Prameha and Diseases of Udakavaha Srotas
(Part-3)

Prof. Muralidhar Sharma
based on the lecture available at–Prameha and Diseases of Udakavaha Srotas

Basically, because this also is from different texts, and different journals and these are not my views, the only thing is I have collected the information and shared the information Comparative with the body size and the appearance of Indian children and western children, basically an Indian child or Indian future would be a relatively shortest stature and underweight. Whereas in the western culture would be chubby babies.  That’s, unfortunately, all our Western doctors, are just following famine theory and they say that we have had a scarcity of food and therefore it has to be supplemented with vitamins. Everyone will be prescribed a vitamin supplement and growth supporting issues and so on. They are not really needed. All that we need to have is go back to the basic tradition which is needed for India is our genes, our genes are not meant for that kind of culture.

Schematic diagram illustrating diabetes risk as a function of three dimensions of body size. The length (A) and cross-sectional area (B) of an internal cylinder of lean mass is considered a marker for metabolic capacity, whereas the volume of the external cylinder of fat mass (C) is considered a marker of metabolic load.

The Elevated Susceptibility to Diabetes in India: An Evolutionary Perspective

Jonathan C. K. Wells, Emma Pomeroy, Subhash R. Walimbe, Barry M. Popkin, Chittaranjan S. YajnikFront Public Health. 2016; 4: 145. Published online 2016 Jul 7. doi: 10.3389/fpubh.2016.00145

  The black color is suggestive of average total linear body mass whereas the white  area represents the fat. Because the whole linear mass is lesser in the Indian races, naturally whenever there’s even a small amount of fat accumulated, that provides the appearance of a bulged abdomen. It is the quality that is attributed to genes. That’s the exact quality that is attributed to the gene, and that gene is responsible for such type of fat deposition. Now it’s named as Harappan gene.

Subramanian SV, Ackerson LK, Smith GD. Parental BMI and childhood undernutrition in India: an assessment of intrauterine influence. Pediatrics (2010) 126(3):e663–71.10.1542/peds.2010-0222 9 PubMed

  In the case of a thin phenotype, there would be better tolerance to that fat accumulation, whereas the thick phenotype has a lesser tolerance to that accumulation of fats. Therefore even a slight amount of fat increase amongst the Indian population results in diabetes much earlier than in western. So we are more prone to diabetes because our body’s structure is not meant for that kind of accumulation of fat.

The capacity–load model illustrated the prospective risk of developing diabetes in three US cohort

Li Y, Ley SH, Tobias DK, Chiuve SE, VanderWeele TJ, Rich-Edwards JW, et al. Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study. BMJ (2015) 351:h3672.10.1136/bmj.h3672

 The risk of diabetes mellitus is now identified with the risk of low birth weight. Those who have a low birth weight, they are having a higher risk of diabetes. It’s not a primary risk factor, whenever there are cumulative factors and precipitating factors results in an early incidence of diabetes and a higher percentage of incidents.

  The vertical axis of the graph shows the risk factors, whereas the horizontal is about the birth weight, the lower the birth weight even with a lesser incidence of the risk factors, diabetes would be pronounced whereas the higher the birth weight, the better tolerance. So that’s the point. Genetically we are meant to have lesser birth weight.

Our heritage and myth of famine gene theory

• Food as Brahma
• Eat to live not live to eat
• Share and spare culture
• Cultivation of food grains was in vogue much earlier than any part of the world. NOT A HUNTER & GATHERER CULTURE
• Concepts of Annadana, Bhooribhojana, Ishta bhojan

  In my opinion, the theory of the famine gene is a myth. Indian tradition had plenty rather than scarcity and is the reason for the western invasion. All the invaded populations have some more here in India because they had the idea that you could get food or some other benefit here, invaders have not come to famine country. Indian Council of Medical Research says that in Bengal there was a famine for five years from 1857, after that famine genes started, genes do not get changed in five years, or the genes get mutated need many generations together.  These genes existed 5000 years earlier, the newspaper report says that that kind of genes existed earlier and that the whole theory of Aryan invasion and cultivation or farming from that area is now being excluded. But as our scientists say that we have that gene and we are in the scarcity area, so there is a need to provide more nourishment. That’s how the whole issue is presented and our culture is not to ‘live for eating’ but instead ‘eat to live. We  were well by agriculture.  The interesting fact is that Annapurna who is supposed to be the goddess of food and prayer to the god implies that the need for food is to achieve knowledge and detachment from the materialistic world. It is the basic theme that we have lost. It looks odd and it becomes a subject of joke when I say that the whole consumption of food it’s not for yourself and it is a universal activity which you have to maintain. The whole idea of food consumption is for maintenance and the rule is whenever you have food you have to share it with others and only after sharing the remaining food to be consumed.  The duty should be serving food to guests first and thereafter whatever is left behind is to be consumed.  In our culture, we have had acquaintances of food so that firstly we share it with others and thereafter we eat food with dear ones.

