diabetes mellitus

AYURVEDIC CONCEPT OF PREDIABETES/DIABETES MELLITUS & ITS MANAGEMENT: A SCIENTIFIC OVERVIEW Dr. Ajai Kr. Pandey Assistant Professor, Department of Kayachikitsa, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, E-mail : [email protected], Ph.No. 09452827885

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t is one of the oldest diseases recognized since antiquity by medical historians. Diabetes mellitus (DM) is a major challenging health problem of the 21st century. It refers to a heterogeneous chronic metabolic disorder that shares the phenotype of hyperglycemia. DM is caused by a complex interaction of genetic, behavioral and environmental factors. It results due to impaired Insulin secretion or insulin resistance, decreased glucose utilization, and increased glucose production (Ginsberg, Huang, 2000). The metabolic deregulation associated with DM, causes secondary pathophysiologic changes in multiple organ systems. It imposes a tremendous burden on diabetics and on the health care system. The world today is witnessing an epidemic of Diabetes mellitus. Globally and nationally, DM with its complications has the most important contemporary and challenging health hazards. It is the leading cause of end-stage renal disease (ESRD), non-traumatic lower extremity amputations, and adult blindness. It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the foreseeable future. One decade ago, the US Department of Health And Human Services and ADA on 27th march 2002 gave the term Prediabetes. It is the state in which some but not all of the diagnostic criteria for diabetes are met. It is often, described as the “gray area” between normal blood sugar and diabetic levels (Arun, Nalini, 2002). Globally, numerous terms have been given for prediabetes such as, borderline diabetes, chemical diabetes, touch of diabetes etc. In the early stages of the disorder, glucose tolerance remains near normal, despite insulin resistance, because the pancreatic beta cells compensate by increasing insulin output (Tuomilehto et al., 2001). As insulin resistance and compensatory hyperinsulinemia progress, the pancreatic islets in certain individuals are unable to sustain the hyperinsulinemic state. IGT is characterized by elevations in postprandial glucose. A further decline in insulin secretion and an increase in hepatic glucose production lead to overt diabetes with fasting hyperglycemia. Prediabetes & DM as disease entity has been vividly described in the context of Prameha/Madhumeha in Ayurvedic classics with striking resemblance of its Ayurvedic concepts with latest knowledge on Diabetes mellitus as known in conventional medical sciences. The causes of Diabetes mellitus are comparable to the disease entity Prameha/Madhumeha of Ayurveda. The major categories of the etiological factors are (1) genetic and hereditary factors and (2) lifestyle related errors such as sedentary habit and high calorie diet. The texts also describe the pathogenesis of this disease in an extremely evolved manner, involving the three Doshas (Kapha predominant doshas) and ten Dushyas (ranging from Rasa to

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Scope of Translational Researches in Ayurvedic Medicine

Ojas, specially Meda). The idea of significance of Meda (Adipose tissue) as the principal Dushya has been recently confirmed also in modern medicine where the central obesity and dyslipidemia are being considered as the main components of the basic matrix of this disease. The recent concept of the Metabolic Syndrome also seems to have been conceived in Ayurveda. Most of the ancient texts emphasize that all three Doshas are involved in this disease but vitiation of Kapha Doshas is the main initiating factor. The involvement of a wide range of Dushyas numbering 10 is of special significance, because such a pathogenic feature of the disease indicates that Prameha vis a vis prediabetes is a systemic disease involving the whole body. Prediabetes & Type 2 DM is largely a preventable disease, while Type 1 DM is generally manageable. However, it is not curable once it established in the organism. The most pertinent fact being realized by many diabetologists is the fact that DM Type-2 is largely a preventable disease through diet and life style management. However, once it is established in the organism it mostly takes an incurable course and continues to develop its progressive stage including Type-2 DM & Type-1 DM and its complications including diabetic neruropathy, nephropathy, cardiomyopathy, carbuncles, etc, a fact that has been clearly conceived in Ayurveda. Many times the complications continue to progress even if the blood sugar levels are controlled by medication. One may find a comprehensive description of drug and non-drug modalities of treatment for different kinds of Diabetes with a wide range of herbal, mineral and herbo-mineral formulations for the treatment of Prediabetes & Diabetes mellitus (Ernst, 2005; Pandey, & Singh, 2000). Seeing this fact it seems profitable to explore the possibilities of developing an Ayurved- inspired line of management and medication for contemporary use today. The issues depicted above can be tackled with the holistic approach of Ayurvedic medicine utilizing the package of exercise, dietary control and stress management with use of such Ayurvedic drugs, which may produce Rasayana effect besides the efficacy to control the dyslipidemia and sugar in the system (Singh, 1998). The Rasayana drugs of Ayrveda are claimed to produce bio-balancing effect, promoting essential nutrition and immune enhancing effect. Such a line of management is preferred in Ayurveda because of the role of Ojas, which is responsible for the immune status of an individual and is depleted in case of Diabetes mellitus and most of the diabetics remain in an immune compromised state (Pandey and Singh, 2003). Because Ojas is considered as one of the major Dushya of Prameha, which can be controlled by Rasayana Therapy. Such an exercise of 'Reverse Innovation' in the management of Prediabetes & Diabetes mellitus and its complications is considered because of the fact that modern management of Diabetes mellitus is really not satisfactory. When such a disease is really established in the system, it is difficult to treat because of its deep seated and widespread pathogenic involvement. Epidemiology/Prevalence of Prediabetes : According to the Centers for Disease Control and Prevention, 41 million U.S. adults aged 40 to 74 have prediabetes. Moreover, the same reports from, the American Academy of Pediatrics show that, one of every 10 males and one of every 25 females have prediabetes aged from 12 to 19 years. Recent data from the USA indicate that the prevalence of IFG is

