From the Desk of the Editor ... AN IJCP GROUP PUBLICATION January-April 2023 Volume 16, Number 1 Pages 8 In This Issue www.ijcpgroup.com In this issue When Gerald Jerry Reaven described syndrome X in 1988, it was considered a landmark development in the history of modern medicine. Connecting the dots, he highlighted the association between various cardiometabolic abnormalities and diseases, thus laying the foundation for the conceptualization and characterization of metabolic syndrome (MetS).1 Reaven’s hypothesis helped expand our understanding and approach to the management of diabetes and associated complications. The concept of metabolic triage, based on the metabolic fulcrum, helps in the informed choice of appropriate glucose-lowering therapy, while the metabolic score assists in grading the severity of metabolic dysfunction.2,3 The modern reader, therefore, may be excused for thinking that MetS is a new concept. Though the construct certainly has contemporary relevance, a similar framework was proposed in Ayurveda centuries ago. The tridosha rubric of Ayurveda describes 3 phenotypes, based on physical and mental attributes as well as the examination of body fluids.4 While Vata dosha broadly corresponds to a state of insulin deficiency and/or excessive sympathetic tone, Kapha dosha mirrors today’s description of MetS. The Kapha phenotype is characterized by overweight or obesity associated with insulin resistance, and is prone to cardiovascular disease and premature mortality. The third dosha Pitta represents a balanced state of metabolism and health. This triage of the doshas—Vata, Pitta, and Kapha— is concordant with the earlier terminologies of Ayurveda and Modern Medicine: Where the Twain Meet ............2 endomorph, mesomorph, and ectomorph phenotypes.5 It is also in agreement with the description of catabolic, eubolic, and maladaptive anabolic states in modern endocrinology and metabolism.2 Ayurveda provides the first description of MetS. Ayurveda goes one step ahead by describing a triage of mental phenotypes: Tamasika, Satvika, and Rajasika,6 which correlate with the physical phenotypes, Kapha, Pitta, and Vata, respectively. The concepts of personoriented care, similar to modern precision-based medicine, are reflected in the understanding that there may be various combinations of the 3 doshas in each individual. In this issue of Alloveda, we explore the wisdom that Ayurveda has to offer with regard to MetS management. Alloveda describes how Ayurvedic principles can be used to strengthen the fight against metabolic dysfunction, and how Ayurvedic interventions can improve metabolic health. Our aim, as health care professionals, is to achieve the best possible health for all our fellow citizens. This task is challenging; however, if we work together, we shall certainly accomplish it. Let’s find unity in diversity, and strength in unity. References 1. Reaven GM. Metabolism. 1987;36(2 Suppl 1):1–8. 2. Kalra S, Gupta Y. US Endocrinol. 2015;11(2):79–80. 3. Kalra S, et al. Indian J Endocrinol Metab. 2017;21(5):762–764. 4. Hankey A. J Altern Complement Med. 2005;11(2):221–225. 5. Koleva M, et al. Rev Environ Health. 2002;17(1):65–84. 6. Shreemad Bhagavad Gita. Chapter 17. Mumbai: Shri Paramhans Swami Adgadanandji Ashram Trust, 2008. The Initial Description of Metabolic Syndrome in Ayurveda Interview: Dr Devika V Chopra ............3 Interview: Dr Mahendra Singh Punia ............5 Dr Sanjay Kalra Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India University Center for Research & Development, Chandigarh University, Mohali, Punjab, India Reverse Pharmacology: Traditional Medicine–Inspired Drug Discovery Strategy ...........4 Integrative Medicine: The Way Forward ............2 Evecare forte Liquid in the Management of Polycystic Ovary Syndrome ............3 Pharmacovigilance in Ayurveda: Drug Interactions ............4 Metabolic Syndrome: Facts and Figures ............4 Cystone forte Tablet in the Management of Urolithiasis ............5 Scan the QR code to subscribe to Alloveda Effect of Yoga on Glycemic Profile in Prediabetes Yoga therapy improves the fasting plasma glucose (FPG), postprandial glucose (PPG), and glycosylated hemoglobin (HbA1c) levels in patients with prediabetes, according to a cohort study published in the journal Metabolic Syndrome and Related Disorders. The study enrolled 100 patients with prediabetes. Impaired fasting glycemia (IFG) was prevalent more in the younger participants, whereas impaired glucose tolerance (IGT) and IFG + IGT were seen more in the middle-aged study participants. The researchers aimed to examine the effect of yoga on FPG, PPG, andHbA1c levels. The selected participants themselves acted as control for the study. The FPG, PPG, and HbA1c levels were evaluated at baseline, 3 months, and 6 months. The SF-36 questionnaire was used to evaluate the quality of life. Including anthropometry measures, yoga had a favorable effect on FPG, PPG, and HbA1c, which indicated that yoga effectively improved glycemic control in patients with prediabetes. The study results therefore concluded that the beneficial outcomes of yoga on glucose control was not just due to its effects on anthropometry measures, but also other mechanisms that are yet to be explored. Source: Rajput R, et al. Metab Syndr Relat Disord. 