Prameha in terms of Diabetes Mellitus, Metabolic syndrome and ...

Prameha in terms of DiabetesMellitus, Metabolic syndrome andObesity with recent advances in itsmanagementProf. H.M. Chandola M.D.(Ay) Ph.DProfessor & Head – Kayachikitsa, Ex-DeanInstitute for Post Graduate Teaching & Research in AyurvedaGujarat Ayurved UniversityJamnagar – 361 008, Gujarat (India)1

Etiological FactorsAsyasukham swapnasukham dadhinigramyodakanuprasah payansi,Navannapanam gudvaikratam chPramehahetuh kaphakrichh sarvam.(Charak, Chikitsa 6/4)Addiction to the pleasures of lounging and sleeping,the excessive use of curds, meat juice of domestic,aquatic and wet-land animals, milks, new grains anddrinks & products of gur and all things that increasekapha are the causative factors of Prameha.3

Purvarupa (Premonitory Symptoms)of PramehaSwedoangagandhah shithilangata chshayyasanswapnasukhe ratishch, hrinetrajivhashravanopadehoghanangata keshanakhativridhih sheetapriyatvam galatalushoshomadhuryamasye karpadadahah bhavishyato mehagadasyarupammutre bhidhavanti pipilikashcha(Charak, Chikitsa 6/13-14)Excessive sweating with foetid odour, flabbinessof body, inclination to lie down, sedentary habits,excessive mucosal discharge, obesity andflabbiness, rapid growth of hairs and nails, thirst,sweetness of mouth, burning sensation in hands& feet, swarming of ants on the urine.4

Prognostic classification1. Sadhya (Manageable) Apathyanimittaja Prameha (NIDDM) Kaphaja Prameha (Early Diabetes) Sthula Pramehi (Obese Diabetics)2. Yapya (Palliative) Pittaja Prameha (Acute Diabetes)3. Asadhya (Unmanageable) Sahaja Prameha (IDDM) Vataja Prameha (Chronic Diabetes) Krisha Pramehi ( Asthenic Diabetics)8

Metabolic syndrome• Central obesity• High cholesterol• High triglycerides• Low HDL cholesterol• Hypertension• Insulin resistance• Hyperglycemia.10

Obesity• Obesity is a state of increased body weight, due toadipose tissue accumulation, that is of sufficientmagnitude to produce adverse health effects. Centralor visceral obesity is associated with a much higherrisk for several disorders and diseases, includingdiabetes, hypertension, hypertriglyceridemia,decreased high-density lipoprotein (HDL)cholesterol, proteinuria, osteoarthritis, pancreatitis,gallstones, fatty change in the liver, hypoventilationsyndrome,etc.11

Diabetes mellitus• Diabetes mellitus is a chronic disorder ofcarbohydrate, fat, and protein metabolism, with arelative or absolute deficiency in insulin secretoryresponse resulting in hyperglycemia. Insulinresistance is a major factor in the development ofType 2 diabetes, which is seen in obese patients.12

Diagnostic criteriaDiabetes• Fasting plasma glucose ≥7.0mmol/l (126mg/dl) or• 2–h plasma glucose* ≥11.1mmol/l (200mg/dl)Impaired Glucose Tolerance (IGT)• Fasting plasma glucose

Diabetes as Prameha &MadhumehaSarva ev Pramehastu Kalena parti karinahMadhumehatvamayanti Tadasadhya bhavantihi(Sush. Nidana 6/29)Jatah Pramehi Madhumehinova na Sadhyauktahsahi Beejadoshat.Ye chapi kechitkulaja vikara bhavantitamstanPravadantya sadyan (Ch.Chi. 6)14

Diabetes as Prameha &MadhumehaUpekshayasya jayante pidaka Madhumehikah(Ch.Su.17)Madhumehe madhusam jayate sa kildwidhaKruddhe dhatukshayadyayaudoshavrittpatheathvaAvritto doshalingani soanimittam pradarshyanKshanatksheenah Kshanatpurno bhajateKrichra sadhyatam (Madh. Pram. Ni 24-25)15

Diabetes as Prameha &MadhumehaMadhuram yacch meheshu prayo madhvivmehatiSarveapi madhumehakhya madhuryacchtanoratah (Vag. Nidan 10/Madh. Pram. Nidan 26)16

Pathogenesis of Kaphaja PramehaOver eatingGeneticsRestPidikaMansaMuscletissueShleshmaG.H.Insulin inactivationInhibited glucose uptakeMedaKledaF.F.A.Sharir KledaHyperglycemiaBastiKidneyMedaAdiposetissueBahumutrataPolyuria17

Pathogenesis of Pittaja PramehaPidikaMansaMuscletissueOver eatingGeneticsPittaAdrenalInsulin inactivationInhibited glucose uptakeMedaKledaF.F.A.Sharir KledaHyperglycemiaBastiKidneyStress strainMedaAdiposetissueBahumutrataPolyuria18

Schema showing correlation of differenttypes/stages of Prameha with DiabetesMellitusDiabetes MellitusNIDDM(Kaphaja, Pittaja Prameha)IDDM(Vataja Prameha/Madhumeha)Early Diabetes Acute Diabetes Chronic Diabetes G.H. Catecholamine Cortisol InsulinKaphaja Prameha Kapha +++ Pitta ++ Vata +++Pittaja Prameha Pitta +++ Kapha ++ Vata ++Vataja Prameha Kapha +++ Pitta +++ Vata +++19

Dosha-Dushya Samgraha• Ayurveda describes 20 subtypes of Prameha as differentclinico-pathological conditions produced out of specificDoshas and Dushyas, showing gross urinary characteristicsand clinical manifestations.• The fractional changes in dushyas namely Meda, Mamsa,Kleda, Shukra, Shonita, Vasa, Majja, Lasika, Rasa & Oja,in association with three morbid doshas manifests differentsubtypes of prameha.20

Early diabetes (Kaphaja Prameha)• Udakameha- Clear urine in larger quantitywithout odour, feels cold sensation while passingurine.• Ikshuvalikameha – Very sweet urine, cold,slightly turbid due to slimy substances and likecrushed cane sugar.• Sandrameha – Precipitate is deposited in the pot,if urine is kept overnight.• Sandra Prasadmeha- Described as Surameha bySushruta & Vagbhata. Literally, sandraprasadmeans -some portion of urine is turbid & some isclean like un-distilled alcohol (Sura).21

Early diabetes (Kaphaja Prameha) contd..• Shuklameha – Urine seems to be mixed with some paste.While passing urine patient feels erection of body hairs. Itis described as Pistameha by Sushruta.• Shukrameha, – Patient passes urine similar to quality ofsemen or semen itself may be mixed with urine.• Sheetameha–Urine is very sweet & enormous with lowtemperature.• Siktameha - Patient start passing small particles like sandin urine.• Sanairmeha- Flow of urine becomes slow & patient feelsdifficulty in passing urine.• Lalameha –Quality of urine is turbid & slimy. It is sticky& threads may be demonstrated like gum.22

Acute diabetes (Pittaja Prameha)• Kalameha –Urine is blackish.• Nilameha –Urine is bluish.• Lohitameha –Urine contains blood and saltish intaste with putrid odour. It is described asShonitmeha by Sushrata & Raktameha by Vagbhata& Madhava.• Manjishthameha –Urine is pink like decoction ofManjishta having putrid odour.• Haridrameha- Urine is turmeric yellow, pungent &associated with severe burning sensation.• Ksharmeha –Not named on the basis of colour.Urine is like an alkali (ash) solution, in smell, colour23and touch.

Chronic diabetes (Vataja Prameha)• Vasameha- Urine contains fat (vasa).• Majjameha –Urine contains bone marrow (majja).It is described as Sarpimeha by Sushruta.• Hastimeha –Lymph (lasika) is passed in the urine.Flow & frequency of urine is almost continuous(incontinence). Simile of such patients is givenwith adult elephant as regards passes of urine.• Madhumeha –Essence of body – Oja, is passed inurine and its taste is sweet & little astringent likehoney.24

Different subtypes of PramehaDiagnosed by examination of Urine incases of D.M.543210KaphajaPramehaPittajaPramehaVatajaPramehaShaneirmehaSandramehaIkshumehaSheetamehaUdakamehaShuklamehaRaktamehaHaridramehaVasamehaMajjamehaSahaj Madhumeha25

Investigations• Fasting Blood Sugar• Post Prandial Blood Sugar• Lipid Profile• Renal Function Test• S. Insulin• Glycated Hb (HbA1c)26

Complications of Prameha (A.S)KaphajaPittajaVatajaPratishyaya (coryza)Sharira shaithilya (laziness)Arochaka (anorexia),Avipaka (indigestion),Praseka(excessive salivation),Chhardi (vomiting)Nidra (hypersomnia),Kasa (cough)Amlika (hyperacidity)Pipasa (excessive thirst)Jvara (fever)Daha (burning sensation)Murchchha (fainting)Atisara (diarrhea)Pandu (anemia)Vrishanavadaranam(cracking of the scrotal skin)Bastimedhra toda(pain in the penis and bladderregionHridgraha(heaviness in the chest)Laulyam(excessive hunger)Anidra (insomnia)Kampa (tremors)Shulam (pain)Baddha purishatvam(constipation)Kasa (cough)Shwasa (dyspnea)

Role of PsychosomaticConstitution (Prakriti) in theProgression and Prognosis ofDiabetes Mellitus –PramehaTreatmentand Response to28

Point ofExaminationVataja Pittaja KaphajaForehead Narrow Medium BroadEyesTeethRound, ugly,dull and duskySmall, Thinand irregularNarrow, fissured,tawny unstableYellowish, irregularwith cavitiesLarge white andshinyShapely anddenseChest Narrow Medium Well formedNailsThin, dry,brittleThin, smooth pinkishor copper coloredThick, smooth,shiningEye-browsNot regular,thinThinThick andregularCalf Small & hard Lax and soft Well formed30

Physiological ExaminationPoint ofExaminationVataja Pittaja KaphajaAppetite, thirst& digestionTakes meal andwater swiftly,constipationEats and drinksrepeatedly, loosemotionsEats slowly,appetite digestionfairDietary likingsLight warmsweet tastesSweet bitter astringentand cold food drinksHot, bitter scar,food drinksPerspiration &micturitionLess quantity Profuse ModerateSexual potency Poor Moderate StrongLiking forcoldnessTolerance toheatMinimum Maximum ModerateMaximum Minimum Moderate31

Psychological ExaminationPoint ofExaminationVataja Pittaja KaphajaPsychic nobility Minimum Maximum ModeratePiousness Minimum Maximum ModerateCourage andboldnessCalmness ofmindMinimum Maximum ModerateMinimum Medium MaximumGrasping power Excellent Moderate MediumMemory Poor Excellent Good32

Ponderal Index and Body Surface Area inDifferent Constitutions of Diabetics461.7Ponderal Index44421.61.5Body Surface Area Sq. mt.Ponderal IndexBody SurfaceArea40Vataja Pittaja Kaphaja1.433

Management of Diabetes• Bio-purification – for obese patients,• Pacificatory measures - Diet control, exercise &therapeutic regimen.• General principle indicated for treatment of Obesity(Medoroga) is also applicable for diabetes (prameha)because primarily fat (meda) and kapha are involvedin both the diseases.• Various ayurvedic drugs as single or polyherbal,herbo-mineral, fermented preparations as Asava &Arishta, Decoction & disease specific medicatedghee, oil etc.34

Neurohumors in different psychosomaticconstitutions (Prakriti) of healthy subjectsV- Vataja P- Pittaja K – Kaphaja1.51 00.230Acetylcholine microgram /ml. of RBC10.58642Histamine microgram /ml. of blood0.1Cortisol microgram % of Plasma20100V P KAcetylcholamine0V P KC atecho lamines0V P KHistamine0V P KCortisol35

G.T.T. & Plasma Insulin in differentpsychosomatic constitutions of Diabetics60016Blood Sugar mg. %500400300200100GTTVatajaPittajaKaphajaPlazma Insulin Micro Unit/ml.1412108642InsulinDiabeticsControl0Fasting 1st hr. 2nd hr.0Kaphaja Pittaja Vataja36

Neurohumors in different psychosomaticconstitutions (Prakriti) of DiabeticsV- Vataja P- Pittaja K – Kaphaja1.5Acetylcholine microgram /ml. of RBC10.51 61 41 21 08642Histamine microgram /ml. of blood0.20.1Cortisol microgram % of Plasma403020100V P KAcetylcholamine0V P KC atecho lamines0V P KHistamine0V P KCortisol37

G.T.T. & Plasma Insulin in differenttypes of Prameha/Stages of D.M.60016Blood Sugar mg. %500400300200100GTTVatajaPittajaKaphajaPlazma Insulin Micro Unit/ml.1412108642Insulin0Fasting 1st hr. 2nd hr.0Control Kaphaja PittajaVataja38

Variations in Neurohumors in differenttypes of Prameha/Stages of D.M.C- Control K- Kaphaja P – Pittaja V- Vataja1.51 60.240Acetylcholine Microgram /ml. of RBC10.51 41 21 08642Histamine microgram /ml. of blood0.1Cortisol microgram % of Plasma3020100C K P VAcetylcholine0C K P VC atecho lamines0C K P VHistamine0C K P VCortisol39

Fasting Blood Sugar & Plasma insulin indifferent body constitutions in diabetics30020Blood Sugar mg. %260220180140VatajaPittajaKaphajaPlasma Insulin micro unit/ml161284VatajaKaphajaPittaja1005yr05yrDuration of illnessDuration of illness40

Dietary Management• The best foods to eat are those that are not sweet, not toooily, have the ability to mitigate kapha , meda and arenourishing.• Ushna (warm) diet is recommended since it will easeKapha, normalize Vata, and stimulate Pitta to intensifydigestion.• In the diet importance should be given to Yava (Barley).• Other spices with antidiabetic are Haridra, Dhanyaka,Jeeraka, Rasona, Methika, Cinnamom etc.• Ayurveda recommends use of Anupana along with diet andany herbs that are being utilized like: Sarodaka, Kushodaka.41

Lifestyle Management•Patients are advised to avoid laziness and sedentarylifestyle.•Sushruta emphasizes importance of regular exercise,including brisk walk, jogging, sports and so on.•Patients are advised to to do Yoga, Pranayama, study theirrespective religion scriptures, which highlight thedevelopment of a positive mental attitude and decreaseanxiety and stress.42

Sr.No.Pramehahara and Madhumehahara(Anti-diabetic) Drugs in AyurvedaName of the Drug Latin Name CharakSamhitaSushrutaSamhitaAstangaHrdaya1. Daruharidra Berberis aristata + + +2. Devadaru Cedrus deodara + + +3. Haritaki Terminalia chebula + + +4. Vibhitaki Terminalia bellirica + + +5. Amalaki Emblica officinalis + + +6. Musta Cyperus rotundus + + +7. Haridra Curcuma longa + + +8. Katphala Myrica esculenta + + +9. Lodhra Symplocos racemosa + + +10. Patha Cyclea peltata + + +43

