Bringing Evidence Basis to Decision Making in Complementary and Alternative Medicine (CAM): Prakriti (Constitution) Analysis in Ayurveda

Predominant Mahabhuta
Representative Dosha
Akash + Vayu
Vata
Agni
Pitta
Jala + Prithvi
Kapha
A theory of tridosha, thereby, seems to be the physiological application of the theory of panchamahabhuta where a compositional enquiry can be made by the observation of functions, and a judgment about compositional imbalance can be made through the malfunction of the system. Because of their potential to represent compositional specificity, a dosha activity observation in healthy state in a person can give us an idea about its normal panchabhautic status i.e., prakriti. This is how a judgment about prakriti can be made through the observation of biological functions in a healthy person.
Incidentally, it should also be known that every single voluntary act of human being, every single interaction with environment, and every edible has also been defined for their possible effects upon the panchbhautic composition of an individual. It is in this purview, the dietary or voluntary recommendations are made in Ayurveda for their possible role in health maintenance or in disease management.

7.3 Evidence Basis to Prakriti: The Scientific Correlates

Prakriti in Ayurveda is essentially explained in terms of relative dosha activity. Dosha, in light of the preceding discussions, can well be considered as the physiological extension to panchmahabhuta theory. This ingenious hypothesis of Ayurveda helps to understand the process of disease and health within the limited knowledge resources available in nature.
Being an identical reflection to functioning dosha, prakriti is supposed to represent physical, mental, and physiological specifications in any individual. On the other hand, dosha and hence the function of the body is proposed to be the reflection of prakriti.
An individual prakriti finally manifests through a mechanism involving an interplay of inherited principles, environment, maternal dietary factors, and age of the mother at the time of conception and the same in turn is reflected through physical and physiological features of the newborn.
It can be hypothesized that possibly the panchbhautic composition and hence the corresponding dosha activities are resumed at the earliest stages of fetal growth (from the status of zygote formation itself). This in turn can affect the fetal growth through the process of cell differentiation determining the physical and functional fate of a cell, tissue, or organ in individual body. Surprisingly, this hypothesis seems similar to the idea of differential gene expression in living cells, which possibly explains to the different fate of cells under the influence of signals leading to the differential expression of genes finally leading to the corresponding activation of mRNA and the production of resultant proteins [2].
Every living cell of an organism is known to be composed of a complete set of substances required to form an entire new organism. This phenomenon is called totipotencey. What a cell will become in the course of normal development depends upon the determination of different cell types (cell fates), which operates through a progressive restriction to their developmental potentials. When a cell chooses a particular fate, it is said to be determined, although it still looks similar to its undetermined neighbors. Determination implies a stable change, as the fate of determined cells does not change. It is possibly at this stage that the prakriti of an individual is finally determined. Differentiation follows determination, as the cell now undergoes a cell-specific developmental program.

7.3.1 Mechanism of Prakriti Determination Through Cellular Differentiation

How does a cell become different from its parent cell? How do two identical daughter cells become different from one another? How might one daughter cell become a neuron, while the other daughter cell becomes a skin cell? A prakriti differentiation among individuals and siblings can aptly be defined through this primary cellular mechanism of cell differentiation. In some cases, determination results from the asymmetric segregation of cellular determinants. However, in most cases, determination is the result of inductive signaling between cells.
Asymmetric segregation of cellular determinants is based on the asymmetric localization of cytoplasmic molecules (usually proteins or mRNAs) within a cell before it divides. During cell division, one daughter cell receives most or all of the localized molecules, while the other daughter cell receives less (or none) of these molecules. This result in two different daughter cells, which then take on different cell fates based on differences in gene expression. The localized cytoplasmic determinants are often mRNAs encoding transcription factors, or the transcription factors themselves. Unequal segregation of cellular determinants is observed during early development of the C. elegans and Drosophila embryos. From Ayurvedic perspective proposing for a five elemental composition to every living cell, this could be the differential distribution of these formative elements among daughter cells leading to their differential fate through variable dosha activity resulting through the differential gene expression.
The prakriti is conceived to be decided at cell determination stage when this is no more changeable. Further to the determination, at the stage of differentiation, it is possibly the elemental predominance, which acts as the signal to differential expression of genes and hence making a path to the morphological and function differentiation of the cells. Without any convincing data to support with, panchamahabhuta theory of Ayurveda seems to operate at a level deeper than differential gene expressions. It tries to underline the various reasons, which may possibly act as the signals to make a cell differentiated. These signals can aptly be called as panchbhut in Ayurveda, and a prakriti may be proposed as a net characterization of determined cells, which are differentiated gradually to express them morphologically and functionally in course of their development.

