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Prameha Nidana (view source)

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|title=Prameha Nidana

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|keywords=Factors affecting disease pathology, Prameha, diabetes, genetic susceptibility, prabhuta mutrata, polyuria, avila mutrata, turbid urine, vikarabhighata, urinary disorders

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|keywords=Factors affecting disease pathology, Prameha, diabetes, genetic susceptibility, prabhuta mutrata, polyuria, avila mutrata, turbid urine, vikarabhighata, urinary disorders, charak samhita, ayurveda

|description=Nidana Sthana Chapter 4. Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes

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=== Introduction ===

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== Introduction ==

The fourth chapter in the [[Nidana Sthana]], dealing with the diagnosis of ''prameha'', follows the diagnosis of ''gulma'' disease associated with the ''mamsa dhatu''. Twenty known types of ''prameha'', including diabetes mellitus (''madhumeha''), have been described here. However, there could be innumerable variations of a disease based on the presence or absence of disease (provoking or mitigating) factors in the body. The manifestation of the disease depends upon the interaction between causative factors, ''dosha, dushya'' and the defense mechanism of the body. Some of these factors can also help determine if there could be a delayed or an early onset of the disease, the severity of the disease, etc. Various etiological factors of ''prameha'' are described here that lead to vitiation of ''kapha, meda,'' and ''mutra''. A vitiated ''kapha'' affects ten fluid-predominant body tissues, resulting in the production of excessive ''kleda'' (moisture/excess discharge of body fluids) that, when intermixed with ''meda'' (lipid)and ''mamsa'' (muscle protein), further vitiates ''mutra'' (urine) and results in ''prameha''. A patient afflicted with diabetes mellitus, on an initial visit to the physician, may complain of numbness, tingling, burning sensation in feet, fatigue, dryness of mouth, drowsiness, etc. It is highlighted these signs and symptoms for an early diagnosis and management of ''prameha''. Ten types of curable ''kaphaja prameha'', six variants of ''yaapya'' (palliative) and four variants of incurable ''vataja prameha'', totaling twenty types of ''prameha'' have been described here in this text. Prodromal symptoms, complications, treatment procedures (enumerated briefly), and some rules (do’s and don’ts) have been included in the course of this chapter.

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===Sanskrit Text, Transliteration and English Translation===

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==Sanskrit Text, Transliteration and English Translation==

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Now we shall expound the chapter ~~on the diagnosis~~ of ~~''prameha''~~. Thus, said Lord Atreya. [1-2]

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Now we shall expound the chapter "Prameha Nidana" (Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes). Thus said Lord Atreya. [1-2]

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==== Types of ''Prameha'' ====

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=== Types of ''Prameha'' ===

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Due to vitiation of three ''doshas'', (any of) twenty types of ''prameha'' could occur. However, there may be innumerable other variations of the disease. We shall now explain the ways in which vitiation of the three ''doshas'' leads to the manifestation of the various types of ''prameha''. [3]

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==== Process of Onset of Disease ====

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=== Process of Onset of Disease ===

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Thus, the presence or absence of specific factors determine the ability or otherwise of the body to resist all types of diseases. [4]

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==== Etiology of ''Kaphaja Prameha'' ====

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=== Etiology of ''Kaphaja Prameha'' ===

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==== Pathogenesis ====

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=== Pathogenesis ===

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Etiological factors (especially ''kapha''-dominant ones), ''doshas'', and ''dushyas'' mentioned in the preceding verses can trigger the manifestation of ''kaphaja prameha''. The aggravated ''kapha'' spreads all over the body quickly because of flaccid muscles and fatty tissues. The ''kapha'' blends quickly with the ''medas'' (fat) – primarily because the fats typically are excessive in quantity and viscous and soft in "favorable" body conditions but also because ''kapha'' and ''medas'' share identical qualities. As ''kapha'' itself is vitiated, it vitiates ''medas'' in the process. The vitiated ''kapha - meda'' then mixes with ''mamsa'' (muscle tissues) and ''kleda'' (moisture/body fluid), in as much as these two are supposed to have already exceeded their quantity. Vitiation of the muscle tissues provides a congenial atmosphere for the manifestation of putrified carbuncles (''pidika'') like ''sharavika'' and ''kacchapika'' in the muscle. The liquid ''dhatus'' in the body get further vitiated and transformed into ''mutra'' (urine). ''Vrikka'' (kidney) and ''basti'' (urinary bladder) are at the two ends of the channels carrying urine; the openings of these channels get affected by ''meda'' (fat) and ''kleda''. The vitiated ''kapha'' obstructs the openings of these channels. This results in the manifestation of ''prameha'' which becomes chronic or incurable due to the affection of all qualities of ''kapha'' and simultaneous vitiation of homogenous and heterogenous ''dhatus''. [8]

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==== Signs, Types, and Prognosis of ''Kaphaja Prameha'' ====

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=== Signs, Types, and Prognosis of ''Kaphaja Prameha'' ===

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#Both ''medas'' and ''kapha'' are amenable to the same treatment. [9-11]

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==== Specific Features of Types of ''Kaphaja Prameha'' ====

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=== Specific Features of Types of ''Kaphaja Prameha'' ===

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Thus, the ten types of ''prameha'' due to vitiation of ''kapha'' have been explained. [12-23]

