Hypercholesterolemia - a sign of imminent Rakthapitha
Dr.P.K.V.Anand
Vaidyaratnam Ayurveda College
A physician’s job is made tougher as common man has become much apprehensive about the health problems related to cholesterol. It is not difficult to avoid medicines that might increase in cholesterol levels in blood. But when the condition of illness demands intervention with an unctuous medicine, it is not easy to keep aside the fear of both physician and patient about the increase of cholesterol. The patient becomes ready to take an oily medicine, when he ignores the warnings projected by the media or by his belief in the physician. Still the patient will be in search of suitable reasons like a second opinion or a lab report to stop this medication by the horror and uncertainty associated with it. However, the cholesterol awareness has placed a major treatment methodology of Ayurveda, the snehana under skepticism, which pushes the system further away from the mainstream. Since the cholesterol is a lipid derivative, even Vaidyas prefer to relate it with medodhathu. Thus the treatment also gets focused on reducing medas. Hence a close look of events which makes cholesterol a matter of discussion is necessary.
Usage of a scientifically proven fact in Ayurveda
When we search for the reasons that make cholesterol a terrorizing object, we find that hypercholesterolemia is not a disease by itself but a pointer to the risk of heart attack, stroke etc. Such risk is estimated based on statistical probability. Here, the results obtained through a standard research protocol, performed under, controlled defined conditions is applied to uncontrolled heterogeneous population. In addition to this, the increased prevalence of heart diseases, in a hypercholesterolemia population of the society has shown sufficient cause and effect relationship between them mathematically. All such demonstrations are a component of accepted means of acquiring knowledge applicable to Ayurveda, being in the form of Prathijna, Hethu, Udaharana, Upanaya, Nigamana, hence could easily be accepted as reliable information for Ayurvedic community.
There exists a big difference that lies in the practical application of this information for treatments. When we enlist among the factors that precipitate heart attack etc., a problem is made in prioritizing the treatments and approaches. The interrelation hypercholesterolemia with other causes, the potential of hypercholesterolemia as the dominant factor that precipitate CVA, is it just an inactive partner who also acts as an indicator of risk, or is it an affected object which gets displaced during the pathogenic activities of disease, etc. are some questions that each physician ought to find answers. Only such deliberations will prevent us from getting misdirected into cholesterol, which is the integral constituent of cells and tissues. Instead we should focus on the event atherosclerosis, which is the immediate causative (Sannikrishta hetu) factor for the above diseases.
The occurrence of hypercholesterolemia
Increase of blood cholesterol by the dietary use of fats should not to be seen like the increase of water in the house hold well or pond when the nearby river is flooding. The rise of cholesterol in the blood pool need not be in direct proportion to the quantity of fat available through alimentary tract. The dietary fat does not turn as such into body fat or cholesterol. They are absorbed by the intestinal villi from intestines, after adhering themselves to the miscells they make in combination with bile salts, without getting digestion. In the intestinal wall they are broken down into chylomicrones, and reach the common pool called blood. The fats from adipose tissue, liver or from other tissues or broken cells are also pooling into the same blood. So it is just a matter of common sense to assume that if there have been no recent changes in dietary fat consumption, the increased fat contents of blood stream is due to pooling of fat is only from the internal sources. The dietary fat has no role in such an increase, as evidenced from the studies on influence of snehapana in the lipid profile[i]. During snehapana, despite the large quantity of fat taken in the fluctuations and atherogenic risks in the lipid profile is not proportionate to the quantity of fat intake.
The fact that cell walls are made up of Cholesterol, makes it the fundamental structural component of body. Interestingly, such pooling of structural constituents from tissues and organs to blood is explained by Chakrapani, in the context of Rakthapitha[ii]. He says that in Rakthapitha, Dhathus like Mamsa etc, gets sweating and dissolution by the heat of pittha, and becomes in a fluid state, to mix with blood. The increase of Cholesterol in blood shows us that the structures made of cholesterol in each cell undergoes this dissolution and flows into blood. The source of heat that vitiates pittha and Rakta could be from the diets that generate vidaha, mental and physical stress, etc. The sustained presence of such heat within physiological limits, puts the body in a state similar to Jwara. The heat of jwara generates Rakthapitha (Jwarasanthapath Rakthapithamudeeryathe). This heat, even if it is not generated by jwara could act in the same way, and lead to Rakthapitha. The Rakthapithaprakopa due to Vidahidravyas and mental stress leads to injuries in the vessal walls, dissolution of Kapha, atherosclerosis and increase of cholesterol in blood. Sandra, snigdha & dravagunas are increased in blood here. It will be interesting to find that the Agryoushadha for Vrana, i.e., Guggulu, is the most accepted anti-hypercholesterolemic drug. This shows that there exists a condition in the body similar to that of a Vrana, which can reminds us about the vascular injury prior to atherogenic activity.
