On the physical level, Ayurveda teaches us that the health of the digestive system is the single most important long term determinant of your health and well being. Healthy digestion leads to a healthy life. Unhealthy digestion leads to an unhealthy life. It’s often that simple. Healthy digestion assures that all of the nutrients taken in through eating are assimilated in a healthy manner into the cells that become you. In other words, you are what you digest! If your digestion is healthy, your body can produce healthy tissues (dhatus). When digestion is weak, the tissues of your body, such as muscle, blood and nerve, become weak and susceptible to disease. The cause (Nidanam) of digestive disease lies in our actions. By indulging our sense of taste in an unhealthy manner, we upset the balance of the bodily doshas. Vata is upset by cold, dry and light foods such as raw vegetables. Pitta is upset by warm, oily, light foods such as deep fried vegetables and Kapha is upset by cold, heavy, moist foods such as cold ice cream and yogurt. In addition, taking foods in an improper manner can be even more harmful than choosing inappropriate foods. Healthy food taken in the wrong way will still cause digestive disease.
The symptoms of poor digestion include excessive gas, constipation, diarrhea, burping, burning, vomiting, indigestion, bloating and pain. In various forms, Western medicine has given them names such as irritable bowel syndrome, ulcers, colitis and pancreatitis among many others. Through the eyes of Ayurveda, the practitioner comes to an understanding of the cause through examining one’s lifestyle. Faulty eating practices are the number one culprit; poor food choices and poor food combining are next in line. Together they make up the major causes of digestive disease. The Ayurvedic Specialist examines the patient and also comes to an understanding the pathogenesis (Samprapti) of the disease or how the disease unfolded within the body of the patient. By understanding of the pathogenesis, the Clinician can develop a treatment plan to reverse the condition. This treatment plan includes both constitutional treatments to address the patient’s lifestyle and direct treatment to target the compromised area of the body.
The key players in the Ayurvedic pathogenesis of digestive disease are as follows. The nature of their imbalance and how they are interacting determines the presentation of the disease. Jatharagni: This is the digestive fire that governs the catabolism (breakdown) of the food into smaller molecules for digestion. When it is healthy, the body is capable of proper assimilation. When it is too weak, the initial digestion of food is compromised and either malabsorption will take place or ama will form. When it is too strong, burning results.
Samana Vayu: This is a subdosha or type of Vata which governs the absorption of nutrients into the body. Assuming they were broken down properly, samana vayu can guide their absorption. Not only does samana vayu govern absorption but it also directly affects agni as would wind when it blows upon a fire. If the wind is strong, the fire is strong. If the wind is weak, the fire burns low. If the wind fluctuates so does the fire. Faulty samana vayu can lead to gas, diarrhea and malabsorption.
Apana Vayu: This type of Vata governs the downward motion, particularly the excretion of toxins and feces. When it is healthy, elimination is normal and the bowel movements are solid but soft. When apana vayu is faulty, a variety of problems can manifest including both constipation and diarrhea.
Kledak Kapha: This type of Kapha governs the protective mucous lining of the digestive system, particularly that of the stomach. When healthy, it keeps agni and vayu in equilibrium, protecting the membranes from too much heat or dryness. When excessive, mucous forms and nausea results. When diminished, the membranes become susceptible to the irritating effects of agni and the drying effects of vayu. In addition, an increase in the solid nature of Kapha can block the digestive tract and cause constipation.
Pachak Pitta: This type of pitta contains the agni. This is called Pachak agni. This aspect of Jatharagni is responsible for the breakdown of food. Its role is essentially that of Jatharagni. However, since Pitta is fire and water in combination, it is possible to have high pitta and low agni. A metaphor often used to explain this is how water can put out a fire. If fire and water increase together, eventually it is possible that the water will put out the fire. This is the case in chronic pitta digestive disturbances. This results in burning as well as ama formation due to poor digestion.
Ama Dosha: Ama is the end result of poorly digested food. It has sticky qualities which adhere to the channels (srotas) of the body, obstructing flow. It is a toxin which accumulates in the digestive system and is later deposited into the organs and tissues of the body where it contributes to disease. Ama leads to foul odors in the breath and body as well as foul smelling gas.
Constitutional treatments include all habits that support healthy digestion. It is in fact more important how you eat than what you eat! While it sounds absurd, it is better to eat a greasy hamburger properly than basmati rice improperly!
