AYURVEDA:

POTENTIALS TO ACCEPT CHALLENGES OF DIABETES MELLITUS

Prof. (Dr.) K.R. Kohli

M.D. (Ayu.) Ph.D.
Director of Ayurved Govt. of Maharashtra Ex-Director, Dabur Research Foundation
Ex. Dean- R.A. Podar Ayu. Medical College Ex. Consultant W.H.O. for Traditional Medicine

Medical disasters
Since the first major Drug- related disaster involving the elixir of Sulfanilamide in 1937, which killed 107 children, there have been several cases of severe adverse reactions and even deaths, eg., Thalidomide in 1961, Practolol in 1974, Benoxaprofen and Phenformin in 1982 and several others, leading to withdrawals and banning of these drugs. Since 1993 , seven other drugs were withdrawn from the market due to fatalities and unacceptable side-effects.

D I A B E T E S

History of Diabetes
Charaka and Sushruta described the disease under the name of 'Prameha' aptly 3000 years B.C. The references to disorders with polyuria are found in Egyptian papyrus (1500 B.C.). The Chinese physicians, Neijing (400 B.C.) and Celsus (30 B.C. 50A.D) of Greece have described the important symptoms of the disease.
Aretaeus named the disease as 'Diabetes' in second century A.D., as he perceived that the condition was characterized by "Melting down of flesh and limbs into urine."

History of Modern Diabetes

Arabian physicians described diabetes around 1000 A.D. Claude Bernard (1850) was the first to note hyperglycemia as a cardinal feature of Diabetes.

Descriptions of the islet cells of 'Langerhans' (1869), production of Diabetes by pancreatectomy by Van Mering and Minkowski (1889) and detection of islet cells lesion in Diabetes in 1901 were followed by successful extraction of insulin by Banting and Best (1921). (Extraction From Bovine Pancreas)
Oral hypoglycemic drugs invented by Frank and Fuchs (1955) simplified the management of NIDDM

PREVENTING DIABETES
FACTS
DIABETES IS SPREADING LIKE AN EPEDEMIC DIABETES SPARES NO ORGAN CARE TODAY WILL HELP US TOMORROW

RISK FACTORS
Positive family history of diabetes Age of 35 years. Over weight, and have gained weight recently. Sedentary life style and lack of exercise Bad obstetric history

WHY DIABETICS NEED CARE?

High incidence: 1 out of 20 persons diabetic 2 times more prone to AMI 5 times more prone to Gangrene 17 times more prone to kidney damage 25 times more prone to blindness No.1 cause of blindness in the developed countries. 2 to 6 times more prone to strokes Incidence of cataract high in Diabetics

195%increase by 2025.

Types of Diabetes
1. Type I Diabetes Mellitus(Insulin Dependant DM)

2. Type II Diabetes Mellitus (Non-insulin Dependant DM) 3. Gestational Diabetes

Prameha as Found in Ayurvedic Texts

In Charak Samhita - Nidana Sthan. The treatment part, prognosis and various formulations, controlling the disease Charak Chikitsa Sthan. "Santarpanjanya Vyadhi" Charak Sushruta - fifth chapter of Nidana Sthan and in eleventh chapter Chikitsa Sthan.

Importance to the Genetic factor.

Separate Chapter on Madhumehs.

Etiological Factors
Apathyakar Aahar (Dietary factors)
CURD, MEATS, MILK & ITS PRODUCTS NEW GRAINS, PRODUCTS OF JAGGERY

Apathyakar Vihar(Behavioral factors)

LEADING A LUXURIOUS LIFE (ASYASUKHAM) EXCESSIVE SLEEP (SWAPNASUKHAM)

Genetic Factors in Diabetes as per Ayurveda

Hereditary & Familial
- Beej(Seed) =Sperm - Beej bhag(fraction of seed) = chromosomes - Beej bhagavyava(smallest fraction of fraction) = genes

Prodromal & Presenting Symptoms of Prameha

Excessive growth of nails and hairs. Sweet taste in the mouth. Dryness of palate and throat. Thirst . Attraction towards cold objects. Presence of excessive Malas all over the body.