11. Vidanga Embelia ribes + + +12. Arjuna Terminalia arjuna + + +13. Dhanvana Grewia tiliaefolia + + -14. Tagara Valeriana wallichii + + +15. Kadamba Anthocephalus indicus + - -16. Shalasara Shorea robusta + + +17. Yavani Trachyspermum ammi + + +18. Khadira Acacia catechu + + +19. Dhava Anogeissus latifolia + + +20. Kustha Saussurea lappa + + +21. Aguru Aquilaria agallocha + + -22. Chandana Santalum album + + +23. Agnimantha Premna integrefolia + + +24. Murva Marsdenia tenacissima + + +25. Gokshura Tribulus terrestris + - -44

26. Ushira Vetiveria zizanoidis + + +27. Guduchi Tinospora cordifolia + + +28. Chavya Piper retrofractum + - -29. Chitraka Plumbago zeylanica + + +30. Saptaparna Alstonia scholaris + + +31. Patola Trichosanthes dioica + + +32. Nimba Azadirachta indica + + +33. Padmaka Prunus cerasoides + + -34. Kutaja Holarrhena antidysenterica + + +35. Dhataki Woodfordia fruticosa + + +36. Utpala Nymphoea stellata + + +37. Shirisha Albizzia lebbeck + + +38. Sarja Vateria indica + + +39. Nagakesara Messua ferra + + +40. Priyangu Callicarpa macrophylla + + +45

41. Palasa Butea monosperma + + +42. Aswatha Ficus religiosa + + +43. Asana Pterocarpus marsuppium + + +44. Vetasa Salix caprea + + +45. Kampillaka Mallotus philippinensis + + -46. Rohitaka Tecoma undulata + + -47. Kapitha Feronia elephantum + - -48. Asmantaka Ficus rumphii + - -49. Soma Ephedra gerardiana + + +50. Ativisha Aconitum heterophyllum + + +51. Vacha Acorus calamus + - +52. Manjistha Rubia cordifolia + + +53. Sati Hedychium spicatium + + +54. Pushkaramula Inula racemosa + + +55. Kramuka Areca catechu + + +46

56. Kiratatikta Swertia chirayita + + +57. Katurohini Picrorhiza kurroa + + +58. Bharangi Clerodendrum serratum + + +59. Pippali Piper longum + + +60. Indruvaruni Cirullus colocynthis + + +61. Vyaghranakha Capparis horrida + - -62. Tejapatra Cinnamomum tamala + + +63. Maricha Piper nigrum + + +64. Danti Baliospermum montanum + + +65. Bhallataka Semecarpus anacardium + + +66. Aragvadha Cassia fistula - + +67. Madanaphala Randia spinosa - + +68. Vikankata Flacourtia ramontchi - + +69. Patala Stereospermum suaveolens - + +70. Kuruntaka Barleria prionitis - + +47

71. Gunja Abrus precatorius - + +72. Kakajangha Peristrophe bicalyculata - + -73. Karanja Pongamia pinnata - + +74. Chirabilva Holopte lea integrifolia - + +75. Karavellaka Momordia charantia - + +76. Kadara Acacia suma - + +77. Bhurja Betula utilis - + +78. Shyonaka Oroxylum indicum - + +79. Meshashrangi Gymnema sylvestre - + +80. Tinisa Ougenia oojeinensis - + +81. Raktachandana Pterocarpus santalinus - + +82. Shinshapa Dalbergia sissoo - + +83. Talamuli Curculigo orchioides - + +84. Shaka Tectona grandis - + +85. Aswakarna Dipterocarpus turbinatus - - +48

86. Mushkaka Schrebera swietenioides - + +87. Snuhi Euphorbia nerifolia - + +88. Sunthi Zingiber officinale - + +89. Paribhadra Erythrina variegata - + +90. Sheivalam Ceratophyllum demersum - + +91. Jalakumbhika Pistia stratiotes - + +92. Durva Cynodon dactylon - - +93. Kaseruka Scirpus grossui - - +94. Vata Ficus bengalensis - + +95. Tinduka Diospyros peregrina - + +96. Kasmarya Gmelina arborea - - +97. Kharjura Beeja Phoenix sylvestris - - +98. Hingu Ferula narthex - - +99. Duralabha Fagonia cretica - - +100. Sariva Hemidesmus indicus - - +49

101. Yuthika Rhinacanthus nasuta - - +102. Madayantika Lawsonia inermis - - +103. Dadima Punica granatum - - +104. Shalaparni Desmodium gangeticum - - +105. Mushali Asparagus adscendens - - +106. Punaga Colopfiyllum inophyllum - - +107. Shalmali Salmalia malabarica - - +108. Bakula Mimusops elengi - - +109. Shrangataka Trapa natans - - +110. Aralu Ailanthus excelsa - - +111. Kasa Saccharum spontaneum - - +112. Madhuka Glycyrrhiza glabra - - +113. Amra Mangifera indica - - +50

Recent advances• Shilajit (Asphaltum punjabinum) is anestablished treatment option for Prameha,Sthaulya, Hridroga etc, that not only mitigatesKapha and Meda, but also has Rasayana(Rejuvenating) property.• In a clinical study on patients with diabetes,Shilajit significantly reduced lipid peroxidationand significantly increased levels of catalase, anantioxidant enzyme.51

Aqueous and alcoholic extract ofGuduchi (Tinospora cardofolia (Willd))reduced glucose levels in rats with alloxaninduced diabetes. The antihyperglycemiceffect may be due to pancreatic islet freeradical-scavengingactivity. This herb alsoreduces the levels of tissue and serumcholesterol, phospholipids and free fatty acids.52

• Meshasringi (Gymmeme sylvestre (Tetz))targets several of etiological factors associatedwith diabetes, including chronic inflammation,obesity and pancreatic β-cell function.• In a study on rats with streptozotocin-induced diabetes, G.sylvestre treatment resulted in 30% increase in total pancreaticweight, and a significant increase in the number of β-cells perislet. The regenerated pancreatic tissue resulted in completecontrol of fasting blood glucose levels within 20-60 days.• Several clinical trials have demonstrated that this drug is;effective in decreasing blood glucose, glycosylated hemoglobin,and glycosylated plasma proteins.53

Effect of Swertia chirata inmaturity onset diabetesBlood sugar mg %25020015010050Before treatmentAfter treatmentChirayata :Rasa –Tikta Veerya– Ushna Vipaka – KatuGuna – Laghu, Ruksha0Fastingblood sugarChirayata ghanavati : Svertia chirataDose: 1 gm. tid, Duration 2 months, n:9P.P. Bloodsugarn= 6(Bhatia S., Chandola H.M.2001) 54

C.tamala (Tejapatra)55

Effect of C. tamala (Tejpatra) on fastingblood sugar in maturity onset diabetesBlood sugar mg. %180170160150140130120110100Diet ControlGroupDrug TreatedGroupBefore TreatmentAfter Treatmentn - 3256

Effect of C. tamala (Tejpatra) on Fasting &P.P. blood sugar in maturity onset diabetes300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar1st hr. PP2nd hr. PPn –2557

Effect of C. tamala on fasting bloodsugar and plasma insulin in diabetesFasting Blood sugar mg. %2001000Before treatment After treatment3020100Plasma insulin micro unit/mlFasting SugrarInsulin58

Immediate effect of C. tamala on fasting bloodsugar cum plasma insulin in diabeticsFasting Blood Sugar mg. %170160150140130120110403020100Plasma insulin micro unit /mlFasting bloodsugarPlasma insulin0 hr. 1 hr. 2 hr.59

Pterocarpus marsupium (Vijayasara)60

Effect of Pterocarpus marsupium inmaturity onset diabetesBlood sugar mg %300250200150100500Fasting P.P. Bloodblood sugar sugar53.44 % fall 62.85 % fallBefore treatmentAfter treatmentn- 6Vijayasar :Rasa – Kashaya, TiktaVeerya – UshnaVipaka – KatuGuna – Laghu, Ruksha61

Tinospora cordifolia (Guduchi)62

Effect of Pterocarpus marsupium alongwith Tinospora cordifolia in maturityonset diabetesBlood sugar mg %350300250200150100500Fasting P.P. Bloodblood sugar sugar38.96% fall 52.76% fallBefore treatmentAfter treatmentGuduchi :Rasa – Katu, Tikta, KashayaVeerya – Ushna Vipaka– Madhur Guna –Laghu, Rukshan- 863

Effect of Pterocarpus marsupium alongwith Tinospora cordifolia and Momordicacharantia in maturity onset diabetesBlood sugar mg %40035030025020015010050Before treatmentAfter treatmentKaravellaka :Rasa – Tikta, Katu,Veerya – UshnaVipaka – KatuGuna – Laghu, Ruksha0Fastingblood sugarP.P. Bloodsugarn- 1245.34 % fall 51.46 % fall64

Effect of Cassia auriculata (Avartaki) inmaturity onset diabetes300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar26.90 % fall 26.93 % falln- 81st hr. PP2nd hr. PP25.97% fall65

Azadirachta indica (Nimba)66

Effect of Azadirachta indica (Nimba) inmaturity onset diabetes300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar22.96 % fall 27.11 % falln- 81st hr. PP2nd hr. PP30.85% fall67

Ficus glomerata (Udumbara)68

Effect of Ficus glomerata (Udumbara)in maturity onset diabetes300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar22.96 % fall 12.45 % falln- 81st hr. PP2nd hr. PP26.56% fall69

Polyherbal Compound (Mamejaka,Meshashringi & Jambu) in maturity onsetDiabetes Mellitus• Mamejaka (Enicostemma littorale)– Guna- Laghu, Ruksha– Rasa – Tikta– Veerya – Ushna– Vipaka – Katu– Part used – Panchang• Meshashringi/Gudmar/Madhunashini(Gymnema sylvestre)– Guna- Ruksha, Laghu– Rasa – Tikta– Veerya – Ushna– Vipaka – Katu– Part used – Leaf, Root bark• Jambu seeds (Syzygium cumini)– Guna- Laghu, Ruksha– Rasa – Kashaya, Madhur, Amla– Veerya – Sheet– Vipaka – Katu– Part used – Fruit, Kernal, Bark, Leaf70

Effect of Polyherbal Compound (Mamejaka,Meshashringi & Jambu) in maturity onsetDiabetes Mellitus300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar23.13 % fall 31.48 % falln- 81st hr. PP2nd hr. PP30.90% fall71

Effect of Compound Herbo-mineralformulation Chandraprabhavati inmaturity onset Diabetes Mellitus300Blood sugar mg. %250200150100Before TreatmentAfter Treatment50Fasting BloodSugar1st hr. PP20.13 % fall 12.65 % falln- 372nd hr. PP13.50% fall72

Student’s Paired ‘t’ Test** Highly significantDose: 1 gm thrice a day(after Breakfast, Lunch & Dinner)Duration: 3 monthsIngredients: Lauha Bhasma – 16 parts, Triphala – 3 parts,Trikatu – 3 parts, Guggulu – 4 parts,Rasanjana, Kiratatikta, Pippalimula, Gokshura,Devadaru, Bidalavana, Trivrutta, Dadim, Bilva (each 1 part)Tanna Ila, Chandola H .M. , 2010

Student’s Paired ‘t’ Test** Highly significant

Role of Constitution in treatment response300Response of C. tamala in Diabetes-In GeneralIn general and constitution wise3 0 0Kaphaja300PittajaVataja350Blood sugar mg. %2502001502 502 0 015010 0Blood sugar mg. %250200150Blood sugar mg. %30025020015010010050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment50F I hr. II hr.Before TreatmentAfter Treatment10050F I hr. II hr.Before TreatmentAfter Treatment75

Response of Inula racemosa in Diabetes -In general and constitution wiseIn General3503003 0 02 50Kaphaja300250Pittaja400350VatajaBlood sugar mg. %25020015010050F I hr. II hr.Before TreatmentAfter Treatment2 0 015010 050F I hr. IIhr.B efo re T reatmentA fter T reatmentBlood sugar mg. %20015010050F I hr. II hr.Before TreatmentAfter TreatmentBlood sugar mg. %30025020015010050F I hr. II hr.Before TreatmentAfter Treatment76

Response of Chandraprabha vati inDiabetes- In general and constitution wiseIn General3003 0 0Kaphaja300Pittaja350VatajaBlood sugar mg. %2502001502 502 0 015010 0Blood sugar mg. %250200150Blood sugar mg. %30025020015010010050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment50F I hr. II hr.Before TreatmentAfter Treatment10050F I hr. II hr.Before TreatmentAfter Treatment77

Response of Diabenese in Diabetes-In general and constitution wiseIn General3503003 0 02 50Kaphaja300250Pittaja450400VatajaBlood sugar mg. %2502001502 0 015010 0Blood sugar mg. %200150Blood sugar mg. %35030025020010050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment10050F I hr. II hr.Before TreatmentAfter Treatment15010050F I hr. II hr.Before TreatmentAfter Treatment78

Response of treatment in Diabeticswith different drugs in EarlyDiabetes (Kaphaja Prameha )300C. tamalaInulaChandraprracemosa abhavati3 0 0300350DiabeneseBlood sugar mg. %2502001502 502 0 015010 0Blood sugar mg. %250200150Blood sugar mg. %30025020015010010050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment50F I hr. II hr.Before TreatmentAfter Treatment10050F I hr. II hr.Before TreatmentAfter Treatment79

Response of treatment in Diabeticswith different drugs in AcuteDiabetes (Pittaja Prameha)300C. tamalaInulaChandraprracemosa abhavati4 0 0300350DiabeneseBlood sugar mg. %2502001503 503 0 02 502 0 0150Blood sugar mg. %250200150Blood sugar mg. %30025020015010010 010010050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment50F I hr. II hr.Before TreatmentAfter Treatment50F I hr. II hr.Before TreatmentAfter Treatment80

Response of treatment in Diabetics withdifferent drugs in Chronic Diabetes(Vataja Prameha)Blood sugar mg. %400350300250200150C. tamala InulaChandrapr4 50 racemosa abhavati4 0 03 503 0 02 502 0 015010 0Blood sugar mg. %400350300250200150Blood sugar mg. %450400350300250200150Diabenese10050F I hr. II hr.Before TreatmentAfter Treatment50F I hr. IIhr.B efo re T reatmentA fter T reatment10050F I hr. II hr.Before TreatmentAfter Treatment10050F I hr. II hr.Before TreatmentAfter Treatment81

Evaluation of Mental Health & Blood sugarlevel in 100 patients of Diabetes MellitusPsychic factorNo. ofPatientsMean FBSmg%Mean PPBSmg%Worry (Chinta) 70 159.31 222.78Anxiety (Udvega) 69 192.66 260.28Anger (Krodha) 69 158.18 225.03Grief (Shoka) 49 159.41 220.19Fear (Bhaya) 28 175.98 234.78Pleasure (Harsha) 1 185 213No psychicsymptom17 156.47 195.3482

Psychic Symptoms observed in100 patientsPsychic Symptom No. of PatientsAnxious 69Tension 70Fear 28Insomnia 67Intellectual cognitive 58Depressed Mood 49Somatic Muscular 56Somatic Sensory 57Cardiovascular 58Respiratory 4583

Psychic Symptoms observed in100 patientsPsychic Symptom No. of PatientsGastrointestinal 51Genitourinary 28Autonomic 57Behavior at interview 53Anger 69Suicidal thoughts 10No symptoms 1784

Effect of Sarasvata Formulation onpsychic symptoms in D.M.ParametersMean ScoreBTAT% ofreliefS.E.pAnxious 3.9 0.9 76.92 0.2

Effect of Sarasvata formulation inDiabetes MellitusParameterB.T.MeanA.T.%reliefS.E.FBS 152.2 123.8 18.66 8.05

Dose: 1 gm thrice a day before mealDuration: 3 monthPoly Herbal Anti diabetic Formulation (PAF):Shuddha Shilajeeta, Shuddha Guggulu, Triphala, Saptarangi, Vijayasara

Drug: Shankhapushpi Medhya RasayanaDose: 500 mg thrice a day before mealDuration: 3 month

Management of Complications of DMCerebral Atherosclerosis, Alzheimer's, Dementia etcShankhapushpi Convolvulus pluricaulisMandukaparniBrahmiVachaJyotishmatiGuduchiCentella asiaticaBacopa monnieriAcorus calamusCelastrus paniculatusTinospora cordifolia

Ischemic Heart DiseasesArjuna BarkTerminalia arjunaGugguluCommiphora wightiiPushkaramulaInula racemosaKusthaSaussurea lappaGokshuraTribulus terristris

Diabetic EnteropathyBilvaKutajaHaritakiAegle marmelosHolarrhena antidysentericaTerminalia chebula

Diabetic NephropathyPunarnavaBoerhavia diffusaGokshuraTribulus terrestrisVarunaCrataeva nurvala

Erectile DysfunctionKapikacchuAshvagandhaShweta MusliJatiphalMucuna pruriensWithania somniferaAsparagus ascendensisMyristica fragrans

Diabetic NeuropathyDashamula KwathaGuggulu Based FormulationsDiabetic RetinopathySaptamrita LauhaMahatriphala Ghrita

Diabetic CarbuncleMahamanjisthadi Kwatha – Internal and LocalLeech applicationKaishora guggulu etc.