1. Meals should begin with grace in order to create a quiet, calm and respectful environment.
2. Food should be eating in quiet without distractions such as television, reading or excessive conversation.
3. Food should be chewed well.
4. Food should be taken warm.
5. Food should be taken with only a small amount of water.
6. One should rest at the completion of the meal to allow food to digest.
7. The largest meal should be taken near the noon hour when the sun is high and the agni (digestive fire) strongest.
8. One should never overeat. Proper eating means that one begins to look at food intake as a sacred experience, in fact, as a form of meditation.
This spiritual perspective on food (Sadhaka) elevates eating to a holy experience whereby the eater connects to all things past, present, and future; knowing that they are taking into their bodies the primal substance of all matter. In this regard, eating is more than satisfying hunger or indulging the sense of taste, it is a time where we take in the prana and substrate that will become ourselves. With this realization, a person can successfully make eating a meditation. Following the proper guidelines above for healthy eating will correct many digestive problems. Failure to follow them will most certainly cause most. In addition to the healthy intake of food, proper food combining assists with proper digestion. From an Ayurvedic perspective, eating bitters such as salad after a meal is better than doing so before. The bitter taste is cold and weakens agni. Taken at the beginning of a meal it can diminish the digestion of all that follows. Likewise, sweets are digested first. Desserts are best eaten before a meal or as between meal snack. Taken immediately after a meal it may upset digestion. Mixing foods of opposite potencies (vira) can sometimes be problem. Milk, which is cool, should not be mixed with yogurt, which is warm; even though both are dairy. Other rules of food combining are good to follow as well, such as avoiding mixing dairy and meat.
Making the proper food choices is another piece of the Ayurvedic puzzle to creating optimal digestion. One’s food choices should be based on their constitution. This is the unique balance of energy in a person’s body and is defined by the balance of the three doshas, vata, pitta, and kapha. Seeing an Ayurvedic physician or Clinical Ayurvedic Specialist is important to ascertain your constitution (prakruti) as well as the energetic basis of the imbalance (Vikruti). Based upon these determinations a food and lifestyle program can be prescribed which is in harmony with your nature and which leads to optimal digestion.
Proper treatment of digestive disease utilizes herbs to target he affected subdoshas, agni and ama. Herbs have constitutional effects based upon their taste (Rasa), Energy (Virya) and Post Digestive Effect (Vipaka), as well as specific effects based upon the medicinal aspect of the herb (Prabhava). By understanding the nature of the herb, the Clinical Ayurvedic Specialist is able to match up the herbal treatment to the prakruti (constitution) and vikruti (imbalance) of the patient.
Treatment of Agni
In digestive disease, agni may have to be strengthened, diminished or simply stabilized. Increasing agni improves digestion and rids the body of ama. Decreasing agni can be helpful in burning indigestion and ulcers. There are many herbs from around the world that the Ayurvedic Specialist can choose from. Traditionally, herbs can increase agni are called Dipanas and include Chitrak, Clove, Asafetida and the Ayurvedic formula Trikatu which contains two types of pepper and ginger. These herbs are particularly effective which agni is low as in diseases of Kapha nature. In this way they diminish nausea and heaviness after eating. In addition, they alleviate gas produced by weak digestion. Other herbs have a stabilizing effect on agni via their effect upon samana vayu. They can also increase agni without aggravating pitta in the process. These include cumin, coriander and fennel. They improve digestion without any risk of causing the burning symptoms of gastritis. When burning indigestion is dominant and the agni is high, bitter herbs are used which lower agni such as dandelion or gentian as well as the Ayurvedic herb Kutki. The Ayurvedic preparation of red coral, praval pishti, is also directly antacid in nature.
Treatment of Samana Vayu
Samana vayu is best treated using carminative herbs which aid the absorption of nutrients. These herbs include nutmeg, fennel, cumin, and coriander. While each has its own prabhava (special medicinal usage in different diseases), they all regulate samana. Samana vayu is also balanced by adopting regular routines in our lives. Samana vayu is known as the stabilizing air. When our lives are stable and our routines strong, samana stays in balance. This is important to good health because as the balancing air, its role is the stabilization of the other aspects of vata as well as agni. Hence, once out of balance, the other energies in the body quickly suffer.
