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GESTATIONAL DIABETES MELLITUS; MANAGEMENT THROUGH AYURVEDA

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 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
Chandla et al. World Journal of Pharmacy and Pharmaceutical Sciences
SJIF Impact Factor 6.647

Volume 6, Issue 12, XXX-XXX Review Article ISSN 2278 – 4357

GESTATIONAL DIABETES MELLITUS; MANAGEMENT THROUGH

AYURVEDA

Anubha Chandla1* Rinku Tomer2 and Rosy Gupta3

1,2
Research Officer (Ayu.) Regional Ayurveda Research Institute for Mother and Child
Health, Nagpur.
3
Professor (DravyaGuna), SKSS Ayurvedic College and Hospital, Sarabha, Ludhiana.

Article Received on ABSTRACT

20 Oct. 2017,
Revised on 12 Nov. 2017,
Accepted on 01 Dec. 2017,
DOI: 10.20959/wjpps201712-10703
Gestational diabetes mellitus is defined as carbohydrate intolerance of
variable degree with onset or first recognition during pregnancy. The
prevalence of gestational diabetes mellitus (GDM) is increasing
worldwide. This disease has many detrimental consequences for the

*Corresponding Author woman, the unborn fetus and child. As per International Diabetes
Dr. Anubha Chandla Federation India is one of the Diabetes capitals of the world, harboring
Research Officer (Ayu.) around 4 million women with GDM alone. IDF estimates that 6 million
Regional Ayurveda
births are affected by some form of hyperglycemia in pregnancy in
Research Institute for
India alone, of which 90% are due to GDM. The management of GDM
Mother and Child Health,
Nagpur. aims to mediate the effects of hyperglycemia by controlling blood
dranubhachandla@gmail.com glucose levels. The main way to treat GDM is through lifestyle
changes such as diet, exercise and checking blood glucose levels. In
modern science subcutaneous insulin therapy (mainly) or oral hypoglycemic agents are being
used for treating women with GDM not controlled by lifestyle modification. However both
therapies have certain limitations and have reported potential risks for mother and fetus. So it
is the need of the hour to establish and adopt a much safer evidence based management
protocol for managing GDM through ayurveda treatment principles i.e. aahara,
vihaara(yoga, meditation, breathing exercises) and herbs having antidiabetic potential. The
present study aims to compile an evidence based ayurveda regime in management of GDM.

KEYWORDS: pregnancy, diabetes mellitus, ayurveda management.

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INTRODUCTION
Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance of variable
degree with onset or first recognition in present pregnancy.[1] GDM is associated with both
short- and long-term adverse effects for the mother and her infant. As per International
Diabetes Federation, Diabetes atlas 2015, one in seven births are affected by GDM.[2] India
being the second leading dweller of diabetic subjects, has become the diabetes capital of the
world harboring around 4 million women with GDM alone.[3] In pregnant women suffering
from gestational diabetes, despite a significant reduction in perinatal mortality observed in
the last decade, the morbidity remained essentially unchanged (10-50%).[4] Ayurveda, the
holistic science of life mainly aims at preventing occurrence of disease by following
particular mode of life and diet and then treating disease if it occurs. The factors which
constitute good health, i.e. balanced dosha, dhatu and mala, optimally functioning indriyas or
sense organs, a happy contented soul and a balanced mind are the very factors that go
towards a smooth pregnancy, labour and healthy progeny and this is what ayurveda treatment
focuses on.

AIMS AND OBJECTIVES

1. To study the efficacy of ayurvedic interventions(diet, yoga, antidiabetic herbs) in
managing GDM
2. To establish evidence based ayurveda treatment protocol in controlling hyperglycemia and
related risks in pregnant women.

Methods of data collection: Texts of Ayurveda, Pub med, Cochrane data base of systematic
reviews and concerned national international journals of science were taken as the source of
study.

Literary review: In ayurveda classics description of diabetes comes under prameha where
its different types and detailed management including aahara, vihaara and aushdha chikista
is very well described. There is no direct reference of GD in Ayurveda but garbha vriddhi is
described as a complication. In garbha vriddhi there is excessive increase in size of abdomen
and perspiration and labor is difficult.[5] It can be understood as overweight fetus or
macrosomia due to GD. Pregnancy is associated with progressive insulin resistance. Human
placental lactogen, progesterone, prolactin and cortisol are associated with increased insulin
resistance during pregnancy.[6] Thus GDM usually presents late in the second or during third
trimester.

