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<big>'''Abstract'''</big>

<big>'''Abstract'''</big>

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''Prameha'' is a set of complex clinical disorders characterized by frequent abnormal micturition, with the etiology involving genetic predisposition as well as improper diet and lifestyle. The clinical conditions described in ''prameha'' have much in common with diabetes mellitus. In the chapter dealing with the treatment for the alleviation of ''prameha'' following topics have been discussed: Etiology of the disease; ''doshas'' and ''dushyas'' involved in the pathogenesis of the disease; Curability and incurability of the disease; Signs and symptoms of the disease; Two types of ''prameha'' patients; Three categories of therapy; viz. ''samshodhana'' (elimination therapy), ''samshamana'' (alleviation therapy) and ''nidana parivarjana'' (avoiding causative factors); Disadvantages of over depletion; Eatables prepared of barley, ''mantha'' (thin gruel) and decoctions for the cure of ''prameha''.  

''Prameha'' is a set of complex clinical disorders characterized by frequent abnormal micturition, with the etiology involving genetic predisposition as well as improper diet and lifestyle. The clinical conditions described in ''prameha'' have much in common with diabetes mellitus. In the chapter dealing with the treatment for the alleviation of ''prameha'' following topics have been discussed: Etiology of the disease; ''[[dosha]]s'' and ''[[dushya]]s'' involved in the pathogenesis of the disease; Curability and incurability of the disease; Signs and symptoms of the disease; Two types of ''prameha'' patients; Three categories of therapy; viz. ''samshodhana'' (elimination therapy), ''samshamana'' (alleviation therapy) and ''nidana parivarjana'' (avoiding causative factors); Disadvantages of over depletion; Eatables prepared of barley, ''mantha'' (thin gruel) and decoctions for the cure of ''prameha''.  

Treatment of ''prameha'' includes, medicated oil, medicated ghee, various recipes of linctus, food preparations; good quality ''asavas'' (fermented drinks) having known therapeutic utility; and different methods of exercise, baths, unctuous and fragrant applications. Though ''prameha'' is widely accepted as description of diabetes, it covers various types of urinary disorders. </div>

Treatment of ''prameha'' includes, medicated oil, medicated ghee, various recipes of linctus, food preparations; good quality ''asavas'' (fermented drinks) having known therapeutic utility; and different methods of exercise, baths, unctuous and fragrant applications. Though ''prameha'' is widely accepted as description of diabetes, it covers various types of urinary disorders. </div>

The word ''Prameha'' literally means urinary disorders with increased quantity of urine with turbidity in it. In the last chapter of [[Nidana Sthana]], ''prameha'' is said to have originated from excess consumption of ghee. This chapter deals with the detail etio-pathogenesis, clinical features, classification and management of ''prameha''. It is widely considered as diabetes mellitus. However, ''prameha'' covers various types of obstinate urinary disorders under its umbrella. The key to management of ''prameha roga'' is to attempt to stop its pathogenesis for which the etiological factors responsible for the origin of the disease are identified. These etiological factors include both faulty dietary habits and life style that cause imbalance between energy consumption and energy expenditure and ultimately cause obesity. Indulgence in high calorie diet including refined carbohydrate and bad fat associated with sedentary life style causes excessive storage of fatty tissue in body to disturb the body mass index. The disturbed body mass index reflects as obesity causing disturbed lipid metabolism and assimilation (FFAs, TG, HDL and VLDL) that in turn causes insulin resistance and produces type-2 DM.  

The word ''Prameha'' literally means urinary disorders with increased quantity of urine with turbidity in it. In the last chapter of [[Nidana Sthana]], ''prameha'' is said to have originated from excess consumption of ghee. This chapter deals with the detail etio-pathogenesis, clinical features, classification and management of ''prameha''. It is widely considered as diabetes mellitus. However, ''prameha'' covers various types of obstinate urinary disorders under its umbrella. The key to management of ''prameha roga'' is to attempt to stop its pathogenesis for which the etiological factors responsible for the origin of the disease are identified. These etiological factors include both faulty dietary habits and life style that cause imbalance between energy consumption and energy expenditure and ultimately cause obesity. Indulgence in high calorie diet including refined carbohydrate and bad fat associated with sedentary life style causes excessive storage of fatty tissue in body to disturb the body mass index. The disturbed body mass index reflects as obesity causing disturbed lipid metabolism and assimilation (FFAs, TG, HDL and VLDL) that in turn causes insulin resistance and produces type-2 DM.  

It is interesting to note that the ancient acharyas (preceptors, teachers) were aware of the fact that insulin resistance is secondary to the dyslipidemia. Therefore, the patients of ''prameha'' are classified as ''sthula pramehi'' and ''krisha pramehi'' which can be identified based on body mass index. All those factors, that cause vitiation of ''kapha'' will cause ''prameha''. At the end of the chapter, it is mentioned that ''jatah/ kulaja'' (hereditary) ''prameha'' and ''madhumeha'' are incurable. ''Prameha'' is also classified as  

It is interesting to note that the ancient acharyas (preceptors, teachers) were aware of the fact that insulin resistance is secondary to the dyslipidemia. Therefore, the patients of ''prameha'' are classified as ''sthula pramehi'' and ''krisha pramehi'' which can be identified based on body mass index. All those factors, that cause vitiation of ''[[kapha]]'' will cause ''prameha''. At the end of the chapter, it is mentioned that ''jatah/ kulaja'' (hereditary) ''prameha'' and ''madhumeha'' are incurable. ''Prameha'' is also classified as  

(1) ''jatah pramehi'' (hereditary) and  

(1) ''jatah pramehi'' (hereditary) and  

The chapter also gives the detailed description of urinalysis for the diagnosis, classification and assessment of prognosis of the disease. Distinctive description of ''raktameha'' and ''siktameha'' correlates with current method of microscopic examination of urine.

The chapter also gives the detailed description of urinalysis for the diagnosis, classification and assessment of prognosis of the disease. Distinctive description of ''raktameha'' and ''siktameha'' correlates with current method of microscopic examination of urine.

Description of ''Sahaja prameha'' and role of genetic predisposition in the development of disease clears all the dout about the scientific validity of [[Ayurveda]].

Description of ''Sahaja prameha'' and role of genetic predisposition in the development of disease clears all the doubt about the scientific validity of [[Ayurveda]].

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Over-indulgence in the pleasure of sedentary habits, excess sleep, curds, soup of the meat of domesticated and aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all ''kapha''- aggravating factors are responsible for the causation of ''prameha''. [4]

Over-indulgence in the pleasure of sedentary habits, excess sleep, curds, soup of the meat of domesticated and aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all ''[[kapha]]''- aggravating factors are responsible for the causation of ''prameha''. [4]

=== ''Dushya'' (vitiated factors) and pathogeneis ===

=== ''[[Dushya]]'' (vitiated factors) and pathogeneis ===

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Aggravated ''kapha'' vitiates ''medas, mamsa'' and ''kleda'' of the body located in ''basti'' (bladder and urinary system) and causes different types of ''kapha'' dominant ''meha''.   

Aggravated ''[[kapha]]'' vitiates ''[[meda]]s, [[mamsa]]'' and ''kleda'' of the body located in ''basti'' (bladder and urinary system) and causes different types of ''[[kapha]]'' dominant ''meha''.   

Similarly, ''pitta'' aggravated by hot things vitiates those elements and causes different types of ''pitta'' dominant ''meha''.

Similarly, ''[[pitta]]'' aggravated by hot things vitiates those elements and causes different types of ''[[pitta]]'' dominant ''meha''.

When other two ''doshas'' are in a relatively diminished state, the aggravated ''vayu'' draws tissues elements (viz. ''ojas, majja,'' and ''lasika'') into the urinary tract and vitiates them to cause ''vata'' dominant ''pramehas''. Different ''doshas'' having entered the urinary tract in vitiated condition give rise to the respective types of ''meha'' with their own dominance. [5-6]

When other two ''[[dosha]]s'' are in a relatively diminished state, the aggravated ''[[vata]]'' draws tissues elements (viz. ''[[ojas]], [[majja]],'' and ''lasika'') into the urinary tract and vitiates them to cause ''[[vata]]'' dominant ''pramehas''. Different ''[[dosha]]s'' having entered the urinary tract in vitiated condition give rise to the respective types of ''meha'' with their own dominance. [5-6]

=== Classification and Prognosis ===

=== Classification and Prognosis ===

''Pittaja pramehas'' are of six types and they are only palliable (''yapya'') because of their incompatibility of the therapies meant for their treatment.  

''Pittaja pramehas'' are of six types and they are only palliable (''yapya'') because of their incompatibility of the therapies meant for their treatment.  