Atherosclerosis develops as healing attempt either failed or partial, in response to micro injuries in the lumen of vessels. During such incomplete healing process, the cholesterol molecules of blood stream, gets adhered in those partially healed sites to grow like salt crystals, to make obstruction in the arteries. As the density of cholesterol lowers, the molecule increases in size. When low density cholesterol increase in quantity and molecular size, and the heart vessels having a lower speed and pressure, makes the deposition, obstruction and atherosclerosis to grow faster. Atherosclerosis in vessels of an important marma like Heart makes it instantaneously fatal. The first event denoting sthanasamsrayam might be the injury on the vessel wall with micro blood spills, on vessels that are already brittle and soft by hypertension, free radical activity, Vidaha or any other such causes. The granulation as a part of the healing of those wound, being abnormal and incomplete, makes the soft mass of wound into a dry, tough and hard mass. This is the abstract of events that becomes atherosclerosis. The entrapment and accretion of cholesterol in this wound mass makes cholesterol, the object of discussion in the context.
Role of cholesterol in the pathogenesis
All such diseases and micro vascular damages are also seen for those who are not having hypercholesterolemia. So very often it appears to be a Nimithakarana, like the separation & fall of an already ripe fruit, caused by insignificant movements caused by breeze or a bird. Actually the proven causative relation between the cholesterol and heart attacks are much stronger. If the role of each of the factors is analyzed, the cholesterol molecules can be considered as substance that gets pulled into the pathogenesis, and Atherosclerosis as that induce (Vyanjaka) the pathogenesis. Hence the cholesterol does not have a role in the atherosclerotic activity, but holds a substantial role in the development of obstruction. The presence of cholesterol in the atherosclerotic scars at the injury sites makes the obstruction. Thus the co-existence of both events has put cholesterol also as an offender, and that has a potential to influence the mathematical findings. The police and crowd are found in a crime scene always, but they are corrective factors and nobody accuse them as causative factors in the event. Similarly the mere passive presence of cholesterol molecules in the atherosclerotic plaques has made it a culprit. There is no information on the purpose involvement of cholesterol in the development of such plaques. It appears that Cholesterol molecules, by its mere availability at the site of injury and entrapment in the plaques, have been accused of acting viciously. By such a change of focus, the actual culprit gets out of focus and the treatment gets misdirected.
Vidaha leading to Raktha and pitha vridhi, the ulcer like status formed in the vessel walls due to micro vascular injuries, its partial healing, the cholesterol entrapment in those sites, hypertension due to various causes, etc creats a favorable platform for rakthapitha to be manifested in a grosser plane. When instrumental causes (Nimitha karana) of Rakthapitha act bleeding starts. If it is near an outlet and blood is seen outside we diagnose it as Rakthapitha. When the bleeding site is not anywhere near the nine outlets, we does not diagnose it as raktapitha, but something else. For example a middle cerebral artery bleeding, which leads to Pakshaghatha is never diagnosed as Rakthapitha, only by the reason that blood is not found by naked eyes. Actually diagnosis should be independent of such subjective variations. The advancement of science has helped us to cross the limits of our sense organs, and we are able to identify a bleed through MRI or CT scans. Bleeding, whether near to or far from an outlet, is to be considered as Rakthapitha, based on the location of bleed, the consequences appear, as in the case of Pakshaghatha or Hridroga.
Coagulated blood (Gradhitha) is a variant condition happening in Rakthapitha. Text has mentioned medicines like the fecal matter of dove are indicated in situations if its sthanasamsraya is in throat. If such coagulated blood or thrombus gets into the heart vessels, or brain vessels it makes heart attack or stroke without making a bleed. Such micro vascular events and their sequels like Pakshaghatha and hridroga are said to be the complications due to the presence of hypercholesterolomia. The accrual of doshas identified by hypercholesterolemia points to the poorvaroopa status of Rakthapitha. The prodromes of Rakthapitha mentioned in the texts are not unique for the disease which makes it clinically impossible to predict the imminent bleeding. Practically no diagnosis of Rakthapitha is made untill there is an evidence of bleed or clot.
