Ayurveda

Link: http://www.rasayu.com/e-journal/vol_3_62.asp

Abstract: Osteoporosis is the prime disorder in geriatrics. It cannot be cured or eradicated; only thing we do is to retard the progress. In order to prevent the osteoporosis, it is important to understand the patho-physiology of the disease.

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The Ayurvedic concepts of division of age according to Dosha and the theory of Rasayana are very well applicable in prevention of osteoporosis. Rasayana therapy is employed in young or middle age for the long term benefits lifelong and to delay the degenerative changes in old age. The efforts to prevent the osteoporosis in young and middle age according to Ayurvedic Rasayana concept can make the life easy after the retirement. The correlation of physiology of bone development and patho-physiology of osteoporosis with Ayurvedic principles makes the picture crystal clear about importance of proactive management of osteoporosis. So in whatever age group one is, it may be the high time to invest for one’s bone health. Also proper care and treatment is very is essential to avoid further complication in patients already suffering from osteoporosis.

Introduction: When we talk about geriatric problems, osteoporosis is the prime topic. Osteoporosis is loss of bone tissue, resulting in bones that are brittle and liable to fracture. Infection, injury and synovitis can cause localized osteoporosis of adjacent bone. Generalized osteoporosis is common in the elderly and in women often follows the menopause. It is also a feature of Cushing’s syndrome and prolonged steroid therapy. Many aged remain unaware of this underlying demon. Most of the times this problem is brought to notice by a bone fracture occurred due to a simple trauma. Females face osteoporosis earlier than males. In females loss of calcium and minerals begin often at the age of 30, where as in males it occurs after 60. In females it accelerates around the age of 45, as estrogen level falls down at menopause. 30% calcium is lost by the age of 70. Once bone loss begins, in females 8% loss occur every 10 yearly, where as in males 3% loss per 10 year occurs. Osteoporosis leads to too many problems like brittle bones, bone fractures, non union of fractures, pain etc. As at the old age, many therapies are inconvenient for patients, it is advisable to prevent osteoporotic changes right from the early age. Wealth is of no use if one doesn’t have good health to enjoy the life. So, a little care for our bone health from young age will be definitely a worth and wise investment for happy life after retirement.

Composition of bone: Bone is a live tissue. It contains following types of cells. Osteoblasts, osteoclasts, osteocytes and osteoprogenitor or mesenchymal cells. Out of which Osteoplasts are with single nucleus. They deposit new bone. Osteoclasts are the giant cells with 15-20 nuclei. They may have up to 100 nuclei. They cause resorption of bone.About 80% of human skeleton is compact bone and 20% spongy bone. Adult compact bone contains about 75% inorganic and 25% organic materials. (Dry weight.) Compact bone tissue is arranged in units called osteons or Haversian system. Bone contains mainly calcium, magnesium and phosphorus as its inorganic material, in which calcium is the major.

Calcium 99% of total body calcium (which is 1 Kg) is in bones. Calcium salts gives the bone its hardness.

Magnesium 50% of total body magnesium occurs in bone. 5% in extra cellular fluid and 45% in cells. Mg behaves like calcium on neuromuscular system.

Phosphorus: 80% of total body phosphorus is in the bones. Other phosphorus is intracellular.

Collagen:It is also an important protein content of bone.

Bones according to Ayurveda:According to Ayurveda, bone i.e. Asthi is the 5th dhatu in our body. Asthi is so called because it remains for longer time, even after death. Bones decomposes at last. Asthi has panchabhautic constitution and it exhibits properties of Prithvi mahabhuta more prominently. Asthi are one of the destinations of Vayu (Vata sthana). The Vayu and Asthi are inversely proportional to each other. That means when Vayu increases in Asthi, Asthi decreases, and vice versa.

Growth & Development of Bones: Bones calcify through the process of ossification. Bone ossification begins at 6th-7th week of intra uterine life. As per length wise growth of bones is concerned, the activity of epithelial plate is the only way that the diaphysis can increase in length.

Calcium: 99% of total body calcium is in bones. The calcium of the bone is in dynamic equilibrium with the calcium in extra cellular fluid (E.C.F.), i.e. the calcium leaves the bone to enter E.C.F. and the same time the E.C.F. calcium deposits in the bone resulting in no net loss or gain in the total calcium of bone. This is seen in adults and called as calcium equilibrium. In growing child positive calcium equilibrium is observed. That means, new bone formation is more than the depletion of bone in the remodeling. While in elderly person, negative calcium balance is observed where bone loss is more than the new bone formation.