Treatment of Apana Vayu
Apana Vayu is the downward moving air which eliminates waste. In the colon it governs the evacuation of feces. Imbalances can lead to either constipation or diarrhea. When the motion is too great, it can be slowed in a variety of ways depending upon the state of the other doshas. Nutmeg for instance, best taken in Takra (Yogurt mixed with water) reduces diarrhea when the origin is Vata. Apana can combine with Pitta as well and when it does bitter / astringent herbs work best such as red raspberry as well as small amounts of psyllium which absorbs water creating bulk. Vitiation of apana can also lead to dry stools and subsequent constipation. Oily herbs and foods help this condition. Herbs such as licorice or shatavari can be effective. The Ayurvedic formula Triphala is commonly used with success as is the Western herb Cascara Sagrada. When the heat of the Pitta is to blame for the dryness and consequent vitiation of the apana, moist cool herbs such as shatavari and cholagogues such as dandelion can be used. When apana is blocked by kapha, stronger purgatives are needed such as senna, castor oil or the Ayurvedic herb trivit.
Treatment of Kledaka Kapha
Kledaka Kapha is the subdosha governing the protective secretions which line mucous membranes. When healthy, digestive secretions are sufficient to protect the stomach lining called the epithelium against acids. When the secretions are diminished as occurs when kledaka is low, burning indigestion occurs. Kledak may be diminished for several different reasons. First, the influence of Vata disturbance can dry up the secretions. This occurs for instance as a result of stress and worry as well as inappropriate diet. In addition, the secretions can dry up due to excess heat as in pitta, conditions such as intensity and anger, as well as too much hot pungent food. When Kledak is low, cool, moist demulcent herbs are used such as licorice or slippery elm which re-hydrate the membranes and increase protection. Kledaka Kapha can also be too high. When this occurs it suppresses the agni resulting in slow digestion and possible nausea. This condition results from too many heavy, sweet foods and is best treated with the category of herbs called dipanas which increase agni and diminish kledaka. This includes the Indian herbs chitrak and the Ayurvedic formula trikatu as well as common pungents such as ginger and cayenne pepper. While herbal therapy is important, following a light diet or fasting for several days will often correct the imbalance. These principles above can be applied to the understanding of all digestive disease and leads the practitioner to a sound treatment protocol in the examination of ulcers and irritable bowel syndrome we shall see how this works.
Treatment of Ama
When ama is present, it must eventually be eliminated. Ama complicates disease because its effects are systemic and it can inhibit the effectiveness of herbs and other medicaments. The problem with treating ama lies in the clinical management of the patient. Purification therapy called Pancha Karma is advised for removing ama. When the patient is strong, Panchakarma is advised. However, purification therapy is also depleting to the body and can cause weight loss. In the case of great weakness such as that which accompanies some chronic diseases, purification therapy is contraindicated or must be modified and applied with great care.
Purification begins with proper preparation. This process called Purva Karma involves properly oiling the body both internally and externally. The external portion is performed using body oils, which may be applied in a variety of ways including massage. The internal portion is performed using medicated ghee. This is a preparation of clarified butter with special herbs cooked in it. Triphala gee and brahmi gee are common preparations as well as bitter ghee prepared with multiple bitter herbs. Once oiled, the patient’s body is exposed to heat, again, from a variety of sources including steam, dry heat, or via a hose attached to a pressure cooker. This last variety is called Nadi Swedana. This combination of oil and heat loosens ama trapped in the tissues of the body and dilates the channels of the body allowing the ama to return to the digestive system for elimination.
During this period special foods are taken, most commonly Kitchari (Mung Dal and Basmati Rice) as well as additional herbs as indicated. The second phase of Pancha Karma is the elimination procedures. These include Niruha Basti (Herbal decoction enemas), virchana (purgation), nasya (Cleansing of the nasal passages and sinuses) and Vamana (Vomiting). Traditionally, bloodletting may also be applied. One or more of these procedures may be administered depending upon the nature of the patient and the nature of the disease. In the final phase of Panchakarma, procedures are administered to rekindle the agni and rebuild the patient’s strength. This process, called rasayana, is what leaves the patient stronger from the procedures than before they began. To rekindle the agni, dipanas are mentioned above are utilized such as Trikatu or Hingwastika.