7.3.2 Mechanism of Cell Differentiation: Ayurvedic View

Ayurveda prima-facie considers the maternal (matraja bhava), paternal (pitraja bhava) inheritance and maternal dietary influence (rasaj bhava) as responsible for distinctive features in every fetus [12]. These influencing factors with reference to the prakriti determination may act via signals which either operate through a differential elemental distribution or support to a particular element group. Ayurveda proposes an elemental predominance representation through the physical, physiological, and mental features attributed to the corresponding element [33]. Following is a summary of Ayurvedic perception of how panchabhuta are represented phenotypically in growing fetus and how they are responsible for bringing specific features to growing fetus (Table 7.2).

Table 7.2

Phenotypical representation of panchbhautic predominance
Elements
Physical feature
Physiological feature
Mental feature
Akasha
Ear, small ness, fine ness
Acoustic capacity
Capacity to distinguish between right and wrong (vivek)
Vayu
Skin, gross and subtle movements, dryness
Touch perception, circulation, internal movements
Impulse generation, motivation
Agni
Appearance, eyes
Warmth, digestion, metabolism, vision
Objective perception
Jala
Tongue, softness and suppleness, oilyness
Taste perception
Flexibility
Prithvi
Nose, physical strength, heaviness, toughness
Olfactory perception
Rigidity
It is proposed that panchamahabhuta are responsible for the arousal of specific perceptions and corresponding sense organs in the body. Apart from physical specifications as softness, roughness, physical dimensions, toughness, and gross appearance, they are also responsible for some specific physiological and mental functions.

7.3.3 Evidences from the Genomic Studies

Because of its invasion into almost every theoretical and practical aspect of Ayurveda, prakriti fundamentally and dosha as its applied extension, presented themselves as the central dogma of Ayurveda. Fascinated by its possible application to Ayurvedic diagnostics and for its being as an evidence to help decision making for personalized treatment, it has recently evoked the scientific community to look at the issue in their own perspectives [9]. It was vividly approached to see if the prakriti has a genomic basis [12, 35]. In a meticulous approach to quantify tridosha through biostatistical methods, Joshi [7] succeeded to conclude that tridosha has a concrete empirical basis which can be utilized for its scientific establishment. Inspired by the initial findings of Patwardhan [12] showing a positive correlation between different prakriti and HLA alleles, an intense brainstorming among biologists ensued and resulted in coinage of a term Ayurvedic biology [36] as a bid to differentiate Ayurvedic understanding of health and disease from that of conventional biology. Clearly underpinning the importance of prakriti to Ayurvedic understanding, Valiathan, the proponent of Ayurvedic biology, stated, “Since innate disposition determines the manifestation of disease and individual response to treatment, one of the first things a physician does is to determine the prakriti of his patient. This is necessary to personalize the treatment in accordance to the basic principles of Ayurveda. It is clearly suggested that dosa prakriti represents phenotypes” [36]. These initial visions and subsequent efforts by Indian academy of science (IAS) and Indian National Science Academy (INSA) provoked the Government of India to launch an innovative project intended to make genomic variation analysis and gene expression profiling of human dosha prakriti based on the principles of Ayurveda. Con sequential to the approaches made to define Ayurvedic genomics [11, 12], a further advancement is made by the identification of biochemical correlates and whole genome expression to the extreme constitutional types as described in Ayurveda [15]. This landmark study interestingly was able to reveal differences at gene expression level, biochemical level, and also genomic level in different phenotypic groups as per the Ayurvedic classification. Differential gene expression is possibly the concept, which looks more appealing with reference to prakriti as it permits various internal and external factors to operate at different levels to make a final cumulative conglomeration of features in the form of phenotype. Some approaches have recently been made to identify the role of various signals in differential gene expression during the developmental phases. It was noted in these studies that specific signals were able to produce specific gene expressions determining the physiological fate of the cell line [24]. This is again in accordance with the fundamentals of prakriti, which repeatedly says that various factors operating at the time of conception and also during the developmental phase of the fetus finally determine the prakriti of an individual.
It would be of interest to note that the concept of prakriti is luring scientists for its novelty since long. Almost a decade back, it was seriously thought as an important factor determining the final outcome of any therapeutic intervention in a given population. Dah anukar and Thatte [1] in a revealing study were able to correlate the therapeutic outcomes with phenotypical specifications as described in Ayurveda [1]. Incidentally, it can also be noted that similar phenotype-response correlation studies are usually done in almost every postgraduate research work conducted so far at various Ayurvedic institutes in India [19].

