Management of Medhovaha sroto vikaras (obesity)

INTRODUCTION

METABOLISM OF MEDODHATU

  Factors which are responsible for the transformation of i.e. digestion, assimilation & metabolism of medo dhatu (ref.Cha.su 6/15)

A)  Usma:-  Agni,  the pitta, which is responsible for digestion.

B) Vata :-  Transports food nearer to pitta for digestion.

C) Kleda:-  Moisture, loosens the food particles.

D) Snigdha:- Softens the ingredients.

E) Kala:- Brings about the maturity of the process of digestion.

F) Samayoga:- Appropriate administration of food brings about the equilibrium of dhatus.

G) Medodhatwagni:- Which digests further the essence of food.

H) Medovaha Srotas:- The channel for assimilation & nourishment of the dhatus.

FUNCTIONS OF MEDA

• Snehana 
•  Strength to the body by nourishment
•  Asthidhatu nourishment
•  Dridhatwa – stability to all the other organs so give a good posture
•  Upalepa –coating on the body surface and on the body channels

DHATU  VAISHAMYA

If there is any discordance among the dhatus, this results in ill-health

The term vaishamya can also be explained as vikriti which is the resultant of the discordance of the dhatus (Vridhi or kshaya)

The equilibrium of dhatus will be distrurbed by the vitiated doshas i.e., vata, pitta, kapha since their seat is in dhatus & the vikriti will be manifested.

  Factors contributory for vikriti are:-

            1. Dosha                                  3. Srotas

            2. Dhatu                                   4. Agni

MEDOVIKRITI

The vikriti of the medodhatu can be explained in terms of both vridhi or kshaya.  If the medodhatu increase in the body,  it leads to bad sequences pertaining to the metabolic as well as fatal disorders.

       Nidana:  In terms of Ahara, Vihara & Kala

      Ahara:  In terms of Kapha medo vardhaka ahara.

      Vihara: Kapha medo vardhaka vihara.

      Kala:  The season with visargakala,  which is favourable for anabolism will cause over nourishment of the dhatus. 

  Medovaha Sroto Dusti:(ref. Cha. Su. 28/15)

            The disease due to vitiated meda shows - premonitary signs & symptoms of prameha and astha nindita purusha.  He says, from the stand point of physical constitution,the following are the 8 types of undesirable persons:- (ref. cha.Su. 22/3)

1. Ati deergha                            
2. Ati hrasva
3. Ati loma
4. Aloma
5. Ati krishna
6. Ati goura
7. Ati krisha
8. Ati sthula

       Here atishoulya are said to be undesirable persons.  They always will be showing the signs of abnormalities and suffer from furious diseases.

NIDANA

      Guru, Madhura, Sheeta, Shleshma, Snigdha    ahara

      Adhika matra sevana ,Adhyashan

      Divashayana ,Avyavaya

      Avyayama ,Na chinta, na shoka ,Beeja swabhawaja

SAMPRAPTI GHATAKA

      OSHA                                           – Tridoshaj

       DUSHYA                        – Rasa, Mamsa, Meda

       SROTAS                          – Rasavaha, Mamsavaha,

                                                                        Medavaha, Swedavaha.

       AGNI                                           – Jatharagni, Dhatwagni.

       AMA                                – Dhatwagni mandyajanya.

       UDBHAVA STHANA              – Koshta. 

       ADHISTHAANA    &   VYAKTA STHANA       – Sarva shareera.

       ROGAMARGA                                            – Bahya-abhyantara roga  Marga.

       DUSHTI PRAKARA                                   – Sangha.

ROOPA

      Chala spik udara & stana Dourgandhya ,Moha ,Utsaha hani ,Jadya ,Sukumartwa ,Kruchhra vyvayatwa ,Gad gadatwa, Alpa ayu ,Kshudra shwasa ,Ayasa ,Alpa bala ,Ati kshudha ,Ati pipasa ,Ati nidra ,Ati sweda

SADHYASADHYATA

Karshyam Varam Sthoulyasya na Bheshajam |

            Almost all the texts consider Sthoulya as kashta sadhya when compared with treatment of krishatwa. Medoroga can be considered as kashta sadhya, if it is navotpanna, having less intensity and without complications.