The diet is slowly increased in both variety and quantity to match the growing strength of the agni and the patient. This process is called Samsarjana Krama. When strength of the agni is sufficient, rejuvenative herbs or preparations are given. These include herbs such as Bala, Ashwagandha and Kapikachhu as well as formula Chyawanprash. Which specific formula is given depends upon the nature of the patient and the disease. The first two phases of Pancha Karma can take from 7 to 28 days to administer in order to remove all the ama present in a person. As these programs are costly in both time and money, multiple shorter programs are often prescribed. Phase three, rejuvenation, can take an additional month but is well worth the effort.
Approaching Two Common Digestive Diseases
Ulcers: Ulcers known as Grahani in Ayurvedic medicine can be cause by vata, pitta or a combination of both. Agni is often disturbed and Ama may or may not present. When ama is present, it must be addressed either initially or later depending upon the strength of the patient. Ulcers from a Western condition are sores in the mucosal surface of the stomach or small intestine. They cause burning, aching pain which may be mild or severe, constant or intermittent. Form an Ayurvedic perspective, ulcers are an advanced form of hyperacidity or Gastritis called Urdvarga Amplapitta. In vata type Grahani, vata has caused a drying of the gastric protective secretion (Kledaka). Pitta may or may not be elevated. The loss of protection leaves the surface of the stomach exposed to normal, excess or even diminished acids, whichever are present. This exposure causes pain which can lead to ulceration and scarring.
The primary subdosha of vata involved is samana vayu, whose wind dries the surface of the affected region and may fan the flames of agni. In addition to a vata pacifying diet and improving the patient’s routines, herbal therapy focuses first on demulcents which assist healing such as licorice, shatavari or comfrey. These rebuild the protective secretions. Bitters may be added to the formula in small amounts of Pitta or agni are simultaneously vitiated to reduced the excess heat. Samana is pacified with herbs such as fennel and cumin. A sample formula based on this theoretical model would be 6 parts Licorice, 2 parts Shatavari, 2 part fennel, 1 part cumin. Dosage: 1-2 grams T.I.D. In Pitta type Grahani, excesses in Pachak pitta are responsible for drying the mucous membranes as well as for creating a strong acid environment. Vata may still be vitiated as well complicating the pathogenesis and treatment. This condition results in bleeding in the stomach or small intestine in addition to the other symptoms. This vata-pitta condition is the most severe of all. In addition to the treatments mentioned above homeostatic herbs such as amalaki and the Ayurvedic preparation of red coral called praval pishti are useful. A theoretical formula based upon this model is 4 parts amalaki 4 parts licorice, 2 parts praval pishti, 1 part fennel. Dosage 1-2 grams T.I.D.
Irritable Bowel Syndrome: Often called Spastic Colitis, Irritable Bowel Syndrome is disorder of the small and large intestines causing chronic intermittent constipation or diarrhea often associated with varying degrees of abdominal pain. This origin of this condition is not well understood in the West and is very difficult to treat. Through Ayurvedic eyes, the practitioner of Ayurveda comes to understand the nature of their patient physically, emotionally, and spiritually. Upon doing so, each patient with I.B.S. will present with a wide variety of imbalances on all three levels. As each person is unique, so too will each presentation be unique. There are, however, many commonalties, and from these the practitioner can come to understand the nature of the disease and develop a plan for managing it. This condition appears to occur most prevalently in those individuals with a Vata prakruti or vikruti. The severity of the condition is somewhat proportionate to the state of ojas. When ojas is low, the condition is more severe.
Symptoms of vata type disease begin with a dull achy discomfort which becomes severe as the condition progresses. There is considerable gas and bloating, as well as malabsorption in more severe cases. The pathology is complex. There is vitiation in samana vayu that leads to imbalances in apana and agni. What makes this condition more significant and difficult to treat than simpler bowel disease is that it is the end result of long standing inappropriate lifestyle habits and routines. Such routines are intertwined with vitiation of the mind or manovaha srota. Vitiation of the mind by vata (prana and samana) leads to less stability in the mind, and thus the mind further associates itself with the senses in an attempt to reestablish harmony. Due to disturbances of prana (the inward moving air governing what we take in through our senses), these association are often themselves disharmonious and lead to further imbalance. Thus faulty habits are devolved.
