Research paper- JANIYAAT PRAMEHI BHAVISHYATEETI - PREDIABETES

                JANIYAAT PRAMEHI BHAVISHYATEETI - PREDIABETES

Prof.Dr.Dattatraya L.Shinde MD; PhD

Dr.Virendra Baburao Pawar MD (Schlor)

Department Of Kayachikitsa ,Bharati Vidyapeeth University,College Of Ayurved , Katraj-Dhanakwadi , Pune -43 (MS),Cell No. -9890111954, Email- dshinde249@gmail.com; lords7007@yahoo.co.in

            Diabetes is a heterogenous disease of carbohydrate metabolism characterized by polyuria, polypepsia, and polydepsia, due to lack of secretion of insulin or resistance to insulin. Diabetes Mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycemia. Several distinct types of DM exist and are caused by  a complex interaction of genetics, environmental factors and lifestyle choices. DM is the leading cause of end- stage renal Disease (ERSD), non traumatic lower extremity amputations and adult blindness. Diabetes is raising an epidemic all over the world esp., in country like India. Increasing worldwide, DM will likely continue  to be the leading cause of morbidity and mortality in near future.

Epidemiology

            The worldwide prevalence of DM has risen dramatically over the past two decades. It is projected that

 the number of individuals with DM will continue to rise in the near future. It is believed to be one of the main

criteria for deaths all over the world. Important concern of concentrating on diabetes mellitus is its prevalence

particularly Type 2 diabetes is rising all over the world .Prevalence of type 2 diabetes rises with increasing age.

 More people may remain undiagnosed esp. in our country where we have very less health concern. If obese

people with impaired glucose tolerance (IGT) and pre-diabetic persons are included along with known

diabetics in India, we may find billions of   diabetics. Another important issue is medical expenditure on

medicines, investigations, regular follow-ups, any disability occurring in between, its surgical corrections   its

overall management, rehabilitation etc. is financial burden on diabetics. If one cannot afford it life remains

miserable and at risk. No doubt for survival & expectancy of life in these pts. finances are needed. Major

cardiovascular risk factors are usually present, before the diagnosis of type 2 diabetes as well as during the

course of the disease. Hence life span or life expectancy of diabetics lowered undoubtedly.

            On this background more research studies are needed in preventive & curative way which are directed

at the disease (DM) and complications of micro & macro vascular disease which will lead to reduced costs o

 diabetics in the future.

            Ayurved not only prescribes the management of diabetes & its complications but also advocated

preventive measures, so that there won’t be occurrence of the diseases & its complications.The principles and

teachings of Ayurveda should be hence followed in diabetes care.

            One interesting thing I have to mention here is the prediabetes or upcoming diabetes is defined by the

ADA( American Diabetes Association) in the year 2002.A person with impaired fasting glucose (IGF –BSL-

110-125 mg/dl) is defined as having pre-diabetes .Such people are at high risk for developing diabetes in the

next decade or coming years and have an increased risk for coronary heart disease.

            Charakacharya ,2000 years back defined the signs & symptoms of Prameha (DM) as’ Prameha

Purvarupan’which is the preclinical, asyptomatic stage of the diabetes ,where the disease may be delayed &

 may be reversed by intensive life style changes esp. diet & exercise.  

Pre- Diabetes

            Type 2 Diabetes Mellitus is preceded by a period of IGT (impaired glucose tolerance/ Glucose challenge Test). This test will diagnose whether diabetes exists or not by indicating whether or not the body is using glucose. Pre-diabetes, also known as“ impaired glucose tolerance” is a health condition with no symptoms, it is a state that occurs when a person’s blood glucose levels are higher than normal but not high enough for a diagnosis of Diabetes.

            It is found that people who develop Pre- diabetes develop type 2 diabetes during an average 3 yrs follow up. Other studies show that many people with Pre- diabetes develop type 2 diabetes in 10yrs.