   This kind of get-together is not shown someone’s richness or it’s not a party, it’s the other way, only after providing food to the society and needy people remaining have to consume. So having a party or get-together, that’s not a real Indian culture to which we are now accustomed. Nowadays every incident is a sufficient reason for us to have food. eg Hi tea, intermittent snacking. This is the basic issue. So primarily the basic issue about increasing diabetes as we are not living as our genes are dictated.  The reality is we need to live as the gens are dictated, our identity is about the intellectual capacity, not physical activity. If we follow that, I’m sure the incidence of diabetes would be reduced if we follow a pattern of diet accustomed to our genetic pattern.

आस्यासुखं स्वप्नसुखं दधीनि ग्राम्यौदकानूपरसाः पयांसि|

नवान्नपानं गुडवैकृतं च प्रमेहहेतुः कफकृच्च सर्वम्|Ch.chi6/4

तत्रेमे त्रयो निदानादिविशेषाः श्लेष्मनिमित्तानां प्रमेहाणामाश्वभिर्निर्वृत्तिकरा भवन्ति; तद्यथा- हायनकयवकचीनकोद्दालकनैषधेत्कटमुकुन्दकमहाव्रीहिप्रमोदकसुगन्धकानां नवानामतिवेलमतिप्रमाणेन चोपयोगः, तथा सर्पिष्मतां नवहरेणुमाषसूप्यानां, ग्राम्यानूपौदकानां च मांसानां, शाकतिलपललपिष्टान्नपायसकृशराविलेपीक्षुविकाराणां, क्षीरनवमद्यमन्दकदधिद्रवमधुरतरुणप्रायाणां चोपयोगः, मृजाव्यायामवर्जनं, स्वप्नशयनासनप्रसङ्गः, यश्च कश्चिद्विधिरन्योऽपि श्लेष्ममेदोमूत्रसञ्जननः, स सर्वो निदानविशेषः|Ch. Ni 4/5

 In the above shloka, various causes of the development of diabetes have been described. Many of those are similar to that of contemporary medicine, any of those substances which can produce the accumulation of energy or calories. I always compared diabetes to that black money. When you earn more than what you need, you have to keep that as a reserve. So instead of paying the tax trade considered, one day that black money becomes a burden. Diabetes exactly in the same manner when you have more calories in your body that are not utilized in a proper manner. Although the message derived from a discussion does not look interesting, we have to convey it to everyone.

Spectrum of diabetic patients in my practice

 In the present situation articulating the complex clinical phenomena of diabetes that I have experienced in my clinical practice, I found it difficult, I couldn’t really make out how to present this issue.  So the classification of patients is primarily based on varieties that I have seen and the percentage is just rough, it may not be very accurate.

The distribution of the patients in the clinical practice will vary from physician to physician because all the patients come to be depending on the perception of society. Some physicians may be perceived as a specialist for diabetes and the pattern of the cases may be different. But what I have found in my practice is the majority of the patients with diabetes recommend that category, where the patients are having some treatment of diabetes, are stabilized or their diabetes is unstable. But they come to you for other disease conditions may not be directly for the diabetes treatment, but you cannot neglect diabetes. Patients who come primarily for the treatment of diabetes are comparatively lesser just about 5%. Many of the patients with whom I diagnosed diabetes are just about 5%. There’s another major category where patients come with diabetic complications, particularly diabetic ulcers and gangrene.

 Whereas patient comes with acute complications are low in number.

Now my strategies and approach to the treatment according to different categories are explained.

