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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 93-103

Role of ayurvedic intervention in the management of anemia


1 Department of Food and Nutrition, Institute of Home Economics, University of Delhi, New Delhi, India
2 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 NCEAR A, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Jul-2019
Date of Decision09-Sep-2019
Date of Acceptance10-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Kapil Yadav
Room No. 37, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_55_19

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  Abstract 

Anemia is an important public health problem in India. Complementary and alternative systems/traditional medicines can also be explored for the control of anemia apart from the existing platforms. Interventions with various herbal and iron formulations have been reported in Ayurveda. Hence, this review was aimed to explore the effect of various ayurvedic drugs on anemia from the existing literature. Literature was searched in PubMed, Google Scholar, Cochrane Library, Medline (Ovid), IndMed and by cross-referencing the articles. Key words used included “Pandu Roga,” “Anemia” and “Ayurveda.” The search was restricted to original research articles published in the English language from January 2005 to June 2018 among human subjects. Randomized and nonrandomized control trials were included in this review, which assessed the effectiveness of ayurvedic drugs on improvement in hemoglobin as well as subjective parameters such as weakness, anorexia, and pallor. Effectiveness of 17 different Ayurvedic preparations was assessed in the studies. The maximum increase in hemoglobin was observed by the drug Sarva-juara-hara-lauha in a dose of 500 mg (145.55 mg elemental iron), when administered daily for 30 days using honey as a vehicle. Increase in hemoglobin from 7.3 ± 1.9 to 12.1 ± 1.6 g/dL was observed. All studies that assessed the effect of the drugs on the basis of subjective parameters reported a decreased percentage of complaints by the patients. No adverse reactions were reported. In conclusion, administration of ayurvedic drugs is an effective and safe approach for prevention and management of anemia in various population groups. However, larger multicentric studies are required to assess the exact potential of these drugs in the control of anemia.

Keywords: Anemia, Ayurveda, Pandu Roga


How to cite this article:
Agarwal I, Yadav K, Ramaswami G, Rai T. Role of ayurvedic intervention in the management of anemia. Indian J Community Fam Med 2020;6:93-103

How to cite this URL:
Agarwal I, Yadav K, Ramaswami G, Rai T. Role of ayurvedic intervention in the management of anemia. Indian J Community Fam Med [serial online] 2020 [cited 2021 May 13];6:93-103. Available from: https://www.ijcfm.org/text.asp?2020/6/2/93/304795


  Introduction Top


Anemia is an important public health problem throughout the world. Globally, around 1.62 billion people are affected by anemia which corresponds to one-fourth of the world's population.[1] The World Health Organization (WHO) defines anemia as “a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs.”[2] The global prevalence of anemia 2011 estimated that the prevalence of anemia among children (42.6%) was the highest followed by pregnant women (38.2%) and women of reproductive age group (29.4%).[2] The burden of anemia is relatively high in Low and Middle Income Countries (LMIC) where malnutrition and infections like malaria and soil-transmitted helminths play a major role. The National Family Health Survey-4 (NFHS-4) reports, 58.5% of under-five children and half of the pregnant women are anemic in India.[3] According to the WHO's classification of countries, anemia is a serious public health problem in India. Iron deficiency is the most common cause of anemia in LMICs, however micronutrient deficiencies such as folate, Vitamin B12 and Vitamin A deficiencies and other conditions such as inflammation, parasitic infections and inherited disorders can also cause anemia.[4] Consumption of diet rich in iron could be the ideal way for control of anemia in the majority of the population. However, poor intake of dietary iron and the presence of iron absorption inhibitors necessitates iron supplementation.[5] In India, oral Iron-Folic Acid (IFA) tablets are supplemented to high-risk populations such as pregnant and lactating women, under-five children (IFA syrup), children of 6–10 years, adolescents and women of reproductive age group.[6] However, the undesirable side effects of oral IFAs, such as epigastric discomfort, nausea, gastritis, diarrhoea, or constipation, leads to poor adherence to oral IFA supplements.[7] The poor adherence to IFA tablets was evidenced by studies conducted in various parts of India and also in NFHS-4 where only 30% of the pregnant women consumed at least 100 IFA tablets.[3],[8],[9] Therefore, there is a dire need for alternative methods of oral iron supplementation with lesser side effects to increase the adherence among the target population.

