The Vata dosha is having Rukshatva and it again changes the Madhura Rasa of Ojainto Kashaya Rasa. This Kashaya Oja is excreted through urinary tract later. Thiscondition is termed as Madhumeha. Ahara with a predominance of Guru, Snigdha, Amla and other kaphapittakarasubstances, leads to the provocation of kapha and Pitta Doshas, Which in turn vitiatesMedas and Mamsa. These increased Dosha-Dushya cause’s vata Avarana by which Gatior movement of Vata Dosha is obstructed. Finally vitiated vata attracts and carry the Ojatowards Basti resulting in the Madhumeha 27. The Samprapti of Madhumeha as described under Samanya Samprapti is the basicmechanism governing the production of the disease. Vata essentially triggers this process.Therefore Madhumeha is a Kapha Vata dosha Pradhana Vyadhi in which the Vata Dushtioccurs in two different pathologic mechanisms: a) Margavarana janya Vata Dushti and b) Dhatukshaya janya Vata Dushti.
UPADRAVA The term Upadrava is applied to a disease which has taken place on, produced bythe Samprapti Ghatakas of original disease & be cured if original disease is treatedsuccessfully. The disease Madhumeha, when severe, involves almost all Dhatus and therespective Srotases. Accordingly, Upadravas appear as and when a particular Srotas isaffected Charaka and Bhela have listed and described common Upadrava at random.Sushruta, Vagbhata and Bhavaprakasha have described them separately as Kaphaja,Pittaja and Vataja.(1) General Complications 30:Trushna, Atisara, Daha, Daurbalya, Arochaka, Avipaka, Putimamsa Pidaka, Alaji,Vidradhi etc.Trushna: Is defined as Paneeya sevana iccha31. It has been described as Asadhya ifTrushna develops as an Upadrava of Madhumeha32 and Charaka says that it is a DirghaRoga and results in Marana if neglected or if developed as Upadrava33.Jwara 34: As a result of Dhatu kshaya and reduced Vyadhikshamatva, Jwara develops.Daha 35: Clinically, Daha is seen especially in Hasta- Pada tala.Dourbalya: as a result of Dhatu Kshaya and Oja Kshaya in the form of Kleda throughMutra.
Putimamsa Pidaka: The Pidaka are the most important Upadrava of Madhumeha asnegligence in treating them makes the disease Asadhya.The Dushita Medas, Mamsa and Shonita with increased Dravata of Sleshma results indevelopment of Pidakas.(2) Specific Complications:(a) Kaphaja meha 36:Makshikopasarpanam, Alasya, Mamsopachaya, Pratishyaya, Shaithilya,Arochaka,avipaka, Kaphapraseka, Chhardi, Nidra, Kasa & Shwasa.(b)Pittaja meha 37:Vrushanayorvadaranam, Bastibheda, Medhra toda, Hridshula, Amlika, Jwara, Atisara,Arochaka, Vamathu, Paridhumayanam, Daha, Murchha, Pipasa, Nidranasha, Panduroga,Pittavidmutranetratva & Vidbheda38.(c)Vataja meha 39:Hridgraha, Laulya, Anidra, Stambha, Kampa, Shula, Baddha purishatva and shosha, kasa,shwasa.
Acharya Charaka has mentioned 7 types of Pidaka as complication of Madhumeha.While Sushruta and Vagbhata has mentioned 10 Pidakas. Sushruta has mentioned thatMadhumeha along with Pidaka is Asadhya. While describing about the Pidaka Sushrutaopines that these Pidaka occurs due to Tridosha and vitiated Meda & Mamsa.These Pidaka are as follows. Table 6 showing various Pidakas developed in Prameha as Upadrava Pidaka Charaka Sushruta Vagbhata Sharavika + + + Kacchhapika + + + Jalini + + + Sarshapi + + + Alaji + + + Vinata + + + Vidradhi + + + Putrini - + + Masurika - + + Vidarika - + +
ARISHTA LAKSHANAWhen a disease pervades a patient such that he may die, nature signals his departure withprecision in varied forms. The concept of Arishta Lakshana hence co-relates with thisconcept. It helps a physician to predict imminent death.The following two features are mentioned by Charaka as Arishta Lakshana i.e. the signsof incurability or indication of ensured death.1. The person in whose body, the flies are attracted after bath also is sure to die due to Prameha 40.2. The person who drinks various kinds of oils & Ghee or other unctuous preparations with Chandala in his dreams may die of Prameha in future.
SADHYASADHYATA Madhumeha or Prameha has been described as Anushangi, which means it isPunarbhavi, in other words once a person is affected with Madhumeha, the disease lastlife long i.e. till the patient is alive. Therefore, one should make all efforts to prevent andcontrol it.In General prognosis of Prameha given by all Acharyas is as follows,Kaphaja Prameha - SadhyaPittaja Prameha - YapyaVataja Prameha - Asadhya when occurred due to Dhatu kshaya & Krichrasadhya when established due to Avarana Charakacharya illustrated the prognosis of Prameha considering the presence orabsence of Poorvaroopa. Kaphaja Meha with Poorvaroopa is considered Krichrasadhyawhile that associated with Pittaja Meha is detailed as Pratyakhyeya. Pittaja Prameha is considered as Yapya, while Vataja Prameha having the statusof Asadhya. This is the result of the nature of disease & associated Dhatus. KaphajaPrameha can be treated with Katu, Tikta & Kashaya Rasa, both the kapha dosha and theassociated Dushya (Sama Dhatus) can also be treated with the same treatment at the sametime. In case of Pittaja Prameha & Vataja Prameha, the disease and associated vitiatedDhatus are having opposite qualities. So they are Yapya and Asadhya respectively.