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Risk factors for GDM[7]

Low risk
a) No known diabetes in first degree relatives
b) Age <25 years
c) Normal body weight before pregnancy(BMI<23)
d) No history of abnormal glucose metabolism
e) No history of poor obstetric outcome

High risk
a) Severe obesity, BMI>30, PCOD
b) Age>35 yrs
c) Strong h/o type 2 diabetes
d) Previous h/o GDM, impaired glucose metabolism or macrosomia
e) Ethnic predisposition(Indians belong to high risk group)
Average risk: women of African, Native American, south or East Asian regions.

Screening protocol[8]
In Indian context, screening is essential in all pregnant women as the Indian women have 11
fold increased risk of developing glucose intolerance during pregnancy compared to
Caucasian women. Recent data on the prevalence of GDM in our country was 16.5% by
WHO criteria of 2 hr PG≥ 140mg/dl. As such universal screening has become important in
our country. Gestational weeks at which screening is recommended: By following the
usual recommendation for screening between 24 -28 weeks of gestation, the chance of
detecting unrecognized type 2 diabetes before pregnancy(pre-GDM) is likely to be missed.
So the recent concept is to screen for glucose in the first trimester itself as the fetal beta cells
respond to maternal glycemic level as early as 16 weeks of gestation. So screening is done at
16 weeks, if negative repeated at 24-28 wks/ any time when symptoms and signs of
hyperglycemia develop and at 32-34 wks. There is usually a two-step approach to diagnosing
diabetes: The initial screening test is Oral Glucose Challenge Test (OGCT).

Oral Glucose Challenge Test: Timings: 24-28 weeks gestation, Testing state: irrespective of
fasting state, Dose of glucose: 75 gm dissolved in glass of water, Blood to be collected after 2
hrs Threshold values: 140mg/dl.

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Oral Glucose Tolerance Test: Done between 24-28 weeks of gestation if OGCT
values>140mg%, testing state: overnight fasting of 8hrs, Dose of glucose: 75gm (WHO)
dissolved in a glass of water, blood is collected in fasting state and at 2hrs after glucose
Either of the values if abnormal, diagnose DM (FBS: ≥126mg% and 2hr PG≥ 140) Health
risks of GDM.[9]

Table No.1.
Mother Fetus New born Child/Adult
Preeclampsia, UTI
Vaginitis, Respiratory distress
Hyperinsulinemia Obesity
Polyhydramnios, syndrome
diabetic coma
Birth trauma Cardiomyopathy Hypoglycemia Type 2 diabetes
Increased CS Still birth Hypocalcemia Metabolic syndrome
Large for Gestational
Type 2 diabetes Hypomagnesemia
Age/Macrosomia
Polycythemia,
Metabolic syndrome Birth trauma hyperbilirubinemia
Cardiomyopathy

General management of GDM: The primary aim of GDM management is to optimize

glucose control (FBS: 90-99 mg/dl and 2hr PPBS<120MG/dl) and improve pregnancy
outcomes. The initial management of GDM involves diet modification and implementation
of an exercise regime.[10] Total calorie intake should be 30 kcal/kg/day (pre pregnant weight,
non-obese). If BMI >27kg/m2 restrict calorie intake to 25k cal/kg/day.

Carbohydrates 40-65%, Fat: 40%, proteins: 20% Moderate exercise (of at least 30 min daily).
Aerobic activities-walking, stationary cycling at least 3 days/wk 20-45 min per session.[11] If
adequate glucose control has not been achieved, the woman generally be prescribed anti-
diabetic medications.

Management of GDM through Ayurveda

Generally beneficial, congenial, purifying and suppressive dietetics and mode of life, not
causing loss of doshas and dhatus but capable of decreasing the aggravated dosha-dhatu
should be used in Garbha vriddhi.[12]

Preventive measures: Adopting preconceptional and thorough antenatal care through

Ayurveda; this aims that a woman enters pregnancy in healthy state of body and mind. While
describing garbhadhan vidhi acharyas have advised certain body purifying measures

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(sanshodhana karma) followed by special dietetics and mode of life for the couple.[13] Again
a special monthwise dietetic regime has been prescribed for the pregnant woman by
following which the woman remains healthy and delivers the child possessing good health,
energy, compactness.[14] Clinical studies have been conducted on this regime and have proved
of great significance to mother and child both.