Conclusion• Prameha is described as a set of complex clinical disorderscharacterized by frequent abnormal micturition, with theetiology involving genetic predisposition as well asimproper diet and life style. The role of stress and obesityin its pathogenesis is also elaborately discussed inAyurvedic classical texts.• The clinical conditions described in Prameha have muchin common with those described in allopathic medicine forObesity, metabolic syndrome & Diabetes Mellitus. TheAyurvedic management of Prameha emphasizes dietaryand lifestyle recommendations and herbal preparations inaccordance with psycho-physiological constitution of thepatient.96

Conclusion• Ayurvedic drugs should be used in its naturalform without disturbing its natural combination/holistic principle of drug. Single drug may havecomposite fractions & each fraction has its ownmedicinal value.• Poly herbal combination potentiate therapeuticefficacy of a particular ingredient of formulationand also counter act adverse effect if present inthe combination. Instead of isolating a particularalkaloid it is suggested that the Ayurvedic Drugsshould be used as a whole.97

ConclusionContd..All patients of diabetes are not similar so astepped care treatment is advised. In earlystage of disease and having Kaphajaconstitution, it is better to use ayurvedic drugsalone. In acute stage and having Pittajaconstitution of patients wherever foundnecessary, oral insulin promoter may be added.In chronic stage and having Vatajaconstitution, insulin therapy may also be addedas these cases are insulin dependent.98

ConclusionContd..• Mental health promoting drugs (Medhya), ifadded along with anti-diabetic therapy, willfurther potentiate anti diabetic effect of theprincipal drug by counteracting stress.• Ayurveda and modern medicine both arecomplimentary and supplementary to each other.Simultaneous administration of ayurvedic drugswill not only potentiate therapeutic efficacy ofthe modern drug rather it will also reduceadverse effect of the modern drug, if any; to leadthe patient a healthy & happy life.99

100

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE D**i/i*%iii/ A *"fi**I*\ +Volume 17, Number 6. 2011, pp. 491-496 riGVIGW MiUClGSMary Ann Liebert, Inc.DOI: 10.1089/acm.2010 0396Prameha in Ayurveda:Correlation with Obesity, Metabolic Syndrome,and Diabetes Mellitus.Part 1-Etiology, Classification, and PathogenesisHari Sharma, MD, DABP, FCAP, FRCPC. DABHM,' and H.M. Chandola, MD (Ay), PhD?AbstractBackground: Obesity, metabolic syndrome, and diabetes meilitus are increasing in epidemic proportions globally. Prameha is a syndrome described in the ancient Ayurvedic texts that includes clinical conditions involved inobesity, prediabetes, diabetes mellitus, and metabolic syndrome.Materials and methods: Integrating the theory and modalities of Ayurveda in the management of these disordersmay prove to be beneficial. Kven though Prameha is a Yridoshaja Vyadhi (a disease involving all three of thepsychophysiologic principles known as Doshas [i.e., Vatu, Pitta, and Kapliaj), it is basically a disease with Kaphapredominance.Results: There are 20 subtypes of Prameha due to the interaction of the three Doshas and 10 Diiblu/us (disturbedfunctioning of the principles that support the various bodily tissues); several of these subtypes have sweeturine, whereas some of them have different coloration of the urine, highlighting the inflammatory conditionsinvolved in the metabolic syndrome. This disease has close ties to Sthauhja (i.e., obesity). With regard todiabetes mellitus, Sahaja Prameha and jatah Prnmchi correlate with type 1 diabetes; Apaihyanimittaja Pramehacorrelates with type 2 diabetes. Madhumeha is a subtype of Vtittija Prameita (Prameha with Vata predominance)that can occur as the terminal stage of type 2 diabetes (in which insulin is required), or as type 1 diabetesbeginning in early childhood. The latter is defined as jatali Pramehi Madltutnehino in Charaka Samhita, one of theclassical Ayurvedic texts.Conclusions: Various dietary, lifestyle, and psychologic factors are involved in the etiology of Prameha, particularlyin relation to disturbances in fat and carbohydrate metabolism. The ancient Ayurvedic knowledge regardingPramehn can be utiliz.ed to expand the current understanding of obesity, metabolic syndrome, and diabetes.Introduction Etiological Classification of PramehaO , ,. , , .... Nidana is the branch of Ayurveda that addresses theHtsiTY, mei Asouc SYN0ROM1-, and diabetes mellitus arc .. ... _. . - n ,increasing in epidemic...proportions.globally., , ,.Ai/urveda. , etioloevc , &'or,,disease., .,I..he.etiology. . byc.of Prameha is discussed' @in., e L i f. . , j. f ... r% , Sushruta Samhita, which identifies two types of Prameha:describes a set or cmnplex clinical disorders with Irequcnt . .. ,1 @,t -t-, --,11 .-f -H - -]|| >d Pnmidhi wh'-h ^al"Va' which is hereditary, and Apathyammtttaja, which ba "wrmn nm un ion, lo (i i\ y . J( , , . ,and dUibcte nu-llitus.'int^ratins Hu- theury .md ,@,dalitics ^"o"0S"' mi''""1"18 """"''"7 ^ """ d"C ' S1"@ticof Ayurveda in the management of these disorders may proveto be beneficial (see Sharma and Chandola, Ayurvedic Con- ^ , . @ l, ,. , @ ,. ,c,,, . \ . , ,. .., ,' . -. , .. ... Sahaja Prameha/Jatah Pramehi (Hereditary)cept of Obesity, Metabolic Syndrome, and Diabetes Mellitus' ' yiin this issue, pp. 000-000). The etiology, classification, path- In Ayurveda, the words Sahajti and jatah indicate geneticogenesis, and m(inag*?ment of Rnunchu are discussed at length predisposition in the pathophysiology of disease. Broadly, inand in detail in the Ayurvedic texts. hereditary diseases there may be two contributing factors:'Center for Integr.itivu Mi-dicim- .md Di-partmont of Pathology. CoHe^e of Modicine, '11iet,)]uo Suite University, Culunilnib, OH.2Institute for Tost Graduate Teaching & Research in Ayurveda, Gujarat Ayurved University, Jamnajiar, India.'

492 SHARMA AND CHANDOLA1. A certain defect in the sperm and ovum (referred to as BijaDoshaJ, which results in a genetic disorder or geneticpredisposition to disease.In regard to Prameha, Charaka Samhita mentions thatexcessive indulgence in Madhura Rasa (foods/drinkswith a sweet taste) by the parents is the chief cause ofthis chromosomal damage to the sperm and ovum. (InAyurveda, foods/drinks with a sweet taste include sugar, milk, butter, rice, and breads.).2. An intrauterine environment that negatively affects the development of the fetus due to the mother's diet, lifestyle,or adverse psychologic state during pregnancy. Thiscongenital aspect can trigger the disease process forwhich there is a genetic predisposition.Regarding Prameha, the overindulgence of MadhuraRasa by the mother during pregnancy is likely to triggerPrameha. Lifestyle factors include laziness or a sedentarylifestyle, and psychologic factors include depression.The diet, lifestyle, and adverse psychologic state of themother during lactation may also play a decisive role in precipitating Pramchn in the infants. In addition, excessive intakeof Madhura Rasa during childhood can contribute to the onsetof Pramelm in children who are genetically predisposed. Thus,hereditary predisposition and unwholesome dietary and lifestyle choices, especially the excessive intake of Mndhiira Rasa,can play a combined role to cause hereditary Prameha.The description of Sahaja Prameha in Sushruta Samhita andJatah Pramehi in Charaka Samhita are quite similar to that oftype 1 diabetes (also known as insulin-dependent diabetesmellirus or juvenile-onset diabetes). Jatah Pramehi Madlmrnehino,as defined in Charaka Samhita, correlates with type 1diabetes beginning in early childhood.Apathyanimittaja Prameha (Acquired)The acquired form of Prameha is referred to as Apathyanimittaja Prameha. The description of Apathyanimittaja Prameha inSitshruta Samhita is very similar to that of type 2 diabetes (alsoknown as non-insulin-dependent diabetes mellitus or adultonsetdiabetes). The types of food and drink likely to precipitatethis disease have been enumerated in all the classical Ayurvedictexts.1"4 These are briefly listed below, along with lifestylefactors and psychologic factors that lead to the onset of Prameha:and Vataja Prameha?'2-4 Ayurveda has identified a progressionof Prameha through several stages. In the initial stage, Kaphais in excess, which vitiates Meda (fat) and Kleda (body fluid),thereby precipitating Kaphaja Prameha. Further progressionresults in Kshaya (loss) of Kapha. Pitta then predominates,which vitiates the blood (Rakta), precipitating Pittaja Prameha.Further progression results in loss of Pitta. This leads to vitiation of Vata, which drags vital substances/vital essenceout of the body through the urine, precipitating Vataja Prameha.' Ayurveda also specifies that any of these three types ofPrameha can be precipitated directly, depending upon geneticpredisposition and improper diet and lifestyle.Correlating the Dosliic classification of Prameha with the etiological,Kaphaja and Pittaja Prameha are always ApathyanimittajaPrameha (acquired), while Vataja Prameha can be either hereditary or acquired. If Kaplwja and Pittaja Pramehn are not managedproperly, in due course of time they lead to Madhwnelia (asubtype of Vataja Prameha), which is a terminal stage of thedisease mat is said to be incurable.1'6 This disease can be equatedwith the terminal stage of type 2 diabetes, which has progressedinto insulin-dependent diabetes. It has been observed that in thePittaja stage of Prameha, mere is a tendency toward moderatehyperglycemia, which may be due to increased adrenal medullary and cortical activities. In Vaiaja Prameha, there may besevere hyperglycemia with hypoinsulinemia.7Correlating Prameha with obesity, metabolic syndrome,and diabetes mellitus, the early manifestation of the diseaseprocess in these conditions, with carbohydrate/ lipid, andprotein metabolism disturbances accompanied by glycosuria,proteinuria, etc., correlate with Kaphaja Prameha, which can beeasily controlled and cured. The inflarmnatory, hepatic, andgallbladder complications, and lipid and blood abnormalitiesare much more in line with the description of Pittaja Pramehn,which can be managed. The advanced stage of disease, withmetabolic disturbances associated with loss of immunity,correlates with type 2 diabetes that has progressed into insulin-dependent diabetes, and correlates with the hereditaryform of type 1 diabetes, which both correlate with VatajaPramelw. Both of these are incurable as described in Aywveda.Ayurveda describes 20 subtypes of Prameha on the basis ofgross urinary characteristics and clinical manifestations. Theseare divided into 10 subtypes of Kaphaja Prameha, six subtypes ofPittaja Prameha, and four subtypes of Vataja Prameha. Followingis a description of the etiological factors (dietary, lifestyle, and1. Dietary factors: Excessive intake of yogurt, meat of psychologic) for tb the three Doshic categories of Prameha, and aaquatic animals, milk, new (not aged) grains, foods/ description of the lurinary changes for the 20 subtypes.drinks containing sugar and jaggery (an unrefined formof cane sugar), cold foods, sweet foods, sour foods, Kaphaja Pramehaunctuous (oily) foods, liquid foods, foods that are heavyto digest, and slimy foods. *@ 1. Dietary factors2: Hm/nnaka (a type of millet grain), Yctvahi2.-Lifestyle factors: Sedentary lifestyle, excessive sitting, (a variety of barley), Avem saliva Linn, (a variety of oats),excessive sleeping, sleeping during the daytime, lack of Chnnaka Chanaka {Pan (Panicum miliaccum Linn., a type of millet grain),exercise, and laziness. Uddalaka llddalaka (Pa- (Paspahtm scrobicufatitm Linn., kodo millet),3. Psychologic factors: Disturbance in mental health caused Naishadha (a type of millet grain), Itkata (Sacchm'um speby extremes of psyche such as Vishada (depression) and cies)/ cies), M.ukundt b/lukitndaka (a type of rice), Mahavrihi (a type of rice),bipolar disorder. Prmnodaka^ (a type of rice), Sugandhakn (a type of- rice),Harenu (Pisum sativum Linn., green peas), Maslia (Vignamungo Linn., urad da! [a legume]), the meat of domestiDoshic Classification of Pramehacated, marshy, and aquatic animaPrameha has been classified according to the predominantDosIuj in the disease process. Ayutveda describes three groupsof basic clinical distinctiveness, which are Kaphnja, Pittajn,