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==== Etiology and Types of ''Pittaja Prameha'' ====

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=== Etiology and Types of ''Pittaja Prameha'' ===

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As described in earlier chapters, these variants also manifest due to permutations and combinations of the six qualities of ''pitta'',i.e., alkaline, sour, saline, pungent, hot and having smell like that of raw fish. [24-26]

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==== Specific Features of Types of ''Pittaja Prameha'' ====

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=== Specific Features of Types of ''Pittaja Prameha'' ===

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Thus, six varieties of ''prameha'' due to vitiation of ''pitta'' are explained. [27-35]

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==== Etio-pathogenesis of ''Vataja Prameha'' ====

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=== Etio-pathogenesis of ''Vataja Prameha'' ===

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''Ojas'' is, by nature, of sweet taste. However, its roughness causes ''vata'' to convert it into an astringent tasting element. This ''vata''-afflicted ''ojas'', when gets into the urinary bladder, causes ''madhumeha''. [36-37]

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==== Incurability of ''Vataja Prameha'' and its Other Characteristics ====

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=== Incurability of ''Vataja Prameha'' and its Other Characteristics ===

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Thus explained are the four variants of ''vataja prameha'' and twenty types of ''prameha'' (due to vitiation of the three ''doshas'').[38-46]

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==== General Prodromal Features of ''Prameha'' ====

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=== General Prodromal Features of ''Prameha'' ===

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#Excessive sleep and continuous drowsiness. [47]

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==== General Complications and Principles of Treatment ====

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=== General Complications and Principles of Treatment ===

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Of all these variants, the curable types of ''prameha'' should be treated with the appropriate elimination and alleviation therapies on time. [48-49]

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==== Consequences of ''Prameha'' ====

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=== Consequences of ''Prameha'' ===

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The individual who follows a dietary regimen or lifestyle that brings his ''doshas'' and ''dhatus'' to a state of equilibrium is said to be leading a healthy life. [50-52]

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==== Summary ====

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=== Summary ===

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Thus, ends the fourth chapter on the diagnosis of ''prameha''.

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==~~= ''~~Tattva Vimarsha~~'' /~~ Fundamental Principles ===

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== Tattva Vimarsha (Fundamental Principles) ==

#''Nidana'' (etiological factors), ''dosha'', and ''dushya'' are three major factors that cause any disease. Besides these, there are temporal influences, pre-existing conditions, genetic predispositions, as well as the presence or absence of resisting factors in the host body that decide the propensity of the affliction of a disease, including ''prameha''.

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#The quality and specific characteristics observed in urine are biomarkers in diagnosis and assessment of ''prameha''.

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==~~= ''~~Vidhi Vimarsha~~'' /~~ Applied Inferences===

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== Vidhi Vimarsha (Applied Inferences) ==

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==== The process of onset of disease ====

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=== The process of onset of disease ===

''Nidana, dosha'', and ''dushya'' are the inherent factors involved in the pathogenesis of diseases. In addition to these inherent factors, the host also has antibodies and disease resisting factors in him. If the resisting factors are weak and ''kala'', or temporal influences (seasonal variations, age), are strong enough for the inherent causes of the disease, then the disease will be severe with complications and rapid progression. If all the four factors (i.e., ''nidana, dosha, dushya,'' and ''kala'') are not strong enough then any of the following manifestations may occur:

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In this chapter, the importance of exogenous (disease causative agents/pathogens), endogenous (deranged body defense mechanism) factors and tissue response in the development of the disease is emphasized. The disease appears either when the exogenous factor (pathogen) is strong enough to overcome the defense mechanism of the body or when the tissue response to exogenous factors or adaptive responses to foreign agents is deranged.

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==== The etymology of ''prameha'' ====

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=== The etymology of ''prameha'' ===

In Sanskrit, the word ''mih'' (from which ''meha'' is derived) denotes water, to wet, and to emit semen. Regarding the above explanation, we can easily postulate that the disease ''prameha'' resulted because of an excessive excretion of something (''ati-pravrittija''). ''Prameha'' comprises of all those diseases that cause clinical abnormalities in urine due to derangement of metabolism at the level of tissues (''dhatvagnimandya'').

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==== The scope of ''prameha'' ====

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=== The scope of ''prameha'' ===

''Prameha'' is a complex syndrome encompassing obesity, metabolic syndrome, diabetes insipidus, alkaptonuria, hemoglobinuria, lipiduria, diabetes mellitus and more. At the gross level, ''prameha'' is considered an endocrinal and metabolic disorder. Classification of ''prameha'' as ''sahaja'' (hereditary) and ''apathyanimittaja'' (acquired) favors the correlation of ''madhumeha'' as diabetes mellitus. The pathological foci of the disease lie in the kidney (''vrikka'') causing the destruction of nephrons (''srotomukh pratirudhyante'').

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Considering the pathogenesis, two types of prameha patients are as given below:

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===== ''Sahaja prameha''/ ''jatah pramehi'' (hereditary) =====

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==== ''Sahaja prameha''/ ''jatah pramehi'' (hereditary) ====

In [[Ayurveda]], the words ''sahaja'' and ''jatah'' indicate genetic predisposition to the disease.