The end result of long standing vata disturbance in the body and mind is the drying out of ojas (the essence which stabilizes and gives endurance to the body and mind). The patient becomes weak, and may lose weight and often presents with anxiety or depression. Treatment of this condition requires addressing the imbalances both psycho–spiritually and physically. The physical component requires nourishing therapy to rebuild ojas. This first requires pacifying samana and apana vayu and normalizing agni. This can be done with spices of mild to moderate pungency such as fresh ginger and cool spices such as fennel and cumin. Takra, a mixture of yogurt and water can be taken to enhance digestion and absorption. Putting the Ayurvedic formula hingwastika or other spices into the takra can be beneficial. Nutmeg and small amounts of psyllium can be added if diarrhea is profound. If constipation is dominant, cascara sagrada or high doses of triphala can be taken.
In the long term, tonic therapy specific to the intestines should be administered. The preparation of triphala called Shita Skhaya (Soak one tsp. of triphala in 8 oz. of room temperature water for 12 hours and then drink the water without the triphala) is most beneficial as a tonic. Once agni is normalized, generalized tonic therapy can be begun. This includes a more nourishing diet as well as herbs such as ashwagandha, shatavari and bala. Managing the psycho-spiritual component of the disease is the most difficult aspect to manage. While herbal therapy is supportive, deepening the patient’s connection to God is imperative. This connection empowers the patient to act in a more harmonious manner and moves the mind attention away from the senses and toward the spirit.
While most any spiritual path can be sufficient, Ayurveda typically employs Yoga and its associated principles in this process. Herbal therapies for the mind which pacify prana and bring about stability include ashwagandha and brahmi. In combination they appear most effective. Pitta imbalance can combine with vata in irritable bowel syndrome. When it does the symptoms present with diarrhea accompanied by rectal burning. Diarrhea may be more predominant and when it is malabsorption is more pronounced and weight loss more rapid. While the pathogenesis of the condition is similar to vata type, vitiation of pachak pitta in the anna vaha srota (stomach and small intestine) accompanies the involvement of the other subdoshas. In addition, the emotional component takes on a more heated quality as sadhaka pitta is vitiated creating greater anger and resentments.
Herbal treatment is modified in these conditions to account for the additional components of the pathogenesis. Cooler digestive herbs are used and formulas should emphasize fennel, coriander and cumin. In the mind chrysanthemum and skull cap may be used in combination with brahmi. Severe diarrhea may have to stopped to prevent continued wasting with herbs such as bayberry, red raspberry and alum root. Takra can also be prepared with 2 parts amalaki 2 parts licorice, 12 part nutmeg 1 part psyllium Dosage 1 tsp. Kapha imbalance can combine with Vata in irritable bowel syndrome. When this occurs, mucous will present in the stools and periods of nausea will occur. Constipation is more common but periods of diarrhea can occur. In addition to the vata pathology of this condition, Kledaka Kapha is vitiated and is responsible for the mucous and nausea. Agni is typically low and significant ama is likely to be present. Emotionally there may be greater depression. While the vata nature of this disease is still dominant herbal modifications should be made to account for the additional pathology. Stronger dipanas such as dry ginger and cayenne pepper or Ayurvedic formula trikatu should be added to formulas. In addition a light simple diet should be followed for several days to alleviate the Kapha and ama aspects of the disease. When ama and excess Kapha are alleviated a more nourishing diet to rebuild ojas can be implemented.
Regardless of the disease, case management is essential and is usually the difference between success and failure. Case management entails the understanding of upasaya and anupasaya or viewing treatment as the process of gaining additional information in the nature of the disease. Treatment which gives comfort supports the diagnosis and the understanding of the disease. Treatment which gives discomfort while not desirable still yields useful diagnostic information. Hence, the practitioner must follow up their patient’s progress and make adjustments to their programs as indicated. These adjustments may include altering the dosage or the herbal formulas, modifying the formulas and coaching the patient to make additional lifestyle changes. Guiding a patient back toward health is a process. The Ayurvedic practitioner’s role should not be looked at as a one of finding the newest or latest magic herb to heal their patients. It is a treatment approach based in a set of principles which guides the practitioner to understand the nature of the patient, the nature of the disease and the nature of the direction of therapy.
Caraka Samhita: Translated by Bhagwan Dash and R.K. Sharma; 3rd ed.; published 1992. Sushrut Samhita: Translated by K.L. Bhishagratna; Published 1994 Ashtang Hrdayam: Translated by Prof. K.R. Srikantha Murthy; Published 1992 Ayurvedic Healing: By Dr. David Frawley Published 1989. Cakradatta: Translated by P.V. Sharma; Published 1994