''Vatika pramehas'' are of four types and they are incurable because of their incompatibility with therapies and dreadful nature of ''vata'' leading to complications. [7]

''Vatika pramehas'' are of four types and they are incurable because of their incompatibility with therapies and dreadful nature of ''[[vata]]'' leading to complications. [7]

=== Vitiating factors involved in pathogenesis ===

=== Vitiating factors involved in pathogenesis ===

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''Doshas'' like ''kapha, pitta'' and ''vata,'' and ''dushyas'' like ''medas, rakta, shukra, ambu'' (body fluid), ''vasa'' (muscle fat), ''lasika'' (lymph), ''majja, rasa, ojas'' and ''mamsa'' are responsible for the causation of ''prameha'' which is of twenty types. [8]

''[[Dosha]]s'' like ''[[kapha]], [[pitta]]'' and ''[[vata]],'' and ''[[dushya]]s'' like ''[[meda]]s, [[rakta]], [[shukra]], ambu'' (body fluid), ''vasa'' (muscle fat), ''lasika'' (lymph), ''[[majja]], [[rasa]], [[ojas]]'' and ''[[mamsa]]'' are responsible for the causation of ''prameha'' which is of twenty types. [8]

=== Twenty types of ''dosha'' dominant ''prameha'' ===

=== Twenty types of ''[[dosha]]'' dominant ''prameha'' ===

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#Low density urine with transparent upper layer (''Sandra prasad meha'')

#Low density urine with transparent upper layer (''Sandra prasad meha'')

#The urine having white colour (''shukla meha'')

#The urine having white colour (''shukla meha'')

#The urine containing seminal fluid (''shukra meha'')

#The urine containing seminal fluid (''[[shukra]] meha'')

#The urine having cold touch (''shita meha'')

#The urine having cold touch (''shita meha'')

#The urine passing out slowly (''shanaih meha'')

#The urine passing out slowly (''shanaih meha'')

#The urine having yellow color like turmeric (''haridra meha'')

#The urine having yellow color like turmeric (''haridra meha'')

#The urine having reddish color like that of ''manjistha'' (''manjishtha meha'') and  

#The urine having reddish color like that of ''manjistha'' (''manjishtha meha'') and  

#The urine having blood in it (''rakta meha'').

#The urine having blood in it (''[[rakta]] meha'').

Four varieties of ''vatika meha'' have the following characteristic features:

Four varieties of ''vatika meha'' have the following characteristic features:

#The urine mixed with ''majja''  (''majja meha'')

#The urine mixed with ''majja''  (''[[majja]] meha'')

#The urine mixed with ''ojas'' (''oja meha'' )

#The urine mixed with ''ojas'' (''[[oja]] meha'' )

#The urine mixed with muscle fat (''vasa meha'')

#The urine mixed with muscle fat (''vasa meha'')

#The urine mixed with lympha (''lasika meha'')

#The urine mixed with lympha (''lasika meha'')

Diminution of other ''dhatus'' or tissue elements (besides those described above) is responsible for the causation of the above mentioned four varieties of ''vatika prameha''. [9-11]

Diminution of other ''[[dhatu]]s'' or tissue elements (besides those described above) is responsible for the causation of the above mentioned four varieties of ''vatika prameha''. [9-11]

=== Criteria for diagnosis ===

=== Criteria for diagnosis ===

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Different types of ''prameha'' are characterized by the color, taste, touch and smell of the respective ''dosha''. ''Vatika'' varieties of ''prameha'' are characterized by grayish or reddish coloration of the urine, pain and attributes of ''majja'', etc. These types of ''vatika prameha'' are incurable. [12]

Different types of ''prameha'' are characterized by the color, taste, touch and smell of the respective ''[[dosha]]''. ''Vatika'' varieties of ''prameha'' are characterized by grayish or reddish coloration of the urine, pain and attributes of ''[[majja]]'', etc. These types of ''vatika prameha'' are incurable. [12]

=== Premonitory signs and symptoms ===

=== Premonitory signs and symptoms ===

Patients suffering from ''prameha'' are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak.  

Patients suffering from ''prameha'' are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak.  

Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more ''doshas'' in the body should be treated with elimination therapy.

Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more ''[[dosha]]s'' in the body should be treated with elimination therapy.

For this purpose, the oleated patient should be given various recipes described in [[Kalpa Sthana]] with a view to eliminating metabolic waste products through both upward and downward tracts. After the waste products (excess metabolic bi-products) are eliminated from his body, the patient should be given ''santarpana'' or nourishment therapy. Because ''apatarpana'' (depletion) therapy in this condition may produce ''gulma'', consumption, pain in phallus and urinary bladder including kidneys and retention of urine. Such patients should be given ''santarpana'' therapy depending upon their power of digestion. [15-17]

For this purpose, the oleated patient should be given various recipes described in [[Kalpa Sthana]] with a view to eliminating metabolic waste products through both upward and downward tracts. After the waste products (excess metabolic bi-products) are eliminated from his body, the patient should be given ''santarpana'' or nourishment therapy. Because ''apatarpana'' (depletion) therapy in this condition may produce ''gulma'', consumption, pain in phallus and urinary bladder including kidneys and retention of urine. Such patients should be given ''santarpana'' therapy depending upon their power of digestion. [15-17]

''Shashtika'' rice with ''shyamaka'' etc., ''truna dhanya'' with ''yava'' as predominant food is advised for ''prameha'' patients.  

''Shashtika'' rice with ''shyamaka'' etc., ''truna dhanya'' with ''yava'' as predominant food is advised for ''prameha'' patients.  

Various food recipes of ''yava'' with honey are indicated in ''kapha'' dominant ''prameha''.

Various food recipes of ''yava'' with honey are indicated in ''[[kapha]]'' dominant ''prameha''.

   

   

Barley soaked in the decoction of ''triphala'' and kept overnight should be mixed with honey. It is a refreshing (''tarpana'') diet. It should be taken by the patient suffering from ''prameha'' regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of ''kaphaja prameha'' and taken by the patient in the form of ''saktu'' (roasted flour), ''apupa'' (pancake), ''dhana'' (roasted barley) and other types of eatables along with jaggery.

Barley soaked in the decoction of ''triphala'' and kept overnight should be mixed with honey. It is a refreshing (''tarpana'') diet. It should be taken by the patient suffering from ''prameha'' regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of ''kaphaja prameha'' and taken by the patient in the form of ''saktu'' (roasted flour), ''apupa'' (pancake), ''dhana'' (roasted barley) and other types of eatables along with jaggery.

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Purificatory therapies including specifically emesis and fasting therapies, administered at the appropriate time, cure ''kaphaja'' types of ''prameha''. Similarly, ''pittaja'' types of ''prameha'' are overcome by purgation, ''santarpana'' (refreshing therapy) and alleviation therapies. [25]

Purificatory therapies including specifically emesis and fasting therapies, administered at the appropriate time, cure ''[[kapha]]ja'' types of ''prameha''. Similarly, ''[[pitta]]ja'' types of ''prameha'' are overcome by purgation, ''santarpana'' (refreshing therapy) and alleviation therapies. [25]

=== Various formulations ===

=== Various formulations ===

The patient suffering from ''prameha'' should take the decoction of ''darvi, surahva, triphala'' and ''musta'' mixed with honey. He may also take ''haridra'' along with the juice of ''amalaki''. [26]

The patient suffering from ''prameha'' should take the decoction of ''darvi, surahva, triphala'' and ''musta'' mixed with honey. He may also take ''haridra'' along with the juice of ''amalaki''. [26]

==== Decoctions for ''kaphaja prameha'' ====

==== Decoctions for ''[[kapha]]ja prameha'' ====

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The following ten decoctions should be mixed with honey and given to patients suffering from ''kaphaja prameha'':

The following ten decoctions should be mixed with honey and given to patients suffering from ''[[kapha]]ja prameha'':

#Decoction of ''haritaki, katphala, musta'' and ''lodhra'';

#Decoction of ''haritaki, katphala, musta'' and ''lodhra'';

#Decoction of ''patha, vidanga, arjuna'' and ''dhanvana'';

#Decoction of ''patha, vidanga, arjuna'' and ''dhanvana'';

#Decoction of ''chavya, abhaya, chitraka'' and ''sapta parna''.

#Decoction of ''chavya, abhaya, chitraka'' and ''sapta parna''.

==== Decoctions for ''pittaja prameha'' ====

==== Decoctions for ''[[pitta]]ja prameha'' ====

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The following ten decoctions should be mixed with honey and given to patients suffering from ''pittaja prameha'':

The following ten decoctions should be mixed with honey and given to patients suffering from ''[[pitta]]ja prameha'':

#Decoction of ''ushira, lodhra, arjuna, lalachandana''

#Decoction of ''ushira, lodhra, arjuna, lalachandana''

#Decoction of ''ushira, musta, amalaka'' and ''abhaya'';

#Decoction of ''ushira, musta, amalaka'' and ''abhaya'';

Two recipes of decoction are described for the treatment of all varieties of ''prameha''. These decoctions can be used for the preparation of ''mantha'' (a drink prepared of roasted corn flour mixed with water), for the impregnation of barley and for the preparation of different kinds of food and drinks.