Complementary and Alternative Medicines or Traditional Medicines, which includes Ayurveda, Unani, Siddha, and Homeopathy (AYUSH) has been widely in India since the ancient period. Acknowledging the wider acceptance of AYUSH, Government of India has integrated the traditional systems of medicine (AYUSH) with the allopathic system, especially in rural areas.[10] Each public health sector facility has a separate department for AYUSH and the AYUSH medical officer manages a wide range of diseases.[11] Among the AYUSH system of medicines, Ayurveda refers to “Science of life” or “Science of longevity,” which is being practiced in India since 2500 BC.[12] Around 70% of the rural population in India follows the Ayurvedic system of medicine.[13] Hence, the Ayurvedic system can be explored for control of high burden of anemia in India. In Ayurvedic classical texts, anemia is referred to as “Pandu” meaning pallor, which is one of the common symptoms of anemia.[14] An Ayurvedic drug “Tablet Punarvadu Mandur (ISM Preparation of Iron)” has already been added in Accredited Social Health Activist (ASHA) drug kit for management of anemia in pregnancy.[15] The ayurvedic system has also indicated the use of various iron-containing and noniron containing herbal formulations for the management of anemia. Hence, this review aims to explore the effect of various ayurvedic preparations in management anemia.


  Methodology Top


Search strategy

Literature search was carried out by two authors in PubMed, Google Scholar, Cochrane Library, Medline (Ovid), IndMed and also by cross-referencing the articles. Key words used for the purpose of this review included “Pandu Roga,” “Anemia,” “Ayurveda” and the search strategy included the Boolean operator - “Ayurveda and Anemia” and also “Ayurveda and Pandu Roga.” Specific key words for restricting the search to interventional studies were not used to avoid missing of relevant literatures. The literature search was done from June to July 2018 and the articles published during the period of 2005 to June 2018 were included.

Selection criteria

Search was restricted to intervention studies published in the English language. Original research involving human subjects were only included in the review. Both Randomized Control Trials (RCTs) and nonrandomized trials based on community/hospital/other facilities were included.

Data extraction

Articles were screened by examining the titles and abstracts and were excluded at this stage. The following articles were excluded:

  1. Articles with full text not accessible
  2. Duplicated articles
  3. Review articles and editorials
  4. Studies without any intervention
  5. Abstract only articles or conference papers.


Full-texts of eligible articles were accessed and read for the purpose of this review. A data extraction sheet was used to extract details such as study title, author name, year of publication, objectives, study participants, interventions, and outcomes.

Outcome

Outcome indicators to assess the impact of Ayurvedic intervention were subcategorized as -

  • Primary outcome


    • Effect on hemoglobin level


  • Secondary outcome


    • Effect on other hematological and biochemical parameters such as serum ferritin, Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin Concentration (MCHC) and MCH and Total Iron-Binding Capacity (TIBC)
    • Effect on subjective parameters of anemia such as Dourbalya (weakness), Aruchi (anorexia), Arohanayasa (exertional dyspnea), Angamarda (fatigue), Hriddava (palpitation), Shiroruja (headache), Pandutva of Netra (pallor), Rukshangata (dryness), Shotha (edema), and Alasya (lassitude)
    • Adverse events following Ayurvedic drug administration.



  Results Top


In total, 1547 articles were obtained using the search strategy. Of them, 1532 were excluded; they were observational studies or conference proceedings (1524), duplication studies (4) and review articles (4). In total, 15 studies were included in this review and the process is depicted in [Figure 1]. No restriction was placed for the geographical region of the studies; however, only Indian studies were found pertinent. Community or facility-based trials published during years 2005–2018 were reviewed.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]
Figure 1: Search strategy for selection of articles

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Type of studies

Seven were RCTs[18],[19],[23],[24],[25],[29],[31] and the remaining 8 were quasi-experimental trials (before and after intervention).[16],[17],[20],[22],[26],[27],[28],[30] Of the 15 studies, 12 were from outpatient or inpatient departments of hospitals, two from schools or colleges and study site was not clearly mentioned in one study. Of the 12 studies from hospitals, 11 were from Ayurvedic health centres.

Study population and sample size

The individuals with anemia identified from outpatient or inpatient departments or from schools and colleges were included in the trails. Sample size in the selected trials varied from 25 to 1646. Of the total studies reviewed, six were among adults,[17],[19],[20],[28],[29],[31] three among adolescents,[23],[24],[25] four among pregnant women,[16],[26],[27],[30] one each among children aged 1–16 years,[18] and geriatric (50–80 years) patients.[22]