Many factors other than calcium play an important role in bone development.

Vitamin C:It is needed for the synthesis of main bone protein collagen. And also for the differentiation of osteoblasts into osteocytes.

Vitamin K & Vitamin B12:These are also needed for protein synthesis.

Vitamin A: This stimulates activity of osteoblasts.

Three hormones take part in regulation of bone formation.Vitamin D (de hydroxycholecalciferol)Small intestine and bone are the principal target organs for vitamin D.Para thyroid hormone (PTH)It acts on bones, kidney, and intestine. It induces high serum calcium level and decreases calcium from bones.

Calcitonin: It takes part in calcium metabolism. Its exact role is not known in human.

Nutrition of bones according to Ayurveda: Bone, as per its Panchabhautic constitution mainly gets its body mass from the nutrient which is prominently Prithvi mahabhautic in constitution. According to Uttarottar dhatu poshan nyay (nutrition of successive dhatu) Asthi gets its nutrition from majja. Majja can be co-related with red and yellow bone marrow.

Need of early age bone care: As mentioned earlier, positive calcium balance is observed in young age, calcium equilibrium is observed in middle age and negative calcium balance is observed in old age. That means if one wants to buildup a good health of bones, the young age is the most ideal period. Efforts in middle age may also be fruitful. But as an old age is a degenerative stage, even vigorous efforts to boost body components may not prove encouraging.

In reference to the Rasayana i.e. rejuvenating treatment, Ayurveda has clearly mentioned to have Rasayana at young age or middle age by the sentence, ‘Poorve Vayasi Madhhye Wa…’. Though the target is to prevent disorders at geriatric age, the treatment is prescribed at the developing age of the human body.

If we consider the stage of Dosha at different age groups, in young age Kafa Dosha is prominent which is responsible for cumulative and integrative action. In middle age pitta Dosha is prominent whereas in old age Vata Dosha is prominent. As Vata is inversely proportional to the Asthi, efforts to treat osteoporosis at elder age are less effective. On the other hand if we follow the principle of Rasayana and start Rasayana for bones at young age or middle age, it will be beneficial for life long. Not only for bones, but also this theory is applicable for all dhatu and whole body. Constructive work is always recommended in constructive age, which is young age.

So, attention towards early age management of geriatric problems like osteoporosis is essential. Early age bone health care is not only important in point of view of prevention of osteoporosis, but also it is important in primary growth and development of child. Because few things are irreversible and that’s why should be taken care when formation is going on. Like:

a) TeethLike bones, calcium is the main constituent of teeth. According to Ayurveda, teeth are derived from bones and called as Updhatu of it. At the time of dental development, if child lacks in nutrients, minerals or the factors which make the nutrients available for development, the child will not get healthy teeth. As the calcium in teeth can not be mobilized, after the completion of development, these teeth remain weak for life time. Dental caries, early teeth loss and related complications are common with these sorts of people in adulthood. If proper care of bone health is taken at child hood, it will serve for the healthy development of its Upadhatu i.e. teeth for life long.

b) Height Height of a person is completely dependant on the lengthwise growth of long bones. The activity of epiphysial plate is the only way that the diaphysis can increase in length. Any damage to the epiphysial plate in a form of trauma, infection, etc may hamper the growth of that particular bone. Malnutrition, insufficient supply of nutrients required for bone development can result into short height. Also obesity can be a hurdle for height wise growth in children. Because, Tissue like adipose tissue can convert androgens to estrogens. As ultimately the sex steroid, especially estrogen in both sexes shuts down growth at epiphysial plate, no further bone elongation occurs. So bone growth remains stunted in children. Hence proper attention towards the development of bones can save one from lifetime frustration of stunted height and related.

How can one take care of bones? In order to gain a good bone health following few points plays an important role.Sufficient intake of nutrientsAbsorption of nutrients Transportation of nutrition to desired sightAppropriate formation of the target tissue /dhatu.Accessory or accompanying components like Prakriti, age etc.a) Nutrients for Asthi (bones) According to Samya-Vaishamya theory of Ayurveda, drugs having similar constitutions as Asthi are useful for the nutrition of Asthi. For example, calcium rich diet like milk and milk products, eggs, fish, green leafy vegetables like spinach, amaranth; cereals, millets, some fruits like custard apple (Sitaphal) provide good calcium supplement. An additional source of calcium is drinking water which may provide up to 200 mg/day. Also the plant drugs having their core boney hard are used to strengthen the bones. For example, khadir (catechu), Babbul, Laksha, etc. also some specific drugs are used, like Asthishrinkhla. Drugs rich in calcium may be occasionally used to compensate deficiency.