2021;19(8):417–421. Editor’s Note Evidence, experience, and eminence have a role to play in medical education and practice. The gold standard for clinical care, however, remains evidence-based medicine. Ayurveda is adapting itself to modern standards and principles by following modern strategies and procedures. Recent research published in leading journals, by authors from various countries, shows that yoga helps improve clinical as well as biochemical parameters of metabolic syndrome. It can thus be used as an adjunct therapy in persons with prediabetes, high-normal blood pressure, and metabolic syndrome. Dr Supriya Bhalerao Associate Professor, BVDU-IRSHA, Pune, Maharashtra, India Dr Hemant Bhargav Assistant Professor (Yoga), Department of Integrative Medicine, NIMHANS, Bengaluru, Karnataka, India Dr Vaishali Deshmukh Director, Deshmukh Clinic & Research Centre, Pune, Maharashtra, India Dr Ashok Kumar Das Consultant Physician and Endocrinologist, PIMS, Puducherry, India Dr Rakesh Sahay Professor and Head, Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India Dr Prashant Mehta Senior Consultant, Medical Oncology/Hemato-Oncology/BMT Amrita Hospital, Faridabad, Haryana, India Dr Jeetendra Singh Professor and Head, Department of Pharmacology, Dr Vasantrao Pawar Medical College, Hospital and Research Center, Nashik, Maharashtra, India Associate Editors Issue sponsored by Himalaya Wellness Company Dear Readers, Alloveda is undergoing a makeover. The next issue of Alloveda will have a new look and comprise additional interesting features. Meanwhile, we are happy to announce the new Editorial Board of Alloveda comprising experts from various streams of medicine. Liv.52 Unparalleled in liver care ® Liv.52 (DROPS, DS SYRUP, DS TABLET, HB CAPSULE, SYRUP, TABLET) Unparalleled in liver care Dr Sanjay Kalra Editor Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India Dr Veena Aggarwal CMD & Group Editor-in-Chief, IJCP Group Editorial Board Liv.52 Unparalleled in liver care ® Liv.52 (DROPS, DS SYRUP, DS TABLET, HB CAPSULE, SYRUP, TABLET) Unparalleled in liver care
2 Ayurveda and Modern Medicine: Where the Twain Meet The human body is a complex creation that runs on multiple biochemical reactions and physiological processes. These ensure optimal functioning of the body in spite of various external and internal challenges. The mind and body, often considered as two different aspects of the being, are actually two faces of the same organism. The activities and functions of the human body are coordinated by the nervous and endocrine systems, which work together to create a perfect homeostasis. Modern medicine acknowledges the coordination between these two systems. The catecholamines (eg, adrenaline, noradrenaline, and dopamine) function as hormones and run the autonomic nervous system as well. Neurotransmitters operate the central nervous system and manage mood by acting both in an endocrine and paracrine manner. The gut–brain axis, as well as other such constructs, bears testimony to the close cooperation between the body and the brain. This linkage is not limited to homeostasis and health; it extends to dysfunctions and diseases as well. While psychosomatic diseases are a huge topic in itself, the effect of the mind on weight and glucose control has been well-documented. The activity of themind can be utilized for diagnostic and therapeutic purposes too. Magnetic resonance spectroscopy and cognitive behavioral therapy are examples of the same. Ayurveda has, for long, appreciated the concept of mind–body medicine. While the tridosha construct lists Vata, Pitta, and Kapha as the 3 basic phenotypes, the triguna rubric of Rajasikta, Satvikta, and Tamasikta provides a “mental phenotype,” “mentotype,” or “emotional type” counterfoil to the same. Ayurveda accepts that there may or may not be concordance between physical phenotypes and emotional makeup. It recognizes various combinations of phenotypes and mental states. Ayurvedic wisdom also finds resonance in the modern descriptions of body types (mesomorph, ectomorph, and endomorph), metabolic classes (eubolic, catabolic, and maladaptive anabolic), and autonomic nervous states (autonomic balance, sympathetic, and parasympathetic). This knowledge is of immense use to the health care professional. While managing any disease, including metabolic syndrome, one must pay adequate attention to both the mind and body. Ensuring autonomic hygiene and mental relaxation is the first, and perhaps the major, rate-limiting step toward achieving metabolic health. While Tamas + Kapha phenotypic persons need to be motivated and encouraged to be more active, Rajas + Vata personalities require assistance in slowing down and relaxing. Whether simultaneously or sequentially, a combination of behavioral and pharmaceutical therapies can be planned to correct existing disorders and achieve the desired outcomes. Awareness about the mechanism of action of drugs helps choose the right treatment for the right person. People with diabetes who have a catabolic habitus may benefit from insulin and appetite-enhancing nutraceuticals, while those with obesity require drugs such as glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter 2 inhibitors, as well as weight-reducing interventions. Modern medicine is a complex arena. An understanding of mind–body medicine, as elucidated by Ayurvedic physicians of the past and enunciated by researchers of recent times, helps us collate these chaotic complexities into a simple, sturdy, and scientific structure. This, in turn, allows us to offer effective evidence-based therapy to our patients in an efficient and error-free manner. Autonomic hygiene/balance eubolic (Pitta Satvikta) The Tripod of the Mind, Body, and Soul Sympathetic catabolic (Vata Rajasikta) Parasympathetic maladaptive anabolic (Kapha Tamasikta) In the forthcoming issues of Alloveda, we will explore and expound upon the similarities between Ayurvedic science and the modern school of thought. We will continue to dissect the details of mind–body medicine. We will recognize and realize how mind–body medicine is ancient in thought, and how Ayurveda is modern in deed. Dr Sanjay Kalra and Dr Vaishali Deshmukh Integrative medicine is a concept that has gained attention and appreciation in the recent years. Though the first PubMed citation on integrative medicine dates back to 1951, the bulk of the research has taken place in the last few years. A PubMed search for “integrative medicine” shows 64,556 results, of which 2066 are clinical trials (1584 randomized clinical trials) and 1133 are metaanalyses. The first article was published in 1951, and it took 25 years for the 10th article to be listed. In contrast, 20,000 articles have been published on integrative