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The diet, lifestyle, and adverse psychological state of the mother during lactation (and only during the stage of pregnancy)may also play a decisive role in precipitating ''prameha'' in the infants. In addition, excessive intake of ''madhura rasa'' during childhood can contribute to the onset of ''prameha'' in children who are genetically predisposed. Thus, hereditary predisposition and unwholesome dietary and lifestyle choices, especially excessive intake of ''madhura rasa'', can play a combined role to cause hereditary ''prameha''. The description of ''sahaja prameha'' in Sushruta Samhita and ''jatah prameha'' in [[Charak Samhita]] are quite similar to that of type-I diabetes (also known as insulin- dependent diabetes mellitus or juvenile- onset diabetes). ''Jatah pramehi madhumehino'', as defined in [[Charak Samhita]], correlates with type-I diabetes beginning in early childhood.

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===== ''Apathyanimittaja prameha'' (acquired) =====

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==== ''Apathyanimittaja prameha'' (acquired) ====

The acquired form of ''prameha'' (''apathyanimittaja pramehi''), in contrast, is a lifestyle condition caused due to sedentary, or inactive living, and psychologic factors include depression and stress.

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All the twenty types of ''prameha'' should be considered as distinct disorders. For example, ''kalameha'' can be considered as an alkaptonuria-a disease of tyrosine and phenylalanine metabolism. ''Vasameha'' can be considered as ''lipiduria'' (as in nephrotic syndrome).

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===== Causative factors of ''prameha''/diabetes mellitus =====

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==== Causative factors of ''prameha''/diabetes mellitus ====

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====== Type I Diabetes ======

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==== Type I Diabetes ====

Type-I diabetes is a multi-genomic disease and heredity plays an important role in determining an individual’s predisposition to it. Secondly, type-I diabetes is an autoimmune disease in which insulin itself could trigger an attack on beta cells by white blood cells (T-cells)<ref> extracts sourced from https://www.niddk.nih.gov/-/media/05040CE3B59147FB88B1B75E5D7C1833.ashx</ref>. Finally, there are environmental factors such as foods, viruses and toxins that could trigger an early onset of the disease.<ref>extracts sourced from https://www.niddk.nih.gov/-/media/05040CE3B59147FB88B1B75E5D7C1833.ashx </ref>

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====== Type II Diabetes ======

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==== Type II Diabetes ====

Food articles that are high in saturated fats, including dairy products (especially whole-milk products like cream and full-fat yogurt), red meat and meat juice (''mamsarasa'') are known to increase the probability of contracting type II diabetes. High saturated fats lead to increase in adipose tissue secretory factors (ATSF), or resistine, that cause insulin resistance.<ref> extracts sourced from http://blog.ncpad.org/2011/07/08/10-dangerous-foods-for-diabetes/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886982/ </ref> <ref> extract sourced from http://www.joybauer.com/photo-gallery/worst-foods-for-diabetes/bacon/ </ref>

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Another important causative factor for type-II diabetes is an inactive/sedentary lifestyle. According to a World Bank report, almost 10% of all deaths reported worldwide in 2008 could be attribute to inactivity, due largely to four major diseases, including type II diabetes.<ref> The Economic Costs of Non‐Communicable Diseases in the Pacific Islands. A Rapid Stocktake of the situation in Samoa, Tonga and Vanuatu. Final Report November2012.</ref> ,

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==== Jaggery and jaggery products including sugar (''gudavaikritum'') ====

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=== Jaggery and jaggery products including sugar (''gudavaikritum'') ===

A study published in the International Journal of Diabetes in Developing Countries showed that jaggery and sugar have nearly the same glycemic values<ref> Uma P., Hariharan R.S., Ramani V. and Seshiah V. Glycaemic Indices of Different Sugars.Department of Diabetology, Madras Medical College & Govt. General Hospital, Madras.1987; 78-82. </ref>. This means that when consumed, both raise blood glucose levels by approximately equal values. The only difference is that the release of glucose from jaggery is comparatively slower than sugar as it is a complex sucrose which takes longer to break down.<ref> extract sourced from http://cosbin2001.blogspot.com/2014/12/health-benefits-of-jaggery-or-gur.html </ref>

(Note: Glycemic Index is a unit which measures the amount of glucose released into the blood by a food source. Foods which release more glucose into the blood will have a high Glycemic Index value and vice versa.)

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==== The classification of ''prameha'' ====

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=== The classification of ''prameha'' ===

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===== Classification by ''Dosha''/Stage of Progression =====

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==== Classification by ''Dosha''/Stage of Progression ====

As for all other disease systems described in Ayurvedic texts, ''prameha'' has been classified according to the predominant ''dosha'' in the disease process. [[Ayurveda]] describes three distinct categories of ''prameha'' by ''dosha'', i.e., ''kaphaja, pittaja,'' and ''vataja prameha''<ref> Shastri KN, Chaturvedi GN. Agnivesha, Charak Samhita, Vidyotini Commentary. Varanasi, India : Chaukhamba Bharti Academy, 2004. </ref> <ref> Shukla VD, Tripathi RD. Agnivesha, Charak Samhita, Vaidyamanorama Hindi Commentary. Delhi, India; Chaukhamba Sanskrit Pratisthana, 2002. </ref>. However, it is important to note here that the dominance of a ''dosha'' varies as the disease progresses. In the initial stage, ''kapha'' is in excess, which vitiates ''meda'' and ''kleda'' causing ''kaphaja prameha''.

