A case-control study for exploring the association of Prakriti with Rheumatoid Arthritis

Abstract

Background

Deha-Prakriti (DP) is a unique contribution of Ayurveda, which distinguishes the population into three main groups viz., Vata, Pitta, and Kapha predominant individuals. Its assessment helps physicians to prescribe a suitable diet, daily regimen, and lifestyle that prevents non-communicable diseases. Amavata (Rheumatoid Arthritis) is a disease that needs personalized management approach.

Aim

To evaluate the association of DP with Amavata (∼Rheumatoid Arthritis).

Objective

To evaluate DP-based susceptibility in the manifestation of Amavata vis-à-vis Rheumatoid Arthritis.

Methodology

A case–control study was conducted from 18.04.2018 to 09.01.2020, involving 150 cases (patients of Amavata), and 150 controls (healthy volunteers), matching in age (between 18 to 50 years), and sex, selected from Jamnagar. CCRAS-PAS for both the groups, Health Assessment proforma of TRISUTRA project CSIR-AYURGENOMICS, were used. Logistic regression analyses were conducted to determine the relationship between DP and Amavata.

Results

The proportion of people with Vata dosha in the case group (53.79%) was substantially higher (P < 0.0001) than in the control group (24.91%). Pitta (39.35%) and Kapha (36.27%) doshas were found to be more prevalent in the control group (P < 0.0001). There was a six-percent rise in the likelihood of developing Amavata with every unit increase in Vata percentage, according to logistic regression analysis.

Conclusion

Vata predominant DP has a significant association with Amavata. Vata predominant DP individuals are more susceptible to Amavata than Pitta and Kapha predominant DP individuals.

Highlights

• •This study investigates the role of Deha-Prakriti in the development of Rheumatoid Arthritis on the western coast of India.
• •It evaluated the strength of association between Deha-Prakriti and the manifestation of Rheumatoid Arthritis with robust evidence.
• •The current study's results provide further support for and revalidation of the Prakriti notion of RA predisposition.

1. Introduction

Ayurveda, a traditional medical system of India, substantiates the psychosomatic constitution of an individual with the concept of Deha-Prakriti (DP), [1]. “Prakriti” is an individual's innate psycho-somatic framework determined at the earliest stages of fertilisation by the relative predominance of Sperm and Ovum [2]. Human constitution is unaltered from conception to death until fatal signs appear [3]. Phenotypic heterogeneity is the main complication encountered in contemporary medicine in the context of complex disease genetics.

DP separates people into Vata, Pitta, and Kapha phenotypes. Ayurveda literature speculated that some individuals may have balanced Vata, Pitta, and Kapha, while some show either Vata or Pitta or Kapha dominance. First-category, people with Sama Prakriti, those have balance of Tridoshas and are healthy while others may develop diseases [4]. Vata, Pitta, and Kapha dominants are weak, medium, and strong respectively [5]. Sama Prakriti people are resistant to diseases. People with only one vitiated dosha are generally unhealthy, but they can stay healthy by eating and exercising according to their constitution [4]. DP determines disease susceptibility, severity, diet, and regimen in Ayurveda [1, Vimana 6/15]. The confirmation of Deha- Prakriti is essential to examine a healthy person or patient's physical, physiological, and psychological traits and recommend a diet and lifestyle for good health, preventative medicine, and therapy. Ayurvedic seers ranked Prakriti evaluation highest among ten key measures to be studied by a physician [1, Vimana 8/84]. DP examination helps determine Samprapti (pathogenesis), Chikitsa (treatment), and Sadhya-Asadhyata (prognosis) of a disease. Subdividing healthy people and patients based on DP can reduce clinical heterogeneity in complex diseases as it diagnoses health differently [1, Sutra 7/41, Cakrapanidutta commentary].