medicine in just 2 years, that is 2021 and 2022. Integrative medicine means a collaborative approach between various schools of medicine, public health policy makers, health care system administrators, clinicians, and different health care specialties. Most important of all, it means the integration of the “reductionist” or elemental approach of medical science with a holistic or person-centered approach. This includes integrating biomedical health with psychosocial well-being and offering comprehensive, psychosomatic management through the integration of evidence-based therapy with communicative “empathy.” Definition One of the most comprehensive definitions of integrative medicine was published in 2018 by the Academic Consortium for Integrative Medicine and Health (ACIMH). Integrative medicine reaffirms the importance of the relationship between the practitioner and patient, focuses on the whole person, supported by evidence, and involves appropriate therapeutic and lifestyle approaches, health care professionals, and disciplines to achieve optimal health and healing. In India, the concept of integrative medicine has been Integrative Medicine: The Way Forward discussed and debated for decades. It is important to understand what integrative medicine stands for, as our nation’s health depends on it. We, therefore, conceptualize integrative medicine as follows: integrative medicine is an approach and practice of medicine that involves all schools of evidence-based science and all relevant health care professionals, along with people seeking health care and their caregivers, in the spirit of person-centered teamwork to achieve optimal holistic well-being. The accompanying Table lists the domains of integrative medicine. Critical Analysis The above definition is similar to the one proposed by ACIMH. It reinforces the need for evidencebased praxis (techniques), appropriate approaches, professionals and disciplines (tools of therapy), the relationship between the practitioner and patient (teamwork), a focus on the whole person (target), and a final goal of optimal health and healing (terminus). It strengthens the earlier definition by mentioning schools of evidence-based science, thus adding structure to integrative medicine. These schools include, but are not limited to, modern medicine, Ayurveda, Homoeopathy, Unani, and Siddha medicine, as well as physiotherapy, nutrition, and psychology. Dr Sanjay Kalra and Dr Hemant Bhargav The new definition also highlights the responsibility of integrative medicine professionals to adhere to evidence-based standards of care. It mentions caregivers as an important contributor to integrative medicine, thus highlighting the role of family, friends, community, and society in health care. The use of the phrase “person-centered teamwork” underscores the rights and responsibilities of all participants and ensures shared “ownership” of health. The Way Forward As the world changes and evolves, so do our health challenges and so should our strategies and solutions. Integrating all our strengths and support systems into a unified structure will improve our societal health. A focus on constructive collaboration, rather than competitive confrontation, will promote harmony and happiness and ensure healing and health. Table. Domains of Integrative Medicine l Macro-Level Structures w Schools of medicine, eg, modern medicine and alternative medicine w Levels of health care, eg, primary, secondary, and tertiary w Health care ecosystems, eg, private and public health initiatives and clinical care l Macro-Level Stakeholders w Payers, eg, health insurance providers w Health care professionals, eg, medicine and nursing w Branches of medicine/surgery l Micro-Level Concepts w Biophysical and psychosocial aspects of health w Evidence-based therapies and communicative empathy w Domains of responsible person-centered care l Micro-Level Players w Health care team members and caregivers w Providers and the patient (or person) w Technical skill provision and humane care
Liquid in the Management of Polycystic Ovary Syndrome 3 Int e r v i e w Doctor, what are the most common triggers for polycystic ovary syndrome (PCOS)? In the past few years, PCOS has become a major health burden for women across the world. Factors such as unhealthy dietary habits including consumption of processed foods, sedentary and stressful lifestyles, obesity, and insulin resistance are some of the most common causes of PCOS. What are the diagnostic criteria for PCOS in adult women? Clinical symptoms of PCOS can vary from irregular menstrual cycles or hyperandrogenism to severe metabolic and reproductive disturbances. A patient is clinically diagnosed with PCOS when she presents with oligomenorrhea; a pelvic ultrasonogram shows 12 or more cystic follicles (2–9 mm) in an ovary; and the patient presents at least 2 symptoms established by the Rotterdam criteria of PCOS (ie, polycystic ovaries, anovulation, and hyperandrogenism). Why isPCOSdiagnosisconsideredchallenging inadolescentwomen? How can one overcome this? PCOSmay bemore challenging to diagnose during adolescence as the physiologic events of puberty overlap with the diagnostic criteria of PCOS. Hence, PCOS should be diagnosed in adolescents using 2 main criteria—irregular menstrual cycles relative to the number of years after menarche and hyperandrogenism by clinical and/or biochemical analyses. What are the health complications associated with PCOS? The prevalence of type 2 diabetes mellitus and hypertension is higher in women with PCOS than in women without PCOS. Women with PCOS are also prone to coronary artery disease and myocardial infarction. PCOS can affect lipid profile, that is, it can increase low-density lipoprotein and triglyceride levels and reduce high-density lipoprotein levels. Untreated PCOS can lead to anovulation, infertility, endometrial hyperplasia, and endometrial cancer. PCOS can also cause psychologic complications such as anxiety and depression. Doctor, what would you suggest for the effective