Honey like urine. Greasiness and numbness over body. Excessive sleep. Fatigue. apathy. lack of pleasure etc. Attraction of Ants over the urine.

Burning sensation in hands and feet.

Pathogenesis of Prameha
Dosha(Humors):Tridoshas i.e., Vata, Pitta, Kapha
( Kaphapredominant )

Dushyas (Affected body tissues ) :

Fatty tissues, blood, Semen, Body fluids, Lymph, Bone marrow, Ojas, Plasma, Muscle tissue, Fluidity in the body

Srotas(Channels): MEDOVAHA , MUTRAVAHA

Pathophysiology of Prameha
NIDAN SEVAN
DOSHA PROPAK & DATHU SAITHALAYA BAHU DRAVATA OF KAPHA DEHA SANCHAR MIXES WITH VITIATED MEDA, KLEDA DRAVA DATHUS CONVERT TO MUTRA KSHARAN VIA MUTRAVAHA STROTASA DHATUKSHAYA MADHUMEHA

PRAMEHA

Classification of Prameha
ACCORDING TO DOSHA- Vataja-4, Pittaja-6,Kaphaja-10.

ACCORDING TO ETIOLOGY
- Dietary, Congenital, Familial

ACCORDING TO MANAGEMENT
- Obese (Sthula), Lean (Krisha)

ACCORDING TO PROGNOSIS
- Sadhya. Asadhya, & Yapya

Madhumeha TYPES: 2
1. Lean Diabetics from the beginning 2. Obese to begin, but later become lean

Prognosis of Prameha/Madhumeha
Kaphaja(Obese)- Curable, Pittaja(Medium)- Palliative, Vataja(Lean)-Incurable Hereditary & Familial Incurable Extreme weightless(Kaphaj Pittaja Vataja Madhumeha): INCURABLE Involvement of fatty tissue, muscles, lymphatics, nerves, & blood vessels

Complications of Diabetes as per Ayurveda

FOR ALL TYPES

Excessive thirst Diarrhea Burning sensations all over body Extreme weakness Indigestion Loss of appetite Foul smelling abscesses/ulcerations

Prameha Upadravas
Vataja Prameha

Pittaja Prameha

Kaphaja Prameha

Desired Treatment of Diabetes

Treat the fluidity of tissues (Bahudravata of Kapha) Make tissues stable (Treat Dhatu Shaithalaya)
Check wasting and flowing of tissues (Dhatu Ksharan) Strengthen the apparatus responsible for formation and flow of urine (Mutravaha Strotasa) Rebuild the deficient tissues (Dhatus)

Stages For Intervention With Ayurvedic Medicines

Newly diagnosed mild to moderate diabetic mellitus. Non Insulin Dependant Diabetes. Post prandial Blood sugar below 350-400 mgm%. Obese Diabetics. Those in whom there is a secondary failure: in such cases Ayurvedic drugs can be combined to their regular hypoglycemic agents. Uncomplicated Diabetes mellitus. Complications need to be assessed by modern means, although some good remedies are available for early nephropathies, neuropathies and retinopathies.

Some Herbs Extensively Used & Researched for Diabetes

Jamun beej churna (Eugenia jambolana) Gudmar patra churna (Gymnema sylvestre) Vijaysar kashtha churna (Pterocarpus marsupium)

Nyagrodha Twak (Ficus bengalensis) Methi seeds (Trigonella foenum-graecum)

Karvellaka (Momordica chirantia) Haridra (Curcuma longa)

