Tag Archives: Hypoglycemia

Hypoglycemia

Definition:
Hypoglycemia is the clinical syndrome that results from low blood sugar. The symptoms of hypoglycemia can vary from person to person, as can the severity. Classically, hypoglycemia is diagnosed by a low blood sugar with symptoms that resolve when the sugar level returns to the normal range….CLICK & SEE

Risk Factor:
While patients who do not have any metabolic problems can complain of symptoms suggestive of low blood sugar, true hypoglycemia usually occurs in patients being treated for diabetes (type 1 and type 2). Patients with pre-diabetes who have insulin resistance can also have low sugars on occasion if their high circulating insulin levels are further challenged by a prolonged period of fasting. There are other rare causes for hypoglycemia, such as insulin producing tumors (insulinomas) and certain medications. These uncommon causes of hypoglycemia will not be discussed in this article, which will primarily focus on the hypoglycemia occurring with diabetes mellitus and its treatment.

Despite our advances in the treatment of diabetes, hypoglycemic episodes are often the limiting factor in achieving optimal blood sugar control. In large scale studies looking at tight control in both type 1 and type 2 diabetes, low blood sugars occurred more often in the patients who were managed most intensively. This is important for patients and physicians to recognize, especially as the goal for treating patients with diabetes become tighter blood sugar control.

Low Blood sugar is Also Bad:
The body needs fuel to work. One of its major fuel sources is sugars, which the body gets from what is consumed as either simple sugar or complex carbohydrates. For emergency situations (like prolonged fasting), the body stores a stash of sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to “make new sugar”) and converts these stores of glycogen to sugar. This backup process emphasizes that the fuel source of sugar is important (important enough for human beings to have developed an evolutionary system of storage to avoid a sugar drought).

Of all the organs in the body, the brain depends on sugar (which we are now going to refer to as glucose) almost exclusively. Rarely, if absolutely necessary, the brain will use ketones as a fuel source, but this is not preferred. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. If for some reason, the glucose level in the blood falls (or if the brain’s requirements increase and demands are not met) there can be effects on the function of the brain.

Our Body’s Natural Protection
:
When the circulating level of blood glucose falls, the brain actually senses the drop. The brain then sends out messages that trigger a series of events, including changes in hormone and nervous system responses that are aimed at increasing blood glucose levels. Insulin secretion decreases and hormones that promote higher blood glucose levels, such as glucagon, cortisol, growth hormone and epinephrine, all increase. As mentioned above, there is a store in the liver of glycogen that can be converted to glucose rapidly.

In addition to the biochemical processes that occur, the body starts to consciously alert the affected person that is needs food by causing the signs and symptoms of hypoglycemia discussed below.

Signs and symptoms:
Hypoglycemic symptoms and manifestations can be divided into those produced by the counterregulatory hormones (epinephrine/adrenaline and glucagon) triggered by the falling glucose, and the neuroglycopenic effects produced by the reduced brain sugar.

Adrenergic manifestations

*Shakiness, anxiety, nervousness, tremor

*Palpitations, tachycardia

*Sweating, feeling of warmth

*Pallor, coldness, clamminess

*Dilated pupils (mydriasis)

Feeling of numbness “pins and needles” (parasthaesia) in the fingers

Glucagon manifestations:

*Hunger, borborygmus

*Nausea, vomiting, abdominal discomfort

*Headache

Neuroglycopenic manifestations:

*Abnormal mentation, impaired judgement

*Nonspecific dysphoria, anxiety, moodiness, depression, crying

*Negativism, irritability, belligerence, combativeness, rage

*Personality change, emotional lability

*Fatigue, weakness, apathy, lethargy, daydreaming, sleep

*Confusion, amnesia, dizziness, delirium

*Staring, “glassy” look, blurred vision, double vision

*Automatic behavior, also known as automatism

*Difficulty speaking, slurred speech

*Ataxia, incoordination, sometimes mistaken for “drunkenness”