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As mentioned earlier, ''prameha'' can be correlated with obesity, metabolic syndrome, and diabetes mellitus. The early manifestation of the disease process in these conditions is characterized by lipid, carbohydrate, and protein metabolism disturbances accompanied by glycosuria, proteinuria, etc., which can be equates with a ''kaphaja'' condition (i.e., which can be easily controlled and cured. ''Pittaja prameha'' can be correlated with the inflammatory conditions accompanied with diabetes like urinary tract infection and diabetic ketoacidosis. The advanced stage of disease, with metabolic disturbances associated with loss of immunity, correlates with type 2 diabetes that has progressed to insulin dependent diabetes, and correlates with the hereditary form of type 1 diabetes, which both correlate with ''vataja prameha''. Both of these forms are incurable as described by Charak.

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==== ''Prameha'' classified according to physique ====

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=== ''Prameha'' classified according to physique ===

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In [[Ayurveda]], much emphasis has been given to the role of ''meda'' in the pathogenesis of ''prameha''. However, its role is not only as a ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. ''Bahudrava shleshma'' (''kapha'' that contains too much liquid) joins and affects ''meda'', causing it to become ''abadha'' (unobstructed or fluid) in nature. This form of ''meda'' has been described to have an effect on ''mamsa'' (muscle tissue), thereby increasing the volume of body fluid. This has been described as ''sharira- kleda'' (body fluid). This route of pathogenesis for ''prameha'' is closely related to obesity.

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==== ''Samprapti'' (pathogenesis) of ''prameha'' ====

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=== ''Samprapti'' (pathogenesis) of ''prameha'' ===

The scientific utility of this chapter lies in the fact that in ''prameha'' the vitiated ''kapha'' first vitiates ''meda dhatu'' followed by ''mamsa'' and other ''dushya'' and then finally vitiates ''mutra'' to manifest as ''prameha''. This signifies that hyperglycemia is preceded by dyslipidiemias. One more interesting fact is that the main culprit of the disease i.e. ''kapha'' is inherently denatured, means it loses its natural properties due to hereditary defect what we know today as genetic susceptability. Furthermore, it is added that if a disease appeared due to genetic default, then it is incurable. A step ahead from the present contemporary knowledge, it is mentioned that as genetic modulation can cause disease similarly a chronic disease can cause gene modulation and vice-versa.<ref> extracts from http://www.jbsoweb.com/admin/php/uploads/215_pdf.pdf </ref>

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==== Various ''dushyas'' involved in the pathogenesis ====

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=== Various ''dushyas'' involved in the pathogenesis ===

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===== ''Medadhatu'' =====

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==== ''Medadhatu'' ====

''Meda'' vitiation is common and dominant ''dushya'' in the pathogenesis of ''madhumeha''. ''Kapha'' and ''meda'' both have close resemblance in regard to functions as well as in regard to qualitative parameters. Both get vitiated more or less by same etiological factors. In ''madhumeha'' vitiation of ''meda'' results by two ways:<ref> sourced from http://www.slideshare.net/ayurmitra/madhumeha-kc041-gdg </ref>

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Excess of fat in the body get converted into FFA and is utilized in energy metabolism especially in the muscles causing retention of glucose in the blood. Increased appetite in ''medoroga'' is due to increased body demand, which is explained to be due to hyperinsulinism or increased secretion of growth hormone. Diabetes has been compared with the fasting state of the body, ketosis is nothing else but the advanced fasting stage of the body, so the deleterious effect of long fast specially in the patient of obesity is same as in diabetic stage.

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====~~= ''Mamsadhatu'' =~~====

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==== [[Mamsa dhatu]] ====

It is one of the main ''dushyas'' (vitiating factors) described by Charak in regards to ''prameha''. He narrated it especially in ''kaphaja prameha'' and ''avaranjanya madhumeha''. ''Mamsa'' and ''Kapha'' possess similar qualities and both give strength to the body. When vitiated, ''mamsa'' loses its normal consistency and develops ''shaithilya'' and provide space in between for the accumulation of morbid matter. That in turn results in ''putimamsa pidika'' (Ca.Ni. 4/8). ''Mamsa dushti'' can be compared to deranged protein metabolism which is an integral part of diabetes mellitus. Research studies have found that glucocorticoid activities and acidosis stimulates protein and amino acid catabolism <ref> May, RC et al. 1996. Glucocorticoids and acidosis stimulate protein and amino acid catabolism in vivo. Kidney Int. 1996 Mar;49(3):679-83. </ref>. Amino acids breakdown in liver results in increased production of urea<ref> Vaudevan et al. 2011. Textbook of biochemistry for medical students, Sixth Edition, JP Medical Publishers </ref> and these free amino acids can be compared with ''abaddha mamsa''. ''Putimamsa'' and ''pidaka'' are the morbid states of ''mamsa dhatu''. Two major changes take place in ''mamsa dhatu'' - protein degradation and reduction in its blood supply, both of which along with elevated blood sugar level form a favorable media for the growth and multiplication of microorganisms. The results are putrefaction and evolution of multiple septic foci in ''mamsa dhatu''. Diminished protein synthesis hampers the healing process and these complications adopt chronic course.

