Efficacy of Samsarjanakrama in a patient with Agnimandya due to vyadhi sankar: A case study

Most of the people experience digestive problems like constipation, diarrhoea, acid eructations, loss of appetite etc. at some stage of life. These are the acute conditions that appear due to Agnimandya (reduced power of digestion, assimilation and metabolism). Conditions that may cause Agnimandya includes changes in diet and lifestyle and chronic diseased conditions. When the Agnimandya or the conditions that may cause Agnimandya persist for longer duration it turns into a life threatening disease. When Doshas (body humours) get aggravated, they affect the Agni (Power of digestion, assimilation and metabolism) and thus the food taken is not digested properly forming the Ama (morbid material). Ama when formed is accumulated in the body over the period of time, forming roots of many diseases. In the present case study the patient has Agnimandya, because of the chronic metabolic conditions. The Agnimandya and consequent nutritional deficiencies are addressed, while preparing the treatment protocol. The central focus of Ayurvedic treatment is the management of Agni and the Ama. The diet was advised on the line of Samsarjana Krama (Sequential administration of liquid diet to normal diet to kindle the Agni or digestive power) and the effect of treatment was analysed after 1 month. The symptoms of the diseases were reduced along with the improvement in the Agni and the nutritional status.


Introduction
Impairment of the Agni is one of the most important etiological factor for causation of diseases as per Ayurveda. There are 4 types of Agni e Samagani (normal digestive, assimilation and metabolic power), Mandagni (reduced power of digestiion, assimilation and metabolism) Teekshnagni (Intense power of digestion, assimilation and metabolism) and Vishamagni (Some time intense and some times reduced power of digestion, assimilation and metabolism) [1, Grahani chikitsa, ch 15/50-51] among them only Samagni is normal and other types being harmful. Impaired state of Agni results in various diseases or disease combinations. Most of the people experience digestive problems like constipation, diarrhoea, acid eructations, loss of appetite etc. at some stage of life. These are the acute conditions that appear due to Agnimandya (reduced power of digestion, assimilation and metabolism). Conditions that may cause Agnimandya include changes in diet and lifestyle and chronic diseased conditions. When the Agnimandya or the conditions that may cause Agnimandya persist for longer duration, it turns into a life threatening disease.
Aggravated Kapha is one among the important causes for Agnimandya (reduced power of digestion, assimilation and metabolism). leading to improper digestion of ingested food consequently producing Ama. Further, accumulated Ama in the due course of time, gives rise to various diseases. In the present case, the metabolic syndrome including components like obesity, hypertension, dyslipidemia, diabetes mellitus, CVD, are produced due to Agnimandya, and Ama.
In Ayurveda "Vyadhi sankara" is the term used for the above mentioned co-existence phenomenon in an individual [ In the present study the patient is suffering from Agnimandya due to coexistence of various metabolic disorders, hence the line of treatment for Agni dipana is based on the Samsarjana Krama (Sequential administration of liquid diet to normal diet to kindle the Agni or digestive power) [2, Siddhi sthana; Kalpana Siddhi Ch 1/ 11-12]. The gradual inclusion of progressively heavy food from light food like Manda (liquid part only), Peya (includes both liquid and rice grains), Vilepi (More rice grains with little amount of liquid), Krishara (Semi solid preparation made of pulse and rice) to Bhakta (Rice) or Rotika (Indian pan cake), Yusha (Soup made of pulses) in a sequential order in Samsarjana krama (Graduated dietetic protocol), enhances Agni [2, Siddhi Sthana; Kalpana Siddhi, Ch 1/12] and brings about better acclimatization.

History of present illness
A 59 years old female, visited Lifestyle OPD of AIIA, with complaints of Anannabhilasha (Loss of Appetite) along with early satiety, Amlapitta (Hyper-acidity), Adhovata and Urdhvavata (Flatulence and Belching) and general weakness along with tachycardia. Patient also complained of constipation. Disturbed sleep along with restlessness at night was also reported. Detailed Examination (

History of past illness
Patient has a history of diabetes (Type2), hypertension, hypothyroidism and CHD. Patient has a history of angioplasty and cholecystectomy.

Family history
She has a family history of diabetes, hypertension and CHD.

Personal history
Prakriti was assessed using the PPAT (by S Rastogi and Prakriti) was found to be Vata-Kaphaj. Dietary information before intervention is provided in Table 2.

Agni
There is a significant change in the Appetite of the patient in the past 3 months and the amount of food intake has reduced to <75% (previously used to eat e 3 chapati now 1 chapati, no rice intake and the amount of vegetable from 1 full bowl to less than half bowl). Agni was assessed based on the "Abhyavaran Shakti" and "Jaran Shakti". Abhyavaran shakti was assessed by the decrease in the amount of intake of food. Jaran Shakti was assessed by the patient's complaint of flatulence.
Also the patient experiences early satiety and sweating and heaviness while taking meal.

Anthropometric measures
Height e 150 cm; Weight e 45 kgs (weight loss in past 3 monthse10 kgs); Mid arm circumference e 12 cm; Waist circumference À36 cms; Waist e Hip Ratio e 0.5.

Intervention
The patient was advised to take Sadhita Manda (liquid part after cooking 1 part of rice in 14 parts of water followed by seasoning with ghee, ginger, long pepper, black pepper and rock salt), for 2 days until the normal hunger is regained. This was followed by Peya and Yusha for 1 week then Vilepi for 1 week.
Followed by Yavagu for 1 week and then the appetite of patient gradually improved and diet was shifted to normal. The adherence and tolerability was assessed by daily follow up of the patient (on call). (The details of the intervention is provided in Table 3) Along with this patient was also taking fruits, tea and milk. Patients total calorie intake was gradually increased to 1200 calories keeping in mind the amount of nourishment required and the Agni of the patient.