Two recipes of decoction are described for the treatment of all varieties of ''prameha''. These decoctions can be used for the preparation of ''mantha'' (a drink prepared of roasted corn flour mixed with water), for the impregnation of barley and for the preparation of different kinds of food and drinks.

Medicated oils and medicated ghee prepared by cooking with these decoctions should be administered to patients suffering from ''vatika prameha''. These decoctions correct the vitiated ''medas'' and ''kapha'', and the aggravated ''vayu'' in these patients gets alleviated by the unctuous ingredients (viz., oil and ghee) included in these recipes. [33-34]

Medicated oils and medicated ghee prepared by cooking with these decoctions should be administered to patients suffering from ''vatika prameha''. These decoctions correct the vitiated ''[[meda]]s'' and ''[[kapha]]'', and the aggravated ''[[vata]]'' in these patients gets alleviated by the unctuous ingredients (viz., oil and ghee) included in these recipes. [33-34]

==== Formulations for ''kaphaja'' and ''pittaja prameha'' ====

==== Formulations for ''[[kapha]]ja'' and ''[[pitta]]ja prameha'' ====

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Powder of ''kampillaka'', barks of ''saptachchada, bibhitaka, rohitaka'' and ''kutaja'' and flower of ''kapittha'' should be added with honey, made to a linctus and taken by patients suffering from ''kaphaja'' and ''pittaja prameha''. One ''aksha'' of the paste of above mentioned drugs should be mixed with the juice of ''amalaki'' and given at the appropriate time to patients suffering from ''kaphaja'' and ''pittaja'' types of ''prameha''. After the digestion of this potion, the patient should be given to eat old rice cooked and mixed with the delicious soup of the meat of animals living in arid land.[35-36]

Powder of ''kampillaka'', barks of ''saptachchada, bibhitaka, rohitaka'' and ''kutaja'' and flower of ''kapittha'' should be added with honey, made to a linctus and taken by patients suffering from ''[[kapha]]ja'' and ''[[pitta]]ja prameha''. One ''aksha'' of the paste of above mentioned drugs should be mixed with the juice of ''amalaki'' and given at the appropriate time to patients suffering from ''[[kapha]]ja'' and ''[[pitta]]ja'' types of ''prameha''. After the digestion of this potion, the patient should be given to eat old rice cooked and mixed with the delicious soup of the meat of animals living in arid land.[35-36]

==== Formulations for ''vata'' association in ''kaphaja'' and ''pittaja prameha'' ====

==== Formulations for ''[[vata]]'' association in ''[[kapha]]ja'' and ''[[pitta]]ja prameha'' ====

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If ''vayu'' is secondarily aggravated along with either ''kapha'' or ''pitta'', then the patient should be administered unctuous preparations. For the ''kapha'' aggravation, medicated oil should be processed with the decoction of ''kapha'' alleviating drugs. .For the pitta aggravation, medicated ghee should be processed with the decoction of ''pitta'' alleviating drugs. ''Trikantaka, ashmantaka, somavalka, bhallataka, ativisha, lodhra, vacha, patola, arjuna, nimbi, musta, haridra, padmaka, dipyaka, manjishtha, aguru'' and ''chandana''- all these drugs together should be used in the preparation of medicated oil for the treatment of ''kaphaja prameha'' which is associated with secondarily aggravated ''vayu''. In case of pitta dominance, ghee shall be processed with above mentioned drugs.  

If ''[[vata]]'' is secondarily aggravated along with either ''[[kapha]]'' or ''[[pitta]]'', then the patient should be administered unctuous preparations. For the ''[[kapha]]'' aggravation, medicated oil should be processed with the decoction of ''[[kapha]]'' alleviating drugs. .For the [[pitta]] aggravation, medicated ghee should be processed with the decoction of ''[[pitta]]'' alleviating drugs. ''Trikantaka, ashmantaka, somavalka, bhallataka, ativisha, lodhra, vacha, patola, arjuna, nimbi, musta, haridra, padmaka, dipyaka, manjishtha, aguru'' and ''chandana''- all these drugs together should be used in the preparation of medicated oil for the treatment of ''[[kapha]]ja prameha'' which is associated with secondarily aggravated ''[[vata]]''. In case of [[pitta]] dominance, ghee shall be processed with above mentioned drugs.  

If the signs and symptoms of all the three ''doshas'' are manifested, then with all the above mentioned drugs together, ghee and oil both in a mixed form should be cooked and given to the patient.

If the signs and symptoms of all the three ''[[dosha]]s'' are manifested, then with all the above mentioned drugs together, ghee and oil both in a mixed form should be cooked and given to the patient.

'''Recipe for all types of prameha:'''

'''Recipe for all types of prameha:'''

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''Lodhra, shati, pushkaramula, ela, murva, vidanga, triphala, yamani, chavya, priyangu, kramuka, vishala, kiratatikta, katurohini, bharngi, nata, chitraka, pippalimula, kushtha, ativisha, patha, kalingaka, keshara, indravaruni, nakha, patra, maricha'' and ''plava''- one ''karsha'' of each of these drugs should be boiled in one ''drona'' of water till one fourth remains. This decoction along with half its quantity of honey should be kept inside a ghee smeared jar for a fort night. This is called ''madhvasava''. It instantaneously cures ''kaphaja'' and ''paittika'' types of ''meha'' when administered in a dose of two ''palas''. It also cures ''pandu, arsha, aruchi, grahani dosha, kilasa'' and different types of ''kushtha''.[41-44]

''Lodhra, shati, pushkaramula, ela, murva, vidanga, triphala, yamani, chavya, priyangu, kramuka, vishala, kiratatikta, katurohini, bharngi, nata, chitraka, pippalimula, kushtha, ativisha, patha, kalingaka, keshara, indravaruni, nakha, patra, maricha'' and ''plava''- one ''karsha'' of each of these drugs should be boiled in one ''drona'' of water till one fourth remains. This decoction along with half its quantity of honey should be kept inside a ghee smeared jar for a fort night. This is called ''madhvasava''. It instantaneously cures ''[[kapha]]ja'' and ''paittika'' types of ''meha'' when administered in a dose of two ''palas''. It also cures ''pandu, arsha, aruchi, grahani dosha, kilasa'' and different types of ''kushtha''.[41-44]

=== ''Dantyasava'' and ''bhallatakasava'' ===

=== ''Dantyasava'' and ''bhallatakasava'' ===

Spit- roasted meat of animals and birds and different eatables prepared of barley should be given to the patient to eat. Different types of ''prameha'' caused by over-nourishment should be alleviated by the administration of elimination therapies, ''arishtas'' (a type of wine), decoctions and various types of linctus.

Spit- roasted meat of animals and birds and different eatables prepared of barley should be given to the patient to eat. Different types of ''prameha'' caused by over-nourishment should be alleviated by the administration of elimination therapies, ''arishtas'' (a type of wine), decoctions and various types of linctus.

Persons habitually taking roasted barley, dry corn- flour, ''mudga'' and ''amalaka'' do not suffer from ''prameha, shvitra'' (leucoderma), ''mutrakrucchra'' (dysuria) and ''kaphaja kushtha''. [46-48]

Persons habitually taking roasted barley, dry corn- flour, ''mudga'' and ''amalaka'' do not suffer from ''prameha, shvitra'' (leucoderma), ''mutrakrucchra'' (dysuria) and ''[[kapha]]ja kushtha''. [46-48]

=== Indications of above treatment ===

=== Indications of above treatment ===

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Effective formulations for producing drying effect on obese patients while describing the management of diseases caused by over- nourishment are useful in the treatment of ''pramehas'' caused by ''kapha'' and ''pitta'' dominance. [49]

Effective formulations for producing drying effect on obese patients while describing the management of diseases caused by over- nourishment are useful in the treatment of ''pramehas'' caused by ''[[kapha]]'' and ''[[pitta]]'' dominance. [49]

=== Various external applications ===

=== Various external applications ===

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Aggravated ''kleda'' (liquid element of the body), ''medas'' (adipose tissue) and ''kapha'' are responsible for the causation of ''prameha''. Keeping this in view, the physician, in the beginning, should administer depletion therapies to patients suffering with  ''kapha'' and ''pitta'' dominant types of prameha. [51]

Aggravated ''kleda'' (liquid element of the body), ''[[meda]]s'' (adipose tissue) and ''[[kapha]]'' are responsible for the causation of ''prameha''. Keeping this in view, the physician, in the beginning, should administer depletion therapies to patients suffering with  ''[[kapha]]'' and ''[[pitta]]'' dominant types of prameha. [51]

=== ''Vata'' dominant ''prameha'' ===

=== ''[[Vata]]'' dominant ''prameha'' ===

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Formulations described earlier for the ''vatika prameha'' are actually meant for ''vata'' dominant ''prameha'' where ''vayu'' is secondarily (subsequently) aggravated. If the ''vayu'' is primarily aggravated in ''prameha'' because of excessive depletion of tissue elements, then it is incurable and the physician need not make efforts to treat. [52]