Ayurvedic Concept of Prediabetes/Diabetes Mellitus & its Management…….

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~26% and that of IGT is ~15% in the adult population. Both IFG and IGT increase in prevalence with age. The prevalence of IFG is similar in men and women, but IGT is more frequent in women. Although there is some overlap between IFG and IGT, most studies have shown that these criteria define different populations at risk for type-2 diabetes and other complications (e.g. CVD). The worldwide prevalence of DM has risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 177 million in 2000. It is believed that >360 million individuals will have diabetes by the year 2030. The prevalence of type 2 DM is rising with alarming rate. It is because of increasing obesity and reduced physical activity in newly industrialized nations. It is estimated that every year a further 7 million people develop diabetes. In Asian countries, India has been projected by WHO as the country with the fastest growing population of diabetic patients and in terms of “Diabetes capital of the world”. According to the Diabetes Atlas 2006 published by the International Diabetes Federation, the number of people with diabetes in India currently around 40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive steps are taken (Mohan, Sandeep, Deepa, Shah, Varghese, 2007). Remembering Facts of Prediabetes/Diabetes mellitus : • Pre-diabetics have moderate to severe insulin resistance in muscle and/or liver and impaired β-cell function. • Epidemiologic studies have demonstrated that subjects with isolated IFG and isolated IGT have a 4% to 6% annual risk for progression to T2-DM compared with less than 0.5% annual incidence in NGT subjects. • Individuals with combined IFG/IGT have approximately 10% annual risk for conversion to T2DM. • Numerous clinical trials have demonstrated an approximately 50% increase in the cardiovascular disease risk, with a somewhat stronger risk in subjects with IGT compared with those with IFG. • Insulin resistance is an important risk factor for atherosclerosis and cardiovascular disease. • The worldwide prevalence of prediabetes/DM has risen dramatically over the past two decades. Worldwide more than 246 million of people suffer from diabetes mellitus. By 2025 this figures could be expected to be 380 millions. Although the prevalence of both type 1 and type 2 DM is increasing worldwide, but the prevalence of type 2 DM is raising with alarming rate. • In 2007, the five countries with the largest numbers of people with diabetes are India (40.9 million), China (39.8 million), the United States (19.2 million), Russia (9.6 million) & Germany (7.4million). • By 2025, the largest increases in diabetes prevalence will take place in developing countries. • Each year a further 7 million people develop diabetes. • Each year 3.8 million deaths are attributable to diabetes. • Every 10 seconds one person dies from diabetic complications. • Every 10 seconds two people develop Type II diabetes. • Diabetes is the fourth leading cause of global death. • At least 50 to 80% of diabetics are unaware of their condition.

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Type II DM is most frequent cause of kidney failure in Western world. 10% to 20% of people with diabetes die of renal failure. 2.5 million People worldwide are affected with diabetic retinopathy. Chances of heart attack or stroke are twice in Type-II diabetics (Wild, Roglic, Green, Sicree, King, 2004). Classification of Prameha: Ancient Indian physicians have tried their level best to classify the disease in different manner such as• Doshika classification : Kaphaja- 10, Pittaja- 06 and Vataja- 04. • Aetiological classification : Sahaja (hereditary) another is Apathyanimittaja (Acquired). • Constitutional classification : Sthula and Krisha Pramehi. • Prognostic classification: Sadhya, Yapya and Asadhya. Classification of Prediabetes/Diabetes mellitus in Ayurveda: 1. Etiological- 2 (“Dao pramehau bhavatah-Sahajoapathyanimittashcha” Su. Ci. 11/3) (a). Sahaja prameha (patients of Type I DM) Matripitribeejadoshakrita, i.e. defects in1. Bija- sperm/ ovum 2. Bijabhaga- chromosome 3. Bijabhagavayava- genes (b). Apathyanimittaja prameha (Prediabetes & patients of Type II DM) It is caused by• faulty dietary habit • sedentary life style • lack of physical exercise • psychological factors: worry, grief, anger, anxiety etc. 2. Constitutional-2: Sthula pramehi: patients of Prediabetes & DM with or without insulin resistance. Krisha pramehi: malnutrition related diabetes mellitus or Type-I DM. 3. Doshika- 3: Urinary Abnormalities. • Kaphaja-10 types- prediabetes & early stage of type-2 DM . • Pittaja-6 types- acute stage of type-2 DM. • Vataja-4 types- advanced stage of type-2 DM or genetic/hereditary form of DM. Prognostic-3: 1. Sadhya: curable (Kaphaja type) 2. Yapya: palliative (Pittaja type) 3. Asadhya: untreatable (Vataja type) The Ayurvedic texts reflect two major categories of Prameha 1. Sahaja Prameha and 2. Apathyanimittaja Prameha, out of these two, Apathyanimittaja Prameha is closely resemblance with the contemporary concepts of Prediabetes/Type-2 Diabetes mellitus. On this basis, Ayurveda has described Sthula Pramehi, which clearly corresponds to the current concepts of overweight & obesity and its role in the genesis of Diabetes mellitus. Thus the Ayurvedic concept of Prediabetes is so advanced than even modern medicine as known