            It is very important to diagnose pre-diabetes earlier as treatment of the condition may prevent more serious health problems. It is commonly seen that the health complications associated with type 2 diabetes often occur before the medical diagnosis is made. People with Pre- diabetes can prevent or delay the development of type 2 diabetes through changes in lifestyle that include modest weight loss and regular exercise. People with Pre- diabetes, intervening early can turn back the clock and return increased blood sugar levels to the normal range. By indentifying the signs of Pre- diabetes before diabetes occurs, one can prevent type 2 diabetes all together and lower the risk of complications associated with diabetes like cardiovascular disease, atherosclerosis, diabetic microangiopathy, diabetic neuropathy, nephropathy and retinopathy. Etc.

Studies have shown that people with pre- diabetes can prevent or delay the development of type 2 diabetes through changes to their lifestyle that include modest weight loss and regular exercise. Thus persons with Pre- diabetes, intervening early can actually turn back the clock and return increased blood sugar levels to normal range.

HETU

Addiction to the pleasure of sedentary habits, sleep, curds, soup of the meat of domesticated and aquatic animals and animals inhabitating marshy lands, milk preparations, freshly harvested food articles, freshly prepared alcoholic drinks, preparations of jaggary and all kapha aggravating factors are responsible  for the causation of Prameha .

Person’s sleeping during day time, not exercising (not doing any kind of physical work), addicted to the pleasure of sedentary habits, excess dietary habits like cold, oily, sweets, and fatty  food and more of liquid preparations are prone to get prameha in the future.

The following factors help in immediate manifestation of prameha due to kapha:

1. Frequent and excessive intake of fresh corns like hyanaka, yavaka (a variety of Hordeum Vulgare Linn.), Cinaka, uddalaka, naisadha, itkata, mukundaka, mahavrihi, pramodaka and sugandhaka.

2. Intake of pulses like fresh Harenu ( Pisum sativum Linn.) and Masa ( Phaseolus radiates Linn.) with ghee.

3, Intake of meat of domesticated, marshy, and aquatic animals.

4. Intake of vegetables, tila ( Sesamum indicum Linn.), oil cake of tila, pastry, payasa (kheer- a type of milk preparation), krushara ( gruel preparation of tila, rice and black gram), vilepi ( type of gruel preparation with four times of water) , and preparations of sugarcane.

5. Intake of milk, fresh wine, immature curd, and curd which are mostly liquid, sweet and immature in nature.

6. Avoidance of unction and physical exercise

7. Indulgence in sleep, bed rest and sedentary habits.

8. Resorting to even such regimens which produce more of kapha, fat (cholesterol) and urine.

The following factors help in immediate manifestation of Prameha due to aggravated Pitta:

1. Intake of hot, sour, saline, alkaline, and pungent food.

2. Intake of food before the digestion of previous meal (ajeerna bhojana).

3. Exposure to excessively hot temperature (hot climate) , heat of the fire, physical over exertion and anger.

4. Eating mutually contradictory food items.

Vata gets immediately aggravated in individual whose body is affected due to following reasons :

1. Excessive intake of astringent, pungent, bitter, rough, light, cold things.

2. Excessive indulgence in sex and physical pleasure.

3. Excessive administration of emesis, purgations, asthapana type of basti and nasya (oleation therapy).

4.Suppression of the manifested urges, fasting, assault, exposure to heat, anxiety, grief, excessive blood letting, staying awake at night and improper posture of the body.

Risk factors for Type 2 Diabetes mellitus:

(Should get tested for Pre- Diabetes)

1) Family History of diabetes (i.e. parent or sibling with type 2 diabetes)

            It is strongly believed that it is due to some genes, which pass from one generation to another. It depends upon closeness of blood relationship if mother is diabetic, risk is 2-3%, father is diabetic, risk is more than the previous case and if both the parents are diabetic, it has much greater risk for diabetes.

2) Obesity & fat distribution (i.e., .≥20% desired body weight or BMI≥27 kg/m² )

            Being overweight means increased insulin resistance that is if body fat is more than 30%, BMI 2  5+ , waist girth 35 inches in women or 40 inches in males.