Krichrasadhya/Asadhya Madhumeha: Madhumeha is included in Vataja Prameha. Here Vata Prakopa might be due toDhatukshaya as it occurs after Kaphaja & Pittaja Prameha. Another important cause isAvarana. When Vata Prakopa is due to Dhatukshaya the type is included in AsadhyaMadhumeha, while the other produced by Avaranjanya Vata is considered asKrichrasadhya. Charakacharya mentioned that Madhumeha produced due to Beejadosha isincurable (Asadhya) Madhumeha is considered Asadhya due to the following reasons.a) Mahatyayatvat.b) Viruddhopakramatvat.Madhumeha with all Poorvaroopa: It has been said by Charaka that if a disease inRoopavastha has all the Poorvaroopa manifested then the disease becomes Asadhya.Madhumeha patients who have Bala Mamsa kshaya can be left untreated. Madhumehawith Pidakas is Asadhya. All Prameha if left untreated terminate into Madhumeha whichis Asadhya.
CHIKITSA Chikitsa means all types of medical procedures, administration of drugs and dietwhich gives relief from disease and helps to maintain healthy state of the body42. Chikitsa Sutra (principles of treatments) and Chikitsa (Management) are the twodivisions of Chikitsa. Both these are described very well in classics. But the concepts andmethods are different in different conditions, considering the Vyadhi Swabhava andAtura. The samprapti should be considered deeply before stepping to manage.CHIKITSA SUTRA: In Charaka Samhita it has been described that in all types of prameha therespective etiological factors should be avoided. The treatment of the disease starts withabstinence from the etiological factors, which is described under the heading of NidanaParivarjana. It is the first and fore most principle in treating the disease. Charaka, Sushruta and Vagbhata consider the body constitution and strength ofthe body of the patient when dealing with the management aspect. Charakacharyaconsiders two types of patients; one is that with obese (sthoola) and strong (Balwan) andthe other without weak (Durbala) and lean (Krisha). The treatment principle for thesekinds of patients is Samshodhana and Samshaman respectively. Sushruta Acharya also says that Sahaja Prameha rogi will be Krisha &Apathyanimittaja Rogi will be Sthoola43.The two types of management emphasized are:(1) Samshodhana Chikitsa [Elimination Therapy](2) Samshaman Chikitsa [Normalizing Therapy]
Like every disease, those factors which are responsible for the production of thediseases are if eliminated and if further, causative factors are prevented prameha can alsobe treated. Madhumeha can be treated in this way although it is described as incurable. InPratyakhyeya vyadhis, symptomatic relief can be given by proper management. Although Vataja Prameha is incurable still Acharya Charaka explains to inducecertain treatment in kaphapittanubandhi Prameha 44.Treatment described for Vataja Prameha can be considered as treatment of madhumeha.MADHUMEHA:(i) Samshodhan Chikitsa: Considering Sthoola and Krisha Pramehi, Samshodhan Chikitsa should beadministered only to the sthoola and Balwan Pramehi. Sarshapa, Nimba, Danti, Bibhitaki& Karanja Siddha Taila or Trikantakadya Sneha (Ghrita or Taila according to doshapredominance should be used for Abhyantara Snehana. Here while explaining theSamshodhan, Charaka describes to use the Malashodhan Yogas from Kalpasthana. Both Pitta and kapha are eliminated through shodhana. Either it may be Vamanaor virechana, so both pitta or kapha doshas which are vitiated are eliminated. Then theVagbhata advised to give Anuvasana and Asthapana Basti Chikitsa after Vamana andvirechana to control the provocation of Vata.Anuvasana with medicated oils and Ghritaare prescribed in madhumeha. After proper Shodhana Chikitsa, Charakacharya details to give SantarpanaChikitsa to the patients, to prevent the complications like Gulma, Bastishula etc.