*Focal or general motor deficit, paralysis, hemiparesis

*Paresthesia, headache

*Stupor, coma, abnormal breathing

*Generalized or focal seizures

Not all of the above manifestations occur in every case of hypoglycemia. There is no consistent order to the appearance of the symptoms, if symptoms even occur. Specific manifestations may vary by age and by severity of the hypoglycemia. In young children, vomiting can sometimes accompany morning hypoglycemia with ketosis. In older children and adults, moderately severe hypoglycemia can resemble mania, mental illness, drug intoxication, or drunkenness. In the elderly, hypoglycemia can produce focal stroke-like effects or a hard-to-define malaise. The symptoms of a single person may be similar from episode to episode, but are not necessarily so and may be influenced by the speed at which glucose levels are dropping, and previous incidence.

In newborns, hypoglycemia can produce irritability, jitters, myoclonic jerks, cyanosis, respiratory distress, apneic episodes, sweating, hypothermia, somnolence, hypotonia, refusal to feed, and seizures or “spells”. Hypoglycemia can resemble asphyxia, hypocalcemia, sepsis, or heart failure.

In both young and old patients, the brain may habituate to low glucose levels, with a reduction of noticeable symptoms despite neuroglycopenic impairment. In insulin-dependent diabetic patients this phenomenon is termed hypoglycemia unawareness and is a significant clinical problem when improved glycemic control is attempted. Another aspect of this phenomenon occurs in type I glycogenosis, when chronic hypoglycemia before diagnosis may be better tolerated than acute hypoglycemia after treatment is underway.

Nearly always, hypoglycemia severe enough to cause seizures or unconsciousness can be reversed without obvious harm to the brain. Cases of death or permanent neurological damage occurring with a single episode have usually involved prolonged, untreated unconsciousness, interference with breathing, severe concurrent disease, or some other type of vulnerability. Nevertheless, brain damage or death has occasionally resulted from severe hypoglycemia.

Causes:-
Hundreds of conditions can cause hypoglycemia. Common causes by age are listed below. While many aspects of the medical history and physical examination may be informative, the two best guides to the cause of unexplained hypoglycemia are usually

1.The circumstances

2.A critical sample of blood obtained at the time of hypoglycemia, before it is reversed.

There are several ways to classify hypoglycemia. The following is a list of the more common causes and factors which may contribute to hypoglycemia grouped by age, followed by some causes that are relatively age-independent. See causes of hypoglycemia for a more complete list grouped by etiology.

Hypoglycemia in newborn infants:-

Hypoglycemia is a common problem in critically ill or extremely low birthweight infants. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant hyperinsulinism, hypopituitarism or an inborn error of metabolism and presents more of a management challenge.

*Transient neonatal hypoglycemia

*Prematurity, intrauterine growth retardation, perinatal asphyxia

*Maternal hyperglycemia due to diabetes or iatrogenic glucose administration

*Sepsis

*Prolonged fasting (e.g., due to inadequate breast milk or condition interfering with feeding)

*Congenital hypopituitarism

*Congenital hyperinsulinism, several types, both transient and persistent

*Inborn errors of carbohydrate metabolism such as glycogen storage disease

Hypoglycemia in young children:-

Single episodes of hypoglycemia may occur due to gastroenteritis or fasting, but recurrent episodes nearly always indicate either an inborn error of metabolism, congenital hypopituitarism, or congenital hyperinsulinism. A list of common causes:

*Prolonged fasting

*Diarrheal illness in young children, especially rotavirus gastroenteritis

*Idiopathic ketotic hypoglycemia

*Isolated growth hormone deficiency, hypopituitarism

*Insulin excess

*Hyperinsulinism due to several congenital disorders of insulin secretion

*Insulin injected for type 1 diabetes

*Hyperinsulin Hyperammonia syndrome (HIHA)due toGlutamate dehydrogenase 1gene.Can cause mental retardation and epilepsy in severe cases.