Formulations described earlier for the ''vatika prameha'' are actually meant for ''[[vata]]'' dominant ''prameha'' where ''[[vata]]'' is secondarily (subsequently) aggravated. If the ''[[vata]]'' is primarily aggravated in ''prameha'' because of excessive depletion of tissue elements, then it is incurable and the physician need not make efforts to treat. [52]

=== Prevention of ''prameha'' ===

=== Prevention of ''prameha'' ===

</div></div>

</div></div>

If the patient suffering from ''prameha'' passes urine which is sweet, slimy and honey-like, then there are two possibilities. It is caused either by the diminution of ''doshas'' having ''vata''-dominant type or by over- nourishment having ''kapha'' dominant type. [55]

If the patient suffering from ''prameha'' passes urine which is sweet, slimy and honey-like, then there are two possibilities. It is caused either by the diminution of ''[[dosha]]s'' having ''[[vata]]''-dominant type or by over- nourishment having ''[[kapha]]'' dominant type. [55]

=== Prognosis ===

=== Prognosis ===

</div></div>

</div></div>

''Kapha'' dominant and ''pitta'' dominant types of ''prameha'', if preceded by their premonitory signs and symptoms, are incurable. Similarly, ''vatika prameha'', where ''vayu'' is aggravated right from the beginning is incurable. ''Pitta'' dominant types of ''prameha'' are generally palliable. But they are curable if ''medas'' (adipose tissue) is not vitiated. [56]

''[[Kapha]]'' dominant and ''[[pitta]]'' dominant types of ''prameha'', if preceded by their premonitory signs and symptoms, are incurable. Similarly, ''vatika prameha'', where ''[[vata]]'' is aggravated right from the beginning is incurable. ''[[Pitta]]'' dominant types of ''prameha'' are generally palliable. But they are curable if ''[[meda]]s'' (adipose tissue) is not vitiated. [56]

=== In-curability of hereditary diseases ===

=== In-curability of hereditary diseases ===

Here are the recapulatory verses:  

Here are the recapulatory verses:  

The causes, ''dosha, dushya,'' curability, characteristics of urine in ''prameha'', two types of patients, three modes of treatment, disadvantages of excess depletion therapy, various food items of ''yava, mantha,'' various decoctions used in treatment of ''prameha,'' medicated oils, ghee preparations, linctuses, diet articles, fermented preparations like ''asava'', various exercises, baths, massage, fragrant applications all these are described in the management of ''prameha''. [59-61]   

The causes, ''[[dosha]], [[dushya]],'' curability, characteristics of urine in ''prameha'', two types of patients, three modes of treatment, disadvantages of excess depletion therapy, various food items of ''yava, mantha,'' various decoctions used in treatment of ''prameha,'' medicated oils, ghee preparations, linctuses, diet articles, fermented preparations like ''asava'', various exercises, baths, massage, fragrant applications all these are described in the management of ''prameha''. [59-61]   

    

    

Thus, ends the sixth chapter dealing with the treatment of ''prameha'' of [[Chikitsa Sthana]] of Agnivesha’s work as redacted by Charak.[6]

Thus, ends the sixth chapter dealing with the treatment of ''prameha'' of [[Chikitsa Sthana]] of Agnivesha’s work as redacted by Charak.[6]

== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

*Excess intake of curds, soup of the meat of domesticated, aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all ''kapha''- aggravating factors are responsible for the causation of ''prameha''.

*Excess intake of curds, soup of the meat of domesticated, aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all ''[[kapha]]''- aggravating factors are responsible for the causation of ''prameha''.

*Over-indulgence in the pleasure of sedentary habits, excess sleep are lifestyle factors leading to ''prameha''.  

*Over-indulgence in the pleasure of sedentary habits, excess sleep are lifestyle factors leading to ''prameha''.  

*Aggravated ''kapha'' vitiates ''medas, mamsa'' and ''kleda'' of the body located in ''basti'' (bladder and urinary system) and causes different types of ''kapha'' dominant ''meha''.   

*Aggravated ''[[kapha]]'' vitiates ''[[meda]]s, [[mamsa]]'' and ''kleda'' of the body located in ''basti'' (bladder and urinary system) and causes different types of ''[[kapha]]'' dominant ''meha''.   

*Similarly, ''pitta'' aggravated by hot things vitiates those elements and causes different types of ''pitta'' dominant ''meha''.

*Similarly, ''[[pitta]]'' aggravated by hot things vitiates those elements and causes different types of ''[[pitta]]'' dominant ''meha''.

*When other two ''doshas'' are in a relatively diminished state, the aggravated ''vayu'' draws tissues elements (viz. ''ojas, majja,'' and ''lasika'') into the urinary tract and vitiates them to cause ''vata'' dominant ''pramehas''. Different ''doshas'' having entered the urinary tract in vitiated condition give rise to the respective types of ''meha'' with their own dominance.  

*When other two ''[[dosha]]s'' are in a relatively diminished state, the aggravated ''[[vata]]'' draws tissues elements (viz. ''[[ojas]], [[majja]],'' and ''lasika'') into the urinary tract and vitiates them to cause ''[[vata]]'' dominant ''pramehas''. Different ''[[dosha]]s'' having entered the urinary tract in vitiated condition give rise to the respective types of ''meha'' with their own dominance.  

*''Doshas'' like ''kapha, pitta'' and ''vata'', and ''dushyas'' like ''medas, rakta, shukra, ambu'' (body fluid), ''vasa'' (muscle fat), ''lasika'' (lymph), ''majja, rasa, ojas'' and ''mamsa'' are responsible for the causation of ''prameha'' which is of twenty types. ''Prameha'' is classified on the basis of characteristics of urine as observed. Indeed the classification depends upon response of urinary system towards internal imbalance of cellular metabolism. This depends upon waste products excreted through urine after interaction of aggravated ''dosha'' and ''dushya''.   

*''Doshas'' like ''[[kapha]], [[pitta]]'' and ''[[vata]]'', and ''[[dushya]]s'' like ''[[meda]]s, [[rakta]], [[shukra]], ambu'' (body fluid), ''vasa'' (muscle fat), ''lasika'' (lymph), ''[[majja]], [[rasa]], [[ojas]]'' and ''[[mamsa]]'' are responsible for the causation of ''prameha'' which is of twenty types. ''Prameha'' is classified on the basis of characteristics of urine as observed. Indeed the classification depends upon response of urinary system towards internal imbalance of cellular metabolism. This depends upon waste products excreted through urine after interaction of aggravated ''[[dosha]]'' and ''[[dushya]]''.   

*Different types of ''prameha'' are characterized by the color, taste, touch and smell of the respective ''dosha''.

*Different types of ''prameha'' are characterized by the color, taste, touch and smell of the respective ''[[dosha]]''.

*Patients suffering from ''prameha'' are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak. The clinical presentation and treatment is different for both categories.  Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more ''doshas'' in the body should be treated with elimination therapy.  

*Patients suffering from ''prameha'' are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak. The clinical presentation and treatment is different for both categories.  Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more ''[[dosha]]s'' in the body should be treated with elimination therapy.  

*After elimination therapy, nourishment therapy shall be prescribed to the patient. If nourishment therapy is not done, then the aggravated ''vata dosha'' leads to complications of ''prameha''.   

*After elimination therapy, nourishment therapy shall be prescribed to the patient. If nourishment therapy is not done, then the aggravated ''[[vata dosha]]'' leads to complications of ''prameha''.   

*The food preparations like yava (barley) which have dry, light to digest and hot properties are predominantly indicated in prameha.

*The food preparations like yava (barley) which have dry, light to digest and hot properties are predominantly indicated in prameha.

*Aggravated ''kleda'' (liquid element of the body), ''medas'' (adipose tissue) and ''kapha'' are responsible for the causation of ''prameha''. Considering this aggravation, ''apatarpana'' (depletion therapies) is the first principle of treatment in ''kapha'' and ''pitta'' dominant types of ''prameha''.

*Aggravated ''kleda'' (liquid element of the body), ''[[meda]]s'' (adipose tissue) and ''[[kapha]]'' are responsible for the causation of ''prameha''. Considering this aggravation, ''apatarpana'' (depletion therapies) is the first principle of treatment in ''[[kapha]]'' and ''[[pitta]]'' dominant types of ''prameha''.

*If ''vata'' is primarily aggravated in ''prameha'' because of excessive depletion of tissue elements, then it is incurable. If ''vata'' is associated and secondarily aggravated, then it is treatable upto some extent.  

*If ''[[vata]]'' is primarily aggravated in ''prameha'' because of excessive depletion of tissue elements, then it is incurable. If ''[[vata]]'' is associated and secondarily aggravated, then it is treatable upto some extent.  

*Persistently avoiding etiological factors after manifestation of disease and during treatment of disease are important principles of management of disease.  