(ii)Samshaman Chikitsa : Samshaman Chikitsa includes mainly Deepana (appetizers), Pachana, (enhancingdigestion), Kshut (Hunger maintenance), Trit (Maintenance of thirst), Vyayama(Exercise), Atapa (Having exposed to sunlight) & Maruta (Exposing oneself towind).According to the conditions of vitiated doshas & Dushyas. Acharya Sushruta explains that Shilajit should be taken along with Salsaradi Ganakwatha. After its digestion patient should take Jangalamamsarasayukta Anna. Heprescribes to take 1 Tula of Shilajatu. Principles of treatment of madhumeha Santarpanajanya Apatarpanajanya Stoola Pramehi Krisha Pramehi Balwan Durbala Samshodhana Chikitsa Samshaman Chikitsa Vamana, virechana, Santarpana Asthapana basti Santarpana
Compound Preparations Used In Prameha: Swarasa: Amalaki, Haridra, Nimbapatra, Bilwapatra, Guduchi Kwatha: Vidangadi, Phalatrikadi, Mustadi, Manjishthadi, Pathadi Churna: Triphaladi, Mustadi, Gokshuradi, Arkadi Gutika: Chandraprabha, Indravati, Pramehantak Vati Guggulu: Gokshuradi Guggul Modaka: Kastur Modaka Avleha: kushavleha, Bangavleha Paka: Pugapaka, Ashwagandhadi paka, Draksha Paka. Asava Arishta: Lodhrasava, Dantyasava, Madhukasava, Devdarvyadiarishta, Lodhrarishta. Ghrita: Dhanvantar ghrita, Trikantakadi ghrita, Sinhamrita ghrita, Dadimadi ghrita, Shalmali ghrita. Rasaushadhi: Vasant kusumakar Rasa, Mehamudgar Rasa, Brihat Bangeshwar Rasa, Prameha gajkesri Rasa, Tribanga Bhasma, Vasant tilaka Rasa.PREVENTION OF PRAMEHA: Acharya Charaka while explaining the nidana of prameha has described conditionor the people who are more prone to acquire the disease they are as follows:- Manda Utsahi Ati sthoola Ati snigdha Mahashana (genetic defect)
The above said conditions lead to the development of Prameha which in turn isthe cause of death in such persons. Hence to prevent the occurrence of disease one should consume the diet which isbeneficial and which is Dhatusamyakara i.e. which maintains equilibrium in the body anddaily regimes should be such that it will maintain the health. And to avoid all the etiological factors i.e. Nidana Parivarjana helps to prevent thedevelopment of disease thereby maintaining the health of an individual, especially inthose above said who are more prone for this disease45. Similarly adopting Dinacharya, Rutu charya and other hygiene measuresdescribed in various classics will help a person to overcome the etiological factors likeAsyasukham, Swapnasukham etc. and to prevent the disease formation.
PATHYA – APATHYA The word “Pathya” is derived from the word “Patha” which means roads orbodily channels and the methods adopted in maintaining the integrity of the bodilychannels or “Srothas” is called as “Pathya”. “Pathya” also means those foods and deeds,which does not do any harm to the body and which gives happiness to body and mind46. While commenting on Charaka Samhita, Chakrapani describes the meaning of‘Patha’ as the channels or Srotas of the body and ‘Pathya’ as that which protects thehealthy state of an individual and cures diseased condition and promotes or restoreshealth. According to Ayurveda every food we consume have its own effect in eitherincreasing or decreasing the Dosha. So when such foods or deeds are done which is not“Pathya” that means which is Apathya-Ahara then the vitiated “Doshas” aggravates thediseases. Those Ahara’s and Vihara which are suitable to Prameha patients are calledPathya and those which induce Prameha are called Apathya. Pathya is having a key rolein the management of Madhumeha. Even in modern science also Diet & Exercise areincluded in diabetes management. So before stepping to manage we have to consider forthe Pathya-Apathya. Madhumeha has been described as Anushangi, which means Punarbhavi i.e. atendency to recur. Hence a Madhumeha patient should stick to Pathya throughout his life.The Pathya-Apathya Nirdesha according to different authors and their Guna and Karmahave been classified into Ahara, Vihara and Achara.
Yava: Yava is Ruksha, Sheeta, Guru, Madhura Rasa Pradhana, Kashaya Rasa Yukta. It isVatahara, Sthiryakara and Balya and so is ideal for both Krusha and SthoolaMadhumeha. It is considered as the principle pathya Ahara in management of PramehaThat is the reason numerous preparations of Yava have been advised.Tikta Shaka : It is Ruksha, Laghu and Pitta -Vata Shamaka and hence is helps inpacifying the Kapha dosha and being Vata Shamaka is beneficial in Madhumeha. Pathya Vihara:Sushruta has described that practice of regular physical exercise, wrestling, actual sports,riding on a horse, or a elephant, long walks, predestrial journeys, practising archery,casting of javelins etc.47Vagbhata has advised Rukshamudvartna, heavy exercises like digging a well and not totake sleep even in night for the patient of Prameha. Also walking on bare foot isdescribed as the best treatment for the poor patients48. Apathya:(a) Ahara:Jala, Milk, Ghee, Oils, Curd, Sugar, Different types of rice preparations, Anupa, Gramyaand Audaka Mamsa, Ikshurasa, Pishtanna, Navanna, Guda, Amla Padartha.(b) Vihara:Eksthana Asana, Divaswapa, Dhoompana, Swedana, Maithuna, Mutravega dharana.
