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Prakṛti and Variations in Platelet Aggregation

As platelet reactivity, which markedly influences the pathological outcome of thrombosis and sensitivity to anti-platelet drugs, has been reported to exhibit inter-individual variations (Bray 2006), Bhalerao et al. (2012) attempted to study whether platelet aggregation in response to adenosine diphosphate (A.D.P.) and its inhibition with aspirin varies in various prakrti subtypes. The prakrti of 137 subjects was assessed by two ayurvedic physicians. The authors observed that platelet aggregation induced by A.D.P. and the inhibitory effect of aspirin differed according to prakrti. Thus,

vata-pitta prakrti individuals had the highest maximal platelet aggregation compared to other prakrti types. These individuals also showed highest inhibition of aggregation after exposure to 2.5 pM aspirin. A limitation of the study is the unequal number of subjects in different prakrti groups and the small sample size (n = 4) in vata-kapha and kapha-vata types. As it is known that the inter-individual differences in platelet aggregation response to A.D.P. are more pronounced at lower concentrations of A.D.P. (1, 2 or 5 pM) (Fontana et al. 2003), the study of platelet aggregation using 1 and 2 pM A.D.P. may prove more fruitful.

Cardiovascular Responses and Prakṛti

With the aim of identifying physiological parameters that can serve as good indicators of prakrti, Tripathi et al. (2011) conducted a study in 90 randomly selected clinically healthy volunteers belonging to dual constitutional types like vata-pitta, pitta-kapha or vata-kapha. They evaluated the variability of heart rate and arterial blood pressure in response to specific postural changes, exercise and the cold pressor test. The results suggest that these basic cardiovascular responses do not vary significantly according to the dual constitutional types. However, the authors noted a significant fall in diastolic blood pressure immediately after performing the isotonic exercise for five minutes in vata-kapha individuals in comparison to pitta-kapha and vata-pitta prakrti.

Autonomic Responses and Prakrti

In a subsequent study Rapolu et al. (2015) investigated whether autonomic function tests vary according to prakrti of individuals. They conducted this study in 106 healthy volunteers of both genders belonging to the age group of 17 to 35 years. The prakrti of these volunteers was assessed using a validated questionnaire and also by the traditional method of interviewing. After confirmation of prakrti, volunteers were grouped into three on the basis of dominant dosa. They were then subjected to various autonomic function tests like the cold pressor test, standing-to-lying ratio, Valsalva ratio and pupillary responses such as pupil cycle time and pupil size measurement in light and dark (Low et al. 2013).

The results of the study suggest that the autonomic function tests in healthy individuals may correlate linearly with the dominant dosa expressed in the prakrti of the individual. Notably, individuals belonging to кар/ш-dominant prakrti showed a tendency to have either a higher parasympathetic activity or a lower sympathetic activity related to their cardiovascular reactivity in comparison to individuals with /)/»«-dominant or vdta -dominant prakrti (Rapolu et al. 2015). This study also suggests that various autonomic function tests, which are already reported to show variability in responses (Manor et al. 1981; Moodithaya and Avadhany 2009; 2012) can be used as indicators of prakrti. However, their clinical suitability needs to be validated.

Isotonic Aerobic Exercise and Prakrti

Tiwari et al. (2012) studied the effect of isotonic aerobic exercise (walking) on some physiological parameters in individuals belonging to three dual-c/dsY/ prakrti (vata-pitta, vata-kapha and pitta- kapha) groups. A total of 83 diabetics (age ranging from 35 to 65 years) were included in this study. 51 diabetics formed the experimental group and 32 formed the diabetic control group. Pulse rate, blood pressure and respiratory rate were measured before exercise, after 1 month and after 3 months. Hematological parameters like blood sugar and cholesterol were estimated before exercise, and after 3 months. Diabetic patients were encouraged to walk for 30 minutes every day for 3 months on empty stomach.

Highly significant decrease in systolic blood pressure was observed in vata-pitta, pitta-kapha and vata-kapha prakrti individuals of the experimental group after the isotonic exercise. All the three groups showed significant decrease in mean pulse rate and respiratory rate after walking. Significant lowering of fasting blood sugar levels was observed in vata-pitta and pitta-kapha individuals of the experimental group. However, all the three groups showed significant lowering of cholesterol and post-prandial blood sugar levels after exercise (Tiwari et al. 2012).