Intervention

Both iron containing and non-iron containing Ayurvedic preparations were studied to assess their effect on anemia [Table 1]. All ayurvedic drugs were produced in a laboratory and were provided to the participants.[16],[17],[18],[19],[20],[22],[23],[24],[25],[26],[27],[28],[30],[31] However, in one study, the participants were asked to purchase the drugs.[29] Of the seven RCTs, two compared iron-containing Ayurvedic preparations with an allopathic oral IFA tablet[23],[29] and three RCTs compared noniron containing Ayurvedic preparations with oral IFA tablet.[19],[24],[25] One RCT compared Ayurvedic iron preparation with a non-Ayurvedic iron preparation.[31] All eight non-RCTs used iron-containing Ayurvedic drug without any control group. The content of iron was mentioned in one RCT and two non-RCTs. A study on children decided the dosage of the drug according to body weight,[18] while a fixed dosage was prescribed to all participants in the rest of the studies. The drugs in some studies were administered along with a vehicle to enhance iron absorption and increase digestibility. Various vehicles used included lemon water,[30] buttermilk,[16],[22],[23],[29] honey,[19],[29] ghee[19],[29] and ginger extract.[29] The duration of intervention ranged from 28 to 120 days and the duration of observation after intervention ranged from 28 days to 180 days. Deworming before the intervention was done among the study participants in all the studies. To ensure compliance, weekly,[24],[25] fortnightly[18],[20] and monthly follow-ups[23] were done in a few studies.
Table 1: Summary of literature on ayurvedic preparations for anemia

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Hemoglobin estimation

The method used for hemoglobin estimation varied between studies. Dacie and Lewis method was used in one study,[29] cyan-meth hemoglobin in two studies[24],[25] and the method of hemoglobin estimation was not mentioned in other studies.

Outcome assessment

Eleven out of fifteen studies assessed the effect of ayurvedic drug based on both objective and subjective parameters[16],[17],[18],[19],[22],[23],[26],[27],[28] and the remaining studies assessed only the objective parameters.[24],[25],[29],[31] Objective parameters include various haematological parameters-hemoglobin, serum ferritin, MCV, MCH, MCHC and TIBC. Subjective parameters were the symptoms of “Pandu,” anemia, which include, Dourbalya (weakness), Aruchi (anorexia), Arohanayasa (exertional dyspnoea), Angamarda (fatigue), Hriddava (palpitation), Shiroruja (headache), Pandutva of netra (pallor), Rukshangata (dryness), Shotha (oedema) and Alasya (lassitude).

Effect on hematological parameters

All studies have assessed the effect of Ayurvedic drugs on hemoglobin concentration and reported an increase in hemoglobin level after the intervention. However, increase in hemoglobin was not statistically significant in four studies.[19],[22],[27],[28] Sharma et al. reported a maximum increase by Sarva-juara-hara-lauha, which contained 145.5 mg elemental iron and was administered with honey as a vehicle for 30 days. Increase in hemoglobin from 7.3 ± 1.9 to 12.1 ± 1.6 g/dL was observed in this drug.[29] Other significant improvement in hemoglobin concentration was observed in Kasisa Bhasma (1.88 g/dL) and Dhatri Avaleha (1.2 g/dL).[31]

Effect on other hematological and biochemical parameters

Other parameters such as serum iron, serum ferritin, TIBC, MCH, MCHC, and MCV were assessed in 12 studies and nine of them have reported significant improvement in the haematological and biochemical parameters.

Effect on subjective parameters

Subjective parameters of anemia such as Dourbalya (weakness), Aruchi (anorexia), Arohanayasa (exertional dyspnoea), Angamarda (fatigue), Hriddava (palpitation), Shiroruja (headache), Pandutva of netra (pallor), Rukshangata (dryness), Shotha (edema), and Alasya (lassitude) were assessed in eleven out of 15 studies included in the review. The objective parameters were also assessed in those studies. Of the eight studies, six reported significant improvement in both objective and subjective parameters, while five studies reported statistically significant improvement only in subjective parameters after the intervention. Eight studies attempted to assess the effect of therapy on signs and symptoms of anemia on a Likert scale in which the severity was ranged from one to four.[16],[17],[18],[19],[22],[23],[26],[27],[30]

Adverse effect

Eleven studies have reported the details on observation of any adverse event following Ayurvedic drug administration. No adverse event was observed during the study period in those studies. The studies have reported mild to moderate gastrointestinal adverse effect for the allopathic oral IFA tablets in the comparative group.


  Discussion Top


In total, 15 studies were included in this review to assess the effectiveness of Ayurvedic preparations on the management of iron deficiency anemia. The studies included both randomized and non-RCTs conducted across various age groups with different ayurvedic preparations and dose, with varied effects on anemia. Both iron-containing and noniron containing Ayurvedic preparations were assessed in the studies. The effect of Ayurvedic drug compared to oral IFA tablets varied across the studies. Significant improvement in subjective parameters of anemia was reported in all the studies and more than one-third of the studies reported improvement in hematological parameters of anemia. Although four studies had reported significant improvement in subjective parameters, there was no improvement in hematological or biochemical parameters. None of the studies of reported serious adverse effect following administration of Ayurvedic preparations.