management of PCOS? Generally, a healthy diet and physical activity are part of the treatment plan for PCOS. Limiting the intake of processed foods; consuming foods with low glycemic index carbohydrates and rich in protein and fiber; and maintaining an exercise routine are recommended for women with PCOS. Lifestyle modifications can regularize the BMI, decrease the level of free androgens and the incidence of metabolic syndrome, and restore the hormonal balance. What therapeutic strategies do you recommend to your patients to manage PCOS? I usually prescribe Evecare forte, a phytopharmaceutical formulation from Himalaya Wellness Company, to my patients with PCOS. Evecare forte is a nonhormonal menstrual modulator for the effective and comprehensive management of PCOS. Evecare forte helps regularizemenstrual cycles and correct the symptoms of hyperandrogenism such as hirsutism and hyperpigmentation. Further, it improves fertility and helps reduce mood swings, anxiety, and depression associated with PCOS. Dr Devika V Chopra, MBBS, DNB Consultant Obstetrician and Gynecologist Hope Clinic Suite B1/2, Anand Nagar Forjett Street, Tardeo Mumbai 400036, Maharashtra India Regularizes endogenous hormone levels Helps reduce the number of abnormal follicles – Corrects the cyclical rhythm Helps in restoring ovulation – Improves fertility rate Insulin-sensitizing activity corrects ovarian dysfunction and other metabolic derangements associated with insulin resistance. Safe, polyherbal, and nonhormonal menstrual modulator (LIQUID, TABLET) Indication PCOS Dosage Liquid: 2–4 teaspoonsful (10–20 ml) twice daily for 3 to 6 months. Tablet: 1 tablet twice daily for 3 to 6 months. ™Trademark This open-labeled clinical study was conducted to evaluate the efficacy and safety of Evecare forte liquid in the management of polycystic ovary syndrome (PCOS). The study included 40 women (aged 18–45 y) with signs and symptoms of PCOS, such as irregular menstrual cycles, weight gain, biochemical/clinical hyperandrogenemia, and hirsutism. All women were prescribed Evecare forte liquid at a dosage of 20 mL, BID, for 3 months. Clinical assessment of signs and symptoms, ultrasonography, hematologic tests, and hormonal assays were performed at each follow-up visit. Treatment with Evecare forte liquid resulted in a significant reduction in the duration of menstrual cycles by the end of 3 months of treatment (P < .035) (Figure). The intermenstrual interval significantly reduced from the entry to month 3 of treatment (P < .0299). The levels of testosterone (P < .0063), luteinizing hormone (LH) (P < .0435), and follicle-stimulating hormone (FSH) significantly reduced by the end of the treatment. The reduction in LH and FSH levels is indicative of an improvement in PCOS. Ultrasonography showed that the number of ovarian follicles reduced to 17.50 ± 5.27 by the end of the study (P < .0252). No adverse effects were reported or recorded. Hence, the study concluded that Evecare forte liquid is a safe nonhormonal menstrual modulator that helps regularize the endogenous hormonal secretion, corrects the cyclical rhythm, and relieves the symptoms of PCOS. Source: Ahalya S. Data on file. Figure. Effect of Evecare forte Liquid on the Duration of Menstrual Cycles P < .035 At Entry Duration of Menstrual Cycles, d Treatment Duration 12 Month 1 Month 2 Month 3 10 8 6 4 2 0 mes with tagline
4 Pharmacovigilance in Ayurveda: Drug Interactions Drugs are active substances that are prescribed in an effort to protect, promote, and prioritize health. Drugs are meant to alleviate symptoms, correct laboratory/imaging abnormalities, resolve disease states, and prevent potential complications. Sometimes, however, adverse effects may occur with the use of a particular drug. Such adverse drug events may or may not be directly due to the drug being used. If causality is proven, the adverse drug event is labeled as an adverse drug reaction (ADR). The increasing use of drugs, in various permutations and combinations, is associated with a greater risk of ADRs. The epidemic of metabolic syndrome and associated diseases requires long-term or indefinite treatment, and thus adds to the risk of ADRs. Traditionally, ADR reporting or pharmacovigilance, has been a neglected aspect of clinical care. The WHO defines pharmacovigilance as “the science and activities relating to the detection, evaluation, understanding, and prevention of adverse effects or any other drug-related problem.” Ayurveda has always understood the importance of pharmacovigilance and ADR. The Table enumerates various types of ADRs listed in Ayurveda. Ayurveda also describes drug– herb interactions and drug– exercise interactions. This is important for modern medical care, in which dieticians, lifestyle coaches, and doctors sometimes work with little or no communication between each other. Well-meaning therapeutic interventions Table. Pharmacovigilance in Ayurveda Modern Term Ayurvedic Term Example Drug interaction Viruddha-dravya-prayoga Hypoglycemia with antibiotics such as levofloxacin and gatifloxacin or antimalarials such as quinine in persons on OADs Overdose of drugs Ati-matra-dravya-prayoga Overdose of insulin in persons with diabetes Administration of unwholesome drugs Ahitatamadravyas Use of appetite-reducing and weight-reducing drugs in type 1 diabetes Administration of drugs across the spectrum of diseases Avastanusara-dravya prayoga Dosage according to eGFR Therapeutic procedural complications Panchakarma-vyapad, Shalya upoya Use of appetite- and weight-reducing procedures in persons with type 1 diabetes and pancreatic diabetes OADs, oral antidiabetic drugs; eGFR, estimated glomerular filtration rate. (eg, dietary restriction or intensive exercise) may lead to ADRs if not accompanied by appropriate and adequate changes in drug regimens and doses. Ayurveda speaks of the need to avoid incompatibility (viruddha-ahara) and ensure appropriate dietary restrictions (pathya-sevana). These must be understood by all medical practitioners. In the forthcoming issues of Alloveda, we will further explore and expand upon, the concept of pharmacovigilance in Ayurveda. We will work together to ensure a healthier and safer world for our fellow citizens. Source: Ajanal M, et al. J Young Pharm. 