DNA Methylation Analysis of Prakrti Groups

Genetic factors alone cannot explain the phenotypic variations observed in the human race. It may involve many non-genetic (epigenetic) influences. Heyn et al. (2013) reported the identification of DNA methylation markers in three human populations viz., Caucasian-Americans, African- Americans and Han-Chinese Americans. Therefore, DNA methylation may contribute to human developmental plasticity, adaptation and manifestation of distinct phenotypes. Rotti et al. (2015) studied the association of natural DNA methylation variations in prakrti-based grouping of populations. Whole blood genomic D.N.A. collected from 147 randomly selected male volunteers of dominant prakrti (Vata = 47, Pitta = 48, Kapha = 52) was used for data analysis. Their study showed that large proportions of D.N.A. methylation patterns are common between various prakrti groups. The observed differences in methylation signatures between prakrti suggests that different mechanisms may influence and sustain the expression of key regulator genes involved in the manifestation of distinct phenotypes. Pitta prakrti showed a higher number of methylated CpG islands in the gene body region, whereas promoters’ regions were more methylated in kapha prakrti (Rotti et al. 2015).

Several methylated sequences of vata prakrti were found to be represented in biological processes like cell communication, transcription, signal transduction pathways and embryo morphogenesis. The associated genes are involved especially in neuronal development. Additionally, the NFIX gene was found to be associated with low body mass index (B.M.I.) which is one of the characteristic signs of vata prakrti (Rotti et al. 2015).

Pitta prakrti showed enrichment of m.RS.R.s (methylated prakrti-specific regions) for metabolism-related pathways like regulation of hormone secretion, regulation of nucleic acid metabolism and several others. Kapha m.RS.R.-associated genes were significantly enriched in cell growth and maintenance, cytoskeleton anchoring activity and cellular adhesion (Rotti et al. 2015). The 501 different m.RS.R.s identified in the present study were sufficient to classify the study subjects on the basis of prakrti, thus providing molecular evidence for one of the core concepts of Ayurveda (Rotti et al. 2015).

Immunophenotyping of Prakrti Groups

Variability in immune response is often attributed to and measured from expression of C.D. markers in lymphocytes. At present, no reports are available on the expression of C.D. markers related to prakrti. Therefore, Rotti et al. (2014) evaluated a panel of lymphocyte subset C.D. markers in individuals belonging to a dominant prakrti. Immunophenotyping was carried out using whole blood samples from 222 healthy subjects, grouped into kapha (n = 95), pitta (n = 57) and vata (n = 70) prakrti. C.D. markers such as C.D.3, C.D.4, C.D.8, C.D. 14, C.D.25, C.D.56, C.D.69, C.D.71 and H.L.A.-D.R. were analyzed using the flow cytometry method. A significant difference in the expression of C.D. markers such as C.D. 14 (monocytes), C.D.25 (activated В cells) and C.D.56 (natural killer cells) was observed between different prakrti groups. C.D.25 and C.D.56 expression was significantly higher in kapha prakrti samples. Similarly, slightly higher levels of C.D. 14 were observed in pitta prakrti samples. Significant difference in the expression of C.D. 14, C.D.25 and C.D.56 markers between three different prakrti was observed. The increased level of C.D.25 and CD.56 in kapha prakrti may indicate better immune response in these individuals.

Association of Prakṛti with Diseases

Individuals belonging to various prakrti are prone to diseases related to the respective element (s) of tridosa (Upadhyaya 1975c). The earliest report on the impact of prakrti on the appearance of diseases is that of Venkatraghavan et al. (1987). They assessed the prakrti of 28 cancer patients attending the out-patient department of Government General Hospital, Madras. 57 normal, healthy individuals were considered as controls. Among the 28 patients, 1 belonged to the vata-dominant prakrti, 17 to the /л'Мз-dominant prakrti and 10 to the kapha-dominant prakrti. The percentage of pitta-dominant prakrti in the control group was 17.54%, whereas 60.7 % patients in the cancer group belonged to p/fta-dominant prakrti. Though limited by small sample size, this study shows that pitta- and кар/га-dominant individuals are more prone to cancer.

Coronary artery disease (C. A.D.) has elements of cellular proliferation and metabolic abnormalities (Ballantyne et al. 2008). Therefore, an anomalous expression of certain elements related to the prakrti of the individual will be more prevalent in C.A.D. So far, no study has demonstrated the association of risk factors (diabetes, hypertension), inflammatory markers and insulin resistance with prakrti in patients suffering from cardiovascular disease. Mahalle et al. (2012) attempted to correlate constitutional types with cardiovascular risk factors, inflammatory markers and insulin resistance among subjects with established C.A.D.