Modern medicine links Amavata to Rheumatoid Arthritis (RA). Heavy, incompatible, unwholesome, and irregular food consumption slows Agni (the digestion process), causes indigestion, and produces Ama (undigested material). Ama trapped in joints by vitiated Vata dosha causes pain, oedema, fever, stiffness, lack of appetite, indigestion, and general soreness [6]. The sickness may exacerbate pain, stiffness, and other symptoms, producing anomalies and impairment. Auto-immune, chronic, progressive, degenerative RA has an unknown cause. 0.5%–1% of people worldwide have this non-communicable condition, and it particularly affects middle-aged women [7,8]. Untreated or unmanaged RA can lead to joint degeneration, disability, comorbidities, and early death [9]. Comorbidities include CVD (Cardio-vascular diseases), cancer (particularly lymphoma, lung, and melanoma), anaemia, infections, depression, and gut disorders [10,11]. Early detection of Amavata (RA) is important because it allows doctors to restore patients' health by prescribing the best drugs, diet, and treatment plan for everyone based on their unique DP. Modern doctors believe in predictive, preventive, personalised, and participatory medicine (P4). Despite contemporary studies, Ayurveda's personalised treatment method inspired scientists to study disease presentation and drug response diversity. Joint problems are more common in Vata-predominant DP [1, Chikitsa 28/37], but the statement lacks vigorous evidence. Theory of causation states that exposure causes consequence which can be understood by inference [12]. Evidence-based retrospective research can be done by assessing a current expected outcome's risk factors. Observational research evaluates the aetiology, occurrence, and susceptibility of a disease. Chronological synchronisation of exposure and outcome establishes causal association. This allows to produce Prakriti-Based Medicine (PBM), or customised medication, defined as “the appropriate medicine to a specific individual at a certain moment, with the exact dose and the perfect quality.” Thus, a retrospective epidemiological analytical case–control approach is opted to assess DP's role in Amavata's causation and its level of connection with the following aim and objectives.

1.1. Aim

To study the association of Deha-Prakriti (Physico-Physiological Constitution) with Amavata (∼Rheumatoid Arthritis)

1.2. Objective

• ∗To evaluate the Deha-Prakriti-based susceptibility in the manifestation of Amavata vis-à-vis Rheumatoid Arthritis

2. Methodology

2.1. Study setting, sample size, and sampling

A case–control study establishes the link between a disease and its etiological causes and indicates their relative predominance. This approach in epidemiology allows the researcher to accomplish his destiny when the findings are generalised or applied to the community, possible only by comparing diseased and healthy risk factors. Case-control studies assist determine susceptibility, prevention, and treatment. It seeks to uncover the inciting factor in sick people and the protective factor in healthy people [13]. In the present study, The cases and controls were taken as a 1:1 ratio matching with age ( ± two years) and sex in both the groups. Considering it as a pilot study, a total of 150 cases (Amavata Patients) and 150 controls (healthy volunteers) were selected through the random sampling method, interviewed, and the history related to the present study was collected through the direct interview method.

2.1.1. Inclusion criteria for cases

Patients aged above 18 years and under 50 years of either sex diagnosed with Amavata (those who were having the symptoms of Amavata [14] and fulfilling the ACR (American College of Rheumatology), 1987 Criteria [15] with positive RA factor-quantitative and C-Reactive Protein (CRP)-quantitative) for less than or equal to 5 years were considered as the case group. From 18th April 2018 to 9th January 2020, both incidence and prevalent cases attending IPGT& RA Hospital, Jamnagar's OPD and IPD, and those prepared to give written informed consent were recruited in the research.

2.1.2. Inclusion criteria for controls

Controls are healthy individuals, who were matched priorly ( ± two years) in age and sex with cases, and drawn from the same source of population (living in the Jamnagar municipal corporation region only). Every control was screened initially through a health assessment questionnaire designed by CSIR-Ayurgenomics unit-TRISUTRA, CSIR-IGIB, New Delhi (Annexure-I) to confirm them as healthy individuals followed by the investigations mentioned above, those who came under the normal range of RA factor, CRP, and who were prepared to give written informed consent were recruited for the present work.

2.1.3. Exclusion criteria for cases

Amavata patients with other comorbidities such as Diabetes, Hypothyroidism, or any other endocrinal and metabolic disorders, and those who refused to participate in the study are excluded.

2.1.4. Exclusion criteria for controls

Unhealthy individuals, less than 18 and more than 50 years of age, and those who were not willing to participate in the study are excluded.

