Diabetes Mellitus is ailment of modern era, which is creating havoc, and its prevalence is on rise with prompt pace, because of unhealthy food habits, lack of exercises and stress. Diabetes mellitus (DM) comprises a group of common metabolic disorders where hyperglycemia is the chief symptom. It is also called protean [widespread] disease because it affects every system and organ in body. Pathologically different sort of DM prevails depending upon complex interaction of genetics, environmental factors, and life-style choices. Etiological, factors contributing to hyperglycemia may include reduced insulin secretion, decreased glucose utilization, and increased glucose production. 

Image of a patient sweating excessively due to Diabetes

The knowledge of DM syndrome has existed in India since pre-historic age. Its earliest reference [1000 BC] is found in mythological form where it is said that the origin of diabetes take place by eating Havishya [charak samhita nidan sthana 11]. Havishya is a special mixture of grains offered as oblation at the time of yagyna [fire ritual] and this yagyna was organized by daksha Prajapati.  DM in Ayurveda is described under the heading Prameha and clinical picture is similar to Madhumeha [one type of 20 type of Prameha]. The word Prameha is derived from the root Miha Sechane means watering, excessive urine passing [quantity and frequency]. The word Prameha means Prabhut Avil Mutrata means excessive and turbid urination.  The etiology, pathogenesis symptoms [roopa and proova roopa] and even principles of management described in Ayurvedic classics, got utmost parlance to those of DM. Ayurveda describe DM as Madhumeha ,which means urine like honey or sweet urine, similarly Diabetes Mellitus is a Latin word which also means honey like sweet urine.
 
Classifications: DM is classified on the basis of the pathogenic process that leads to hyperglycemia, not on the basis of, earlier criteria like type of therapy or age of onset. The two broad categories of DM are type 1 and type 2.  Type 1A DM results from autoimmune beta cell destruction, which leads to insulin deficiency. Individuals with type 1B DM lack immunologic markers indicative of an autoimmune destructive process of the beta cells.  However, they develop insulin deficiency by unknown pathology and they are usually ketosis prone.  Type 2 DM is characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production. Distinct genetic and metabolic defects in insulin action and/or secretion give rise to the common phenotype of hyperglycemia in type 2 DM.
 
Two features of the current classification of DM are different from previous classifications. First, the terms insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) are obsolete. Since many individuals with type 2 DM eventually require insulin treatment for control of glycaemia, the use of the term NIDDM generated considerable confusion. A second difference is that age is not a criterion in the classification system. Although type 1 DM most commonly develops before the age of 30, an autoimmune beta cell destructive process can develop at any age. It is estimated that between 5 and 10% of individuals who develop DM after age of 30 have type 1A DM. Likewise, type 2 DM more typically develops with increasing age, but it also occurs in children, particularly in obese adolescents. 
 
According to Ayurvedic classifications DM is classified in Sahaja Prameha and Apthyanimitthaja which can be correlated with type 1 and type 2 DM. Similarly on the basis of management, DM is classified in to two broad categories 1) Lean Diabetic and 2) Obese Diabetic. In ancient text book of surgery Sushruta Samhita, it is described [Chikitsa Adhyaya 11:3 ] that Sahaja Prameha [congenital DM] is of krisha constitution [lean or asthenic constitution] and those of Apathya nimitthija pramehi [due to unhealthy or incorrect eating and living styles] is of sthula constitution [obese constitution], which can be correlated with type 1 and type 2 DM.  In Ayurveda DM is described under the head Prameha and; Madhumeha [DM] is one of its 20 subtypes, it is also mentioned that all subtypes if not properly treated and cured eventually terminate in Madhumeha [DM] {Charak samhita Ni 4:3}.  As a matter of facts all subtypes of prameha are classified according to the nature and other physical properties of urine and all of them are not similar to DM, and can be kept under different metabolic, Nephrological and other systemic ailments.
 
Madhumeha has got parlance with DM Syndrome.  According to prognosis [sadyaasadhyata] Charak had classified Prameha in three categories 1) Sadhya or curable: this includes Kaphaja Prameha [predominance of Kapha humor], usually due to improper life style and dietary habits, and patient is usually sthula [obese];  2) Yapya or Palliable: this includes Pittaja Prameha [predominance of pitta humor]; and 3) Asadhya [incurable]: This includes Vattaja Prameha [Predominance of Vata humor], patient is usually asthenic or lean.  Charak also said that the congenital case of Prameha or one inheriting the disease from his Diabetic Parents is incurable because of genetic factor [Type 1 DM]; whatever diseases are familial are said to be incurable [ch chi :6:57] 
  
Pathogenesis of Madhumeha [DM]
 
The Madhumeha can be categorized in to two broad types according to description in classical text of Ayurveda. 
 
1 Avrita vaatjanya Madhumeha [Primary DM]
2 Dhatu kshyajanya Madhumeha [secondary DM]
 
Primary madhumeha [DM] : It is vaataj in nature and seemed to be fulminant from advent and can be compared with type 1 DM and advent is usually early [juvenile], usually patient is lean from the advent of ailment.
 