The prakrti of 300 patients with C.A.D (>25 years) was assessed. Biochemical parameters, inflammation markers (h.s.C.R.P., T.N.F.-alpha and I.L.-6) and insulin resistance (H.O.M.A.-I.R.) of the subjects were measured. The mean age of patients was 60.97 ± 12.5 years and 62.3% of subjects belonged to the vata-kapha prakrti. Triglyceride, V.L.D.L. and L.D.L. were significantly higher and

H. D.L. cholesterol was significantly lower in vata-kapha prakrti in comparison with other prakrti groups. Vata-kapha prakrti was correlated with diabetes mellitus, hypertension and dyslipidemia. Inflammatory markers and H.O.M.A.-I.R. were also high in vata-kapha prakrti. Inflammation markers were correlated positively with both vata-kapha and kapha prakrti. There is strong relation of risk factors (diabetes, hypertension, dyslipidemia), insulin resistance, and inflammatory markers with vata-kapha and kapha prakrti. The major limitation of the study was male predominance, and lower numbers of subjects in some groups of prakrti (Mahalle et al. 2012).

A similar study was reported by Manyam and Kumar (2013). They assessed the prakrti of 75 patients with established Parkinson’s disease and 73 normal subjects with no known neurological disease. The results showed that the incidence of Parkinson’s disease was highest in individuals belonging to vata prakrti. The incidence of the disease was higher in men than in women.

Irritable bowel syndrome (I.B.S.) is a functional gastrointestinal disorder with no known organic cause. It is characterized by chronic abdominal pain, discomfort, bloating and alteration of bowel habits. Depending on the predominant symptom, I.B.S. can be classified into subtypes such as

I. B.S. with diarrhea (I.B.S.-D.), I.B.S. with constipation (I.B.S.-C.) and I.B.S. with mixed symptoms (I.B.S.-M.). Complete cure of I.B.S. cannot be achieved, as there is no pathology in the gut that can be targeted by therapeutic agents (Ford 2013). Therefore, Shirolkar et al. (2015) tried to evaluate the prakrti of I.B.S. patients and their correlation with I.B.S. subtypes. Fifty I.B.S. patients were grouped into ram-dominant, р/Яя-dominant and кар/ш-dominant prakrti using a 24-item questionnaire. Of the 50 I.B.S. patients enrolled, 22 patients each were of vata- and p/to-dominant prakrti, while 6 patients belonged to the кар/га-dominant prakrti.

In the vata-dominant group, I.B.S.-C. was found in 13 patients, I.B.S.-D. in 8 and I.B.S.-M. in 1. In pftta-dominant group I.B.S.-D. was found in 13, I.B.S.-C. in 6 and I.B.S.-M. in 3. In the kapha- dominant group, I.B.S.-C. was found in 5 patients and I.B.S.-M. in 1. The authors concluded that prakrti examination in I.B.S. may help in detecting proneness to developing a given I.B.S. subtype (Shirolkar et al. 2015).

Prakrti in Therapeutics

Identifying phenotypic and genetic heterogeneity, gene-gene interactions and allelic spectrum is a major challenge in understanding complex diseases. Of the several factors which contribute to this, phenotypic heterogeneity is a serious limitation encountered in modern medicine (Manchia et al. 2013). Juyal et al. (2012) opine that conditioning association studies on prior risk, predictable in Ayurveda, will uncover much more variation and advance diagnostics and therapeutics. They attempted identification of genetic susceptibility markers in a rheumatoid arthritis (R.A.) cohort by combining the prakrti-based grouping of individuals with genetic analysis tools. Association of 21 markers from commonly implicated inflammatory and oxidative stress pathways was tested using a case-control approach in a total cohort comprising 325 cases, 356 controls and the three subgroups separately. A few postulates of Ayurveda on the disease characteristics were also tested in the various prakrti groups using clinico-genetic data (Juyal et al. 2012).

Inflammatory genes like I.L.lp and C.D.40 seem to be the determinants in the vata subgroup, while oxidative stress pathway genes are observed in the pitta and kapha subgroups. Fixed effect analysis of the associated markers from C.D.40, S.O.D.3 and T.N.F.-a. with genotype versus prakrti interaction terms suggests heterogeneity of effects within the subgroups, suggesting disease-specific pathways. In addition to these, disease characteristics such as severity were most pronounced in the vata group. The findings of this study suggest the existence of discrete causal pathways for rheumatoid arthritis etiology in prakriti-based subgroups, thereby validating concepts of prakrti and personalized medicine in Ayurveda. This exploratory study supports the contention that subgrouping of patients based on prakrti may help overcome the limitation of phenotypic heterogeneity which hampers progress in complex trait genetics research (Juyal et al. 2012).