PRAMEHA IN AYURVEDA, PART 1 4932. Lifestyle factors'1: Lack of physical activity, excessive 2. Lifestyle factors: Excessive physical exercise, excessivesleep, too much lying down, too much sitting, seden- sexual intercourse, excessive use of Pandiakarmatary habits. (AyurveJic purification procedures), suppression of3. 1'sychologic factors: Depression. natural urges, fasting, injury, excessive exposure to the4. Subtypes and urinary clinical manifestations: sun, staying awake at night.2. -, ., , - @ , 3- 1'sychologic factors: Mental trauma, anxiety, and grief.2@ Udakamcha- Clear urine ,n larger quantity without d ^ ^ u ^.^ man,fatat,0J:odor; patient teels cold sensation while passing urine.@ iksiiiivalikaniL'lia2: Very sweet urine, cool, slightly @ Vasumcha? Urine contains Vasa (fat).viscid, turbid due to slimy substances, and resem- @ Mujjanu'lin-} Urine contains Majja (bone marrow). It isbling the juice of sugar cane. described as Sarpimeita in Sushntta Samhila 1@ Sti'idnuiwha2: If urine is kept overnight, precipitate is @ Hi^tiuwha-2 Lasika (lymph) is passed in the urine. Thepresent in the container. flow and frequency of urine is almost continuous@ SaudrapmsailtmhiC: Literally, Saiidraprasadmeha means (incontinence).a portion of the urine is turbid and a portion is clean @ Madhuiiieliar Urine is astringent and sweet in taste,like Sara (undistilled alcohol). Described as Surawclm yellowish--white in color, and nonunctuous. Ojas2 (tbein Susliruta Samtiita1 and Ashtauga llridaya* subtlest material substance in the body; tbe essence of@ Shuklnmcha : Urine is white and appears as if it is the body; Ojas maintains the body's immunity andmixed with flour (paste). While passing urine the vitality) is passed in the urine. This subtype is depatientfeels erection of body hairs. It is described as scribed as Ksliaudnuwha' {urine with color and tastePislilameha in Sitslirala Saiiihita.* like honey) in Sushruta Samhila.' Slmkrarm'ha2: Patient passes urine similar to quality ofsemen or semen itself may be mixed with urine. prakriti (Psychophysiologic constitution) and Prameha@ Shcctiimciia~: Urine is very sweet and abundant, withlow temperature. ' Praknti is tbe psychophysiologic constitution of an in-@ Siktamdia2: Patient passes small particles like sand in dividual and is determined at the time of birth by thethe urine. individual's Dosha proportions, f-ach individual has a@ Shanairraclia2: Flow of urine becomes slow and patient certain ratio of Vata, Pitta, and Kapha that is unique to him/feels difficulty in passing urine. hcr> as lonS as this 'atio is maintained, the individual will@Ulamcha1: Urine is turbid and slimy; it is sticky and bl' Healthy. If an imbalance occurs in the Doshas due tothreads may be demonstrated like gum. improper diet and lifestyle or other factors, the beginningof the disease process can occur. The Prakriti of an indi-Pittaja Prameha vidual plays an important role in the progression andprognosis of the disease and response to treatment. The1. Dietary factors: Intake of Llshmi (foods that are hot in prL,dominant Dosha(s) in the individual's Prakriti affectspotency), sour loods, excessively salty toods, alkaline lho Doshlc mani(estation ,,f tht, d;M,asl, proa.ss. in a studvfoods, pungent toods, eating before the previous meal is l)n prilkrM and jiabL.,es mellitus, it was observed that thecompletely digested, eating mutually contradictory progr(,ssi(m of disi,,,se is sUm ,n d,abetic patients withfoods- (these are foods that should not be eaten to- Kaphaja prakril, {Pmfriti in which Kapha is the dominantgether, e.g. milk and bananas, milk and salty loods, @@,,,,,,. ,hl,se pillienls had miW hypi.rg|ycl,mia wilh ra,yogurt and sour fruits, etc.). insu!m dl,ficicncy. ln contrast, progression is quick in di-2. Lifestyle factors: Exposure to very intense heat ol the abL,tl^ having Vata~a prakrili {pnknti in which Vata is thesun or lire, overexertion. ^ dominant Dosha); these patients had severe hyperglyeemia3. Psychologic factors: Anger. with hyp

Dosha predominance KnphnjaBody constitution Obeseaccordingto physiqueEtiology AcquiredStage of disease Early/withoutTable 1. Features of Prambha Classified on the Basis of Prognosisprocess complicationsClinical Mild hyperglyceminmanifestations due to disturbedcarbohydrate and fattyacid metabolismHyperinsutinemiaSHARMA AND CHANDOLASadhya YapyaAsadhyaAsadhya(curable) (controllable)tdiffiruh(dificulttomanage)in ,@..@..iPittajaAcquiredAcute,youngadultsModemtohyperglycemiaduetohyperadrenalismVatajaAsthenicHereditary(tvpe1diabetes)Acquired(advanced.insulin-dependentstageoftype2diabetes)Chronic/advanced/withcomplicationsSeverehyporglycemmduetohypoinsulinemiaResearch correlating diabetes mellitus to conditions within the oral cavity. It lends to adversewith Doshic types of Prameha changes in the gums and pcriodontal tissues: effects that may. ... , , , . , bv evident even before clinical diabetes is recognized andA preliminary studv was conducted to correlate the tin- ,. , @ , , , , Vderiving pathology of different stages of diabete mdlitus dlaK"^- Conversely penodontal diseases, including ginwill,'the- different Doshic tvpes of Prumcha? A small sample 8-.t,s and severe penodon,,t,s, can make ,t more difficult toof . patients . with .. a complaint . . of . diabetes ,.. mellitus ... or previ- . control . , diabetes. I enodontaf disease is associated with*,, . , ,. . r,. . . , ,r, ,. . higher levels of insulin resistance, often a precursor of type 2ously known to be diabetic was selected. The diagnosis was ... .. . , , . . . . /, ,, y* ,estabhshed @ i- i t and j confirmed @@@ j using @ a glucose i tolerance ltest. diabetes, ,. lt) ' as we .. ,. as with higher h. L eve , s or glyeated hj , hemoe fi o-@. Plasma insulin, .. catecholamme, i i @ and j cortisol .@ i i levels iwere bm- , Ihese . hndines ; mav e\, relate , . to , the , prodromal , symptom rmeasured . in the . patients. -T-, The i b i ood . sugar i eve i , has i been ' excessive , excretion .. or Malas ,, in the buccal cavity. J A sweet, , ,L, \ .. ,, t. , , , taste in the mouth is a prodromal symptom that mav becorrelated with plasma insulin and plasma cortisol levels.. r -.' @Since _. diabetes ,.. mellitus ... is . a progressive . disease, ,, i_i blood j glu- i explained .' by , the presence \. ot glucose ., in the saliva. If blood ,cose, plasma.insulin,. ..andjplasmaIcortisol@ ihaveu ubeen eorreglucose", levels.are high,., - ,.-glucose.isaalso@present, ,in@theisaliva,lated with duration of illness and age of the patient. The ', mpatients with features of Kiiphnja Prameha were identified as , i ' , , . . @ -f . ., ,. , @ /@ (@ @ li j @.@,., A burning sensation in the hands and feet is an importanthaving mi d nypertrlycemia (i.e., fasting blood sugar rbS. , . . . ... r @-.@> /j, ^ j l - i- @ t> @ u @ Mature of neuropathy that results from diabetes mellitus.up to 140 me/dL), and hypennsulinemia. Patients havingr ' @ .f n . , , , . , , @ /,-@> hxcessive sweat as a consequence of obesity may result infeatures of Pittaia Prameha had moderate hyperglyeemia (H3S . . .. .l i .tj uj ^ -c @ > @ tofr ,140-2DUmg/dL},., _^, ,,with. ,high, ., catecnolaminel . ' @and,cortisol@ i bacterial,growth,. ,that.leads.to,.body, J ,odor..Excessive.thirst.., @. h ,' c h ,, .. , may be directly related to disturbed glucose metabolism,levels. These patients were found to be more easily stressed. _, J \ ,. t ._. . , r, , ., . n . @ j -i- j Thus, the symptoms described in the Purvurupa of PramehaPatients with features of Vatnia Iramcha were identified as . . . - ,.'.. r ,f, . . , , ' ,rD. nrn . ... , . include prediabehc symptoms and early manifestationhaving severe hyperglycemia rro> 25Umg/uL) and hy- ' , . r . ^ .b ^-,->f 6 -: r , , ,. b . . (vascular changes, obesity, etc.) of diabetes or subdimcalpoinsulinenua. lhe results ot this study indicate a correlation ,. "of Kiiphaja Pramehn and Pittaja Prameha with type 2 diabetesmellitus, and Vataja Prameha with type 1 diabetes mellitus.Sthaulya (obesity) and PramehaSamprapti (Pathogenesis) of Prameha The striking relationship between Prameha and Sthaulya. (obesity) has been discussed in Ayurvedic literature, wherePurvarupa (prodromal symptoms) of Prameha ,. .- . . , . , ,,, * ,- .@ u -L i aK lK iff Prameha n> said to be one of the complications of obesity. AsIn Ayuroeda, Purvarupa refers to prodromal symptoms1"'-1 >i result of physical inactivity and excessive intake of sweetthat are seen when full manifestation of the disease has not substances, there is formation of Ania, which is a buildup ofyet taken place. For Pramehn, these symptoms include ex- toxins from improperly digested food and metabolic prodcessivesweat, body odor, laziness, inclination towards rest, ucts. The buildup of Ama leads to additional formation ofpresence of excessive Mains (waste products) in the eyes, Meda (fat). This refers to an increase in adipose tissue in theears, teeth, throat, palate, and tongue (buccil cavity), execs- body, resulting in the individual becoming overweight. Itsive growth uf hair and nails, matting of the hair, excessive reflects the current understanding of the peculiar metabolicthirst, a sweet taste in the mouth, a burning sensation in the state in obese individuals, wherein carbohydrate is largelyhands and feet, attraction of insects and ants toward the converted to fatty acids. The multifactorial involvement ofbody and urine, and so on. Diabetes has a close relationship Mi'da (fat), Kapha, Vata. and Agni (digestive metabolic activ-

PRAMEHA IN AYURVEDA, PART 1 495ity) is 'i common pathophysiologic phenomenon of-' bothPrameha and obesity. Hyperinsulinemia and insulin resistance are pervasive leatures ot obesity, increasing withweight gain and diminishing with weight loss. Insulin resistance is linked more closely to intra-abdominal fat than tofat in other locations.11 12 A pathway through which obesitycauses insulin resistance has been discovered in mice, in theform of an adipose tissue-derived hormone named resistm@an important link between obesity and diabetes.13Clinraka Samhita has firmly established the relationship between obesity and Prameha: The role of Meda (fat/adipose tissue] is of great importance in the pathogenesis ol Prameha. Itsrole is not only as Dushya (disturbed functioning of the Dhatus),but something more than that. According to Charaka Samtiita,Haluuirava Slilrsiwia (Kapha that contains too much liquid) joinsand affects Main, causing it tobecome Ahnidhi (unobstructed orfluid) in nature. This form of Meda has been described as actingon Mamsa (muscle tissue), thereby increasing the volume ofbody fluid. This has been described as Shariru-Kledii (body offluid) in Ayurveda. Thus, excess water in the blood causes increased diuresis. This is how the Sharira-Klcdti is converted intourine, as discussed in Charaku Samhita. This route of pathogenesisfor Pramclia is closely related to obesity.Vataja Prameha as type 1 diabetes mellitusThe pathogenesis of Vataja i'ramdia is similar to that oftype 1 diabetes mellitus. Vala that is agitated due to variousprecipitating causes acts on the body in such a way that thereis passage of Vtisa (fat), Mujja (bone marrow), Lnsika (lymph),and Ojns (essence of the body/immune substances/vitality)through the urine. This condition indicates impaired renalfunctioning as a result of diabetes, leading to a dire prognosis. Due to Dhatiikshaifa (loss of tissues), the patient becomes very weak and emaciated.'Charaka Samhita details a very specific pathogenesis forMadhwueha, which is a subtype of Vataja Prameha.' When anindividual excessively consumes the foods that cause Prameha, Kupiia and Pitta become vitiated, then adipose tissue andmuscle tissue become disturbed and cause impaired functioning of Vata. Subsequently, Vata gets vitiated and extendsto the urinary bladder along with Ojas, resulting in Ojas beingexpelled in the urine. In Ayunvdn, Ojna is considered vitalto the maintenance of health; its loss in Prameha leads tomany complications, including Prameha Pidikii (boils andcarbuncles). This advanced condition is comparable to noninsuiii>dependenttype 2 diabetes progressing into insulindependentdiabetes. It is the stage of diabetes in which thereare eomplicalions, including nephropathy, which result invital substances of the body being excreted through the urine.Prameha as a metabolic disorder and its relationshipto mental stressObesity, metabolic syndrome, and diabetes mellitus arecommon in having metabolic disorders. In the pathogenesis ofPnunefui, the role of intermediary metabolic products is veryimportant, because it is a disease generated as a consequenceof improper metabolism of food substances. In Ayurveda,A ma refei's to the toxic intermediary products of digestion andmetabolism that result from improperly digested food. Therelationship between Prameha and Amu is well documented.1 ifthe Agni (digestive metabolic activity) is not proper, accumutationof Ania occurs, which uitim

496 SHARMA AND CHANDOLAmicturition, with the etiology involving genetic predi.spositionas well as improper diet and lifestyle. The role oi stressand obesity in its pathogenesis is also elaborately discussedin the Ayurvedic texts. The different types of Prarm'hti haveclinical manifesto lions that have much in common with thosedescribed in allopathic medicine for obesity, metabolic syndrome, and diabetes mellitus.Part 2 of this article will focus on the management otPmmeha in Ayurveda, which emphasizes dietary and lifestyle recommendations and herbal preparations, in accordance with the psychophy.sioiogic constitution of the patient.Ayurveda also addresses the management ot psychologicfactors that contribute to the development ol Prameha. Anabundance of research has.been conducted on the herbs usedin tht.' management of Pmmcha, demonstrating their antidiabetic,hypolipidemic, and antioxidant effects. ' iaAcknowledgmentsThe authors are very thankful toKamayani Shukla, MD(Avli)for her outstanding contributions in giving final shape to themanuscript. We arc also thankful to Shyam Pr.it.ad, PhD, andAnju P. Ramachandran, PhD, Department of Kayarhikitsa, Institute for Post Graduate Teaching & Research in Ayurveda,Gujarat Ayurved University, Jnmnagar, lor facilitating thecompletion of the manuscript. We also thank Hllen Kauffman forher assistance in the preparation of the manuscript.Disclosure StatementNo competing financial interests exist.References1. Shastri A. Sushruta Samhita, Ayurveda-Tattva-Samdipikacommentary, 14th ed. Varanasi, India: (_ haukh.imbha Publications, 2003.2. Sliukla VD, Tripathi RD. Agnivesha, Charaka Samhit.i,Vaidyamanorama Hindi commentary. Delhi, India; Ch.iukhambaSanskrit Pratishthana, 2002.3. Shastri KN, Chaturvcdi GN. Agnivesha, Charaka Samhita,Vidyotini commentary. Varanasi, India: CluukliamLw itlwatiAcademy, 2004.4. Gupta KA, Upadhyaya YN. Vagbhata's Ashtangahridayatn,Vidyotini commentary. Varanasi, India: ChaukhambhaPrakashana, 2007.5. Gupta KA, ed. Vagbhata's Ashtanga Samgraha. Bombay,India: Nirnayasagar Press, 1951.6. Chandola MM, Bhatia S. Concept of diabetes mellitus inAyurveda and its treatment with certain indigenous drugs.AYU Int 2

