International Journal of Medical and Pharmaceutical Sciences

CRITICAL APPRAISAL OF MEDICAL NUTRITION THERAPY IN AYURVEDA FOR DIABETES MELLITUS

Gupta Archana, Byadgi P.S.

IJMPS
Vol 02 issue 02 Category: Review Received on: 31/12/11 Revised on: 23/01/12 Accepted on: 10/02/12

Department of Vikriti Vigyan, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi Corresponding author E-mail: psbyadgi@rediffmail.com

ABSTRACT
Diabetes mellitus is a disease as old as humanity and is one of the major problems in clinical practice even today. To tackle this disease, the physician should identify a target level of glycaemic control for each patient and provide the patient with the educational and pharmacologic resources necessary to achieve this level. The first line of therapy in a patient with suspected type 2 Diabetes involves advice about dietary and life style modification. This can help achieve adequate glycaemic control in approximately 50% of the patients; while anti diabetic drugs will be required in 20% to 30% and insulin in the rest. Thus, patient education should be viewed as a continuing process with regular visits for reinforcement. Amongst all the available therapies for diabetes mellitus, Ayurveda is the oldest. Ayurvedic approach towards diabetes and all other diseases is that they are caused by doshic imbalance. Still, the speciality in the management of Diabetes (prameha) through Ayurvedic approach is that it has described the complete change of life style for the patients along with dietary modifications and drugs. In Ayurveda, the management of any disease (including prameha) is based on the individuals constitution or Prakriti and the line of treatment chosen according to the individuals strengths (bala) assessed by the various parameters of rogi pariksha and the strength of the disease (roga bala). These points are analyzed by observing the following various parameters such as Charakokta dashavidha pariksha, Sushrutokta dwadashavidha pariksha etc to name a few i.e. prakriti, vikriti, satwa, satmya, ahara etc.. Based on these factors, the management is individualized for each patient with drugs, diets and life style modification. Thus, it is attributed the combined use of these three factors described in Ayurveda, will produce very significant metabolic advantages for the prevention and treatment of diabetes and its complications.

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International Journal of Medical and Pharmaceutical Sciences

Keywords type 2 diabetes (prameha/madhumeha), doshic imbalance, fibric diet, life style modification, Yava, Barley, amalaki, mudga INTRODUCTION The first line of therapy in a patient with suspected type 2 Diabetes involves advice about dietary and life style modification. This can help achieve adequate glycaemic control in approximately 50% of the patients; while anti diabetic drugs will be required in 20% to 30% and insulin in the rest. Thus, patient education should be viewed as a continuing process with regular visits for reinforcement (1) .Thousands of years ago, Ayruveda has discussed, about diabetes & clearly defined it. DM was known to by the name Asrava (Prameha)/Madhumeha, since Indian civilization which started from Vedic period. In spite of advances in modern sciences, Diabetes has been a global problem. WHO has projected that 346 million people worldwide have diabetes. In 2004, an estimated 3.4 million people died from consequences of high blood sugar. More than 80% of diabetes deaths occur in low- and middle-income countries. Death due to diabetes will double between 2005 and 2030. Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of type 2 diabetes (10). In Ayurveda, madhumeha is also included as a Maharoga (major disease) that means this disease affects all parts of the body & the physiology of each cell. It also disturbs five sheaths of the bodyannamaya kosha[Food sheath], pranamaya kosha[Energy sheath], manomaya sheath[Mind sheath], vijnana maya kosha[Intellectual sheath], and anandamaya kosha[Bliss sheath](3) . In Ayruvedic texts, the full description about Prameha has been described by Charaka Samhita, Sushruta Samhita, Astanga Sangraha & Hrudaya, Hareeta Samhita. Prameha defined as a group of Urinary disorders, which are characterized