A literature review conducted by Prajapati and Acharya found that there are around 176 Ayurvedic formulations with 37 different dosage forms are available for management of anemia (Pandu).[12] Around 17 Ayurvedic preparations with different dosage have been used in the studies included in the current review. The mode of action of Ayurvedic preparations and their components were mentioned in all the 15 studies. However, few studies which included iron-containing Ayurvedic preparations have not mentioned the iron content explicitly. Studies have mentioned that the vehicle which is administered along with the Ayurvedic preparation has substantial role on the effect of the drug. However, the effect of vehicle has not been explored in any of the studies. Samal J had conducted a similar review on Ayurvedic preparations on the management of anemia, included studies published till 2014.[32] The newer studies included in the current review has relatively shorter intervention period (30–90 days) and tried to compare the effectiveness of iron-containing and noniron-containing iron preparations with oral IFA tablets. Ayurvedic drugs were found to have similar effects as IFA tablets with less side effects.

Ayurvedic preparations such as Kasīsa bhasma, Navayasa Curna, Punarnavadi Mandura, Dhatri Lauha, Pradarantaka, Lauha, Sarva-Juara-Hara Lauha, Vrihat Yakrdari Lauha, Sootshekhar Rasaootshekhar plus Sitopaladi Churna, Amaranthus viridis, BioIron, Vajravatakmandura, Trikatrayadi Lauha, and Amalaki Rasayana reported significant improvement in hematological parameters compared to the baseline values or control group. The noniron containing Ayurvedic preparation Dhātrī avaleha, also showed significant improvement in hematological parameters after the intervention. However, Punarnava Mandura, Pandughnivati, and Dhatrilauhavati, which are iron-containing Ayurvedic preparations have not shown significant improvement in hematological parameters. Punarnava Mandura, an Ayurvedic preparation which is included in ASHA's drug kit under National Health Mission, showed significant improvement in hematogical parameters in two studies[16],[29] but failed to show such effect in two other studies.[22],[28] The difference in study population, duration of intervention and dosage of the Ayurvedic preparation could be the reason for such variation. The studies without significant improvement in hematological parameters provided only half of the dose of Ayurvedic drugs, compared to the studies with significant improvement. The duration of dosage was either same or more and included geriatric patients in the previous one. The subjective symptoms of anemia improved in all the studies, though there no improvement in hematological parameters in a few studies. This difference could be due to multiple facts such as nonblinding, social desirability bias and the detection bias in the trials.

The studies included different age group population such as children, adults, pregnant women and also geriatric population. The Ayurvedic preparations were found to be palatable among children and also had components with laxative effect to relieve constipation among the elderly. The most common and undesirable adverse event, gastrointestinal disturbance associated with oral IFA intake was not reported in any of the Ayurvedic preparations. Indeed, none of the studies have reported any adverse event. However, few case studies have reported lead toxicity associated with Ayurvedic preparations used for the management of fertility, low back pain, arthritis, and diabetes from various parts of the world.[12],[33],[34] None of the studies included in this review mentioned about monitoring for heavy metal poisoning. Exploring the risk of heavy metal poisoning and standardization of Ayurvedic preparations is very crucial to include this traditional system of medicine in routine care for the management of anemia. Further research on Ayurvedic preparations in the management of anemia from community-based studies are also required. Furthermore, the role of the vehicle with different Ayurvedic preparations and cost-effectiveness compared to oral IFA should also be explored.

Findings of this review have few important public health implications. The Ayurvedic system of medicine is followed by more than one-third of the rural population in India and also gaining popularity in urban areas. Research evidence suggests that Ayurvedic preparation can improve the hemoglobin level and other hematological parameters of anemia across various age groups, including pregnant women and children. Therefore, Ayurvedic preparations could be effective in reducing the burden of anemia in India, where medical pluralistic culture is prevalent. However, public health policy measures are required to implement, regularize and monitor the Ayurvedic preparations for control of anemia.

The review has a few limitations. All the studies included in this review were from India. Hence the study results cannot be generalizable to other high or low- and middle-income countries. However, the traditional systems of medicines are indigenous to each country; therefore, nongeneralizability to other countries need not to be taken with serious concern. Second, all the studies have been conducted in controlled settings such as Ayurvedic health facilities or other facilities such as schools and colleges, where the acceptance and adherence to the prescribed medications could be different from the general population. The results have to be interpreted with caution because of the limited sample size, study site, design, and the bias associated with the studies.


  Conclusion Top


This review concludes that the administration of ayurvedic drugs could be an effective approach for prevention and management of anemia in various age groups. Major advantage with ayurvedic formulations is that they are considered to be safe and do not result in any adverse reactions. They can be incorporated and promoted at all levels of health care along with the allopathic drugs for control of anemia. However, larger multicentric studies are required to assess and prove the exact potential of these drugs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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