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today. Because the hereditary influence in relation to Prediabetes is still awaited in modern system of medicine. However, it was well conceived in the Ayurvedic lexicons in the context of Prameha. According to classical texts of Ayurveda, all Pramehas have the potential to become incurable (Madhumeha) if left untreated (Grover, Yadava, Vats, 2002). Kaphaja urinary disorders are curable because the causative Dosha and the affected tissues (Dushyas) have the same properties, thus requiring the same type of therapy. Although the Pittaja urinary disorders are controllable, the resulting disorders may persist for life. Because the causative Dosha is Pitta, but the tissues and waste products (Dushyas) are different, requiring a different type of therapy. Vataja urinary disorders are untreatable because tissues (Dhatus) and bio-immuno-strength (Ojas) undergo deterioration. Recent studies have observed a relationship between the body constitution and relative amounts of hyperglycemia and insulinemia consistent with Ayurvedic prognosis. Kapha constitution patients showed the highest level of insulinemia and the lowest levels of FBS and PPBS. Vata patients showed the lowest level of insulinemia and the highest levels of FBS and PPBS due to hypoinsulinemia. Pitta patients were in the middle. Etiopathigenesis of Prameha/Prediabetes: In conventional medicine, it is also believed high calorie diet, sedentary habits, and stressors (physical, mental, social etc.) play an important role in the eiopathogenesis of Prediabetes but its actual cause is still unknown. Side by side positive familial history, overweight and obesity are the basic risk factors for insulin resistance and for the development of type-2 diabetes mellitus. Those patients who were fall in the stratum of IGT or IFG are at increased risk of cardiovascular disease. (Diabetes Care, 2002). Ancient scholars of Ayurveda give similar opinion. Asyasukham svapnasukham dadhini gramyaodakanooparasah payansi. I. Navannapanam gudavaikritam ca prameha hetuh kaphakéchcha sarvam . II. (C.S.Ci.- 6/4) Daopramehobhavatah Sahajaoapathyanimittashcha I. ( S.S.Ci.-11/3)

It includes following lifestyle errors: 1. Use of early-ripened Pulses and grains. 2. Use of sugarcane and its product like-Guda, Khanda, Sharkara, Sugar etc. 3. Use of milk and its products, Mandaka dadhi. 4. Intake of meats and soups of different Anupa, Audaka and Gramya animals. 5. Lack of exercise, Laziness, Excessive sleep during day, alcohol consumption etc. 6. Psychological factors such as Anxiety, Anger, Worry, Grief etc. have been described to play an important role. 7. Indulging sex / sleep with full belly etc. 8. Excessive consumption of alcoholic beverages. (Basavaraja -14th century A.D.). 9. Person having Medavrittavata. 10. Person associated with Overweight & Obesity. 11. Person have positive family history (Sahaja Prameha). According to Sushruta Madhura Ahara, taken in excess along with day sleep, and sedentary life style, may convert into fat due to metabolic block (Ama Rasa). It contributes to the adiposity of the body leading to overweight. So the present day concept of metabolic syndrome in obese patients where most of the carbohydrate being converted into fatty acids is well conceived in Ayurveda. Overweight in prediabetic patients has been observed to be associated with hyperinsulinemia and increased FFAs level. Due to the increased FFAs level in the serum, the glucose entry to the cells is hampered, resulting in insulin resistance and finally diabetes. The FFAs are the soluble form of fat, which are fit