UPADRAVA-Prameha ,Prameha pidikas, Kushta ,Arshas ,Shleepada ,Apachi ,Kamala,Urusthambha ,Udara ,Vata vikara ,Atisara ,Jwara ,Bhagandara ,Vidrudhi ,Vata pitta vikara

ASTA DOSHAS OF ATISTHOULYA

• Ayusho hrasa (Deficient in longevity) – other dhatus do not grow to the extent, fat grows.
• Jawoparodha (slow in movement) – the bodily movement is impaired due to looseness, tenderness & heavyness of fat.
• Kruchra vyavayata (difficulty to indulge in sexual intercourse) – small quantity of semen and also due to obstruction to the channel of semen by medas.
• Dourbalya (weakness) – due to the disturbance in equilibrium of dhatus.
• Dourgandhya (foul smell) – inherent defect & nature of the fat tissue and also due to excessive sweating.
• Swedabadha (excessive sweating) – mala of meda is sweda. As the fat is associated with kapha and as it is fluid, multitudinious and heavy, as such it cannot withstand physical exercise and it brings about excessive sweating.
• Ati Kshut & pipasa – because of the sharp digestive power and presence of vayu in excessive quantity.

CHIKITSA

SANTARPANA  (strengthening therapy) in  MEDHOKSHYA related diseases

APATARPANA (thinning therapy) in  MEDHOVRUDHI related diseases

(for any type of treatment, to be successful there must be elimination of AMA from the body, no VIBHANDA)

This can be discussed under two headings – i.e. Shodhana & Shamana.

SHODHANA CHIKITSA (Panchakarma) –  snehana,swedana,vamana,virechana,nasya&basti

• LEKHANA BASTI -            Saindhava ,Madhu ,Moorchita Sarshapa taila ,Yava kshara ,Triphala kwatha ,Gomutra ,Ushakadigana dravya (Ushaka, Saindhava, Shilajatu, Kaseesa, Hingu, Tutha)Ref:S.S.Chi.35th

SHAMANA CHIKITSA-     Eventhough Meda, Vata & Kapha Nashana is said as Chikitsasutra, the drug planned should have Deepana & Pachana property to enhance Agni & Amapaka. As obstruction of srotasa is main factore in medoroga, the drugs must have Rookshna & Chedana property  to produce srotovishodhana.Along with these Ati teekshna, ushna, rooksha, guna dravyas are advised as they are opposite to manda, snigdha & sheeta gunas of kapha & meda.

PATHYA-

AHARA : -Even-though the disease is Santarpanajanya; langhana is contraindicated as it increases the vata that is the prime cause for the Medoroga.

      There by if the food is not supplied timely aggravates agni & creates many disturbances in the body.Keeping this in the mind, dietetics has to be planned in such a way that ahara should be guru for agni but at the same the time it should cause Apatrapana.

      Such as – Priyangu, Yava, Mudga, Kodrava, Kulattha, Patola, Amalaki, etc.

VIHARA : -Vyayama, Vyavaya, Anidra, Chinta, Shoka, Shrama, Gamana are the vihara roopa treatment mentioned in the classics.

Compiled by

Dr.Goutham.M

drgautham.mattapally@gmail.com

A CRITICAL REVIEW ON MADHUMEHA CHIKITSA SUTRA

Life style disorders are diseases which are associated mainly with the way a person or group of people lives. These include disorders such as diabetes mellitus, hypertension, heart disease, stroke, obesity,  tobacco and nutrition-induced cancers, chronic bron-chitis etc. It is estimated that the total number of people with diabetes will rise from 171 million in 2000 to 366 million by 2030. As per WHO report, currently half a billion people (12% of the world’s population) are considered obese. A healthy lifestyle promotes building and maintaining healthy bones, muscles and joints as well as helps in controlling weight. It increases self esteem, reduces stress and promotes social well being. Ayurveda has great potential in preventing life style disorders. According to Ayurveda a healthy person is one who remains established in self along with equilibrium of Tridosha. Dietetic factors, lifestyle as well as environmental factors affect the Tridosha. Disease is the result of disturbance in homeostasis of Tridosha. Inclusion of Prameha among the eight major disorders in Caraka Nidana, shows the significance the disease was given by the seer. It seems the disease was quite prevalent among the masses and was considered important in as much as it was incurable besides imposing a ban on dietary freedom of the patient.

