Role of Low Carbohydrate Diet and Panchakarma Therapy in Reduction of Hba1c with Special Reference to Diabetic Retinopathy in Type 2 Diabetes Mellitus - Case Series

: Diabetes Mellitus (DM, Type I and II included) are prevalent metabolic disorders that cause high blood sugar levels over an extended period of time due to unhealthy lifestyle modifications. Diabetic retinopathy (DR) is a complication that causes abnormalities in the retina to be seen as early as 10 years after the onset of DM or even earlier. The DR is main cause of visual impairment in patients with DM. Considering the limitations of standard treatments for DR there is a need for complementary medicine. Panchakarma has been documented to be effective in controlling DM. This article explores the role of diet and panchakarma in three different patients suffering with DR. The patients underwent eye assessment and evaluation of the various risk factors for DR followed by study therapy. The eye evaluations post study therapy show improvement in near vision and visual acuity in both eyes of the three patients described herein. In these patients, ophthalmoscopy confirmed that the exudates and haemorrhages were decreased post-treatment. We report no side effects or adverse events related to study therapy in the concerned patients. Hence, DR may be prevented by strict glycemic control and annual dilated eye examination by an ophthalmologist. Therefore, we conclude positive effect of study therapy for DM patients with DR. Studies with larger sample size and follow up are warranted to generalize this finding.


Introduction
Diabetes Mellitus (DM) is a metabolic condition characterized by unusually high blood sugar levels as a result of a combination of environmental or inherited causes.High blood sugar levels for a long time can harm the entire body and its processes, leading to diabetic neuropathy, diabetic nephropathy, and diabetic retinopathy.[1] Diabetic retinopathy (DR) is caused by progressive damage to the blood vessels of the light-sensitive tissue in the retina.The standard treatment for DR is LASER Photocoagulation, which prevents blood and fluid leaking in the retina but does not address the underlying pathophysiology of the disease [2,3].DR is characterized by haemorrhages, abnormal growth of blood vessels, hard exudates, aneurysms, and cotton wool spots eventually leading to partial/complete blindness.[3,4].The duration of the disease is the best predictor of DR while severity of hyperglycaemia is key alterable risk factor associated with DR.The duration of DR in all the 3 cases ranged from one to two years.

Case Description
Clinical Symptoms: DR related clinical symptoms seen in patients were ranging from blurred vision, floaters and flashes, partial vision loss, dark areas in the vision, distorted vision to poor night vision [3,5,6].

Patient 1
Before: Vitreous Haemorrhage (left eye more than the right eye).
Left eye: Long standing vitreous haemorrhage, hazy view of fundus due to haemorrhage.
The scan was not possible due to vitreous haemorrhage.
After: Resolved vitreous haemorrhage in both eyes.

Patient 2
Before: Right eye infero temporal fresh bleed, supero temporal fresh bleed.Left eye inferior bleed resulting in hazy view of retina, inferior blood vessels not visible.Multiple hard exudates.Proliferative diabetic retinopathy with vitreous haemorrhage.
After: Right eye resolved macular edema with few cystic spaces.Left eye resolved macular edema with Vitreo Macular Traction.

Discussion
The medication administered to three patients comprised of Gudmar, Amalki, Haridra extract which are known to prevent microvascular and macrovascular complications.Additionally, Daruharidra is antihyperglycemic and reduces glucose resistance [3,6,7].The low carbohydrate diet followed by the patients was a diet enough energy required [8][9][10].The low carbohydrate diet provides sufficient amount of energy but reduced insulin production thereby leading to fats and proteins usage for energy source in absence of carbohydrates.This gradually reduces the weight.[5,8].Also, we observed average HbA1C (glycatedhaemoglobin) level among three patients with diabetic retinopathy was 9.2% before treatment vs. 6.5% after treatment.Studies have shown that each 1% increase in HbA1c level above 7% increases the chance of the incidence of progression to proliferative diabetic retinopathy by 50%.and development of diabetic macular edema increases by 40%.Conversely, if you reduce your HbA1c by 1% when it's elevated, chance of diabetic macular edema is reduced by 40%.
The goal of Ayurvedic Samshodhana Chikitsa (Bio-cleansing therapy), which includes Panchakarma treatment, is to remove toxic substances from the body and consequently improve immunity.Panchakarma therapy removes disease causing elements and preserve the balance of Doshas thereby increasing the body's tolerance to various therapeutic regimens [3,5,8].Carbon dioxide and other volatile chemicals are expelled from the body through the lungs.Sweat and other body can remove water soluble impurities but liver can only eliminate minor part of fat-soluble harmful substances.Therefore, hazardous fat-soluble substances build up in the body which can be eliminated using oil/ghee in Panchakarma processes [9][10][11].A complication of long-term uncontrolled diabetes caused by defective metabolism and endocrine dysfunction, diabetic retinopathy affects the retina.Rakata (being both a dosha and a dushya) affects all three doshas, particularly vata, pitta, rakta, and kaphaanubandha.The significance of an integrated strategy in healthcare is emphasized by this study.Given the benefits of Ayurvedic treatments, joint research is required to produce evidence for the treatment of DR on a bigger scale [12][13][14].

Conclusion
Diabetic Retinopathy is preventable through glycemic control, healthy lifestyle, eating habits, and annual dilated eye examination by an ophthalmologist.All Ayurvedic treatments of panchakarma were found to be clinically safe and very effective as no adverse events or drug reactions were noticed during the course of therapy.A larger randomized control trial is warranted to generalize the finding s of current study.

Figure 1 .
Figure 1.Patient 1 retina scan, A: Before -vitreous hemorrhage in both eyes; B: After -resolved vitreous hemorrhage in both eyes.
Patient 1 (P1): Male, 59 years old.Disease history: CAD -Percutaneous transluminal coronary angioplasty, hypothyroid, uncontrolled DM (1997 first diagnosis of DM and on Insulin treatment since 2007).He approached Ayurveda based clinic (Madhavbaug clinic) in 2017 for the treatment of the same.

Table 1 .
Clinical and demographic details.