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===== ''~~Majjadhatu~~'' =====

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==== ''Majja dhatu'' ====

''Majja dhatu'' is not vitiated to maximum extent but ''vata'' causes its ''kshaya'' i.e. depletion. Thus vitiated ''majja'' produces symptoms like ''netragaurava'' (heaviness in eyes), ''angagaurava''(heaviness in body) in patient of ''madhumeha''. The ketone bodies production due to excessive utilization of fat may be referred to ''dushti'' of ''vasa'' and ''majja''. ''Murchcha'' (temporary loss of consciousness) occurs due to dushti of ''majja'' in diabetes mellitus. The condition of hyperglycemic coma is characterized by the accumulation of ketone bodies.

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===== ''Shukra'' =====

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==== ''Shukra'' ====

''Shukra'' also get vitiated in the pathogenesis and produces symptoms like ''daurbalya'' (fatigue) and ''krichavyavayata'' (difficulty in sexual intercourse), because normal functions of ''shukra'' is to maintain ''dehabala''. It also plays role in the precipitation of ''sahaja'' (genetic) ''prameha''. Sexual impotency and testicular hypofuctions have been reported in diabetes mellitus.

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===== ''Ojas'' =====

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==== ''Ojas'' ====

''Ojas'' as ''dushya'' is mainly involved in ''vataja prameha'' i.e. ''ojomeha'' (''madhumeha''). The symptoms of ''ojakshaya'' manifests, like ''gurugatrata'' (heaviness in body), ''nidra'' (sleepiness), ''tandra'' (drowsiness) and ''daurbalya'' (fatigue) can be correlated with immunocompromised stage in diabetes mellitus due to deranged immunity.

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===== ''Kleda'' =====

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==== ''Kleda'' ====

This is one of the body components mainly involved in the pathogenesis. The literary meanings of ''kleda'' are wetness, moisture and dumpness etc. The physiology of ''kleda'' is mainly related with ''mutra'' and ''sweda'' along with ''meda''. Thus, when ''kleda'' is involved then it directly affects the above factors. In normal physiology ''mutra'' and ''sweda'' maintain the balance of ''kleda''. Especially ''sweda'' holds it in the body and ''mutra'' gets excreted out of the body according to the body condition and requirement. If ''kleda'' gets vitiated it directly affects the physiology of ''mutra'' and ''sweda'' and disrupts the assemblage of bodily elements causing ''shaithilya''. Thus, the symptoms manifest due to ''kleda'' vitiation are ''prabhutamutrata'' (polyuria), ''swedavrddhi'' (increased sweating), ''shaithilya'' (weakness), ''daurgandhya'' (bad smell) and ''avilamutrata'' (polyuria).

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The glycosuria raises the ''osmolar'' concentration of the urine and osmotic diuresis resulting in water and sodium loss along with potassium leads to generalized weakness in the patient of diabetes mellitus. The level of catecholamines is increased in DM causes excessive sweating that further leads to loss of electrolytes such as sodium and chlorides through the skin. The whole phenomenon described under ''kleda'' can be correlated with water and electrolyte imbalance.

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===== ''Vasa'' =====

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==== ''Vasa'' ====

Charak described it as a subtype of ''vatajaprameha'' i.e. ''vasameha''. ''Vasa'' is the ''upadhatu'' (minor tissue or sub-tissue) of ''mamsa'' and the unctuousness present in the ''mamsa dhatu'' is called ''vasa''.

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===== ''Lasika'' =====

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==== ''Lasika'' ====

This is one of the liquid component present just beneath the skin. ''Lasika'' also get vitiated by ''vata'' resulting ''lasikameha''. There is no direct reference related to ''vasa'' and ''lasika dushti''.

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===== Exclusion of ''asthi'' as a ''dushya'' =====

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==== Exclusion of ''asthi'' as a ''dushya'' ====

Among the ten ''dushyas'' of ''prameha, asthi'' (bone) is not included. According to modern physiology, bone is a tissue that undergoes frequent remodeling and has a large capacity for regeneration. In the adult remodeling occurs so that the skeleton is replaced approximately every 10–11 yr. This physiological remodeling is initiated by osteoclasts that re-absorb bone and is followed by the formation of an equivalent amount of new bone by osteoblasts,<ref> Parfitt A. 1982 The coupling of bone formation to bone resorption: a critical analysis of the concept and of its relevance to the pathogenesis of osteoporosis. Metab Bone Dis Relat Res 4:1–6. </ref> <ref> Mundy G 1989 Local factors in bone remodeling. Rec Prog Horm Res 45:507–531. </ref> bone loss is noted when the amount of bone resorption exceeds the amount of new bone formation.

