JFP_AE_Shekelle.finalREV 9/20/05 2:40 PM Page 876 APPLIED EVIDENCE New research findings that are changing clinical practice Paul G. Shekelle, MD, PhD; Mary Hardy, MD; Are Ayurvedic herbs Sally C. Morton, PhD; Ian Coulter, PhD; for diabetes effective? Swamy Venuturupalli, MD; Joya Favreau, MD; Limited evidence shows that some herbs and formulas Lara K. Hilton, BA have glucose-lowering effects, and deserve further study Southern California Evidence- Practice recommendations 82 and D-400 were most often studied. Based Practice Center which ■ Limited randomized control trial data Thirty-five of the studies included came includes RAND, Santa Monica, from the Western literature, 27 from Calif (PGS, SCM, LJ, IC, MH) and observational studies show that and Cedars-Sinai Medical the herbs Coccinia indica, holy basil, the Indian. Seven were randomized Center, Los Angeles, Calif fenugreek, Gymnema sylvestre, and controlled trials (RCTs) and 10 controlled (MH, SV, JF); and Greater the herbal formulas Ayush-82 and D-400 clinical trials (CCTs) or natural experiments. Los Angeles VA Healthcare System, Los Angeles, Calif have glucose-lowering effects. But these Twenty-two studies went on to further (PGS) herbs are not as well studied as others analysis based on a set of criteria. Of more familiar to Western medicine. (B) these, 10 were RCTs, CCTs, or natural experiments, 12 were case series or ■ Inform patients who ask about cohort studies. There is evidence to Ayurveda that traditional practitioners suggest that the herbs C indica, holy basil, rely on the interaction of several com- fenugreek, and G sylvestre, and the ponents, of which herbs are just one, herbal formulas Ayush-82 and D-400 and that no formal studies have looked have a glucose-lowering effect and at Ayurveda as a whole system. (B) deserve further study. Evidence of Abstract effectiveness of several other herbs is Objective To evaluate and synthesize less extensive (C tamala, E jambolana, the evidence on the effect of Ayurvedic and Momordica charantia). therapies for diabetes mellitus. Conclusions There is heterogeneity Design Systematic review of trials. in the available literature on Ayurvedic Measurements and main results We treatment for diabetes. Most studies found no study that assessed Ayurvedic test herbal therapy. Heterogeneity exists as a system of care. Botanical therapy in the herbs and formulas tested (more was by far the most commonly studied than 44 different interventions identified) Ayurvedic treatment. Herbs were studied and in the method of their preparation. CORRESPONDING AUTHOR either singly or as formulas. In all, 993 Despite these limitations, there are Paul G. Shekelle, MD, PhD, West Los Angeles VA Medical titles in Western computerized databases sufficient data for several herbs or herbal Center, 111G, 11301 Wilshire and 318 titles identified by hand-search- formulas to warrant further studies. Blvd, Los Angeles, CA 90073. ing journals in India were examined, E-mail: [email protected]. At the time of this study, Dr. yielding 54 articles reporting the results iven the US population’s increas- Shekelle was a Senior of 62 studies. The most-studied herbs ing interest in herbal and alter- Research Associate of the were G sylvestre, C indica, fenugreek, native therapies, it is just a matter Veterans Affairs Health G Services Research and and Eugenia jambolana. A number of of time before you will be fielding ques- Development Service. herbal formulas were tested, but Ayush- tions from patients about Ayurveda— CONTINUED 876 VOL 54, NO 10 / OCTOBER 2005 THE JOURNAL OF FAMILY PRACTICE JFP_AE_Shekelle.final 9/20/05 9:49 AM Page 877 Are Ayurvedic herbs for diabetes effective? ▲ a comprehensive system of health care that doshas dominates. Body types can be dom- originated in India roughly 3000 years ago, inated by a single humor (vata, pitta, or emphasizing the relationships among body, kapha), or they can be dominated by com- mind, and spirit. Diabetes has been a par- binations: vata-kapha (when vata and ticular focus of this medical system, and a kapha are present in almost equal few Ayurvedic herbs do indeed appear to amounts); vata-pitta; pitta-kapha; or vata- exert glucose lowering mechanisms. pitta-kapha. A person’s dosha body type is But how strong is the evidence? expressed physically and emotionally; for Though Ayurveda involves the interaction example, a person with a vata-dominant of many kinds of therapy, this review body type will have a thin frame and an examines only the literature pertaining to insecure temperament. The Ayurvedic herbal remedies your patients with dia- physician takes body type and imbalances betes are likely to ask about. among the doshas into consideration when treating a patient. Application to diabetes. The Indian ■ Ayurveda more than herbs word for diabetes is madhumeha, from Ayurveda (Sanskrit for “knowledge of life” madhu, meaning “sweet/sweetness,” and or “knowledge of longevity”) has now meha, meaning excessive urination. spread beyond India’s borders to include Classical Ayurvedic therapy for madhume- the rest of the Indian subcontinent, Sri ha (diabetes) begins with an assessment of Lanka, Malaysia, Mauritius, South Africa, the dosha imbalance. In all types of prame- Japan, Russia, Europe, and North has (urinary disorders), kapha is vitiated, America. At its root, Ayurveda seeks to but in madhumeha, vata is often aggravat- restore an individual’s innate harmony. ed as well. Therefore, therapies will be Primary Ayurvedic treatments include diet, directed at both vata and kapha simultane- exercise, meditation, herbs, massage, ously to restore the balance of the doshas.1,2 exposure to sunlight, controlled breathing, Herbs are a commonly used treatment and detoxification treatments. in Ayurveda. Ethnobotanical studies of Dosha imbalance. Ayurveda considers traditional herbal remedies used for dia- FAST TRACK human beings a microcosm of nature. All betes around the world have identified Ayurvedic living and nonliving things are believed to more than 1200 species of plants with consist of 5 basic elements: ether (space), hypoglycemic activity. These plants are treatments: air, fire, water, and earth. In humans these broadly distributed throughout 725 differ- diet, exercise, elements combine and manifest in the ent genera. The pharmacopoeia of India is meditation, herbs, human body as 3 humors, or doshas, especially rich in herbal treatments for known as vata, pitta, and kapha. diabetes. Eighty-five percent of the 20 massage, sunlight, The doshas govern all biological, psy- antidiabetes plants most widely used controlled chological, and pathophysiological func- around the world are prescribed in India.3 breathing, tions. They are fundamental to human A few of the herbs commonly used by detoxification health, and an imbalance of the doshas Ayurveda practitioners to treat diabetes brings on illness. Consequently, Ayurveda are summarized in the TABLE. seeks to bring the doshas back into harmo- In response to the increasing interest ny. Balanced doshas, as well as good- in Ayurveda and herbal treatments for dia- quality tissues (dhatus), proper digestion, betes in this country, the National Center and elimination of excretions (malas), for Complimentary and Alternative are considered essential in Ayurveda for Medicine (NCCAM) requested we con- maintaining health. duct a systematic review of Ayurvedic Dosha body type influences treatment. therapy for diabetes. This paper reports In addition, humans are endowed at birth the results of that review, and is a conden- with 1 of 7 body types, depending on sation of an evidence report available at which dosha or combination of the 3 basic www.ahrq.gov/clinic/epcsums/ayurvsum.htm. www.jfponline.com VOL 54, NO 10 / OCTOBER 2005 877 JFP_AE_Shekelle.final 9/20/05 9:49 AM Page 878 APPLIED EVIDENCE TABLE Ayurvedic characteristics of herbs commonly used to treat diabetes HERB TASTE (RASA) INCREASES (AGGRAVATES) DECREASES (PACIFIES) Gymnema Kasaya (astringent) Kapha, Pitta Momordica Tikta (bitter) Kapha, Pitta Trigonella (fenugreek) Tikta (bitter); Madhura (sweet) Pitta Kapha, Vata Coccinia indica Kasaya (astringent); Tikta (bitter) Vata, Pitta Pterocarpus Kasaya (astringent) Vata Source: Kapoor, 1990;32 Dash, 198733 Mishra, Singh, and Dagenais, 2001.34 ■ Methods • The in-person literature search in Identification of literature India—we obtained 16 volumes of We used the search term “Ayurveda” plus abstracts from various Indian Ayurvedic the names of 16 major botanicals charac- journals, as compiled by the Central teristically used in Ayurveda for an initial Council for Research in Ayurveda and search of the Western literature. The Siddha (CCRAS) library. This yielded herbal terms were added to the search to 318 titles. increase its sensitivity, making it possible to • An additional online search of the find studies that used Ayurvedic herbal previously mentioned databases for com- therapy without necessarily being directly mon botanicals used in the treatment of identified as Ayurvedic studies. diabetes. This search yielded 773 addi- We were concerned that a large body tional articles. of literature existed in India that could not • A search of the online CINAHL FAST TRACK be obtained through the conventional database, which yielded 70 articles. Table 1 lists search strategy outlined above. Hence, we • The reference lists of important arti- decided to conduct a search for Ayurvedic cles in the Ayurveda/diabetes literature. We a few Ayurvedic literature from the Indian subcontinent. A identified