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for utilization in energy metabolism, coming from adipose tissue. So one can conclude that triglyceride content of Adipose tissue is an example of Baddha Medas and FFAs may be compared with Abaddha Medas. Hence, sometimes the Kaphaja type of Prameha is correlated with Type 2 diabetes mellitus with or without Insulin resistance. The relationship of Ama with psychological factors, as stated in Charaka Samhita (Sharmā, & Dāsh, 2009; Jadavaji, Acharya, 1992), is the evidence of relationship of Prameha with mental stress. The emotional factors enhance the level of counter-regulatory hormones (cortisol, ephinephrine, norephinephrine) that may alter the carbohydrate, protein and fat metabolism. The mode of action of these hormones in the genesis of diabetes is through mobilization of FFAs from TG of adipose tissue. Adrenal hyperactive secretion causes excess glucose in the blood. On the other hand excess thryroid secretion causes lipolysis and protein breakdown resulting in muscle wasting. Stress also increases sympathetic activity which causes increased insulin secretion but the other glands are predominant that check the insulin response at tissue level. Risk Factors for Type 2 Diabetes Mellitus : • Family history of diabetes (i.e., parent or sibling with type 2 diabetes) • Obesity (BMI 25 kg/m2) • Habitual physical inactivity • Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) • Previously identified IFG or IGT • History of GDM or delivery of baby >4 kg (>9 lb) • Hypertension (blood pressure 140/90 mmHg) • HDL cholesterol level 250 mg/dL (2.82 mmol/L) • Polycystic ovary syndrome or acanthosis nigricans • History of vascular disease (Source:Adapted from American Diabetes Association, 2007). Samprapti Ghataka: Dosha Dushya Agni Ama Srotasa Srotodushti Adhishthana Pratyatma lakshana Sancarsthana Roga Marga Sadhya/asadhyata Vyadhi Svabhava

Tridosha (specially Kapha Dosha) Rasa, Rakta, Lasika, Mamsa, Meda, Kleda, Majja, Oja, Shukra, Jala (Specially Meda) Jathharagni, Dhatvagni, Bhutagni (Specially Medoagni) Aparipakva Ama and Aparipakva dushyas Rasavaha, Medovaha, Mutravaha, Raktavaha, Udakavaha, Mamsavaha, Majjavaha, Shukravaha (Specially Rasavaha and Mutravaha srotasa) Atipravritti, Sanga, vimargagamana Vasti Prabhuta Mutrata & Avila-Mutrata Sarvagna Sharira via Rasayani Abhyantara Kaphaja-Sadhya, Pittaja-Yapya Vataja- Asadhya Chirakari

Purvarupas (Prodromal Symptoms) of Prameha : Ayurveda once again exhibits here its observational supremacy by furnishing prodromal features of Madhumeha, which covers the pre-diabetic stage or early clinical manifestation or


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subclinical stage of diabetes mellitus. Purvarupas are valuable signs and symptoms to predict the disease in its early stage & to check its progression towards Madhumeha and its complications by applying appropriate therapeutic measures. Prodromal symptoms Kesheshu Jatalibhava- matting of hairs Asya Madhurya- sweetness in mouth Karapada daha- burning sensation in hands and feet Karapada suptata- numbness in hands and feet Mukhatalu kantha Shosha- dryness in oropharyngeal region Pipasa- feeling of thirst Alasya- lethargyness Kaye Malam- accumulation of wastes over the body Paridaha angeshu- burning sensation over the body Suptata angeshu- numbness over body parts Pipilika Mutrabhisaranam- attraction of ants, flies towards urine Mutre cha mutradoshana- changes in the color, quantity, nature and consistency of urine Visra sharira gandha- unpleasant smell from body Sarvakala nidra- desire of excessive sleep Sarvakala tandra- feeling of drowsiness Snigdha gatrata- oiliness over the body Pichchhila guru gatrata- sliminess and heaviness over body parts Madhura mutrata- sweetness of urine Shukla mutrata- whiteness and turbidity in urine Sada- always feels lazyness Shvasa- difficulty in breathing Keshanakha Ativriddhi- overgrowth of hair and nails Shita Priyata- likeliness of cold things Hridaya Netra Jihva Sravanopdehafeeling unwanted things over heart, eyes, ears and tongue Sveda- excessive sweating Dehe Chikkanata- greasiness of body

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Regarding the excessive excretion of Malas in the buccal cavity, one significant modern observation may be quoted i.e. thickening of vascular wall of buccal mucosa, especially of gums has been reported in prediabetic condition (Lozano, Camerini, Avalos, Krall, Marble, 1964). It is now known that the health complications associated with type-2 diabetes often occur before the medical diagnosis of diabetes is made. Impaired glucose tolerance is a risk factor for cardiovascular disease, but not impaired fasting glucose (Choudhary, Umesh & Pandey, 2013). Therefore, Purvarupa of Prameha may be correlated with the clinical conditions of (1) Prediabetic stage, (2) Early Stage of Type-2 DM, (3) Subclinical stage of Type-2 DM. Clinical feature of Prediabetes or diabetes mellitus: Ayurveda has described 20 subtypes of Prameha as different clinic-pathological conditions, which is outcome of interaction of specific Doshas and Dushyas at different level that may lead to gross urinary characteristic and clinical manifestations. Vagbhata