2013;5(4):116–120. The science of integrating well-documented clinical experiences and experiential observations into research ideas through transdisciplinary exploratory studies is known as reverse pharmacology. These clinical observations of reverse pharmacology are used to develop effective drug candidates from the leads through preclinical and clinical research. Reverse pharmacology utilizes traditional medicine and the knowledge of traditional healers to discover drugs. This is also known as “from bedside to bench side,” and it reverses the pipeline from clinics to laboratories, which happens in reverse in general. The traditional strategy for drug discovery is: Molecule → Rat or Mice → Man The reverse pharmacology approach is: Man → Rat or Mice → Molecule One of the best-known drug discoveries using reverse pharmacology is reserpine, an alkaloid isolated from Rauwolfia serpentina, also known as Indian snakeroot. In 1931, Indian scientists Sen and Bose successfully demonstrated the antihypertensive and sedative properties of reserpine. However, they noted several unusual side effects such as gynecomastia, depression, and extrapyramidal syndrome. Later, in 1949, Rustom Jal Vakil published a trial of R serpentina on patients with essential hypertension. According to his study, R serpentina reduced systolic and diastolic blood pressure. Although it took years to deduce the mechanisms of these side effects, these clinical efforts led to the discovery of new antidepressant, antiParkinson’s, and prolactin-reducing drugs. At present, reserpine is available in the market as an antihypertensive alkaloid. This was probably the first time the principles of reverse pharmacology were systematically used for focused, fast-track drug discovery based on Ayurveda. Reverse pharmacology is more time- and costefficient and has a higher success rate than the conventional method of drug development, which is more expensive and time intensive. Additionally, reverse pharmacology has led to the development of a few promising lead molecules, such as curcumin (from Turmeric/Haridra) for inflammation; psoralen (from Babchi/Bakuchi) for psoriasis; and papain (from Papaya/Erandakarkati) for increasing platelet count. Hence, it can be concluded that reverse pharmacology will continue to be useful in the future for discovering novel uses for old prescription drugs. Source: Patwardhan B, et al. Drug discovery and ayurveda. In: Patwardhan B, et al, eds. Integrative Approaches for Health. Academic Press; 2015:229–258. Reverse Pharmacology: Traditional Medicine–Inspired Drug Discovery Strategy Dr Sanjay Kalra and Dr Supriya Bhalerao Dr Jeetendra Singh Metabolic Syndrome: Facts and Figures z Metabolic syndrome is a cluster of risk factors, which includes waist circumference (> 40'' in men and 35'' in women), raised triglycerides (≥ 150 mg/dL), low high-density lipoprotein cholesterol (< 40 mg/dL in men or < 50 mg/dL in women), impaired fasting glucose (≥ l00 mg/dL), and high blood pressure (≥ 130/85 mmHg).1 According to the latest National Family Health Survey 2019–2020 (NFHS-5), 21% of women and 24% of men aged ≥ 15 years are hypertensive, and 39% of the women and 49% of the men in this age group are prehypertensive. More men (14%) than women (12%) have high random blood glucose levels (> 140 mg/dL). The percentage of overweight or obese women has increased from 21% to 24% and from 19% to 23% among men.2 z The global prevalence of metabolic syndrome ranges from 7.1% to 41.6%. According to the ATP III criteria, the estimated prevalence is 35% in USA, ~ 25% in Latin America, 20.7% to 37.2% in the Gulf countries, and 26.1% in South Asia.3 The prevalence is also rising among children (2.8%) and adolescents (4.8%).4 z According to a meta-analysis published in 2020, the overall prevalence of metabolic syndrome in India was 30%. The prevalence was higher among older adults aged 50 to 59 years comparedwith adolescents aged 18 to 29 years (52% vs 13%, respectively), in people living in urban areas compared with rural areas (32% vs 22%, respectively), and in women compared with men (35% vs 26%, respectively).5 z Up to 80% of individuals with diabetes have metabolic syndrome. The life expectancy is reduced by a decade among these patients.6 z The risk of developing type 2 diabetes 5 to 10 years later increases 5-fold in people with metabolic syndrome, while the risk of cardiovascular disease increases 2- to 3-fold.6 z Individuals with sedentary lifestyle are nearly 7 times more likely to have metabolic syndrome; the chances are 5.5 times higher with the use of palm oil. Individuals who eat meat (≥ 2 times per week) are 5.9 times more likely to have metabolic syndrome compared with those who do not eat meat or eat once in a week.6 z The prevalence of metabolic syndrome among adult patients with psoriasis has been reported to be 32%.7 A cross-sectional study from Singapore mentions the prevalence of metabolic syndrome to be 45.1% in patients with psoriasis.8 z In patients with acute pancreatitis, the incidence rate of metabolic syndrome has been calculated to be ~ 31%.9 References 1. Swarup S, et al. Metabolic Syndrome [Updated October 24, 2022]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. 2. National Family Health Survey (NFHS-5), 2019–21. India Report. http://rchiips.org/nfhs/NFHS-5Reports/NFHS-5_INDIA_REPORT.pdf. Accessed January 12, 2023. 3. Meher T, Sahoo H. Clin Epidemiol Glob Health. 2020;8:1047–1052. 4. Noubiap JJ, et al. Lancet Child Adolesc Health. 2022;6(3):158–170. 5. Krishnamoorthy Y, et al. PLoS One. 2020;15(10):e0240971. 6. Gemeda D, et al. J Diabetes Res. 2022;2022:8162342. 7. Liu L, et al. J Eur Acad Dermatol Venereol. 2022;36(11):1969–1979. 8. Chan WMM, et al. Singapore Med J. 2020;61(4):194–199. 9. Shen Z, et al. BMC Gastroenterol. 2021;21(1):17.