Secondary madhumeha [DM] results from the complication of all subtypes of 20 prameha and can be compared with type 2 DM
 
Etiology: includes excessive intake of Navanna [newly harvested Paddy] which is rich in carbohydrates,Gudavikriti [jaggery and sugar products]; Payamsi, Dahini [milk and curds], Gramya Anupa rasa [meat and flesh of aquatic and land animals] which is rich in trans fats and lipids.  Other factors includes Asaya sukham [lack of exercise and sedentary life style]; savapna sukham [excessive sleeping habits]. These improper life style and dietary habits eventually leads in madhumeha ,especially to those who are prone [have family history of DM]
 
Clinical Features: Poorva rupa [Prodromal symptoms ]: These are the symptoms which occur prior to manifestation of disease. If in this stage we recognize the disease process by these symptoms, than it can be prevented by taking proper care of our routine and diet regimen, these poorva rupa or pre occurring prodromal symptoms are as under and they have been dealt with great details by three principle texts of Ayurveda [Vrahat Tryahi].  Because of the utmost importance in prevention of such a deadly ailment which clings to life forever: excessive sleep, fatigue, apathy, lack of pleasure, excessive growth of nails and hairs, sweet taste in mouth, dryness of palate and throat, thirst, attraction towards cold objects, greasiness and numbness, burning sensations over hand and feet, honey like urine[turbid and sweet ].  As for as modern medical view is concerned type 2 DM is preceded by a state called impaired glucose tolerance [IGT] for long period and by taking proper preventive measures like diet control and exercise can prevent or delay.
 
DM Symptoms and criterion for Diagnosis: The chief symptoms of DM syndrome according to Ayurveda and modern medicines are given under; although most patients with type 2 diabetes mellitus are asymptomatic for years. 

1. Polyuria: increased urinary output and increased frequency; in Ayurveda this symptom is termed as prabhootavila mootrata [increased output and frequency of turbid urine]
    
2. Polydipsia: Excessive and frequent thirst in Ayurveda it is termed as Trishna
    
3. Unexplained weight loss These three symptoms are called cardinal symptoms of DM, apart from this, following symptoms are also described in Ayurvedic text as valuable for diagnosing DM
    
4. Maduratwa in mootra [sweet urine]
    
5. Pani-Pada Daha: Bunning sensation over feet and palms and Lower extremity paresthesias- pins and needle sensation; other most common symptoms encountered are lethargy, fatigue, nocturnal, erectile dysfunction.

Few cases of DM remain undiagnosed and accidentally at time of routine checkups come to notice. The revised criteria for the diagnosis of DM emphasize the FPG as a reliable and convenient test for diagnosing DM in asymptomatic individuals. A random plasma glucose concentration (200 mg/dl) accompanied by classic symptoms of DM (polyuria, polydipsia, weight loss) is sufficient for the diagnosis of DM; Fasting plasma glucose of >125 mg/dl and two hour post glucose load (75g), plasma glucose levels 200 mg/dl, and confirmed by repeat test is sufficient criterion to confirm the diagnosis Treatment.  The basic principle or Chikitsa Sutra according to Ayurvedic point of view is Shodhana [purification] and Shamana [suppression] 

Shodhana or purification is generally done in obese diabetic with adequate body strength and requires expertise in assessment of vitiated doshas and therapy to be applied. Mismanagement would lead to more harm than any good.  Hence in general practice shaman Chikitsa is prevalent and popular.  

Shaman Chikitsa: [pacificatory management]: The herbs used in the management of DM syndrome are bitter, astringent, and pungent in Rasa [taste].  All herbs having these tastes are having some anti-diabetic quality. While treating DM herbs are used either individually or with combination of other herbs or mineral [yoga or composite formulae]. 

Single drugs [herbs]: 

1- Karvellaka or karela, Bitter gourd [Momoradia charantia ] also known as bitter melon, is one herb that has proven beneficial in the treatment of diabetes. Karavella has a long history of use as an herb for diabetes in Asia, Africa and Latin America. The plant extract was referred to the as vegetable insulin. Various studies have demonstrated the potent antioxidant activity of karavella. Treatment With karavella resulted in a significant increase in various antioxidant enzyme levels in the liver and kidney of diabetic rats. The extract of karavella exerted rapid protective effects against lipid per oxidation by scavenging free radicals, thereby reducing the risk of diabetic complications. Other studies have demonstrated the blood glucose lowering activity of karavella. The effect of karavella on fasting and post-prandial (two hours after food) blood glucose levels was studied in 100 cases of moderate non-insulin dependent diabetic subjects. Drinking of an aqueous homogenized suspension of the vegetable pulp led to significant reduction of both fasting and postprandial serum glucose levels. This hypoglycemic action was observed in 86 (86%) cases. 

The active components in karavella are thought to be an alkaloid memordicine, glycosides charantin and vicine, and polypeptide-p. (Polypeptide-p is an Insulin like protein Karvellaka also reduces increased lipids specially cholesterol 

2- Meshshringi [Gymnema sylvestre] also called Gudmar and madhunashini: It controls hyperglycemia and carbohydrate metabolism in in liver and in skeletal muscles. It causes complete obliteration of sweet perception by tongue due to excessive copper content in leaf. The active hypoglycemic agent is gymnemic acid and two crude saponins, gymnemosides-a and gymsemoside 

3-Bimbi [coccinia indica] also called Durike bel or kunduru: The root of this herb contains hypoglycemic principle, and fruit contains a bitter glycoside containing cuceubirocin B. The expressed juice of tuberous root stem and leaves is used to control glucose in DM 

4-Nimba [Azadirachta indica] also called Neem: Leaves and bark of this plant is used in DM, it is very good detoxifier, Liver stimulant and lowers the glycosuria. It is also good for keeping the blood vessels healthy and thus prevent diabetic vasculopathies.  

Similarly different composite drug combination is also described in Ayurvedic texts, a few of them are Abhyadi kashyam, Nyogradhi churna, Nishaamalki kashyam, Asana bilvadi kashyam, Chandra prabha vati, Pramehantak Rasa and Vasant kusumakar rasa.  Author of this paper has developed a composite herbal drug combination and found it very much effective in proper management of Type -2 DM.  

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