2.1.4.1. Ethical clearance

The Institutional Ethics Committee of the Gujarat Ayurved University's Institute for Post Graduate Teaching and Research in Ayurveda, Jamnagar, gave their approval; vide Ref. PGT/7-A/Ethics/2017–18/3042 dated 19/02/2018.

2.2. Assessment of DP

DP of both the groups is assessed by CCRAS-Prakriti Assessment Scale (PAS) (http://ccras.res.in/ccras_pas/), administered in their convenient language to assess different traits, employing direct observation, tactile examination, and interrogation by a single person by implementing the SOP's (Standard Operative Procedures) mentioned in CCRAS-Prakriti Assessment Manual [16]. Based on the characters found in every individual, the relative percentage of each dosha is calculated, and the dominating percentage of dosha (output) determines the DP of that individual. Based on the output, the assessment method is as follows.

• 1.Ekadoshaja Prakriti: more than 66% of one Prakriti characteristics
• 2.Dwandwaja Prakriti: close to or equal percentage of two Prakriti characteristics & differences between two Doshas is 25–30%
• 3.Sama Doshaja: close to or equal percentage of three Prakriti i.e. 30-34%

2.3. Method of data collection

The present study was initiated after IEC approval and CTRI registration. The goal of the study, what is anticipated of them, and the predicted participant benefit of observing and analysing were all stated to all the participants prior to the study. After getting the informed consent, the data were collected by filling CRF (Case Record Form) and CCRAS-PAS scale. The method of one-on-one (face-to-face) interviewing was used to collect the data. The Prakriti assessment includes physical (anatomical), physiological, psychological, and sociological (behavioural) traits, which were evaluated through the SOPs/questionnaire mentioned in the CCRAS-PAS scale. Physical traits were evaluated through Darshana (inspection) and Sparshana (tactile) examination, which were found at the time of the interview. Remaining physiological, psychological, and behavioral traits were evaluated through the questionnaire, and the status was considered during disease-free status. The output of the Prakriti assessment was obtained in terms of the percentage of doshas.

2.4. Scrutiny of the medical records

The onset of the sickness, its duration, the details of medical examinations, drugs, previous illnesses, a detailed history of the condition, and anthropometric parameters were recorded. The details were filled in the CRF. Reports of the radiographs, hematological, and biochemical parameters were also screened thoroughly.

2.4.1. Avoiding bias

To counteract recall bias, patients with persistent memory impairment were excluded from the present study. Recall bias was addressed by assuring research participants that both case and control groups had the same chances and motivations to recall earlier occurrences. All the participants were counseled about the importance of DP assessment, to implement a suitable diet and regimen to prevent upcoming diseases and minimize complications.

2.5. Statistical analysis

The Chi-square analysis was performed to determine the relationship between various socio-demographic variables and DP with Amavata. If the Cell values are less than 5 or 0 then chi-square with Yates correction was applied. The Mann–Whitney U test is applied to find the mean difference of each dosha's percentage in DP between the two groups as the data were not normally distributed. Both tests were analyzed using the Statistical Package for Social Sciences (SPSS, USA) version 20.0 software [17]. P ≤ 0.05 was statistically significant. The main objective of the present study was to evaluate the DP based susceptibility in the manifestation of Amavata vis-à-vis Rheumatoid Arthritis (RA). Thus, the incidence of RA was regressed upon the DP through logistic regression, coding the incidence of RA as 1 and 0 otherwise. As DP is expressed in terms of percentages which add up to 100 for everyone, a mixture model was considered [18,19]. A logistic regression model was fitted taking the percentages of Vata, Pitta, and Kapha and their two-way and three-way interactions. The forward stepwise logistic regression method was employed to remove unwanted variables from the model. From the final model after stepwise regression, the odds ratios were obtained through exponentiation of the regression coefficients. Variable importance metric was also worked out for the final set of features included in the model. 10-fold cross-validation was used to validate the fitted model. A k-fold cross-validation was conducted by randomly removing k observations from the estimate dataset and predicting the response level for the separated observations, then repeating the procedure with a different sample of k observations each time. In place of a single pair of training and validation datasets, the findings are then combined over several samples collected, yielding a highly verified accuracy level. The Logistic Regression analysis was done using R Version 4.0.2 [20].

