Prevalence of prodromal symptoms of diabetes

Prevalance of Poorvaroopas in Prameha - 

Objective

  To estimate the point prevalence of prodromal symptoms of diabetes which persists long after the diagnosis, as well as the kind of Dosha dushti, in relation to these persisting poorvaroopas.

Design

  A cross sectional survey, for the presence of poorvaroopas, attending the diabetic op of vaidyaratnam research centre and charitable hospital.  The questionnaire administered to ascertain the presence of prodromal symptoms listed in the classics along with its degree of severity as understood and recorded by a  Ayurvedic physician. 

Background

The diagnosis of DM is based on blood sugar levels in the English medicine.  In Ayurveda the diagnosis of a manifested case is based on the excessive quantity and turbidity of urine.  The differentiation of prameha to 20 different categories is primarily by the nature of alteration in quality and quantity of urine.  Many of the changes in urine are not identifiable in a laboratory set up and also not practically looked for in  clinical practice.  This makes it difficult in understanding, categorizing and assessing the Dosha dushti of prameha roga in the present era.  The prodromal symptoms of prameharoga can be used as and effective tool to estimate the dosha dushti.  With reference to Prameha roga, poorvaroopas are important diagnostic tool and in some contexts, the tool for differential diagnosis.  The presence of pramehapoorvaroopa is the differentiating factor from adhogarakthapitha in manjishtameha or rakthameha.  To find out the association of any disease with medovahisrothas, the Prameha poorvaroopas are also instrumental.  Poorvaroopas are defined as vague manifestations of the disease. When the same turns vivid, they are named as symptoms.  Thus poorvaroopas, which continues to exist after the diagnosis of prameha, should be considered as the symptoms of prameha.  These clinical manifestations are one set of effective pointers to assess the Dosha dushti in in prameha roga.  Poorvaroopas pointing towards dosha dominance are named as visishtapoorvaroopas.  When they continue to exist after the manifestation to the disease, they are useful in understanding fractions of vikalpa samprapthi.

The presence of glucose, which is responsible for the sweetness of the urine, is explained in Ashtanga sangraha as a poorvaroopa for all pramehas, indiscriminate of Dosha domination or special types such as ikshumeha, madhumeha, etc.  This is substantiated by the poorvaroopas list of Ashtanga Hridaya, which says the sweetness of urine is to be inferred when it attracts ants.  This makes it hard to differentiate the appearance of roopas by  the simple criteria like presence of sugar in the urine.

Subjects: 

The setting for the study was the special diabetic O.P. for the clinical trial of the new ant diabetic drug mehanil of vaidyaratnam oushadhasala functioning at vaidyaratnam research center and charitable hospital during 2002 February to 2002 June.  The  patients participated, were from age  19 to 64, majority of them from age group 40 to 50, followed immediately by the group 50 to 60.  Among the participants 23% were males. Duration of illness since diagnosis among the participants were one week 2 %, 6 months 7%, one year 17%, less than two years 33%, more than two years 41% etc.,   Out of the 82 cases participated 38% were using oral hypoglycemic agents / insulin and the rest were attempting only simple house hold Ayurvedic remedies or diet & activity control measures.  57% of them had blood sugar with in normal limits while the rest were mild to moderate hyper glycemics at the time of recording the data. 

Methods

After explaining the purpose and obtaining the consent all the cases were subjected to fasting and postprandial blood sugar blood tests, prior to recording.  A case sheet Performa designed to record the presence, frequency and intensity of the poorvaroopas was used.  Each of the subjects was interviewed in single sitting separately by junior Ayurvedic physicians.  The nature and meaning of each symptom were explained to the patient in Malayalam and the response as they understood it was recorded. The questionnaire included all the poorvaroopas of prameha listed in the bruhathrayees.  The Dosha vridhi lakshanas and nanatmaja vikara as per Ashtanga Sangraha were used to classify the symptoms according to Dosha dominance. 