Actual management
Dietary regime: Diet management plays a significant role in regulating blood sugar level in
DM. Following can be included in the diet (in moderation).

Table No.2.
Bitter vegetables like methi (fenugreek) leaves, karela(bitter gourd), tomatoes,
Vegetables spinach, cucumber, radish, sponge gourd, sahjan(drumstick) leaves & fruits,
broccoli, cauliflower, cabbage
Moonga(green gram), chana daal(Bengal gram), raungi/lobia(black eyed pea),
Pulses
kaabuli chana(chick pea)
Spices Turmeric, cinnamon, fenugreek seeds, garlic
Cereals Wheat, (jau) barley, oats, shashtika rice, bajra(pearl millet)
Fruits Plums, kiwi, lime, oranges, guava, apple, peaches, gooseberry
Dry fruits Almond, apricot, walnut

Yoga
Yoga is a very essential component of ayurveda treatment regime for GD. Yoga is an ancient
mind-body practice that originated in India and encompasses a system of postures (asana),
deep breathing (pranayama) and meditation (dhyana) to bring balance to the physical,
mental, emotional and spiritual dimensions of the individual. Pregnancy is a condition in
which women undergo distinct physiological changes and stress and is accompanied by
unique physical and psychological demands. It is hypothesized that maternal stress may
affect the intrauterine environment and alter fetal development during critical periods,
through either activation of the placental stress system, causing the release and circulation of
corticotrophin releasing hormone, or through diminished blood flow and oxygen to the
uterus.[15] Mind-body practices that cultivate general health, diminish distress and increase
self-awareness, such as tai chi or yoga, maybe be particularly effective in addressing both the
physical and psycho emotional aspects of pregnancy and labor.[16] Meditation and imagery,
have been found to reduce anxiety and endocrine measures, such as cortisol, in women during
labour.[17]

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Regime for yogasana in pregnancy: Yogasana should not be practiced empty stomach.
Light diet is advised one hour before. Also yogasana with lying down on abdomen and
involving much twists and turns are contraindicated. Yogasana are also contraindicated in
cases of threatened abortion, recurrent abortion. The commonly recommended schedule is to
practice yoga from 18 to 32 week of gestation, 1 hour session of yoga at least thrice a week.

Table no. 3. First trimester asanas.[18]

Lying on the back, gentle twists, Supta Baddha Konasana, Marjariasana(Cat
Asanas pose), adho mukha svanasana (dog pose), Uttanasana, Tadasana, surya
namaskar (sun salutation-I), vrikshasana (tree pose), baby pose.

Table No.4. Second trimester asana.[19]

Lying on the back or on the side, pelvis and hip openers, gentle twists, Setu
Bandha, Supta Baddha Konasana, Uttanasana, sun salutation-I with variations,
Trikonasana, Ardha Chandrasana (with and without the wall), Virabhadra asana
(warrior pose), Prasarita Padottanasana(wide legged forward bend) When
Asanas
seated, strengthening and releasing the shoulder girdle, poses that allow pelvic
asymmetry, Baddha Konasana, Upavishta Konasana, Vajrasana, baby pose,
Matsya Kridasan (Flapping Fish Pose), Vajrasan (Thunderbolt Pose), Kati
Chakrasan (Waist Rotating Pose).

Table. 5: Third trimester asanas.[20]

Ardha Titali Asan (Half Butterfly), poorna titali asan
Contracting and compressing the pelvic floor compared to releasing and relaxing it;
Birth advancing poses, Modified sun salutation, sun salutation-I with variations and
Asanas modifications, warrior poses.
Pelvic openers, pelvic asymmetry, strengthening the thighs and shoulder girdle,
stretches, gentle twists. Less lying on the back and more variations on the side; baby
pose, cat pose.