MODERN REVIEWDEFINITION: Diabetes mellitus is a group of metabolic disease characterized by hyperglycemiaresulting from defects in insulin secretion, insulin action or both.CLASSIFICATION: The current expert committee of American diabetes association has proposedchanges to the WHO classification scheme. The revised Etiologic classification ofdiabetes mellitus is as follows:1. Type 1 diabetes (beta -cell destruction, usually leading to absolute insulin deficiency.) A. Immune mediated. B. Idiopathic2. Type 2 diabetes (may range from predominantly insulin resistance with relativeinsulin deficiency to a predominantly secretory defect with insulin resistance.3. Other specific Types: A. Genetic defect of beta-cell function: a. Chromosome 12, HNF-1 Alpha (MODY 3) b. Chromosome 7, Glucokinase (MODY 2) c. Chromosome 20, HNF 4 Alpha (MODY 1) d. Mitochondrial DNA e. Others B. Genetic defects in insulin action: Type A insulin resistance, Rabson Mendenhall Syndrome, Lipoatrophic,
C. Diseases of exocrine pancreas: Pancreatitis, Trauma / Pancreatectomy, Neoplasia, Cystic Fibrosis, Hemochromatosis, fibrocalculous pancreatopathy. D. Endrocrinopathies: Acromegaly, Cushing’s syndrome, Glucagonoma, Pheochromocytoma, Hyperthyroidism, Somatostatinoma, Aldosteronoma. E. Drug or Chemical induced : Vacor, Pentamidine, Nicotinic Acid, Glucocorticoids, Thyroid Hormone Diazoxide, beta -adrenergic agonists, Thiazides, Dilantin, Alpha-Interferon. F. Infections: Congenital rubella, Cytomegalovirus & Others G. Uncommon forms of immune mediated diabetes: “Stiff-man” syndrome, Anti-insulin receptor antibodies. H. Other genetic syndromes sometimes associated with diabetes Down’s syndrome, Klinefelter’s syndrome, Turner’s syndrome, Wolfram’s syndrome, Friedreich’s ataxia, Huntigtion’s Chorea, Laurence-Monn-Biedl syndrome, Myotonic dystrophy, Porphyria, Prader-Willi syndrome & others.4. Gestational Diabetes Mellitus (GDM)
CRITERIA FOR DIAGNOSISThe revised criteria for diagnosis according to American diabetes association is as under(1) Symptoms of diabetes plus random plasma glucose concentration > 200 mg/dl (11.1 mol/l), random is defined as any time of day without regard to time since last meal. Or(2) FPG >126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8hrs. Or(3) 2-hr PG > 200 mg/dl or (11.1 mmol/l) during an OGTT. The test should be performedusing a glucose load containing the equivalent 75g anhydrous glucose dissolved in water.INVESTIGATIONS: 1. Blood Glucose Tests: Fasting Postprandial Tolerance Tests HbA1c 2. Urine Glucose Tests 3. Insulin Tests S. Insulin Insulin Sensitivity Test 4. Other complimentary Tests: Glycated Serum Protein (GSP), S. Fructosamine,
EPIDEMIOLOGY & PREVALENCE : Diabetes has been described as an epidemic, but predications for future increasesin prevalence, especially in developing countries point to a major health care crisis for thefuture. Current estimates suggest that the prevalence of type 2 diabetes worldwide is setto increase from its present level of 150 million to 250 million by the end of the decadeand 300 million by 2025. These figures represent only clinically diagnosed diabetes &many of more cases of diabetes remain undiagnosed and untreated. The long term complications associated with type 2 diabetes carries a crushingburden of morbidity and mortality. The Indian diabetic population is predicted to rise>80.9 million by the year 2030. Current prevalence rates are 10-18% in the urban Indian adult population & thereis evidence that the prevalence of type 2 diabetes is increasing in rural population also.INSULIN BIOSYNTHESIS, SECRETION & ACTION :BIOSYNTHESIS: Insulin is produced in the beta cells of the pancreatic islets. It is initiallysynthesized as a single chain 86 amino acid precursor polypeptide, preproinsulin. Themature insulin molecule and C peptide are stored together and co secreted from secretorygranules in the beta cells.SECRETION: Glucose levels > 70 mg/dl stimulate insulin synthesis, primarily by enhancingprotein translation and processing, as well as inducing insulin secretion. Glucosestimulates insulin secretion through a series of regulatory steps that begin with transport
into the beta cell by the GLUT2 glucose transporter. Glucose physophorylation byglucokinase controls glucose regulated insulin secretion.ACTION: Once insulin is secreted into the portal vein approximately 50% is removed andderanged by the liver. Unextracted insulin enters the systemic circulation and binds to itsreceptor in target sites. The insulin receptor belongs to the tyrosine kinase class ofmembrane bound receptors. Insulin binding to the receptor stimulates intrinsic tyrosinekinase activity, leading to receptor autophosphorylation and the recruitment of intracellular signaling molecules, such as insulin receptor substrates (IRS) 1 and 2. These andother adaptor proteins initiate a complex cascade of phosphorylation anddephosphirylation reactions. Ultimately resulting in the wide spread metabolic andmitogenic effects of insulin. Activation of other insulin receptor signaling pathwaysinduces glycogen synthesis, protein synthesis, lipogenesis and regulation of various genesin insulin responsive cells. In fasting state, low insulin levels promote hepatic gluconeogenesis andglycogenolysis, decrease glycogen synthesis, reduce glucose uptake in insulin sensitivetissues, promote mobilization of stored precursors, allows glucagons to stimulateglycogenolysis and gluconeogenesis by the liver and renal medulla.AETIOPATHOGENESIS: TYPE 1 DIABETES MELLITUS: Type 1 diabetes develops as a result of the synergistic effects of genetic,environmental and immunologic factors that ultimately destroy the pancreatic beta cells.When diabetes becomes overt clinically, majority of beta cells are destroyed. Type 1
diabetes is a multi-factorial autoimmune disorder showing familial aggregation, the rateof familial aggregation being consistent with the significance of the genetic contributionto the disease.AETIOPATHOGENESIS: TYPE 2 DIABETES MELLITUSGenetic Factors: Among monogenic forms of type 2 diabetes, Various phenotypes inMODY(maturity onset diabetes mellitus) patients suggest the disorder to be geneticallyheterogeneous MODY 1 diabetes is caused by mutation of the nuclear factor-4a gene(HNF-4a/MODY1), MODY 2 by mutation of the glucokinase gene (GCK/MODY2), andMODY 3 by mutation of the hepatocyte nuclear factor-1a gene (HNF-1a/MODY3)MODY 1 and MODY 3 are characterized by severe disturbance of insulin secretion andsevere hyperglycemia associated with microvascular complications.Metabolic abnormalities : Insulin resistance : Insulin resistance is a diminished ability of insulin to perform its biologicalfunction. Although individuals with insulin resistance secrete abnormally high amountsof insulin to compensate for the disturbance, to stimulate glucose transport to themuscular and adipose tissue, and to inhibit the hepatic production of glucose, the plasmaconcentration of glucose is on a continuous rise. Although insulin resistance is animportant factor for the development of type 2 diabetes, a majority of people with insulinresistance do not develop diabetes.