Results and discussion

Out of 43 poorvaroopas listed 30 were related to Kapha kopa, 11 related to pitha kopa and 2 related to vathakopa.  The point prevalence for kapha kopa is 31 in the population studied.  Among them the most common symptoms are sleepiness and inclination towards lying down, sitting etc, in a moderate intensity.  Swasa, thandra, gurugathratha, danthamala, hrudupalepa, nethropalepam and bahikaye maladhikyam were next set of frequent symptoms, but the intensity were mild in most of them.  Although a sticky feel in the natural outlets was reported by two, nobody reported presents of ants on the body surface, knotty feel in the hairs and soiling natural outlets.  Moothradosha , which was listed among these, does not limit itself to a narrow sense, thus lacks specificity in reporting and recording.  Interestingly 11% of people recorded to have madhuramoothratha, actually used to taste their urine to track changes in urine sugar. 

The pitha kopa symptoms were prevalent in 61% cases, except seethecha all were in moderate intensity.  Pipasa, sweda, saidhilya and sada were prominent features in almost all cases; the period of study was in summer.  Hence the humid and hot climate also could have contributed to an extend for this result. The domination of pitha kopa lakshanas could be suggestive of vidaha type of activities prevalent in prameha roga, which can be assumed as the reason for the classics to direct sthambhana as a major treatment approach in prameha .

 The two vathakopa lakshanas were prevalent in 84% of cases mostly in moderate intensity.  This suggests the possibility of progression toward vatha dominant madhumeha or vatha domination due to dhathusadhilya, ojakshaya, etc. But, only 2 symptoms of vatha are listed in this study among poorvaroopas, in spite of the controversies it carry.  Angasupthi which was originally listed among Vathakopa symptoms needs reconsideration when the results are discussed. This symptom can also be due to kaphopalepa and not an exclusive symptom of vathakopa.  Considering prevalence of upalepa related signs in the cases, also by the absence of sparsendriya nasa, we should relate the supthatha  as a kapha dominant condition.  The second symptom mukhasosha sends mixed messages.  So many were uncertain about the exact meaning and how to recognize it.  Many understood it as dryness in mouth, many as loss of fleshy cheeks, some as flabby and skinny changes in the face, some as loss of strength in the region, and some as sticky feel and thirst.  Thus although these two symptoms are recorded as highly prevalent, they does not suggest the dominance of Vatha in the symptomatology.    

Conclusions

            Almost all poorvaroopas of Prameha roga continues to be present during the vyakthavastha of the disease, which makes it difficult to separate both stages.  There should be larger discussions for identifying  the prodromal stage in advance from the disease stage.  It will help the high risk group to identify and take appropriate measures to delay the onset.   Discussions and studies should also consider establishing the prevalence of Pitha dominant state in the current manifestations of Prameharoga, which in turn helps to change our focus to more Pithasamana measures in treatment.   Such studies in various aspects of Prameha manifested nowadays will throw more light on the Samprapthi of Prameham.

Point prevalence of each of the prodromal symptoms after diagnosing Diabetes Mellitus

Kaphaja poorvaroopas	prevalance	Paithika poorvaroopas	prevalance	Vathika poorvaroopas	Prevalence
Asyamadhuryam	19.51	Thalusosha	80.49	Angeshu supthatha	80.49
Angeshu sneha	30.49	Kanta sosha	81.71	Mugha sosha	87.80
Moothre Pipeelika	30.49	Pipaasa	96.34
Sareere pipeelika	0	Seethecha	37.80
Swasa	45.12	Angeshu sweda	93.9
Nidra	79.27	Panipada daha	26.83
Thandra	42.68	Moothere visragandha	45.12
Alasya	60.98	Sareere visragandha	10.98
Pichila gathratha	25.61	Sadana	79.27
Guru gathratha	43.9	Paridaha	41.46
Madhura moothratha	10.98	Angasaidhilya	81.71
Swasa mala	18.29
Thalu mala	24.39
Gala mala	12.20
Jihwa mala	13.41
Dantha mala	51.22
Chidreshu upadeha	2.44
Moothradosha	2.44
Sayyabhishanga	76.83
Asanabhishanga	75.61
Hrudupadeha	57.32
Netropalepa	47.56
Sravanopalepa	18.29
Jihwopadeha	18.29
Swapnabhishanga	64.63
Naghavridhi	29.27
Kesa vridhi	8.54
Jatila kesa	0
Bahir maladhikya	35.37
Chidreshu maladhikya	0