3) History of GDM (Gestational Diabetes mellitus)

            Or, delivery of baby over 9 lbs. (1lbs. = 450gms)

4) Age≥45 yrs

Increased age is a factor, which gives more possibility than in younger age. This disease may occur at any age, but 80% of cases occur after 50yrs, incidences increases as age does in this group. Type 2 cases often (but not always) start after 40 yrs ( or still later), patients are often (but not always) obese and have physical under activity.

5) Previously identified IFG (Impaired Fasting Glucose) or IGT (Impaired Glucose Tolerance)

6) Hypertension

            (BP ≥140/90 mm of Hg)

7) Polycystic Ovarian Syndrome

8) Poor diet

Malnutrition related diabetes : Improper nutrition, low protein and fiber intake of refined products are the expected reasons for developing diabetes.

9) Sedentary lifestyle

Sedentary lifestyle is a global public health problem.  Persons with such lifestyle are more prone to diabetes, when compared to those who exercise thrice a week, are at lower risk of falling prey to diabetes.

10) Stress

Either physical injury or emotional disturbance is frequently blamed as the initial cause of the disease. Any disturbance in corticosteroid or ACTH therapy may lead to clinical signs of the disease.

11) Sex

It is commonly seen elderly esp. males but strong evidence of developing diabetes in females with multiple pregnancy has been observed or in females suffering from Polycystic Ovarian Syndrome (PCOS)

12) Drug induced

Clozapine, olanzapine, risperidone, quetiapine, & ziprasidone are known to induce type 2 DM

13) Infection

Some of the staphylococci are supposed to be responsible factor for infection in pancreas

PURVARUPA  (Premonitory signs and symptoms)

            The prodromal features are those, which appear before the onset of the disease, that is before the involvement of the specific dosha. The clinical features manifested incompletely due to the pathogenic process being minimal should be taken as the specific prodromal features of the disease.

1. Jatilibhavam kesheshu– matting of the hair
2. Madhurya masasya- sweet taste in the mouth
3. Karpadayo suptatadaahi- numbness & burning sensation in hands &legs
4. Mukha taalu kantha shosha-dryness of the mouth, throat & palate
5. Pipasaam-polypepsia
6. Aalasya-fatigue
7.  Malam kaaye- exudation of excreta from the body
8. Kayachhidreshu padeham- feeling as if the body covered with  extraneous material
9. Shatpada pipilikabhishcha- swarming of ants over the body, attraction of ants by the body
10.  Mutre abhidhawanti pipilikaashcha- swarming of ants on the urine, urine attracting ants
11.  Mutrecha mutradoshan- different doshas entered the urinary tract in vitiated conditions
12.  Swedo angagandha- sweating ,emanation of foul smell from the   body
13.  Snigdha picchil gurugatranaam- heaviness of the body
14.  Saada- fatigued, weakness
15.  Shwasa- breathlessness
16. Talu gala jivha danteshu malotapatti- excessive formation of excreta from palate, throat, tongue, dentures etc.
17.  Vruddhishcha nakhanaam- excessive growth of nails
18.  Sheetapriyatvam- liking for cold things
19.  Keshyavruddhi- excessive growth of the hair
20.  Hrunetra shravanopadeha- exudation of excreta from eyes, tongue and ears
21.  Shithilatvam ange- flabbiness of the body
22.  Sweda- sweating
23. Shayyasanswapnasukha tarbhashanga- liking for constantly lying on the bed, sitting, sleeping and leading an easy life , a feeling as if the cardic region is covered with extraneous material
24.  Ghanaangata- corpulence of the body
25.  Paridaaham- burning sensation
26.  Suptatachaangenshu- numbness of the body

SYMPTOMS OF PRE-DIABETES

            Although most people with pre- diabetes have no symptoms at all. Symptoms of Diabetes may include unusual thirst, a frequent desire to urinate, blurred vision, or extreme fatigue. Very obese children and very obese adolescents may show pre-diabetes & diabetes like symptoms. Medical investigations like Fasting Plasma Glucose (FPG), & Impaired Glucose Tolerance (IGT) may show signs that suggest pre- diabetes may be present.