5 Int e r v i e w Tablet in the Management of Urolithiasis Doctor, what preexisting medical conditions can trigger urolithiasis? Preexisting medical conditions such as chronic kidney disease, hypertension, gout, type 2 diabetes mellitus (T2DM), hyperlipidemia, obesity, hyperthyroidism, and certain malignancies can increase the risk of development of renal calculi. Conditions such as obesity, hyperlipidemia, and T2DM are more specifically associated with the formation of calcium oxalate and uric acid stones. What are the symptoms associated with urolithiasis? Urolithiasis typically presents with sudden, severe flank or back pain on one side of the body that can radiate to the groin and may result in blood in the urine, pain while urinating, increased frequency of urination, fever and chills, and nausea and vomiting. What are the causative factors for the formation of different types of urinary calculi? The chemical composition of urinary calculi depends on the abnormalities in urine composition. The process of renal stone formation depends on the urinary pH and chemical composition of the supersaturated urine. Urinary pH of 5.0 to 6.5 promotes calcium oxalate stone formation, urinary pH of > 7.5 promotes calcium phosphate stone formation, and urinary pH of < 5.05 promotes uric acid stone formation. Can dietary habits influence urolithiasis? Yes, diet can strongly influence the formation of renal calculi. Low intake of vitamin A and high intake of animal protein, vitamin D, sodium, refined sugars, and oxalate-rich foods (eg, beans, berries, coffee, chocolate, soda, spinach, and potatoes) can lead to the formation of renal calculi. Low fluid intake and frequent alcohol intake can lead to systemic dehydration that results in the development of urolithiasis. Doctor, can urolithiasis reoccur? What measures can be taken to avoid urolithiasis relapse? Yes, urolithiasis can reoccur. The recurrence rate is higher in men than women. Urolithiasis can reoccur during pregnancy and in patients with obesity and those with a family history of renal calculi. It is, thus, imperative to drink plenty of fluids, eat a balanced diet, avoid excess salt intake, and consume only moderate amounts of dairy products to reduce the risk of urolithiasis relapse. In obese patients, moderate physical activity and weight management to achieve a healthy BMI help reduce the risk of relapse. Doctor, what do you prescribe to your patients for the management of urolithiasis? In addition to lifestyle and dietary modifications, I generally prescribe Cystone forte tablet, an Ayurvedic proprietary formulation from Himalaya Wellness Company, for the comprehensive management of urolithiasis. Cystone forte tablet helps in the expulsion of large calculi and relieves associated obstructive symptoms, such as frequency of micturition, hematuria, and pain, and postlithotripsy complications. Dr Mahendra Singh Punia, MS, MCh (Urology) Senior Consultant Capital Urology and Dental Clinic F-87, Ram Path, Shyam Nagar Sodala, Jaipur 302019, Rajasthan India In the management of large kidney stones… Cystone® forte Expels kidney stones and prevents recurrence ( TA B L E T ) START with for a minimum of 4 weeks For the e ective management of urolithiasis... FORTE Advantage • Faster dissolution • Offers quick relief • Reduces recurrence • Treats large kidney stones • Economical Dosage 2 tablets twice daily. Indications • Urolithiasis (urinary stones up to 12 mm) and crystalluria • For the management of post-lithotripsy complications ® Regd. Trademark Cystone forte Expels kidney stones and prevents recurrence An open-label study was conducted to evaluate the efficacy and safety of Cystone forte tablet in the management of urolithiasis. A total of 65 patients (aged 18–50 y) with renal stones measuring > 5 and < 12 mm were prescribed Cystone forte at a dosage of 2 tablets, BID, for 3 months. Patients were evaluated for calculi size, and clinical symptoms such as colicky pain at the loin, pain in the abdomen, hematuria, dysuria, nausea/vomiting, pain on micturition, tenderness in kidney–urethra–bladder (KUB) area, fever and chills, and loss of appetite. Treatment with Cystone forte resulted in a significant reduction in calculi size from 6.82 ± 2.03 to 2.91 ± 2.31 mm (P < .0001) and a decrease in the presence of renal calculi. After the treatment, 6 patients reported that the stone evacuated and the symptoms reduced by the end of month 1. Expulsion of renal calculi of 5 to 6.9 mm was observed in 20 of 35 patients; expulsion of renal calculi of 7 to 12 mm was observed in 16 of 30 patients (Figure). Symptoms such as colicky pain at the loin, pain in the abdomen, hematuria, dysuria, nausea/vomiting, pain on micturition, tenderness in the KUB area, fever and chills, and loss of appetite were relieved in most of the patients by the end of the study. No serious adverse effects were reported. Hence, the study concluded that Cystone forte is safe and effective in the management of urolithiasis. Source: Palaniyamma D, Jeyaraman R. J Urol Res. 2017;4(4):1093. ames with tagline ION) ith tagline 30 16 35 20 Before Treatment Complete Expulsion of Kidney Stones Size of Calculi: 7 to 12 mm Before Treatment Complete Expulsion of Kidney Stones Size of Calculi: 5 to 6.9 mm Figure. Effect of Cystone forte on the Expulsion of Renal Calculi