Prenatal yoga under expert supervision significantly reduces pregnant women‟s stress and
enhances their immune function. Studies have been conducted to monitor maternal and fetal
response to 26 yoga postures in pregnancy, which state that practicing yogasana does not
have any adverse on mother (BP) and fetus (FHR).[21]

Role of Pranayama and meditation in GDM

Pranayamic breathing, also known as deep breathing, is defined as a voluntary manipulation
of breath movement and serves as the cornerstone of any yoga practice. Slow deliberate, deep
breathing activates the parasympathetic nervous system mainly by stretching of lung tissue
and the vagal nerves. This leads to a physiological response characterized by a decrease in
heart rate, blood pressure, metabolic rate and oxygen consumption. Deep breathing also

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increases neuroplasticity, defined as the reorganization of neural pathways as an adaptive

response. Studies reveal an increase in neuroplasticity in those who perform yoga, thereby
improving concentration, intelligence quotient scores, and motor control.[22]

Breathing exercises recommended in Pregnancy

Table No.6.
Anulom Vilom It strengthens the body mentally as well as physically. It provides
Pranayam more oxygen to the body so more oxygen is transferred to the fetus
Effective breathing exercise releases agitation, anger, calms the mind,
Bhramaripranayam
improves concentration and removes toxins from body

Herbs in ayurveda for GDM: many different plants have been used individually or in
formulations for treatment of diabetes and its complications. Among these the commonly
used are; turmeric, neem, amalaki, haritaki, bitter gourd, bilva, cinnamon, gymnema,
fenugreek, Allium sativum, Eugenia jambolana, Phyllanthus amarus, Pterocarpus
marsupium, Tinospora cordifolia, Trigonella foenum graecum and Withania somnifera.

Pterocarpus marsupium(Vijaysaar)[23]
Pterocarpus marsupium has been shown to cause pancreatic beta cell regranulation. The
heartwood of the tree is used to make tumblers/ goblets/beakers which are filled with water
and allowed to stand overnight to give „Beeja wood water‟ the positive activity of which
against diabetes has been confirmed. Epicatechin, its active principle, has been found to be
insulinogenic, enhancing insulin release and conversion of proinsulin to insulin in vitro.

Trigonella foenum graecum (Fenugreek)[24]

It is found all over India and the fenugreek seeds are usually used as one of the major
constituents of Indian spices. 4-hydroxyleucine, a novel amino acid from fenugreek seeds
increased glucose stimulated insulin release by isolated islet cells in both rats and humans.

Tinospora cordifolia (Guduchi)[25]

It is a large, glabrous, deciduous climbing shrub belonging to the family Menispermaceae. It
is widely distributed throughout India and commonly known as Guduchi. Oral administration
of the extract of Tinospora cordifolia (T. cordifolia) roots for 6 weeks resulted in a significant
reduction in blood and urine glucose and in lipids in serum and tissues in alloxan diabetic
rats. The extract also prevented a decrease in body weight.

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Phyllanthus amarus (Bhuiawala)[26]

It is a herb of height up to 60 cm, from family Euphorbiaceae. It is commonly known as
Bhuiamala. It is scattered throughout the hotter parts of India, mainly Deccan, Konkan and
south Indian states. Traditionally it is used in diabetes therapeutics. Methanolic extract
of Phyllanthus amarus was found to have potent antioxidant activity. This extract also
reduced the blood sugar in alloxanized diabetic rats. The plant also shows anti-inflammatory,
antimutagenic, anticarcinogenic.

Ocimum sanctum (Holy basil)[27]

It is commonly known as Tulsi. The aqueous extract of leaves of Ocimum sanctum showed
the significant reduction in blood sugar level in both normal and alloxan induced diabetic
rats.

Momordica charantia (Bitter gourd)[28]

Momordica charantia is commonly used as an antidiabetic and antihyperglycemic agent in
India as well as other Asian countries. Extracts of fruit pulp, seed, leaves and whole plant was
shown to have hypoglycemic effect in various animal models. The phytochemical
momordicin, charantin and a few compounds such as galactose-binding lectin and insulin-like
protein isolated from various parts of this plant have been shown to have insulin mimetic
activity.

Eugenia jambolana (Indian gooseberry, jamun)[29]

Oral administration of pulp extract of the fruit of Syzygium cumini to normoglycemic and
STZ induced diabetic rats showed hypoglycemic activity in 30 min possibly mediated by
insulin secretion and inhibited insulinase activity.

Emblica officinalis (Amalaki)[30]

It decreases lipid peroxidation, antioxidant, hypoglycemic.

Azadirachta indica (Neem)[31]

Hydroalcoholic extracts of this plant showed anti-hyperglycemic activity in streptozotocin
treated rats and this effect is because of increase in glucose uptake and glycogen deposition in
isolated rat hemidiaphragm. Apart from having anti-diabetic activity, this plant also has anti-
bacterial, antimalarial, antifertility, hepatoprotective and antioxidant effects.

