Saturday, July 21, 2018

Diabetes; An Intro to the Ayurvedic Perspective


Diabetes is becoming a global problem with 450 million people diagnosed worldwide.
In 2015, 23.4 million people in the United States were diagnosed with diabetes, compared to only 1.6 million in 1958.

In Adolescents, cases of type 2 diabetes in 1980 were ZERO and cases of type 2 diabetes in 2010 were 57,638. For decades, type II diabetes was considered an adults-only condition. In fact, type II diabetes was once called adult-onset diabetes. What was once a disease mainly faced by adults is becoming more common in children. Among people under the age of 20, type I diabetes rose 23 percent between 2001 and 2009, and among all ages its Quadrupled Worldwide Since 1980. 

Ayurveda defines health as an optimal balance of the three doshas, with a healthy bio-fire, or enzymatic and digestive capacity (agni), balanced tissue metabolism and waste disposal, combined with an enthusiastic nature, clarity of sense perception and balanced mind and emotions. Thereby a healthy person is physically, psychologically, socially and spiritually sound and Ayurveda is truly a holistic medicine and way of life. (Doshic questionnaire).


To understand Ayurveda, it is important to understand the tri-doshic theory as the source of the universe and the key to elucidate the pharmacological, pathological and therapeutic factors in the treatment of diseases. (click here and scroll down for article about the doshas).


Disease is assessed based upon the person’s elemental constitution at birth or one’s genetic combination, or their dosha, as seen in their physical and psychosomatic make up, which plays a key role in the disease or healing process.

The disease we call Diabetes, can be found in Ayurvedic texts dating back over 1,000 years in the Charaka and Susruta Samhitas, where it is called madhumeha and/or prameha, which mean profuse urination, with all disorders that present with excessive urination are a type of madhumeha, and include 20 major categories, with each treated according to the doshas involved. 

Ayurveda sees madhumeha not as one disease, but as a multifaceted syndrome with various, complex metabolic disorders. It includes diabetes mellitus types I and II, and calls these prameha and includes the systems involved, the complications of the disease and the state of mind that assists in pain management. So its definition is way more intricate than the modern medical definition of this disease which only differentiates 2 main types: mellitus and insipidus.

Diabetes Mellitus and its associated disorders, is a metabolic disorder of the metabolic transformation or digestive capacity (agni). When there is a dysfunction of the agni, the carbohydrate metabolism, or the earth and water elements, are disturbed, characterized by increased blood sugar, the passing of sugar in the urine, and dysfunction and damage to the urinary system, which are the water carrying channels and is especially due to a dysfunction of the agni of the pancreas and production of insulin.

Diabetes is classified as either insulin dependent (IDD)-type I or non-insulin dependent (NIDD)-type II. Diabetes insipidus, at least in the beginning, is an imbalance of the diuretic hormone vasopressin. It is rare and occurs most often in young people.
(Ayurvedic Perspectives On Selected Pathologies, Vasant Lad, BAMS, MASc).
 

Our tissues (dhatus) have a normal level of moisture or liquid (kleda). One function of kleda is to maintain the body’s water-electrolyte balance. It also nourishes and lubricates all the tissues. It is associated with kledaka kapha in the stomach and in the spreading stage of prameha, kledaka kapha overflows from the GI tract and enters the blood plasma (rakta dhatu), and as it spreads, this kledaka kapha disturbs the kleda present in all the tissues (dhatus). The function of urine is to remove excess liquids, so when kleda is increased, urination is also increased, called polyuria, hence the profuse urination.

The first 3 stages of any disease are called accumulation (sanchaya), provocation (prakopa) and spreading (prasara). High blood sugar is described in Ayurveda as increased kapha in the rasa and rakta dhatus (circulatory and lymphatic systems). The increased kledaka from the dhatus starts leaking via the digestive system, through the kidneys and into the bladder, causing the symptoms of diabetes that occur after the dosha enters the third stage of the disease process.

During this period, one may accumulate tarter on the teeth, sticky sweat even after a bath, an increase in nasal crust, ear wax, sebaceous secretions and smegma. Excess urination, nocturnal urination, and at the end of urination the anal sphincter muscles constrict and create goose bumps. It’s common to have a sweet taste in the mouth, the breath to smell like vinegar, and the pulse becomes slow and sluggish with the stomach pulse showing a kapha spike. 

The general pathogenesis (samprapti) almost always begins with increased kapha, as seen in most of the signs and symptoms. Later, vata and pitta can enter the picture, because prameha is a complex syndrome that can involve all three doshas.