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seems to have paid much attention in diagnosing the disease in its early stage explaining the following in his treatise Rasaratna samucchaya. (1) Asvasthyam sarva gatreshu–persisting & vague uneasiness in the body. (2) Shoshah– Asyasosha- feeling of dryness in the body and dryness in the mouth. (3) Taapo angah-burning sensation in the body. (4) Bahumootrata-increased frequency of micturition. (5) Karshyam-emaciation. The above conditions alarm us to understand their observational supremacy. In advanced stage urinary changes become more prominent such as- Prabhootamutrata-excessive urination. (a) Avilamootrata-turbidity in urine. (b) Madhviva mehati-passes urine similar to Madhu. (c) Madhuryacha tanoratah-patient’s body starts yielding sweet smell and taste. (d) Mootreabhidhavanti Pipeelikashcha-ants, flys etc are attracted towards urine & body parts. Beside the common symptoms of Prameha, following features are specific to diabetes mellitus, which indicates the observational supremacy of ancient sages. (1) Urine is astringent, sweet, pale and ununctuous (C.Ci.4/44). (2) Urine is just like Ksaudra (honey) in taste and color (S.Ni.6/14). (3) Whole body becomes sweetened (A.H.Ni.10/18-27). (4) Ojas (immune strength) is diminished, the person becomes timid, week, wearied, having disordered of senses, loss of luster, neurasthenic, dry and emaciated (C.Su.17/43). (5) Diabetic patients prefer sedentary life style. (S.Ni.6/28). Possible mechanism of diabetic complications in biomedical science Hyperglycemia

↑ Intracellular Glucose

↑ AGEs

Abnormal protein function

Altered cell function

↑ Circulating AGEs

• Renal, vascular connective tissue effects • Cytokines growth factors

↑ Sarbltol

Altercations in osmolalty myoinositol, and rodax potential Altered enzyme function (cPLA2, Na, KATPase) Altered cell function

Complications of diabetes

↑ DAG

PKC activation

Altered gene axprassion

Growth factors


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Possible mechanism of diabetic complications in Ayurveda Apathyaja prameha--Bija dosha --Obesity --Stress ↓ Prameha/Madhumeha (prolong duration) (Hyperglycemia & dyslipidimia in plasma i.e. Increased sugar & FFAs level ↓ Impaired Pitta component i.e- Dhatvagni and Bhutagni vyapara; i.e cellular biofire (Formation of unwanted, antigenic & auto-toxic products) ↓ Disturbance of Dhatus parinama and activities of Dhatus ↓ Dhatukshaya + Ojokshaya + Vyadhisvabhava itself ↓ Resulting impairment of Vyadhikshamatva ↓ Vata and Pitta prakopa (Impaired Psycho-neuro-humoral mechanism) ↓ Alter the form of Kapha dosha i.e- bioprotective factor ↓ Deranged function of Vatavaha srotasa (Impaired the sensory and motor functions of nerve\ nervous system as a whole) ↓ Diabetic complications

Diagnostic Criteria for Diabetes mellitus: Historically, Ayurvedic diagnosis of DM was primarily based on the sweetness of urine that was identified by a swarm of flies and ants over the urine. Ayurvedic texts give the signs and symptoms of 10-Kaphaja, 6-Pittaja and 4-VÁtaja Pramehas for diagnosis, which is based on physico-chemical characteristics of urine. However, on this basis physician is unable to reach the final diagnosis. So the newer diagnostic tools and techniques should be be utilized as an aid for diagnosis and assessment of prognosis, until a still better and simple method is introduced in Ayurveda. Prediabetic/diabetic diagnosis can broadly divided into two groupsI. In asymptomatic undiagnosed individuals: 1. Testing of all individuals at the age of 45 years and if it is normal, it should be repeated at 3 years intervals. 2. Testing should be carried out more frequently in individuals, who— • are obese (BMI >=27 kg/mt2) • have a first degree relative with diabetics. • are a member of a high risk ethnic population. • are hypertensive (>=140/90 mmof Hg) • have HDL level < 35 mg/dl &/ or triglyceride level≥ 250 mg/dl. • on previous testing has IGT or FPG. II. In symptomatic individual having Prediabetes: Prediabetes is usually diagnosed with a blood test: • Fasting blood sugar (glucose) level of: • 110 to 125 mg/dL (6.1 mM to 6.9 mM) - WHO criteria (Choi et al., 2002)