by profuse urination with several abnormal qualities. These are classified into twenty types. According to the predominance of doshas (three humours that governs the human body), they are classified as follows: Vataja PramehaFour subtypes, Pittaja Pramehasix subtypes, Kaphaja Pramehaten subtypes. The fundamental principal of Ayurveda states that to keep the normal state of functioning of the body, these three doshas (V, P, K) must be present in a proper balance within the body. If even one of doshas is vitiated, than it can lead to diseases, and Prameha is one of them. In Charaka Samhita, another classification of Prameha has been described, as of 2 types: Sahaja: due to genetic factors, can be compared with type 1 DM, mostly seen in lean individuals and Apathya Nimittaja: due to unwholesome diet & life style, can be compared with type 2 DM, mostly seen in obese individuals. ETIOPATHOGENESIS The word Prameha refers to the dilution of everything in the body, not only urine. The two main cause of Prameha are lack of exercise and excessive consumption of food having Ushna, Snigdha & Guru Nature, that increases Kapha, Medhas & Mootra, which are the major factors for Prameha: Yashcha kinchith vidhiranyepi sleshma medho moothra samjananam sa sarva: nidana vishesha(4). Diabetes, when considered according to Ayurveda, is a kaphaja metabolic disorder in which there is diminished functioning of agni leading to a tendency toward high blood sugar. Its unique assessments states that the disease occurs when toxins get accumulated in the tissues and causes circulation blockage. In charaka samhita the causes of Prameha have been described as follows: AsyasukhamSvapnasukham dadini Gramyaudakanooparsah payamsi Navannapanam gudavaikrutamcha pramehahetuh kaphakruccha sarvam(5) . Asyasukha means happiness of tongue, i.e. mostly eaten food is sweets, salty & sour in taste. According to Ayurveda healthy food

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International Journal of Medical and Pharmaceutical Sciences

should contain all the six tastes viz: sweet (madhura), sour (amla), salty (lavana), bitter (tikta), pungent (katu), and astringent (kashaya) But if only one taste like sweet is prominent in the diet, it can increase kapha & medas (fat) and causes prameha. The term Swapnasukham refers to the day time sleeping immediately after meals for more than 30 min &sleeping more at night. It also means that not living an active life with good amount of exercise & sports. The type of food & drinks likely to precipitate the prameha have been mentioned in all the classical Ayurvedic texts as everyday consuming yoghurt & other milk products in large quantity; excessive use of the meat of pig, fish, buffalo, beef ; Fresh grains (non-aged rice, millet, wheat etc); Fresh wine (it causes heaviness & imbalances the tridoshas whereas old wines promote circulation in the body and increases digestion). Hence, in this fast modern world, most people do not bother about the specific details for the consumption of new rice and other cereals, with the result being the increasing number of diabetics in the world. In Ayurveda there is lot of information available regarding the food materials. Traditionally, people in the various part of world consumed one year old grains and never consumed fresh grains unless during drought. This was because they were aware about the fact that it predisposes them to prameha. The description of this acquired form of prameha; refers to as Apathyanimittaja prameha(6), which is very similar to that of type 2 diabetes. Thus, we found that these factors (dietary, life-style, psychologic) which are briefly listed below are responsible for the onset of prameha:-dietary factors- excessive consumption of food that are heavy to digest like cold, sweet, sour, unctuous(oily), liquid & slimy foods; life style factors excessive sedentary life style, excessive sleeping, sleeping during the day time, leak of exercise & laziness; phychologic factors Excessive stress, disturbance in mental health caused by extremes of phyche such as depression (Vishada) and bipolar

disorders; Another important etiological factor is related to the Prakriti of body, which is the psychophysiologic constitution of an individual & is determined at the time of birth by the individuals dosha proportions. The Prakriti of an individual plays an important role in progression & prognosis of the diseases and response to treatment. The doshic manifestation of the disease process is also affected with the predominant doshas in the individual Prakriti. In a study conducted on Prakriti & diabetes mellitus, it was hypothesized that the progression of disease is test in diabetic patients with kaphaja Prakriti (i.e. Prakriti in which kapha dosha is the dominant) and vataja Prakriti also has quick progression. These values are moderate in the case of patients with pittaja Prakriti. Ayurvedic Management of Diabetes The drastic disease diabetes can be controlled by giving comprehensive attention to 3 aspects. They are Ahara (Diet), Vihara (life style modifications) and Aushadha (medicine). The role of Ahara & Vihara are equally or even more important in diabetes to control blood sugar level as well as to prevent complications of this disease. In a patient with suspected type 2 diabetes mellitus, the first line of therapy involves advice about dietary & life style modifications. It has been observed that exercising increased the bodies sensitively to insulin, thus controlling blood sugar elevations. AHARA (DIET): - In a diabetic patient, always a balanced diet should be maintained and the intake of food products which are having katu, tikta & kashaya tastes should be increased because these are generally considered good. A balanced diet which is ideal for diabetes are low in fat, carbohydrates and cholesterol. The foods having high glycemic index like potatos, junk food like pasta & while bread, which are rich in carbohydrates, must be avoided because they easily enter into the blood stream and get converted to glucose very fast. The intake of fast food, bakery items & calorie rich soft