Prameha is most often due to hyperglycemia or an increased blood sugar, caused by diminished insulin production by the pancreas (kloma) due to its faulty agni. It is a chronic endocrine disorder that affects the metabolism of carbohydrates, proteins and fats as well as the water–electrolyte balance. It can cause functional and structural changes in the body’s cells, and create complications of the eyes, kidneys, nervous system and other organs.

There can be other causes of prameha, classified as kapha types of which there are 10, Pitta types 6, and vata types 4. Some are:
·Secondary condition to pancreatitis, a pitta disorder. Viral infections can create pancreatitis.
·Heredity plays a role in the destruction of beta cells in the pancreas, which can cause pancreatitis or neoplasm or tumor of the pancreas, leading to diabetes.
·A tumor of the pancreas-pitta/kapha
·Autoimmune dysfunctions-tejas (inflammation) burns ojas (immunity or antibodies) and affects the pancreas, pitta/kapha.
·Obesity, usually associated with non-insulin dependent diabetes; a metabolic disorder of kapha.
·Wrong diet, emotional overeating and excess consumption of heavy, damp and cold foods and sugar, kapha.
·Pregnancy, when there is an excessive demand for insulin that can lead to gestational diabetes. Also there is a natural increase in kapha, as kapha is responsible for the creation of the new baby and placenta. That kapha can inhibit the pancreatic function, which can also lead to gestational diabetes.
·Liver diseases, including hepatits and cirrhotic changes can lead to portal hypertension and affect the pancreatic function, resulting in diabetes, pitta/kapha.
·Corticosteroid therapy is a drug induced cause of diabetes. Steroidal hormones are kapha provoking and steroid toxicity may create underactive thyroid, water retention, hypertension and obesity. It also compromises kidney functions and causes “moon face”, which results in a swollen and fatty appearance of the face, kapha.
·Worry, anxiety, fear and anger are all connected to cerebral kloma (form of kapha or kleda) and these can affect glandular functions and lead to prameha, vata/pitta/kapha.
·Stress affects the nervous system, which governs all the functions of the body and mind. It affects blood flow, inhibits rejuvenation, increases stress hormones, affecting the endocrine system, hormones, triglycerides, cholesterol and blood sugar.
Primarily aggravated kapha, are fatty tissue, muscle tissue and body fluids.
Moderately affected pitta, are bone, blood, and plasma. 

Chronic conditions deplete the body, especially lymph, muscle, vata, and ojas - the healthy and refined form of kapha that governs immunity and our ability to love and be loved. 

(Charaka Samhita: 6/4) The etiology or (Nidana):
·Sedentary lifestyle
·Excessive sleep or sleeping during the day
·Meat soup or meat made of domesticated, aquatic or animals from a swampy habitat
·Milk or dairy products
·Recently harvested grains or drinks
·Preparations made of unrefined cane sugar or jaggery 
·That which aggravates kapha: 
(Ashtanga Hrdayam: Ni. 10/1-3)
·Food, drinks and activities that cause an increase of fat (medas), urine (mutra)     and kapha are the primary causes for prameha such as:·Food which is Sweet,   Sour, Salty, Fatty, and not easily digestible, slimy and cold,
 
·New grains
 ·Beer 
 ·Sugar cane juice 
 ·Molasses 
 ·Milk 
 ·Always sitting in one place, sedentary lifestyle
 ·Sleeping at inappropriate times or during the day

Purva Rupas – Premonitory Signs & Symptoms:
Sweating
Body odor
Flabbiness of the body
Desires constant rest and sleep, or sitting, has an easy life, laziness
Heaviness in the cardiac region
Exudation from eyes, tongue and ears
Overweight, excessive growth of hair and nails
Liking of cold comforts
Dryness of throat and palate
Sweet taste in the mouth
Burning sensation of the hands and legs
Swarming of ants especially near urine

Diagnosis of Dosha involvement
An Ayurvedic consultation includes visual observations, pulse, questioning and urine analysis to assess and classify in order to choose the proper treatments.
For urine analysis, take some urine in a cup and put a drop of sesame oil into the urine.
· If the urine takes a snake like image it is a Vata disease· If the urine takes an "umbrella" shape it is Pitta disease· If the urine takes a pearl shape it is Kapha disease
Oil Drop
· If the oil drop attains Mandala (circular shape) Vata is predominant,  · If the oil drop attains Budbuda(bubbles) shape Pitta is predominant· If the oil drop attains Bindu (globule or droplet) and sinks in the urine Kapha is predominant.