1 Fresh diagnosis, Patient visiting for other complaints

 The diagnosis of diabetes patients is based on classical clinical signs of polyphagia, polydipsia, and polyuria. But beyond that, there are many other classic stigmata that can help  in  making the diagnosis of diabetes at an early stage even before there are  classical signs.  Among those stigmata quite important are the infections in the genital area balanitis or vaginitis.

Unconventional stigma

Numbness [Neuritis]

Balanitis/Vaginitis

Brachial neuralgia

Frozen shoulder

Taeniasis /Folliculitis

Sleep disorders

Sexual incompetence

Frozen shoulder or balanitis

I make it a rule a patient comes to the clinical symptoms of frozen shoulder or balanitis as per rule get a sugar profile done and more than 70% would be diabetic. Older textbooks included this as stigmata but the recent revelation has been removed, but the incidence is quite important.

So now that I’m putting this beyond the text.  The text doesn’t mention about that but that’s one of the important issues whenever you come into a situation with a frozen shoulder or the first thing is to get the sugar profile  and there’s a high chance that you may have identified diabetes patients and identifying diabetes patients is an advantage for both patients as well as you know, the other one.

Numbness

 Other signs which have to make you cautious about the possibility of diabetes are either a patient coming with the symptom of numbness, particularly those who will say that I cannot make out whether I have a chappal or not, they are the ones who tend to have diabetes quite frequently. It could be a sign of complications.  Sexual incompetence and sleep disorders are important and should be investigated to rule out diabetes.

 Once you have diagnosed the patient with diabetes and there are no other critical complications, my approach to the treatment is to just advise about the diet and exercise. I will discuss that diet and exercise in a later part. I advised diet and exercise for one month. After reviewing the blood sugar level after one month and only when it is beyond the critical level, I would start treatment.

There are certain types of patients who say that I’m on borderline diabetes. Borderline diabetes is another somewhat confusing issue in which there is a very typical cut-off line. The cut-off lines suggested are different, like American guidelines, and WHO guidelines. So I have my guideline that is when the fasting blood sugar is more than 160 and postprandial more than 200 and when it’s more than two readings then I only consider that patient as diabetes unless there are other clinical signs. If the patient has other classic clinical evidence of diabetes or if there are any complications even at a lower sugar level, I have to consider that as diabetes. So that depends upon the clinical presentation. So in such a condition, if there are no other clinical signs, I would consider that as borderline or impaired glucose tolerance. In that condition keeping the patient under observation and with the diet. If the patient is still shown to be diabetic my first prescription would be considering the target of Kapha Dosha and Meda Dhatu.

• Asanadi kwatha
• Chandraprabha vati
• Arogyavardhini

Virechana

 It is game changer if Samsarjana krama is followed.

If the patient would follow proper Sansarjan Krama then only I recommend Virechan.  In case of the case of diabetes, Virechana can result into more complication if rjana Krama would not followed properly. Therefore Virechan should be advised only in such patients who can be reliable about the following of proper Samsarjan Krama otherwise could lead in more complications. You can see a significant relief in majority of the patients and majority of the patients can be maintained as non-diabetics after Virechana.

HbA1C levels

  HbA1C levels whether to consider for diagnosis of diabetes Mellitus is one of the controversial issue. Also there is always change in cut off levels of HbA1C levels, latest one is 7.5 and indicating non diabetic status. I consider patient as diabetic when HbA1C levels are more than 8, till I considered it as non-diabetic. I’ll try to manage the patient with  Asanadi Kwath, Chandraprabha and Arogyvardhini etc.

Management depending on other added clinical signs

This is not the primary treatment for diabetes, it is additional treatment. The other additional prescription will be depending upon other additional clinical signs.

Neuritis/ Underweight – Ashvagandharishta

Balanitis – Gandhaka Rasayana

Taeniasis –Laghu  Soot Shekhar Vati+Gandhaka Rasayana

Neuralgia – Ekangaveera /Vishamusti vati

Stress – Saraswatarishta

Stress:

Stressed being another of the factors, many times the patient may identify the stress. Many patients may not identify that stress and say that everyone would be, and most of the stressful patients would say that I don’t have any stress. Those who have identified the stress, they are safer and those who say that I don’t have any stress usually have more severe stress, and in that condition,  I would prescribe Saraswatarishta in mild to moderate stress levels and ‘Smriti

Sagar Rasa’ in severe stress. That’s the strategy for fresh diagnosed diabetes and patient visiting for other complaints.