Etymology of Prameha

            The word Prameha consists two words i.e. Pra (Upsarga-Prefix) and Meha. Meha is derived from the root ‘Mih Sechane’meaning to purfuse (watering), Excessive quantity and frequency is indicated by the prefix (pra).That is why the main characteristic features of prameha said to be Prabhuta Mutrata and Avil Mutrata.

Etymology of Madhumeha

            The word Madhumeha consists two words i.e.Madhu & Meha.The word Madhu is derived from the root ‘Manyante Visheshena Janati Jana Yasmin’. The root “Manjane” is applied by Dha Adesha and it shows the similarity of urine in taste,colour and appearance etc. The word Meha was initially found in Rigveda as Mehanadthanam Karanallium (Rigveda 10/163.15). The commentator of Rigveda Sayanacharya, interpreted the word Mehana as Medhra,which denotes Shishna (penis). In Sanskrit literature the mih is used to denote To make water, To wet, to emit semen. Madhumeha is the disease in which the excretion is having quality similar to madhu in its colour,smell,taste &consistency.

DEFINITION

Prameha:

            Acharya Vagbhatta describes Prameha as frequent and copious urine with turbidity;i.e.Prabhutavil Mutrata.

Madhumeha:

            Madhumeha is a clinical entity in which patient passes large quantity of urine similar to Madhu having kashaya & Madhura taste, Ruksha texture & Honey like colour and thus body attains sweetness. (A.H.Ni.10/18, Cha.Ni.4/44) Acharya Sushruta has narrated that untreated prameha in its initial stage, gets converted into Madhumeha & becomes incurable. [Su.Ni.6/30]Acharya Sushruta narrated the term Kshaudrameha, in place of Madhumeha .The Kshaudra is one of the varieties of Madhu.So it is clear to us, that Kshaudrameha resembles madhumeha. On the other hand, the word “Diabetes mellitus” consists of two words - Diabetes and mellitus, diabetes word derived from Greek which means ‘excessive discharge of urine’ and word mellitus derived from Latin word mellitus, meaning ‘mellite’ (i.e. sweetened with honey; honey-sweet). The Latin word comes from mell, which comes from mel, meaning “honey”; sweetness; pleasant thing. So, above descriptions shows that word Madhumeha and Diabetes mellitus have similar literal meaning.

Importance Of Madumeha treatment

            Madhumeha has been classified under the Vatika type of Prameha. The Vata may be provoked either directly by its etiological factors, Avarana by Kapha and Pitta to its path or by continuous depletion of Dhatus. Vagbhata has classified the Madhumeha into two categories viz. Dhatukshayajanya Madhumeha and Avaranajanya Madhumeha. The factors which provoke the Vata directly causes  Apatarpanajanya Madhumeha while the factors which provoke Kapha and Pitta causes Santarpanajanya Madhumeha. The Apatarpanajanya Madhumeha patients are usually Lean  and are equivalent to Type I Diabetes mellitus, while the Santarpanajanya Madhumeha patients are Obese equivalent to Type II Diabetes mellitus. In Avaranajanya Madhumeha, Kapha is the predominant Dosha while the important Dushyas are Meda and Kleda. Type 2 Diabetes mellitus is mainly associated with Avaranajanya Samprapti. In Madhumeha, the main Avaraka are Kapha, Pitta, Rasa, Mamsa and Meda, and out of these Meda is predominant. Principle of management of Avarana is Sramsana, Rasayana treatment and the use of Shilajatu & Guggulu (Ch. Chi. 28/241). Sushruta suggested common treatment for Kustha,Prameha, Sthaulya and Shotha (Su. Chi. 10/3). In Madhumeha, the Dhatukshaya is predominant, so if in its management the drugs against its main Dushya Meda i.e. Medoghna Dravyas are used, they will increase Vata dosha, leading to increase in severity of the disease. So at the same time we have to energize the starved tissues by giving Santarpana treatment i.e. by Balya and Rasayana drugs. A lot of research work has also been done by modern science also to study the antihyperglycemic action of these drugs. So the above ingredients can take for the Samana treatment of Madumeha. In Avaranajanya Madhumeha or the Sthula Madhumeha patients, the Shodhana therapy has been recommended before the administration of the Shamana drugs because the excessively vitiated Doshas can not be alleviated by Shamana Chikitsa alone. In the patients of Madhumeha, the Kapha and Pitta are vitiated excessively and they remain lying in the lower parts of the body owing to the inefficiency of the Dhamanis (Su. Chi. 12/8). This is the rule that the Dosha should be eliminated through the nearest passage (A. H. Su.13/29).So Sodhana is also a good line of treatment in Mdhumeha.