*Persistently avoiding etiological factors after manifestation of disease and during treatment of disease are important principles of management of disease.  

*The curability of ''kapha'' and ''pitta'' dominant ''prameha'' depends upon intensity of involvement of ''meda dhatu''.  

*The curability of ''[[kapha]]'' and ''[[pitta]]'' dominant ''prameha'' depends upon intensity of involvement of ''[[meda dhatu]]''.  

*Patients who suffer from prameha since birth (congenital) and those who are borne of ''prameha'' parents (hereditary) are not curable because of the morbidity in their ''bija'' (genes). Similarly, other hereditary (''kulaja''/familial) ailments are considered as incurable.

*Patients who suffer from prameha since birth (congenital) and those who are borne of ''prameha'' parents (hereditary) are not curable because of the morbidity in their ''bija'' (genes). Similarly, other hereditary (''kulaja''/familial) ailments are considered as incurable.

== Vidhi Vimarsha (Applied Inferences ) ==

== Vidhi Vimarsha (Applied Inferences ) ==

=== Role of ''kapha'' dominant diet ===

=== Role of ''[[kapha]]'' dominant diet ===

In ''prameha, kapha'' is the main culprit both as ''dosha'' as well as ''dushya''. Diet having high contents of bad fat and carbohydrates like curd (Fat=  3g/ 100g, carbohydrate= 7.8g/100g, Protein= 5.25g,  calories= 63), meat soup (calories= 902), jaggery (Fat= 0g/ 100g, carbohydrate= 97.2 g/100g, Protein= 0.5g/100g, calories= 367), newly harvested grains that are having high calories than old one  (If dry grains are held for only a few months, minimum nutritional changes will take place, but if the grains are held with a higher amount of moisture, the grain quality can deteriorate because of starch degradation by grain and microbial amylases) etc., causes ''prameha''. All the causative factors are in diet that have high content of bad fat like saturated fats and no good fats like polyunsaturated or monounsaturated fats (which are mostly present in plant originated dietary products). It is advisable that maximum percentage of daily fat consumption should come from plant origin to lower the risk of dyslipidemia.

In ''prameha, [[kapha]]'' is the main culprit both as ''[[dosha]]'' as well as ''[[dushya]]''. Diet having high contents of bad fat and carbohydrates like curd (Fat=  3g/ 100g, carbohydrate= 7.8g/100g, Protein= 5.25g,  calories= 63), meat soup (calories= 902), jaggery (Fat= 0g/ 100g, carbohydrate= 97.2 g/100g, Protein= 0.5g/100g, calories= 367), newly harvested grains that are having high calories than old one  (If dry grains are held for only a few months, minimum nutritional changes will take place, but if the grains are held with a higher amount of moisture, the grain quality can deteriorate because of starch degradation by grain and microbial amylases) etc., causes ''prameha''. All the causative factors are in diet that have high content of bad fat like saturated fats and no good fats like polyunsaturated or monounsaturated fats (which are mostly present in plant originated dietary products). It is advisable that maximum percentage of daily fat consumption should come from plant origin to lower the risk of dyslipidemia.

Optimum levels of fat in the diet are given below:

Optimum levels of fat in the diet are given below:

=== Diagnosis of ''prameha'' based on characteristics of urine ===

=== Diagnosis of ''prameha'' based on characteristics of urine ===

Different categories of ''prameha'' are described to possess the color, taste, touch, and smell of the respective ''doshas''. For example, in ''kaphaja prameha'', the urine is characterized by white color, sweet taste; cold touch and ''ama gandha'' (smell like that of flesh). In the same way, the characteristic features of ''pittaja prameha'' are to be determined. ''Vayu'' itself is colorless. Therefore, different varieties of ''vata'' dominant ''prameha'' are characterized by grayish or reddish color of urine as a result of the ''prabhava'' (specific action) of the ''vayu''.

Different categories of ''prameha'' are described to possess the color, taste, touch, and smell of the respective ''[[dosha]]s''. For example, in ''[[kapha]]ja prameha'', the urine is characterized by white color, sweet taste; cold touch and ''ama gandha'' (smell like that of flesh). In the same way, the characteristic features of ''[[pitta]]ja prameha'' are to be determined. ''[[Vayu]]'' itself is colorless. Therefore, different varieties of ''[[vata]]'' dominant ''prameha'' are characterized by grayish or reddish color of urine as a result of the ''prabhava'' (specific action) of the ''vayu''.

''Vata'' dominant ''prameha'' is already described to be incurable (''asadhya''). Again repeating the statement regarding its incurability implies that the presence of several symptoms including the grayish and reddish coloration of urine right from the origin of disease is incurable; and if these signs and symptoms appear at later stage, then the condition is incurable. In the latter type, attributes of ''majja'' etc., need not to be present. Alternatively, it can be explained that when at a later stage, any type of ''prameha'' gets associated with ''vayu'' and characterized by grayish and reddish coloration of urine, and then it also becomes incurable. In addition when ''kaphaja'' and ''pittaja'' types of ''prameha'' are associated with the passage of ''majja'' etc., in the urine, they become incurable. It is stated, “All types of ''prameha'', if not treated in time, leads to ''madhumeha'' and become incurable” <ref> Sushruta. Nidana Sthana, Cha.6 Prameha Adhyaya  In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1</ref>

''[[Vata]]'' dominant ''prameha'' is already described to be incurable (''asadhya''). Again repeating the statement regarding its incurability implies that the presence of several symptoms including the grayish and reddish coloration of urine right from the origin of disease is incurable; and if these signs and symptoms appear at later stage, then the condition is incurable. In the latter type, attributes of ''[[majja]]'' etc., need not to be present. Alternatively, it can be explained that when at a later stage, any type of ''prameha'' gets associated with ''[[vayu]]'' and characterized by grayish and reddish coloration of urine, and then it also becomes incurable. In addition when ''[[kapha]]ja'' and ''[[pitta]]ja'' types of ''prameha'' are associated with the passage of ''[[majja]]'' etc., in the urine, they become incurable. It is stated, “All types of ''prameha'', if not treated in time, leads to ''madhumeha'' and become incurable” <ref> Sushruta. Nidana Sthana, Cha.6 Prameha Adhyaya  In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1</ref>

==== 1. ''Kaphaja prameha'' (progressive stage from pre-diabetic to diabetes mellitus type-2) ====

==== 1. ''[[Kapha]]ja prameha'' (progressive stage from pre-diabetic to diabetes mellitus type-2) ====

*''Udakameha'' – Osmotic diuresis (having characteristic similar to that of water)

*''Udakameha'' – Osmotic diuresis (having characteristic similar to that of water)

**Pre-diabetic stage - hyperglycemia causes decrease reabsorption of water and excessive loss of water through urine.

**Pre-diabetic stage - hyperglycemia causes decrease reabsorption of water and excessive loss of water through urine.

**Autonomic diabetic neuropathy leading to retrograde ejaculation of sperm.

**Autonomic diabetic neuropathy leading to retrograde ejaculation of sperm.

==== 2.''Pittaja prameha''- (Stage of infection & inflammation in diabetes) ====

==== 2.''[[Pitta]]ja prameha''- (Stage of infection & inflammation in diabetes) ====

*''Ksharameha''- the patient passes urine having the smell, color, taste and touch like those of alkalies. (pH of urine become alkaline)

*''Ksharameha''- the patient passes urine having the smell, color, taste and touch like those of alkalies. (pH of urine become alkaline)

**Increased urinary pH due to UTI in diabetes.

**Increased urinary pH due to UTI in diabetes.

=== Importance of Barley ===

=== Importance of Barley ===

Barley should constitute the principal ingredient of food of the patient suffering from ''prameha''. The patient suffering from ''kaphaja prameha'' should take eatable prepared of barley mixed with honey.

Barley should constitute the principal ingredient of food of the patient suffering from ''prameha''. The patient suffering from ''[[kapha]]ja prameha'' should take eatable prepared of barley mixed with honey.

Barley soaked in the decoction of ''triphala'' and kept overnight should be mixed with honey. It is a refreshing (''tarpana'') diet. It should be taken by the patient suffering from ''prameha'' regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of ''kaphaja prameha'' and taken by the patient in the form of ''saktu'' (roasted flour), ''apupa'' (pan-cake), ''dhana'' (fried barley) and other types of eatables along with jaggery.

Barley soaked in the decoction of ''triphala'' and kept overnight should be mixed with honey. It is a refreshing (''tarpana'') diet. It should be taken by the patient suffering from ''prameha'' regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of ''[[kapha]]ja prameha'' and taken by the patient in the form of ''saktu'' (roasted flour), ''apupa'' (pan-cake), ''dhana'' (fried barley) and other types of eatables along with jaggery.

Various eatables prepared from the barley or bamboo seed or wheat previously eaten by asses, horses, cows, swans and deer and collected from their dung should be given to the patient suffering from ''prameha''.