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International Journal of Medical and Pharmaceutical Sciences

drinks give remarkable rise to blood glucose level which stimulated the beta cells of pancreas of secrete more insulin. As the person ages, the capacity of production of insulin comes down. Insulin resistance is associated with dyslipidimias, obesity & sedentary daily routine. A resistance to insulins action lead to hyperglycemia & associated symptoms. In an attempt to overcome the resistance to insulin, the pancreas is stimulated to release large amount of insulin. As the person ages the islets of langerhans cannot keep up pace with increased insulin secretion and the person becomes hyperglycemic. Hyperglycemia is itself toxic to beta cells of pancreas which further reduce insulin secretion. So in the diabetic patients such diet is preferred which is having low glycemic index. Person should try eating 4 5 small meals in a day rather than three large meals and drink at least 8 glasses of water a day to flush out those harmful toxins from the body and to keep healthy. In all Ayurvedic classics, the group of pathya Ahara dravyas are described in detail & they cover all the food group noted in the following table; CerealsYava, Barley {Chenopodium Album}, Godhooma(Wheat), Shyamaka, Kodrava, Bajara PulsesMudga {Green gram}, Chanaka {Gram}. VegetablesTikta shakas, Methika, Nimba{Azadirachta Indica}, Karavella{Momordica charantia}, Patola {Trichosanthas Anguina}, Rasona{Garlic}, Udmbara{Ficus racemosa},Broccoli, Beans, Asparagus, Green leafy vegetables. FruitsJambu {Black berry}, Syzygium cumini, Tala phala {Borassus flabellifer}, Kharjura {Phoenix sylvestris}, Kamala {Nelumbo nucifera}, Utpala {Nymphoea Stellata}, oranges, pears,apples. FleshHarinaDeer flesh, ShashakaRabbit, Birds like Kapotha, Titira Liquor, Old sura {Old wine}. OilsMustard, Ingudi {Balanitis aegypotiaca}.

Life Style Modifications (Vihara):- Life style contributes a lot in health and disease. DM is a disease which is positively interlinked with lifestyle. A study shows that a person with high levels of physical activity, a healthy diet, no smoking habits , and alcohol consumption in moderation had an 82% lower rate of diabetes. Obesity & physical inactivity has been found to contribute to approximately 55% of cases of type 2 diabetes. An Ancient Indian life style consists different cultural and religious activities and daily regimens responsible for loss of extra calories taken by an individual. In Sushruta Samhita(6), about treatment it is written that a type 2 DM patient should walk barefoot for 800 miles in a year (AV. 3.5 km/day) or do heavy work like digging a well etc. Physical exercise results in lightness in the body, stability of the organs, increased pain endurance, balances the doshas by normalizing the metabolism. Yogic postures and Pranayama (breathing exercise) also play an important role in control of DM. Ayurvedic life style consists of various health promoting & protective measures. Maintenance of a healthy life by ones own right action is called Swasthavritta which literally means the regime of obideing in ones own nature. According to Ayurveda one should observe certain disciplines or duties to achieve a healthy and happy life. Some of them are daily regimen (Dinacharya), seasonal regims (ritucharya), precautionary observance in sexual activity (brahmacharya), rules of conduct for the wellbeing of oneself and the society (sadavritta), rules for taking food (ahara vidhi), precautionary measures against untimely old age (rasayana & vajikarana), conduct & practice to achieve self realization (naisthiki chikitsa). Ayurveda outlines practices to be done on a daily basis as indication of timely sleep & rise, regular light exercise which makes the body proportionate in shape & improves function of agni which is responsible to balance the doshas of body.