3. Results

Various demographic-related variables of both groups are summarized in Table 1. Age group, gender, marital status, educational status, occupation, type of family, and DP are documented along with their Chi-square values in Table 1. Age group and gender were found to have non-significant associations with Amavata among both the groups. Marital status, educational status, occupation, type of family, and DP were found to have significant associations with Amavata among cases and controls. The means of dosha in DP of both groups were found to be significantly different (Table 2). To assess the influence of DP in the manifestation of Amavata, a mixture model of logistic regression was applied, and the results are depicted in Table 3, Table 4. No interaction came out as significant at one percent level of significance. The McFadden pseudo R² for the model was 0.41. Marital status, educational status, occupation, type of family, and DP were found to have significant associations with Amavata among cases and controls. With every unit increase in the percentage of Vata, there was a six percent increase in the chance of having Amavata. Similarly, the chances of Amavata incidence decreased by 7.5% with every unit increase in the percentage of Pitta component. Given the Vata and Pitta percentages, the Kapha percentage had no specific role being determined by the other two components. The Vata percentage came out to be the most dominant factor with an important metric of 9.12 (Table 3, Table 4).

Table 1a.

Summary tables of exposure variables vs category levels.

Variable	Level code	label	Cases n (%)	Controls n (%)	χ2 value	df	P-value
Age group	1	18–30	30 (20%)	28 (18.7%)	1.722	2	0.423
	2	31–40	59 (39.3%)	50 (33.3%)
	3	41–50	61 (40.7%)	72 (48%)
Gender	1	Male	21 (14%)	21 (14%)	0.001	1	1.00
	2	Female	129 (86%)	129 (86%)
Marital status	0	Unmarried	17 (11.3%)	34 (22.7%)	7.7	1	0.021
	1	Married	133 (88.7%)	116 (77.3%)
Education	0	Uneducated	17 (11.3%)	8 (5.3%)	19.746	5	<0.001
	1	Primary	33 (22%)	16 (10.7%)
	2	Secondary	54 (36%)	50 (33.3%)
	3	Higher-secondary	15 (9.68%)	14 (9.3%)
	4	Graduate	20 (13.3%)	42 (28%)
	5	Post-graduate	11 (7.3%)	20 (13.3%)
Habitat	1	Rural	31 (20.7%)	9 (6%)	16.333	1	<0.001
	2	Urban	119 (79.3%)	141 (94%)
Socio-economic status	1	BPL	41 (27.3%)	27 (18%)	8.929	2	0.03
	2	LMC	81 (54%)	77 (51.3%)
	3	UMC	28 (18.7%)	46 (30.7%)
Occupation	1	Student	13 (8.7%)	26 (17.3%)	32.681a	3	<0.001
	2	House-wife	109 (72.7%)	74 (49.3%)
	3	Govt. employee	1 (0.7%)	21 (14%)
	4	Private employee	30 (19.42%)	29 (19.3%)
Religion	1	Hindu	132 (88%)	135 (90%)	4.66	1	0.46
	2	Muslim	18 (12%)	15 (10%)
Type of diet	1	Vegetarian	111 (74%)	108 (72%)	0.152	1	0.696
	2	Mixed diet	39 (26%)	42 (28%)
Type of Family	1	Nuclear	34 (22.7%)	119 (79.3%)	96.372	1	<0.001
	2	Joint	116 (77.3%)	31 (20.7%)
Deha-Prakriti (predominant Dosha)	1	Vata (V + VP + VK)	126 (84%)	27 (18%)	137.281a	2	<0.001
	2	Pitta (PV + PK)	4 (2.7%)	68 (45.3%)
	3	Kapha (K + KP + KV)	20 (13.3%)	55 (36.7%)
Deha-Prakriti (detailed)	1	V (Vataja)	35 (23.3%)	3 (2%)	150.795a	7	<0.001
	2	VP (Vata-Pittaja)	43 (28.7%)	16 (10.7%)
	3	VK (Vata-Kaphaja)	48 (32%)	8 (5.3%)
	4	PV (Pitta-Vataja)	3 (2%)	20 (13.3%)
	5	PK (Pitta-Kaphaja)	1 (0.7%)	48 (32%)
	6	K (Kaphaja)	1 (0.7%)	4 (2.7%)
	7	KP (Kapha-Pittaja)	5 (3.3%)	36 (24%)
	8	KV (Kapha-Vataja)	14 (9.3%)	15 (10%)