*Gastric dumping syndrome (after gastrointestinal surgery)

*Other congenital metabolic diseases; some of the common include

*Maple syrup urine disease and other organic acidurias

*Type 1 glycogen storage disease

*Type III glycogen storage disease. Can cause less severe hypoglycemia than type I

*Disorders of fatty acid oxidation

*Medium chain acylCoA dehydrogenase deficiency (MCAD)

*Familial Leucine sensitive hypoglycemia

*Accidental ingestions

*Sulfonylureas, propranolol and others

*Ethanol (mouthwash, “leftover morning-after-the-party drinks”)

Hypoglycemia in older children and young adults:-

By far, the most common cause of severe hypoglycemia in this age range is insulin injected for type 1 diabetes. Circumstances should provide clues fairly quickly for the new diseases causing severe hypoglycemia. All of the congenital metabolic defects, congenital forms of hyperinsulinism, and congenital hypopituitarism are likely to have already been diagnosed or are unlikely to start causing new hypoglycemia at this age. Body mass is large enough to make starvation hypoglycemia and idiopathic ketotic hypoglycemia quite uncommon. Recurrent mild hypoglycemia may fit a reactive hypoglycemia pattern, but this is also the peak age for idiopathic postprandial syndrome, and recurrent “spells” in this age group can be traced to orthostatic hypotension or hyperventilation as often as demonstrable hypoglycemia.

*Insulin-induced hypoglycemia

*Insulin injected for type 1 diabetes

*Factitious insulin injection (Munchausen syndrome)

*Insulin-secreting pancreatic tumor

*Reactive hypoglycemia and idiopathic postprandial syndrome

*Addison’s disease

*Sepsis

Hypoglycemia in older adults:-

The incidence of hypoglycemia due to complex drug interactions, especially involving oral hypoglycemic agents and insulin for diabetes rises with age. Though much rarer, the incidence of insulin-producing tumors also rises with advancing age. Most tumors causing hypoglycemia by mechanisms other than insulin excess occur in adults.

*Insulin-induced hypoglycemia

*Insulin injected for diabetes

*Factitious insulin injection (Munchausen syndrome)

*Excessive effects of oral diabetes drugs, beta-blockers, or drug interactions

*Insulin-secreting pancreatic tumor

*Alimentary (rapid jejunal emptying with exaggerated insulin response)

*After gastrectomy dumping syndrome or bowel bypass surgery or resection

*Reactive hypoglycemia and idiopathic postprandial syndrome

*Tumor hypoglycemia, Doege-Potter syndrome

*Acquired adrenal insufficiency

*Acquired hypopituitarism

*Immunopathologic hypoglycemia

Treatment:-
Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause, and taking measures to hopefully prevent future episodes.

Reversing acute hypoglycemia:-
The blood glucose can be raised to normal within minutes by taking (or receiving) 10-20 grams of carbohydrate. It can be taken as food or drink if the person is conscious and able to swallow. This amount of carbohydrate is contained in about 3-4 ounces (100-120 ml) of orange, apple, or grape juice although fruit juices contain a higher proportion of fructose which is more slowly metabolized than pure dextrose, alternatively, about 4-5 ounces (120-150 ml) of regular (non-diet) soda may also work, as will about one slice of bread, about 4 crackers, or about 1 serving of most starchy foods. Starch is quickly digested to glucose (unless the person is taking acarbose), but adding fat or protein retards digestion. Symptoms should begin to improve within 5 minutes, though full recovery may take 10-20 minutes. Overfeeding does not speed recovery and if the person has diabetes will simply produce hyperglycemia afterwards.

If a person is suffering such severe effects of hypoglycemia that they cannot (due to combativeness) or should not (due to seizures or unconsciousness) be given anything by mouth, medical personnel such as EMTs and Paramedics, or in-hospital personnel can establish an IV and give intravenous Dextrose, concentrations varying depending on age (Infants are given 2cc/kg Dextrose 10%, Children Dextrose 25%, and Adults Dextrose 50%). Care must be taken in giving these solutions because they can be very necrotic if the IV is infiltrated. If an IV cannot be established, the patient can be given 1 to 2 milligrams of Glucagon in an intramuscular injection. More treatment information can be found in the article diabetic hypoglycemia.