Impaired Insulin Secretion : In type 2 diabetes mellitus, insulin secretion initially increases its response toinsulin resistance to maintain normal glycemia. Eventually the insulin secretory defectprogresses to a state of grossly inadequate insulin secretion. The reason for decline ininsulin secretory capacity in type 2 diabetes mellitus is unclear.Obesity: The state of obesity is associated with dyslipidaemia, hyperinsulinemia, insulinresistance and impaired glucose toleranceEnvironmental Factors : The migration of populations to more urban settings, as well as increasingaffluence in developing countries contributes for the establishment of diabetes. Foodshighly rich in carbohydrate and fat, sedentary life style, Stress & Strain are triggeringfactors for type 2 diabetes.CLINICAL FEATURES :The classic symptoms of diabetes are as follows: Polyuria Polydipsia Unexplained Weight loss These are sometimes associated with polyphagia and blurred vision. Pruritisvalvae or balanitis is a common presenting symptom since the external genitalia areespecially prone to infection by fungi which flourish on skin & mucous membranescontaminated by glucose. Acute, life threatening consequence of diabetes arehyperglycemia with ketoacidosis or the non-ketoic hypersmolar syndrome.
TREATMENT:The goals of therapy for type 1 or type 2 diabetes mellitus: 1. Eliminate symptoms related to hyperglycemia. 2. Reduce or eliminate long term micro vascular, macro vascular complications. 3. Allow the patient to achieve as normal a life style as possible.So the management can be planned as under: (1) Education of Patient about diabetes mellitus, Nutrition and Exercise. (2) Monitoring the level of glycaemic Control. (3) Assessment of glycaemic Control. (4) Oral Hypoglycemic Agents (5) InsulinNUTRITON: Medical Nutrition Therapy (MNT) is an integral component of DiabetesManagement.Nutritional Recommendations for Diabetics: Carbohydrate: Whole grains, fruits, vegetables and low fat milk should be included in the healthy diet. The total amount of carbohydrate in diet is more important than source or type. As sucrose does not increase glycaemic index to a greater extent than is caloric amounts of starch, sucrose and sucrose containing foods do not need to be restricted. Protein – Protein intakes > 20% of total daily energy should be avoided. Fat – Less than 10% of energy intake should be derived from saturated fats.
Vitamins & Minerals – As there is no evidence of benefit from it, vitamins & minerals are not advisable if person do not have underlying deficiencies. Antioxidant – Routine supplementation of antioxidants is not advised because of uncertainties related to long term efficacy & safety.EXERCISE: The possible benefits of physical activity for the patient with type 2 diabetes aresubstantial, and recent studies strengthen the importance of long term physical activityprograms for the treatment & prevention of Diabetes mellitus. It reduces the risk ofcardiovascular disease, Hyperlipidaemia, Hypertension & Obesity. A great deal of evidence has been accumulated supporting the hypothesis thatphysical activity among other therapies, may be useful in preventing or delaying the onsetof type 2 DMINSULIN ADMINISTRATION: Insulin is available in rapid, short, intermediate and long acting types.Conventional insulin administration involves subcutaneous injection with syringesmarked in insulin units. Several pen like devices and insulin containing catridges areavailable that deliver insulin subcutaneously. The appropriate insulin dosage is dependenton the glycemic response of the individual to food intake & exercise regimens. All
insulin requiring individuals should be instructed to carry at least 15 gm carbohydrate tobe eaten or taken in liquid form in the event of a hypoglycemic reactionORAL HYPOGLYCEMIC AGENTS : Table 9 showing Characteristics of oral drugs for diabetes Mechanism of Example Anticipated Agent Specific Action Reduction Advantages in HbA1C% Insulin increases Insulin Glipizide Lower fasting Secretagogues secretion 1-2 blood glucose Sulfonylureas Short onset of Meglitinide Repaglinide action, lower PPBG Biguanides Decreases Weight loss, Hepatic glucose Improve lipid production, weight Metformin 1-2 profile, No loss, hypoglycemca increases glucose utilization Alpha- Decreases Acarbose 0.5-1 No risk of Glucosidase Glucose miglitol hypoglycemia inhibitors absorption Thizolidinediones Decreases Rosiglitazone 1-2 Insulin & Insulin resistance, Proglitazone Sulfonylurea increases glucose requirements, utilization triglycerides.