Various eatables prepared from the barley or bamboo seed or wheat previously eaten by asses, horses, cows, swans and deer and collected from their dung should be given to the patient suffering from ''prameha''.

=== Contemporary management of ''prameha'' ===

=== Contemporary management of ''prameha'' ===

'''Disease management''': 1. Wholesome diet 2. Exercise 3. Pacification of ''dosha''

'''Disease management''': 1. Wholesome diet 2. Exercise 3. Pacification of ''[[dosha]]''

'''Important medicines''': 1. ''Shilajatu'' 2. ''Asana'' 3. ''Jambu'' 4. ''Yashada'' 5. ''Kumbha'' 6. ''Haridra'' 7. ''Amalaki'' 8. ''Tikta rasa''

'''Important medicines''': 1. ''Shilajatu'' 2. ''Asana'' 3. ''Jambu'' 4. ''Yashada'' 5. ''Kumbha'' 6. ''Haridra'' 7. ''Amalaki'' 8. ''Tikta rasa''

! scope="col"| Vehicle

! scope="col"| Vehicle

|-

|-

| rowspan="6"| ''' ''Kapha'' dominant'''

| rowspan="6"| ''' ''[[Kapha]]'' dominant'''

| 1. Juice of ''Bilva'' leaves

| 1. Juice of ''Bilva'' leaves

| 10-20 ml

| 10-20 ml

| Milk

| Milk

|-

|-

| 3. ''Shilajatu rasayana''  

| 3. ''Shilajatu [[rasayana]]''  

| 250-500 mg

| 250-500 mg

| Between two meals, two times

| Between two meals, two times

| --

| --

|-

|-

| rowspan="2"| ''' ''Vata'' dominant'''

| rowspan="2"| ''' ''[[Vata]]'' dominant'''

| 1. ''Trivanga bhasma''  

| 1. ''Trivanga bhasma''  

| 120-500 mg

| 120-500 mg

==== ''Gymnema Sylvester'' ====

==== ''Gymnema Sylvester'' ====

''Meshashringi'' (Gymnema Sylvester (Retz.) R.Br.; Gurmar) targets several of the etiological factors associated with diabetes, including chronic inflammation, obesity and pancreatic B-cell function<ref>Leach MJ. Gymnema sylvestre for diabetes mellitus: A systematic review. J Alter Complement Med 2007; 13: 977-983</ref>.  In a study on rats with streptozotocin – induced diabetes, G. sylvestre treatment resulted in 30% increase in total pancreatic weight and a significant increase in the number of islets and number of B-cells per islet. The regenerated pancreatic tissue resulted in complete control of fasting blood glucose levels within 20-60 days. Normal rats in this study did not experience an increase in insulin release when treated with G. Sylvestre extract, indicating that this herb has a normalizing effect on the blood glucose and may, therefore, be safer than conventional oral hypoglycemic agents such as sulphonylureas<ref>Shanmugasundaram ER, Gopinath KL, Radha Shanmugasundaram K, Rajendran VM. Possible regeneration of the islets of Langerhans in streptozocin- diabetic rats given Gymnema sylvestre leaf extracts. J Ethnnopharmacol 1990; 30: 265-279</ref>. Several clinical studies have demonstrated that G. Sylvestre effective in decreasing blood glucose levels in patients with type 1 and type 2 diabetes<ref>Leach MJ. Gymnema sylvestre for diabetes mellitus: A systematic review. J Alter Complement Med 2007; 13: 977-983</ref><ref>Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.Antidiabetic  effect  of a leaf extract from Gymnema sylvestre in non-insulin – dependent diabetes mellitus patients. J Ethnnopharmacol 1990; 30: 295-300</ref><ref>Shanmugasundaram ER, Rajeswari G, Baskaran K, et al. Use of Gymnema sylvestre leaf extract in the control of blood glucose in in insulin- dependent diabetes mellitus. J Ethnnopharmacol 1990; 30: 281-294</ref>. Two (2) clinical trials investigated the effects of combining G. Sylvestre treatment with conventional therapy compared to the conventional therapy alone. In 22 patients with type 2 diabetes, treatment with G. Sylvestre extract significantly reduced blood glucose, glycosylated hemoglobin, and glycosylated plasma proteins, whereas, with conventional treatment alone (i.e. glibenclamide or tolbutamide), these values increased or remain the same. The patients receiving the herbal extract were able to decrease the dosage of their conventional drug, and five patients were able to discontinue the drug entirely and maintain their glucose level using only G. sylvestre<ref>Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.Antidiabetic  effect  of a leaf extract from Gymnema sylvestre in non-insulin – dependent diabetes mellitus patients. J Ethnnopharmacol 1990; 30: 295-300.</ref>. In 27 patients with type 1 diabetes, G. Sylvestre treatment reduced fasting blood glucose, glycosylated hemoglobin, and glycosylated plasma protein levels<ref>Shanmugasundaram ER, Rajeswari G, Baskaran K, et al. Use of Gymnema sylvestre leaf extract in the control of blood glucose in in insulin- dependent diabetes mellitus. J Ethnnopharmacol 1990; 30: 281-294</ref>.

''Meshashringi'' (Gymnema Sylvester (Retz.) R.Br.; Gurmar) targets several of the etiological factors associated with diabetes, including chronic inflammation, obesity and pancreatic B-cell function<ref>Leach MJ. Gymnema sylvestre for diabetes mellitus: A systematic review. J Alter Complement Med 2007; 13: 977-983</ref>.  In a study on rats with streptozotocin – induced diabetes, G. sylvestre treatment resulted in 30% increase in total pancreatic weight and a significant increase in the number of islets and number of B-cells per islet. The regenerated pancreatic tissue resulted in complete control of fasting blood glucose levels within 20-60 days. Normal rats in this study did not experience an increase in insulin release when treated with G. Sylvestre extract, indicating that this herb has a normalizing effect on the blood glucose and may, therefore, be safer than conventional oral hypoglycemic agents such as sulphonylureas<ref>Shanmugasundaram ER, Gopinath KL, Radha Shanmugasundaram K, Rajendran VM. Possible regeneration of the islets of Langerhans in streptozocin- diabetic rats given Gymnema sylvestre leaf extracts. J Ethnnopharmacol 1990; 30: 265-279</ref>. Several clinical studies have demonstrated that G. Sylvestre effective in decreasing blood glucose levels in patients with type 1 and type 2 diabetes<ref>Leach MJ. Gymnema sylvestre for diabetes mellitus: A systematic review. J Alter Complement Med 2007; 13: 977-983</ref><ref>Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.Antidiabetic  effect  of a leaf extract from Gymnema sylvestre in non-insulin – dependent diabetes mellitus patients. J Ethnnopharmacol 1990; 30: 295-300</ref><ref>Shanmugasundaram ER, Rajeswari G, Baskaran K, et al. Use of Gymnema sylvestre leaf extract in the control of blood glucose in in insulin- dependent diabetes mellitus. J Ethnnopharmacol 1990; 30: 281-294</ref>. Two (2) clinical trials investigated the effects of combining G. Sylvestre treatment with conventional therapy compared to the conventional therapy alone. In 22 patients with type 2 diabetes, treatment with G. Sylvestre extract significantly reduced blood glucose, glycosylated hemoglobin, and glycosylated plasma proteins, whereas, with conventional treatment alone (i.e. glibenclamide or tolbutamide), these values increased or remain the same. The patients receiving the herbal extract were able to decrease the dosage of their conventional drug, and five patients were able to discontinue the drug entirely and maintain their glucose level using only G. sylvestre<ref>Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.Antidiabetic  effect  of a leaf extract from Gymnema sylvestre in non-insulin – dependent diabetes mellitus patients. J Ethnnopharmacol 1990; 30: 295-300.</ref>. In 27 patients with type 1 diabetes, G. Sylvestre treatment reduced fasting blood glucose, glycosylated hemoglobin, and glycosylated plasma protein levels<ref>Shanmugasundaram ER, Rajeswari G, Baskaran K, et al. Use of Gymnema sylvestre leaf extract in the control of blood glucose in insulin- dependent diabetes mellitus. J Ethnnopharmacol 1990; 30: 281-294</ref>.