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Aegle marmelos (Bel or Bilva)[32]

Administration of aqueous extract of leaves improves digestion and reduces blood sugar and
urea, serum cholesterol in alloxanized rats as compared to control. Along with exhibiting
hypoglycemic activity, this extract also prevented peak rise in blood sugar at 1h in oral
glucose tolerance test.

Gymnema sylvestre(Gurmar)[33]: The major bioactive constituents of gymnema are a group

of oleanane type triterpenoid saponins known as gymnemic acids. Gymnema‟s antidiabetic
activity appears to be due to a combination of mechanisms. It increases the activity of
enzymes responsible for glucose uptake and utilization, and inhibits peripheral utilization of
glucose by somatotrophin and corticotrophin.

DISCUSSION
As per the Ayurveda classics, milk and drugs of madhura group have been advised in entire
pregnancy. Other dietary components like honey, ghee, freshly prepared butter, meat soup,
krishra(khichadi), paayas(kheera) have been included at particular months of pregnancy. On
the whole the diet advised is rich in all micronutrients and promotes the health of mother and
baby. Milk is a whole diet and drugs of madhura varga are nourishing as well as have
antioxidant properties. Clinical studies have proved that a daily snack containing leafy green
vegetables, fruit, and milk before and during pregnancy prevents gestational diabetes.[34]

Yoga reduces anxiety, depression and pregnancy related uncomfortable experiences Effect of
integrated yoga on anxiety, depression & wellbeing in normal pregnancy.[35] A randomized
study of yoga in high-risk pregnancy has shown that yoga can potentially be an effective
therapy in reducing GD, hypertensive related complications of pregnancy and improving fetal
outcomes.[36]

A randomized control study on yoga-based visualization and relaxation in high-risk

pregnancy has shown significantly better uteroplacental and fetoplacental blood flow velocity
in the yoga group compared to the control group. The RI in the right uterine artery was
significantly better in the yoga group. This is important because pharmacological solution for
hypertension related complications of pregnancy has shown limited effectiveness in reducing
the uterine artery resistance to blood flow. In spite of these findings, clinical research in
pregnancy involving CAM therapies are still very few and in between. We were able to find

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only one Doppler study using yoga interventions, which also reported fewer complications of
pregnancy and significantly higher birth weight in the yoga group (P < 0.018).[37]

Also studies have been conducted proving that systematic and safe adoption of yoga therapy
module can be effective in reducing the stress level in high risk pregnancies (GDM, PIH,
IUGR, Preeclampsia).[38] Previous study on yoga showed that yoga is a noninvasive,
economical and easy-to-learn solution to improve the quality of life of pregnant women,
improve their abilities to perform their social roles, and potentially prevent adverse obstetrics
outcomes. Pregnancy is a very special time in women's life and yoga can give her the
opportunity and tools to enjoy this miraculous period to the fullest.[39] It was demonstrated
that meditation, breathing, and relaxation techniques which are the essential components of
yoga have a direct and positive impact on the activities of the autonomic nervous system in a
pregnant women.[40]

Mindfulness meditation improves parasympathetic functions in pregnant women and is a

powerful modulator of the sympathetic nervous system during pregnancy. There was a
significant decrease in perceived stress scores, a significant decrease of blood pressure
response to cold pressor test and a significant increase in heart rate variability in the test
group (p< 0.05, significant) which indicates that mindfulness meditation is a powerful
modulator of the sympathetic nervous system and can thereby reduce the day-to-day
perceived stress in pregnant women.[41]

The hypoglycemic effect of some herbal extracts has been confirmed in human and animal
models of type 2 diabetes. The World Health Organization Expert Committee on diabetes has
recommended that traditional medicinal herbs be further investigated.

CONCLUSION
Women with GDM have extra physiological challenges that when left unattended, have the
potential to increase negative pregnancy outcomes for both mother and child. By reviewing
the available literature this can be concluded that gestational diabetes can be managed
effectively on Ayurveda treatment principles (diet, yoga, herbs) which ensure healthy
maternal and fetal outcome. Major hindrance in amalgamation of herbal medicine in modern
medical practices is lack of scientific and clinical data proving their efficacy and safety.
There is a need for conducting clinical research in herbal drugs, developing simple bioassays
for biological standardization, pharmacological and toxicological evaluation and developing

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various animal models for toxicity and safety evaluation. It is also important to establish the
active component/s from these plant extracts.

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