Tulasi Himalaya Ensures rapid control of URT disorders Ensures rapid control of URT disorders Relieve cough and cold with... TulasiHimalaya (SYRUP, TABLET) Indications • Upper respiratory tract disorders • Productive and dry cough • Recurrent respiratory infections • As a supportive therapy for chronic lung diseases: – Chronic obstructive pulmonary disease (COPD) – Asthma and bronchitis Ocimum sanctum | Holy Basil Each tablet contains 250 mg extract of Tulasi leaf. Each 5 ml of syrup contains 112 mg extract of Tulasi aerial part. Delicious Honey Flavor Dosage Tablet: 2 tablets twice daily. Syrup: Children: 5 ml (1 teaspoonful) twice daily. Adults: 10 ml (2 teaspoonsful) twice daily. Available in 60s and 200 ml ® Regd. Trademark Medical Nutrition Therapy Medical nutrition therapy (MNT) is an age-old concept that finds a place of pride in Ayurveda. In a discussion on the origin of man and the pathogenesis of diseases, Acharya Atreya felt that there is no point in confrontational debate regarding the etiopathogenesis or management of disease.Rather, he felt that aunified theory involving nutrition aswell as other aspects of healthwould serve the purpose of medicine in a better way. Acharya Atreya suggested a unifying concept in Charaka Samhita (Sutrasthana, Ch XXV, v.31): wholesome food promotes growth, while unwholesome food is the cause of diseases. This, perhaps, is the first mention of nutritional theory of diseases as well as the therapeutic role of MNT. The fact that this predates Hippocrates by tens of centuries is a topic for another day. Ayurveda understands the dynamic and personcentered nature of MNT. Apart from the specific food TULASI Order: Lamiales Family: Lamiaceae Genus: Ocimum Species: sanctum Linn English name: Holy Basil Sanskrit name: Tulasi Morphology and Habitat Ocimum sanctum L is an aromatic herb that grows across India and other countries such as Australia, West Africa, Malaysia, and a few Arab countries.1 It is a branched subshrub that grows 30 to 60 cm tall with hairy stems and purple– red flowers. The leaves are petiolate, ovate, and slightly serrated.1,2 Principal Constituents The main phytoconstituents are methyl eugenol, β-caryophyllene, (E)-caryophyllene, eugenol, β-elemene, methyl chavicol, and linalool.3 Pharmacological Actions O sanctum exerts therapeutic effects through its antimicrobial, antioxidant, anti-inflammatory, analgesic, antipyretic, antiallergic, immunomodulatory, antiasthmatic, antitussive, diaphoretic, antistress, antiemetic, antispasmodic, antidiabetic, and antihypercholesterolemic properties.4 In an experimental study, the methanol extract of O sanctum inhibited acute inflammatory reaction by reducing pedal edema induced by carrageenan. The aqueous suspension also reduced the croton oil–induced granuloma and exudate, indicating inhibition of chronic inflammation. This study also showed its analgesic and antipyretic effects.5 O sanctum L seed oil has been shown to lower lipid peroxidation and increase reduced glutathione levels.6 In a randomized controlled trial, ethanolic extracts of leaves of O sanctum were administered to 22 healthy volunteers. A statistically significant increase in interferon-γ (P = .039) and interleukin-4 (P = .001) levels along with an increase in the percentages of T-helper cells (P = .001) and natural killer cells (P = .017) was seen after 4 weeks of the treatment, which indicates its immunomodulatory effect.7 The bronchodilatory activity of O sanctum capsules (200 mg) was examined in 41 patients with mild-to-moderate asthma, and its efficacy was compared with that of 2 mg salbutamol tablets for 1 week with a washout period of 1 week between the treatment with the 2 drugs. Treatment with O sanctum significantly improved lung function and symptoms.8 References 1. Verma S. J Phytopharmacol. 2016;5(5):205–207. 2. Bast F, et al. Sci World J. 2014;2014:847482. 3. Joshi RK. J Pharmacogn Phytochem. 2017;6(2):261–264. 4. Cohen MM. J Ayurveda Integr Med. 2014;5(4):251–259. 5. Godhwani S, et al. J Ethnopharmacol. 1987;21(2):153–163. 6. Gupta S, et al. Indian J Exp Biol. 2006;44:300–304. 7. Mondal S, et al. J Ethnopharmacol. 2011;136(3):452–456. 8. Vinaya M, et al. Int J Basic Clin Pharmacol. 2017;6(3):511–517. item, its quantity, time of consumption, method of preparation, and place of consumption also matter. At the same time, diet should be chosen according to the individual’s constitution (body), pathology (pathophysiology), and condition (medical status). Understanding the intricacies of nutrition has always been a challenge as Agnivesa (Sutrasthana, v.34) says: “Sir, but the instruction (imparted) in this way would not be understood by the majority of the physicians.” Acharya Atreya replies (v.35) that an understanding of nutrition will help in understanding of medicine as well. This reminds modern physicians of the need to be well-versed with the science of diet and nutrition. In today’s scenario, nutrition forms the basis of metabolic syndrome, a confounding factor in its presentation, and a contributor to the comorbidities and complications. Nutritional therapy is necessary to care for persons with metabolic syndrome and has the potential to cure some aspects of it. The wide spectrum of malnutrition also has to be understood: protein– energy malnutrition, overweight/obesity, and hidden hunger (vitamin/mineral deficiency) are equally significant. Each individual is unique, and MNT must be crafted to suit the person’s needs and requirements. MNT is complex too: Acharya Atreya lists 152 means of alleviating disease, which include foods, beverages, thoughts, and behaviors (v.41). He also teaches how to choose person-centric MNT and explains the possibility of food–drug and food–food interactions. Alloveda shall continue to explore the age-old wisdom of Ayurveda and highlight its relevance to modern medicine. Dr Madhur Verma Department of Community/Family Medicine All India Institute of Medical Sciences Bathinda, Punjab, India
J 7 Copyright 2023 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in this newsletter Alloveda, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher. This newsletter is Published and Edited by IJCP Academy of CME at Regd. Office: 3rd Floor, 39 Daryacha, Hauz Khas Village, New Delhi - 110 016. E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com, HIP/IN/Bengaluru/3987 as a part of its social commitment toward upgrading the knowledge of Indian doctors. Disclaimer: Although great care has been taken in compiling and checking the information given herein to ensure that it is accurate, the Publisher shall be in no way directly or indirectly responsible for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise. IJCP Publications Ltd. does not guarantee, directly or indirectly, the quality or efficacy of the product or service described in the advertisements or other material which is commercial in nature in this publication. Printed at Sri