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MbUIUINtVolume 17, Number 7, 2011, pp. 589-599@ Mary Ann Liebert, Inc.nni- m inR9/acm.2010.0397Prameha in Ayurveda:Correlation with Obesity, Metabolic Syndrome,and Diabetes Mellitus. Part 2@Management of PramehaHariSharma, MD. DABP, FCAP, FRCPC, DABHM; and H.M. Chandola, MD (Ay), PhD2Background: Obesity, metabolic syndrome, and diabetes mcllitus are increasing to epidemic proportions globally. Pranwha is a syndrome described in the ancient Ayuvvcdic texts that includes clinical conditions involved inobesity, prediabetes, diabetes meliitus, and metabolic syndrome.Materials and methods: Various dietary, lifestyle, and psychologic factors are involved in the etiology of iJrn-Introduction ihitraja (acquired) I'rumd.a, Sr>m3!vxlk;i'U (bicipurificttor.) isObesity, metabolic syndrome, and,diabetes,., melhtus...areconsidered,the ideal.,.option..h .Fcr,physically\\-wvzV. patientsF '... . , , ,. . , Stwtshumana (pacification oi tlu: Doshr^) is lecommendedincreasing to epidemic proportions globally. Auurueda _ , - . ,- , ,- ,h , h v @ , j. j "i / Samshamana is also utilized after biopurificnticn in thost>describes a set of complex clinical disorders with frequent , , _,f " ', , . @ @ .I .@ i 11 j r> i t,-i patients who undergo bamsnoahtina. fhe measures used forabnormal micturition, collectively called Prameha, which K, ,, ,. ., , , , -.. . , , . . , ,. , Sthatih/a (obesitv) can be utilized tor the tn^na^cment ofcorrelate m many ways with obesity, metabolic svndrome, , , ^ , @ , , , ,, ,, ,,i t i i ,, ' """ ^jL t\.nt til thL rmm cbji.t.h\ lor l i \t i /@ ( i u I i (P i 1 i v h -, f imanagetTiont of m\ di li l 1 hi n ^n ^ me it uf I i!i i f i I l f ' id i ' ' in tdepends ori mullipl i | l ts s Ii s il l f \ 1 i>ph\s l'i tn 1 (' ' ' / 'constitution of tl l p _nt t 1 bh ,_ it ' >^ 1 , ^ i ' t i < i ( / (@ , ' i n i s fthu patient is ^hvsieil!^ stro i u u sugars v th \ it i i h \ i ' 1 ' ' i i'Center I:r Inl nti\ t11 di ir i l I uti i r th r \^ i [ c > l i Of]?t_. t ..... f.,.. t r i I t r

590SH ARM A AND CHANDOLAScvntarpnnn and Brimhnna, for patients with Vaiajn Framdiu.'1"*Santarpana refers to a highly nutritious, high-calorie dietintended to increase weight, and Brimhcma likewise refers toincreasing the body bulk or weight.Dietary managementAwiirvcda considers diet to be one of the primary pillars ofhealth. Food is an imperative internal factor that accounts forhealth as well as disease. As Hippocrates said 2000 yearsago, "Let rood be your medicine and medicine be yourfood."6 The proper diet imparts physical strength and help?diminish the morbidity of the Doshas, thereby maintainingequilibrium of the bodily tissues. Eating a proper diet is a keystep in preventing and controlling Apathyanimitlaia (acquired) Prtimeha. The role'of Ashta Aaham Vi'dhivibhcsluf andAnyatana Ankara Vidriwidharaf (dietetic regulations) has primary importance among the multiple preventive aspects ofPramehn. - @, '"What you eat." The prime aspect of the dietetic re^uhtionscan be referred to as "what you oat." Patii-n^ \ ithPrnmeha must cat a diet that pacifies the disease.1 The bestfoods to eat are those that are not sweet, not too oily, luvethe ability to mitigate Kaphn and Mcda, and an? nourishing.Foods and drinks that arc sweet in taste, such as dairyproducts, Ikshu (sugar cane), sugar products, foods withGuru (heavy) quality and Shceta (cold) quality (such as icecream), A^adya (alcoholic beverages and wines), and so onshould be avoided since they further provoke Kriphn andMeda.In the diet, first and foremost importance should be givento Yava (barley).3 A preparation called Apupa (a type of cake)made with barley can be eaten. Research, shows the.consumption of barley kernels and products made from baileyflour enriched with /J-glucan improves glucose tolerance,reduces insulin responses, and lowers inflammatory markers.7"10 Preparation of food from barley grain soaked' over-@ night in a decoction of Triphaln [an herbal mixture comprisedof Phyilanthus emblica Linn., Termirialia bellirica (Gaeitn.)Roxb., and Terminalia chebu'.a (Gaertn.) Retz.] helps mitigatePrameha. Research on Triphala and the herbs that comprise; ithas shown beneficial antidiabetic effects, In a study on-ratswith alloxan-induced diabetes, Triphalz reduced thi bloodglucose level significantly. It also scavenged hydibxy) andsuperoxide radicals in vitro and inhibited Upid' peroxideformation.11 Keeping lipid levels and their oxidation in checkis an important aspect in the management of obesity,, metabolic syndrome, and diabetes. Research on Arrfahiki. (Amla;Phyilanthus emblica; also known as Emblica oficimlis Cacrtn.)shows that it has antidiabetic, hypolipidemic, and antioxidantproperties.12 Amla reduced lipid peroxidatior; andstrongly inhibited production of advanced gly cosy kitedendproducts in rats with streptozotocin-induced d iabctes.1-1 Jnaging rats, Amla prevented dyslipidcmia and oxidativestress.14 Terminalia belcrka reduced alloxan-induced hyperglyceiniaby 50% in rats and significantly decreased oxidativestress.15 In a study on experimental myocardial injury inducedby isoproterenol, pretreatment with T. cliebula extract decreased lipid peroxide formation and ameliorated the effect oi:isoproteienol on myocardial marker enzymes, indicating areduction in myocardial necrosis.10In addition to bailey, preparing food from the seeds ofVenn (bamboo) and Godhooiim (wheat) soaked overnight in adecoction of Triphala may also be beneficial for Prameha.Studies conducted on extracts of bamboo (Bmnbusa denrfrocalaimts)have demonstrated hypoglycemic effects* ina 1! oxan-induced diabetes in rabbits1' and rats.18 With regardto wheat, foods with a low glycemic index and foods rich inwhole grain are associated with a reduced risk of metabolicsyndrome, type 2 diabetes, and cardiovascular disease.1 ~21A possible mechanism relates to the colonic metabolism ofindigestible carbohydrates, with a link between gut microbialmetabolism and key factors associated with insulin resistance.7-3An abundance of research has been conducted on theh'j.iltii-promoting properties of spices, including antidiabetic,a iiti1 ixidant, and lip id-lowering properties.""""25 Turmeric(Cifrcuina longa Linri.) and curcumin, the pigment that givestnum&ric its orange-yellow color, have been extensively ressr.V&hcdin relation to diabetes. More than 35 years ago, ity.'&k ::hown that curcumin can modulate blood glucose levelsiiVfcrftents with diabetes.26 Current research has shown mattutmeric extracts suppress blood glucose levels in mice withEypc*2 diabetes,27 prevent lipid pcroxidation and aortic fattystreak formation ui rabbits,28 and increase high-density lipo'profein(HDL) cholesterol.'1'1 Curcumin significantly decreases blood cholesterol and triglycerides in rats withstrepiozotocin-induced diabetes.""0 Tetrahydrocurcuinin, anactive metabolite ot curcumin, significantly reduces bloodglucose, increases plasma insulin, and reduces lipid peroxidation,cholesterol, and triglycerides in rats with diabetes.31Ciircumin is an effective irnnrunornodulator/'"" and it reducesthe1 impact of advanced glycosylated endproducts m diabetes.26 In Ayurocda, Haridrn (turmeric) and Amalaki are considered one of the best simple herbal combinations tomanage Prameha.3 They can be taken in powder form or aspart of the diet since Hiiridra is a spice commonly used in thepreparation of various dishes and Amalaki is a seasonal fruit.'. Additional spices with antidiabetic effects include cinnamon; Jeeniku (Cuminum cyminum Linn., cumin), Dhanyaka(Cori.wdnim sufivum Linn., coriander), Sliunthi (Zingiber ofjiciniile,Rose.,, ginger), Metljika (TrigomtUa foetium-graecumLinn., fenugieek), and Rnsona (Alliuni sntivum Linn., garlic).Cir.v-amon reduces serum glucose, @ triglycerides, and lowitensitylipoprotein (LDL) in patients with type 2 diabetes.33Curiiin reduces levels of blood glucose, glycosylated hemoglbl5ii"i,.plasma diolesterol, and. triglycerides in rats withsaUo>can-induced diabetes. It was more effective in treatingdiabetes than the idrug glibaiclamide.34 Coriander significantly decreased lipid peroxide, lev els and increased the activity, of antioxidant. enzymes in rats fed a high-fat diet.3r; Italso'significantly decreased levels of total cholesterol andtriglycerides, and increased levels of HDL cholesterol.30 Similar pharmacologic actions are seen with ginger. It reducesRpid levels, atherosclerotic lesions, and lipid peroxide levels:37 Fenugreek significantly reduces fasting blood glucose,trigiyecrides, and very

PRAMEHA IN AYURVEDA, PART 2 591and triglycerides.40 In rats with diabetes, it displayed immunomodulatbryand neuroprotective actions,41 reducedoxidative stress,42 and showed a significant effect on keycarbohydrate metabolic enzymes.4"1 Garlic lowered fastingblood glucose and serum triglyceride levels in a double-blindplacebo-controlled study on patients with type 2 diabetes.44In rats with streptozotocin-induced diabetes, it significantlydecreased serum glucose, total cholesterol, and triglycerides.The antidiabetic effect was greater than that of glibenclamide.'15Garlic significantly decreased total cholesteroland LDL, and significantly raised HDL, in a randomized,double-blind, placebo-controlled study on male patients withmild hypercholesterolemia.116 Similar results were seen in astudy.'on patients wittvcoronary artery disease, hi whichgarlic significantly reduced total serum cholesterol arid tri-'"glyceridiis, and significantly increased HDL/1'Vegetables'that mitigate Pramehn include Kiiraveflaki (Momoniiaicharantia Linn.; bitter gourd; bitter melon) and Paloh(Trichcsp.nthes artguina Linn.). M. dwrnntia administered orallyproduced a significant hvpoglyccmic effect in rabbits with alloxan-induceddiabetes.45 In rats with aHoxan-induced diabetessubjected to a chronic sucrose load, M. clmrantia maintainednormal glucose levels, reduced triglyceridc and LDL levels,and increased @ HDL levels. It also improved the antioxidantstatus, as evidenced by low levels of thiobarbituric acidreactivesubstances and normal levels of reduced glutathionc.Upon termination of the treatment, the rats were underoxidative stress and reverted back to diabetic conditions.49Feeding dried bitter gourd powder to rats with streptozotocininduceddiabetes decreased fasting blood glucose by nearly30%.5D An aqueous extract powder reduced fasting bloodglucose in rats with diabetes by 48%, an effect comparable tothat of glibenclarnide.''1 A methanol extract of bitter gourdnormalized blood glucose, reduced triglycerides and LDL, andincreased KDL in rats with diabetes. Discontinuation of theextract resulted in reversion to n diabetic stated2 Ai/uiivJa advocates using Tikia Shake?''' (green ieafy vegetables) as a maincomponent of the diet for patieiits with Pramelui. Judiciousadministration of legumes and grains such as Kodmva {kodomillet), Mudga (green gram, moong dal), Kulctha (Macrolylomauniflqrum Linn., horse gram), Adhaki Beeja (pigeon peas, tcor@dril), and so orr may be helpful. Oils such as Sarshapa Tail/i*4(mustard oil) and Ingiidi [Bnlanites asgyptinca (Linn.) Del.] can beused to prevent any further increase in lipicl levels.Ayurveda does not prohibit meat in .the diet of Pramclwpatients; however, frying of the meat is not recommended."Harlna (venison) and Shashakn (rabbit) are the recommendedmeats for Pramehn patients. The meat of domesticated animals is not recommended, and tliis correlates with currentresearch findings. Consumption of red meat and processedmeats are associated with an increased risk of diabetes inwomen.^5""57 Frequent consumption of processed meat hasbeen associated with an increased risk of diabetes in men.58A systematic review and meta-analysis oi studies on red andprocessed meats concluded that the consumption of processed meats is associated with a higher incidence of coronary heart disease and diabetes mellitus.59Ushnam Aiweeynt refers to eating a diet mat is warm. Thisis recommended since it will ease Krtpha, normalize Vain, andstimulate Pitta to intensify the power of digestion. However,food that is. extremely hot should n.o.t be. eaten. Leftovers orold food that is reheated should also not be eaten.Ayurveda recommends the use of Amtpana (an adjuvant)along with the dier and any herbs that are being utilized. Inaddition to the action of disease correction, the adjuvant actsas a carrier to transport the therapeutic phytochemicals intothe system, and may even act as a catalyst in the interactionof the various phylochemicals. Sarodaka and Kushodcka aredrinks that can be employed in this regard.3 Sarodaka is waterprepared from Khndira [Acticia catechu (Linn, f.) Willd.] thathas been boiled, then cooled down. Kushodnka is water prepared from Kusha [Destnostachyn bipiimata (Linn.) Stapfj thathas been boiled, then cooled. These drinks can be taken withmeals, with herbs, cr whenever the patient feels thirst. Theyare particularly helpful for obese individuals who are suffering from Prameha, since they weaken both Kapha andMeda. Another recommended drink is called Raga. It isusually prepared from, small- sour fruit." such as Ajn':;'aki,Knpuha5* {Fcrouia linonhi (Linn.) Swing1.;.1!, Jr.nibu {Syzygiv.nicumird '(Linn.) Skecls], ru\ so cL\>!o'.:j with a modestamount of sr.lt."How much you eat." Another consideration in tiis dietetic regulations is "how much you eat." The recommendation in this regard is Matnwat Asneeyr.t, which means tlvjfood should' be eaten in due measure:1 The quantity of foodthat is appropriate is not the same, for everyone. It variesaccording to the individual's psychophysiologic constitutionand Agni (digestive and metabolic process). The. idealamount of food is determined by the individual's level ofsatiety. Gum Aaluira (foods with a heavy quality) should beeaten to half of one's satiety level, whereas Laghit Aaham(foods with a light quality) can be eaten until the individualread^s Adi satiety.* With regard to optimal digestion of ameal, one can visualize the stomach as being divided intothree parts: One third should be filled with solid food, l -*third with 1 ^ id 1 r \ A n d rcn it t rjallow for tl ur j, \ \ r cF il rs n he d ^process.3 The prjtt incj.it off 1 o the udiv 1 inot produce undu p ro t tH torn ai v ill not le itin discomfort during activities such as waiting, standing,sleeping, talking, and so on; and will satisfy .the individual'shunger and thirst. .Eating-an excessive.amount of food,-mayprovoke all ihe.Dcrhas, and-.catiiig.,^.insufficient amountwill uiipairi the@ ";.:;'ijrrjij^i of-i'.ifi.D.vs^a (trw fundamental ,principles th;.t enppoit the various bodily Cs5i".cs)."When you eat." @ For optimal digestion, it .is important toconsider,"when you eat.'.' Jeerne. Asneeyai refers to the recommendation that one should eat only after the previousmeal has been fully digested. Untimely ingestion and overeating leads to accumulation of.the Doshns and overwhelmsAgni (the digestive power), which contributes to the development of Apnthyan'mnttaja (acquired) Prameha. Digestion ofthe previous meal can b