==== ''Tinospora cordifolia'' ====

==== ''Tinospora cordifolia'' ====

''Mamejjaka'' (Enicostema littorale Blume) is used as a single herb and also as a part of an anti-diabetic mixture<ref>Shanmugasundaram ER, Gopinath KL, Radha Shanmugasundaram K, Rajendran VM. Possible regeneration of the islets of Langerhans in streptozocin- diabetic rats given Gymnema sylvestre leaf extracts. J Ethnnopharmacol 1990; 30: 265-279</ref>. In a clinical study on patients with type 2 diabetes, E. littorale reduced blood glucose and prevented the progression of diabetic complications. There was a significant improvement in the lipid profile, blood pressure, and kidney function<ref>Upadhyay UM, Goyal RK. Efficacy  of Enicostemma littorale in type-2 diabetic patients. Phytother Res 2004; 18:233-235</ref>. It significantly reduced blood glucose and lipid peroxides in rats with alloxan- induced diabetes, and increased superoxide dismutase, catalase, and glutathione peroxidase<ref>Prince PS, Srinivasan M. Enicostemma littorale Blume aqueous extract improves the antioxidant status in alloxan induced diabetic rat tissues. Acta Pol Pharm 2005; 62: 363-367</ref>. In studies on rats with streptozotocin- induced type 1 diabetes, E. littorale significantly reduced glucose, cholesterol, and triglyceride levels<ref>Vishwakarma SL, Sonawane RD, Rajani M, Goyal RK. Evaluation of effect of aqueous extract of Enicostemma littorale in streptozotocin –induced type-1 diabetic rats. Indian J Exp Biol 2010; 48:26-30</ref>, and ameliorated diabetic nephropathy. Serum creatinine and urea were significantly decreased and glomerular function improved<ref>Sonawane RD, Vishwakarma SL, Lakshmi S, et al. Amelirotion of STZ-induced type 1 diabetic nephropathy by aqueous extract of Enicostemma littorale Blume and swertiamarin in rats. Mol Cell Biochem 2010; 340:1-6</ref>. In rats fed a hypercholesterolemic diet, E. littorale decreased serum cholesterol, triglycerides, LDL, VLDL, liver, and kidney cholesterol levels, and lipid peroxidation levels. There was an increase in HDL and an increase in reduced glutathione levels<ref>Vasu VT, Modi H, Thaikoottathil JV,Gupta S. Hypolipidaemic and antioxidant effect of Enicostemma littorale Blume aqueous extract in cholesterol fed rats. J Ethnnopharmacol  2005; 101: 277-282.</ref>.

''Mamejjaka'' (Enicostema littorale Blume) is used as a single herb and also as a part of an anti-diabetic mixture<ref>Shanmugasundaram ER, Gopinath KL, Radha Shanmugasundaram K, Rajendran VM. Possible regeneration of the islets of Langerhans in streptozocin- diabetic rats given Gymnema sylvestre leaf extracts. J Ethnnopharmacol 1990; 30: 265-279</ref>. In a clinical study on patients with type 2 diabetes, E. littorale reduced blood glucose and prevented the progression of diabetic complications. There was a significant improvement in the lipid profile, blood pressure, and kidney function<ref>Upadhyay UM, Goyal RK. Efficacy  of Enicostemma littorale in type-2 diabetic patients. Phytother Res 2004; 18:233-235</ref>. It significantly reduced blood glucose and lipid peroxides in rats with alloxan- induced diabetes, and increased superoxide dismutase, catalase, and glutathione peroxidase<ref>Prince PS, Srinivasan M. Enicostemma littorale Blume aqueous extract improves the antioxidant status in alloxan induced diabetic rat tissues. Acta Pol Pharm 2005; 62: 363-367</ref>. In studies on rats with streptozotocin- induced type 1 diabetes, E. littorale significantly reduced glucose, cholesterol, and triglyceride levels<ref>Vishwakarma SL, Sonawane RD, Rajani M, Goyal RK. Evaluation of effect of aqueous extract of Enicostemma littorale in streptozotocin –induced type-1 diabetic rats. Indian J Exp Biol 2010; 48:26-30</ref>, and ameliorated diabetic nephropathy. Serum creatinine and urea were significantly decreased and glomerular function improved<ref>Sonawane RD, Vishwakarma SL, Lakshmi S, et al. Amelirotion of STZ-induced type 1 diabetic nephropathy by aqueous extract of Enicostemma littorale Blume and swertiamarin in rats. Mol Cell Biochem 2010; 340:1-6</ref>. In rats fed a hypercholesterolemic diet, E. littorale decreased serum cholesterol, triglycerides, LDL, VLDL, liver, and kidney cholesterol levels, and lipid peroxidation levels. There was an increase in HDL and an increase in reduced glutathione levels<ref>Vasu VT, Modi H, Thaikoottathil JV,Gupta S. Hypolipidaemic and antioxidant effect of Enicostemma littorale Blume aqueous extract in cholesterol fed rats. J Ethnnopharmacol  2005; 101: 277-282.</ref>.

A pilot study on an herbal mixture containing  ''tejapatra'' (Cinnamomum Tamala)<ref>Chandola HM, Tripathi S N. Hypoglycemic response of C.tamala in diabetes. In: Bajaj JS,ed. Diabetes Mellitus in developing Countries. New Delhi: Interprint, 1984: 383-386.</ref><ref>Chandola HM, Tripathi S N, Udupa KN. Effect of C.tamala on plasma insulin vis-à-vis  blood sugar in patients of diabetes mellitus. J Res [[Ayurveda]] Siddha 1980;1:3455-357. </ref>, ''pushkarmula'' (Inula racemosa), ''mamejjaka'' (E.littorale), ''meshashringi'' (Gymnema Sylvestre), and ''jambu'' (Syzygium cumini) seeds with ''karvellaka'' (bitter gourd; bitter melon; Momordica charantia) juice, administered at a dose of 5g twice a day before meals, decreased fasting and post- prandial blood glucose levels in patients with diabetes<ref>Singh B, Singh G, Vyas SN, Chandola HM. The role of  Virechana and herbal drugs in the management of MadhuMeha (diabetes mellitus). MD (Ayu) thesis. Institute of  Post Graduate Teaching and Resaerch in [[Ayurveda]], Gujarat [[Ayurveda]] University, Jamnagar, India, 1992</ref>. ''Avartaki'' (Cassia auriculata Linn.) and ''methika'' (Trigonella foenum- graecum) as single herbs and decoction of ''nimba'' or ''neem'' (Azadirachta indica A.juss;) have also demonstrated blood glucose- lowering  action33. In a clinical study on patients with type 2 diabetes, neem showed significant hypoglycemic effect. The effect of ''neem'' was comparable to that of glibenclamide<ref>Waheeda A, Miana GA, Ahmead SI. Clinical investigation of hypoglycemic effect of seeds of Azadirachata indica in type-2 (NIDDM) diabetes mellitus. Pak J Pharm Sci 2006; 19: 322-325</ref><ref>Khosla P, Bhanwra S,Singh J, et al. A study of hypoglycaemic effect of Azadirachata indica (Neem) in normal and alloxan diabetic rabbits. Indian J Physiol Pharmacol 2000:44:69-74</ref>.  

A pilot study on an herbal mixture containing  ''tejapatra'' (Cinnamomum Tamala)<ref>Chandola HM, Tripathi S N. Hypoglycemic response of C.tamala in diabetes. In: Bajaj JS,ed. Diabetes Mellitus in developing Countries. New Delhi: Interprint, 1984: 383-386.</ref><ref>Chandola HM, Tripathi S N, Udupa KN. Effect of C.tamala on plasma insulin vis-à-vis  blood sugar in patients of diabetes mellitus. J Res [[Ayurveda]] Siddha 1980;1:3455-357. </ref>, ''pushkarmula'' (Inula racemosa), ''mamejjaka'' (E.littorale), ''meshashringi'' (Gymnema Sylvestre), and ''jambu'' (Syzygium cumini) seeds with ''karvellaka'' (bitter gourd; bitter melon; Momordica charantia) juice, administered at a dose of 5g twice a day before meals, decreased fasting and post- prandial blood glucose levels in patients with diabetes<ref>Singh B, Singh G, Vyas SN, Chandola HM. The role of  Virechana and herbal drugs in the management of MadhuMeha (diabetes mellitus). MD (Ayu) thesis. Institute of  Post Graduate Teaching and Research in [[Ayurveda]], Gujarat [[Ayurveda]] University, Jamnagar, India, 1992</ref>. ''Avartaki'' (Cassia auriculata Linn.) and ''methika'' (Trigonella foenum- graecum) as single herbs and decoction of ''nimba'' or ''neem'' (Azadirachta indica A.juss;) have also demonstrated blood glucose- lowering  action33. In a clinical study on patients with type 2 diabetes, neem showed significant hypoglycemic effect. The effect of ''neem'' was comparable to that of glibenclamide<ref>Waheeda A, Miana GA, Ahmead SI. Clinical investigation of hypoglycemic effect of seeds of Azadirachata indica in type-2 (NIDDM) diabetes mellitus. Pak J Pharm Sci 2006; 19: 322-325</ref><ref>Khosla P, Bhanwra S,Singh J, et al. A study of hypoglycaemic effect of Azadirachata indica (Neem) in normal and alloxan diabetic rabbits. Indian J Physiol Pharmacol 2000:44:69-74</ref>.  

