Standard treatment guidelines of Diabetes through Ayurveda

Ministry of AYUSH Government of India has released its Protocol for prevention and Control of Diabetes through Ayurveda'on First National Ayurveda Day.

Diabetes is a leading cause of mortality, morbidity, and health-system costs. The 2011UN High-Level Meeting on Non-Communicable Diseases (NCDs) set a global target to halt the rise in the age-standardised adult prevalence of diabetes at its 2010 levels, by 2025.

Diabetes touches almost every part of life. It can cause various health problems over time- ranging from neuropathy to nephropathy to retinopathy. It causes impairment in the peripheral blood flow and microvasculature and leads to end-organ damage. Diabetes in pregnancy can cause other problems- both for the mother and the foetus. However, most of these problems can be prevented by timely action. Ayurveda considers Prameha, as a disease of Medadhatu (Body Fats or adipose tissue) Dushti with additional derangement in mansadhatu (muscle tissue), Kleda, Rasadhatu, Raktadhatu, Majja, Shukra etc. Ayurvedic line of Treatment starts from correction of medadhatu dushti (Deranged Adipose Tissue), which is responsible for further Pathophysiology of Prameha.
Until recently, it was a belief of Modern Science, that Diabetes is a disease of deranged Carbohydrate Metabolism. But research in this field has highlighted the importance of lipid metabolism and its role in the development of diabetes.

Standard treatment guidelines :

General Diagnostic criteria for

• Increased frequency of urine


• Turbidity in urine


• Excessive thirst & hunger


• Lethargy


• FBS125 mg/dl and (or) PPBS >200 Plus


• Any 5 or more of the following symptoms


• Sweating (Subjective)


• Foul body odour - (Subjective)


• Looseness of body ( Subjective)


• Tendency to rest ( Subjective)


• Eye discharge / Ear Wax ( Subjective)


• Heaviness of body ( Subjective)


• Like cool surroundings ( Subjective)


• Sweet taste feeling ( Subjective)


• Burning / Numbness - Palms & Soles ( Subjective)


• Ants noted in the toilet - ( Subjective)

Sthoola Pramehi –
General Diagnostic criteria + BMI > 25

Krisha pramehi –
General Diagnostic criteria + BMI < 18

Kapha Pramehi
General Diagnostic criteria + BMI > 25 Plus some of the following feature

• Medium onset of Diabetes (2 -6 years)


• Use of spicy salty diet


• Bulk eating habit


• Indigestion predominant Upper GIT symptoms and recurrent URT symptoms

Pitta Pramehi

General Diagnostic criteria + BMI >18 , <25 Plus some of the following features

• Recent onset of Diabetes (2-6years)


• Use of high-calorie diet


• Bulk eating habit


• Acidity predominant Upper GIT symptoms and Recurrent UTI

Vata Pramehi

General Diagnostic criteria + BMI <18 Plus some of the following features

• Chronic onset of Diabetes (>6years)


• Use of dry low nutritional diet


• Less eating habit

Level 1: at solo Ayurveda physician clinic

Clinical Diagnosis: - On the basis of history and clinical presentation patient can be diagnosed provisionally as with subtypes as Sthoola / Krisha and doshic variety Kapha/ pitta/ vata.

Patients diagnosed as sthoola / kapha / Pitta and having at least moderate physical strength and blood sugar level as follows may be treated at this level.

FBS >110 upto 180

PPBS > 200 upto 280

Investigation:
Blood-sugar level

Urine- sugar

Treatment: in the initial stage when the patient is having mild raised blood sugar levels and not associated with major complications, along with diet restriction, two or more of following drugs may be given:

Pathya-apathya (Diet and lifestyle education):
Do's (Pathya)

Use of Purana dhanya (grains harvested 1 year back), Bharjit Dhanya (roasted grains) – When the grains are roasted, carbohydrates in the grains are transformed into short chain pyrodextrines, which are easy to digest and have low glycemic index. Yava- (Barley) It has low glycemic index, high fiber
content. Helps in controlling BSL levels and cholesterol. Provides satiety and minimizes hunger pangs. In the pulses, Mudga and Kulattha, Adhaki,
Masura, Makushtha are recommended, Tikta Shaka: green leafy vegetables like fenugreek. Atasi (Flaxseed), sarshapa (mustard), are recommended.

Jangal mansa in roasted form: Flesh of animals living in dry geographical locations are good source of protein and Vitamin B12.

Chart Showing Various diet Useful in

Type of Diet Name

Cereals Yava (Barley) (Hordeum vulgare), godh£ma (wheat), kodrava (grain variety –Paspolum scrobiculatum) udd¡laka (according to dhanvantari Nighantu forest variety of k°drava), Kangu (Setaria italica), Madhulika (Eleusine coracana), Shyamaka (Echinochloea frumentacea), Jurnahva (Sorghum vulgare), Vajranna (Pennisatum typhoides), Purana shali (old rice),.

Pulses Adhaki (red gram-Cajamus cajan), kulattha (horse gram) and mudga (green gram), Masura (Lentils), Makushtha (Moth Bean/Acpnite bean), Chanaka (Cicer arietinum) should be taken with bitter and astringent leafy vegetables.