7.4 Clinical Application of Prakriti Identification: Translating Theory into Practice

Prakriti typology is finally determined as per the differential distribution of three dosha in an individual. A unilevel increase of dosha is called mono-doshic prakriti, which in turn can be vata, pitta, or kapha predominant respectively. An exigency of any two dosha among the three is called bidoshik (dvandaja) prakriti. There can be three such combinations including vata-pitta, vata–kapha, and pitta-kapha among this category of prakriti. Finally, a homogenous distribution of three dosha in an individual forms another category called as homogenous constitution (sam prakriti)(Fig. 7.1). Sam prakriti representing a homogenous distribution of dosha is considered as an ideal prakriti because of its proximity to health owing to the balance of physiological activities consequential to a dosha balance there in. In real clinical situation, however, this is a rarity and a heterogeneous distribution of dosha is commonly observed. Interestingly, a heterogeneous distribution of dosha is marked in ayurveda for its disease proneness consequential to its association with particular dosha and simultaneous dissociation with others. Among many possible variables of heterogeneous prakriti, a single dosha predominance prakriti is further identified as sadatura (ever sick people) for its exceeding proneness and quick adherence toward diseases. It is conventionally belived that the people with a specific dosha predominance have an increased preponderance of suffering the disease due to the same dosha if there are discrepancies in diet and routine favoring the exigency of the same. Similarly, as an important health promotive measure,they are advised to go for a balanced diet with special care to not exceed the factors which may lead to an excess of the predominant dosha in their prakriti.

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Fig. 7.1

Prakriti typology: a proposal to differential distribution of dosha
Prakriti identification, besides its role in the identification of the disease susceptibility, has also been identified as a key factor in the prognostication of a disease. Coneventionally, a disease where the causative dosha is found similar to that of primary constitution of the patient is presumed to be difficult to treat. Conversely, an antagonizing combination of the two is proposed as an indicator to a fair to good prognosis.
It is a known fact that a drug does not lead to similar effects upon its every recipient. These variations of drug effect among individuals are primarily due to the pharmacodynamic differences among individuals getting reflected through variable handling of the drug by their own biological system. Prakriti of an individual again intercepts at this point by determining as to what would be the possible impact of a drug in a given individual. It is interesting to note that the adversities of a drug are more common in people where the properties of a drug are similar to that of the patient prakriti. A pitta prakriti person, for example may be more prone for the adversity from a drug which is having pitta augmentive property. Individual drug sensitivities and adversities are tried to be explained in this connotation of Ayurveda [16, 21].
Despite its seemingly promising implications upon clinical practice, a serious attempt to bring prakriti examination in routine medical practice has sparingly been attempted. A definitive role of prakriti to the prevalence and prognosis of rheumatoid arthritis( RA) was identified in 2001 by Rastogi et al. [19].This report identified a vata-pitta constitutional subtype as more prone yet fairly treatable fraction among the RA population. RA was found to be less severely manifested in this population subgroup. Conversly, a vata–kapha subgroup of RA population is found to be worst hit owing to its severe presentation leading to a bad prognosis. A similar approach was applied recently in a clinical trial upon lymphatic filariasis treated with an ayurvedic traditional herbal formulation (ATF) [10]. A prakriti

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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on Bringing Evidence Basis to Decision Making in Complementary and Alternative Medicine (CAM): Prakriti (Constitution) Analysis in Ayurveda
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