Abbreviations: BPL-Below Poverty line, LMC- Lower middle class, UMC- Upper middle class.

^aWith Yates correction (as the cell values less than 5).

Table 2.

Comparison of involved Dosha in Deha-Prakriti among cases and controls.

Involved Dosha	Study groups		U- value	P-value
	Case group (n = 150)	Control group (n = 150)
	Mean ± S.D.
Vata	53.79 ± 15.75	24.91 ± 17.59	14.929	<0.001
Pitta	21.81 ± 11.67	39.35 ± 14.61	−11.446	<0.001
Kapha	24.52 ± 15.13	36.27 ± 17.26	−6.149	<0.001

Table 3.

Regression analysis of Deha-Prakriti and Amavata.

Prakriti element	Estimate	Std. Error	z value	Pr (>|z|)
Pitta	−0.077450	0.008684	−8.919	<2e-16 ∗∗∗
Vata	0.0589	0.0065	9.117	<2e-16 ∗∗∗

Signif. codes: 0 ‘∗∗∗’ 0.001 ‘∗∗’ 0.01 ‘∗’ 0.05 ‘.’ 0.1 ‘’ 1.

Table 4.

Log-Odds for Pitta and Vata Deha-Prakriti elements.

	log-odds	2.5%	97.5%
Pitta	0.9254731	0.9087842	0.9403677
Vata	1.0606992	1.0481276	1.0751187

4. Discussion

A relationship was established between DP and Amavata (Rheumatoid Arthritis). Various other demographic characteristics were also analysed, and significant association was discovered for marital status, education status, habitat, socio-economic status, occupation, and type of family, however, no association was found with age, gender, religion, and type of diet. Two groups have participated in the present study; one is the case group consisting of Amavata patients (n = 150); the other is the control group (n = 150), comprising healthy persons. Both groups were matched by their age and sex. So, the age and gender were deemed non-significant. The ratio of cases and controls in the present investigation was almost 1:1. Most of the participants were females (n = 129), covering 86%, as Amavata (Rheumatoid Arthritis) mainly affects the women population. Various autoimmune disorders, such as Rheumatoid Arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSc), have a significant prevalence in females. Epigenetics and the hormonal foundation of male sexual behaviour appear to be two important elements at play, either of which may influence other issues, including changes in the microbiome. The inherited predisposition to RA can be explained by differences in the hormones estradiol and progesterone in females and testosterone in males. By decreasing cytokine (e.g., TNF) communication (high estradiol levels), developing immunological tolerance, and reducing severity throughout pregnancy, estradiol reduces synovial inflammation [21]. By increasing Tregs and lowering Th17 generation, progesterone may mitigate the effects of RA on the pregnant woman's immune system [22,23]. Testosterone may protect against the development of RA autoantibodies [24]. Two X-linked genes, TIMP1 and Interleukin-9 receptor (IL9R), have been linked to sex differences in rheumatoid arthritis (RA). Both genes were shown to have Single-Nucleotide Polymorphisms (SNPs) that were associated with either RA in general (TIMP1) or RA that was positive for the anti-cyclic citrullinated peptide (anti-CCP) antibody [25]. In addition, those who are predisposed to inflammatory arthritis due to genetic factors like the common epitope may also be affected by anomalies in their gut microbiota. The HLA genotype (DRB1∗0401) of females may play a role in altering the composition of the gut microbiota, leading to both an increase in pro-inflammatory cytokines and the translocation of bacteria [26], which may develop RA.