b) Jatharagni & Digestion of food Digestion of food plays an important role in nutrition of bones, one and all. Food is the main source of calcium and other essential nutrients. According to the concept of Ayurveda, Agni is the digestive power in the body. It is the factor responsible for any transformation in the body. Jatharagni digests the food and makes it available for the absorption in body. Unless the Agni is functioning properly, whatever nutrients we eat will not be beneficial for the body completely. The jatharagni can be compared with the cumulative function of gastric juices, gastric acidity, bile and digestive enzymes together.

The function of Agni can be illustrated as follows, Hunger and thirst are caused by Agni at meal time. When person is hungry, gastric juices are secreted in more quantity. For absorption of calcium gastric acidity is of great help. Calcitonin decreases serum calcium and prevents bone resorption. Calcitonin secretion is stimulated when there is secretion of gastro-intestinal hormones, gasrtin and cholecystokinin – pancreozymine which are secreted after meals. In this period calcium absorption from the gut rises, this is well established. This way serum calcium does not become dangerously high and extra calcium in serum coming from food is deposited on the bones. In addition glucagons also stimulate it.

The custom of Tambul bhakshanam in India can also be justified on the same ground as, ‘Tambul bhakshanam’ is advised after meals. Tmbul contains lime, catechu and betel leaves. This provides good calcium supplement and nutrition to bones. Also the increased absorption of calcium at that particular time makes this calcium available for bone nutrition. Catechu used in Tambula is also an important drug for bones according to Ayurveda. Also it helps to improve the digestion. Appetizers like Marich, Jiraka, Dadimamla, etc. and other spices are also useful as they stimulate the hunger. So absorption of calcium, iron etc. is enhanced.

c) Grahani & absorption of nutrients Native place of Agni or pitta is ‘grahani’ which is anatomically compared with duodenum. The well function of grahani is said to be responsible for good digestion of food. Also it functions for differentiation of nutrients and waste products, absorption of nutrients, formation of urine and faeces etc.

The importance of Grahani can be explained in following manner. Daily requirement of calcium is 0.8 gm/day in adults. It may be less than even 0.5 gm/day. If the dietary calcium intake is low, the absorption of calcium by intestine becomes very avid. Whereas where the dietary calcium intake of the calcium is high, the intestinal calcium absorption becomes poor. Thus the intestine regulates the calcium by adjusting the absorption of calcium. This adjustment of absorption is made possible by changing the availability of 1, 25 dehydroxy cholecalciferol (a vitamin D derivative). Active transport against concentration gradient depends on 1, 25 dehydroxy cholecalciferol which occurs in the duodenum. Passive diffusion occurs in small intestine in small amounts i.e. nearly 15%. Where 1, 25 dehydroxyl cholecalciferol is low, calcium absorption also decreases.

Total calcium we get is from dietary calcium and calcium from G.I. juices. In this way the Agni and grahani plays a main role in nutrition of bones. Thus the efficient digestive system leads to good nourishment. Drugs like Chitrak, Musta, Erandkarkati (papaya) are well known to improve digestion.

d) Bhrajakagni &Vitamin D Another form of Agni that regulates the bone formation is Bhrajakagni. This can be explained as the digestive power that digests the nutrients from skin and make it available for body. It also illustrates the skin colour. Vit. D is formed under skin in presence of U.V. rays in sunlight. Vit. D3 irradiated dehydro cholesterol. Small intestine and bones are the principal target organs. So, the Bhrajakagni should be proper for proper formation of vitamin D. Also enough exposure to the sunlight is essential. Massage with oil and then fomentation with steam or warm water is also a good exercise to worship the Bhrajakagni. Food material like liver, egg yolk, butter, cheese, milk and other milk products, fish, fish liver oil are consumed as vitamin D supplement.

e) Dhatwagni & formation of target Rasa (lymph/serum), Rakta (blood), Mamsa (flesh), Meda (fat), Asthi (bone), Majja (marrow), Shukra (semen) are the 7 dhatu that constitute the body. Nutrient material from the digested food is separated in grahani and picked up in the circulatory system. Saptadhatwagni works for digestion of useful component of digested food for the formation of respective dhatu. Asthi dhatwagni digests nutrients for the nourishment of bones.