Kaphaja Prameha (10)
Urine resembling water, Hydruria
Urine resembling sugar cane juice, Glycosuria
Dense Urine, Chyluria
Dense urine at the bottom and clear at top, Belluria
Whitish urine
Urine containing seminal fluid, Spermaturia
Urine which is cold, Phosphaturia
Urine contain sand like substances, Graveluria
Urine passing slowly
Urine containing slimy material, Pyuria

Pittaja Prameha (6)
Urine resembling the mixture of alkalis, Alkalinuria 
Urine that has a blackish color, Melanuria
Urine having bluish color, Indigouria
Urine having blood in it, Hematuria
Reddish color urine, Hemoglobinuria
Bright yellow urine, Urobilinuria

Vataja Prameha (4)
Urine mixed with nervous tissue (majja), Myelouria
Urine mixed with muscle fat, Lipuria
Urine mixed with lasika or lymph, some consider this Diabetes Insipidus
Urine that is sweet like honey and mixed with ojas, Diabetes Mellitus 
If kapha/pitta type of prameha are left untreated, then they may develop into Madhu meha – indicating chronicity and hence also the involvement of vata.
If vata type of prameha is the primary manifestation, then it is considered incurable.

Types of Premehi Patients
  1. Obese and strong–Sthoola Pramehi  (kapha/pitta)
  2. Lean and weak–Krisha Pramehi  (kapha/vata) 

Kaphaja: Curable –due to compatibility of treatment. Since bitter and pungent drugs (herbs and spices) are advised for this condition, and they also alleviate kapha, there is no contradiction in the line of treatment.

Pittaja:  Palliable – due to mild contradiction of therapies. Drugs (herbs and spices), which are pungent in taste, cannot be used in pittaja types as they would further aggravate pitta, lymph (rasa) and blood (rakta).

Vataja: Incurable –due to incompatible intervention, as a result of chronicity of the disease with complications, as well as contradictory therapies. They tend to be severe and associated with complications.

Treatment–Chikitsa
The prevailing strategy in conventional medicine for managing DPN focuses on stringent glycemic control by intensive maintenance of target blood sugar level to slow the progression. The symptomatic treatment in painful diabetic neuropathy includes tricyclic antidepressants, SSRI group drugs, antiepileptic drugs and opiods. Such medical intervention may not always produce effective results and are associated with known adverse effects. 













The line of Ayurvedic treatment of prameha, however, is determined as per therapeutic classification. 

Herbs or insulin, if necessary, can regulate blood sugar, and there also needs to be a holistic treatment program to treat this syndrome. That usually includes proper diet, daily exercise, yoga, hygienic measures, an appropriate lifestyle and panchakarma cleansing, all according to the individual’s constitution and the particular type of prameha.

For those who are strong (Sthula pramehi) – Bio Purifactory Panchakarma therapy (Shodhana) is a strong cleansing or elimination of excess kledaka kapha and includes therapeutic emesis and/or therapeutic purgation, as well as avoiding the causes already listed, followed by palliative care after the panchakarma and the kleda kapha has been removed.

For those who are lean and weak (Krisha Pramehi) – Palliative management (Shamana) – Mild cleansing followed by stronger rejuvenation and strengthening therapies with Ayurvedic formulas and diet considering the individual’s constitution and condition and the specific complications.

Peripheral Neuropathy is a common and costly complication of both type I and type II diabetes. Prevalence of neuropathy is estimated at about 8% of newly diagnosed patients and greater than 50% in those with longstanding disease. In classical Ayurvedic texts, the clinical features of peripheral neuropathy are described in the context of prameha and its various stages called burning palms and soles (khara pada daha).

Complications in pitta types of prameha include urinary tract infections, testicular hypo functioning, recurrent hypoglycemia, causing dizziness and early neurological symptoms like paresthesia, especially burning, GI symptoms including GERD, and diabetic diarrhea.
Complications of vata type of prameha are emaciation, urine retention, and neurological symptoms as various types of pain, palpitation, and vata types of respiratory features characterized with dry cough and breathing difficulties. Other classical texts mention sparsha vatra and tvak shunyata, characterized by severe pain, burning sensation and absolute loss of sensation. Tvak shunyata presents as lack of ability to differentiate hot and cold or soft and rough.  (Ayurveda Journal Of Health, vol 15 issue 4).

Localized vata/pitta clinical presentations may be effectively managed with internal administration of kshira bala taila 101, and external applications of shata dhouta ghrita (100X medicated ghee)  and a treatment of Takra Dhara: pouring medicated buttermilk over the entire body.
For other vata/pitta cases where vata is predominant or for lean or emaciated diabetic individuals, medicated rice bolus poultice (shashtika pinda sveda) is commonly practiced which improves muscle bulk and strength. 


In autonomic or peripheral neuropathy associated with insomnia or loss of balance and coordination, shirodhara (medicated oil poured on the forehead) is beneficial.


For Vata predominant cases, pour medicated oil, 4-5 liters over the entire body, followed by an abhynaga massage with the same medicated oil at home.