592SHARMA AND CHANDOLAshown promising results as adjuvants to the principal ther-contain a detailed description of lifestyle management lor ; apy \ . patients with diabetes. In a survey study of 100 pa-with type 2 diabetes, disturbances in mental healthPmmeha. Sushruta Samhita emphasizes the importance of iriertaregular exercise, including brisk walking, jogging, sports, (e.g., I anger, grief, worry, fear, anxiety, and so on) were nowrestling, fencing, horseback riding, and so on. Patients areadvised to avoid laziness and a sedentary lifestyle. It is essential to perform exercise such as walking or jogging tobum extra calories in the body. Sushruta Samhita states that ifa person follows an active lifestyle, he/she can overcomeApathyanimittaja (acquired) Prameha "within 1 year.5 Exercisebrings lightness to the body, reduces fat, and improves theability to work. Ayuroeda recommends stopping the workoutwhen slight sweating develops on the forehead. The Ayurvedictexts provide a cautionary note about the preservationand maintenance of hea'Ith for asthenic diabetics (type 1 diabetics) since they are Vata-predominant. These patients arenot advised to undertake vigorous exercise, as it will furtherprovoke Vata and result in a poor prognosis.Meditation, Pranai/ama (breathing exercises), and A

PRAMEHA IN AYURVEDA, PART 2Box 1. Research in Theses, CD-ROM, and WebsiteBhatia S, Chandola HM, Singh G. A clinical study on the role of Manasa Bhava in the etiopathogenesis of Madhumehaand its management by Saraswata Choorna. MD(Ayu) thesis. Institute for Post Graduate Teaching & Research inAyurveda, Gujarat Ayurvcd University, Jamnagar, India, 2001.Plants of Ayurveda, version 1.0, CD ROM on Dravyaguna. Sponsored by Ministry of Environment and Forest, Government of India (New Delhi) and RGUHS (Bangalore). Designed and developed by FRLHT (Bangalore), 2005.Singh B, Singh G, Vyas SN, Chandola HM. The role of Virerhana and herbal drugs in the management of Madhumeha(diabetes mellitus). MD(Ayu) thesis. Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat AyurvedUniversity, Jamnagar, India, 1992.Marvvah B, Singh G, Chandola HM. A clinical study on the role of certain Ayurvedic drugs in management ofMadhumeha (diabetes mellitus). MD(Ayu) thesis. Institute for Post Graduate Teaching and Research in Ayurveda, GujaratAyurvcd University, jamnagar, India, 1990.Clinical Research on-Diabetes mellitus, reported on website of India's Central Council for Research in Ayurveda andSiddha. Online document at: http://ccras.nic.in/Rcsearch_Activities/20081015_diabetes.htm Accessed June 12, 2010.Deka D, Chandola HM, Singh G. A clinical study on Klaibya (male sexual dysfunction) in Madhumeha and Uccharaktachapaand its management by Vajikarana Yoga. PhD thesis. Institute for Post Graduate Teaching and Research inAyurveda, Gujarat Ayurved University, Jamnagar, India, 2004.Virani N, Chandola HM, Vyas SN, Jadeja DB. A clinical study on etiopathogenesis of erectile dysfunction (Klaibya) indiabetic and non-diabetic patients and its management with Ashvattha. MD(Ayu) thesis. Institute for Post GraduateTeaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, India, 2009.Dwjvedi KN. KiTect of Dashamoola on diabetic neuropathy. MD(Ayu) thesis. Institute of Medical Sciences, BanarasHindu University, Varanasi, India, 1986.Upadhyaya JM, Singh K. Role of Saptamrita Lauha in Timira with special reference to myopia. MD(Ayu) thesis,institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, India, 1993.Gupta Durgesh P. A clinical study on Akshi Tarpana with and without Nasya on Timira with special reference tomyopia. MD(Ayu) thesis. Institute for Post Gradviate Teaching and Research in Ayurveda, Gujarat Ayurved University,Jamnagar, India, 2009.Anil Kumar E, Study on various preparations of Manjishthadi Kvatha and its effect in Tvak Rogas (skin diseases).MD(Ayu) thesis. Government Ayurveda College, Kerala University, Trivandrum, India, 1985.Shringi MK. Therapeutic efficacy of leech application, Kaishore Guggulu, and Neem oil in skin disorders [in Hindi].MD(Ayu) thesis. National Institute of Ayurveda, Jaipur, India, 1996.Hota P. A clinical study on Vatarakta and its management with Kaishor Guggulu. MD(Ayu) thesis. GopabandhuAyurved Mahavidyalaya, Utkal University, Puri, India, 1997.type 2 diabetes, treatment with G. sylvestr? extract significantly reduced blood glucose, glycosylated hemoglobin, andglycosylated plasma proteins, whereas with conventionaltreatment alone {i.e., glibenclamide or tolbutamide), thesevalues increased or remained the same. The patients receiving the herbal extract were able to decrease the dosage oftheir conventional drug, and 5 patients were able to discontinue the drug entirely and maintain their blood glucoselevels using only G. si/lvestrc.^ In 27 patients with type 1diabetes, G. sylvestre treatment reduced fasting blood glucose, glycosylated hemoglobin, and glycosylated plasmaprotein levels. Insulin requirements decreased and serumlipids returned to near normal levels. Patients on insulintherapy alone had no significant reduction in serum lipids,glycosylated hemoglobin, or glycosylated plasma proteins.8SAqueous and alcoholic extracts of Cuducli't [Tinospora cordifolia(Willd.) Hook. f. & Thomson] reduced glucose levels inrats with alloxan-mduced diabetes. The antihyperglyccmiceffect may be due to pancreatic islet frec-radical-scavengingactivity. This herb also lowers the levels of tissue and serumcholesterol, phospholipids, and free fatty acids (Plants ofAyurveda, 2005; see Box i).86"89 Kiratatiktn [Swertia chirata(Roxb.) Buch.-Mam.; also known as Swertia chirayita (Roxb.)H. Karst] is a potent antidiabetic herb. In a pilot study,Swertia chirata produced a significant decrease in fasting andpostprandial blood glucose levels in patients with diabetes.81It contains swerchirin, a xanthone found in the Swertia species of plants. Xanthones are a unique class of biologicallyactive compounds with antioxidant properties. Research hasshown swerchirin produces a significant decrease in bloodglucose levels in rat models.'"' y A 60% decrease in bloodglucose induced by swerchirin was accompanied by amarked depletion in /(-granules and insulin in the pancreaticislets. Glucose uptake and glycogen synthesis by the diaphragm muscle was significantly enhanced in vitro by thescrum of swerchirin-treated rats. It was therefore concludedthat swerchirin lowers blood glucose levels by stimulatinginsulin release from the islets of Langcrhans.9'1Shilajatu (Shilajit, Asphaltnm punjnbianiim) is a resinous,mineral-rich substance with vegetative origins that is foundin the Himalayan mountains. It is recommended for manydiseases, such as Pramcha, Sthau!ya (obesity), Hridroga (heartdisease), and so on. It is an established treatment for diabetesthat not only mitigates morbid Kaphn and Meda, but also hasrejuvenating properties.911 In a clinical study on patients withdiabetes, Shilajit significantly reduced lipid peroxidation andsignificantly increased levels of catalase, an antioxidant enzyme.9' In rats with diabftes, Shilajit produced a significantreduction in blood glucose levels as well as beneficial effectson the lipid profile. Using Shiiajit in combination with

594glibenclamide or metformin significantly enhanced rhability to Jower glucose and improve the lipid profile, co:pared to administering the drugs alone.''"1 Shilajit atlemuit^treptozotocin-induced hyperglycemia in rats and reducthe decrease in superoxide dismutase activity in pancreaislet cells. It was postulated that Shilajit acts as a free-radkscavenger."Oiaraka Samhita recommends Madlm-asnva, a polyhertfermented preparation, for patients with Pramcha. Hypoglcemic effects in animal models have been noted for somethe ingredients of Mudluoasava, including Tcjapatra [Cim;momum Umiak (Bueh.-Ham.) T. Nees & Eberm.J, Pushkarmu(hiuJa racemosa Hook. f.), and Chirauata (Kiratatikta, Swerichirata).l3lV5'm'wl As discussed previously, in a pilot stucon patients with diabetes, S. chirata produced a significaidecrease in fasting and postprandial blood glucose levels.A pilot study on Tcjapatra showed insulin-releasing activila? well as a decrease in fasting and postprandial blood gUcose levels in patients with diabetes.102'103Mamejjaka {Eritcoslema Uttoralc Blume) is used as a sing]herb and also as part of an antidiabetic mixture.KH Inclinical study on patients with type 2 diabetes, E lit lorn,reduced blood glucose and prevented the progression cdiabetic complications. There was significant improvemerin the lipid profile, blood pressure, and kidney function.10" jsignificantly reduced blood glucose and lipid peroxides i.rats with alloxan-induced diabetes, and increased superoxiddismutase, catalase, and glutafchione peroxidase.106 In sludieon rats with sbeptozotocin-indueed type 1 diabetes, C. littarak significantly reduced glucose, cholesterol, and triglyc^ride levels,10' and ameliorated diabetic nephropathy. Sei'un:reatinine and urea were signiricantly decreased, mid glomerular function improved.1 * In rats'fed a hypercfiolestci"Dlemic diet, E. Uttoralc decreased serum cholesterolxiglycerides, LDL, VLDL, liver and kidney diolesteroJ levdsind lipid pera.xidation levels. There was an increase in HDLmd an increase in reduced glutatJiione levels.10?A pilot study on an herbal mixture am tabling TejapatnCinnamomum tamala), Pushkarmula (Jnula racemosa), h/nimejjak:,E. littoruk), Mesliaskrhig; (Gytnneiiw sylvustre), and Jaitibu (Syyghuitaivunf) seeds with Kctravrtlnka (bitter gourd; bitteinelon; Montordica chanmtia) juice, administered at a dose oJig twice a day before meals, decreased fasting and postnundialblood glucose le\els in patients with diabetes (Singht al., 1992; see Box 1). Avurtaki {Cassia auriculata Linn.) and'lethika {Trigondla foenum-gmecum) as single herbs and deoctionof Nimbn {Azadiradila indies A. Juss.; Nsj/jO have alsoSHARMA AND CHANDOLAemonstrated blood glucose-lowering action (Marwah et al.,990; see Box 1). In a dinical study on patients with type 2iabetes, Neem shewed significant hj'poglycemic activity.110i rabbits witli alloxan-mduced diabetes, the hypoglycemictfect of Neeiit was comparable to that of glibunelamide.111The herbs Cokshura (Tribuluz terrestris Linn.),112 Asana"teracarpiis mavtuyuun Roxb.),6i Kulatha [Vigrm unguicuhta-bin.) VValp.], and Saptapama [Alstonia scholaris (Linn.) R.Br.]re also beneficial in treating Prameha. These herbs can besed in different combinations, depending on the Doshicivolvemcnt and severity of the illness. An herbal mixtureimprised of one part each of Ktirnvdhikn (bitter gourd: bitter.elon; M. chanvitia), Jambu (S. cwn'mi), Gummr (Meshae-hringi,. svlviisire), and Awra (Mangifera iudica Linn.), taken alongith Shilajit, was investigated in a cibiical study on 805 patientswith diabetes. The results showed a statistical!}' si;nificnnt reduction in fasting and postprandial blood glucosalong with clinical improvement (website of India's CentrCouncil for Research in Ayurveda and Siddha; see Box IVijayit&iradi Kiuatha, Nishakatnkadi Kumtha,u? KatakagadmuKioatha, Saptaranguadi Vati, and Chandraprabha Vati acefew oUVr polyherbal combinations that have an antidiabet:effect. Given the abundance of Ajairvedic herbs that are useto treat Pramcha, further research and clinical trial? in thfield may determine which are most effective in managindiabetes mellitus.Management of complicationsPatients with diabetes are at high risk for a number of con:jliostiond. Ayurvedic herbs that target specific organ functionire helpful in managing these disorders. A large bod)' of research has been conducted cm these herbs. For cardiovasciilaimplications, Arjuna {Tennmalia arjunn Linn.),113'116 GugguhConimtphora wighsi't (Am.) Bhandari],11' Pttslikiinnula (hurfa in@cmosa),ll'~u9 and Kushiha [Snussurea lappa (Decne.) C.Baailicj'120'121 can be utilized. Bitva [Aeglc marmclos (Linn.) Corricrr.],1^'1"3 Kutaju [Holarrhena antidyscutericn (Roxb. ox FlemingVail, ox A. DC.],12*125 and Haritaki'{Tennmalia chebuh)126-@ arcLelpful in managing diabetic cntcropatrry. For diabetic nc-@liropathy, Pimamaz>a (Boorliai'ia diffusn Linn.),126'1'9 GokshwiTribulus h'rrestris)^^'1'^' and Varuna {Cratacva nuivala Buch.-fam.)'W35 are useful. Knpiknc.chu [Muaina pruriais (Linn.)Cl,13^178 Ashwngmdha (Withaiw sarrmifera)@ SltPeta Mush'1rf/wjntvjs aiiscertdens Roxb.) (Deka et al, 2004; see Box 1),shwunha (Ficus rdigiosa Linn.) (Virani et a]., 2009; see Box 1),ltd Jntiphxla {Mymlica fragrant Houtt.) (Deka et af,, 2004; seeox 1) can be utilized lor erectile dysfunction. For diabeticriunipathy, Dashnmuh Kwalha (Dwjvedi, 1986; see Box 1) and(jgy/i/-based formulations are helpful. For diabetic retinopaiy,Saptiinirita Lntlut fUpadhyaya and Singh, 1993; see Box I)140id Mnhatriphrtla Ghiita (Gupta Diu-gesh, 2IJ09; see Box 1) are@commended. Lucal and internal administration of MaliaanjishthadsKtvathn (Anil Kumar, 1985; see Box 1) and Kaishorugguhi (Shringi, 1996; Hota, 1997; see Box 1) can be utilized furirioiLS skin manifestations. For cerebral diseases such as deefitiaand Alzlieimer disease, Shankhapnshpi (Convolvulusuriaiulis),71-^41^42 Mnndukaparni [CentcHti asiatiat (Linn.)rb-1,1*3""5 Brtthwi (B. monnieri),73U6M7 Vitcha {Acorns cnlnu$)/^M9fyoHshwati (Celastruf pauiculatus Willd.),150']51 andiduchi (Titiospora cordifolin)152'1'' are recommended,inclusionsIn At/nrveda, Prameha is described as a set of complexnical disorders characterized by frequent abnormal micriu'on,with tlie etiology involving genetic predisposition as;]| as improper diet and lifestyle. The role oi stress andesity in its pathogenesis it, also elaborately discussed in the'iirvedic texts. The clinical conditions described in Pniniehnve much in common with those

