Abstract

Modern medicine has recognized prediabetes as a well-characterized syndrome only in the last two decades. However, Ayurveda has clearly described distinct stages of diabetes thousands of years ago. The Ayurvedic classification represents the entire clinical spectrum of diabetes that we encounter today. In this article, we present the Ayurvedic perspective on prediabetes with regard to etiology, clinical features and management, which emphasizes lifestyle modification as the key approach to manage the dysglycemia.

Keywords: Ayurveda, dysglycemia, kapha prameha, pitta prameha, vata prameha, shadakriyakaal

PREDIABETES IN MODERN MEDICINE

The first use of the word ‘prediabetes’ dates back to 1918, when it was used¹ to describe dogs with partial damage to the pancreas. The term was used in clinical medicine, mostly in obstetric medicine, intermittently, with only 6 more PubMed citations in the next 30 years.² Interest has spiked in the last two decades, and prediabetes is now a well-characterized and well-described, clinical syndrome.

PREDIABETES IN AYURVEDA

Ayurveda, however, has clearly described distinct stages of diabetes thousands of years ago. Charaka Samhita, Nidanasthanam, Chapter 4, lists 20 types of prameha or urinary disorders.³ These are further classified into 10 types of kapha prameha, 6 types of pitta prameha and 4 types of vata prameha.

While there is controversy regarding the appropriateness of this classification, kapha prameha seems equivalent to prediabetes, and pitta prameha appears to allude to early uncomplicated diabetes. The various types of vata prameha suggest a catabolic or advanced state of diabetes with vascular or visceral complications. Put together, the Ayurvedic classification represents the entire clinical spectrum of diabetes that we encounter today.

Murthy et al⁴ present a comprehensive analysis of the classification, pathophysiology and clinical features of prameha. We must note that this opinion piece was written at a time when modern diabetology was not well developed, and when the concept of prediabetes had not been established.

DIVERSITY OF DYSGLYCEMIA

Atreya clearly mentions that the disease can present in asymptomatic or symptomatic manner, with varied natural trajectories and combination of clinical features. Many of the symptoms and complications of diabetes are listed in the narrative. There is a rightful emphasis on the relationship of fat and prameha. A step-wise progression of dysfunction is delineated, with various stages being described. The etiopathogenesis of diabetes is shared, as are the precipitating and aggravating factors for worsening. In fact, the concept of diabetes remission is alluded to as well.

The particular etiology, dosha and dhatu (tissue strength), in combination, decide the response of the body to diabetes. Asymptomatic, mild, late-onset, partial or full-blown manifestations may occur based upon various permutations and combinations of etiopathogenesis. This implies that Ayurveda understood the epidemiological triad (host, etiological factor and environment) as well as

the epidemiological quartet (including time) that have been postulated in modern medicine. The multifaceted causation is clearly mentioned, in a way similar to that of the ominous octet.⁵

ETIOLOGY

The etiological factors listed by Charaka are mentioned in Table 1.

Prameha approaches immediately like a bird to its nest-tree, the person who is greedy in eatables and has dislike for bath and walking.

Death, in the form of prameha, takes away immediately the person who is dull in activities, over-obese, over-uncted and voracious eater.

(Charaka Samhita, Nidanasthanam, Chapter 4:50-52.)

CLINICAL FEATURES

Clinical features that are mentioned in Nidanasthanam, Ch. IV are listed in Table 2. Rastogi et al⁶ classify symptoms and signs of prediabetes as anatomical, physiological and neurocognitive. While some of these are symptoms and signs of hyperglycemia and its neurological complications, others may be associated with micronutrient malnutrition, urinary tract or skin infection. While this approach encourages astute clinical observation, it would be fallacious to create a separate clinical symptomatology for prediabetes.

MANAGEMENT

Prediabetes is best managed by lifestyle modification. This is taught in Charaka Samhita. It is noteworthy that the following verse discusses “happy life” in diabetes, a concept that is now termed as glycemic happiness or euthymic euglycemia.⁷

The person who takes food which maintains the equilibrium of dhatus and also practices various physical activities enjoys happy life.

(Charaka Samhita, Nidanasthanam, Chapter 4:50-52.)

Ayurveda also enjoins us to practice prevention at all levels, from primordial to tertiary. These concepts are worded in Ayurveda as the six stages of shadakriyakaal.⁶ While sanchaya refers to the stage of primordial prevention, prakopa and prasaara call for primary prevention. Sthaana samshraya is a stage where both primary and secondary prevention can be practiced. Vyakti and bheda are full blown clinical stages in which secondary and tertiary prevention are required.

Khirodkar et al⁸ reinforce this concept, calling for preventive action during the phase of purva rupa or predisease. They point out the importance of managing atisthaulya (obesity) as a means of managing prediabetes as well as preventing diabetes and its complications.

SUMMARY

A rational reading of Ayurvedic texts demonstrates the clarity of thought with regards to multifactorial etiology and multifaceted presentation of diabetes. The natural history of dysglycemia is well delineated, with an emphasis on possible remission of diabetes through a healthy lifestyle. While frank diabetes is thought to be incurable, this does not hold true today. With modern management diabetes can easily be managed, even though it may not be curedUse of physio-friendly pharmacotherapy and lifestyle interventions can help achieve diabetes remission, provided that therapy is instituted in a timely manner. Prediabetes management holds the promise of preventing establishment of diabetes.

REFERENCES

1. Auer J, Kleiner IS. Morphine hyperglycemia in dogs with experimental pancreatic deficiency. J Exp Med. 1918;27(1):49-63.
2. Available at: https://pubmed.ncbi.nlm.nih.gov/?term=prediabetes&sort=date&sort_order=asc. Last accessed January 3, 2024.
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7. Kalra S, Das AK, Priya G, Joshi A, Punyani H, Krishna N, et al. An expert opinion on “glycemic happiness”: delineating the concept and determinant factors for persons with type 2 diabetes mellitus. Clin Pract. 2021;11(3):543-60.
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