In both the study groups, married participants occupied a major portion. As the significantly included age group belonged to 31–50 (81%) years, the highest number of participants were married. Most of the individuals in both groups belonged to urban environment as the present study has been conducted in Jamnagar municipality region only. However, compared with the control group, the patients with Amavata from the rural region were much greater as they may have irregular eating patterns and disturbed lifestyles. Housewives (homemakers) were shown to have a substantial part; however their percentage is larger in the case group when compared with control group. The government and private employees were more in the control group than cases which show that they are professionally comfortable and devoid of any physical as well as psychological stress which may keep them healthy. In the present investigation, the highest number of cases and controls had secondary education status. However, the percentage of illiterate was much larger in the case group (11.3%), whereas, in the control group, just 5.3% were uneducated. It implies that literacy has a key impact on the causation of Amavata. Health literacy imparts knowledge about a healthy lifestyle and its relevance to people, helping them prevent disease conditions. The highest number of participants were below the poverty line and lower-middle-class categories. However, their percentage is slightly greater in the case group (81.3%) than in the control group (69.3%) which is statistically significant. The socio-economic status (As per NCAER 2010- National Council for Applied Economic Research survey research guidelines) and habitat are interconnected elements. Due to their poor economic situation, they cannot afford hygienic and nutritious food. Moreover, they always strive for day-to-day requirements. It provokes them to consume unclean, incompatible, stale, and non-nutritious food. This may lead to the production of Ama in the body, which plays a crucial part in the manifestation of RA [6].

Religion and type of food (vegetarian or non-vegetarian) were shown to have a nonsignificant association with Amavata as the study has been done at Jamnagar and its peripheries which is a Hindu prominent region. The highest number of cases or patients of Amavata were from joint families (77.3%), whereas the maximum number of controls or healthy volunteers were from nuclear families (79.3%). It implies that the type of family has a crucial effect on the occurrence of Amavata. This may be related to the fact that in joint families, women suffer from excessive physical stress, which is nothing but Atishrama (over-effort), leading to the aggravation of Vata [1, Chikitsa 28/15-18] and further to the appearance of Amavata. Most of the time, in joint households, homemakers have irregular food patterns; disturbed sleep patterns may lead to Ama production which has a significant function in the presentation of Amavata [6,1, Vimana 2/9].

In both groups, Sama Doshaja DP was not found. In the case group, the most number of patients with Amavata were found to have Vata predominant DP (84%) however, in the control group, the maximum number of healthy volunteers were of Pitta predominant DP (45.3%) and Kapha prominent DPs (36.7%). In the case group, single Vataja, Vata-Kaphaja, and Vata-Pittaja persons occupied 23.3%, 32%, and 28.7%, respectively. It highlights the vulnerability of Vata dominating DP and the protecting nature of Pitta, Kapha prominent DPs. The chi-square test, Odds Ratio, Mann–Whitney U test, and Logistic Regression analysis have also validated this aspect (Table 1a, Table 1b, Table 1c, Table 2, Table 3, Table 4). At the biochemical level, Vata dosha is responsible for Vishamagni (an irregular digestion mechanism) [1, Vimana 6/12]. Moreover, due to instability (attributed to the predominance of Rajo-guna in their Sattva), unable to control their intellect, will be quickly affected by psychological factors. Due to this reason, individuals will not get appropriate sleep, which is also responsible for poorer immunity [27]. The research suggests that the Vataja DP individuals are considerably weak physically as well as psychologically. Ayurveda, clearly mentions that Vata-dominant DP people are unable to tolerate intense physical effort as compared to Pitta and Kapha prominent DP individuals [1, Vimana 8/98-99]. It was also stated that Vata dominating DP has poor immunity, but Pitta, Kapha predominant DP have strong immunity [28]. It has been substantiated by Rotti H et al., who reported that Kaphaja DP samples had much increased CD25 (activated B cells) and CD56 (natural killer cells) levels than other Prakriti groups. Moreover, CD14 levels were observed considerably higher in Pittaja DP samples. Increased CD25 and CD56 in Kaphaja DP may suggest a larger antibody response, which is compatible with Ayurvedic literature references [27].