The herb ''gokshura'' (Tribulus Terrestris Linn.)<ref>Amin A, Lotfy M, Shafiullah M, Adeghate E. The protective effect of Tribulus terreestris in diabetes. Ann NY Acad Sci 2006; 1084: 391-401</ref>, ''asana'' (Pterocarpus marsupium Roxb.)<ref>Anonymous. Sahasrayogam. 23rd ed. Alappuzha, Kerala, India: Vidyarambam Publisheres, 2000:93</ref>, ''kulatha'' (Vigna unguiculata (Linn.) Walp.), and saptaparna<ref>Dasa G. Bhaishajyaratnavali. Varanasi, India: Choukhamba Sanskrit Sansthan, 2000</ref> (Alstonia scholaris (Linn.) R.Br.) is also beneficial in treating ''prameha''. These herbs can be used in different combinations, depending on the doshic involvement and severity of illness. An herbal mixture comprised of one part each of ''karvellaka'' (bitter gourd; bitter melon; Momordica charantia), ''jambu'' (Syzygium cumini), ''gurmar'' (Meshashringi G.sylvestre), and ''amra'' (Moringa indica Linn.), taken along with ''shilajit'', was investigated in a clinical study on 805 patients with diabetes. The results showed a statistically significant reduction in fasting and postprandial blood glucose along with clinical improvement (website of India’s Central Council for Research in [[Ayurveda]] and Siddha).

The herb ''gokshura'' (Tribulus Terrestris Linn.)<ref>Amin A, Lotfy M, Shafiullah M, Adeghate E. The protective effect of Tribulus terreestris in diabetes. Ann NY Acad Sci 2006; 1084: 391-401</ref>, ''asana'' (Pterocarpus marsupium Roxb.)<ref>Anonymous. Sahasrayogam. 23rd ed. Alappuzha, Kerala, India: Vidyarambam Publisheres, 2000:93</ref>, ''kulatha'' (Vigna unguiculata (Linn.) Walp.), and saptaparna<ref>Dasa G. Bhaishajyaratnavali. Varanasi, India: Choukhamba Sanskrit Sansthan, 2000</ref> (Alstonia scholaris (Linn.) R.Br.) is also beneficial in treating ''prameha''. These herbs can be used in different combinations, depending on the doshic involvement and severity of illness. An herbal mixture comprised of one part each of ''karvellaka'' (bitter gourd; bitter melon; Momordica charantia), ''jambu'' (Syzygium cumini), ''gurmar'' (Meshashringi G.sylvestre), and ''amra'' (Moringa indica Linn.), taken along with ''shilajit'', was investigated in a clinical study on 805 patients with diabetes. The results showed a statistically significant reduction in fasting and postprandial blood glucose along with clinical improvement (website of India’s Central Council for Research in [[Ayurveda]] and Siddha).

''Prameha'' is described as a set of complex clinical disorders characterized by frequent abnormal micturition, with the etiology involving genetic predisposition as well as diet and life style. The role of stress and obesity in the pathogenesis is also elaborately described in ''prameha'' have much in common with those described for obesity, metabolic syndrome and diabetes mellitus. The management of ''prameha'' emphasizes dietary and life style recommendation and herbal preparations. Due to the richness and complexity of the compound in plants, herbal therapy has always been thought to act on multiple targets. Even one single compound can have multiple target which acts as a double edge sword in managing diabetes mellitus. ''Medhya'' or mental health promoting drugs, if added along with anti-diabetic therapy, will further potentiate anti-diabetic effect of the principal drug by counteracting stress. [[Ayurveda]] and modern medicine both are complimentary to each other. Simultaneous administration of Ayurvedic drug will not only potentiate therapeutic efficacy of modern drug rather it will also counteract or reduce the adverse effects of the modern drug, if any; to lead the patient a healthy and happy life. Moreover, organ specific ''rasayana'' may be added for prevention and cure of complications. Ayurvedic drugs should be use in its natural form without disturbing its natural combination/holistic principle of the drug. Single drug may have composite fractions and each fraction has its own medicinal value. Polyherbal combination potentiate therapeutic efficacy of a particular ingredient of the formulation and also counteract adverse effect if present in the combination. Instead of isolating a particular alkaloid it is suggested that the Ayurvedic drug should be use as a whole. All patients of diabetes are not similar, so a stepped care treatment is recommended. In early stage of disease and patients having ''kaphaja'' constitution, it is better to use Ayurvedic drugs alone. In acute stage and having ''pittaja'' constitution of patients wherever found necessary, oral insulin promoter may be added. In chronic stage and having ''vataja'' constitution, insulin therapy may also be added as these cases are insulin dependent.

''Prameha'' is described as a set of complex clinical disorders characterized by frequent abnormal micturition, with the etiology involving genetic predisposition as well as diet and life style. The role of stress and obesity in the pathogenesis is also elaborately described in ''prameha'' have much in common with those described for obesity, metabolic syndrome and diabetes mellitus. The management of ''prameha'' emphasizes dietary and life style recommendation and herbal preparations. Due to the richness and complexity of the compound in plants, herbal therapy has always been thought to act on multiple targets. Even one single compound can have multiple target which acts as a double edge sword in managing diabetes mellitus. ''Medhya'' or mental health promoting drugs, if added along with anti-diabetic therapy, will further potentiate anti-diabetic effect of the principal drug by counteracting stress. [[Ayurveda]] and modern medicine both are complimentary to each other. Simultaneous administration of Ayurvedic drug will not only potentiate therapeutic efficacy of modern drug rather it will also counteract or reduce the adverse effects of the modern drug, if any; to lead the patient a healthy and happy life. Moreover, organ specific ''[[rasayana]]'' may be added for prevention and cure of complications. Ayurvedic drugs should be use in its natural form without disturbing its natural combination/holistic principle of the drug. Single drug may have composite fractions and each fraction has its own medicinal value. Polyherbal combination potentiate therapeutic efficacy of a particular ingredient of the formulation and also counteract adverse effect if present in the combination. Instead of isolating a particular alkaloid it is suggested that the Ayurvedic drug should be use as a whole. All patients of diabetes are not similar, so a stepped care treatment is recommended. In early stage of disease and patients having ''[[kapha]]ja'' constitution, it is better to use Ayurvedic drugs alone. In acute stage and having ''[[pitta]]ja'' constitution of patients wherever found necessary, oral insulin promoter may be added. In chronic stage and having ''[[vata]]ja'' constitution, insulin therapy may also be added as these cases are insulin dependent.

[[Ayurveda]] has a vast array of herbs and herbal mixtures that are used in the treatment of ''prameha''. A large number of these herbs have demonstrated efficacy in research investigations. The herbs have various properties including hypoglycemic, antihyperglycemic, hypolipidemic, antihyperlipidemic, insulin promoting and antioxidant properties. Some of these herbs are capable of counteracting stress induced catecholamines, which are proven insulin antagonists. Hence, the choice of the herb or combination of herbs for the patient depends upon the stage of the disease, disturbances in the psychophysiologic constitution of the patient, and mode of action of the herbs. Further research is needed in the clinical setting to elucidate the Ayurvedic modalities that are effective in the management of obesity, metabolic syndrome and diabetes mellitus in light of their similarities with ''prameha''<ref>Sharma H, Chandola HM.Prameha in [[Ayurveda]]: Correlation with Obesity, Metabolic Syndrome, and Diabetes Mellitus.Part 2- Management of Prameha. The Journal of Alternative and Complementary Medicine.2011. 17(7):589-599</ref>.

[[Ayurveda]] has a vast array of herbs and herbal mixtures that are used in the treatment of ''prameha''. A large number of these herbs have demonstrated efficacy in research investigations. The herbs have various properties including hypoglycemic, antihyperglycemic, hypolipidemic, antihyperlipidemic, insulin promoting and antioxidant properties. Some of these herbs are capable of counteracting stress induced catecholamines, which are proven insulin antagonists. Hence, the choice of the herb or combination of herbs for the patient depends upon the stage of the disease, disturbances in the psychophysiologic constitution of the patient, and mode of action of the herbs. Further research is needed in the clinical setting to elucidate the Ayurvedic modalities that are effective in the management of obesity, metabolic syndrome and diabetes mellitus in light of their similarities with ''prameha''<ref>Sharma H, Chandola HM.Prameha in [[Ayurveda]]: Correlation with Obesity, Metabolic Syndrome, and Diabetes Mellitus.Part 2- Management of Prameha. The Journal of Alternative and Complementary Medicine.2011. 17(7):589-599</ref>.

=== Future Scope for Research ===

=== Future Scope for Research ===

#Fundamental studies to observe link between ''meda'' (adipose tissue) and urinary disorders are needed.

#Fundamental studies to observe link between ''[[meda]]'' (adipose tissue) and urinary disorders are needed.

#Searching herbs describe in the chapter for their potential in reducing FFAs and blood glucose level.

#Searching herbs describe in the chapter for their potential in reducing FFAs and blood glucose level.

#Clinical studies to evaluate the efficacy of anti-lipidemic drugs and its comparison with hypoglycemic drugs in the management of type-2 diabetes mellitus.

#Clinical studies to evaluate the efficacy of anti-lipidemic drugs and its comparison with hypoglycemic drugs in the management of type-2 diabetes mellitus.