PRAMEHA IN AYURVEDA, PART 2595Ayurveda has a vast array of herbs and herbal mixtures thatare used in the treatment of Pramehi. A large number of theseherbs have demonstrated efficacy in research investigations.The herbs have various properties, including hypoglycemic,anrihyperglycemic, hypolipidemtc, antihyperlipidemic, insulinpromoting,and antioxidant properties. Some of these herbs arecapable of counteracting stress-induced catecholamines, whichare established insulin antagonists. Hence, the selection of theherb or combination of herbs for the patient depends upon the.stage of the disease, disturbances in the psychophysiologicconstitution of the patient, and mode of action of the herbs.Further research is needed in the clinical setting to elucidate theAyurvedic modalities that are effective in the management oiobesity, metabolic syndrome, and diabetes mellitus, in light oftheir similarities with Pramchn.AcknowledgmentsThe authors are very thankful to Dr. Kamayani Shukla,MD(Ayu) for her outstanding contributions in giving finalshape to the manuscript- We ate also thankful to Dr. ShyamPrasad and Dr. Anju P. Ramachandran, PhD scholars, Department of Kayachikitsa, Institute for Post GraduateTeaching & Research in Ayurveda, Gujarat Avurved University, Jamnagar, for facilitating the completion of themanuscript. We also thank Ellen Kauffman for her assistancein the preparation of the manuscript.Disclosure StatementNo competing financial interests exist.1. Sharma H, Chandola HM. Ayurvedic concept of obesity,metabolic syndrome, and diabetes mcllitus. 1 Aitern Complement Med 20U;17:549-552.2. Sharma H, Chandola HM. Pramdni in Ayurveda: Correlation with obesity, metabolic syndrome, and diabetes mellitus.Part 1@Etiology, classification, and pathogenc-sis. ]Altcm Complement Mcd 2011; 17:491-496.3. Acharya VJT, ed. Agnivesha, Charaka Samhita. Varanasi,India: Chaukhambha Sanskrit Sansthan, 2004.4. Shaslri KN, Chaturvedi GN. Agnivesha, Charaka Samhita,Vidyotini commentary. Varanasi, India: ChaukhambaBharati Academy, 2004.5. Shastri A. Sushruta Samhita, Ayurveda-Tattva-SamdipikaCommentary. 14th ed. Varanasi, India: ChaukhambhaPublications, 2003.6. Dijsselbloem N, Vanden Berghe W, De Nacyer A, HaegemanC. Soy isoflavone phyto-pharmaceuticals in interleukin-6affections: Multi-purpose nutraceuticals at the crossroad ofhormone replacement, anti-cancer and anti-inflammatorytherapy. Biochem Pharmacol 2004;68:1171-1185.7. Nilsson AC, Ostman EM, Knudsen KE, et al. A cereal-basedevening meal rich in indigestible carbohydrates increasesplasma butyrate the next morning. J Nutr 2010; 140:1932-1936.8. Nilsson AC, Ostman EM, Hoist J.I, Bjtinrk IM. Includingindigestible carbohydrates in the evening meal of healthysubjects improves glucose tolerance, lowers inflammatorymarkers, and increases satiety after a subsequent standardized breakfast. J Nutr 2008;138:732-739.. CasiragW MC, GarsetH M, Testolin G, Brighcnti F. Post*prandial responses to cereal products enriched with barleybeta-glucan. J Am Coll Nutr 2006:25:313-320.. Behail KM, ScholfieM DJ, Hallfrisch JG. Barley beta-glucanreduces plasma glucose and insulin responses comparedwith resistant starch in men. Nutr Res 2006;26:644-650.. Sabu MC, Kuttan R. Anti-diabetic activity of medicinalplants and its relationship with their antioxidant property. JEthnopharmacol 2002;81:155-160.Krishnaveni M, Mirunalini S. Therapeutic potential of1'hyllnnthus emblica (Amla): The Ayurvedic wonder, J BasicClin Physiol Pharmacol 2010;21:93-105.Rao TP, Sakaguchi N, Juneja LR, et al. Amla {Emblica oficinalisGaertn.) extracts reduce oxidative stress in srreptozotocininduccddiabetic rats. J Med Food 2005;8:362-368.Yoko/awa T, Kim HY, Kim HJ, et al. Amla {Emblica officinnlisGaertn.) prevents dyslipidaemia and oxidative stressin the ageing process. Br J Nutr 2007;97;1187-i 195.Sabu MC, Kuttan R. Antidiabetic and antioxidant activityof Termmalia belmca Roxb. Indian ] Exp Bioi 2009;47:270-275.Suehalatha S, Shyamala Devi CS. Protective effect of Terminaliachcbula against experimental myocardial injui-y induced by isoproterenol. Indian j Exp Biol 2004;42:174-178.Bapat SK, Ansari KV, Chandra V. Hypoglycicmic effects ofBnmbiaa dendrocalamus. Indian j Physiol Pharmacol 1969;13:189-190.Kar A, Choudhary BK, Bandyopadhyay NG. Comparativeevaluation of hypoglycaemic activity of some Indian medicinal plants in alloxon diabetic rats, j Ethnopharmacol2003;84:105-108.Barclay AW, Petocz P, McMillan-Price ], et

attenuates aortic tatty streak development in rabbits. Ajterioscler Thromb Vase Biol 2002;22:1225-1231.29. Ravindran PN, Nirmal Babu K, Sivaraman K, eds. Tlumeric: The Genus Curcuma. New York: CRC Press, 2007.30. Babu PS, Srinivasan K. Hypolipidemic action of curciunirthe active principle of turmeric (Curcuma longa) in slieptczotocin induced diabetic cats. Mo] Cell Eioehem 1997;16t169-175.31. Murugan P, Pan L. Effect of tetrahydrocurcumin on lipkperoxidation and lipids in streptuzotocm-nicolinamide.induced diabetic rats. Basic Clin Pharmacol Toxicol 200699:122-127.32. Strimpakos AS, Sharma RA. Curcumin: Preventive anttherapeuticproperties in laboratory studies and clinicatrials. Antioxid Retfox-Signal 200S;10:511-545.33. Khan A, Safdar M, Ali Khan MM, et al. Cinnamon improves glucose and ]ipids of people with type 2 diabetesDiabetes Care 2003;26:3215-3218.34. Dhandapajii S, Subramanian VR, Rajagopal S, NamasivayairN. Hypolipideniic effect of Cuminum cyminum L. on alloxaninduceddiabetic rats. Pliarmacol Res 2002;46:251-255.35. Qiithra V, Leelamma S. Coriandrum salivum changes thelevels of lipid peroxides and activity of antioxidnnt enzymes in experimental animals. Indian J Biochem Biophya1999^6:59-61.36. Ciiithra Vr Leelan-una S. Hypolipidemic effect of corianderseeds (Coriandrum sativum): Mechanism of action. PlantFoods Hum Nil tr 1997^1:167-172.37. Sharma H, Chandola HM, Singh G, Basisht C. Utilization ofAjoin'eda in health care: An approach for prevention,health promotion, and treatment of disease. Part 1 @Ayurveda, the science of life. J Altern Complement Mod2007;13:1011-1019.38. Kassaian N, Azadbakht L, Porghani B, Amini M. Effect offenugreek seeds on blood glucose and lipid profiles in type2 diabetic patients. Int J Vitam Nutr Res 2009;79:34-39.39. Gupta A, Gupta R, Lai B. Effect of Trigondla focnumgraectun(fenugreek) seeds on glycaemic control and Insulinresistance in type 2 diabetes mellitus: A double blind placebo controlled study. J Assoc Physicians India 2001 ;49:1057-1061.10. Sharma RD, Raghurain TC, Rao NS. Effect of fenugreekseeds on blood glucose and serum lipids in type 1 diabetes.Eur J Clin Nutr 1990;44:301-306.tl. Hamden K, Masmoudi H, Carreau S, Elfeki A. Immunomodulatory,beta-cell, and neuroproteclive actions offenugreek oil from alloxan-induced diabetes. ImnumophannacolImmunotoxicol 2010;32:437-445.\ . Aruiida B, Stanely Mahizen Prince P. Supplementation offenugreek leaves reduces oxidative stress in streptozotocininduceddiabetic rats. J Med Pood 2005;8:3S2-385.3. Devi BA, Kamalakkannan N, Prince PS. Supplementationof fenugreek leaves to diabetic rats: Effect on carbohydratemetabolic enzymes in diabetic liver and kidney. PhytotherRes 2003;17:1231-1233.4. Sobenin IA, Nedosugova LV, Pilatova LV, et al. Metaboliceffects of time-released garlic powder tablets in type 2 diabetes mellitus: The results of double-blinded placebocontrolledstudy. Acta Diabetol 2008;45:l-6.5. Eidi A, Eidi M, Esmacili E. Antidiabetic effect of garlic(Ailium sativum L.) in normal and strepto^otocin-induceddiabetic rats. Phytomcdicine 2006;13:624-629.5. Sobenin IA, Andrianova IV, Demidova ON, ct al. 1-ipidloweringeffects of time-released garlic powder tablets inSHARMA AND CHANDOLAdouble-blinded placebo-controlled randomized study.Atheroscler Thromb 2008;l5:334-338.47. Bordia A, Vernia SK, Srivastava KC. Effect of garli(Allium sativum) on blood lipids, blood sugar, fibrinogeand fibrinolytic activity in patients with coronary arterdisease. Pro.sraglandins Leukot Essent Fatty Acids 19958:257-263.48. Akhtar MS, Athar MA, Yaqub M. Effect of Momordiccharantia on blood glucose Jevel of normal and ailoxandiabetic rabbits. Planta Med 1981;42:205-212.49. Chaturvedi P, George S. Momordicn charantia maintainnormal glucose levels and lipid profiles and prevents oxidalive stress in diabetic rats subjected to chronic sucrosiload. J Med Food 2010;!3:520-527.50. Shetty AX, Kumar GS, Sambaiah K, Salimath PV. Effect obitter gourd {Momordicn charnntia) on glycaemic status irslreptozotocin induced diabetic rats. Plant Foods Hun'Nutr 2005;60:109-112.51. Virdi }, Sivakami S, Shahani S, et al. Aiitihyperglycenikeffects of three extracts from Momordiai chamntia. J Bthnophannacol2003;88:107-lll.52. Chaturvedi P. Role of Momordica charantia in maintainingthe normal levels ot lipids and glucose in diabetic rafs fed aJiigh-rat and low-carbohydrate diet. Br J Biomed Sci 2005;62.124-] 26.\ . Paradkar BH, ed. Vagbhata's Ashtanga Hridayam. Varanasi,Indi^: Kdshnadas Academy, 2000.54. Mishra B. Bhavaprakasha. 7th ed. Varanasi, India: CliauklwmbhaSanskrit Series, 20UO:606.5. Fung Tf, Schulzc M, Manson JE, ct al. Dietary pattcins,meat intake, and the risk of type 2 diabetes in women. ArchIntern Med 2004;l 64:2235-2240.@6. Schulzc MB, M.mson JE, Willett WC, Hu FB. Processedmeat intake and incidence of type 2 diabetes in youngerand middle-aged women. Diabetologia 2003;46:1465-1473.7. Song Y, Manson JE, Buring JE, Liu S. A prospective studyof red meat consumption and type 2 diabetes in middleagedand elderly women: The Women's Health Study,Diabetes Care 20'04;27:2108-2115.8. van Dam RM, Willett WC, Rimrn EB, et al. Dietary fat andmeat intake in relation to risk of type 2 diabetes in men.Diabetes Care 2002;25:417-424.i>. Micha R, Wallace SK, Mozaffarian D. Red and processedmeat consumption and risk of incident coronary heartdisease, stroke, and diabetes meLlirus: A systematic reviewand me la-analysis. Circulation 2010;121:2271-2283.3. Sharma H, Clark C- Contemporary Ayurveda. London:ChLirchill Livingstone, 199S.I. Bijlani RL, Vempati RP, Yadav RK, et al. A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetesmelHtus. j Aitem Complement Med 2005;l 1:267-274.1. Malhotra V, Singh S, Tandon OP, Sharma SB. The beneficial effect of yoga in diabetes. Nepal Med Coll J 2005;7:145-147.i. Singh S, Malhotra V, Singh KP, et al. Role of yoga inmodifying certain cardiovascular functions in type 2 diabetic patients. J A&soc Physicians India 2004;52:203-206.Malhotra V, Singh S, Singh KP, et ai. Study of yoga asanasin assessment of pulmonary function in N1DDM patients.Indian J Physiol Pharmacol 2002;46:3Z3-320.. Malhotra V, Singh S, Tandon OP, et al. Effect of yogaasanas on nerve conduction in type 2 diabetes. IndianJ Physiol Pharmacol 2002;46:298-306.