Vegetables Navapatola (young Tricosanthus dioica), young vegetables variety of banana, tanduleyaka (Amaranthus spinosus), vastukam (bathuva), all bitter vegetables (tiktasakam) like methika (Fenugreek leaves), Karavellaka (Bitter gourd), Bimbi (Kovai), Shigru fruits and leaves (Drum stick), Vrintaka (Brinjal), Rakta vrintaka (Tomato), Putiha (mint leaves), Suran (amorhophellus), Curry leaves, Mulaka (radish), Kushmanda (Ash Gourd), Kritavedhana (Ridge gourd), Alabu (Bottle gourd),

Fruits Jambu (Syzigium cumini) kapitha (Feronia limonia), amlaki (Phyllanthus embilica), Bilva (Bael), Dadima (Pomegranate), Naranga (Orange), Parushaka (Falsa Gravia asiatica), Udumbara (fig) etc fruits.

Flesh birds like kapota (pigeon),Titira (Grey Francolin)

Oils Condiments Atasi (Linum usitatisimum), saràapa (mustard). Haridra (Turmeric), Maricha (Pepper), Tvak (Cinnamon), Lashuna (Garlic), Shunthi (Ginger), Methika (Fenugreek), Dhanyaka (Coriander), Jeeraka (cumin seeds)

Vihara (Lifestyle):
Ayurvedic texts suggest Long walks, swimming, hard labor like pulling carts, digging wells, serving animals etc. All this involves muscular activity, which will help in maintaining muscle tone and peripheral utilization of glucose. Today, weight training exercises can be done. Following norms should be followed before or after exercise:

• Exercise should be initiated at low intensity and should be gradually increased


• It should not be done after eating heavy meals.


• It should be done regularly at fixed timings.


• Before exercise, a person should have taken proper sleep, his diet should have been digested properly.

Don'ts (Apathya): Ahara
Excessive use of Sweets, fruit salad, Sugar cane, Fruits like Mango, Water melon, Chikoo, Dates, Jack fruits, Custard apple, Banana, Grapes, Cashew
nuts, and other fruits with high glycemic index, use of cold drinks, intake of oil, Ghee, fried food, Over indulgence of meat especially of wetland animals, To take food before complete digestion of past food, To take food in improper time and in varied quantity.

Vihara
Day time sleep especially just after taking heavy meal; Irregular pattern of sleep i.e less than 5 hours or more than 10 hours in a day or in improper
way; No or less or infrequent exercise

Referral criteria: Patient not responding to above mentioned management in terms of symptomatology and reduction in blood sugar levels and developing signs of complication of Diabetes may be referred to next level

Level 2: Ayurvedic hospital with indoor facilities:
All patients referred from level 1 and those patients diagnosed as Krisha parmehi / Vata / Durbala / Pitta with medodushti may be treated at this level

Clinical diagnosis:
Same as level 1for a fresh case reporting directly.

Investigation: - same as level 1; in addition
1. Hb A1C
2. Lipid profile

Treatment:-
In addition to the management mentioned in Level 1, few of the following drugs may be added as per the requirement and status of the patient.
Rasaushadhi (Herbo-mineral drugs) or herbal drugs of potential pharmacovigilance importance can be used at this level. Patient may be kept under observation while prescribing these kinds of medicines.

Pathya-apathya (Diet and lifestyle education): same as level 1
Referral criteria: Patients' blood sugar not well under control and having associated conditions like Macrovascular complications like Ischemic heart disease, microvascular complications like diabetic kidney disease, retinopathy, neuropathy etc may be referred to the next level.

Level 3: Hospitals with indoor facilities like Panchakarma, Ksharasutra etc. and have integrative facilities
All patients referred from level 2 should be treated at this level
All patients willing to undergo Shodhana line of management for better recovery in Sthoola Balavan / Kapha / Pitta pramehi also should be treated at this level.
All patients of Krisha pramehi / Vata / Durbala patients should be treated at this level

Patients having HbA1c above 9 should be treated at this level.

Clinical Diagnosis: Same as level 1for a fresh case reporting directly
Investigation:-
1. Serum electrolytes
2. Blood urea and serum creatinine2.
3. Urine for Micro albumin
4. ECG
5. Fundus examination

Treatment:
In addition to the management of Level 1 and Level -2, if needed Panchakarma procedures can be performed.

• Udavartana with Yavakolakulatha churna, Triphala Powder or Yava powder


• Snehapana with Sarshapa taila, Dhanwantara ghrita, Kalyanalkmghrita


• Vamana Karma with Madanaphala Churna (5-10gm), Pippali Churna (1-2gm), Vacha Churna (2-3gm), Rock salt(5-6gm), honey(Q.S), for Vamanopaga- Nimba Kashaya.


• Virechana – With Brihat triphala churna, Mishraka sneha,


• Asthapana Basti prepared with decoction Surasadigana or nygrodhadigana.

Patient with Apatarpana Janya presentation (Vata predominance)
1. Yapana Basti/Madhutailika Basti with Erandmoola Decoction, Shatapushpa Paste Honey and oil in equal quantity, rock salt.
2. Anuvasanavasti with Dhanwantahra ghrita, Dhanwntahara taila, Guggulithiktaka ghrita
3. Shirodhara
4. Sarvanga taila / Kseeradhara

Pathya-apathya (Diet and life style education): same as level 1
Here modifications in diet and exercise should be made as per the strength and built of the patient is concerned. Moderately nourishing article which do not aggravate kapha and medus can be advised.