Sudhindra Offset, Bengaluru, on behalf of IJCP Publications Ltd. A defendant isn’t happy with how things are going in court, so he gives the judge a hard time. Judge: Where do you work? Defendant: Here and there. Judge: What do you do for a living? Defendant: This and that. Judge: Take him away. Defendant: Wait, when will I get out? Judge: Sooner or later. A thief broke into my house last night....He started searching for money; I woke up and joined him in the search, too. A man was driving when he saw the flash of a traffic camera. He figured that his picture had been taken for exceeding the speed limit, even though he knew that he was not speeding. Just to be sure, he went around the block and passed the same spot, driving even more slowly, but the camera flashed again. Now he began to think that this was quite funny, so he drove even slower as he passed the area again, but the traffic camera again flashed. He tried a fourth time with the same result. He did this a fifth time and now was laughing when the camera flashed as he rolled past, this time at a snail’s pace. Two weeks later, he got five tickets in the mail... for driving without a seat belt. Q: Did you hear about the claustrophobic astronaut? A: He just needed a little space! Q: What sits at the bottom of the sea and twitches? A: A nervous wreck! Time laugh To Patient: What is the cost of plastic surgery? Doctor: It is about $10,000. Patient: Well, what if we arrange for the plastic? An old female patient complains to her doctor. Patient: Doctor, when I touch my left shoulder, it’s painful; when I touch my abdomen, it’s painful; when I touch my head, it also is painful! What do you think is the problem? Doctor: I think you have hurt your index finger! Patient: Doctor is there any chance I’ll be able to play the violin after the surgery? Doctor: After some healing, yes, of course! Patient: Great! How exciting. I did not know how to play it before! Q: How does the receptionist at a urology department answer the phone? A: This is the urology department—can you hold? Scan the QR code below or write to publications@himalayawellness.com to provide feedback/suggestions on Alloveda (SOLUTION) ® ® Regd. Trademark • Renormalizes the effect of endogenous substances that affect hair growth • Stimulates scalp microcirculation and improves nutrient supply to hair bulbs • Improves the regeneration of damaged hair follicles • Improves the tensile strength of hair • Enhances the hair follicular density • Reduces scalp inflammation and itching Directions for Use Spray an adequate quantity of Hairzone Solution over a ected areas of the scalp, and gently massage for 5–10 minutes. Best if left overnight. May be rinsed the next morning. In severe cases, apply twice daily. Indications • Hair loss of varied etiologies Telogen effluvium | Anagen effluvium | Alopecia areata | Drug-induced alopecia including chemotherapy and radiotherapy | Diffuse hair loss • Hair fall due to dry scalp and itchy scalp • Also, in hair loss due to typhoid, malnutrition, and fever Hairzone Prevents hair fall, promotes hair growth Duration of Therapy: Minimum 6 weeks For the management of hair loss…
www.himalayawellness.com E-mail: write.to.us@himalayawellness.com ( SYRUP, TABLET ) ® In low platelet count… ® Regd. Trademark Dosage Syrup: 2 to 5 years: ½–1 teaspoonful (2.5–5 ml) twice daily. 5 to 10 years: 1–2 teaspoonsful (5–10 ml) twice daily. 10 to 18 years: 2–3 teaspoonsful (10–15 ml) twice daily. Tablet: 1–2 tablets twice daily. Indication Thrombocytopenia •Boosts platelet count and reverses thrombocytopenia caused by dengue • Carica papaya in Platenza is well repor ted to decrease peripheral platelet destruction. •Piperine in Piper nigrum is a natural bioenhancer, which helps boost the bioavailability of other phytochemicals. •Exhibits proven antipyretic and hepatoprotective proper ties •Is compatible with currently available treatments •Is free from adverse effects of current therapies •Provides an affordable cost of therapy Only for reference by a registered medical practitioner, hospital, or laboratory ® Regd. Trademark Dosage 2 to 5 years: 2.5 mL to 5 mL twice daily. 5 to 10 years: 5 mL to 10 mL twice daily. 10 to 18 years: 10 mL to 15 mL twice daily. Carica papaya complex with bioenhancer for low platelet count Indication Thrombocytopenia Improves platelet count • Modulates the p oduction and differentiation of platelets through the action of thrombopoietin • Pr motes the differentiation of megakaryocytes into platelets • Carica papaya in Platenza is well repor ted to decrease peripheral platelet destruction. Reduces fever in dengue • Piper nigrum and Tinospora cordifolia offer antipyretic proper ty. Safe for the pediatric population • No adverse effects repor ted Makali, Bengaluru 562162, India Only for reference by a registered medical practitioner, hospital, or laboratory In line with Himalaya’s commitment toward a green future, Alloveda newsletter is printed with VOC-free, vegetable-based inks on eco-friendly paper made from sustainable sources. Nurturing Wellness, Sustaining Nature. ® Regd. Trademark Dosage 2 to 5 years: 2.5 mL to 5 mL twice daily. 5 to 10 years: 5 L to 10 mL twice daily. 10 to 18 years: 10 mL to 15 mL twice daily. Carica papaya complex with bioenhancer for low platelet count Indication Thrombocytopenia Improves platelet count • Modulates the production and differentiation of platelets through the action of thrombopoietin • Promotes the differentiation of megakaryocytes into platelets • Carica papaya in Platenza is well repor ted to decrease peripheral platelet destruction. Reduces fever in dengue •Pip r nigrum and Tinospora cordifolia offer antipyretic proper ty. Safe for the pediatric population • No adverse effects repor ted Makali, Bengaluru 562162, India Only for reference by a registered medical practitioner, hospital, or laboratory In line with Himalaya’s commitment toward a green future, Alloveda newsletter is printed with VOC-free, vegetable-based inks on eco-friendly paper made from sustainable sources. Nurturing Wellness, Sustaining Nature.
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