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100 to 125 mg/dL (5.6 mM to 6.9 mM) - ADA criteria (Choi et al., 2002) • Two-hour glucose tolerance test after ingesting the standardized 75 Gm glucose solution the blood sugar level of 140 to 199 mg/dL (7.8 to 11.0 mM). • Glycosylated hemoglobin between 5.7 and 6.4 percent. III. In symptomatic individual having Diabetes mellitus: Diabetes is diagnosed (ADA-2000) by measuring blood glucose levels. It is diagnosed by three ways and each must be confirmed on subsequent day. They are• Classical symptoms of diabetes + casual glucose concentration > 200 mg/dl. • Fasting plasma glucose (FPG) ≥126 mg/dl. • 2 hour plasma glucose (PPG) ≥ 200 mg/dl. • Glycosylated Hb (HbA1c- < 6.5% in normal individual) Blood urea, Serum creatinine, Lipid profile, Serum cholesterol, CRP, NCV etc are needed to assess the complications. Prevention & Management of Prediabetes & diabetes mellitus: No doubt, the knowledge of prediabetes/diabetes mellitus in conventional system of medicine is so advanced. Side by side, several drugs were also developed to tackle different aspects of the pathogenic steps. Modern medicine have been developed αglucosidase inhibitors to manage post prandial hyperglycemia at digestive level, it has sulphonylurea to enhance glucose uptake through multiple pathways at tissue/cellular levels, in order to tackle the problems of insulin resistance, it has biguanides and insulin sensitizers glitazones. However, its management remains unsatisfactory and challenging because of danger of complications, drug hypersentivity, drug intolerance, fear of hypoglycemic episode with sulphonylureas and resistance to insulin are the major. Recent evidences suggests that consuming a heart-healthy diet, losing excess weight, staying active and by adopting mental relaxation can reverse prediabetes progression to type-2 diabetes mellitus. It is believed that Prediabetes is likely to have full-blown diabetes within 5 to 10 years. By exercising regularly and losing weight, the risk of diabetes can be lowered by 60 percent. In this concern, Ayurveda emphasizes the role of environmental factors, daily routine, seasonal changes, lifestyle, diet, regular exercise and Rasayana for maintaining good health in general. The management of DM/Prameha emphasizes dietary and lifestyle recommendations, herbal, herbo-mineral and mineral preparations in accordance with the aetiopathology and psychosomatic constitution. Charaka and Sushruta have strongly emphasized the first and foremost principle of prevention as well as the treatment of any disease is to protect oneself from causative factors i.e.-Sanksepatah kriyayogo nidanam parivarjanam (C.Ci.6\53, S.U.1\25). Caraka has divided the diabetics into two groups, i.e. Sthula pramehi (obese diabetics) and Krisha pramehi (lean and thin diabetics) on the basis of vitality, constitution and etiology of the disease. This warrants different lines of management for the two types of diabetics. In Sthula pramehi (Prediabetics & type-2 diabetics) biopurificatory measures and lightening measures are advocated, such as- Sthulah pramehi balavanihaikah krsastathaikah paridurbalasca.I Sambrmhanam tatra krsasya karyam samsodhanam dosa baladhikasya. II (C.Ci.6\15.). At present, the goal of


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Prediabetic treatment is not only to normalize the blood glucose level within the range but also to improve the Ojas status, Agni status & improve the quality of life. 1. Abstinence from etiological factors: “Nidana Parivarjana” is firmly advocated in Ayurveda for the management of diseases. Prediabetes is a clinical entity in which lifestyle modification can reverse Prediabetes and check its further progression to Type-2 diabetes mellitus. Food enriched with any type of fermented material, excessive water intake, milk, oil, ghee, sugarcane & its products, newly cultivated graims, soups and meat of aquatic and near aquatic animals should be avoided to the patients of Prameha. 2. Ahara (Diet and dietary rule): Diet is the first line defense against Prediabetes. The Ashta Aharavidhivishesha Ayatanas are kept in mind while prescribing diet. Yava is considered as the best diet for Pramehi. Charaka opines that Yava first given to animals and then remaining parts collected from the dung of that animals to be consumed by Pramehi. Old Shali, Shashtika (Variety of rice), Yava, pulses like Chanaka, Adhaki, Mudga and Kulattha are advised by Sushruta in Prameha. In this context, Sushruta wants to convey the role of less intake of carbohydrate rich food for the management of Prameha. The quantity and quality of the diet should be decided based on Agni Bala and vital power of the body. Contemporary dietary guidelines are given below. • Reduce high calories intake will improve insulin sensitivity and lower blood sugar. • Reduce total fat and saturated fat will improve body ability to use the insulin.. • Avoid high fat foods include fast food burgers and cheese, ground meats like sausage and many convenience foods like frozen pepperoni pizza and chicken pot pie. • Increase intake of good sources of omega-3 fatty acids such as salmon, herring, trout, sardines, flax seeds, flax seed oil, and walnuts. Because omega-3 fatty acids may improves the insulin sensitivity in the body tissues. • Eat the right amount of carbohydrates from unprocessed and unrefined foods as much as possible. Examples include vegetables and fruit, dried beans and whole grain breads, cereals, and pasta. • Eat 20 to 35 grams of fiber every day. A high fiber diet improves insulin sensitivity by slowing down digestion of carbohydrate digestion Good sources of fiber are beans, lentils, vegetables, whole fruits, oats, bran, whole-grain breads, and cereals • Limit alcohol intake: If you do not currently drink alcohol, do not start up for the sake of preventing diabetes. 3. Vihara (Exercise and Yoga): Physical exercise: Physical activity is the lifestyle factor most consistently reported to improve insulin resistance. Insulin moves sugar from the bloodstream into the cell where it is burned for energy. Exercise promotes sugar burning in the cell, the same as insulin. Exercise has such a strong impact on blood sugar that it can improve prediabetes even without other lifestyle changes. Aerobic exercise is particularly recommended for pre-diabetes. The American Diabetes Association recommends exercising at least 30 minutes a day, five days a week, for a total 150