Upasayas prove that hypercholesterolemia is related to a stage of Rakthapitha than Medoroga. E.T.Narayanan Mooss, Chief physician of Vaidyaratnam Nursing Home, selects Amruthashadanga yoga for hypercholesterolemics, especially hypertriglyceredimics. It is found to be very effective in reducing both. This yoga mentioned in Chikitsamanjari, is almost the same with the Shadangapana mentioned in Rakthapitha, where Sundi is avoided. Here the space of Sundi is replaced by Amrutha. The commonly it is prepared as per Thoyapakavidhi and used, which is a method of administration detailed in Jwarachikitsa. When we run away from dietary or medicinal fats in the fear of cholesterol for long term, we are prone to develop dementia and other Medhakshaya diseases, says Dr.M.R.V.Namboodiry, DAME, Kerala state. There are a lot of people who approach Ayurveda physicians with half cooked information, skepticism and prejudice. We will be able to ensure the effect of treatments only when we make them also Bhishagvasya.
The risk of hypercholesterolemia by snehapanam
We might not be able to reach a unified opinion on the matters related to blood lipid levels. Since the blood pool holds floating levels of lipids at any given moment, it appears that the lipid level assesments are so uncertain and are like counting the population of crows in a city. Some popular physiology texts puts the daily requirement of dietary fat at 15gms/day. Everyday food that holds 3000Kcal/day is estimated to have 15.25gms of fat in it. In diseases like nephritis or chronic renal failure, 15 to 40 gms of fat can be added to every day diet. In heart diseases and atherosclerotic conditions, the food should be rich in essential fatty acids but the overall fat content should not exceed 30gms/day. In diabetes the daily intake of fat should be limited to 20 gms. This shows that even the modern scientists are not favoring an absolute avoidance of fat in diseases. The flooding information and the panic about cholesterol compel the patients to hesitate the intake of 10 drops of Ksheerabala oil or a teaspoon of ghee as a medicine. As an alternative they could have reduced these 10 drops of fat or a teaspoon of fat from their daily diet rather than from the medications. Unfortunately, the Ayurveda physician, who depends on the belief of the patients a lot, becomes hesitant to prescribe fats even when there is hypertension.
Those who are under pathya diet during treatment, the fatty and heavy food stuffs are controlled but not avoided completely. Having a fat free diet for those who are habituated with sneha is both asatmya and anupasaya for them. Moreover, as per the Pathya instructed, it is essential to use a minimum quantity of fat in the diet during snehapana, swedana and throughout panchakarma. Thus, without avoiding the dietary fats, during snehapana, the patient consumes 40gms to 400gms of fat every day, yet no significant increase of neutral fats or cholesterol is found at the end of it. Despite the use of ghee in this high quantity every day, in the use of many medicated ghee preparations for snehapana, the average tryglyceride levels and cholesterol levels at the end of snehapana, are lesser than the original level. Even if we find an increase of cholesterol levels after snehapana, as in the case of Indukanthaghritha, it becomes normal after 3-4 weeks after the sodhana treatment. Such evidences show us that fat from the dietory source is not always the cause for hypercholesterolemea. The Triglycerides, the terror of heart patients, is lowered immediately after snehapanam. The LDL levels are also showing a sustained and uniform decline. Even in those with mild increase, as happening in the snehapana with Indukanthaghritham, there is a proportionate increase of HDL levels which holds the atherogenic index in a safer level. The changes in lipid levels happening due to snehapana, are not persistant as shown by a repeat test after three weeks.
Conclusion
Cholesterol, an essential structural component is also the precursor for hormones which regulate metabolic activities. Ironically, the deficiency of such an important fundamental constituent of this high importance, is not reported or discussed much, is not said to cause any fatal illness, but will make only minor symptoms like hair fall, fatigue etc. Mental stress, Vidahi foods and ignoring cooling or the body with a liberal bath, or absence of purificatory therapy at regular intervels, leads to persistance of heat in the body, which makes almost the same effects of heat as in Jwara. The hypercholesterolemia should be seen as Poorvaroopa of Rakthapitha and treated accordingly. Administration of Snehadravyas in such conditions should follow the guidelines of snehana in Jwara and Rakthapitha. Focusing on absolute avoidance of dietory or medicated fats will not yeild results neither in reducing cholesterol level nor in preventing its complications.
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