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International Journal of Medical and Pharmaceutical Sciences

In this manner, Ayurveda is not only restricted to drugs for the treatment of diabetes but takes a much broader perspective. Ausadha (Drugs): - In Ayurveda, herbs are mentioned which help to control the increased blood sugar include(7) Amla(Phyllanthus emblica), Triphala(Fruitsof haritaki, vibhitaki, amalak), Asana(Pterocarpus marsupium), Guduchi (Tinospora cardifolia), Arjuna(Terminalia arjuna), Methika(Trigonaella foenugraecum), Haridra(Curcuma Longa), Khadira(Acacia catechu), Musta(Cyperus rotendus), Aristaka(Azadirachta indica), Gokshura(Tribulus terrestris), Saptarangi(Casearia esculenta), Karela (Momardica charantia), Bhunimba(Andrographis paniculata), Meshashrungi(Gymnema sylvestrae), Jambu(Syzygum cumini), Daruharidra (Berberis aristata), Mamajjaka(Enicostemma littorale), Shilajith, Guggul etc. The various combinations of these drugs are used for the management of diabetes mellitus. CONCLUSION The world health organization (WHO) states that about 346 million people worldwide suffer from diabetes. Ayurveda has a major role to play in this scenario because it offers natural remedies and treatments with no side effects. The most common problem in a diabetic patient is general body weakness and a deterioration of the major organs as eyes, kidneys etc. in due course of time inspite of good glycaemic control by the modern medicines. Ayurveda can have its role here, because it has still not been assessed that what effect do these Ayurvedic medicines and life style management have an these long term complications. Although studies have been carried out on various Ayurvedic regimens for the management of diabetes in different parts of the country which have given very positive results, no such long term study on incidence of complications after Ayurvedic management has been conducted but in the need of the

hour. It is further stressed here that Ayurveda addresses the individual as a whole and its management therapy is also based on the same principle of overall improvement of the individual. This is the reason why thousands of years back they understood the implication of lifestyle modification in this disease and envisaged it along with ahara and aushadha. This holistic approach of Ayurveda for the management of Diabetes demonstrates the in depth and scientific knowledge of this science which should be practiced in the field to reap benefits to large number of people suffering from this dreaded disease. REFERENCES 1. Davidsons principles &practice of Medicine, edited by Nicki R. colledge, Brain R. walker, Stuart H.Ralston; Churchill Livingstone Elesevier; 21st edition. 2. Ayurvedic Concept of Diabetes Mellitus (www.diabetesmellitusinformation.com/Ayurveda-diabetes mellitus.htm) 17 nov 2010 3. Ayurvedic Management of Diabetes Mellitus; Dr CS Krishna Kumar, Chief Physician, Nagarjuna Ayurvedic Group, Kalayanthani,Thodupuzha, email: nhcltdpa@md5.vsnl.net.in:Dr K Krishnan Namboodiri, Chief Physician, Nagarjuna Ayurvedic Centre, Kalady, Okkal 683550, email: nagarjuna@vsnl.com . 4. Byadgi P.S. Prameha, In Parameswarappas Ayurvediya VikritiVijnana & Roga vijana, Volume 2, Reprint. Varanasi, India: Chowkhamba Prakasan; 2009; 355. 5. Agnivesha. Prameha chikitsa, In Acharya Trikamji Jadavaji. Charaka Samhita (Charaka and Dridhabala with Chakrapani), Reprint. Varansi, India: Chowkhamba Prakahsan; 2007; 242. 6. Sushruta. Pramehachikitsum, In Ayurveda-Tattva Sandipika. Susruta Samhita (by Kaviraja Ambikadutta

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International Journal of Medical and Pharmaceutical Sciences

Shastri), Reprint. Varanasi, India: Chowkhamba Prakahsan; 2007; 62. 7. Diabetes Mellitus in Ayurveda, ancient diagnostic methods, its treatment in Ayurveda & lifestyle (ayurvedasara-dr shivakumar blog,,ayurvedasara.com/content) 8. American Journal of Clinical Nutrition, Vol. 78, No. 3, 610S-616S, September

2003; American Society for Clinical Nutrition 9. Effectively Treat Diabetes With Ayurveda; www.cdc.gov/diabetes. 10. Diabetes, World Health Organization http://www.who.int/mediacentre/factsheets /fs312/en/index.html

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