DIABETES AND AYURVEDA

Prof. Kohli

PROGNOSIS OF PRAMEHA/MADHUMEHA Kaphaja(Obese)- Curable, Pittaja(Medium)- Palliative, Vataja(Lean)-Incurable Hereditary & Familial Incurable Extreme weightloss(Kaphaj Pittaja Vataja Madhumeha): INCURABLE Involvement of fatty tissue, muscles, lymphatics, nerves, & blood vessels

Line of treatment
1) Snehanam External & Internal 2) Shodhanam
Vamanam Virechanam Basti

3) Shamanam 4) Pathya Apathyas 5) Vyayamam (exercises)

Some herbs used for Diabetes

Jamun beej churna Gudmar patra churna Vijaysar kashtha churna Nyagrodha (Vat) Fenugreek seeds (Methika churna) Karvellaka(Karella) Amala Haridra Kirat tikta

GYMNEMA SYLVESTRE

Gymnema
Researches show that Gymnema lowers the blood glucose by following mechanisms It appears to correct the metabolic derangements in diabetic rabbit liver, kidney and muscle. This herbal therapy appears to bring about blood glucose homeostasis through increased serum insulin levels provided by repair/regeneration of the endocrine pancreas. Gymnema therapy appears to enhance endogenous insulin, possibly by regeneration/revitalisation of the residual beta cells in insulin-dependent diabetes mellitus.. studies suggest that the component of Gymnema sylvestre inhibits the increase in the blood glucose level by interfering with the intestinal glucose absorption process

Gymnema
Gymnema sylvestre stimulates insulin release in vitro by increased membrane permeability. Persaud SJ, Al-Majed H, Raman A, Jones PM. Suppression of glucose absorption by extracts from the leaves of Gymnema inodorum. Shimizu K, Ozeki M, Tanaka K, Itoh K, Nakajyo S, Urakawa N, Atsuchi M. Beta cells may be regenerated/repaired in Type 2 diabetic patients on GS4 supplementation. This is supported by the appearance of raised insulin levels in the serum of patients after GS4 supplementation. J Ethnopharmacol 1990 Oct;30(3):295-300 Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.

PTEROCARPUS MARCIPIUM BARK

 An active constituent of Pterocarpus marsupium, (-)-epicatechin (1) in,low doses, has been reported to reverse hyperglycemia in alloxan diabetic rats when given before or within 24 hr after the dose of alloxan. The antihyperglycemic activity of ethanolic extract of Vijaysara bark at the dose of 0.25 g/kg b.w. was found to be more effective than that of glibenclamide and metformin. Vijayasar is useful in the treatment of newly diagnosed or untreated mild NIDDM patients Indian J Med Res 1998 Jul;108:24-9

VIJAYSAR

Jamun Beej

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF G.SYLVESTRE (GUDMAR PATRA) ON SYMPTOMS OF DIABETES MELLITUS

RATE OF SHIFT OF GRADES OF LOSS OF LIBIDO
6

5 4

3 2

1 0 INITIAL AFTER 4 WKS. GRADE 1 AFTER 8 WKS. AFTER 12 WKS. GRADE 2 GRADE 3

GRADE 0

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF G.SYLVESTRE (GUDMAR PATRA) ON SYMPTOMS OF DIABETES MELLITUS

RATE OF SHIFT OF GRADES OF POLYDIPSIA
14 12 10 8 6 4 2 0 INITIAL AFTER 4 WKS. GRADE 1 AFTER 8 WKS. AFTER 12 WKS. GRADE 2 GRADE 3

GRADE 0

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF G.SYLVESTRE (GUDMAR PATRA) ON SYMPTOMS OF DIABETES MELLITUS

RATE OF SHIFT OF GRADES OF WEAKNESS
14 12 10 8 6 4 2 0 INITIAL AFTER 4 WKS. GRADE 1 AFTER 8 WKS. AFTER 12 WKS. GRADE 2 GRADE 3

GRADE 0

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF G.SYLVESTRE (GUDMAR PATRA) ON SYMPTOMS OF DIABETES MELLITUS

IMPROVEMENT IN MEAN GRADE SCORES OF POLYURIA

2 1.8

GRADE SCORES

1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 INITIAL AFTER 4WKS. AFTER 8WKS. AFTER 12 WKS.