In blood calcium occurs in serum. On average serum calcium level is 10 mg/ 100 ml. about half of this i.e. 5 mg/100 ml occurs in ionized form. This is the active form. Of the rest 50%, most i.e. about 4 mg/100 ml bounds with the serum protein. The rest 1 mg/100 ml occurs in complex with citrate and phosphate. The combine amount of complex calcium and ionized calcium is the ultra filterable calcium of serum. Also it is called diffusible fraction.

It is not important what level of calcium is in the serum, but the most important thing is its usable fraction and the dhatwagni that makes it available for use in body. For example, in condition of severe protein malnutrition, protein bound calcium decreases but ionized calcium remains normal. As a result, total serum calcium decreases but patient doesn’t suffer from calcium deficiency syndrome. On the other hand, when blood pH increases protein bound fraction of calcium in serum increases. Hence in alkalosis though total serum calcium level remains within normal limits, patient may suffer from tetany, the calcium deficiency symptom. In this way normal functioning of dhatwagni is important for appropriate use of available nutrients.

As the dhatwagni is responsible for the utilization of available nutrition from circulation for the nutrition of specific dhatu, it is also important to maintain dhatwagni in proper function. As the jatharagni is the governing Agni, maintenance of jathragni serves for welfare of all other Agni in body. Also specific medicines are used for boosting of specific Dhatwagni.

Treatment of Asthisaushirya (Osteoporosis): As the precautions described earlier, the treatment can also be divided into various categories as follows.

a) Nutrition: All essential nutrient elements as described earlier should be included in diet in adequate quantity. Calcium containing drugs like Prawal panchamrit, Bhasma of Kukkutand twak (egg shell), Shankha, Shukti, Varatika, Mukta (pearl), Prawal (coral), and Ajaasthi should be used. Even adequate exposure to sunlight is necessary to get vitamin D. In addition to that, Rasayana drugs like Chyavanprash, Brahma Rasayana, Shilajatu Rasayana, Agastya Haritaki shows good results.

b) Digestion: As digestion plays an important role, much attention is needed towards this. Rather this issue should be considered at first, because improper digestion is the root cause of most of the diseases. Indigestion results into ‘Aam’ that is responsible for Srotorodh- a sort of obstruction in the systemic functions of body is also a product of improper digestion. Aam pachan and dipan drugs like Kravyada rasa, Chitrak Haritaki, Hingwashtak churna, Lavanbhaskar churna, Jeerakadyarishta, Drakshasava, Panchakolasava can be taken for that.

c) Dhatwagni: As the amount of nutrients like calcium is not required in much quantity, on the contrary over intake of calcium retards its absorption through gut. Hence drugs modifying the dhatwagni to improve absorption and deposition of calcium should be used. Drugs like Khadir Saar, Babul, Laksha, doesn’t contain much significant chemical constituent similar to bone, but it probably works by improving the dhatwagni for bones. Other drugs modifying Dhatwagni are Suvarna malini vasant, Madhumalini vasant, Asthi-Majja pachaka guggul, Aabha guggul, Lakshadi guggul, Abhrak bhasma etc.

d) Exercise: Proper exercise certainly improves bone health. Bones undergoing stress are remodeled as a tough one. Exercise like jogging, weight lifting, sit ups and other weight bearing exercises can help a lot.

e) Snehana: As Asthi and Vayu are in inverse proportion, use of Sneha like oils, ghee, vasa, majja are useful to reduce hollowness of bones. Snehanea in form of Snehabasti, Majja Basti, Tikta ksheer basti, Sidhha Ghrit basti, external application and internal consumption is useful. Also Tiktak ghrit, Mahatiktak ghrit are useful. Swedana (fomentation) followed by Snehana is also useful. Panchakarma as well shows good results.

f) Menopausal treatment: In case of females, special attention should be given. Because hormonal imbalance at menopause is responsible for osteoporosis there. Treatment for menopausal syndrome must be followed along with above mentioned things. Also regular check up is advisable to rule out progress.

Authors: *Dr. Pranit Ambulkar and **Dr. Swati Rahangdale

* National Institute of Ayurveda, Jaipur. ** Government Ayurved College, Nanded, India.

Source: Harrison’s principles of internal medicine, 16th editionGuyton’s textbook of medical physiology, 11th editionRasa yoga sagara by Hariprapanna SharmaChakradatta- Rtnaprabha commentary by NishchalkaraAshtanga Sangraha- Indu commentary (CCIM)