As the molecular basis of the different prakrti types has become evident, a new term, “ayurge- nomics”, has come into vogue. Ayurgenomics aims at integration of Ayurveda and genomics for furthering personalized nutrition, diagnosis and treatment of diseases. Validation of the fundamental concepts of Ayurveda and subsequent application of prakr/j'-based phenotyping in complex diseases can offer the least invasive and most affordable way to assess susceptibility to diseases and prognosis. Ayurgenomics can also guide therapeutic and dietary recommendations. Research in Ayurveda had so far been confined to exploration of active principles from Ayurveda herbs indicated in the treatment of various diseases. With the burgeoning of ayurgenomics, efforts are now being made to establish the molecular basis of the principles of Ayurveda (Mukerji and Prasher 2011; Banerjee et al. 2015).

Uniform Method for Assessment of Prakṛti

Astahgahrdaya describes the signs of vata-, pitta- and kapha prakrti (Upadhyaya 1975c). However, various authors have employed questionnaires that do not reflect the teachings of Astahgahrdaya (Venkatraghavan et al. 1987; Joshi 2004; Patwardhan et al. 2005; Prasher et al. 2008; Aggarwal et al. 2010; Ghodke et al. 2011; Shilpa and Murthy 2011; Tripathi et al. 2011; Bhalerao et al. 2012; Juyal et al. 2012; Mahalle et al. 2012; Suchitra and Nagendra 2012; Tiwary et al. 2012: Suchitra and Nagendra 2013; Manyam and Kumar. 2013; Rotti et al. 2014a, 2014b, 2015; Suchitra et al. 2014; Govindaraj et al. 2015; Rapolu et al. 2015; Shirolkaret al. 2015). Kurande et al. (2013a) conducted the first study to investigate comprehensively the inter-rater reliability of prakrti assessment. 15 registered ayurvedic physicians having 3-15 years of experience assessed the prakrti of 300 healthy subjects. Poor to substantial levels of reliability were obtained for the assessment of prakrti. The authors therefore concluded that an objectively defined questionnaire should be used in ayurvedic clinical studies. Such objectivity in diagnosis will improve the confidence of physicians and these methods can be incorporated into ayurvedic clinical trials (Kurande et al. 2013b).

A major problem encountered in ayurvedic diagnosis is the determination of prakrti of individuals. Based on the striking similarities between psychological somatotypes advocated by William H. Sheldon (Vertinsky 2007) and prakrti types of Ayurveda, Rizzo-Sierra (2011) proposed a finite genopsycho-somatotyping of humans. This concept is based on a set of common physiological, morphological and psychological attributes related to a common basic birth constitution which remains somewhat permanent during human lifetime, as it is assumed that this primordial constitution is programmed in the D.N.A. of the individual. This approach provides a tool for classifying human population based on broad and finite phenotype clusters, cutting across barriers of ethnicity, language, geographical location or self-reported ancestry. Rizzo-Sierra (2011) proposes for males that every basic constitution has an associated identification organ, a measured property or marker, a soma and some general psychic tendencies suggesting specific behavior pattern. He proposes three basic extreme genopsycho-somatotypes or birth constitutions. They are mesomorphic or andrus (Pitta), endomorphic or thymus (Kapha) and ectomorphic or thyrus (Vata). This method of genopsycho-somatotyping further postulates that male andrus constitution across races shares similarities in androgen (An) nuclear receptor behavior, while thymus constitution is mainly regulated by T-cells (Tc) nuclear receptor behavior. The thyrus constitution shares similarities in thyroxine (Th) nuclear receptor behavior. According to this hypothesis, these proposed nuclear receptors regulate the expression of specific genes, thereby controlling the embryonic development and metabolism of the human organism in very profound ways. The method predicts small differences in measured properties (An, Tc and Th nuclear receptor behavior) within a birth constitution by modulation effects in melanocyte-stimulating hormone receptor behavior (Rizzo-Sierra 2011). The endocrinological perspective proposed by Rizzo-Sierra (2011) encompassing the ayurvedic concept of prakrti may provide insights for further studies in human classification. Exploratory studies combining genopsycho-somatotyping and extensive experimentation can provide objective and speedy method of assessing the prakrti of individuals.

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