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Diabetes has also been associated with a net loss of bone. A number of studies have reported that type 1 diabetes alters bone remodeling by reducing the formation of new bone, leading to osteopenia. This has been shown by a decrease in bone mineral density in humans and alterations in the formation of new bone in animal studies<ref> Hayward M, Fiedler-Nagy C 1987 Mechanisms of bone loss: rheumatoid arthritis, periodontal disease and osteoporosis. 22:251–254. </ref> <ref> Tuominen J, Impivaara O, Puukka P, Ronnenmaa T 1999 Bone mineral density in patients with type 1 and type 2 diabetes. Diabetes Care 22:1196–1200. </ref> <ref> Krakauer J, McKenna M, Burderer N, Rao D, Whitehouse F, Parfitt A 1995 Bone loss and bone turnover in diabetes. Diabetes 44:775–782. </ref> <ref> Macey L, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME 1989 Defects of early fracture-healing in experimental diabetes. J Bone Joint Surg Am 71:722–733. </ref>. In contrast, the presence of bone loss in type 2 diabetes is less clear, and current understanding suggests that this form of diabetes is not typically associated with osteopenia<ref> Gebauer G, Lin S, Beam H, Vieira P, Parsons J 2002 Low-intensity pulsed ultrasound increases the fracture callus strength in diabetic BB Wistar rats but does not affect cellular proliferation. J Orthop Res 20:587–592. </ref> <ref> Barrett-Conner E, Holbrook T 1992 Sex differences in osteoporosis in older adults with non-insulin-dependent diabetes mellitus. JAMA 268:3333–3337. </ref> <ref> Loe H 1993 Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 16:329–334. </ref> <ref> Nelson R, Shlossman M, Budding L, Pettitt DJ, Saad MF, Genco RJ, Knowler WC1990 Periodontal disease and NIDDM in Pima Indians. Diabetes Care 13:836–840. </ref>. The reasons for the lower bone mineral density in type 1 diabetes are not known.

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==== ''Vataja prameha'' as type 1 diabetes mellitus ====

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=== ''Vataja prameha'' as type 1 diabetes mellitus ===

The pathogenesis of ''vataja prameha'' is similar to that of type-1 diabetes mellitus. ''Vata'' is agitated due to various precipitating causes acts on the body in such a way that there is passage of ''vasa'' (fat), ''majja'' (bone marrow), ''lasika'' (lymph), and ''ojas'' (essence of the body /immune substances / vitality) through the urine. This condition indicates impaired renal function as a result of diabetes, leading to a dire prognosis. Due to ''dhatukshaya'' (loss of body tissues) the patient become very weak and emaciated.

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''Hastimeha'' can be correlated with polyuria in diabetic ketoacidosis due to osmotic dieresis and electrolyte imbalance. Insidious increased thirst (i.e. polydipsia) and urination (i.e. polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA).<ref> https://www.coursehero.com/file/pd3u7l/Ketones-include-acetone-beta-hydroxybutyrate-and-acetoacetate-Progressive-rise accessed on 12 June 2017 </ref>

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====''Poorvarupa'' (prodromal symptoms) of ''prameha'' ====

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===''Poorvarupa'' (prodromal symptoms) of ''prameha'' ===

For ''prameha'', these symptoms include excessive sweat, body odor, laziness, inclination towards rest, presence of excessive ''malas'' (waste products) in the eyes, ears, teeth, throat, palate, and tongue (buccal cavity), excessive growth of hair and nails, matting of the hair, excessive thirst, a sweet taste in the mouth, a burning sensation in the hand and feet, attraction of insect and ants toward the body and urine, and so on. Diabetes has close relationship to conditions within the oral cavity. It leads to adverse changes in gums and periodontal tissues: effects that may be evident even before clinical diabetes is recognized and diagnosed.<ref> https://www.coursehero.com/file/pd3u7l/Ketones-include-acetone-beta-hydroxybutyrate-and-acetoacetate-Progressive-rise accessed on 12 June 2017 </ref> Periodontal diseases are associated with higher levels of insulin resistance and are often a precursor of type 2 diabetes as well as with the higher levels of glycated hemoglobin<ref> Hampton T. Studies probe oral health diabetes link. JAMA 2008; 300:2471-2473. </ref>. These findings may relate to the prodromal symptoms of excessive excretion of ''malas'' in the buccal cavity. A sweet taste in the mouth is a prodromal symptom that may be explained by the presence of glucose of saliva. If blood glucose levels are high, glucose is also present in the saliva, which can increase cavities and increase the risk of oral candidiasis.

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The role of ''meda'' (fat/adipose tissues) is of great importance in the pathogenesis of ''prameha''. Its role is not as ''dushya'' (disturbed functioning of the ''dhatus''), but something more than that. According to [[Charak Samhita]], ''bahudrava shleshma'' (kapha that contains too much liquid) joins and affects ''meda'', causing it to become ''abaddha'' (unobstructed or fluid) in [[Ayurveda]]. This has been described as ''sharira-kleda'' (body of fluid) in [[Ayurveda]]. Thus, excess water in the blood causes increased diuresis. It is very important to elaborate the term ''bahudrava shlesma''. ''Shleshma/ kapha'' is one among the three basic humors regulating all physiological and psychological process in the living organism. At its normal state, it causes binding of body tissues i.e. maintain the tissues integrity, represent the normal cell mediated immunity etc. ''Bahudrava'' means that ''kapha'' loses its natural properties and get vitiated, it is important to mention here that this derangement may be acquired or congenital, Whatever may be the cause this vitiated ''kapha'', it is unable to perform its normal functions. Describing the physical properties of ''kapha'' it is mentioned that it is unctuous in touch and looks like ''ghrita'' (ghee). Thus, it can be said that ''kapha'' in body represents lipid components of the body and vitiated ''kapha'' can be correlated with dyslipidemia. Role of dyslipidemia and metabolic abnormalities in the pathogenesis of diabetes is very obvious and well elaborated in modern medicine. Among the metabolic abnormalities that commonly accompany diabetes are disturbances in the production and clearance of plasma lipoproteins. Moreover, development of dyslipidemia may be a harbinger of future diabetes. A characteristic pattern, termed diabetic dyslipidemia, consists of low high density lipoprotein (HDL), increased triglycerides, and postprandial lipemia. This pattern is most frequently seen in type 2 diabetes and may be a treatable risk factor for subsequent cardiovascular disease.<ref> http://press.endocrine.org/doi/10.1210/jcem.86.3.7304 accessed on 12 June 2017 </ref>