Investigations and Diagnosis

Diagnostic tests  for Prediabetes are Fasting Plasma Glucose test (FPG) & the Oral Glucose Tolerance Test (OGTT) and are done for all ages and races .If blood glucose level is abnormal following the FPG, it is Impaired Fasting Glucose (IFG) .If  blood glucose level is abnormal following the OGTT,it is Impaired Glucose Tolerance (IGT).

                

         

            FPG                                       OGTT

Diabetes types & reversal

DIAGNOSIS OF PRAMEHA ACCORDING TO AYURVED

            In a person who finds premonitory signs & symptoms of Prameha also with excessive urination, should be diagnosed as Pramehi. Also who finds total or atleast half of these signs & symptoms with excessive urination, is diagnosed as Pramehi.

PRAMEHA UPADRAVAS

            Complications of prameha are thirst, diarrhea, fever, burning sensation, weakness, anorexia, and indigestion. Carbuncles which putriify the muscle tissues like alaji and vidradhi appear during the chronic stage of the disease.

Samprapti

All pramehas finally leads to madhumeha. Tridosha and rest sampratpti ghataks take part in the pathogenesis of madhumeha as follows:

TREATMENT OF PREDIABETES

1.      Lose modest amount of weight (5-10% of total body weight) through diet and moderate exercise, such as walking-30mins a day and 5 days a week.

2.      Treatment for cardiovascular risk factors, such as smoking, tobacco chewing, hypertension and high cholesterol.

           

            Pramehas get immediately cured by different types of strenuous exercises, unction, bath, sprinkling of water over the body and application of ointment made by sevya (ushira), tvak, ela, aguru,candana, etc.

            Factors responsible for the causation of different types of Prameha should be avoided even after these pramehas are manifested. For the prevention of the occurrence of a disease different etiological factors are described during the treatment of that particular diseases (even after its manifestation)

            Patients suffering from Prameha can be classified into two categories .viz.,

1)      Those who are Obese and strong

2)      Those who are Emaciated and weak

Patients belonging to the latter category should be given nourishing therapy. Patients of the former category who are strong and who have more doshas in the body should be administered elimination therapy.

For elimination therapy (Vamana, Virechana) , various recipes are described. After the excreta are eliminated from the body, the patient should be given santarpana or refreshing therapy because apatarpana (fasting) therapy in this condition may produce gulma (cystic tumour) , consumption, pain in phallus and urinary bladder including kidney and  retention of urine. Such patients should be given santarpana therapy depending upon their power of digestion.

Factors responsible for the causation of different types of Prameha should be avoided even after these pramehas are manifested. For the prevention of the occurrence of a disease different etiological factors are described to be avoided. These very causative factors are also required to be avoided during the treatment of that particular  diseases (even after its manifestation).

Pramehi should live like sanyasi (muni) without covering over the head and should walk bare footed 100 yojan (~300km) or should get in physical work like digging well, ponds etc. or should have their livelihood on urine and cowdung and should always live in the company of cows.

APATHYA (STRICTLY CONTRAINDICATED)

            Sitting on the same place continuously (not doing physical work), sleeping during day time, using new cereals, curd in meals, suppression of urge of passing urine, smoking, hot fomentation, blood letting, drinking alcohol, like sauvirak, sura etc taila (oils), ksharghruta (ghee), guda (jaggery), sour foods, sugarcane juice, pishtanna (food rich in carbohydrates) and meat of aquatic animals.

PATHYA (INDICATED)

            Vegetables having bitter taste, padawal,(bitter gourd) meat of non-domesticated animals, saidhav lavan (rock salt) and pippali (Piper longum), Shali type of rice, pulses  like moong, kulitha (pulses)

FOLLOW UP

            If a person’s blood sugar levels (BSL) is in normal range, it is advised and reasonable to be checked every 3 yrs, If one is diagnosed for having pre-diabetes, blood sugar levels are to be checked for type 2 diabetes every year at least for 3 years, after the diagnosis.

A large 3 year medical study in patients at risk of developing type 2 diabetes suggests that lifestyle changes with exercise and mild weight loss, and treatment with medications that work to sensitize a person to the actions of insulin, can decrease the chance that a person with pre-diabetes will get type 2 diabetes.