Results
Patient was treated from October 2018 to November 2018. Outcome on all the parameters showed significant improvement. The weight of the patient increased from Kg to 48 Kg in 36 days (Table 4) Tachycardia improved and pulse rate at the 36th day was within normal limits (86 BPM). Food intake was increased to 75% which was less than 75% in the beginning of the study (measurement was done based on the required calorie intake. In the beginning of the study patient complained of early satiety along with various Dhatu kshaya symptoms like Ruksha kesha (Dry hair), Ruksha Tvak (Dry Skin), Hridrva (Palpitations on little efforts), Arasagyta (Tastelessness), Hrullas (Nausea), Tvak sputana (Cracking of lips), pallor, Sandhi shithilata (Weakness of joints), Bhangura danta (Brittle tooth), Danta Shoola (Pain in dentures), Mukha shosha (Dryness of mouth), Daurbalya (Fatigue), Durmana (Irritation). In the end of the study there was Decrease in palpitations and nausea but no improvement was noticed in twak and Kesha. Cracking of lips and pallor also decreased significantly, there was no weakness of joints, tooth ache, dryness of mouth and fatigue were also relieved. Patients diet intake pattern was also recorded in the beginning, a few changes were made including walking after meals and the gap between sleep and meals was increased (Table 5). There was improvement in the patient's overall condition post treatment on 37 th day.

Discussion
In case of wholesome food intake, medicine is not required and medicines won't do any good in case of unwholesome food intake  [5]. The root cause of all the diseases is Agnimandya. In this particular case the patient has a disease complex of hypothyroidism, diabetes mellitus, hypertension and cardiac disorders. The first problem that patient suffered was hypothyroidism, which is otherwise correlated to Medo Dhatvagnimandya [6], followed by other diseases. Diabetes mellitus is a type of Vataja Prameha, Agnimandya due to Vata [5] is thus one of   Apart from Agnidipana the other factors that should be considered, while prescribing a dietary intervention is the nutrient quality of the food articles. The Manda, Peya and Vilepi are taken in the current study, because these food items are time tested for enhancement of Agni, and are used in Samsarjana Krama also [2, Sidhi Sthana; Vamanvirechan vyapad Sidhi, Ch 6 /24]. Manda, Peya and Vilepi were prepared using rice and water (in varying amount), to gradually increase the Agni. Manda is easily digestible as it is isoosmolar with the human body fluids (Osmolarity is the amount of total number of solute particles in a liter of liquid [7]). In Peya the amount of grains is more as compared to the Manda, but the amount of water was kept equal (14 parts), the food is also and brought about Raktavriddhi the fuel for Agni. Apart from enhancing the Agni these dietary items are high in nutrition and hence cover the nutrient loss also.
While giving the various preparations 'Trikatu' and 'Ghrita' were added as adjuvant, both Trikatu [5] and Ghrita act as Deepana (enhance digestion) and thus enhance the absorption of nutrients in food and active principles in medicines. Trikatu helps in digestion of Ama formed due to Agnimandya and Trikatu also prevents further Ama formation [8, ch 38/ 59]. Ghrita reduces the dryness due to its Snigdhata (unctuousness). As per eight factors of food intake (Ashta Ahara Vidhi) intake of unctuous food is advocated [2, Vimana Sthana; Rasa Vimaniya, Ch 1/21], in this case intake of ghee enhances Agni. Peya and Vilepi were advised to be taken with Mudga Yusha, as it breaks the monotony of the taste and also enhances the nutritive value by adding the limiting protein methionine in the rice meal. Warm water was advised after the meals as it quenches the thirst and also it helps in enhancement of the Agni and is always conducive to the human beings [8, ch 45/39-40]. Also, Takra (butter milk) was advised along with the Vilepi, as it enhances the Agni and also reduces obstruction in channel due to lekhana (scraping) property [8, ch 45/ 74].
Apart from the dietary preparations given at the meal time, patient was also taking fruits and tea. Only apple and Pomegranate were advised to be taken with the seasoning of salt and pepper. Apple is high in nutrients, with salt and pepper there is increased digestibility and absorption. Pomegranate helped to reduce palpitation due to Pittahara, Hridya (cardiac tonic) property and brought about Raktavriddhi [9]. by rich minerals, vitamins and antioxidants. As the patient was accustomed for intake of Tea, it was restricted to only 2 cups/day. Lifestyle of the patient before treatment was well managed and hence no changes were made.

Conclusion
The case mentioned above was diagnosed with Vyadhi Sankara in terms of Ayurveda, patient's condition was deteriorating, because of the Agnimandya. The dietary advice was given on the line of S. krama to improve the status of Agni, which was the root cause for multiple ailments. The Agni improved and also nutritional status showed a little improvement with relief of symptoms like nausea, palpitation, pallor and cracking of lips after treatment.

Future recommendations
Cases of chronic Agnimandya can be treated in the line of Samsarjanakrama with success. This line of dietary intervention not only enhances the Agni, but also improves the nutritional status.

Strengths and limitations
There is very limited work on how Ayurvedic diet can help a patient in various diseases. And a very little published work is available on Ayurvedic diet as an intervention; the strength of this work is that the author has used only Ayurvedic methods of diet and lifestyle assessment and intervention.
Limitations e this work could have been more comprehensive, if the Ayurvedic assessment scales for nutritional status and quality of life were available.

Source(s) of funding
None.

Conflict of interest
None.