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==== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001. 86 (3): 965-971. </ref>====

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=== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001. 86 (3): 965-971. </ref>===

Defects in insulin action and hyperglycemia could lead to changes in plasma lipoproteins in patients with diabetes. Alternatively, especially in the case of type 2 diabetes, the obesity/insulin-resistant metabolic disarray that is at the root of this form of diabetes could, itself, lead to lipid abnormalities exclusive of hyperglycemia.

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The lipoprotein abnormalities commonly present in type 2 diabetes, previously termed noninsulin-dependent diabetes mellitus, include hypertriglyceridemia and reduced plasma HDL cholesterol. In addition, low density lipoprotein (LDL) are converted to smaller, perhaps more atherogenic, lipoproteins termed small dense LDL. In contrast to type 1 diabetes, this phenotype is not usually fully corrected with glycemic control. Moreover, this dyslipidemia often is found in prediabetics, patients with insulin resistance but normal indexes of plasma glucose. Therefore, abnormalities in insulin action and not hyperglycemia per se are associated with this lipid abnormality. Several factors are likely to be responsible for diabetic dyslipidemia: insulin effects on liver apoprotein production, regulation of lipoprotein lipase (LpL), actions of cholesteryl ester transfer protein (CETP), and peripheral actions of insulin on adipose and muscle.

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==== Different colors of Urine ====

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=== Different colors of Urine ===

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===== White =====

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==== White ====

*Phosphaturia is usually intermittent, occurring following a meal or after ingesting a large quantity of milk.<ref> http://doctor.ndtv.com/faq/ndtv/fid/8091/What_is_the_cause_for_white_cloudy_urine.html accessed on 12 June 2016 </ref>

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*White cloudy urine can rarely be due to chyluria (lymph fluid), resulting from a communication with between the lymphatic system and the urinary tract.<ref> http://ehealthforum.com/health/topic35228.html accessed on 12 June 2016 </ref>

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===== Red / Pink =====

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==== Red / Pink ====

*The presence of red cells, free hemoglobin (from broken down red blood cells), or myoglobin (from broken down muscle cells)

*Hemoglobinuria - urinary tract infection, urinary stone, or urinary malignancy.

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===== Blue / Green =====

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==== Blue / Green ====

*An inherited form of high calcium (called "familial hypercalcemia") can result in blue urine, which has lent this disease the nickname "blue diaper syndrome". Another metabolic disorder, indicanuria, can cause blue urine due to tryptophan indole metabolites.<ref> http://www.freerepublic.com/focus/f-chat/1424388/replies?c=1 accessed on 12 June 2016 </ref>

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===== Brown /Black =====

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==== Brown /Black ====

*Melanin and melanogen, found in the urine of patients with melanoma, will darken standing urine from the air-exposed surface downward.<ref>https://answers.yahoo.com/question/index?qid=20100106090425AACh3og accessed on 12 June 2016 </ref>

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*In porphyria cutanea tarda, the urine will appear reddish brown in natural light but fluoresces pink under ultraviolet light.

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==== Prognosis ====

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=== Prognosis ===

On the basis of prognosis, patients of ''prameha'' have been classified into three groups: ''Sadhya'' (curable), ''Yapya'' (controllable), and ''Asadhya'' (difficult to manage).

</div>

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===== Features of ''Prameha'' Classified on the Basis of Prognosis =====

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==== Features of ''Prameha'' Classified on the Basis of Prognosis ====

{| class="wikitable"

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|}

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==== Future Scope for Research ====

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=== Future Scope for Research ===

#Assessment criteria for the classification of various types of Prameha based on both physical as well as laboratory parameters.

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#Retroprospective clinical study to establish the fact that dyslipidemia is the cause of diabetes and not the consequence of diabetes.

</div>

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~~=== Glossary ===~~

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~~#विकाराभिनिर्वृत्तिः vikArAbhinirvRuttiH- Appearance of disease~~

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~~#चिराद्वाऽप्यभिनिर्वर्तन्ते,cirAdvA~apyabhinirvartante- delayed appearance of disease or increased incubation period~~

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~~#तनवोवा tanavovA – disease manifested with minor symptoms~~

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~~#मृजाव्यायामवर्जनं mRujAvyAyAmavarjanaM- Lack of Exercise & Sedentary Life style~~

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~~#बहुद्रवःश्लेष्मा Bahudrava shleShmA- dyslipidemia~~

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~~#बह्वबद्धंमेदो- Bahvabaddham medo- Excessive Free Fatty Acids~~

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~~#प्रागतिभूयस्त्वात्; prAgatibhUyastvAt- Excessive in amount~~

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~~#शरीरशैथिल्यात्; sharIrashaithilyAt- obesity, immobilization due to excessive fat.~~