One situation where starch may be less effective than glucose or sucrose is when a person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors prevents starch and other sugars from being broken down into monosaccharides that can be absorbed by the body, patients taking these medications should consume monosaccharide-containing foods such as glucose tablets, honey, or juice to reverse hypoglycemia.

Prevention:
The most effective means of preventing further episodes of hypoglycemia depends on the cause.

The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise, or alcohol intake.

Many of the inborn errors of metabolism require avoidance or shortening of fasting intervals, or extra carbohydrates. For the more severe disorders, such as type 1 glycogen storage disease, this may be supplied in the form of cornstarch every few hours or by continuous gastric infusion.

Several treatments are used for hyperinsulinemic hypoglycemia, depending on the exact form and severity. Some forms of congenital hyperinsulinism respond to diazoxide or octreotide. Surgical removal of the overactive part of the pancreas is curative with minimal risk when hyperinsulinism is focal or due to a benign insulin-producing tumor of the pancreas. When congenital hyperinsulinism is diffuse and refractory to medications, near-total pancreatectomy may be the treatment of last resort, but in this condition is less consistently effective and fraught with more complications.

Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal insufficiency usually ceases when the appropriate hormone is replaced.

Hypoglycemia due to dumping syndrome and other post-surgical conditions is best dealt with by altering diet. Including fat and protein with carbohydrates may slow digestion and reduce early insulin secretion. Some forms of this respond to treatment with a glucosidase inhibitor, which slows starch digestion.

Reactive hypoglycemia with demonstrably low blood glucose levels is most often a predictable nuisance which can be avoided by consuming fat and protein with carbohydrates, by adding morning or afternoon snacks, and reducing alcohol intake.

Idiopathic postprandial syndrome without demonstrably low glucose levels at the time of symptoms can be more of a management challenge. Many people find improvement by changing eating patterns (smaller meals, avoiding excessive sugar, mixed meals rather than carbohydrates by themselves), reducing intake of stimulants such as caffeine, or by making lifestyle changes to reduce stress.

Herbal medication for Hypoglycemia:-
THE following HERBS as stated below can help to ease low blood sugar with symptoms that include lightheadedness, headache, irritability, depression, anxiety, cravings for sweets, confusion, night sweats, weakness in the legs and arms, swollen feet, insatiable hunger, eye pain, nervous tics, mental disturbances, insomnia, aggressiveness, hair-trigger temper.

Cinnamon bark extract, coral calcium with trace minerals, L-carnitine, bilberry extract, Mexican wild yam, dandelion root, milk thistle extract.

Quik Tip
: Cinnamon bark decreases insulin resistance and improves blood-sugar profiles better than most prescription drugs, USDA studies confirm.

Hypoglycemia as “folk” medicine:-
Hypoglycemia is also a term of contemporary folk medicine which refers to a recurrent state of symptoms of altered mood and subjective cognitive efficiency, sometimes accompanied by adrenergic symptoms, but not necessarily by measured low blood glucose. Symptoms are primarily those of altered mood, behavior, and mental efficiency. This condition is usually treated by dietary changes which range from simple to elaborate. Advising people on management of this condition is a significant “sub-industry” of alternative medicine. More information about this form of “hypoglycemia”, with far more elaborate dietary recommendations, is available on the internet and in health food stores. Most of these websites and books describe a conflation of reactive hypoglycemia and idiopathic postprandial syndrome but do not recognize a distinction. The value of most of their recommendations is – from a scientific perspective – unproved.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.medicinenet.com/hypoglycemia/article.htm
http://en.wikipedia.org/wiki/Hypoglycemia
http://www.herbnews.org/hypoglycemiadone.htm

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Irritable Bowel Syndrome in Children

Irritable bowel syndrome (IBS) is a digestive disorder that causes abdominal pain, bloating, gas, diarrhea, and constipation—or some combination of these problems. IBS affects people of all ages, including children…..click & see

IBS is classified as a functional disorder because it is caused by a problem in how the intestines, or bowels, work. People with IBS tend to have overly sensitive intestines that have muscle spasms in response to food, gas, and sometimes stress. These spasms may cause pain, diarrhea, and constipation.