PRAMEHA IN AYURVEDA, PART 259766. Kyizom T, Singh S, Singh KP, et al. Effect of Pranayam.and yoga-asana on cognitive brain functions in type 2 diabetes-P3 event related evoked potential (ERP). IndiaiJ Mod Res 2010;l31:63fr-640.67. Singh RH, Narsimhamurfhy K, Singh G. Neuronutrienimpact of Ayurvedic Rasayana therapy in brain agingBiogerontoiogy 2008;9:369-374.68. Kuikami SK, Dhir A. Withanin sonmifera: An Indian ginseng. Prog Neuropsychopharmacot Bio] Psychiatry 200832:1093-1105.69. Mishra LC, Singh BB, Dagenais S. Scientific basis for ihttherapeutic use of Withanin somnifera (Ashwagandha): Areview. Altern Med Rev 2000;5:334-346.70. Kumar V. Potential medicinal plants for CNS disorders: Aroverview. Phytuther Rus 2006;20:1023-i035.71. Bihaqi SVV, Sharma M, Singh AP, Tiwari M. Neuroprotectiverole of Convolvulus plurianilis on aluminium inducedneurotoxicity in rat brain, f Ethnopharmacol 2009;! 24:409-415.72. Mathew J, Peeyush Kumar T, Khan RS, Paulose CS. Behavioraldeficit and decreased GADA receptor functionalregulation in the cerebellum of epileptic rats: Effect ofBacopa manuieri and bacoside A. Epilepsy Behav 2010; 17:441-447.73. Uabundit N, Wottanathorn J, Mucimjpura S, IngkaninanK. Cognitive enhancement and neuroprotective effects ofBacopa monnicn in Alzheimer's disease model. ] Ethnopliarmacol2010;127:26-31.74. Calabrese C, Gregory VVL, l.eo M, et al. Effects of a standardized Bacopa uwnnieri extract on cognitive performance,anxiety, and depression in the elderly: A randomized,double-blind, placebo-controlled trial. J Altcm Complement Med 2008;i4:707-713.75. Bolska NV, Guriev AM, Danilcts MG, et al. Water-solublepolysaccharidc obtained from Acuru> calamus L. classicallyactivates macrophages and stimulates Thl response. IntImmunopharmacol 2010; 10:933-942.76. Si MM, Lou JS, Zhou CX, et al. Insulin releasing and alphaglucosidaseinhibitory activity of ethyl acetate fraction ofAcorus calamus in vitro and in vivo. J Ethnopharmacol2010;128:154-159.77. Wu HS, Zhu DF, Zhou CX, et al. Insulin sensitizing activityof ethyl acetate fraction oi Acorus calamus L. in vitro and invivo. J Ethnopharmacol 2009;123:288-292.78. Soumyanath A, ed. Traditional Medicines for ModemTimes: Antidiabetic Plants. Boca Raton, FL: CRC Press,2006.79. Grover JK, Yadav S, Vats V. Medicinal plants of India withanti-diabetic potential. J Ethnopharmacol 2002;81:81-100.SO. Saxena A, Vikram NK. Role of selected Indian plants inmanagement of type 2 diabetes; A review. J Altern Complement Med 2004;!5:369-378.il. Sharma H, Chandola HM, Singh G, Basisht G. Utilization ofAyurveda in health care: An approach for prevention,health promotion, and treatment of disease. Part 2@Ayurveda in primary health care. J Altern ComplementMed 2007;13:1135-1150.!2. Leach M|. Gyinnema sytvettre for diabetes meliitus: A systematic review, j Altern Complement Med 2007; 13:977-983.13. Shanmugasundaram ER, Gopinath KL, Radha ShanmugasundaramK, Rajendran V'M. Possible regeneration of theislets of Langerhans in strcptozotocin-diabetic rats givenCymncma sylvestre leaf extracts. ] Ethnopharmjcol 1990;30:265-279.Baskaran K, Kizar Ahamath B, Radha ShanmugasundaranK, Shanmugasundaram ER. Antidiabctic effect of a leaextract from Gymncma suhestre in non-insulin-dependendiabetes mcllitus patients. J Ethnopharmacol 1990;30:295-300.Shanmugasundaram ER, Rajeswari G, Baskaran K, et alUse of Gymncma sylvestre leaf extract in the control of blootglucose in insulin-dependent diabetes mellitus. I Ethnophannacol 1990;30:281-294.Slanely P, Prince M, Menon VP. Hypoglycaemic and otheirelated actions of Tinospora cordifolia roots in alloxaninduceddiabetic rats. J Ethnopharmacol 2000;70:9-15.Slanely Mainzen Prince P, Menon VP. Hypoglycaemic andhypolipidaemic action of alcohol extract of Tinospora cordifolia roots in chemical induced diabetes in rats. PhytotheiKes2003;l7:4l0-4l3.Stanely Mainzen Prince P, Menon VI'. Antioxidant action oiTinospora cordifolia root extract in alloxan diabetic rats.Phytother Res 2001; 15:213-2J 8.Stanely Mainzen Prince P, Menon VP, Gunasekaran CHypolipidaemic action of Tinospora cordifolia roots in alloxan diabetic rats. J Ethnopharmacol 1999;64:53-57.Bajpai M, Asthana RK, Sharma NK, ef al. Hypoglycemiceffect of swerchirin from the hexane fraction of Swertiadiiraifita. Pianta Med 1991;57:"IO2-1O4.Sekar BC, Mukherjee B, Cliakravarti RB, Mukherjee SK.Effect of different fractions of Swertia chirayita on the bloodsugar level of albino rats. J Ethnopharmaco! I9S7;21:175-181.Chandrasekar B, Bajpai MB, Mukherjee SK. Hypoglycemicactivily of Swertia chirayita (Roxb ex Hem) Karst. IndianJHxp Biol 1990^8:616-618.Saxt'na AM, Bajpai MB, Mukherjee SK. Swerchirin inducedblood sugar lowering of strepto/.otocin treated hyperglyccmicrats. Indian J Exp Bio] 1991;29:674-675.Saxena AM, Bajpai MB, Murlhy PS, Mukhcrjee SK. Mechanism of blood sugar lowering by a swerehirin-conlaininghexane fraction (SWI) of Swertia chirayiUt. Indian J Exp Biol1993;31:178-181.Af-arwal SP, Khanna R, Kannarkar R, el al. Shilajit: A review, i'hytother Res 2007;21:40"l-405.Acharya VJT, Acharya N, eds. Sushruta Samhita. Varanasi,India: Chaukhambha Orientalia, 2005:456.Saxena N, Dwivedi UN, Singh RK, el al. Modulation ofoxidative and antioxidative status in diabetes by Asphaltumivmjabinum. Diabetes Care 2003:26:2469-2470.frivedi NA, Mazumdar B, Bhatt jD, Hemavathi KG. Effect.if shilajit on blood glucose and lipid profile in alloxan-,nduced diabetic rats. Indian ] Pharmacol 2004;36:373-376.^hattacharya SK. Shilajit attenuates slreptozotocin induced.iiabetes mcllirus and decrease in pancreatic islot superoxdedismutase activity in rats. Phytother Res 2006;9:41-44.rripathi SN, Tiwari CM, Upadhyay BN, Singh RS.Screening of hypoglycemic action in certain indigenousirugs: Short research communication. J Res Indian Medtoga Homoeopathy 1979;14:3-4.^holap S, Kar A. Effect* of Inula racemota root and Gymicina sylveslir leaf extracts in the regulation of corticosteoidinduced diabetes mellitus: Involvement of thyroidlormones. Pharmazie 2003;58:413-415.rhandola HM, Tripathi SN. Hypoglycemic response of:. tamala in diabetes. In: Bajaj JS, ed. Diabetes Mellitus-i Developing Countries* New Delhi: Jntcrprint, 1984:83-386.

103. Chandola HM, Tripafhi SN, Udupa KN. IZffect ot (tamala on plasma insulin vis-a-vis blood sugar in patien!of diabetes mellitus. J Res Ayurvcda Siddha 1980;l:345357.104. Sharma TV. Priya Nighantu. Varanasi, India: ChaukhambSurabharati Prakashana, 2004:101.105. Upadhyay UM, Goyal RK. Efficacy of Enicextcnnnlittorale in type 2 diabetic patients. Phytofher Res 2004;It233-235.106. Prince PS, Srinivasan M. Enkostcmma titloralr Blumaqueous extract improves the antioxidanl status in alloxaninduced diabetic rat tissues. Acta Pol Pharni 2005;62363-367.107. Vishwakarma SL, Sonawane RD, Rajani M, Coyal RKEvaluation of effect of-aquoous extract of Emcostemma litlorale Dlume in strepto/ofocin-induced type 1 diabolic ratsIndian j Exp Biol 2010;48:26-30.108. Sonawane RD, Vishwakarma SL, Lakshmi S, et a!. Amelioration of STZ-induccd type 1 diabetic nephrupathy b)aqueous extract of Enicoslemma lit lorale Blume and svvcrtiamarinin rats. Mol Cell Biochem 2010;340:l-6.109. Vasu VT, Modi H, Thaikoottathil JV, Gupta S. Hypolipidaemicand antioxidant effect of Enicostcmma tittorale Biumi.aqueous extract in cholesterol fed rats. J Ethnupharmacol2005;101:277-282.110. Waheed A, Miana GA, Ahmad SI. Clinical investigation olhypoglycemic effect of seeds of Azadiraclita indiat in type-2(NIDDM) diabetes mellitus. Pak J Pharm Sci 2006; 19:322-325.111. KhosJa P, Bhanwra S, Singh }, et al A study of hypo-Iycaemieeffects of Azidiraclita indica (Nicem) in normal andalloxan diabetic rabbits. Indian J Physio! Pharmacol 2(100;44:69-74.112. Amin A, Lotfy M, Shafiullah M, AdeghateE. The protectiveeffect of Tribulus terrestris in diabetes. Ann N Y Acad Sci2006;1084:391-401.113. Anonymous. Sahasrayogam. 23rd ed. Alappuzha, Kerala,India: Vidyarambam Publishers, 2000:93.114. Dasa G- Bhaishajyaratnavali. Varanasi, India: ChaukhambhaSanskrit Sansthan, 2000.115. Gauthaman K, Banerjee SX, Dinda AK, et al. Temiinuliaarjuua (Roxb.) protects rabbit heart against isdiemicreperfusioninjury: Role of antioxidant enzymes and heaishock protein. J Ethnopharmacol 2005;96:403-409.16. Dwivedi S, Aggarwal A, Agarwal MP, Rajpal S. Roie ofTerminatia arjuna m ischaemie mitral regurgitation. Int JCardiol 2005;l00:507-508.17. Singh RP, Singh R, Ram P, Batliwala PG. Use of PushkarGuggul, an indigenous antiischemic combination, in themanagement of ischemic heart disease. Int J Pharmacog1993;31:147-160.18. Patel V, Banu N, Ojha JK, et ai. Effect of indigenous drug(Pushkarmuia) on experimentally induced myocardial infarction in rats. Act Nerv Super (Praha) 1982;suppi 3fpt 2)-387-394.19. Miller AL. Botanicai influences on cardiovascular dismast1.Altem Med Rev 1998^:422-431.20. Dwivedi S, Somani PN, Udupa ICN. Role of Inulo mcemosnand Saussurea lappa in management of angina pectoris,Pharm Biol 1989;27:217-222.21. Dwivedi S, Chansuria JPN, Somani PN, Udupa KN. Influence of certain indigenous drugs on the prostaglarxli.iE2-like activity in the ischaemie rabbit aorta. Indian Drug?;1987;24:378-382.SHARMA AND CHANDOLA122. Vijayalakshmi K, et al. Activity of leaf extract of Aegtimrmelos (L.) Correa against some pathogenic bacteri;Aniruth 2002;6:17-20.123. Mazumder R, Bhattacharya S, Mazumder A, ft al. Antidiarrhoea! evaluation of Aegle inarmelos {Correa) Linn, rooextract. Phytother Res 2006;20:82-84.124. Kavitha D, Shilpa PN, Devaraj SN. Antibacterial and antidiarrhoeal effects of alkaloids of Holarrhena nntidysenteriaWALL. Indian J Exp Biol 2004^2:589-594.125. Dallal M, Srujan D, Bhat KK, et al. Antibacterial activity oHolarrhena antidyseuterica [KurchiJ against the enteriipathogens. Indian J Pharmacol 2000;32:392-393.126. Tripaihi VN, Tewari SK. Clinical trials of Haritaki (Terminflliachcbula) treatment of simple constipation. Sachitta;Ayurveda 1983;35:733-740.\ 7. Ahmad I, Mehmood Z, Mohammad F. Screening of sonuIndian medicinal plants for their antimicrobial propertiesJ Ethnopharmncol 1998;62:183-193.28. Singh RH, Udupa KN. Studies on the Indian indigenousdrug Punarnava {Boerhaavia difiisa I,.) Part IV: Preliminarycontrolled clinical trial in nephrotic syndrome, j Res IndianMod 1972;7:2S-33.29. Singh RP, Shulda KP, Paiidey BL, et al. Recent approach inclinical and experimental evaluation of diuretic action ofPunarnava (B. difusa) with special reference to nephroticsyndrome. J Res Educ Indian Med 1992;ll:29-36.30. Prasad KVSRG, Sujatha D, Bharathi K. Herbal drugs inumlithiasis: A review. Pharmacognosy Rev 2007; 1:175-] 79.31. An.ind R, Patnaik GK, Kulshrcshtha DK, Dhawan BN.Activity of certain fractions of Tribulus terrestris fruitsagainst experimentally induced urolithiasis in rats. Indianj fixp Biol 1994^2:548-552.32. Kavitha AV, Jagadec-san G. Role of Tribulus terrestris (Linn.)(Zygophyllacea) against mercuric chloride induced ncphrotoxicityin mice, Mus muscvilus (Linn.). J Environ Biol2()06;27(2 suppl):397-400.)3. Singh RG, Singh RP, Usha, et al. Experimental evaluation ofdiuretic action of herbal drug (Tribulus tsrreslris Linn.) onalbino rats. J Res Educ Indian Med 1991;10:19-21.VI. Dc-shpande PJ, Sahu M, Kumar P. Crahieva mirvala Hookand Forst (Varuna): The Ayurvedic drug of choice in urin.ii-ydisorders. Indian] Med Res 1982;76(suppl):4f>-53.55. Varalaksllini P, Shamila Y, Latha E. Effect of Crahiczm nurvnlnm experimental urolithiasis. J EthnophannacolI990;28:313-321.!6. Amin KMY, Khan MN, ZiUur-Rehman S, Kh.-ia NA. Sexualfunction improving effect of Mucuna pruriras in sexuallynormal male rats. Fitotsrapia 1996;67:53-58.7. Anantha Kumar KV, Srinivasan KK, Shanbhag T, Rao SC.Aphrodisiac activity of the seeds of Mucuna pruriens. IndianDrugs 1994;31:321-327.6, Suicsh S, Prithiviraj E, Prakash S. Doye- and time-dependenteffects of ethanolic exlracf of Mucuna pruriens Linn, seed onsexual behaviour of normal male rats. J Ethnopharmacol200^122:497-501.9. Abdel-Magied EM, Abdel-Rahman HA, Harraz FM. Theeffect of aqueous extracts of Cynomorium coccineum andVvitkanui somnifera on testicular development in immatureWistar rats. J Ethnopharmacoi 2O0'I;75:l-4.'X Sharma KR, Bh.atia RP, Kumar V. Role of the indigenousdrug Saplainrita Laulia in hemorrhagic retinopathies. AnnOphthalmol 1992;24:5-8.I. Dhingrj D, Valecha R. Evaluation of the antidopressanti:kcactivity of Convolvulus pluricaulis Choisy in the mouse

PRAMEHA IN AYURVEDA, PART 2 599forced .swim and tail suspension U\ ls. Med Sci Monit 149. Shukla PK, Khanna VK, Ali MM, et al. Neuroproteclive2OO7;13:BR155-BR161. ctlecl of Acanif calamus against middle cerebral artery oc-142. Mui.lg.il V, Udupa KN. Anticonvulsivc aetkin ofShankha- elusion-induced ischacmi.i in rat. Hum Exp Toxicoi 2(11)6;pushpi. I Res Indian Med Yoga Homeopathy 1977;]2: 25:1S7-194.127-129. 150. C.ittu M, Boss KL, Terry AV Jr, Buicafuscn JJ. Reversal of143. Veerendra Kumar Mil, Cupla YK. Kffect of d'utdht asiutlai scopolamine-induceei deficits in navigational memoryon cognition and oxidative stress in an intracerebroven- performance by the seed oil of O/dSinis puniculatua. f'hartricularstreptozotixin model of Alzheimer's disease in rats. macol Biochem Behav l997;57:793-7yt(.Clin Cxp Pharmacol Physiol 2003;30:336-342. 151. Kumar MH, Gupta YK. Antraxidant property of Cdastrus144. Appa Rao MVR, Srinivasan K, Rao K. The effect of Man- ymiiculatus Willd.: A possible mechanism m enhancingdookap.irni (G-n/W/o nsmfiVo) on Ihc general mental abilily cognition. Phytomedicine 20t)2;'l:3n2-311.(medhyal of mentally retarded children. J Res tndian Med 152. Vinuiha B, Prashanth D, S.ilma K, et al. Screening of sc-1973; ;9-U,. leeted Indian medicinal plants for .icelylcholinesler.ise in-145. Dhanasekaran M, Holcomb LA, I lilt AR, ef al. Cctilfllu hibitory activity. J Kthnopharmacol 2007:109:359-363.asinlua extract selectively decreases amyloid beta Ie\els in 151. Rawal AK, Muddeshvvar MC, Biswas SK. Rubui ivnl/folin.hippocampus of Alzheimer's disease animal model. I'hyt- i-iiS'iunil cretial Linn, and liiwspon: omlifolia exert neumotherRes2009;23:14-19. protection by modulaling the antioxidant system in rat146. Zhou Y, Shell YH, /hang C, et al. Triterpene saponins from hippocampal slices sub|ected to oxygen glucose deprival^nvpamonnwri and their antidepressant effects in two mice fion. BMC Complement Altern Med 2004;4:11.models. J Nat Prod 2007;70:652-655.147. Singh KH, Singh I.., Sen SP. Studies on the anti-anxiety ef- Address correspondence, to:feet of the Medhva Rasayana drug Brahmi {Bacnpa mmmwri /;@,.,- simrma, MD, DABP, FCAI>, IKCl'C DA1IHML.inn.): I'arl 11. Lxpenmental studies, J Res Indian Med Yoga Cl,,;(l,r far ,,l([,xrnj,K, MedKincHomeopathy 1979; 14:1-*. r,,(. f); S/ , Umvmll148. Mukherjee PK, Kumar V, Mai M, Houghton PJ. In vilro 2wg Kmm RJacetylcholinesterase inhibitory activity of the essenlial oil cd 'from Acorus ailtvnus and its mam constituents. Unnta Med20