            Changing the person’s lifestyle habits with increased physical activities and mild weight loss was more effective than medications at reducing the risk of developing type 2 diabetes. For some people with pre-diabetes, intervening early can actually return increased blood sugar levels to the normal range.

References

1)      Dr.Ambikadatta shastri , Editor,(14^th edi)Susruta samhita nidan sthana chapter 6/3 chaukhamba publications Varanasi.

2)      Pandye G.S Editor,(6^thedi.)Charak samhita nidan sthana chapter  4/46 ,chaukhamba publications Varanasi

3)      Dr.Ambikadatta shastri , Editor,(14^th edi)Susruta samhita nidan sthana chapter 6/5 chaukhamba publications Varanasi.

4)      Shri.Lalchandra Vaidya,Editor (6^th edi)Ashtang Hrudayam of Vagbhat nidan  sthan chapter 10/38,Motilal Banarasidas Varanasi

5)      Pandye G.S Editor,(6^thedi.)Charak samhita sutra sthana chapter  21/8,chaukhamba publications Varanasi

6)                   

Narendranath shastri (edi 5^th 2005)Madhavnidanam medorog chapter ,Motilal Banarasidas Varanasi

7)      Pandye G.S Editor,(6^thedi.)Charak samhita sutra sthana chapter  21/20,chaukhamba publications Varanasi

8)      Pandye G.S Editor,(6^thedi.)Charak samhita sutra sthana chapter  28/29,chaukhamba publications Varanasi

9)      Dr.Ambikadatta shastri , Editor,(14^th edi)Susruta samhita sutra sthana chapter 24/9, chaukhamba publications Varanasi.

10)  Dr.Ambikadatta shastri , Editor,(14^th edi)Susruta samhita sutra sthana chapter 24/9, chaukhamba publications Varanasi.

11)  Dr.Ambikadatta shastri , Editor,(14^th edi)Susruta samhita sharir sthana chapter 9/12, chaukhamba publications Varanasi.

12)  Yoga Ratnakara, Edition 1^st , edited by Dr. Indradev Tripathi, Krishnadas Academy, Varanasi, India, 1998

13)  Harrison’s Principles of Internal medicines, edition 15^th, edited by – Eugene braunwald, Amthonys fauci etc, Published by Mc. Graw Hill New York, USA, 2001.

14)     K sembulingam, 5^th edition, essentials of medical physiology,jaypee brothers,medical publishers, new delhi

15)  Dr. sujit k. chaudhari, 2^nd  edition, quintessence of medical    pharmacology, new central book agency,Calcutta

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17)   Principles and practice of medicine; 16th edition. Davidson

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19) www.diabetesinformationhub.com

20) http:/www.diabetes.org/pre-diabetes

21) http:/www.ndep.nhih.gov/campaigns/smallsteps

1)                                                                                                             

Name                                  - Prof .Dr.D.L.Shinde                     

Educational Qualifications –MD;PhD (Kayachikitsa), Pune University

Permanent Address            - Bharati Vidyapeeth University ,College Of Ayurved,Katraj-            

                                              Dhanakawadi,Pune-43

Date Of birth                      - 3^rd April, 1968

Family background            - I belong from a respectable farmer’s family.

Qualities                            – Hardwork,Honesty, Integrity, Peaceful, Enthusiastic, Accomodative  

                                             & tough

Area Of Specilization Studies

1)      Diabetes, Hypertension, Atherosclerosis ,Metabolic Syndrome, cardiac diseases

2)      Spinal Cord injuries, Nervous System Disorders & Rehabilitation.

3)      AIDS & related infections like Herpes Zooster, skin infections etc.

4)      Research –Osteoarthritis project at IRSHA ,Bharati Vidyapeeth

Work Experience

Teaching & clinical experience for 20 yrs.

Book published – Anna He PurnaBrahma, Executive Editor – Arogya Sarita –monthly magazine

Lectures on Pune Akashwani

Lectures at social organizations ,conducting CME for medical fraternity

Organizing medical camps

Lectures as Resource person