IBS may be a cause of recurring abdominal pain in children. The diagnosis of IBS is based on having abdominal pain or discomfort plus any two of the following:

  • The pain is relieved by having a bowel movement.
  • The onset of pain is associated with a change in the frequency of stools.
  • The onset of pain is associated with a change in stool consistency.

The symptoms must be present for at least 12 weeks in the preceding 12 months, and there should be no diseases that might cause the symptoms.

In children and adolescents, IBS affects girls and boys equally and may be diarrhea-predominant, constipation-predominant, or have a variable stool pattern.

Children with IBS may also have headache, nausea, or mucus in the stool. Weight loss may occur if a child eats less to try to avoid pain. Some children first develop symptoms after a stressful event, such as teething, a bout with the flu, or problems at school or at home. Stress does not cause IBS, but it can trigger symptoms.

To diagnose IBS, the doctor will ask questions about symptoms and examine the child to rule out more serious problems or diseases. IBS is not a disease—it is a syndrome, or group of symptoms that occur together. It does not damage the intestine, so if the physical exam and other tests show no sign of disease or damage, the doctor may diagnose IBS.

In children, IBS is treated mainly through changes in diet—eating more fiber and less fat to help prevent spasms—and through bowel training to teach the child to empty the bowels at regular, specific times during the day. Medications like laxatives are rarely prescribed because children are more susceptible to addiction than adults. When laxatives are necessary, parents must follow the doctor’s instructions carefully. Learning stress management techniques may also help some children.

For More Information

International Foundation for Functional Gastrointestinal Disorders (IFFGD) Inc.
P.O. Box 170864
Milwaukee, WI 53217–8076
Phone: 1–888–964–2001 or 414–964–1799
Fax: 414–964–7176
Email: iffgd@iffgd.org
Internet: www.iffgd.org

Additional Information on Irritable Bowel Syndrome

The National Digestive Diseases Information Clearinghouse collects resource information on digestive diseases for National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Reference Collection. This database provides titles, abstracts, and availability information for health information and health education resources. The NIDDK Reference Collection is a service of the National Institutes of Health.

To provide you with the most up-to-date resources, information specialists at the clearinghouse created an automatic search of the NIDDK Reference Collection. To obtain this information, you may view the results of the automatic search on Irritable Bowel Syndrome.

If you wish to perform your own search of the database, you may access and search the NIDDK Reference Collection database online.

 Irritable Bowel Syndrome: Herbal Help

Natural help for Irritable Bowel Syndrome

Home Remedy for IBS

Homeopathy & IBS

Homeopathic Treatment for IBS

National Digestive Diseases Information Clearinghouse:
2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
Fax: 703–738–4929
Email: nddic@info.niddk.nih.gov
Internet: www.digestive.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.


Source:http://digestive.niddk.nih.gov/ddiseases/pubs/ibschildren/index.htm

Pumpkin may treat diabetics

The common vegetable Pumpkin will now be more tastier than ever as Chinese scientists have claimed that it can “drastically” reduce the need for daily insulin injections for millions of diabetic patients worldwide.

Scientists have discovered a compound in pumpkin that has been known to promote the regeneration of damaged insulin-producing beta cells in diabetic rats, thereby improving the level of insulin in their blood.

Laboratory data showed that diabetic rats that had been fed pumpkin extract had only five per cent less plasma insulin and eight per cent fewer insulin-positive cells than normal healthy rats, according to a research paper published this week in the US-based Journal of the Science of Food and Agriculture.

The researchers fed 12 diabetic rats and 12 normal rats either a normal diet or a diet supplemented with pumpkin extract for 30 days.