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF POWDERS OF E.JAMBOLANA, P.MARSUPIUM & G.SYLVESTRE ON F.B.SUGAR REDUCTION

250

B L O O D S U G A R

200
INITIAL 4 WKS

150

8 WKS 12 WKS

100

I N
M G M %

50

0
INITIAL 4 WKS 8 WKS FBS(EJP) 12 WKS FBS(GSP)

FBS(PMP)

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF POWDERS OF E.JAMBOLANA, P.MARSUPIUM & G.SYLVESTRE ON P.P.B.SUGAR REDUCTION

350 300
INITIAL

B L O O D

250 200 150

4 WKS

8 WKS 12 WKS

S U G A R

100 50 0
PPBS(PMP) PPBS(EJP) PPBS(GSP)

Jamun & Nyagrodha

Hypoglycemic activity of Eugenia jambolana and Ficus bengalensis: mechanism of action. Achrekar S, Kaklij GS, Pote MS, Kelkar SM. Biochemistry Division, Bhabha Atomic Research Centre, Bombay, India.

FICUS BENGALENSIS

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF FICUS BENGALENSIS ON FASTING & P.P.B.SUGAR REDUCTION

PPBS FBS

350
B L 300 O O D

INITIAL 4 WKS 8 WKS 12 WKS INITIAL 4 WKS 8 WKS 12 WKS

250
S U 200 G A R

I N

150

M 100 G M % 50

KARELA: Momordica charantia

KARELA
Diabetes Res Clin Pract 2001 Mar;51(3):155-61 Hypotriglyceridemic and hypocholesterolemic effects of anti-diabetic Momordica charantia (karela) fruit extract in streptozotocin-induced diabetic rats. Ahmed I, Lakhani MS, Gillett M, John A, Raza H. These results suggest that M. charantia fruit extract exhibits hypolipidemic as well as hypoglycemic effects in the STZ-induced diabetic rat.

KARELA
Bangladesh Med Res Counc Bull 1999 Apr;25(1):11-3

Effect of Momordica charantia (Karolla) extracts on fasting and postprandial serum glucose levels in NIDDM patients. Ahmad N, Hassan MR, Halder H, Bennoor KS.
Department of Pathology, Sher-e-Bangla Medical College, Barisal.

This hypoglycaemic action was observed in 86 (86%) cases The results indicated that there was a significant (Student's t-test, P < 0.004) increase in the number of beta cells in M. charantiatreated animals when compared with untreated diabetics, however, their number was still significantly less than that obtained for normal rats.

Karela is the well-known plant as an anti-diabetic. Its mode of action is studied intensively in last several years. It shows Orally administered karela extracts shows lower glucose concentrations independently of intestinal glucose absorption and involve an extrapancreatic effect. Momordica charantia extract lowered blood glucose by depressing its synthesis, on the one hand through depression of the key gluconeogenic enzymes glucose-6phosphatase and fructose-1, 6-bisphosphatase and on the other by enhancing glucose oxidation by the shunt pathway through activation of its principal enzyme G6PDH. The mechanism of action of M. charantia could be partly attributed to increased glucose utilization in the liver rather than an insulin secretion effect. Oral feeding of M. charantia fruit juice may have a role in the renewal of beta cells in STZ-diabetic rats or alternately may permit the recovery of partially destroyed beta cells.