Ayurvedic preventive diabetic foot care includes foot massage (pada abhynaga) with medicated oil.

In kapha/vata presentations, where kapha is predominant, as in diabetic amyotrophy, a medicated powder massage (udvarttana) is performed and a hot medicinal powder poultice (curna panda sveda) are beneficial. 


In autonomic neuropathy with gastrointestinal symptoms like constipation or GERD, judicious use of mishraka sneha, shows to improve gastrointestinal motility. It is useful in obstinate constipation, colic, pain and inguino-scrotal swellings and various diseases due to vata manifesting in the GI tract. Maha dhanwantaram tablet may be used as a palliative formula for GERD with symptoms like nausea, dysphagia, epigastric discomfort, and gastroparesis.

In chronic diabetic cases at the vata predominant stage, dhanwantaram ghrita is indicated for internal administration.

For erectile dysfunctions seen in diabetic peripheral neuropathy patients, milk decoctions of ashwagandha and bala yields promising results.

In diabetic foot ulcers medicated ghee with turmeric is effective for internal administration and external application.

For diabetes retinopathy a therapy called tarpana with patoladi ghrita applied to the eyes has shown remarkable improvement in visual acuity.


            Dietary modifications are also very important in management of diabetes. 


A beneficial diet includes: Turmeric, cinnamon, feneugreek, barley, honey, roasted meat, corn meal, green gram (mung dal),  cooking foods with ghee and spices. 


Consume one meal per day of medicated gruel, with Mishraka Sneha, effective in maintaining euglycemia and improving quality of life.  

Dashamula medicated gruel is successfully practiced in various stages of diabetes as a diet therapy.

Avoid foods and drinks that are cold, moist, heavy, fried, boiled, fermented or carbonated.

Lifestyle – Exercise!!

Body Treatments–Several are already listed above. There are a variety of body treatments, selected according to the person’s constitution, condition and disease classification. Including Shirodhara or Takra Dhara, which are classically recommended for many types and conditions of pramehaThey are a stream of either warm herbalized oils or takra poured on the forehead. This is deeply relaxing, sooths and calms the nervous system, synchronizes brain waves, calms the mind, and enhances blood circulation to the brain. The affects of the deep relaxation are valuable to the body, mind and energy. 

We can use udvartana massage to dry and reduce a heavy and moist person. This also increases lymphatic circulation and drainage, so we want to reduce some of the kleda first with diet and lifestyle rather than circulate it, then introduce this treatment.  If the person is not very damp we can provide an abhyanga massage, which is the signature massage of Ayurveda, that is a lymphatic drainage performed with warm herbalized oils, preceded by garshana silk glove and completed with a hot towel compress.  


Nasya is often helpful, which is a tri-fold treatment of neti pot, nasya oil and gargle, cleansing and nourishing of the sinuses, head and neck.  


Medicine: Ayurvedic Herbs: (Aushadha) to include: Triphala, Shilajatu, Chardunika (Gymnema Sylvestre), bilva leaf, guduchi, and Guggulu preparations. Gymnema Sylvestre showed similar glucose lowering effects as the corticosteroid-inhibiting drug, ketoconazole. Experimental and clinical studies revealed anti-diabetic and adaptogenic properties of the aqueous extract of bitter gourd (momordica charantia or karavellaka). The aqueous extract of the fruit was more effective in diabetes than the powder of the dried fruit. 

This article is not meant for any diagnosis or treatment, but rather to provide Ayurvedic education to get an idea of how an Ayurvedic professional will analyze a case and organize a health plan according to the individual’s constitution and condition. Please do not attempt to self treat. Always seek the consultation and supervision of an experienced and properly educated Ayurvedic Practitioner along with your doctor.

The earlier we notice imbalances, especially within the first 3 stages, the easier it is to correct them. The longer the imbalances are ignored, the harder it will be to reverse them. Articles and mid level workshops are tools for people to become aware of the Ayurvedic wisdom of life. It is advised to seek the analysis and guidance of a properly educated and experienced Ayurvedic Practitioner to pinpoint the root causes of imbalance and create a well rounded and appropriate health plan and keep you on track to a life well lived.

Chaya has been an Ayurvedic Practitioner, Ayurvedic Yoga Therapist and Massage Therapist at some of the largest yoga and health centers in the country for 20 years. She can be reached at her private practice in Gainesville, The ChayaVeda™ Integrative Healing Arts Studio, by visiting ChayaVeda.com

Ayurvedic Perspectives on Selective Pathologies, Vasant Lad, BAMS, MASc
Referenced from DIABETES MELLITUS (MADHUMEHA) AND AYURVEDIC MANAGEMENT: AN
EVIDENCE BASED APPROACH;  Article in WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES · August 2015

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