OBJECTIVES OF MADHUMEHA CHIKITSA

• The objectives of therapy for diabetes are to:

·         eliminate symptoms of hyperglycaemia

·         achieve optimum control

·         reduce or eliminate microvascular and macrovascular

·         complications of diabetes mellitus

·         treat associated disorders

·         allow the patient to achieve as normal a lifestyle as possible.

MADHUMEHA CHIKITSA

During treatment of Vataja Prameha following points should be taken in account.

- Madhumeha type i.e.Dhatukshayajanya or Avaranjanya

- Bala of patient with respect to Doshabala, Agnibala.

- Beeja Dosha

Although vatika mehas are incurable still Acharya Charaka explains to induce certain treatment in kaphapittanubandhi Vatika meha. [Cha.Chi.6/52]Achrya Sushruta has described that all types of prameha if not treated properly in time, gets converted into madhumeha. [Su.Ni.6/30] So the treatment described for vatika meha can be considered as treatment of madhumeha.

Samshodhan Chikitsa

DOSHA KADACHIT KUPYANTHI JITHA LANGHANA PACAHNE

JITHA SAMSODHANEYIR THU NA THESHAM PUNARUTHBHAVA  // CHA:SU:16/20//

Doshadushti nirharana

Doshadooshya sameekarana

Srothovishudhi

Doshakopa even after the langana & pachana(samana) because of uncomplete eradication of vitiated doshas. So Samsodhana is a best line of treatment.

Role Of Vasti,Virechana and Vamana In MADHUMEHA

Considering Sthula & krisha pramehi,Samshodhan Chikitsa should be administered only to the sthula & Balvan Pramehi. Ghrita or Taila according to dosha predominance should be used for Abhyantara Snehana.Here while explaining the Samshodhan ,Charaka describes to use the Malashodhan yogas from Kalpasthana Both Pitta & kapha are eliminated through shodhana. Either it may be vamana or virechana, because of; Pittantam Vamanam, Kaphantam Virechanam.In Virechana pitta is eliminated first, then Samyak lakshana of virechana is kaphadarshan, so both pitta & kapha doshas which are vitiated are eliminated. Then the described Anuvasana & Asthapana Basti chikitsas are able enough to control the provocation of vata. Like this all the doshas are normalized to keep the dosha samyata. Anuvasana with medicated oils & ghritas are prescribed in madhumeha. After proper Shodhan Chikitsa, Charakacharya details to give santarpan chikitsa to the patients.

Samshaman Chikitsa

According to condition of vitiated Dosha proper Shamana Chikitsa should be given. Due to less strength (Bala) of patient, Acharyas mentioned various Tarpana Upakarma in Vatika Prameha. Acharya Charaka & Vagbhatta says that the kashaya yogas should be enriched with sneha and given to vatika mehas(madhumeha).

·         Dravya yoga – Salsaradi ,Nyagrodhadi

·         Swarasa –Bilavapatra , Guduchi ,Satavari, Haridra , Amalaki

·         Choorna – Mammajak, Nimba, Jambu Beeja, Eladi Nyagrodhadya, Amalaki,

·         Haridra.

·         Kwatha –Phalatrikadi ,Asanadi, Mustadi, Triphaladi, Vidangadi (Y.R.)

·         Gutika –Chandraprabha, Gokshuradi guggulu.

·         Avaleha –Bangavaleha, Salaradhi, Kushavaleha

·         Paka –Puga paka,Aswagandha pak (Y.R.)

·         Ghrita –Trikantakadhya, Mahadadi madya.

·         Asava-arishta – Lodhrasava, Dantyasava, Jambvasa, Loharista,

·         Devadarvyarist.

·         Rasaaushadhi – Shilajit, Trivanga, Swarnamakshika, Vasantkusumakar, Indra

·         vati, Bhrihatbangeshwarrasa, Chandrakalarasa, Pramehagajakeshari,

·         Pramehantak.