COMPLICATIONS OF DIABETES MELLITUS:Complications of Diabetes mellitus fall into two major divisions i.e. Acute Complications& Chronic Complications.Acute Complications: Hypoglycemia Diabetic Ketoacidosis Non Ketoic hyperosmolar stateChronic Complications :(1)Macro vascular Complications: Coronary artery disease. Peripheral Vascular disease. Cerebro vascular disease.(2)Micro vascular Complications : Diabetic Eye disease Retinopathy (non-proliferative / proliferative) Macular edema Glaucoma Cataracts Diabetic Neuropathy Poly neuropathy /mono neuropathy Diabetic Nephropathy(3) Other Gastro intestinal [gastro paresis, diarrhea]
Genito urinary [uropathy /sexual dysfunction] Dermatologic infections. Diabetic foot. Management of Type 2 Diabetes Diagnosis of type 2 DM: use one of three test RBS > 200 mg per dl + symptoms FBS > 126 mg per dl OGTT - 2-hr PG > 200 mg per dl Patient education/ diet and exercise Goal: FBS < 126 mg per dl Initiative Monotherapy (if diet and exercise alone are inadequate) Options for MonotherapySulphonylureas Meglitinide Biguanides Thizolidinediones Alpha-Glucosidase Inhibitors Initiate combination therapy if single agent is inadequate If therapeutic goals are not achieved using above combination: Adopt insulin therapy with or without oral drugs
DRUG REVIEW Management of diabetes mellitus or Prameha is based on three main aspects i.e.Diet, Exercise and Drugs. Diet management holds first and the foremost place in themanagement of type 2 diabetes or NIDDM. Majority of the cases of type II diabetes canbe treated or controlled just by modifying diet and exercise only. All the classics have emphasized on regulation of diet in Prameha patient andhave indicated various Ahara Dravya’s which are beneficial for Prameha patients. Thesebeneficial Ahara Dravya’s are mentioned under the heading of Pathya Ahara i.e. whichdoes not vitiates the Dosha responsible for the disease but in turn help in pacifying theDosha’s and helping the body to over come the disease for speedy recovery. There areplenty of Pathya Dravya’s mentioned in different texts. Keeping this in view these Pathya Dravya’s were analyzed and the commondravya’s were selected like: - Yava (barley), Mudga (green gram), Kulatha (horse gram),Rajashimbi (soybean), Godhuma (wheat bran) and Triphala and were combined to form acompound. The above said Dravya’s were made into fine powder and then made into granulesform. This compound is named as Nutritional compound which was administered to thepatients in the dose of 15 gm twice daily with warm water.
Table 10 showing description of Dravya’sDravya’s Varga Family Latin NameYava Shuka Dhanya Gramineae Hordeum vulgareGodhuma Shuka Dhanya Gramineae Triticum aestivumMudga Shimbi Dhanya Leguminacae Vigna radiate Sub Family– PapilionacaeKulatha Shimbi Dhanya Dolichos biflorusRajashimbi Shimbi Dhanya Leguminacae Glycine Max Sub Family– Papilionacae MerrillHaritaki Combretacae Terminalia - ChebulaBibhitaka Combretacae Terminalia - BelliricaAmalaki Euphorbiacae Emblica - Officinalis
Prameha is a disease of Kapha predominance, and Madhumeha of Vata Doshapredominance with formation of Kleda in the body. Hence the management should be ofKapha- Vata Shamana and Kleda Nashaka. Keeping this in View even the various Pathya mentioned in different text haveproperties of Kapha-Vata Shamana and Kleda Nashaka. Action or Karma of any Dravya depends on its Rasa, Virya, Vipaka or Prabhva.Which Guna is responsible for the Karma of the particular Dravya is dependent on thePanchabhoutika combination of that Dravya. Hence it has been mentioned that someDravya’s act by its Rasa, some by its Virya or Vipaka or in some cases by the Prabhavaof that Dravya. Yava has been mentioned as the important Pathya for Prameha Patients. ThoughYava is Madhura and Guru but the properties of Yava, which are generally Kaphavitiating properties but Yava is an exception for it as it helps in pacifying the KaphaDosha. Similarly Godhuma is Madhura, Guru and Sheeta, old variety of it helps inpacifying Kapha Dosha. Yava is Ruksha, Sheeta, Guru, Madhura Rasa Pradhana, Kashaya Rasa Yukta. Itis Vatahara, Sthairyakara and Balya and so is ideal for both Krusha and SthoolaMadhumehis. Kulatha, Bibhitaka, Mudga, Haritaki are Kashaya Rasatmaka and YavaRajashimbi are having Kashaya as Anurasa. Kashaya Rasa is Vayu and PrithviMahabhuta Pradhana which helps in Pitta and Kapha Shamana. Kashaya Rasa isStambhaka, Shoshaka, Ropaka and Mutra-Sangrahaniya also helps in Kleda Nashakawhich is the major factor in Samprapti of Mahumeha.
