Words: Prof G G GANGADHARAN
Diabetes mellitus [DM], ranked as one of the four principal non-communicable diseases [NCD], affects 422 million people worldwide. It is the seventh leading cause of disability and is directly responsible for 1.5 million deaths, with another 2 million attributed to related causes. The economic cost of DM, which includes cost of medical care and wage loss, has been estimated to be US$825 billion globally, with China [$170 billion], the USA [$105 billion], India [$73 billion], and Japan [$37 billion] bearing the brunt of the burden. The perception of individuals of ‘healthcare’ as extending beyond the mainstream allopathic system to encompass a wide range of traditional medical systems and complementary healthcare practices must be taken in to account when combating DM and other NCDs.
Complementary and alternative medicine [CAM] use in DM is widespread, with Ayurveda being used by patients with estimated rates of 14, 16.2 and 40 per cent in India and 13.6 per cent in Malaysia. 29.6 per cent of users in one survey reported lowering of blood sugar with concomitant use of Ayurveda and allopathy; however, it is difficult to evaluate the effect of Ayurveda per se as it raises questions about possible drug interactions. Few patients informed their allopathic physician [29 per cent], or consulted them before starting CAM treatment [20 per cent]. This suggests that allopathic physicians may benefit from knowing more about CAM systems such as Ayurveda.
The Basics
The closest clinical correlate to DM in Ayurveda is the disease entity prameha. The proposed aetiologies of prameha, i.e., aberrant genetic factors [sahaja] and unhealthy diet and lifestyle [apathyanimittaja] overlap considerably with modern medical theories of DM. Unhealthy lifestyle includes lack of physical and mental exercise and excessive daytime sleep. Overeating, alcohol abuse, excessive consumption of food that is heavy [guru], unctuous [snigdha], sour [amla] and salt [lavana], are unhealthy dietary habits in this context. Individuals with prakriti dominated by either kaphadosha [kaphaprakriti], or a combination of vataand kaphadosha [vatakaphaprakriti] are considered at greater risk of prameha.
This hypothesis is supported by correlation of these prakriti types with risk factors for cardiac disease like insulin resistance, cytokine [IL6] and inflammatory markers. Kaphaprakriti is significantly correlated with BMI and high levels of triglyceride, total cholesterol, VLDL and low levels of HDL. Recent evidence supports a genetic basis for various prakriti types and differential disease susceptibility. Fifty-two single nucleotide polymorphisms have been identified that significantly differentiate between kapha, vata and pitta prakriti. More specifically, kapha prakriti shows a strong correlation with 34 unique regions of DNA methylation and high BMI simultaneously and CYP2C19 gene polymorphism associated with slow metabolism of various drugs. This is particularly relevant to the central role of metabolism [agni] in prameha according to Ayurveda; what’s more, a sub-optimal agni leads to nutritional aberration at the tissue [dhatu] level, progressively affecting the nourishment of multiple tissues [dhatukshaya] in due course.
Multifactorial Approach
The multifactorial approach to disease conceptualisation in Ayurveda coupled with the fundamental therapeutic principle of restoring balance between the dosha [homeostasis] results in a multi-component management strategy including pharmacotherapeutics, systemic cleansing [shodhanachikitsa], dietary and lifestyle modification. The goals of treatment in Ayurveda are apunarbhavatva, or achieving homeostasis that does not relapse to the prior diseased stage [non-recurring] and yonyamanyamudeerayet, or achieving homeostasis without causing any disturbance to any other systems, or without side-effects.
Treatment of DM is customised based on prakriti [constitution] and disease stage. Dietary modification is an essential component of clinical management; further it is strongly recommended for prevention of prameha. For example, ensuring optimal nutrition and mild exercise is the focus for patients of lean build [krisha], while cleansing and weight loss via light, yet nutritious diet and vigorous exercise are prescribed for overweight, or obese [sthula] patients. Portion size and number of meals are to be tailored to individuals’ agni [metabolic capacity].