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minutes or more. Examples of aerobic exercises include- brisk walking, biking, swimming, low impact aerobics, and some team sports like basketball or football. Thousand years back Sushruta has recommended exercise and diet for the management of poor and rich patients. Poor patients should move from one to the other village and earn his living by begging. For rich patients he has also described that persons who eats Shyamaka, fruits of Amalaki, Tinduka, Ashmantaka, live along with animals, and breaking the stones, becomes free from Prameha within one year. Mental relaxation: Meditative Asanas such as Shvasana, Pamdmasana, Siddhasana, Vajrasana is found beneficial for mental relaxation. Anulomaviloma, Bhramari Pranayama is helpful for the removal of mental stressors. Yoga and Asanas: Yama and Niyama is performed in daily life. Asanas likeMayurasana, Bhujangasana, Pashchimottanasana, Gomukhasana, Halasana etc are helpful by promoting peripheral glucose utilization and by improving insulin sensitivity at target level. 4. Aushadhi (Medicines): Pharmacological approach is only indicated to those patients in which lifestyle modification failed or is not sustainable and who are at high risk for developing Type-2 diabetes. Metformin and Acarbose help to prevent the development of frank diabetes, and have a good safety profile (Lilly, Godwin, 2009; The Diabetes Prevention Program Research Group, 2002). In Ayurvedic classics, a number of herbal and herbo- mineral drugs are advocated for the treatment of Prameha in general. Drugs having Katu (pungent), Tikta (bitter) and Kashaya (astringent) Rasa are indicated in all types of Prameha such as- Vijayasara, Nisha, Amalaki, Mamajjaka, Mamajjaka, Jarula, Jamboo, Bilvapatra, Tejapatra, Nimba, Karvellaka, Pippali. Gudoochi, Khadira, Kramuka, Bhoomyamalaki, etc. 1. Promotion of Agni status (promote metabolism): drugs having Deepana, and Pachana properties such as Pippali, Shunthi, Maricha, Chitraka etc. 2. Promotion of Ojas status (promote immune status): drugs having Rasayana, Jivaniya & Pramehaghna properties, such as Nisha, Amalaki, Guduchi, Shilajatu etc. Conclusion: Prediabetes was well known clinical entity since antiquity. The feature described in Ayurvedic classics seems very contemporary and scientific. Ayurveda considers lifestyle errors play a major role in the diathesis of Prediabetes/ Prameha. Scholars and researchers of biomedical sciences have recently conceived the idea of Medas as the principal Dushya of Ayurveda, opines that central obesity and deranged lipid metabolism are considered as the main pathogenic component of the basic matrix of Prediabetes and Type-2 Diabetes mellitus (Sharma, Hari, Chandola, 2011). The recent concept of the Metabolic Syndrome also seems to have been conceived in Ayurveda. In accordance with the these centuries old Ayurvedic descriptions about prediabetes/diabetes mellitus, conventional system of medicine also recognizes that diabetes mellitus is strongly associated with disglycemic state, where metabolic homeostasis of carbohydrates, proteins and lipids is deranged by insulin and other governing factors. Therefore, if this inappropriateness in metabolic homeostatic disturbance is not managed properly and on time, prolonged hyperglycemia results, further aggravation may lead to cellular damage and ultimately being responsible for the