Table 1b.

Association of Deha-Prakriti (frequency) in the manifestation of Amavata (∼RA).

Deha-Prakriti	Group		Total	χ2 value	Degrees of freedom (df)	p-value	Inference
	Control	Case
K	4	1	5	150.795a	7	<0.0001	Statistically Significant
V	3	35	38
KP	36	5	41
KV	15	14	29
PK	48	1	49
PV	20	3	23
VK	8	48	56
VP	16	43	59
TOTAL	150	150	300

^aWith Yates correction (as the cell values less than 5).

Table 1c.

Odds ratio and χ² between cases and controls for three types of Deha-Prakrits.

Sr. No.	Etiological factors	Odds Ratio	CI (95%)	χ2	P	Type of association
1.	VataPrakriti	23.92	13.08–43.73	130.73	<0.0001	Positive
2.	PittaPrakriti	0.03	0.01–0.09	72.533a	<0.0001	Negative
3.	KaphaPrakriti	0.27	0.15–0.47	21.778	<0.0001	Negative

^aWith Yates correction (as the cell values less than 5).

Alpa-Bala (less-strength) hinders Vataja DP individuals to perform physical exercise. The incidence is much larger in Vata-Kaphaja DP since there are more chances for the vitiation of Agni than in other individuals. The aggravation of Vata is extremely prevalent in Vata predominant DP people, compared with the Pitta and Kapha dominating DP people. The Samprapti of Amavata says that the formation of Ama is another central point, which envelops various explanations. By default, Kapha and Vata predominant DP persons experience diminished and irregular digestive systems, respectively [1, Vimana 6/12]. Hence, Kapha and Vata predominant DP individuals are more prone to the development of Ama in their body, compared with Pitta predominant DP individuals as their digestive capacity is larger.

The mean proportion of Vata in DP of the case and control groups were 53.79 ± 15.75 (mean ± S.D.), 24.91 ± 17.59, respectively. It reveals the preponderance of Vataja DP phenotypic traits. A similar thing was noticed in majority of the phenotypic traits. The mean percentage of Pitta dosha DP of the case and control groups were 21.81 ± 11.67, 39.35 ± 14.61, respectively. It indicates the protective nature of Pitta dosha in the control group as it is accountable for the maintenance of Agni at the biological level. The mean weightage of implicated Kapha dosha in the case and control groups was 24.52 ± 15.13, 36.27 ± 17.26, respectively. It signifies that the dominant stable mind, which is a safeguarding element for the development of Amavata. At the biological level, Pitta dosha is responsible for good digestive strength, predominance of Agni mahabhuta stops the development of Ama [29]. Kapha, is responsible for Sthira Chitta (stability of mind), high intellectual levels, stops an individual from involvement in Prajnaparadha. It instructs an individual to consume nutritious dietary food substances and helps to develop a healthy lifestyle. Furthermore, it is delineated that even though an individual who consumes Pathya (Wholesome) and Matravat (appropriate quantity i.e., neither less nor excess) Ahara, if his or her mind is afflicted with Chinta (worry), Bhaya (fear), Shoka (grief), Krodha (anger), Dukha (irritable), the Ama will be formed in their body [1, Vimana 2/9]. Predominant of Vayu mahabhuta, Rajo-guna, and instability of Sattva, readily involve in Prajnaparadha (intellectual error). The above indicated psychological variables would easily afflict the Vata predominant DP than the other two DP individuals. By default, Vata predominant DP persons have irregular and disturbed sleep patterns, which may also contribute to the aetiology of Amavata [1, Vimana 8/98].