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~~#प्रकृतिविकृतिभूतत्वात् prakRutivikRutibhUtatvAt- derangement in the natural characteristic.~~

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~~#वङ्क्षणबस्तिप्रभवाणांva~gkShaNabastiprabhavANAM- ureter, originating from kidey pass via inguinal region.~~

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~~#अच्छं acchaM- clear~~

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~~#माधुर्यमास्यस्य mAdhuryamAsyasya- Sweet taste of mouth~~

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~~#करपादयोःसुप्ततादाहौ karapAdayoH suptatAdAhau- Peripheral neuritis~~

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#abhīkṣṇamअभीम- Recurrent,Frequent, Multiple. The term signifies an act that is happening repeatedly, frequent and in more amounts generally refers to repeated bouts of illness or feature of disease. Recurrence of the bout is due to the léna doña present in the body channels. These léna doña wait for a potencification and after which they result in bout of the illness.

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#āvilaḥ आिवलःTurbid, dense,hazy, concentrated. The literal meaning of the term is to be not clear or polluted, creating the increased density or concentration of fluid. According to its different prefix or suffix it signifies antithetical meaning.

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~~#āvila mūtram आिवलमूम - Turbid urine Turbid or unclear urination, mostly found in urinary disorder.~~

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~~#Mukhamädhuryam- Sweetness in mouth. A form of Dysgeusia characterized by sweetness in mouth.~~

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~~#Pipélikädhävanammütreñü- Passage of sweet urine. A symptom in diabetes mellitus where the ants get attracted towards the urine, signifying the presence of sweetness in the urine.~~

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~~#Pipélikänäàsaïcära iva sparçaù- Formication A form of paraesthesia or tactile hallucination; a sensation as if ants are creeping under the skin.~~

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~~#Piñöanibhaà mütram- Thick and highly concentrated urine. Urine resembling flour.~~

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~~#Prameha- Diabetes The disease characterized by symptoms of frequent excessive and turbid urination.~~

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~~#Alälämeha - A stage in diabetes mellitus wherein the person passes turbid and viscous type of urine.~~

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~~#Ikñumeha- A stage in diabetes mellitus wherein the patient passes urine that is very sweet in taste;,~~

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~~#Udakameha- A stage of diabetes mellitus characterized by water like consistency and appearance.~~

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~~#Kälameha- A stage of diabetes mellitus wherein the urine turns blackish in color.~~

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~~#Kñärameha- A stage of diabetes mellitus wherein the urine resembles like water mixed with alkali.~~

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~~#Nélameha- A stage of diabetes mellitus wherein the person passes bluish colored urine.~~

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~~#Piñöameha- A stage of diabetes mellitus wherein the individual passes excessive urine that is white in color and along with horrippulation.~~

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~~#Majjä meha- A stage of diabetes mellitus wherein the urine resembles the consistency of bone marrow.~~

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~~#Madhumeha- Diabetes mellitus. A stage of diabetes mellitus wherein the urine and blood gets sweetened like honey.~~

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~~#Maïjiñöhä meha- A stage of diabetes mellitus characterized by reddish colored urine (Rubia cordifolia i.e. maïjiñöhä, a Indian plant.).~~

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~~#Lasikä meha- A stage of diabetes mellitus wherein the urine resembles like that of serous fluid.~~

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~~#Vasä meha- A stage of diabetes mellitus characterized by fatty appearance of urine (color resembling fat attached with muscles).~~

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~~#Çanairmeha- A stage of diabetes mellitus wherein the person has increased frequency with reduced flow of urine~~

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~~#Çétameha- A stage of diabetes mellitus wherein person passes cold and sweet urine in excessive quantity.~~

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~~#Çukrameha- A stage of diabetes mellitus wherein the person pasess excessive urine along with semen.~~

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~~#Sändrameha- A stage of diabetes mellitus whereinthe urine solidifies when kept overnight.~~

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~~#Sändraprasädameha- A stage of diabetes mellitus wherein the urine solidifies on keeping aside overnight.~~

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~~#Surä meha- A stage of diabetes mellitus wherein the urine has layers with solid precipitations at bottom and a clear liquid upper part resembling a kind of alcohol.~~

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~~#Sikatämeha- A stage of diabetes mellitus wherein person passes urine mixed with sand like substances.~~

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~~#Lohitä meha- A stage of diabetes mellitus wherein the urine has salty taste and is reddish in color~~

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~~#Haridrä meha- A stage of diabetes mellitus wherein characterized by yellowish colored urine (Curcuma longa Turmeric, i.e.Haridra, a Indian tuber.).~~

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~~#Hasti meha- A stage of diabetes mellitus wherein patient passes excessive urine with heavy flow.~~

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~~#Kåçapramehi- Diabetes associated with emaciation.~~

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~~#Sahajapramehi- Congenital, hereditary diabetes mellitus. The term signifies diabetes mellitus due to hereditary or congenital causes.~~

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~~#Lasikävatmütram- Urine resembling lymph The term signifies urination resembling lymph in characteristics.~~

=== Related Chapters ===

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* [[Prameha Chikitsa]]

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*[[Prameha Chikitsa]]

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* [[Kiyanta Shiraseeya Adhyaya]]

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===References===

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==References==

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