On average, the rats receiving the pumpkin supplements experienced a 36 per cent increase in plasma insulin compared to the untreated rats, Professor Xia Tao, the paper’s lead author and a teacher at Shanghai‘s East China Normal University said.

However, Xia, a professor at the College of Life Science, emphasised that further research was needed to evaluate the effects in human beings.

“But I tend to believe pumpkin extract could also promote regeneration of pancreatic beta cells in humans,” he was quoted as saying by China Daily

Source:The Times Of India

Fatigue

So many people In our modern society feel overwhelmingly tired. Low vitality seems to be the bane of our daily experience. Everything about our existence in today’s world is moving at such a fast pace that it just leaves us breathless. It seems as if there is never enough time to accomplish our goals. The rhythm of life should be a balance of activity and rest. But today’s world just does not seem to allow for that.

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No matter how tired we may be, we all have the ability to correct the situation through proper nutrition, supplementation, and exercise, combined with the proper balance of rest and activity. The first step is to discover the source of the tiredness.

Nutritional biochemistry, environmental toxins and allergies, stress, adrenal weakness, low thyroid, sleep disorders, hypoglycemia, gut toxicity, and food allergies are some of the causes that can propel us into an unbroken cycle of fatigue. In the following pages we shall go more deeply into the various causes of fatigue and their remedies and thereby hopefully discover the secret pathway to our own radiant health and vitality.

Usually it takes us quite a while to develop fatigue and likewise it will take us a while to build our energy reserves back up. We should be patient with ourselves and unravel the mystery of the cause of our state of fatigue and work consistently to restore our natural state of abundant energy.

Symptoms:

Fatigue refers to a feeling of tiredness or weariness. It can be temporary or chronic. This condition can be remedied by adequate rest. Chronic or continuous fatigue is ,however, a serious problem which requires a comprehensive plan of treatment.

Causes:
A specific character trait, compulsiveness, can lead to continuous fatigue. Many persons constantly feel that they cannot take rest until they finish everything that needs to be done at one time. Thease persons are usually tense and cannot relax unless they complete the whole job, no matter hotwired they may be .

The main cause of fatigue is lowered vitality or lack of energy due to wrong feeding habits. The habitual use of refined foods such as white sugar, refined cereals, white flour products and processed food have very bad effects on the process in general. Certain physical and mental condition also creates fatigue. These include anemia, intestinal worms, low blood pressure, and low blood sugar any kind of infection in the body , liver damage, allergy to foods and drugs, insomnia mental tension, and unresolved emotional problem.

Healing Options:

Herbs : The patient suffering from fatigue should eat nutritious foods, which supply energy to the body. Cereal seeds in their natural state relieve fatigue and provide energy. These cereal seeds are corn seeds, wheat seeds, rye seeds, maize seeds.

Vitamin B , Dates and Lemon balm ….very helpful for all kinds of fatigue.

Ayurvedic Supplements: 1. Keshari Kalp 2. Musli pak 3.Drakshasava (Special)

Diet : Nutritional measures are most vital in the treatment of fatigue. Studies reveal that people who eat snacks in between meals suffer less from fatigue and nervousness, think more clearly, and are more efficient than those who eat only three meal daily .These snacks should consists of fresh or dried fruits, fresh fruit or vegetable Juices, raw vegetables, or small sandwiches of whole gram bread. These snacks should be light and less food should be consumed at regular meals .The snacks should also be taken at specified timing such as 11 am, 4 p.m.

Lifestyle: Chronic fatigue caused by poor circulation can be remedied by daily physical exercise. It will help relieve tension, bring a degree of freshness, renew energy, and induce sleep. Massage cold applications increasing in degree gradually or alternate hot and cold baths, stimulate the muscles to renewed activity, thereby relieving fatigue.

Yoga Exercise: 1.Basic Breathing (Pranayama) 2.The Shoulder Stand (Sarvang Asana) 3.The Lotus (Padma Asana)

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.

Source:Allayurveda.com