KARELA

SHILAJEET

DIABETES AND AYURVEDA

Prof. Kohli

EFFECT OF SHILAJITTU ON FASTING & P.P.B.SUGAR REDUCTION

PPBS FBS

350
B L O O D

300

INITIAL 4 WKS

250

8 WKS

S U G A R

200
INITIAL 4 WKS 8 WKS

150

I N
M G M %

100

50

METHI
Effect of Trigonella foenum graecum (Fenugreek) on blood glucose in normal and diabetic rats. Khosla P, Gupta DD, Nagpal RK. Department of Pharmacology, Pt. B. D. Sharma Medical College, Rohtak. Trigonella foenum graecum (Fenugreek) was administered at 2 and 8 g/kg dose orally to normal and alloxan induced diabetic rats. It produced a significant fall (P < 0.05) in blood glucose both in the normal as well as diabetic rats and the hypoglycemic effect was dose related.

METHI
Hypoglycaemic and antihyperglycaemic effects of Trigonella foenum-graecum leaf in normal and alloxan induced diabetic rats. Abdel-Barry JA, Abdel-Hassan IA, Al-Hakiem MH.
Department of Chemistry, College of Science, University of Basrah, Iraq.

DIABETES AND AYURVEDA

Prof. Kohli

COMPLICATIONS OF DIABETES AS PER AYURVEDA

FOR ALL TYPES

EXCESSIVE THIRST DIARRHOEA BURNING SENSATIONS ALL OVER BODY EXTREME WEAKNESS INDIGESTION LOSS OF APPETITE FOUL SMEELING ABSCESSES/ULCRATIONS

DIABETES AND AYURVEDA

Prof. Kohli

PRAMEHA UPADRAVA. (DIABETIC NEUROPATHY)

Generalised weakness Weakness of limbs Numbness of a part burning sensation of the hands & feet Pain in a particular part of the body. Pain in the region of the bladder & genitals Tremors Chronic constipation Impotency Diabetic Ulcers. (Carbuncle)

DIABETES AND AYURVEDA

Prof. Kohli

VASANT KUSUMAKAR RAS

Swarna(gold) 6.89% Roupya(silver) 6.89% Abharak(mica) 13.79% Parad(mercury) 13.79%
Naga(lead) 10.34% Vanga(tin) 10.34% Loha(iron) 10.34% Praval(red coral) 13.79% Mouktik(pearls) 13.79%

SENSORY NEUROPATHY

A palace seen from a normal eye

A palace seen from a Diabetic eye

A Clinical evaluation of Nishadiyoga in Diabetic Retinopathy

Dr. Sanjay Nipanikar M. D.(Ayu)
Group Leader Medical Services, Tulip Lab Pvt. Ltd.

Prof. K. R. Kohli M.D. (Ay), Ph.D

Director- Ayurveda, Govt. of Maharashtra

Aims and Objectives of the Study

To evaluate the effect of Nishadiyoga on symptoms of visual impairment in cases of Prameha Upadrava with special reference to Diabetic retinopathy.

Materials and Methods

Type of Study: Open Uncontrolled
Number of Patients: 30 Patients

Study Center: M. A. Podar Hospital and Drishti Eye and Retina Center, Opera House, Mumbai.
Dose: Two tablets each of Weighing 500mg twice daily on empty stomach.

Duration of Treatment: 3 months Diet: whatever advised for effective control of Diabetes was prescribed.

Inclusion Criteria
Established cases of Diabetic retinopathy were

selected.
Patients of both sexes and age between 25 to 70

years were selected in the trial.

Good glycemic control (HbA1c < 7) of patients

selected in the trial was maintained through out the period of trial.

Exclusion Criteria
Patients having retinal detachment and retinal injury requiring immediate medical and /or surgical intervention were not included in the study. Patients with history of previous surgery for ophthalmic cause were excluded. Patients with renal failure, Pulmonary tuberculosis, liver disorders, Pregnancy and lactation were not included in the trial.

Patients with other types (Hypertensive Retinopathy).

of

retinopathy

Assessment of Patients
CBC, Hb % and ESR, Urine examination BUN, BUL, Serum Creatinine and Glycosylated Hb% was done at the starting and at the

end point of study.

Blood sugar (Fasting and Post Prandial) and urine sugar

was done after every 4 weeks.

Although fundoscopy was done at monthly intervals,

fundus photographs and vision test for Diabetic retinopathy was performed at entry and at the end of study.

The Screening Process

Fundoscopy with dilated pupils Dilatation of Pupils with Tropicamide solution 2% Slit Lamp Examination Fundus Photography

Selection of Drug
Drug should have capacity to check Bahudravata,

Ushana and Rooksha guna of Kapha, Pitta and Vata respectively.

It should possess Sthira, Sheeta and Snigdha

Properties.
Drug should be Chakshushya i.e. beneficial for eyes. It should have properties to correct Dhatukshaitilya

and Dhatuksharan
And above all drug should have Rasayana property.

Nishadiyoga
Haridra Amalaki Haritaki Vibhitak

Nyagrodha Yashtimadhu Shatavari Musta.

Equal parts of extracts of each ingredients were taken and a tablet each of weighing 500 mg is made. M/s Zandu Pharmaceutical Ltd helped in preparation of Tablets.

Contents of Nishadiyoga

Curcuma longa

Ficus bengalensis

Terminalia belerica

Terminalia chebula

Phyllanthus embelica

Asparagus racemosus

Cyperus rotundus

Glycerrhiza glabbra

Properties of Nishadiyoga
Pramehaghna
Rasayana

Chakshushya

Pramehaghna
Majority of the contents of the drugs have

been used in many classical formulations, which are in use since long to treat Prameha Vyadhi and its Upadravas i. e. complications. Drugs like Nyagrodha, Haridra, Triphala and Mustha have proven anti-diabetic activity.

Chakshushya
The literary meaning of this word is the substance, which has wholesome action towards improving the eyesight.
The drugs with this action possess capacity to reach upto minute senses. Thus they are very potent drug and have specific site of action as Chakshu i. e. eye. Drugs like Haridra, Shatavari, Amalki, Yashtimadhu, Haritaki and Bibhitak have strong Chakshushya action.

Rasayana
Providing adequate and proper nutritious food / material to the body. Proper functioning of the Srotas where Dhatu is produced.
Proper functioning of Vata, which is responsible for the transportation of processed material

Proper functioning of the digestive power at all levels i.e. Jatharagni, Dhatavagni and Bhutagni. Proper functioning of all Indriyas.

Results

Assessment of result in 30 patients of Diabetic retinopathy

Improvement Same Worsen

18 16 14 12 10 8 6
10

17

4 2 0
Improvement Same Worsen

PATIENT NO. 1
BEFORE TREATMENT AFTER TREATMENT

Moderate to severe NPD Moderate to severe NPDR Reduced exudates and Hemorrhages, Better Improvement

PATIENT NO. 2
BEFORE TREATMENT AFTER TREATMENT

Clinically significant macular edema

BDR, Reduced exudates and hemorrhages, Better Improvement

PATIENT NO. 3
BEFORE TREATMENT AFTER TREATMENT

CSME, Reduced exudates and Focal Maculopathy Hemorrhages

PATIENT NO.4
BEFORE TREATMENT AFTER TREATMENT

BDR

BDR, Reduced Exudates.

PATIENT NO. 5
BEFORE TREATMENT AFTER TREATMENT

Severe NPDR, CSME

CSME, reduced exudates and Hemorrhages

PATIENTS NO. 6
BEFORE TREATMENT AFTER TREATMENT

Moderate to Severe NPDR, Moderate to Severe NPDR

Increased exudates, Worsen

Conclusion
This study strongly suggests that there is a (33.33%) chance of improvement in the condition of retina after 12 weeks of treatment with Nishadiyoga Ghanvati. Considering the available management in day to day practice, this management is relatively safe, easily available with greater extent of chance of recovery.

WHAT DO YOU AIM AT?

The cure of Prameha patients should be understood from the non-slimy and unturbid condition of the urine and from its clear transparent aspect and bitter or pungent taste.