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early and late diabetic complications (Pandey and Singh, 2012). The recent scientific understanding of cause, types, course of development of disease, and consequently its complications are in fact not different from Ayurveda. It seems likely therefore, that therapeutics described in Ayurvedic lexicons may also find relevance in the management and treatment of the cause and course of diabetes as a whole. Similarly, evaluation of diabetes described in Ayurvedic classics, reveals the fact that they are amazingly relevant even today and have the capabilities to take global care of it. It seems that issues depicted above can be tackled with the holistic approach of Ayurvedic therapeutics by utilizing the package of exercise, dietary control, Rasayana drugs and bio-purificatory measures of Ayurveda, which may not only control the lipid and sugar metabolism in the system but also control its progression to Type-2 DM. References: American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases. The prevention or delay of type 2 diabetes. Diabetes Care 2002; 25: 742749. Arun, N., Nalini, N. (2002). Efficacy of turmeric on blood sugar and polyol pathway in diabetics albino rats. Plant Foods for Human Nutrition, Volume 7, Number 1, 2002, pp. 41-52(12). Bharati, Singh, R.H., Chansouria, J.P. (1996). Hypoglycemic property of Shilajatu and Yashada Bhasma. Ancient Sci. of Life. 16:118-121. Choi, K.M., Lee, J., Kim, D.R., et al. (2002). Comparison of ADA and WHO criteria for the diagnosis of diabetes in elderly Koreans. Diabet Med 19:853–857. Choudhary, Umesh & Pandey, Ajai Kr. (2013) “A Clinical assessment of the Role of Panchakarma therapy in the care of Young Prediabetics”. International Journal of General Medicine and Pharmacy (IJGMP). Vol. 2, Issue 1, 15-24.

Classification and diagnosis of diabetes and other categories of glucose intolerance. Diabetes, 1979, 28:1039–1057. Ernst, E. (2005). The efficacy of herbal medicine-an overview. Fundamental Clin. Pharmacol. 19;405. Ginsberg, H.N., Huang, L.S. (2000). The insulin resistance syndrome: impact on lipoprotein metabolism and atherothrombosis. J Cardiovasc Risk. 7:325–3. Grover, J.K., Yadava, S., Vats, V. (2002). Medicinal plants of India with anti-diabetic potential. J. Ethanopharmacol. 81: 81-100. Jadavaji, Vaidya, Acharya, Trikamji. (1992). Charaka Samhita, Chaukhamba Surbharati Prakashan, Varanasi Reprint edition, 1992. Lilly, M., Godwin, M. (2009): "Treating prediabetes with metformin: systematic review and meta-analysis". Canadian Family Physician 55 (4): 363–9. Lozano, Castaneda, O., Camerini, D., Avalos, Ra., Krall, Lp, Marble, A. (1964). Two Years' Experience with Acetohexamide. Metabolism. 13:99-106. Mohan, V., Sandeep, S., Deepa, R., Shah, B., Varghese, C. (2007). Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 125(3):217-30. Pandey, A. K. & Singh, R.H.(2000): A study of Immune status in patients of Diabetes mellitus with the role of Pancakarma and Naimittika Rasayana drugs, MD (Ay) Kayachikitsa thesis, IMS, BHU, Varanasi. Pandey, A.K. and Singh, R.H. (2003). A Study of the Immune status in patients of diabetes mellitus and their Management with certain Naimittika RasÁyana drugs. JRAS. Vol XXIV. No. 3-4. :48-61. Pandey, A.K. and Singh, R.H. (2012). A Clinical study on certain diabetic complications under the influence of Naimittika Rasayana Therapy (with special Reference to Nishamalaki & Shilajatu), Ph.D., Kayachikitsa thesis, IMS, BHU, Varanasi.

106 Scope of Translational Researches in Ayurvedic Medicine Roy A K, et. al. (1991). “Amalaki as Rasayana” Janjua, Hamdard, Inter. Jour. of Pharmacology. Vol. 29(2) 117-126: 34 (2), 104. Sharma, Hari, Chandola, H.M. (2011). Ayurvedic Concept of Obesity, Metabolic syndrome & DM. The JACM, Vol. 17-nnumber 6, pp 459-552. Sharma, P.V. (2001). Sushruta Samhita, Chaukhamba Vishwabharati, Varanasi, Ist Ed. Sharma, Pandit, Sadanand. (Ed.) Chakradatta, Meharachand L. Publication, New Delhi. Sharmā, R.K. & Dāsh, Bhagawān. (2009). Charaka Samhita, Eng. translation, Chowkhambhā Sanskrit Series Office, Varanasi. Sharma, R.K. and Das, B. (2001). Charaka Samhita, English Translation and critical exposition. Chaukhambha Bharati Sanskrit, series office, Varanasi. Singh R.H. (1998). The Holistic Principle of Ayurvedic Medicine, Pub. Chaukhambha Surbharati, New Delhi. The Diabetes Prevention Program Research Group: Reduction in the evidence of type 2 diabetes with life-style intervention or metformin. N Engl J Med 2002; 346: 393-403. Tripathi, Y.B., Shukla, S., Chauraisa, S., Chaturvedi, S. (1996). Antilipid peroxidative property of Silajatu. Phytother. Res. 10 : 269-270. Tuomilehto J, et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 344:1343-1350. Wild, S., Roglic, G., Green, A., Sicree, R., King, H. (2004). Global prevalence of diabetes. Diabetes Care. 27(5): 1047-1053.