Haritaki though is Kashaya; it is Mrudurechaka and Anulomaka which helps inVatanulomana. Kulatha though being Kashaya, due to its Snigdha Virya it helps in VataShamana. Yava and Kulatha helps in absorption of Kleda in the body thereby helps inRokshana Karma. The Guna’s of all the dravya’s mentioned above are Ruksha, Laghu which areopposite to that of Kapha which help in pacifying the Kapha Dosha. In Dhatukshayajanya Madhumeha, Dravya’s like Godhuma, Amalaki, Rajashimbiwhich are Madhura, Sheeta, Balya, Tarpaka help in over coming the Dhatukshaya andthere by relieving the symptoms like Daurbalya, Alasya etc. Triphala i.e. Haritaki, Bhibhitaka and Amalaki, though are Aushadi Dravya’s, arementioned as Pathya for Prameha. Triphala is Pathya, deepana, Kapha-Pittahara,Rasayana and Mehahara. Properties of various Dravya’s in Triphala not only help inPacifying the Prameha disease as such but help in preventing the complication ofMadhumeha also. Charakacharya gives importance to Triphala by mentioning that if aperson is consuming Triphala regularly he won’t suffer from Prameha. Hence various factors like Rasa, Virya, Vipaka of Dravya’s help in pacifying thevitiated Dosha’s thereby establishing normalcy of Dosha’s and relieving the disease.
Table 11 showing Nutritional values of the ingredients in supplement (Per 100 g) Dravya CHO Protein Fats Fibre Calorie Gly. index Barley 69.6 11.5 1.3 3.9 336 22 Wheat bran 71.2 11.8 1.5 1.2 346 54 Green gram 59.9 24.5 1.2 0.8 348 54 Horse gram 57.3 22 5.3 0.5 322 73 Soybean 20.9 43.2 19.5 3.7 432 14 Analyzing the nutritive value’s of above dravya’s, they are mainly low in fat, richin fibre content, have low glycaemic index and moderate in carbohydrate i.e. mainlycontain complex carbohydrates and rich in caloric values which help diabetes patients invarious aspects. The rich fibre content of barley (Yava), soybean (Rajashimbi), and wheat bran(Godhuma) slows down the carbohydrate digestion and absorption and so improvesglycemic control.Glycemic index: - Jenkins and wolever (1981) coined term glycemic index to describe inquantitative way the rise in blood sugar that different carbohydrate foods produced.The glycemic index is rise in blood glucose induced by test food expressed as percentageof that induced by same amount of pure glucose.Factors affecting glycemic index of isolated food are-Speed of digestion of carbohydrates.
Amount and type of dietary fibre.Presence of monosaccharide such as fructose, which are slowly absorbed in gut.Glycemic index = Blood glucose area of test food X 100 Blood glucose area of reference foodWhite bread is preferred as reference food because it is palatable and generally accepted.A 100% value is given to mean blood glucose for three hours following ingestion of 50gcarbohydrate in white bread. The glycemic index value in commonly consumed foods iscompared with 50g carbohydrate in white bread. The Dravya’s like barley (Yava), soybean (Rajashimbi), and wheat bran(Godhuma) have a low glycemic index of 22, 14 and 54 respectively which helps incontrolling the raise in post prandial blood glucose levels. The protein contents in these Dravya’s helps the patients to over come theemaciation caused by utilization of fats and proteins for energy needs of the body, in turnavoids formation of ketone bodies and further complications. The rich fibre content in these dravya’s also helps in reducing the LDLcholesterol levels in the body, thereby helps in preventing the complication like heartdiseases, hypertension, etc. There are plenty of researches available proving the efficacy of rich fibre andcomplex carbohydrate diet in lowering blood glucose levels and avoiding long termcomplications of the disease.
METHODOLOGY Among the several health problems existing today, Diabetes mellitus is a majordisease considered as one of the arch enemy of mankind. Though, the discovery ofinsulin and other hypoglycemic drugs is a great achievement of modern science, but thehazardous side effects of hypoglycemic drugs after long term use are incurable and hencean ideal therapy is still obscure. In Ayurveda, Diabetes mellitus closely resembles a disorder called Madhumeha,which is a subtype of Vataja Prameha. The Ayurvedic management of Diabetes aims notonly to achieve a strict glycemic control, but also to treat the root cause of the disease.For it various modalities of treatment are developed, which depends upon the underlyingpathology.AIMS AND OBJECTIVES OF THE STUDY 3. To study the effect of various Pathya Ahara in the form of nutritional compound in Prameha 4. To study the improvement in nutritional status, and over all health status of patients by administration of adjuvant nutritional compound.
MATERIALS AND METHODSSELECTION OF PATIENTS Patients attending the OPD and IPD of S.D.M. college of Ayurveda and Hospital,Hassan were randomly selected irrespective of age, sex, religion, occupation, maritalstatus etc. and were divided in two groups considering the inclusion criteria for the study.INCLUSION CRITERIA 1. Mild to moderate cases of diabetes mellitus having fasting blood sugar within range of 121 mg/dl to 220 mg/dl and post prandial blood sugar within range of 181 mg/dl to 280 mg/dl were selected. 2. Patients above the age group of 25 years and below 60 years of age were selected 3. Patients within 5 years of diagnosis for diabetes mellitus were selected for the study.EXCLUSION CRITERIA 1. Severe form i.e. patients having fasting blood sugar above 221 mg/dl and post prandial blood sugar above 281 were excluded. 2. Patients with uncontrolled blood sugars were excluded. 3. Patients with other systemic disorders and complications of diabetes mellitus were excluded from the study.