Commonly prescribed dietary items include cereals like barley [Hordeum vulgareL], wheat [Triticum aestivum] and aged rice [Oryza sativa]; pulses like green gram [Vigna radiata], bengal gram [Cicer arietinum], horse gram [Macrotyloma uniflorum]; vegetables like bitter gourd [Momordica charantia]; fenugreek [Trigonella foenumgraecum], snake gourd [Trichosanthes cucumerina]; garlic [Allium sativum Linn]; fruits like Java plum [Syzygium cumini]; Indian gooseberry [Phyllanthus emblica], wood apple [Limonia acidissima], date palm [Phoenix sylvestris] and Indian fig [Ficus racemosaL]; meat of animals like deer and rabbit and birds like pigeon and partridge and aged wine. A number of herbs prescribed in Ayurveda for DM have anti-hyperglycaemic, anti-hyperlipidemic, antioxidant, insulin-sensitising and pancreatic beta cell regenerative activity, demonstrated using in vivo and in vitro models of diabetes mellitus.
These include Guduchi [Tinospora cordifolia], Jambu [Euginia jambolana], Aswattha [Ficus religiosa], Bijasara [Pterocarpus marsupium, Apamarga [Achyranthes aspera], Patraka [Cinnamomum tamala], Karavellaka [Momordica charantia], Gudmar [Gymnema sylvestre], Palandu [Allium cepa], Mamejjak [Enicostemmalittorale], Lasuna [Allium sativum], Daruharidra [Berberis aristata]; Bimbi [Coccinia indica] and Nipava [Cyamopsistetragonoloba].
Clinical Studies
Clinical trials have predominantly tested proprietary, polyherbal preparations rather than medicines, or treatment regimens used in routine clinical practice. Significant reductions in glycosylated haemoglobin [HbA1C], fasting and post-prandial blood glucose have been demonstrated for several preparations. But, the results are undermined by methodological weaknesses, such as inadequate sample size and lack of proper randomisation and allocation concealment.
Despite common usage of Ayurveda simultaneously with allopathy, there has been little research on integrative clinical care. A randomised, double-blind placebo-controlled crossover study found that addition of a polyherbal tea containing Pterocarpus marsupiumRoxb, Salacia reticulata Wight, Cinnamomum zeylonicum Blume, Artocarpus heterophyllus Lam and Tinospora cordifolia [Willd].
Hook F&Thoms for three months to a standard regimen of glibenclamide significantly improved glycaemic control with few and mild gastrointestinal side-effects. It is important to note that these studies evaluated the efficacy of a single pill, or tonic, rather than ‘whole-system Ayurveda,’ i.e., the customary practice of following an entire regimen of internal and external medications, diet, exercise and other interventions, customised to individual patients. A preliminary investigation of a modified form of whole-system Ayurveda, adding diet, exercise and meditation, according to principles of Ayurveda to a single polyherbal pill has shown limited benefit in patients with high baseline HbA1C, indicating the need for further study.
Conclusion
Ayurveda has a well-developed conceptual framework for DM; it incorporates diet and lifestyle as causative factors and a multifactorial approach to management. While there is evidence from preclinical studies to support the proposed actions of many herbs, clinical trials are but just a few.
Ayurveda also has prescriptions for prevention of diabetes mellitus, which have received little attention. The holistic approach of Ayurveda, which includes medication, diet and exercise regimens seems well-suited to the management of lifestyle disorders such as DM.
While there is increasing understanding of the mechanisms of action of several herbs used in Ayurveda, there is little clinical research on the efficacy and safety of Ayurveda management. Given the national and international focus on mainstreaming traditional systems, further research is urgently required.
The overall clinical effect of whole system treatment regimen as well as potential interactions with allopathic medicines should be investigated. Outcomes should include biochemical parameters, psychological well-being, ability to achieve and maintain changes in diet and cost-effectiveness.
Prevention of disease and maintenance of health that are critical management strategies in Ayurveda and other traditional medicine systems are also valuable areas of exploration, given the vital need to arrest the rapid increase in NCD prevalence. Finally, patients with DM are already practicing integrative medicine; this behooves medical practitioners of all systems to develop safe, evidence-based models of integrative care for the benefit of society.