 SPECIFIC TREATMENT OF MADHUMEHA

            Acharya Charaka has given detail treatment of Prameha but he has not given specific treatment for Madhumeha. Hence common treatment and line of treatment should be followed. Sushruta has given specific treatment of Madhumeha explaining in separate chapter.(Su.Chi. 13).He has given specific medicines for Madhumeha like Shilajita, Suvarnamakshika, Rajatmakshika and Tuvarak. Sushruta mentioned ‘Salsaradi Gana Bhavit’ Shilajita in Madhumeha after Shodhana Chikitsa. (Su.Chi. 13/10/11) Patient who takes one tula (100 pala) ShilajitAfter its digestion patient should take Jangalamamsarasayukta Anna will be cured from Madhumeha. (Su.Chi.13/12).

 PROBABLE MODE OF ACTION OF BASTI IN MADHUMEHA

            The drugs selected for the Asthapan having Pramehaghna property and can act against the vitiation of Dosa and Dusya because of their qualities. For Anuvasan purpose the oil is medicated with the help of same drugs to enhance Pramehaghna action. It also normalizes the functions of Vyana and Apana. Thus Basti can act as a purificative, curative and preventive measure. Basti due to purification, eliminates the excess of deranged metabolic waste and it inturn clears the Avarana of Vata and normalize the functions of Vyana and Apana. Thus the normalized Vata in turn help to stop the depletion of Vital Dhatus through urine. Once the proper purification is done then the digestive power is going to become normal and the proper metabolism starts which in turn's help to form the Samyak Dhatus. Again in the Madhumeha when depletion of Dhatus is stopped the strength of the body is get increase.

NIDAN PARIVARJANA

            This is primary principle to be followed in every disease. Charaka described that etiological factors i.e. Nidana Sevana of Prameha should be avoided. It is one of the treatments of disease. (Ch.Chi.6/15) Chakrapani quotes that avoidance of etiological factors in Prameha is very important to control further progress of disease. sufficient but along with this proper diet management is necessary, various Acharyas mentioned various types of diet. This diet is managed according to Sthula and Krusha.

PATHYA –APATHYA

Following are Pathya and apathya for Madhumeha rogi according to Ayurvedic classics.

PATHYA:

1. Ahara:

·         -Shookadhanya: Jeerna shali, Shastika, Kodrava, Yava, Godhuma, Uddalaka,

·         Shyamaka.

·         -Shimbi Dhanya: Chanaka, Adhaki, Kulattha, Mudga.

·         -Shaka Varga: Tikta Rasatmak Leafy Vegetables, Also Having Kashaya Rasa,

·         Patola, Karavella, Shigru.

·         -Phala Varga: Jambu, Dadima, Shrungataka, Amalki, Kapitta Induka,

·         Khajura, Kallinga.

·         -Mamsa Varga: Vishkira Mamsa, Pratuda, Jangal Mamsa

·         -Tail Varga: Danti Ingudi Sarshapa, Atasi

-          Udaka Varga: Sarodaka, Kushodaka, Madhudaka.

-          Krittanavarga: Apupa, Saktu, Yavodana, Yusha

·         Others – Madhu, Lasuna, Hingu, Saindhava, Maricha

2. Vihara:

To walk, different play, Vyayama, barefooted roaming at different places

without and umbrella, Jitendriya Vrutti, Apatarpak kriya.

APATHYA:

1.Ahara: Excess consumtion of water, milk, ghee, oil, curd, sugar, rice

preparations, Anupa Gramya, Audaka Mamsa Pishtanna, Navanna.

2.Vihara: Eksthana Asana, Atinidra, Divaswapna, Avyayam, Dhumapana,

Sweda, Mutravega Dharana.

CHALLENGES IN THE PRESENT DAY AYU MANGEMENT OF  MADHUMEHA

§  No easy going approach

§  Ayurvedic Medicines

§  Quality & Supply Problems

§  Cost

§  Late results (Evaluation)

§  Patient’s Education

§  Not all diabetes can be treated by Ayurvedic drugs alone

§  Success depends on chronicity of the disease & regularity of drug intake, exercise & diet.

§  Avoid making tall claims

Compiled by

Dr.Vishnuraj.S

§                                                                   v4vishnuraj@gmail.com