DIAGNOSTIC CRITERIA Diagnosed cases of diabetes mellitus within 5 years of detection were selected forthe study. Mild to moderate diabetic cases were selected based on the following standardreference chart for classification along with the clinical signs and symptoms mentioned inthe classics.FBS 70 to 120 mg/dl normal 121 to 170 mg/dl mild 171 to 220 mg/dl moderate 221 and above severeRBS 120 to 180 mg/dl normal 181 to 230 mg/dl mild 231 to 280 mg/dl moderate 281 and above severePPBS 120 to 180 mg/dl normal 181 to 230 mg/dl mild 231 to 280 mg/dl moderate 281 and above severeAs per classification of S.N Khosle at al.nagarjuna
LABORATORY INVESTIGATIONS1. Hematological – Total count, Differential count, E.S.R., Hb%.2. Fasting blood sugar3. Post prandial blood sugar4. Urine – microscopic, albumin, sugar.RESEARCH DESIGN The randomly selected patients were divided into two groups, each having 15patients. A comparative study based on the pre-test and post-test design was undertakenwith following two groups.GROUP A:- Group A consist of patients with standard Ayurvedic drug treatment withAsanadigana Kashaya 30 ml twice daily before food and Nisha-Amalaki tablet 2 tab.twice a day for period of two months. The patients were asked to follow the exercise anddiet recommended.GROUP B:- Group B patients were asked to follow the same line of treatment as in Group Aalong with the exercise and diet recommended in Group A. Addition to this the patientsin Group B were given a nutritional compound prepared from various Pathya Ahara. The nutritional compound was prepared in the form of granules and wasadministered to the patients 15gm twice a day with warm water before food for a periodof one month.The patients were provided with standard diet chart which was similar to all the patients.
ASSESMENT CRITERIA Efficacy of treatment was assessed in the reduction of signs and symptoms beforeand after the course of study with the help of self-graded assessment scale. Changes inthe following symptoms were noted & taken for assessment. (1) Fasting Blood sugar (2) Post Prandial Blood Sugar (3) Fasting Urine sugar (4) Post Prandial Urine sugarPippasa:-Normal thirst up to 1.5 liters per day 0Feels thirsty up to 2 liters per day 1Feels very thirsty 3 liters per day 2Always thirsty more than 3 liters per day 3Kshuddha:-Normal timely manifestation /can control hunger 0Slightly increased/Can control hunger up to 1 hr. 1Excessive hunger / cannot withstand 2Feels hungry even after consuming food 3Mutra Vega:-Frequency of Micturation at night 0-1 0Frequency of Micturation at night 2-3 1
Frequency of Micturation at night 4-5 2Frequency of Micturation at night more than 5 3Karpadadaha:-No burning sensation in hands or feet 0Occasional burning sensation in hands or feet 1Frequent burning sensation in hands and feet 2Persistent/continuous burning sensation 3Daurbalya:-No weakness 0Feels tiredness after strenuous work 1Feels frequent tiredness even after mild work 2Always associated with tiredness 3Sweda:-No sweating 0Profuse sweating after hard work 1Profuse sweating even after mild work 2Sweating even at rest 3FOLLOW UP OF THE STUDY Patients were asked report once in 15 days from the starting of the course of thestudy for a period of two months.
OBSERVATIONS A clinical study was conducted in 30 patients who were classified into 2 groups,15 patients kept as control group (Group A) and 15 in trail group (Group B). Each andevery case was studied as per age, sex, socio-economic status, religion, occupation, etc.All the data is presented in the form of tables. Signs and symptoms are studied forimprovement in individual factors and the results were subjected to statistical analysis. Table 13 Showing Age wise distribution Age group Group-A % Group- B % Total % 25-30 00 00 01 6.67 01 3.33 30-35 01 6.67 00 00 01 3.33 35-40 00 00 02 13.33 02 6.67 40-45 04 26.67 00 00 04 13.33 45-50 00 00 04 26.67 04 13.33 50-55 03 20 04 26.67 07 23.33 55-60 07 46.67 04 26.67 11 36.67 Among both the groups out of 30 patients 11 [36.67%] were in age group of 55-60 years, 07 patients [23.33 % ] in the age group of 50-55 years, and 04 patients [13.33 %] in the age group 45-50 and 40-45 each, 02 [6.67% ] in age group of 35-40, and 01 [3.33 %] each in 30-35 and 25-30 age groups.
Table 14 showing the sex ratio of both the groups Sex Group A % Group B % Total % Male 12 80 8 53.33 20 66.67 Female 03 20 7 46.67 10 33.33 Total 15 15 30Out of 30 patients 20 [66.67 %] patients were male and 10 [33.33 %] patients were of female sex. Table 15 shows Religion wise distribution Religion Group A % Group B % Total % Hindu 14 93.33 15 100 29 96.67 Muslim 01 6.67 00 00 01 3.33 Total 15 15 30 Out of 30 patients 29 [96.67 %] patients belongs to Hindu and 01 [3.33%] patients belongs to the Muslim religion.