The present investigation has indicated that DP is a risk factor connected with Amavata. DP is not a changeable element, but it can be considered a diagnostic and preventive tool by adopting acceptable dietary patterns and lifestyles. Ayurveda literature also indicates the same as the diet and regimen which is having the Viparita guna (opposite qualities) to the individual's Deha Prakriti (body constitution) is wholesome for the preservation of positive health. Whereas in the case of the equilibrium state of all the three Doshas, it is optimal to supplement with the food having all the six tastes in an appropriate quantity [1, Sutra 7/41]. Patient education in cognitive therapy is effective in lowering improper conduct and fostering positive health behavioural adjustments as per their DP. Refraining from bad food patterns, improper lifestyle, and Prajnaparadha (intellectual error) can be done through cognitive therapy. Cognitive therapy can help an individual to avoid improper eating habits, a flawed lifestyle, and Prajnaparadha (intellectual error) [30]. The study's significance may be evaluated in terms of how evidence-based epidemiological research is methodically implemented into public health policies [31]. It's crucial to think about the population and high-risk approach to risk behaviour prevention, as well as the viability of lifestyle modification counseling as per their DP [32,33].

Future large-scale studies with sufficient sample sizes at a multi-centric level will lend credence to the claims made in the ayurveda literature, paving the way for researchers to investigate not only the variations in disease severity but also the best ways to prevent complications in different DP people of Amavata. The current study will help doctors more precisely use treatment modalities including Shodhana (purificatory) and Shamana (palliative) procedures, as well as setting the framework for future interventional studies. For instance, Vaitarana-basti's efficacy, can be assessed in uncomplicated Vataja, Vata-Pittaja, and Vata-Kaphaja DP individuals, allowing for the development of a PBM or individualised prescription. Analysing the connection between food and gut microbiota in geographically diverse groups and DP can help healthcare providers design tailored meal plans for patients taking Amavata, perhaps improving their quality of life. This approach may be useful for treating other chronic conditions as well [34]. Comparability of case–control research for exposure analysis is not evident as for an RCT (randomised controlled Trial), matching was done in terms of age and sex achievable using inclusion or exclusion criteria solely.

4.1. Limitations of the study

In the present study, many of the patients fall under the chronic disease phase as they approached ayurvedic management at least after one year of the disease onset. In the early stage of Amavata, the symptoms are related to Amavastha, whereas, in the chronic stage, the symptoms are related to Niramavastha. Hence, the Kapha predominant DP did not show any association with the disease incidence. Although, the disease incidence is more in Vata-Kaphaja DP followed by Vata-Pittaja and single Vataja predominant DP. Besides, the mean difference of Kapha dosha involvement in DP is less when compared to Pitta dosha (Table-2). Moreover, in the inclusion criteria, if only the patients who were recently diagnosed or those who had the onset within one-year duration were enrolled, either it may change the results or it may show a significant association with Amavata. Hence, the logistic regression analysis did not show any significant association between Kapha predominant DP and Amavata.

5. Conclusion

Using a case–control study of 300 individuals, 150 of whom had Amavata, the association analysis is performed at ITRA (previously IPGT & RA) hospital in Jamnagar. Statistical analysis of qualitative data using the Chi-square test and the Odds Ratio revealed a statistically significant association between Vata dominance and the development of Amavata in DP patients. The risk of developing Amavata was significantly lower in those with Pitta- or Kapha-dominant DP. In this study, Vata-kaphaja DP had the highest incidence of Amavata, followed by Vata-Pittaja, single Vataja, and Kapha-Vataja. The mixed logistic regression model revealed the quantitative role of DP in predicting Amavata, showing that for every unit rise in Vata, the likelihood of Amavata increased by six percent. As Pitta percentage increased, Amavata incidence reduced by 7.5 percent. It strongly suggests that the Vata predominant DP is a causative factor of Amavata (RA), while the Pitta predominant DP acts as a protective factor. Community-based education programmes may teach DP-recommended diets and practises to lower Amavata risk.

Source of funding

The present work is funded by IPGT & RA (Institute for Post-Graduate Teaching and Research in Ayurveda), Jamnagar.

Authors contribution declaration

Rajkumar C: Conceptualization, Methodology, Data Collection, Data Curation, Statistical Analysis, Writing- Original draft, Review & Editing. Baghel A S: Conceptualization, Methodology, Supervision, Writing- Original draft, Review & Editing. Shubhangi Kamble: Methodology, Supervision, Writing- Original draft, Review & Editing. Bhagavathi NNL: Conceptualization, Methodology, Writing- Original draft, Review & Editing.

Declaration of competing interest

There are no conflicts of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: