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A STUDY ON “SHUKRA ABAHUTVAT MEDASAAVRUTA MARGATVAT CHA KRUCCHRA VYAVAYATA” IN STHOULYA.
By
Dr. GEETHA. P, B.A.M.S.
Dissertation submitted to the Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore.
In the partial fulfillment of the requirements for the degree of
DOCTOR OF MEDICINE (AYURVEDA)
in
AYURVEDA SIDDHANTA
Under The Guidance of Dr. K. NASEEMA AKHTAR M.D. (Ayu)
Professor & HOD
Department of Post-Graduate Studies in Ayurveda Siddhanta
G.A.M.C., Mysore.
Co-Guide
Dr. V. RAJENDRA. M.D. (Ayu)
Assistant Professor, Department of Post-Graduate Studies in Ayurveda Siddhanta
G.A.M.C., Mysore
DEPARTMENT OF POST GRADUATE STUDIES IN AYURVEDA SIDDHANTA,
GOVERNMENT AYURVEDA MEDICAL COLLEGE,
MYSORE.
2010
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ACKNOWLEDGEMENT
I bow to the sacred feet of Almighty, without the blessings of whom this study would
not have been completed.
I sincerely express my indebtedness and profound gratitude to my Guide
Dr. K.Naseema Akhtar, Professor and HOD, Department of PG Studies in Ayurveda
Siddhanta, Government Ayurveda Medical College, Mysore for her valuable guidance
& encouragement through out my PG studies.
Words at my command are not adequate to convey the depth of my feelings of
gratitude to my esteemed co-guide Dr. V. Rajendra, Assistant Professor, Department
of PG Studies in Ayurveda Siddhanta, Government Ayurveda Medical College,
Mysore for his valuable guidance, and support throughout my study.
I am grateful to Principal Dr.Ashok D.Satpute, Government Ayurveda Medical
College, Mysore for his support and encouragement.
I sincerely express my indebtedness and profound gratitude to Dr.N.Anjaneya
Murthy, Professor and former HOD, Department of PG Studies in Ayurveda
Siddhanta, Government Ayurveda Medical College, Mysore, for his everlasting
support and inspiration.
I am thankful to Late. Dr. G.N. Shakunthala, Professor and former HOD,
Department of PG Studies in Ayurveda Siddhanta, Government Ayurveda Medical
College, Mysore, for her continuous supervision and help at every stage of this study.
I owe my deep sense of gratitude to all my teachers Dr. T.D. Ksheera Sagar,
Dr.T.R.Shantala Priyadarshini, Dr.Shreevathsa, Dr.V.A.Chate, Dr. Ananda
Katti for their support and guidance.
I thank Dr. Ayyana gowdar, Dr.Chandramouli, Dr.Balakrishna, Dr. Gopinath, Dr.
Fathima, Dr. Shantaram, Dr. Umashankar, Dr. T.G. Ramesh, Dr.Mythreyi, Dr. Anant
Desai, Dr.Adarsh, Dr.Nalini, Dr. Mamatha, Dr. Negalur, Dr.Nagesh, Dr.Raju kurne,
Dr.Srinivas yadav, Dr. Shenoy, Dr. Suman and Dr. Shilpa and all other teachers and
hospital staff for their support in this study.
viii
I personally thank Dr. Gajanana Hegde and Dr. Jyothi Hegde for their kind support.
I thank Dr.Lancy D’souza for his valuable help and guidance in the statistical
analysis and interpretations.
I personally thank Mr.Amith, KCDC and all the staff of the Laboratory for their kind
support.
I express enormous amount of thanks to my senior Colleagues Dr.Soubhagya Bilagi,
Dr.Aparna.K and My junior colleague Dr. Pallavi and Dr,Aravind, for their timely
suggestion, support and encouragement through out my study.
I am thankful to my senior colleagues Dr.Yogesh, Dr.Savita Shenoy, Dr.
Vijayalakshmi, Dr.Kedar Sharma, Dr.Annapoorani, Dr.Pankaj Pathak and Dr.Rajesh
Bhat. I owe my special thanks to my classmates, Dr.Ranjith kumar shetty,
Dr.Kalyani, Dr.Ramesh kumar.K. L and Dr.Kavitha for their suggestions and help
throughout the study.
I thank my younger colleagues, Dr. Athika jan, Dr Arhanth, Dr.Rekha, Dr. Preetha,
Dr. Arun, Dr. Atul , Dr. Divyarani and Dr. Sapna for their help.
I thank Dr.Ananta shayana, Dr. Sameena, Dr. Shreedhar murthy, Dr. Vyasraj, Dr.
Ranjini, Dr. Parveen, Dr. Kiran, Dr.palavi and Dr. Aditya for their support in my
dissertation.
I personally thank Dr.Chandrashekar, Dr.Kiran, Dr.Satyamurthy Bhat, Dr.
Gurubasavaraj, Dr.Poornima, Dr.Ahalya, Dr.Seetalakhmi and Dr.Pushpa for
their support in my dissertation.
I thank Dr. Prasad, Principal SDM, Udupi and Dr Niranjan, Assistant professor,
SDM, Udupi for their support in my dissertation.
This acknowledgement would not be complete without paying obeisance to my
husband Dr Radhakrishna R Rao K.S and my mother P Sumithra for their support
and encouragement throughout the study. I thank my children Medha karnik and
Rohan karnik for their support and help throughout my study.
I also owe my heart felt gratitude to my teachers of under graduation who initiated
and instilled in me the knowledge of this holy science.
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LIST OF ABBREVIATIONS
A.K: Amara Kosha
A.H: Ashtanga Hrudaya
A.S: Ashtanga Sangraha
B.P:Bhava Prakasha
B.Raj : Basava Rajeeyam
Cha: Charaka Samhita
Cha Su: Charaka Samhita sutra sthana
G.Ni: Gada nigraha
IIEF: International Index of Erectile Function
M.K: Medini Kosha
M.Ni : Madhava nidana
S.K: Shabdartha koustubha
S.K.D: Shabda kalpa Druma
Sha: Sharangdhara Samhita
Su. Sushruta Samhita
Su Su: Sushrutha Samhita sutra sthana
V.Sena: Vanga Sena
Y.R: Yoga Ratnakara
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ABSTRACT
Background of the study
Obesity has increased at an alarming rate in recent years & has become one of the
major health hazards globally. Erectile Dysfunction is one of the complications of
obesity which is not greatly emphasized by the medical practitioners and researchers
as well. Almost 8 out of every 10 men who suffer from erectile dysfunction are
overweight. Studies show that obese males have a 30% higher chance of developing
the condition than the people of normal weight. In recent years several informations
are available with regard to obesity related sexual dysfunction. It is also noteworthy
that there is a lot of information available in the classical literature of Ayurveda
regarding the relationship between obesity and sexual act. Obesity is described as
‘Sthoulya’ and difficulty in performing sexual act is termed as ‘krucchra vyavayata’.
Charaka Samhita establishes the relationship between these through the statement
“Shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” which literally
means: “difficulty in sexual act as an effect of shukra abahutva and medasaavruta
margatva”.
The present study was conducted to compile the available information regarding the
relation between Sthoulya and krucchra vyavayata, in classical literature of Ayurveda
and to validate the statement of Charaka Samhita. The present work also intends to
evaluate it through an observational study in male patients of Sthoulya.
xii
Objectives of the Study
To compile and interpret the available information on the relationship between
Sthoulya, shukra abahutva and krucchra vyavaya.
To validate the statement of Charaka Samhita “Shukra abahutvat medasaavruta
margatvat cha krucchra vyavayata”.
To understand shukra abahutvat by the quantitative and qualitative changes in
Shukra in patients of Sthoulya through an observational study.
Method
A Single group observational study
Intervention
33 obese individuals between age group 30 to 60 years were assigned into a single
group. They were assessed for sexual function and semen analysis.
Results
Significant results were observed in overall satisfaction orgasmic function and
erectile functions of obese individuals. In rest of the components of IIEF like sexual
desire, intercourse satisfaction, there was no significant findings observed.
The parameters like liquefaction time, viscosity, sperm count, were at statistically
significant levels suggesting that there is no much change seen in the semen
qualitatively in obese individuals.
xiii
There was no statistically significant difference in semen volume, motility (class a
and b) and overall impression. Correlation studies suggest the fact that the extent of
erectile dysfunction varies directly with the hip waist ratio.
Interpretation and Conclusion
Significant results were observed in overall satisfaction and orgasmic function,
suggesting that there was mild dysfunction observed in these two parameters.
Statistically significant results were observed in erectile functions of obese individuals
suggesting that there is no erectile dysfunction seen in obese individuals. But the
degree of dysfunction from severe to mild is comparatively more in obese individuals.
In rest of the components of IIEF there was no significant findings observed. But
some amount of dysfunction from severe to mild was observed in these two
components also.
It is observed from the study that the relationship between BMI and erectile
dysfunction was not significant statistically. However the study suggests that the
erectile dysfunction increases proportionately with waist hip ratio. There is no direct
relation between BMI and erectile dysfunction but Correlation studies suggest the fact
that the extent of erectile dysfunction varies directly with the hip waist ratio.
Even though there are no significant changes in all the semen parameters, 60%
individuals had the semen volume less than 2 ml indicating that some amount of
abnormality observed in semen volume suggest that the probability of a lesser volume
of semen is more in obese individuals.
It was concluded that there is a relation between Sthoulya and krucchra vyavaya.
xiv
Keywords
Sthoulya
vyavaya
krucchra vyavaya
shukra abahutva
medasaavruta marga
obesity
Erectile dysfunction.
xv
CONTENTS
Particulars Page no
Introduction 1
Objectives 4
Review of literature 5
Review on Sthoulya 5
Review on obesity 23
Review on vyavaya 38
Review on krucchra vyavaya 46
Review on normal human sexual response cycle 48
Review on difficulty in sexual act 52
Review on Sthoulya with krucchra vyavaya 53
Review on articles related to obesity with sexual dysfunction
58
Materials and methods 61
Observations and results 68
Discussion 101
Conclusion 145
Summary 146
Bibliographic references 148
Annexure I- XXII
xvi
LIST OF TABLES
Table No
Particulars Page No.
1. Showing Nidanas of Sthoulya mentioned in different Ayurvedic texts 8
2. Showing the Lakshanas of Sthoulya mentioned in different Ayurvedic texts
14
3. Showing the Upadravas of Sthoulya mentioned in different Ayurvedic texts
16
4. Showing the reasons for the increasing prevalence of obesity-the 'obesogenic' environment
26
5. Showing the classification of obesity based on BMI 31
6. Showing the Complications of obesity 35
7. Showing the effect of lakshans in different stages of vyavaya 57
8. Showing the distribution of age in the individuals of Sthoulya 68
9. Showing the Distribution of Marital Status in the individuals of Sthoulya
68
10. Showing the Distribution of Religion in the individuals of Sthoulya 69
11. Showing the distribution of Education in the individuals of Sthoulya 69
12. Showing the distribution of Socio-Economic status in the individuals of Sthoulya
70
13. Showing the distribution of cardinal symptoms in the individuals of Sthoulya
70
xvii
14. Showing the distribution of Nature of work in the individuals of Sthoulya
71
15. Showing the distribution of exercise in the individuals of Sthoulya 71
16. Showing the distribution of nature of diet in the individuals of Sthoulya 72
17. Showing the distribution of nature of diet in the individuals of Sthoulya 72
18. Showing the distribution of predominant rasa preferred in the individuals of Sthoulya
73
19. Showing the distribution of appetite in the individuals of Sthoulya 73
20. Showing the distribution of nature of sleep in the individuals of Sthoulya
74
21. Showing the distribution of sleep during daytime in the individuals of Sthoulya
74
22. Showing the distribution of sleep during night time in the individuals of Sthoulya
74
23. Showing the distribution of Habits in the individuals of Sthoulya 75
24. Showing the distribution of Prakruti in the individuals of Sthoulya 75
25. Showing the distribution of Samhanana in the individuals of Sthoulya 75
26. Showing the distribution of Satmya in the individuals of Sthoulya 76
27. Showing the distribution of Sattva in the individuals of Sthoulya 76
28. Showing the distribution of abhyavaharana Shakti in the individuals of Sthoulya
76
xviii
29. Showing the distribution of jarana Shakti in the individuals of Sthoulya 77
30. Showing the distribution of vyayama Shakti in the individuals of Sthoulya
77
31. Showing the distribution of koshta in the individuals of Sthoulya 77
32. Showing the Scores of IIEF related to Erectile Functions in the individuals of Sthoulya
78
33. Showing the Scores of IIEF related to Orgasmic Functions in the individuals of Sthoulya
78
34. Showing the Scores of IIEF related to Sexual Desire in the individuals of Sthoulya
79
35. Showing the Scores of IIEF related to Intercourse Satisfaction in the individuals of Sthoulya
79
36. Showing the Scores of IIEF related to Overall Satisfaction in the individuals of Sthoulya
80
37. Showing the Semen volume in the individuals of Sthoulya 80
38. Showing the Liquefaction time of Semen in the individuals of Sthoulya 81
39. Showing the Viscosity of Semen in the individuals of Sthoulya 81
40. Showing the Sperm count in the individuals of Sthoulya 81
41. Showing the Motility of Sperms in the individuals of Sthoulya 82
42. Showing the Motility of Sperms ( class a & class b ) in the individuals of Sthoulya
82
43. Showing the Morphology of Sperms in the individuals of Sthoulya 82
xix
44. Showing the Impression of Semen Analysis in the individuals of Sthoulya
83
45. Showing the Correlations of BMI with Erectile Functions in the individuals of Sthoulya
83
46. Showing the Correlations of BMI with Semen Analysis in the individuals of Sthoulya
84
47. Showing the Correlations of waist hip ratio with Erectile Functions in the individuals of Sthoulya
84
48. Showing the Correlations of waist hip ratio with Semen Analysis in the individuals of Sthoulya
85
List of Illustrations
Sl. No.
Particulars Page No.
1. Showing the incidence of Age 86
2. Showing the incidence of marital status 86
3. Showing the incidence of Educational level 87
4. Showing the incidence of socio-economic status 87
5. Showing the incidence of Cardinal symptoms of Sthoulya 88
6. Showing the incidence of Cardinal symptoms of Sthoulya 88
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7. Showing the incidence of Nature of work 89
8. Showing the incidence of Duration of Exercise 89
9. Showing the incidence of Nature of Diet 90
10. Showing the incidence of Nature of food 90
11. Showing the incidence predominant taste Preferred 91
12. Showing the incidence of Nature of appetite 91
13. Showing the incidence of Nature of Sleep 92
14. Showing the incidence of Duration of Day sleep 92
15. Showing the incidence of Duration of sleep at night 93
16. Showing the incidence of Prakruti 93
17. Showing the incidence of Sattva 94
18. Showing the incidence of Koshta 94
19. Showing Scores of IIEF related to Erectile Functions 95
20. Showing Scores of IIEF related to Orgasmic Functions 95
21. Showing Scores of IIEF related to Sexual Desire 96
22. Showing Scores of IIEF related to Intercourse Satisfaction 96
23. Showing Scores of IIEF related to Overall Satisfaction 97
24. Showing Semen volume 97
xxi
25. Showing Liquefaction time of Semen 98
26. Showing Viscosity of Semen 98
27. Showing Sperm Count 99
28. Showing Motility of sperms 99
29. Showing Morphology of sperm 100
30. Showing Impression of Semen Analysis 100
List of flow charts
Sl No Particulars Page no
1. Showing the pathogenesis of obesity 34
2. Showing the samprapti of Sthoulya 111
3. Showing the samprapti of krucchra vyavaya in sthoulya 126
Key for Master Chart
M.Sta: Marital Status
M: Married
U.M.: Unmarried
Reli: Religion
H: Hindu
Mu: Muslim
Ed.: Education
PS: Primary School
MS: Middle School
HS: High School
G: Graduate
PG: Post Graduate
SES: Socio-Economic Status
LM: Lower Middle Class
M C: Middle Class
UM: Upper Middle Class
R: Rich
BMI: Body Mass Index
W.H.R: Waist hip ratio
C.S.U.: Chala Sphik Udara Stana
K.S: Kshudra Shwasa
A.U.H: Alasya Utsaha Hani
Doub: Daurbalya
Nidr.A: Nidradhikya
Dour: Daurgandhya
Snig: Snigdhangata
Ati.Pip:Atipipasa
Ati.Ks: Atikshudha
Alp.Vya: Alpa Vyavaya
G.S: Gatra Sada
Swed: Swedadhikya
P: Present
Ab: Absent
Nat.W : Nature of work
H.manual: Hard Manual Mild.W : Mild Work
Mod. M.W : Moderate manual work
Sed.W : Sedentary work
xxi
Dt: Diet
Mix : Mixed Diet
Veg: Vegetarian
In.H.F: Intake of Heavy food regularly
N.I.F: Normal quantity with increased
frequency
S.R.F: Small quantity with regular
frequency
U.S.M: Use of snacks between meals
Ex.Dt: Excessive dieting
PreTast; Predominant taste Preferred
All: All Rasas preferred
Y: Yes
N: No
Sl.Nat: Sleep Nature
Satis: Satisfactory
Unsat: Unsatisfactory
K.P: Kapha-Pitta
K.V: Kapha-Vata
V.P.: Vata-Pitta
Abh.Sha: Abhyavaharana Shakti
Ja.Sha :Jarana Shakti
Vya.Sha: Vyayamashakti
Ma: madhyama
Pr: Pravara
Av: Avara
K: Kroora
E.F: Erectile function.
Org.F: orgasmic function
SexD: sexual desire,
I.Sat: intercourse satisfaction
OvSat: overall satisfaction
Severe: Severe dysfunction
Md to mod: Mild to moderate dysfunction
Mild: Mild dysfunction
Mod: Moderate dysfunction
No dys: No dysfunction
Semvol: Semen Volume
Liqu: Liquification Time
Vis: Viscosity
Count: Sperm Count/ml
Mot.a; Motility a
Mot.ab: Motility a & b
Morp; Morphology
Imp: Impression
N: Normal
Abn: Abnormal
B.Line: Border Line
xxii
1
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
INTRODUCTION
Sthoulya is a medical condition characterized by excessive accumulation of
medas in the body, especially in the areas of buttocks (sphik), breasts (stana) and
abdomen (udara).
Over weight and obesity are the two medical conditions described in Western
Medical science which are equivalent to Sthoulya.
With the increasing prevalence of obesity, it is viewed as one of the serious health
problems of 21st century1.
Both Ayurveda and Western Medical science agree with the fact that obesity
has many adverse effects on health and increases the risk for various diseases,
particularly heart diseases, type2 diabetes mellitus and osteoarthritis.2, 3.Lot of clinical
and research studies are being conducted over the past 2-3 decades to understand the
role of obesity as a risk factor in various disorders.
The negative effect of obesity on the sexual abilities of men is greatly
understudied subject despite the fact that sexuality is one of the important areas of
normal health. It is hypothysed that obesity has a negative effect on sexual abilities.
However the relationship between obesity and sexual dysfunction has not been
completely clarified.The studies that are conducted in this direction are seldom,
eventhough some studies suggest that obesity is characterized by low levels of
androgen in men with Erectile dysfunction (ED) 4.
Interestingly the link between obesity and sexual dysfunction has been
emphasized in charaka Samhita. Not only the relation between the two but also the
probable pathophysiology has been hypothysed.
2
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
On the contrary, the relationship between obesity and sexual dysfunction is
greatly understudied, despite the great attention that has been focused on “Sthoulya”
and its management by Ayurvedic research community.
In the above situation to explore and validate the time old statement of
Charaka Samhita “shukra abahutvat medasaavruta margatvat cha krucchra
vyavayata” may play an important role in establishing the relationship between the
two.
In this background it was felt necessary to examine the statement of Charaka
Samhita.The current study was undertaken to analyse the statement conceptually and
to validate it through an observational study.
The study consisted of two parts. Firstly, a detail conceptual analysis of the
statement to understand the relationship between Sthoulya and sexual dysfunction.
The second part of the study was an observational study. The study was conducted in
33 obese males using an IIEF questionnaire assessing 5 specific areas of sexual
functioning. The observational study of a single group also consisted of semen
analysis of all individuals of the above group except three in whom semen analysis
could not be carried out because of Erectile dysfunction and low volume of semen.
The results of the study were observed and statistically analysed using
descriptive statistics, frequencies and percentages, Chi- Square test, Pearson’s product
moment correlation tests.
In the study it was observed and recorded that the relationship between
Sthoulya and krucchra Vyavaya was statistically insignificant.However observations
also revealed that varying degree of sexual dysfunction was observed in all the 5
specific areas of sexual functioning in 28 individuals suggesting that obesity has a
possible significant role in reducing the quality of sexual functioning in males.
3
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Eventhough the conclusions drawn from the study for the metabolic syndrome
is very preliminary and needs to be confirmed through larger epidemiological studies,
the probable link between the two may be a useful motivation for men to improve
their health related life style choices advocated by Ayurveda, which can reduce the
prevalence of obesity and hopefully the burden of sexual dysfunction.
4
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
OBJECTIVES OF THE STUDY
The study is partly conceptual and partly observational.
The conceptual part deals with the following objectives:
To compile and interpret the available information on the relationship between
Sthoulya, shukra abahutva and krucchra vyavaya.
To validate the statement of Charaka Samhita “Shukra abahutvat medasaavruta
margatvat cha krucchra vyavayata”.
The observation part deals with the following objective:
To understand shukra abahutvat by the quantitative and qualitative changes in
Shukra in patients of Sthoulya through an observational study.
5
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
STHOULYA
The significance of sthoulya as a pathological condition has been recognized
in Ayurvedic literature since the period of Charaka Samhita. It has been considered as
the most important condition among Ashtanindita purusha in Charaka Samhita.
Bruhatrayis consider sthoulya as an abnormal condition. However the later literature
of Ayurveda recognizes it as a separate disease entity under the heading of Medoroga.
Madhava nidana discussed this condition in an independent chapter. The later authors
also have paid lot of attention to this disease. Sthoulya in terms of obesity has also
been considered as a great health problem in the present era drawing lot of attention
of the researchers and clinicians as well.
Derivation
Sthoulya is a term which is ‘A’ karanta napumsaka linga.It is derived from the mula
dhatu ‘xjÉÑ’ with ‘AcÉç’ and ‘wrÉgÉç’ pratyaya as suffixes. The vyutpatti of the term
Sthoulya is as follows.
xjÉÔsÉxrÉ pÉÉuÉÈ ‘wrÉgÉç’ CÌiÉ | S.K5
xjÉÔsÉrÉÌiÉ CÌiÉ xjÉÔsÉÈ iÉxrÉ pÉÉuÉÇ CÌiÉ pÉÉuÉÉjÉåï‘wrÉgÉç’ mÉëirÉrÉå M×üiÉå xjÉÉæsrÉqÉç CÌiÉ mÉSÇ ÍxÉkrÉÌiÉ ||
xjÉÑ + AcÉç = xjÉÔsÉ + wrÉgÉç = xjÉÉæsrÉ
By the derivation the meaning of the term Sthoola is “the one which is bulky, big or
thick”
6
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Definition
1. xjÉÔsÉxrÉ pÉÉuÉÈ xjÉÉæsrÉqÉç | Vachaspatyam6 & S.K.D7
The bhava which is expressed in sthoola is sthoulya.
2. qÉåSÉåqÉÉÇxÉÉÌiÉuÉ×kSiuÉÉŠsÉ ÎxTüaÉÑSU xiÉlÉÈ |
ArÉjÉÉåmÉcÉrÉÉåixÉÉWûÉå lÉUÉåÅÌiÉxjÉÔsÉ EcrÉiÉå || Cha. Su 8, B.P.9
Sthoulya is a condition in which there is excess of medas and mamsa which is
deposited in areas like sphik, udara and stana causing pendulous movement in
those parts. There will also be malnourishment and lack of enthusiasm in
activities.
Synonyms
uÉQíûÉåÂÌuÉmÉÑsÉÇ mÉÏlÉmÉϳuÉÏ iÉÑ xjÉÔsÉ mÉÏuÉUå | A.K 10 Following synonyms are used for Sthoulya in Indian context
Peenam (fat, corpulent, muscular, thick, large, fleshy )
Peeva (to be fat / corpulent)
Sthoolam(big)
Peevaram (fat, stout, large, thick, dense)
Stoutness, bigness, largeness, thickness, grossness, denseness, excessive size or
length, doltishness are the different terminologies which represent Sthoulya.
Classification
Even though a systemic classification of Sthoulya is not available in the classical
literature of Ayurveda, an attempt can be made to classify the same based on the
terminologies used in various context represent Sthoulya.
7
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Charaka Samhita: 1.Sthoola
2. Atisthoola
Sushruta Samhita: 1. Sthoulya
2. Medoroga
Ashtanga Hrudaya: 1. Adhika
2. Madhya
3. Heena
Nidana
Classical literature of Ayurveda lists out various etiological factors for the
manifestation of Sthoulya as a disorder. They are related to various aspects of life
process starting from genetic disorder to the dietary factor. These etiological factors
can be categorized as below.
1. Aharatmaka Nidana / Dietary Factors
2. Viharatmaka Nidana / Behavioural factors
3. Manasika Nidana / Psychological factors
4. Beeja Doshaja / Hereditary or genetic factors
5. Anya Karana / all other causative factors
Aharatmaka Nidana / Dietary Factors
The Aharatmaka Nidanas mentioned in Charaka Samhita are Atisampoorana,
atisevana of guru, madhura sheeta and Snigdha aharas.In this context Atisampoorana
refers to Ati bhojana 11
In Sushruta Samhita, the nidanas like Adhyashana (consumption of food before the
proper digestion of previous meal) and Shleshmala ahara sevana can be considered as
the Aharatmaka Nidana. Here Adhyashana refers to ajeerna bhojana.12
8
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Viharatmaka Nidana / Behavioural factors
Avyayama (lack of exercise), Avyavaya (absence of sexual intercourse) and
Divaswapna (day time sleep) are mentioned as the etiological factors.13, 14, 15
Manasika Nidana / Psychological factors
Charaka Samhita has mentioned Achintyam (lack of mental activity) and
Harsha Nityatvam (a continuous relaxed state of mind) as the causative factors of
Sthoulya. These can be considered as the Manasika nidana.16
Beeja Doshaja / Hereditary or genetic factors
Beeja Svabhava is considered to be an etiological factor for Sthoulya, which
may be induced characters of either mother or father. Only in Charaka Samhita, the
concept of Beeja Swabhava is explained. 17
Anya Karana / all other causative factors
Among the other causes, excessive administration of Bruhmana chikitsa is considered
as the major cause for Sthoulya. Excessive and continuous administration of
treatments such as Snehana, Snehabasti, Snana, Utsadana and swapna are considered
as the etiological factors of Sthoulya.18, 19
Table No. 1. Showing the Nidanas of Sthoulya mentioned in different Ayurvedic
texts
Sl
no
Nidana Cha Su A.S A.H M.Ni B.P Y.R G.Ni Sha V.sena B.Raj
A Aharatmaka
Nidana
1 Atisampoorana + - - - - - - - - - -
2 Adhyashana - + - - - - - - - - -
3 Guru ahara + - + - - - - - - - -
4 Madhura
ahara
+ - - - - - - - - - -
9
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
5 Sheetala ahara + - - - - - - - - - -
6 Snigdha
aharas
+ - - - - - - - - - -
7 Shleshmala
ahara
- + - - + + + + + + +
B Viharatmaka
Nidana
Avyayama + + - - + + + + + + +
Avyavaya + - - - - - - - - - -
Divasvapna + + - - + + + + + + +
C Manasika
Nidana
Achintyam + - - - - - - - - - -
Harsha
Nityatvam
+ - - - - - - - - - -
D Beeja Doshaja
Beeja
Svabhava
+ - - - - - - - - - -
E Anya Karana
Ati Bruhmana
chikitsa
+ - - + - - - - - - -
Ama - - + - - - - - - - -
RasaNimittaja - + - - - - - - - - -
Samprapti
The samprapti of Sthoulya has been briefly dealt in all the three major
classical text books of Ayurveda.
Charaka Samhita has narrated the pathophysiology of sthoulya by
highlighting the process medasavruta vata20. It states that the set of nidanas increase
medas alone at the cost of other dhatus in vulnerable people. Due to the avarana of
10
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
vayu by medas, vata is specially confined to koshta, resulting in exaggerated speed of
digestion. This causes the habit of over eating and repeated intake of food. The major
portion of the food thus consumed is ultimately converted into medas resulting in
sthoulya.
The samprapti of all the eight major lakshanas of sthoulya such as Ayushohrasa,
javaparodha, is also discussed in Charaka samhita21.
The version of Sushruta Samhita regarding the pathophysiology of sthoulya
differs slightly from that of Charaka Samhita. It states that, due to the indulgence of
nidanas, there will be formation of annarasa (Amarasa), which is predominantly
madhura in nature. The annarasa thus produced circulates all over the body in the
state of amavastha itself. As a consequence of this there is an excess production of
sneha and medas. This in turn results in sthoulya22.
Nibandha sangraha vyakhya of Dalhana on Sushruta Samhita elaborates and
throws some more light on this process of pathogenesis. The commentary tries to
critically analyze how ama is produced in people who are predominant of medas,
though they have teekshnagni. The reasons attributed for amotpatti are
Dhatvagnimandya and adhyashana. Even though medasvi people have teekshnagni
the dhatvagnimandya eventually leads to the production of ama. (kÉÉiuÉÉÎalÉÍpÉÈ AmÉÉMüÉiÉç
AÉqÉ CirÉÑcrÉiÉå).
The ama rasa which is produced due to rasadhatvagnimandya, remains in ama
avastha itself in the dhatu poshana krama, still medodhatu upachaya takes place at
the cost of rakta and mamsa. There are three reasons attributed for this23.
11
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
ÌuÉÍzɹ AÉWûÉU uÉzÉÉiÉç- due to intake of specific diet which is conducive to
medodhatu.
ASع uÉzÉÉiÉç-due to Adrushta (for which specific reasons cannot be attributed.)
qÉåSxÉÉuÉ×iÉ qÉÉaÉï-due to marga avarana by medodhatu.
In Ashtanga sangraha, the samprapti of sthoulya is explained as follows;
Due to the intake of nidana such as guru ahara, the anna rasa produced is
predominantly in amavastha, which mixes up with sleshma which will be adherent or
concealed (samleena) in dhatus. The resultant material causes the shlatheekarana of
dhatus. As an end result of this process sthoulya takes place24.
Indu teeka on Astanga Sangraha adds that the increase of medo dhatu is
correspondingly high when compared to other dhatus in dhatu pariposhana krama
because of the specific reasons which are favourable for medo vriddhi25.
Madhava nidana tries to integrate the views of both Charaka Samhita and
Sushrutha samhitha in formulating the pathophysiology of sthoulya.
Intake of nidanas such as avyayama, divaswapna, sleshmala ahara forms the
anna rasa which has the predominance of madhura rasa as a result of which there is
an increase of sneha guna and medo dhatu in the body. The medo dhatus thus
excessively produced causes margavarodha. As a result of which other dhatus are
depleted causing symptoms such as inability to perform all the activities, kshudra
shwasa, trushna and moha26.
Madhukosha commentary on Madhava nidana emphasizes the role of
untimely food as the cause of the formation of ama in people who are obese. In
addition to this there is an upalepa of madhura rasa in annavaha srotas. As a result of
12
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
that annavaha srotas predominantly contains madhura anna rasa irrespective of rasa
consumed, initiating the Pathophysiology of medo vruddhi27.
The samprapti of sthoulya explained in Yoga ratnakara, Bhavaprakasha,
Sharangadhara, Vangasena, Basavarajeeyam and Gadanigraha, is same as that
mentioned in Madhava nidana.
Poorva roopa
While discussing sthoulya as a pathological condition classical text books of
Ayurveda do not enumerate any of the poorva roopas. Hence, roopa expressed in
subtle form are to be considered as the poorva roopa of sthoulya. This is in
accordance with the general principles of Ayurvedic nidana panchaka.
Roopa
Charaka Samhita has described ashta doshas inherent to the Ati sthoola persons
and can be taken as the primary clinical features of sthoulya28. They are as follows:
1. Ayushohrasa- decreased life span
2. Javoparodha- sluggish movement
3. Krucchra Vyavayata- difficulty in sexual intercourse
4. Dourbalya- weakness
5. Dourgandhya- bad/ unpleasant body odour
6. Swedabadha- excessive sweating
7. Kshut atimatra- excessive hunger
8. Pipasa atiyoga- excessive thirst
The individual causes of all these eight doshas have been mentioned separately.
13
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Atisthoulya affects the longevity of life because of the disproportionate
nutrition and over production of medodhatu causing under nutrition or under
production of other dhatus.
Bodily movements are sluggish as a result of shaithilya, soukumarya and
gurutva of medas.
Krucchra vyavaya occurs because of ‘Shukra Abahutvat medasavruta
margatvat cha’. This has been described in detail elsewhere.
Dourbalya is due to the asamatva of dhatus.
Dourgandhya is caused by the inherent defect and the nature of the medas and
also due to excessive sweating.
In sthoola persons, medas is associated with kapha and there is predominance
of gunas such as dravatva, gurutva and vishyanditva. These qualities
associated with a decreased threshold for physical exercise causes excessive
sweating.
The last two doshas namely atikshudha and ati pipasa are caused as an effect
of teekshnagni and prabhoota vata in koshta29.
The other cardinal features of sthoulya described in classical text books are as
follows: 30, 31
Chala sphik udara stana
Ayathopachaya
Ayatha utsaha
The other features of sthoulya described in different classical text books can be listed
as follows.
In Sushruta samhita, the lakshanas mentioned are kshudrashwasa (exertional
dypsnoea), Swapna (excessive sleep), Kratana (snoring), gatra sada (a sence of
14
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
weakness in the body), Gadgadatva (stammering/ slurred speech) and Alpa prana
(remains weak) 32.
Ashtanga Sangraha has also mentioned the same lakshanas enumerated in
Sushruta samhita with some minor differences. It has included jadya and alpa ayu
bala and at the same time has excluded alpa vyavaya mentioned in Sushruta
samhita33.
Madhava nidana adds one more lakshana “Moha” to the above mentioned
lakshanas34. Other text books such as Bhava Prakasha, Yoga Ratnakara, Gada
nigraha, Sharangadhara samhita, Vangasena and Basavarajeeyam have also
endorsed the lakshanas mentioned in Madava nidana.
Table No 2. Showing the Lakshanas of Sthoulya mentioned in different
Ayurvedic texts.
S.No Laskanas Cha Su A.S M.Ni B.P Y.R G.Ni Sha V.Sena B.raj
1 Ayushohrasa + - - - - - - - - -
2 Javoparodha + - - - - - - - - -
3 Krucchra
vyavaya
+ - - - - - - - - -
4 Dourbalya + - - - - - - - - -
5 Dourgandhya + + + + + + + + + +
6 Swedabadha + + + + + + + + + +
7 Kshutatimatra + + + + + + + + + +
8 Pipasatiyoga + + + + + + + + + +
9 Chala Sphik + - + + + + + + + +
10 Chala udara + - + + + + + + + +
11 Chalastana + - + + + + + + + +
12 Ayathopachaya
utsaha
+ - + + + + + + + +
13 Kshudra
Shwasa
- + - + + + + + + +
14 Swapna - + - + + + + + + +
15
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15 Kratana - + - + + + + + + +
16 Gatra sada - + - + + + + + + +
17 Gadgadatva - + + - - - - - - -
18 Sarvakriyasu
asamartha
- + - + + + + + + +
19 Alpa vyavaya/
maithuna
- + - + + + + + + +
20 Shwasa - - + - - - - - - -
21 Atinidrata - - + - - - - - - -
22 Ayasakshamata - - + - - - - - - -
23 Jadya - - + - - - - - - -
24 Alpa ayu bala - - + - - - - - - -
25 Moha - - - + + + + + + +
26 Alpa Prana - - - + + + + + + +
Upashaya
The upashaya and anupashaya of sthoulya are not described in classical
literature of Ayurveda.
Upadravas
Sushruta Samhita describes the following as the upadravas of Sthoulya. They
are Prameha pidakas, Jwara, Bhagandhara, Vidradhi and Vatavikaras35. In Ashtanga
Sangraha, the upadravas mentioned are Shwasa, Jwara, Bhagandara, Meha,
Urustambha, Pitaka and Vidradhi36. In Bhavaprakasha37 & Vangasena38, Kushta,
Visarpa, Bhagandara, Jwara, Atisara, Moha, Arsha, Shleepada, Apachi and Jantava
(krimi) are mentioned as the upadravas of sthoulya. In Yogaratnakara the upadravas
mentioned for sthoulya are similar to that of Bhavaprakasha except krimi39.
Charaka samhitha describes this phenomenon with a simile of dhaavagni
destroying a forest. Impaired vata & Agni associated with the disproportionate
16
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
increase of medodhatu results in very serious complications. Sometimes it may be
fatal also40.
Madhava nidana and Gada nigraha also endorses the view of Charaka Samhita in
respect of upadravas of sthoulya.
Table No 3. Showing the Upadravas of Sthoulya mentioned in different Ayurvedic
texts.
Sl no Upadravas S.S A.S B.P Y.R V.Sena
1. Prameha pidaka + - - - -
2. Jwara + + + + +
3. Bhagandara + + + + +
4. Vidradhi + + - - -
5. Vata vikara + - - - -
6. Meha - + - - -
7. Urustambha - + - - -
8. Udara - + - - -
9. Shwasa - + - - -
10. Pidaka - + - - -
11. Kushta - - + - +
12. Visarpa - - + + +
13. Atisara - - + + +
14. Moha - - + + +
15. Arsha - - + + +
16. Shleepada - - + + +
17. Apachi - - + + +
18. Kamala - - + + +
19. Jantava - - + - +
17
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Sadhyaasadhyata
Sthoola is considered as one among the ashta nindita purushas. It is
considered to be a difficult condition for treatment because of the complexity
involved in the management. The treatment procedures like santarpana & apatarpana
cannot be adopted. The main difficulty with the Sthoola persons is that if they are
given santarpana measures they will grow more corpulent, they even cannot
withstand apatarpana measures because of their strong digestive power41.
Sthoulya which occurs due to beeja dosha is asadhya since all sahaja vyadhis
are said to be asadhya42.
If sthoulya is associated with upadravas it is very difficult to cure. The
upadravas of sthoulya are mainly due to vata & Agni vaishamya. These upadravas
are daaruna in nature as they destroy life43.
Treatment
The chikitsa sutra advocated in Sthoulya is
aÉÑ cÉÉiÉmÉïhÉÇ cÉå¹Ç xjÉÔsÉÉlÉÉÇ MüzÉïlÉÇ mÉëÌiÉ | cÉ. xÉÔ. 21/20
The management of Sthoulya is considered as difficult and challenging
because of the complexity of treatment involved.This has been highlighted in charaka
Samhita while describing the chikitsa of sthoulya and karshya. It is considered that
the treatment of karshya which is the opposite condition of sthoulya is simple and
straight forward. All treatment modalities which cause bruhmana will alleviate
karshya. On the other hand the treatment of sthoulya is relatively difficult because
neither bruhmana nor karshana can be carried out easily. Bruhmana increases the
body mass while karshana even though is supposed to reduce the body mass is
difficult to carry out because of the strong digestive power which normally
accompanies the condition of Sthoulya44.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
The treatment principles of sthoulya mentioned in various Ayurvedic texts are
mainly aimed at the correction of Vata, kapha & medas45, 46. This can be achieved by
adopting the following treatment procedures.
In general nidana parivarjana is considered as the basic management modality
of all the diseases and Sthoulya in particular. Sthoulya is a condition caused by the
intake of brumhana ahara & vihara in excess. The management of the condition is
invariably dependent on all such factors which results in bruhmana. This includes
avoidance of excessive sleep (aswapna), indulgence in regular exercises & sexual
activities, regular mental activities is also considered as the integral part of
management. An individual planning to reduce his weight should accustom to these
activities & increase them gradually.
The other important management strategy in Sthoulya is Langhana Chikitsa47.
Langhana chikitsa should be carried out both as shamana & shodhana therapy. The
latter is carried out by the procedures which include Virechana, Basti &
Raktamokshana 48. Charaka Samhita advocated teekshna, ushna & ruksha bastis49.
Similarly Sushrutha samhitha advocates lekhana bastis50. Even though Vamana is
also one among the shodhana therapy, it is contraindicated in the management of
Sthoulya. 51Among the two varieties of sweda only anagni sweda is indicated in the
management of sthoulya. Udvartana with ruksha dravyas is one another important
upakrama in the management of sthoulya52.
Shamana
As per the chikitsa sutra of sthoulya the shamanoushadhis prescribed for
sthoulya should be guru & atarpana. By the virtue of guru guna the ahara &
oushadhas minimize the aggravated vata & also reduces the teekshnagni. The
Atarpana guna of ahara & oushadhas will help in the reduction of medho dhatu.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
According to Charaka Samhitha in this context the term guru indicates the qualitative
aspect of ahara & oushadha53.
Shamana chikitsa includes deepana, pachana, kshut and trushna nigraha, vyayama,
atapa and maruta sevana54. For the management of sthoulya, the drugs which reduce
vata, kapha and medas should be used55. One of the ways of achieving this objective
is through langhana. Akasha and Vayavya Mahabhuta dominant Dravyas are
attributed to have laghavakara action, so Akasha and Vayavya Mahabhuta dominant
articles can be used for management of Sthoulya56. Katu and Kashaya Rasa are having
Karshana, Upachayahara properties, while Tikta rasa is having Lekhana and
Medoupashoshana Karma .Hence, Katu, Tikta and Kashaya Rasa dominant drugs can
be used for treatment of Sthoulya57.
Shamanoushadhis mentioned in Ashtouninditeeya adhyaya are Guduchi,
Bhadramusta, Triphala, Takrarista, Nagara, Kshara, Makshika, Vidanga, Kalaloha,
Bilvadipanchmula with Madhu and Shilajatu with Agnimantha Svarasa are advised
for prolonged period 58.
Apart from this the Drugs and formulations mentioned for sthoulya are:
Karshana Yavagu of brashta Gavedhuka59,
Lekhaniya Mahakashaya60,
Bibhitaka61,
Venuyava62 and
Madhudaka are advocated as they are Medonashaka and Lekhaneeya63.
In Sushruta Samhita, administration of Virukshana and Chedaneeya Dravya
especially Shilajatu, Guggulu, Gomutra, Triphala, Loha Raja, Rasanjana and Madhu
are advised. In this context, Dalhana has explained that Virukshana property helps to
20
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
reduce Meda and Chedaneeya property helps to remove obstruction from body
channels, particularly from Medovaha srotas by its srotovishodhana property64.
In 38th chapter of Sushruta Samhita Sutrasthana various groups of drugs like
Varunadi Gana, Salasaradi Gana, Rodhradi Gana, Arkadi Gana, Mustakadi
Gana,Trayusnadi Gana etc. are mentioned as Medonashaka65.
Shamana yogas mentioned in other Ayurvedic literatures are listed below.
Churna Yogas
Vidangadi churna with madhu
Brihat panchamoola with madhu
Rasanjana with madhu
Triphala
Shilajatu
Guggulu Yogas
Navaka guggulu
Trayushanadi guggulu
Amrutadya guggulu
Rasayanas
Louha rasayana with milk or soup prepared out of wild animals.
Taila Yoga
Triphaladya Taila – Pana, Abhyanjana, Gandusha, Nasya and Basti.
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Pathya-Apathya
Pathya-Apathyas are advised on the basis of ahara and vihara.
Pathyas in the form of Ahara
The various types of ahara which are to be used in Sthoulya are listed below:
As per Charaka Samhita, the pathyas mentioned for the management of
sthoulya are Prashatika, Priyangu, Shyamaka, yavaka, yava, jurnahva, kodrava,
mudga, kulattha, chakramudgaka, adhaki beeja, patola and amalaka as food followed
by honey diluted in water.Arishtas which are meda, mamsa and kaphahara are used
as Anupana.All these are to be prescribed based on the individual need in the
management of Sthoulya66.
Pathyas advocated in Sushruta Samhita for sthoulya are yava, mudga, koradushaka,
shyamaka, uddalaka and other dravyas which promote rukshata and reduces medas67.
In Ashtanga Sangraha, the pathyas mentioned for Sthoulya are similar to that
of Charaka Samhita with the addition of Mastu and Takra which are indicated as
pana68.
In Vangasena and Gadanigraha pathyas enumerated for sthoulya are puranashali,
mudga, kulattha, uddalaka and kodrava69,70.
Basavarajeeyam enlists a detailed prescription of food articles in the form of
puratana venu, koradusha, neevara, priyangu, jurna, yava, kulattha, churnaka,
masura, mudga, tuvara, madhu, laja, takra, sura, pingala matsya, dagda vartaka
phala, triphala, guggulu, palasha, katutraya, sarshapa taila, ela kshara, aksha taila,
pratapta neera, shilajatu, patrotha shakagaru and other dravyas which are deepana
and predominant of katu tikta kashaya dravyas71.
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Pathyas in the form of Vihara (activities)
The activities which are indicated for the management of Sthoulya are
Prajagara (Being awake during night), vyavaya (sexual intercourse), Vyayama
(excercise), and chinta72. Sushruta Samhita has mentioned vyayama as the only
activity advocated for Sthoulya73. Whereas Ashtanga Hrudaya highlights chinta as an
important vihara (activity) for the management of Sthoulya74. Basavarajeeyam enlists
the activities such as chinta(to think about), shrama(be tired of doing anything)
jagarana(Being awake late night), vyavaya (sexual act), udvartana, langhana ,atapa
and Hasthi Ashwayana for the management of Sthoulya75.
Apathyas in the form of Ahara (food)
For the management of sthoulya the following food articles are said to be
apathya. They are most of the rasayanas, shali, godhuma, masha, matsya mamsa,
madhura dravyas, derivatives of milk and derivatives of sugar cane76.
Apathyas in the form of vihara
The activities which are said to be apathya for the management of sthoulya are
snana, sweda, divanidra, souhitya, sugandha and sukha sheelata77.
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OBESITY
Obesity is widely regarded as a pandemic problem with potentially disastrous
consequences to human health. The prevalence of obesity has increased threefolds
within the last 20 years and continues to rise. Obesity has its influence on both
mortality and morbidity. The only medical benefit of obesity is seen in osteoporosis,
where bone density increases in response to increased mechanical stress. Obesity may
lead to profound psychological consequences for individuals.
In obesity, there will be increased storage of adipose tissue. When food
supplies are intermittent, the ability to store energy in excess of what is required for
immediate use is essential for survival. Fat cells, residing within widely distributed
adipose tissue depots, are adapted to store excess energy efficiently as triglyceride
and, when needed, to release stored energy as free fatty acids for use at other sites.
This physiologic system, orchestrated through endocrine and neural pathways,
permits humans to survive starvation for as long as several months. In the presence of
nutritional abundance and a sedentary lifestyle, and influenced importantly by genetic
endowment, this system increases adipose energy stores and produces adverse health
consequences like obesity.
Definition
Obesity is defined as a state of increased body weight, due to adipose tissue
accumulation, that is of sufficient magnitude to produce adverse health
effects.78
Obesity is a state of excess adipose tissue mass.79
A condition in which there is an excessive amount of body fat is known as
obesity. Obesity is an abnormal growth of adipose tissue due to an
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
enlargement of fat cell size or an increase in fat cell number or a combination
of both80.
Excess deposition of adipose tissue in the body is known as obesity.
Obesity refers to an increase in total body fat. When body weight is 20%
above ideal body weight, for age, sex and height the condition is termed as
obesity. It is often expressed in terms of body mass index (BMI)81.
Obesity has been more precisely defined by the National Institutes of Health
(the NIH) as a BMI of 30 and above.
Prevalence of Obesity
The increasing prevalence of medically significant obesity raises great Concern.
Obesity has reached epidemic proportions globally, with more than 1 billion adults
overweight - at least 300 million of them clinically obese - and is a major contributor
to the global burden of chronic disease and disability. Obesity is more common
among women and in the poor; the Prevalence in children is also rising at a
worrisome rate. India is following a trend of other developing countries that are
steadily becoming more obese and it has reached epidemic proportions in India in the
21st century, with morbid obesity affecting 5% of the country's population82.
Prevalence of Obesity in India is estimated to be 22 million (Especially abdominal) of
which 75% are women and 58% men83.
Indians are genetically susceptible to weight accumulation especially around the
waist. While studying 22 different single nucleotide polymorphism (SNP)s near to
MC4R gene, scientists have identified a SNP (single nucleotide polymorphism)
named rs12970134 to be mostly associated with waist circumference.
25
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Epidemiological factors
The epidemiological factors which favour the development of obesity are:
Age
Obesity is most prevalent in middle-age, but can occur at any stage of life.
Obesity in childhood and adolescence is likely to be followed by obesity in adult life.
Fat increases in both sexes after puberty and during adult.
Sex
Normally, women are more prone to be obese than men. The young women contain
fat approximately 15% of body weight and it is about more than young man. In the
phase of puberty and adolescence fat accumulates in body due to hormonal changes.
This phenomenon is more predominant in females.
Occupation
Some occupations predispose an individual to obesity Ex: cooks, barmen,
businessmen.
Socioeconomic Status
There is clear inverse relationship between socio–economic status and obesity. Within
some affluent countries however, obesity has been found to be more common in the
lower socio- economic groups. In developing countries it can occur only in the
prosperous elite. After so many surveys, it is observed that the increased prevalence
of obesity is seen in middle, lower and upper socioeconomic classes respectively. The
prevalence of obesity is not related with quantum of money but it depends upon faulty
eating habits and life style.
Other Medical conditions
The National Institute for Health and Clinical Excellence (NICE) systematic review
identified a body of evidence from cohort studies that pregnancy is associated with
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postpartum weight gain. One good quality systematic review of a range of cohort and
other observational studies found that women lose weight after birth, and that those
who breastfeed may lose more weight for longer.
NICE systematically assessed five cohort studies which examined the association of a
number of variables with weight change during menopause. The findings suggest that
weight gain during menopause transition is itself inconsistent and may indicate
underlying behavioral variables (eg reduced physical activity) contributing to weight
change.
Table No.4.Showing the reasons for increasing prevalence of obesity-the
'obesogenic' environment84
Synonyms of Obesity:
Corpulence - The condition of being excessively fat
Adiposity- the state of being fat; obesity, a tendency to become obese
Fattiness - State or quality of being fatty.
Stoutness- the property of excessive fatness
Enormity - enormous size or extent;
Increasing energy intake ↑ Portion sizes ↑ Snacking and loss of regular meals ↑ Energy-dense food (mainly fat) ↑ Affluence Decreasing energy expenditure ↑ Car ownership ↓ walking to school/work ↑ Automation; ↓ manual labour ↓ Sports in schools ↑ Time spent on video games and watching TV ↑ Central heating
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Plumpness - the bodily property of being well rounded
Embonpoint- The condition of being plump; stoutness.
Etiology of Obesity
The etiology of obesity arises from a complex interplay of behavioral and genetic
factors.
Specific causes of weight gain can be explained under the following headings.
Genetic Factors
Behavioral Factors
Endocrinal Factors
Drugs
Genetic Factors:
A few rare single gene disorders have been identified which lead to a system complex
inducing obesity. These include mutations of the melanocortin – 4 receptor (MC4R)
that accounts for approximately 5% of severe early onset obesity, the Prader-Willi
syndrome and mutations in the leptin gene85.
Behavioral Factors: Includes
Dietary factors,
Smoking cessation,
Alcohol consumption
Workplace stress and obesity
Sleep duration and obesity
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a. Dietary factors
High fat diets do not switch off appetite; also fat consumption induces very little
energy expenditure as most is stored. Consumption of energy dense foods and drinks,
often high in fat and sugar but low in bulk. This increases energy intake substantially.
A World Cancer Research Fund (WCRF) systematic review resulted in a range of
statements on the associations between dietary components and obesity. Low energy-
dense foods (marked by consumption of wholegrain cereals and cereal products)
probably protect against weight gain, overweight, and obesity. High energy-dense
foods (marked by intake of animal fats) are probably a cause of weight gain,
overweight, and obesity, particularly when large portion sizes are consumed regularly.
Sugary drinks probably cause weight gain, overweight, and obesity. ‘Fast foods’
probably cause weight gain, overweight and obesity.
b. Smoking cessation
Giving up smoking which induces a fall in energy expenditure and leads to an average
weight gain of 2.8kg in males and 3.8kg in females.
Studies show that those who quit smoking for at least a year experience greater weight
gain than their peers who continue to smoke. The amount of weight gained with
cessation may differ with age, social status and behaviors. A follow-up study of a
cross-sectional survey covering European adults also found substantially greater
weight gain and increased waist circumference in those who quit compared to those
who continued to smoke, at one year86.
c. Alcohol consumption
Alcohol consumption promotes weight gain by providing substantial energy. It can
also stimulate appetite and loosen restraint.
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d. Work stress and obesity
Studies have shown that the relationship between exposure to work stress and
the risk of obesity
A high quality cohort study assessed whether work stress was linked to development
of obesity during mid-life. The study involved 6,895 men and 3,413 women taken
from the Whitehall II cohort and followed them for 19 years. This study considered
adult, mostly
Caucasian / European ethnicity British civil servants and found there is a very likely
causal, dose-response relationship between exposure to work stress and the risk of
obesity at follow up87.
e. Sleep duration and obesity
Studies have shown that there is a definite relationship between sleep duration
and obesity
A large, good quality prospective cohort study considered female, middle-aged nurses
and the relationship between self-reported sleep duration at baseline with self-reported
weight gain and risk of incident obesity after a median follow-up of around 12 years;
although the accuracy of exposure and outcome measurement is unclear and reverse
causation and bias cannot be excluded, it found that less than seven hours reported
sleep showed a dose response relationship with increased weight gain, compared to
those reporting seven hours of sleep and that weight gain was greater in those with a
BMI<25 at baseline88.
Endocrinal Factors
Obesity is associated with some endocrinal disorders like:
Hypothyroidism
Hypothalamic tumors or injury
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Cushing's syndrome
Insulinoma
Drug
Prolonged use of some drugs result in obesity:
Tricyclic antidepressants
Corticosteroids
Sulphonylureas
Anti-seizure medicines
Oestrogen-containing contraceptive pill
β-blockers
Lithium
Antacids
Administration of Insulin for type 2 diabetes
Breast cancer medicines
Mood stabilizers
Migraine medicines
Antipsychotics
Among all the etiological factors, Endocrinal Factors & Drugs are potentially
reversible causes of weight gain
Classification
Obesity is classified based on a number of factors which include:
Based on BMI
Based on cause/ Mode of onset
On the basis of etiological factors
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On the basis of Fat distribution
On the basis of Histopathology
Based on BMI
The World Health Organization (WHO) and International Obesity Task Force have
classified Obesity based on body mass index (BMI).
Table.No. 5.Showing the classification of obesity based on BMI
Based on cause/ Mode of onset
Primary Obesity: Primary obesity is that which is not associated with a
demonstrable clinical condition. Primary obesity occurs due to life style
modifications.
Secondary Obesity: Secondary obesity is that which is associated with an
identifiable medical disorder, such as a congenital syndrome, a
hypothalamic or other endocrinal disorders or drug therapy. It occurs
secondary to any underlying pathology.
On the basis of etiological factors
A. Physiological: Observed temporarily during puberty and pregnancy.
B. Pathological: It can be further divided into three viz.
BMI (kg/m2) Classification* Risk of obesity
18.5-24.9 Normal range Negligible
25.0-29.9 Overweight Mildly increased
> 30.0 Obese
30.0-34.9 Class I Moderate
35.0-39.9 Class II Severe
> 40.0 Class III Very severe
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Exogenous
Endogenous
Idiopathic
Exogenous: It is caused by overeating and sedentary habits.
Endogenous: Due to endocrine disorders
Cushing’s syndrome
Hypothyroidism
Hypothalamic tumours
Hyperinsulinism
Polycystic ovarian syndrome
Idiopathic: Obesity is labeled as idiopathic when every possible
cause of weight gain has been investigated and ruled out.
On the basis of Fat distribution
Generalized (Gynoid or pear shaped.)
Central type: ( Abdominal, visceral, android, apple shaped)
On the basis of Histopathology
Hyperplastic obesity: There will be increase in adipocyte’s number.
Hypertrophic obesity: There will be increase in adipocyte size.
Pathogenesis
Obesity is a disorder of energy balance. When food derived energy chronically
exceeds energy expenditure, the excess calories are stored as triglycerides in adipose
tissue. The energy equation consisting of intake and expenditure, are regulated by
neural and hormonal mechanisms and therefore influence the body weight. This
mechanism ie. Neurohormonal mechanism has three components.
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1. The afferent system, which generates humoral signals from the adipose tissue
(leptin), pancreas (insulin) and stomach.
2. The central processing unit, located primarily in the hypothalamus, which
integrates the afferent signals.
3. The effector system, which carries out “orders” from the hypothalamic nuclei
in the form of feeding behavior and energy expenditure.
In the afferent system, Ghrelin is a short term mediator produced in the stomach. The
level of ghrelin rise sharply before every meal and fall when the stomach is “filled”.
Whereas the insulin and leptin exert long term control over the energy cycle by
activating catabolic circuits and inhibiting the anabolic pathways. Leptin has more
important role than insulin in the central nervous system control of energy
homeostasis.
The adipocytes communicate with the hypothalamic centers that control appetite and
energy expenditure by secreting leptin.Leptin has two effects
It inhibits anabolic circuits that normally promote food intake and inhibit
energy expenditure.
Leptin triggers catabolic circuits through a distinct set of neurons.
The net effect of leptin is to reduce food intake and promote energy expenditure.
Hence over a period of time, energy stores are reduced and weight is lost. This in turn
reduces the circulating levels of leptin, and a new equilibrium is reached. This cycle is
reversed when adipose tissue is lost and leptin levels are reduced below a threshold.
Equilibrium is again reached, since with low leptin levels, the anabolic circuits are
relieved of inhibition and catabolic circuits are not activated, resulting in net gain of
weight89.
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Flow Chart .No.1. Showing Pathogenesis of Obesity
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Table.No. 6.Showing the Complications of obesity.90
Risk factors Outcomes
'Metabolic syndrome'
Type 2 diabetes
Hypertension
Hyperlipidaemia
Coronary heart disease
Stroke
Diabetes complications
Liver fat accumulation Non-alcoholic steatohepatitis
Cirrhosis
Restricted ventilation Exertional dyspnoea
Sleep apnoea
Respiratory failure (Pickwickian syndrome)
Mechanical effects of weight Urinary incontinence
Osteoarthritis
Varicose veins
Increased peripheral steroid
interconversion in adipose tissue
Hormone-dependent cancers (breast, uterus)
Polycystic ovary syndrome (infertility,
hirsutism)
Others Psychological morbidity (low self-esteem,
depression)
Socioeconomic disadvantage (lower income,
less likely to be promoted)
Gallstones
Colorectal cancer
Skin infections (groin and submammary
candidiasis; hidradenitis)
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Treatment91
1. Goal
An attempt is made to reduce weight by approximately 10% from base
line. Further weight reduction is attempted after initial success.
Reduce weight at a rate of about ½-1Kg per week for six months.
2. Dietary Therapy
Low fat diet
Encourage low calorie diet with low fat. The reduction is usually to
the tune of 500 calories/day.
Reducing fat alone without reducing total calories is not sufficient.
Low fat diets have a lower energy density than high fat diets and as
humans respond mostly to volume of food eaten rather than calories
this should lead to a lower energy intake.
Low fat diets also have higher fiber content and this may also
enhance satiety.
Very low carbohydrate diet
Use of very low carbohydrate but normal or high saturated fats.
Found to produce loss of weight equivalent to that produced by low
fat diet.
These diets work by reducing caloric intake by removing a wide
range of carbohydrate rich food.
High protein diet
It makes use of the increased satiety effect of protein with the
modest reduction in carbohydrate. Fat is kept low at 30%.
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Physical exercise
It reduces abdominal fat and increases cardio respiratory fitness.
Moderate exercise should be done for 30-45 minutes per day, 3-5
days a week.
Behaviour modification
It is a useful adjuvant to diet and physical exercise.
Patients often require motivation to lose weight.
3. Pharmacotherapy
Drugs are used when BMI is more than or equal to 30kg/m2 .Currently
approved drug are Sibutramine,olistat rimonabant, phentermine and
diethypropion.
4. Surgery: Known as Bariatric surgery. Useful in patients with BMI more than
or equal to 35-40kg/m2 when other methods have failed and patients have
identifiable medical, physical or psycho-social problems associated with
obesity. Various options include:
Jejuno ileal shunt
Laproscopic adjustable gastric banding
Liposuction
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KRUCCHRA VYAVAYA
The term Krucchra Vyavaya is specifically mentioned in Charaka Samhita. However
the detail of what is to be specifically considered as Krucchra Vyavaya is not
available. In order to understand the definition and scope of Krucchra Vyavaya, it is
essential to examine the two components of the term viz. ‘Krucchra’ and ‘Vyavaya’.
Vyavaya
The term vyavaya represents sexual intercourse. It is the physical act through which
“Kama”, one among the four pursuits of life is achieved. Ayurveda attaches a lot of
importance to the method of copulation. The details of which are discussed under
dinacharya and ratricharya
Sexual activities are elaborately explained in the classical literature of Ayurveda
under stree sevana vidhi. This Vidhi includes explanation about the sexual intercourse
and also about the eligible people, erogenous zones, the code and conduct during the
act, the timing and frequency of intercourse.
Men who copulate following all these norms of ratricharya obtain longevity of life
and their aging process is delayed. They are also endowed with Varna, bala and
sthiropacitamamsa92.
Derivation
The term ‘Vyavaya’ is a Pullinga pada. The Vyutpatti of which is as follows.
ÌuÉ+AuÉ+ChÉç+bÉgÉç urÉuÉÉrÉ
ÌuÉ AuÉ CÌiÉ EmÉxÉaÉï ²rÉ mÉÔuÉïMü ‘ChÉç’ kÉÉiÉÉã: aÉirÉjÉåï ‘bÉgÉç’ mÉëirÉrÉå M×üiÉå urÉuÉÉrÉ CÌiÉ mÉSqÉç ÍxÉkrÉÌiÉ |
It is derived from the mula dhatu ‘ChÉç’ with two prefixes namely ‘ÌuÉ’ & ‘AuÉ’ and a
suffix ‘bÉgÉç’. By the derivation the meaning of the term vyavaya is “copulation”93.
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Synonyms
aÉëÉqrÉkÉqÉï: qÉæjÉÑlÉÇ ÌlÉkÉÑuÉlÉÇ UiÉqÉç | A.K94
urÉuÉÉrÉ: xÉÑUiÉå AliÉkÉÉæï mÉÑÇxÉÏ YsÉÏoÉÇ iÉÑ iÉãeÉÍxÉ | M.K
AoÉë¼cÉrÉï x§ÉÏaÉqÉlÉÇ aÉëÉqrÉkÉqÉï mÉëuÉ×̨ÉËUÌiÉ mÉrÉÉïrÉÉ: | A.S95
Following synonyms are used for vyavaya :
1 aÉëÉqrÉ kÉqÉï- means sexual intercourse.
2 qÉæjÉÑlÉ-Relating or belonging to copulation
3 ÌlÉkÉÑuÉlÉÇ -Sexual intercourse
4 xÉÑUÌiÉ-Great enjoyment or delight.
5 AliÉkÉÉï-To place within, deposit, conceal.
6 iÉãeÉxÉÏ -Semen virile
7 AoÉë¼cÉrÉï -Not keeping a vow of continence.
The different meanings of the term vyavaya are intervention , interposition ,
separation by insertion , being separated by entering , pervading , penetration , change
, transmutation, sexual inter course , copulation , wantonness , lasciviousness ,
covering , disappearance and interval space96.
Sexual Physiology
Normal sexual act is dependent upon the excitement which is proportional to the
strength of body and mind97. Male sexual act comprises of the following phases:
Sankalpa
Cheshta
Nishpeedana and
Shukra chyuti
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Sankalpa
Sankalpa means the mental preparation for the sexual act. Charaka Samhita has
highlighted the mental preparation for the sexual act as an important prerequisite.
Appropriate psychic stimulus can greatly enhance the ability of a person to get
erection and thus to perform sexual act.
Jalpakalpataru vyakhyana of Gangadhara on charaka Samhita explains sankalpa as
cheerful/ joyful state of mind, due to actions such as ramana, vasana98 etc where as
Ayurveda deepika commentary of Chakrapani explains sankalpa as yoshita
anuraga99.
Simple imaging or sexual fantasy can cause erection. This has been emphasized in
Sushruta Samhita by stating that Prasannata of manas is invariably needed for
samharsha. Dalhana in his Nibandha Sangraha commentary stresses that clarity of
senses and happy disposition of mind as a necessary prerequisite for good arousal. In
this context, the term suprasanna refers to the state of mind which is devoid of
irshyadi bhavas100.
Sushruta Samhita has compared the process of ejaculation with that of lactation in
females, as both are deeply associated with psychological factors. It also considers
touching, seeing, remembering sexual objects and constant affection towards the
partner as the cause for shukra chyuti101.
The role of environment acting as an enhancer of sexual desire is mentioned in
Charaka Samhita. A pleasing environment which induces happiness of mind frees the
mind from anxiety & thus excites the man sexually by elevating the mood. Even a
good aroma, sounds of ornaments of women, a pleasant state of sensory faculties and
musical melodies enhance the sexual drive. Intoxicating beverages also add to sexual
excitement102.
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Cheshta
Physical action (cheshta) follows sankalpa. Cheshta is a ‘kriya’ according to Charaka
Samhita. Jalpakalpataru vyakhyana of Gangadhara on Charaka Samhita explains
cheshta as shareera dolayitvadi vyapara103.
In Nibandha Sangraha commentary, Dalhana defines cheshta as ‘Kaya
parispandana’ ie. the response of the body or vibrations of the body. The main object
and means of sexual arousal is ‘tactile stimulation’. The sense of touch pervades all
the senses and shukra which is present all over the body is sensitive to tactile
stimulation104.
Sushruta Samhita has mentioned samharsha as one of the cause for shukra chyuti.
Nyaya chandrika commentary of Gayadasa on Sushruta Samhita explains samharsha
as vishishta sparsha of ishta yuvati105.
Specific part of the body is required to be stimulated to get maximum arousal and
potentiating sexual act. These are known as “Kama sthanas” (erotic zones). The
specific zones in the body are Seemanta (parting of the hair), netra (eyes), adhara (the
lip), kapola (the cheek), gala (neck), kukshi (belly), kucha (breast), urasthala (chest
region), nabhi (the navel), shroni (the hip & loins), bhaga (perineum), janu (the
knee), gulpha (the ankle), pada (the foot) and angushta (the finger). During shukla
paksha, zones on the left side of the body, starting from seemanta towards
padangushta in sequence is considered as the sites of arousal in female. This sequence
is reverse in case of Krishna paksha106.
To get optimum level of arousal, specific acts are mentioned. The act of scratching
with nails should be done in seemanta, kukshi and kanta pradesha. Chumbana
(kissing) on netra and kapola, biting with dantagra is to be carried out in adhara.
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Mild patting in vaksha (chest) Firm massaging in kucha and shroni (the hip & loins),
Chapetika (a slap with the open hand) in nabhi pradesha are mentioned in
Yogaratnakara107.
Nishpeedana.
mÉÏQûlÉÇ lÉÉUÏ mÉÑÂwÉrÉÉåÈ mÉUxmÉU xÉÇqÉÔNïûlÉÇ A§É cÉ lÉÉUÏ mÉÑÂwÉ xÉÇrÉÉåaÉÈ mÉëkÉÉlÉÇ MüÉUhÉÇ iÉiÉç xÉWûMüÉUÏÍhÉ cÉå¹ÉSÏÌlÉ||
Nishpeedana refers to mutual union of male and female. Specific stimulation of
genital parts especially in the upastha causes ejaculation. The process of physical
pressure is called Nishpeedana.108
Jalpakalpataru vyakhyana of Gangadhara on Charaka Samhita explains
Nishpeedana as peedana of yoni, shepha and upastha109.
Different positions of vyavaya
Charaka Samhita has mentioned different positions of vyavaya .They are
Nyubja (prone ie. Female superior position)
Vama parshva( Left lateral)
Dakshina parshva( right lateral)
Uttana ( Male superior)
Among these uttana is the best position to get healthy progeny. Rest of them are said
to vitiate doshas and hence are not advisable110.
Shukra chyuti
Nishpeedana results in shukra chyuti. Shukra is present in the entire body and
responds to the stimulation of skin. The process is similar to that of water coming out
of a wet cloth on squeezing. The final process ‘ejaculation’ is because of chestha,
sankalpa and nishpeeda. Even though shukra is sarva shareera vyapi, it is due to the
Nishpeedana of yoni and shepha, the shukra chyuti takes place111.
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Charaka Samhita has given three comparisons for the pervasion of shukra in
the entire body112. They are,
1. The juice present in sugarcane.
2. Ghee available in curds.
3. Oil present in sesame seed.
Based on this, Chakrapani in his Ayurveda deepika commentary categorizes
individuals into three groups according to the duration of sexual act and the effort
needed to express out the shukra. When shukra is ejaculated without much effort,
then it is compared with the extraction of juice from sugarcane. If it is ejaculated with
moderate effort and time, then it is like extracting ghee from curds and if it is
ejaculated with much effort and time, then it is like extracting oil from the sesame
seeds113.
Charaka Samhita has explained 8 factors contributing to the ejaculation of shukra114.
They are,
Harsha: Harsha is defined as the desire produced from sankalpa leading to
erection and ejaculation. Harsha is mental excitement which is rati nimitta.115
Tarsha: Tarsha is passionate desire in female partner.
Saratva: Saratva is ‘asthairya’ i.e., instability. Because of fluidity shukra is
unstable
Paicchilya: sliminess. Because of this guna shukra flows out without any
friction
Gaurava: Heaviness. Because of this guna it moves downwards.
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Anu bhava and Pravana bhava: The shukra is able to come out from the
minute channels due to its subtleness and flowing nature.
Drutatva of maruta. Apana vayu is responsible for shukra nishkramana. Vata
has a very fast action. Apana vayu controls and stimulate the sex organs
especially the sites of shukra, exerts force during the sexual act. As a result of
which shukra comes out of its place and is ejaculated through the genital
organ.
Bhavaprakasha explains the act vyavaya in a slightly different way. It states that,
there will be an urge of Makaradhwaja at the time of stree purusha samyoga. By
rubbing between medhra and yoni, the shareera ushma of men, excited by vata,
liquifies the retas present all over the body, then vayu brings it through the urinary
passage and deposits it inside the yoni of a woman116.
After vyavaya, one has to follow specific diet and regimen in order to restore strength.
They are snana, lepana of chandanadi dravyas (anointing the body with chandana
etc.) exposure to breeze (himaanila) use of sweets prepared out of sugar and
sugarcane, plain milk or milk with sugar, cold water (sheetamu), Mamsa rasas, yusha,
sura and prasanna. (A variety of fermented drink). Thereafter one should have
adequate sleep117, 118,119.
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Krucchra
Derivation
The term ‘Krucchra’ is a Napumsakalinga pada and is derived from the root ‘M×üiÉÏ’
and with ‘UMçü’ suffix, it becomes ‘M×ücNíÇ’ (Krucchram) means Chedana or cutting or
difficulty or pain.
‘M×üiÉÏ’ +‘UMçü’ ‘M×ücNíÇ’
M×üiÉÏ (NåûSlÉå ) CÌiÉ kÉÉiÉÉåÈ M×üliÉÌiÉ CirÉjÉåï ‘UMçü’ mÉëirÉrÉå M×üiÉå ‘M×ücNíÇû’ CÌiÉ mÉSÇ ÍxÉSèkrÉÌiÉ | S.K120
Synonyms
Following synonyms are used for Krucchra
mÉÏQûÉ oÉÉkÉÉ urÉjÉÉ SÒZÉÇ AÉqÉlÉxrÉÇ, mÉëxÉÔÌiÉeÉÇ,|
xrÉÉiÉç Mü¹Ç M×ücNíqÉÉÍpÉsÉÇ Ì§ÉwuÉåwÉÉÇ pÉå±aÉÉÍqÉ rÉiÉç || A.K121
mÉÏQûÉ- Pain, suffering, annoyance
oÉÉkÉÉ- Pain, trouble,annoyance
urÉjÉÉ- Uneasyness,Pain
SÒZÉÇ-With difficulty, to be sad or uneasy
AÉqÉlÉxrÉÇ- Pain, suffering
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mÉëxÉÔÌiÉeÉÇ- Difficult, pain
Mü¹Ç-Difficult, troublesome
M×ücNíÇû –Causing trouble or pain.
AÉÍpÉsÉÇ- Formidable.fearful, suffering pain
The different terminologies which represent Krucchra are causing trouble or pain,
painful, attended with pain, miserably, painfully and with difficulty122.
Krucchra Vyavaya
After analyzing the terms ‘Krucchra’ and ‘Vyavaya’, the KrucchraVyavaya is defined
as follows:
M×ücNíåûhÉ qÉWûiÉÉ SÒÈZÉålÉ urÉuÉÉrÉ M×ücNíû urÉuÉÉrÉ ||
The difficulty experienced during vyavaya is known as krucchra vyavaya.
Krucchra Vyavaya may be understood / appreciated at different phases of vyavaya.
Desire for sexual intercourse is the prerequisite one. This is explained under the
heading Sankalpa. Loss of desire towards sexual act is the foremost cause for
krucchra vyavaya.
Chesta is the second phase in sexual intercourse. As tactile stimulation is the main
object of sexual arousal. Without chesta proper arousal is not possible though the
person has desire for sex.
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Nishpeedana is the third phase in the act of vyavaya,it is the sexual intercourse. (lÉÉUÏ
mÉÑÂwÉrÉÉåÈ mÉUxmÉU xÉÇqÉÔNïûlÉÇ). Vyavaya depends on the position of purusha and stree during
the act. Improper position leads to difficulty in sexual intercourse which is also
considered as krucchra vyavaya.
Shukra chyuti is the fourth phase in the act of vyavaya. Proper chesta, Sankalpa, and
nishpeedana results in Shukra chyuti .Delayed or premature Shukra chyuti is because
of improper chesta, Sankalpa, and nishpeedana which is also considered as krucchra
vyavaya.
Regarding Shukra chyuti there are eight specific factors influencing that in the form of
Harsha, Tarsha, Saratva, Paicchilya, Gaurava, Anu bhava, Pravana bhava and
Drutatva of maruta. Among them the former two factors viz Harsha and Tarsha
represent the psychological factors which are responsible for Sankalpa.
Harsha: Sankalpa results in harsha.By harsha dhwajochraya occurs. Improper or
absence of dhwajochraya is considered as a cause for krucchra vyavaya.
Tarsha: It is nothing but vanitabhilasha. Loss of desire towards female partner is one
of the cause for krucchra vyavaya.
The latter six factors namely Saratva, Paicchilya, Gaurava, Anu bhava, Pravana
bhava, depend on the quality of the shukra formed. If the shukra produced does not
possess shuddha shukra lakshanas, then it lacks in above mentioned factors which
invariably becomes a cause for krucchra vyavaya. Apart from these, normalcy of
apana vata is necessary for shukra chyuti. Any abnormality in the function of apana
vata can become the cause for krucchra vyavaya.
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NORMAL HUMAN SEXUAL RESPONSE CYCLE
The human sexual response cycle123 is a five-stage model of physiological response
during sexual stimulation. These phases, in order of their occurrence, are
Appetitive Phase
Excitement phase
Plateau phase
Orgasmic phase and
Resolution phase
The term was coined by William H. Masters and Virginia E. Johnson in their 1966
book Human Sexual Response
Appetitive Phase
Sexual desire is a complex interaction of physiologic, cognitive and behavioural
components and is shaped by developmental and cultural influences124. The essence
of this phase is the motivation and drive of the individual for sexual interaction. This
is the phase which occurs before the actual sexual response cycle. This phase is
characterized by the sexual fantasies and a desire to have sexual activity125.
Excitement phase
This is the first true phase of the sexual response cycle, which starts with physical
stimulation and or by appetite phase. The duration of this phase is highly variable and
may last for several minutes (or longer) 126.
The excitement phase (also known as the arousal phase or initial excitement
phase) is the second stage of the human sexual response cycle. It occurs as the result
of any erotic physical or mental stimulation, such as kissing, patting or viewing erotic
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images, that lead to sexual arousal. During the excitement stage, the body prepares
for coitus or sexual intercourse. The major changes during this phase are listed below.
Penile erection, due to vasocongestion of corpus cavernosa.
Elevation of testes with scrotal sac.
The excitement phase results in an increase in heart rate, an increase in breathing rate
and a rise in blood pressure. The sex flush tends to occur more often under warmer
conditions and may not appear at all under cooler temperatures. It has also been
commonly observed that the marked degree of the sex flush can predict the intensity
of orgasm to follow.
Plateau phase
This is an intermediate phase just before actual orgasm, at the height of excitement. It
is often difficult to differentiate the plateau phase from the excitement phase. The
duration of this phase may last from half to several minutes127. Further increases in
circulation, muscle tension and heart rate occur in both sexes. Sexual pleasure
increases with increased stimulation. Also, respiration continues at an elevated level.
The following important changes occur during this phase:
Sexual flush (inconsistent).
Autonomic hyper activity.
Erection and engorgement of penis to full size.
Elevation and enlargement of testes.
Dew drops on glans penis (2-3 drops of mucoid fluid with spermatozoa).
During this phase, the male urethral sphincter contracts (so as to
prevent urine from mixing with semen, and guard against retrograde
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ejaculation) and muscles at the base of the penis begin a steady rhythmic
contraction. Males may start to secrete seminal fluid or pre-ejaculatory
fluid and the testicles rise closer to the body.
Orgasmic phase
This is the phase with a peak excitement followed by a release of sexual
tension and rhythmic contractions of pelvic reproductive organs. The duration of this
phase may last from 3-15 seconds. The important changes are as follows:
4-10 contractions of penile urethra, prostrate, vas, and seminal vesicles; at
about 0.8 sec. intervals.
Autonomic excitement becomes marked in this phase. There will be
doubling of pulse rate and respiratory rate and 10 – 20 mm increase in
systolic and diastolic BP.
Ejaculatory inevitability precedes orgasm.
Ejaculatory spurt (30-60cm; decreases with age).
Contractions of external and internal sphincters128.
Orgasms are often associated with other involuntary actions, including vocalizations
and muscular spasms in other areas of the body, and a generally euphoric sensation.
Heart rate is increased even further.
In men, orgasm is usually associated with ejaculation. Each ejection is associated with
a wave of sexual pleasure, especially in the penis and loins. Orgasm generally
climaxes in the ejaculation of semen, which contains millions of sperm. Ejaculation
consists of two steps.
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During the first phase, called the emission phase, seminal fluid builds up in the
urethral bulb of the prostate gland. As the fluid accumulates, the male senses he is
about to ejaculate. This is often experienced as inevitable and uncontrollable.
During the second phase, there will be contractions of urethra and penis along with
prostrate so that semen spurts out of the penis. The first and second convulsions are
usually the most intense in sensation and produce the greatest quantity of semen.
Thereafter, each contraction is associated with a diminishing volume of semen and a
milder wave of pleasure.
Resolution phase
The resolution phase occurs after orgasm and allows the muscles to relax, blood
pressure to drop and the body to slow down from its excited state.
This phase is characterized by the following features129:
A General sense of relaxation and well being, after the slight clouding of
consciousness during the orgasmic phase.
Disappearance of sexual flush followed by fine perspiration.
Gradual decrease in vasocongestion from sexual organs and rest of the
body.
Refractory period for further orgasm in males varies from few minutes to
many hours, some being immediate (no refractory) and some being as
long as 12 to 24 hours.
The resolution phase is marked by a general sense of well being and enhanced
intimacy and possibly by fatigue as well.
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Difficulty in Sexual act
The difficulty experienced during the sexual response cycle is considered as difficulty
in sexual act. Difficulty may be appreciated at different phases of sexual response
cycle.
In appetite phase disorders manifest in amotivation, disinterest and lack of desire for
sexual activity130.
The significant problem of excitement phase is failure of genital response to the
stimulation resulting in erectile disorder .Sometimes there may be delayed erection or
erection is not hard enough for penetration131.
Inhibited orgasm is the specific problem of orgasmic phase. In orgasmic dysfunction,
orgasm either does not occur or is considerably delayed. Premature ejaculation occurs
when there is an inability to control ejaculation sufficiently for both partners to enjoy
sexual stimulation. In the absence of orgasm the resolution takes longer in both men
and women. There is a sense of heaviness in the pelvic region, throbbing ache because
of congestion132.
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RELATIONSHIP OF STHOULYA WITH KRUCCHRA
VYAVAYA
All classical literatures of Ayurveda as well as the contemporary science have
emphasized the disease Sthoulya and its consequence. One problem related to obesity
that may cause concern and constitute a major problem for the individual, is the
possible link between obesity and sexual function. This relationship is often
overlooked by health professionals and is rarely mentioned in textbooks on sexuality
or endocrinology. Ayurveda stresses the coexistence of Sthoulya and sexual
dysfunction.
Ayurvedic literature starting from the time of Charaka Samhita stresses the
relationship between obesity and sexual dysfunction.
Charaka Samhita has considered vyavaya as one of physical activity the lack of which
is also a causative factor for Sthoulya. While the non indulgence in sexual activity
results in Sthoulya. Excessive indulgence results in shosha and so many other
debilitating disorders133.
Sushruta Samhita has also explained about the relationship that exists between
sthoulya and vyavaya. Where as the later authours like Madhvakara134, Bhava
mishra135 have mentioned only alpa vyavaya as the lakshanas of sthoulya.
The relationship between Sthoulya and krucchra vyavaya has been very clearly
narrated in the following statement of Charaka Samhita
zÉÑ¢ü AoÉWÒûiuÉÉiÉç qÉåSxÉÉÅuÉ×iÉ qÉÉaÉïiuÉÉiÉç cÉ M×ücNíûurÉuÉÉrÉ.|| cÉ.xÉÔ.21/3
ie. Shukra abahutva (Alpa shukra) and medasavruta marga are the causes for
Krucchra vyavaya.
Yogendranath sen opines that Shukra abahutvat is nothing but shukra alpatvat and
kruchra vyavaya is the difficulty experienced during the sexual act136.
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Sushruta Samhita has mentioned that alpa vyavaya in sthoulya occurs due to the
obstruction to the marga by kapha and medas.
MüTü qÉåSÉåÌlÉÂkSqÉÉaÉïiuÉÉiÉç cÉ AsmÉ urÉuÉÉrÉÉå pÉuÉÌiÉ || xÉÑ. xÉÔ. 15/32
By these statements the causes attributed to Krucchra vyavaya are
Alpa shukra
Margavarana by medas alone or medas and kapha.
Causes for Alpa shukra in Sthoulya
As it is mentioned that “dhatavohi dhatvaaharaha”137, the condition of the subsequent
(uttarottara) dhatus depends on the healthy condition of the previous dhatus. In
sthoulya only medodhatu upachaya takes place, at the cost of other dathus. As a result
of this the rest of the dhatus including shukradhatu are deprived of their nutrients.
This inturn results in alpa shukrata.
To understand the pathogenesis of alpa shukrata in sthoulya, the knowledge of dhatu
poshana krama is very essential.
Charaka Samhita explains the nourishment of all the dhatus takes place
simultaneously138. (ie. Eka kala dhatu poshana nyaya as per Arunadatta)139.
The various nyayas which are proposed to understand the dhatuposhana can be
appreciated at various levels of Eka kala dhatu poshana only.
The various stages of dhatu poshana include
1. Rasa which is formed after ahara paka circulates throughout the body
continuously.
2. The rasa thus formed circulates in different channels of the body to nourish
the dhatus. (kedara kulya nyaya)
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3. The specific amsha of this rasa is absorbed by the respective dhatus for their
poshana. (Khale kapota nyaya)
4. After absorption, the particular amsha is converted into specific form which is
conducive to the respective dhatus. (ksheera dadhi nyaya)
In Sthoulya, the pathogenesis may occur at any of these stages resulting in Alpa
shukrata, which are explained below
1. The annarasa (Amarasa), which is formed due to indulgence in nidanas, will
be predominantly madhura in nature.
2. The annarasa thus produced circulates all over the body in the state of
amavastha itself.
3. The madhura annarasa which is produced has more affinity towards
medodhatu.
4. The madhura anna rasa thus absorbed is converted into medodhatu only
depriving other dhatus of the nourishment leading to Sthoulya. This in turn
affects Shukradhatu resulting in alpa shukra.
Causes for Avruta marga
In Sthoulya there will be improper formation of medas which in turn obstruct the
marga initiating the pathogenesis140.
Dalhana in Nibandha sangraha commentary on Sushruta Samhita throws some light
on this concept. In Sthoulya there will be formation of ama due to dhatvagnimandya.
This ama is circulated in the body resulting in excessive production of sneha and
meda. Thus produced meda along with kapha causes obstruction to the marga
resulting in Alpa vyavaya141.
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The effect of sthoulya on Vyavaya
In Sthoulya, there will be alpa shukra and margavarana by medas causing kruchra
vyavaya. The ashta doshas of sthoulya mentioned in Charaka Samhita are considered
as the cardinal symptoms142.
Ayushohrasa, a symptom of Sthoulya occurs because of the disproportionate nutrition
and over production of medodhatu. This results in the under nutrition or under
production of Shukra dhatu, resulting in alpa shukra. Vyavaya depends on the
quantity of shukra formed. Because of alpa shukra, there is krucchra vyavaya.
In Sthoulya, there will be javoparodha, because of shaithilya, soukumarya and
gurutva of medas. In vyavaya the role of cheshta is very important. The sluggish
movement of the body affects the cheshta, which results in krucchra vyavaya.
Dourbalya, Dourgandhya and Swedabadha will disturb the routine of the person
which will in turn affect desire for sex ie. Sankalpa leading to krucchra vyavaya.
Ati Kshut and Ati Pipasa are not tolerated by an obese person and when he indulges in
the sexual act, in this situation the performance will not be up to the mark.
Apart from the ashta doshas, the other cardinal features of Sthoulya described in
classical text books are Chala spik udara stana, Ayathopachaya and Ayatha utsaha.
Chala spik udara stana may cause discomfort during the act, thus affecting cheshta,
leading to krucchra vyavaya. Ayathopachaya, basically affects the formation of
shukradhatu which results in qualitative and quantitative changes in shukra, leading
to krucchra vyavaya. Ayatha utsaha is the lack of desire for doing any activity which
will include sexual act also. This affects the sankalpa stage of vyavaya leading to
krucchra vyavaya
In a nutshell, the symptoms manifested in sthoulya will hinder each and every stage of
vyavaya and thus affecting performance level leading to krucchra vyavaya.
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Table No. 7. Showing the effect of lakshans in different stages of vyavaya
Stages of Vyvaya
Sl.No Lakshanas Sankalpa Cheshta Nishpeeda Shukra
chyuti
1 Ayushohrasa - - -
2 Javoparodha -
3 Dourbalya
4 Dourgandhya - - -
5 Swedabadha - -
6 Ati Kshut - - -
7 Ati Pipasa - - -
8 Chala spik udara
stana,
-
9 Ayatopachaya - - -
10 Ayata utsaha - - -
The efficacy of the sexual act is determined by the quantum of shukra and its easy
flow through shukravaha srotas including ejaculation. In sthoulya decreased quantum
of shukra and obstruction of the marga by medas which hinders its easy flow and
ejaculation, making the act difficult143.
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THE ARTICLES RELATED TO OBESITY WITH SEXUAL
DYSFUNCTION
The relationship between obesity and sexual dysfunction was not considered with
great importance in contemporary medical science. Since last decade lot of research
work are being done to understand the relationship between obesity and sexual
function. Some of the research works are quoted below:
1. Effect of Lifestyle Changes on Erectile Dysfunction in Obese Men A
Randomized Controlled Trial
Katherine Esposito, MD; Francesco Giugliano, MD; Carmen Di Palo, MD; Giovanni
Giugliano, MD; Raffaele Marfella, MD, PhD; Francesco D'Andrea, MD; Massimo
D'Armiento, MD; Dario Giugliano, MD, PhD , published in JAMA. 2004; 291:2978-
2984.
Randomized, single-blind trial of 110 obese men (body mass index 30) aged 35 to 55
years, without diabetes, hypertension, or hyperlipidemia, who had erectile dysfunction
that was determined by having a score of 21 or less on the International Index of
Erectile Function (IIEF).This study shows that Lifestyle changes are associated with
improvement in sexual function in about one third of obese men with erectile
dysfunction at baseline.
2. Obesity and Sexual Quality of Life
Ronette L. Kolotkin,*† Martin Binks,‡§ Ross D. Crosby,¶_ Truls Østbye,† Richard E.
Gress,** and Ted D. Adams** Kolotkin, Ronette L., Martin Binks, Ross D. Crosby,
Truls ØStbye, Richard E. Gress, And Ted D. Adams. Obesity andsexual quality of
life. Obesity. 2006;14:472– 479.
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This study was conducted to 1) examine the prevalence of sexual quality-of-life
difficulties in obese individuals and 2) investigate the association between sexual
quality of life and BMI class, sex, and obesity treatment–seeking status.
Results: Higher BMI was associated with greater impairments in sexual quality of
life.
3. Obesity, the metabolic syndrome, and sexual dysfunction,
K Esposito and D Giugliano Department of Geriatrics and Metabolic Diseases,
University of Naples SUN, Naples, Italy published in International Journal of
Impotence Research (2005) 17, 391–398. doi:10.1038/sj.ijir.3901333; published
online 19 May 2005
This study suggests that one-third of obese men with ED can regain their sexual
activity after 2 yr of adopting health behaviors, mainly regular exercise and reducing
weight.
4. Male obesity and reproductive potential
A Ghiyath Shayeb, Siladitya Bhattacharya, published in Br J Diabetes Vasc Dis 2009;
9: 7–12.The study revealed that obesity has a detrimental effect on semen quality and
that there are several potential mechanisms underlying this phenomenon.
5. Sexuality and obesity, a gender perspective: results from French national
random probability survey of sexual behaviors
Nathalie Bajos, research director, honorary professor, Kaye Wellings, professor,
Caroline Laborde, research assistant, Caroline Moreau, research fellow for the CSF
Group .The study was conducted to analyse the association between body mass index
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(BMI) and sexual activity, sexual satisfaction, unintended pregnancies, and abortions
in obese people and to discuss the implications for public health practices, taking into
account the respondents’ and their partners’ BMI.
Obese men were less likely than normal weight men to report more than one sexual
partner in the same period (0.31, 0.17 to 0.57, P<0.001) and more likely to report
erectile dysfunction (2.58, 1.09 to 6.11, P<0.05).
6. Link Found Between Obesity and Erectile Dysfunction
Irwin Goldstein, M.D. is Director of Sexual Medicine, Alvarado Hospital, San Diego
and Clinical Professor of Surgery at University of California, San Diego. Dr. Mario
Maggi The study was published in The Journal of Sexual Medicine, the official
journal of the International Society for Sexual Medicine.
The results showed that obesity was significantly associated with a higher physical
contribution to ED, while there was no difference seen with relational or
psychological determinants.
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MATERIALS AND METHODS
The materials used for the study can be categorized as follows
1. Literary sources
2. Assessment tools(Instruments)
Collection of Material
1. Literary
For the present study the primary sources of literature were different classical
texts books of Ayurveda. Along with that related information are compiled from
other sources such as Vedic and Upanishad scripts, the literature on different
Indian philosophies. Information are also gathered from the texts books of
contemporary medical science and different Journals. Previous studies conducted
on similar subjects at different universities and other research center is compiled.
Information available on internet is also incorporated.
2. Assessment tools
a) Weighing Machine
b) Measuring Tape
c) Scale for measuring height (Plotted on wall)
d) Vernier calipers
e) A multidimensional scale for assessment of erectile dysfunction- A
Questionnaire (international index of erectile function)
f) Semen analysis
Description of the questionnaire
This questionnaire was developed and standardized by ROSEN R. C. et.al. Urology,
1997 Jun; 49(6):822-30. Relevant domains of sexual function across various cultures
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were identified via a literature search of existing questionnaires and interviews of
male patients with erectile dysfunction. An initial questionnaire was administered to
patients with erectile dysfunction, with results reviewed by an international panel of
experts. Following linguistic validation in 10 languages, the final 1- 5 item
questionnaire, the International Index of Erectile Function (IIEF), was examined for
sensitivity, specificity, reliability (internal consistency and test-retest repeatability),
and construct (concurrent, convergent, and discriminant) validity.
In the beginning of the questionnaire instructions are given as to how the questions
are to be answered, and the terminologies used in the questionnaire are defined. IIEF
contains 15 questions and each question has 5 options.
Methodology
1. Measurement of Weight
Patient was asked to remove the slippers and was asked to stand on the
weighing machine devoid of any accessories (like hand bag, mobiles). The
reading was observed and recorded in kilograms.
2. Measurement of Circumferences
Measurements were taken in centimeters using a measuring tape at
different levels like:
a) Waist – at the level of umbilicus.
b) Hip – at the level of maximum circumference.
3. Skin fold thickness of triceps were taken using vernier calipers – skin fold at
the triceps region was held between the fingers and the thickness was measured
using calipers.
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4. Measurement of Height
Heights were taken by asking the patient to stand bare foot with their heel,
back and head touching the wall. In that position a metal scale was placed over the
head perpendicular to the wall and the corresponding reading on the wall was
recorded in centimeters.
Methodology:
Method to assess Erectile function through the IIEF scale.
A multidimensional scale for assessment of erectile dysfunction i.e. International
index of erectile function (IIEF) was used to assess erectile function. The
questionnaire was converted to the vernaculam Kannada by the researcher. Each
question was carefully translated and care was taken to convey the same meaning of
the original questionnaire. The individuals were informed about the questionnaire and
the purpose of administering it to them. A written consent was also obtained. They
were informed about the 15 questions and instructions were given to mark whichever
appropriately suits them among the 5 options of answers. It was also suggested to
answer all the questions compulsorily. No time limit was fixed to complete the
questionnaire. However they were informed not to indulge in an undue delay. In some
under educated persons each question was read and explained and was scored on the
options of answer given by the patient.
Scoring was done based on the standardized methods of the scale which consists of
scoring of different factors such as erectile function, orgasmic function, sexual desire,
intercourse satisfaction and overall satisfaction.
Investigation:
Semen Analysis was done in all the patients after administering the questionnaire.
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Methods
Aim: To validate the statement of Charaka Samhita “Shukra abahutvat medasaavruta
margatvat cha krucchra vyavayata in sthoulya”.
Objectives of the study
To compile and interpret the available information on the relationship between
Sthoulya, shukra abahutva and krucchra vyavaya.
To validate the statement of Charaka Samhita “Shukra abahutvat
medasaavruta margatvat cha krucchra vyavayata”.
To understand shukra abahutvat by the quantitative and qualitative changes in
Shukra in patients of Sthoulya through an observational study.
Source of Data:
Sample: For the 3rd objective a minimum of 33 patients whose BMI is >30,
approaching the OPD of Government Ayurveda Medical College and Hospital,
Mysore and also from other available sources was selected for the study.
Inclusion Criteria:
Male Patients between age group of 30-60, who have primary obesity and who
are willing for the study were selected.
Patients with BMI more than 30 are selected.
Exclusion Criteria:
Patients with other systemic disorders that interfere with the study and
individuals with congenital anomalies of uro-genital tract are excluded.
Obesity secondary to other endocrinal disorder is excluded.
Patients who have already undergone Vasectomy are excluded.
Patients who have undergone other surgical interventions which interfere with
sexual activity /performance are excluded.
Individuals having Infection or anomalies of genital organs are excluded.
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Diagnostic Criteria:
Patients with BMI more than 30, along with the below said criteria are
considered.
Waist measurement.( >102)
Waist hip ratio. ( >1.0 )
Disproportionately increased weight for specific height.
Sampling Method
The study was conducted on obese individuals, from O.P.D. and I.P.D. of
Government Ayurveda Medical College and Hospital, Mysore and other available
sources.
Research Design
After screening, the selected individuals were assigned to one group. This is an
observational study. The readings were recorded to assess various parameters of this
study.
Statistical Analysis
Statistical Analysis to assess Individual and comparative effects of the data, was done
using descriptive statistics, frequencies and percentages , Chi- Square test, Pearson’s
product moment correlation. All the statistical methods were carried out through the
SPSS (Statistical presentation system software) for Windows (version 16.0)
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Criteria of Assessment
Scoring Algorithm for IIEF
All items are scored in 5 domains as follows:
Domain Items Range Max Score
Erectile Function 1,2,3,4,5 &15 0-5 30
Orgasmic Function 9,10 0-5 10
Sexual Desire 11,12 0-5 10
Intercourse Satisfaction 6,7,8 0-5 15
Overall Satisfaction 13,14 0-5 10
Clinical Interpretation
I. Erectile function total scores can be interpreted as follows:
Score Interpretation
0-6 Severe dysfunction
7-12 Moderate dysfunction
13-18 Mild to moderate dysfunction
19-24 Mild dysfunction
25-30 No dysfunction
II. Orgasmic function total scores can be interpreted as follows:
Score Interpretation
0-2 Severe dysfunction
3-4 Moderate dysfunction
5-6 Mild to moderate dysfunction
7-8 Mild dysfunction
9-10 No dysfunction
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III. Sexual desire total scores can be interpreted as follows:
Score Interpretation
0-2 Severe dysfunction
3-4 Moderate dysfunction
5-6 Mild to moderate dysfunction
7-8 Mild dysfunction
9-10 No dysfunction
IV. Intercourse satisfaction total scores can be interpreted as follows:
V. Overall satisfaction total scores can be interpreted as follows:
Score Interpretation
0-3 Severe dysfunction
4-6 Moderate dysfunction
7-9 Mild to moderate dysfunction
10-12 Mild dysfunction
13-15 No dysfunction
Score Interpretation
0-2 Severe dysfunction
3-4 Moderate dysfunction
5-6 Mild to moderate dysfunction
7-8 Mild dysfunction
9-10 No dysfunction
68
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
OBSERVATIONS
In the present study 37 individuals were registered out of which there were 4 drop-
outs. Among these 33 individuals semen analysis could not be done in 3 patients as 2
individuals had a very low sample volume of semen and the other one had the severe
erectile dysfunction. All the 33 individuals completely answered the questionnaire
that was given for the study. The study was concluded in a sample size consisting of
33 individuals
Table No .8. Showing the distribution of age in the individuals of Sthoulya.
Range Frequency Percentage P value
30-35 17 51.5
36-40 6 18.2
41-45 5 15.2
46-50 3 9.1
51-55 1 3.0
56-60 1 3.0
Age
Total 33 100.0
0.000
Out of 33 individuals, 17 individuals (51.5%) were in the age group of 30-35, 6 were
in (18.2%) the age group of 36-40, 5 were in (15.2%) the 41-45 age group , 3 were in
46-50 age group, 1(3.0%) in 51-55 age group and 1(3.0%) in 56-60 age group.
Table No.9. Showing the distribution of Marital Status in the individuals of
Sthoulya.
Frequency Percentage P value
Married 32 97
Unmarried 1 3
Marital
Status
Total 33 100.0
0.000
69
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals, 32 individuals (97%) were married and 1 individual (3%) was
unmarried.
Table No. 10. Showing the distribution of Religion in the individuals of Sthoulya.
Frequency Percentage P value
Hindu 29 87.9
Muslim 4 12.1
Religion
Total 33 100.0
0.000
Out of 33 individuals, 29 individuals (87.9%) were Hindus and 4 individuals (12.1%)
were Muslims.
Table No.11.Showing the distribution of Education in the individuals of
Sthoulya.
Frequency Percentage P value
Primary School 1 3.0
Middle School 1 3.0
High School 15 45.5
Graduate 13 39.4
Post Graduate 3 9.1
Education
Total 33 100.0
0.000
Out of 33 individuals, 1 patient had studied till Primary (3.0%), 1 patient had
studied till Middle School (3.0%), 15 patients had studied till High School (45.5%),
13 patients were Graduates (39.4%) and 3 patients were Post graduates (9.1%).
70
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No.12.Showing the distribution of Socio-Economic status in the individuals
of Sthoulya.
Out of 33 individuals,4 individuals were belonging to Lower middle class(12.1%),23
individuals were belonging to middle class( 69.7%),5 individuals were belonging to
Upper middle class (15.2%) and one individual belonging to Rich ( 3.0%).
Table No.13. Showing the distribution of cardinal symptoms in the individuals of
Sthoulya.
Frequency Percentage P value
Chala Spik udara stana 33 100.0 -
Kshudra shwasa 21 63.6 0.117
Alasya utsaha hani 9 27.3 0.009
Dourbalya 8 24.2 0.003
Nidradhikya 15 45.5 0.602
Dourgandhya 10 30.3 0.024
Snigdhangata 10 30.3 0.024
Atipipasa 4 12.1 0.000
Atikshut 4 12.1 0.000
Alpa Vyavaya 15 45.5 0.602
Gatra sada 11 33.3 0.056
Swedadhikya 21 63.6 0.117
Frequency Percentage P value
Lower middle class 4 12.1
Middle class 23 69.7
Upper middle class 5 15.2
Rich 1 3.0
Socio-
Economic status
Total 33 100.0
0.000
71
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals, the symptom Chala Spik udara stana was present in all
individuals( 100%), 21 individuals( 63.6%) were suffering from kshudra shwasa,9
individuals presented with alsya utsahahani (27.3%), 8 individuals suffered from
dourbalya( 24.2%) 15 individuals were suffering from nidradhikya ( 45.5%)10
individuals were suffering from dourgandhya( 30.3%), 10 snigdhangata( 30.3%), 4
individuals were suffering from atipipasa and atikshuda ( 12.1%),15 individuals were
suffering from Alpavyavaya( 45.5%) ,11individuals were suffering from gatrasada (
33.3%) and 21individuals were suffering from Swedadhikya ( 63.6%).
Table No.14. Showing the distribution of Nature of work in the individuals of
Sthoulya.
Frequency Percentage P value
Hard Manual 1 3.1
Moderate manual 17 51.5
Mild 4 12.1
Sedentary 11 33.3
Nature of
work
Total 33 100.0
0.000
Out of 33 individuals, 11 individuals were doing Sedentary work (33.3%), 4
individuals were doing Mild work (12.1%), 17 individuals were doing Moderate
manual work (51.5%) and 1 individual was doing Hard Manual work (3.1%).
Table No .15. Showing the distribution of exercise in the individuals of Sthoulya.
Frequency Percentage P value
No exercise 23 69.7
Does exercise 10 30.3
Exercising
Practice
Total 33 100.0
0.024
72
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals, 23 individuals did not involve in Exercise (69.7%) and 10
individuals involved in Exercise (30.3%).
Table No.16. Showing the distribution of nature of diet in the individuals of
Sthoulya.
Frequency Percentage P value
Vegetarian 8 24.2
Mixed 25 75.8
Nature of diet
33 100.0
0.003
Out of 33 individuals, 8 individuals were vegetarians (24.2%) and 25 individuals
were having mixed diet (75.8%)
Table No.17. Showing the distribution of nature of diet in the individuals of
Sthoulya.
Frequency Percentage
P
value
Intake of heavy food 9 27.3 0.009
Normal food with
increased frequency
2 6.1 0.000
Small quantity with
regular interval
21 63.6 0.117
Use of snacks between
the meals
8 24.2 0.003
Nature of
diet
Excessive dieting 0 0 -
Out of 33 individuals, regarding the nature of food, intake of heavy food was noticed
in 9 individuals (27.3%), 2 individuals (6.1%) were taking Normal food with
increased frequency, 21 individuals (63.6%) were having the habit of taking Small
73
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
quantity with regular interval, 8 individuals (24.2%) were having the habit of taking
snacks between the meals and none of the individuals were excessive diet.
Table No.18. Showing the distribution of predominant rasa preferred in the
individuals of Sthoulya.
Out of 33 individuals, 5 individuals (15.2%) preferred predominantly Madhura rasa,
8 individuals (24.2%) preferred predominantly katu rasa and 20 individuals (60.6%)
preferred all the rasas.
Table No. 19. Distribution of appetite in the individuals of Sthoulya.
Out of 33 individuals, 3individuals (9.1%) were having poor appetite, 7 individuals
(21.2%) were having moderate appetite 22 individuals (60.7%) were having good
appetite and 1 individual (3.0%) was having severe appetite.
Frequency Percentage P value
Madhura 5 15.2
Katu 8 24.2
All 20 60.6
Predominant rasa
preferred
Total 33 100.0
0.003
Frequency Percentage P value
Poor 3 9.1
Moderate 7 21.2
Good 22 66.7
Severe 1 3.0
Appetite
Total 33 100
0.000
74
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No. 20. Distribution of nature of sleep in the individuals of Sthoulya.
Out of 33 individuals, 28 individuals (84.8%) were having satisfactory sleep, 5
individuals (15.2%) were having unsatisfactory sleep.
Table No. 21. Showing the distribution of sleep during daytime in the individuals
of Sthoulya.
Frequency Percentage P value
No sleep 22 66.7
30 min 1 3.0
60min 8 24.2
0.000
120min 2 6.1
Sleep during
daytime
Total 33 100.0
Out of 33 individuals, 11 individuals were in the habit of Day sleep of which 1
individual (3.0%) sleeps for 30minutes, 8 individuals(24.2%) sleep for 1hour and 2
individuals (6.1%) sleep for 2hours and 22 individuals (66.7%) were not having the
habit of day sleep.
Table No. 22. Showing the distribution of sleep during night time in the
individuals of Sthoulya.
Frequency Percentage P value 6hrs 2 6.1 7hrs 9 27.3 8hrs 13 39.4 9hrs 4 12.1
10hrs 5 15.2
Sleep during night time
Total 33 100.0
0.020
Frequency Percentage P value
Satisfactory 28 84.8
Unsatisfactory 5 15.2
Nature of
sleep Total 33 100.0
0.000
75
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals,2 individuals(6.1%) slept for 6 hrs at night, 9 individuals
(27.3%) slept for 7 hrs at night, 13 individuals ( 39.4%) slept for 8hrs at night, 4
individuals ( 12.1%) slept for 9hrs at night and 5 individuals( 15.2%) slept for 10hrs
at night.
Table No. 23. Showing the distribution of Habits in the individuals of Sthoulya.
Frequency Percentage P value
Smoking 2 6.1
Alcohol 5 15.2
Habits
Tea and coffee 33 100.0
0.000
Out of 33 individuals, 2 individuals (6.1%) had the habit of smoking, 5 individuals
(15.2%) had the habit of taking alcohol and all the individuals had the habit of taking
tea and coffee.
Table No .24. Showing the distribution of Prakruti in the individuals of Sthoulya.
Frequency Percentage P value
Vata-Pitta 1 3.0
Kapha-Pitta 22 66.7
Kapha-Vata 10 30.3
Prakruti
Total 33 100.0
0.000
Out of 33 individuals, 1 individual is of vata- pitta prakruti, 22 individuals were of
kapha-pitta and 10 individuals were of kapha-vata prakruti.
Table No.25. Showing the distribution of Samhanana in the individuals of
Sthoulya.
Frequency Percentage
P
value
Madhyama 30 90.9
Pravara 3 9.1
Samhanana
Total 33 100.0
0.000
76
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals, 30 individuals (90.9%) were of madhyama samhanana, 3
individuals (9.1%) were of Pravara samhanana.
Table No .26. Showing the distribution of Satmya in the individuals of Sthoulya.
Frequency Percentage P value
Avara 5 15.2
Madhyama 1 3.0
Pravara 27 81.8
Satmya
Total 33 100.0
0.000
Out of 33 individuals, 5 individuals (15.2%) were of avara satmya.1 individual (3.0
%) was of madhyama satmya, 27individuals (81.8%) were of Pravara satmya.
Table No .27. Showing the distribution of Sattva in the individuals of Sthoulya.
Out of 33 individuals, 2individuals (6.1%) were of avara sattva.24 individual (72.7
%) were of madhyama sattva, 7 individuals (21.2%) were of Pravara sattva.
Table No.28. Showing the distribution of abhyavaharana Shakti in the
individuals of Sthoulya.
Frequency Percentage P value
Avara 2 6.1
Madhyama 24 72.7
Pravara 7 21.2
Sattva
Total 33 100.0
0.000
Frequency Percentage
P
value
Avara 1 3.0
Madhyama 32 97
Abhyavaharana
Shakti Total 33 100.0
0.000
77
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Out of 33 individuals, 1individual (3.0%) has avara abhyavaharana Shakti and 32
individuals (97%) have madhyama abhyavaharana Shakti.
Table No .29. Distribution of jarana Shakti in the individuals of Sthoulya.
Out of 33 individuals, 1 individual (3.0%) had avara jarana Shakti, 29 individuals
(87.9%) had madhyama jarana Shakti and 3 individuals (9.1%) had pravara jarana
Shakti.
Table No .30. Distribution of vyayama Shakti in the individuals of sthoulya
Out of 33 individuals, 13 individuals (39.40%) had avara vyayama Shakti and 20
individuals (60.6%) had madhyama vyayama Shakti.
Table No.31. Showing the distribution of koshtha in the individuals of Sthoulya.
Out of 33 individuals, 1 individual (3.0%) had kroora koshtha and 32 individuals
(97%) had madhyama koshtha.
Frequency Percentage P value
Avara 1 3.0
Madhyama 29 87.9
Pravara 3 9.1
Jarana
Shakti
Total 33 100.0
0.000
Frequency Percentage P value
Avara 13 39.4
Madhyama 20 60.6
Vyayama
Total 33 100.0
0.223
Frequency Percentage P value
Madhyama 32 97.0
Kroora 1 3.0
Koshta
Total 33 100.0
0.000
78
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
RESULTS
Table No .32. Showing the scores of IIEF related to Erectile Functions in the
individuals of Sthoulya.
Frequency Percentage P value
Severe Dysfunction 4 12.1
Moderate Dysfunction 3 9.1
Mild –Moderate Dysfunction 7 21.2
Mild Dysfunction 5 15.2
No Dysfunction 14 42.4
Scores of
IIEF
related
Erectile
Functions Total 33 100.0
0.020
Out of 33 individuals,4 individuals (12.1%) had Severe Erectile Dysfunction.3
individuals (9.1%) had Moderate Dysfunction,7 individuals (21.2%) had Mild –
Moderate Dysfunction, 5 individuals(15.2%) had Mild Dysfunction and 14
individuals (42.4%) had no Erectile dysfunction.
Table No. 33. Showing the scores of IIEF related to Orgasmic Functions in the
individuals of Sthoulya.
Out of 33 individuals,2 individuals (6.1%) had Severe orgasmic Dysfunction.5
individuals (15.2%) had Moderate Dysfunction,4 individuals (12.2%) had Mild –
Moderate Dysfunction, 12 individuals(36.4%) had Mild Dysfunction and 10
individuals (30.3%) had no orgasmic dysfunction.
Frequency Percentage P value
Severe Dysfunction 2 6.1
Moderate Dysfunction 5 15.2
Mild –Moderate Dysfunction 4 12.1
Mild Dysfunction 12 36.4
No Dysfunction 10 30.3
Scores of
IIEF
related
Orgasmic
Functions Total 33 100.0
0.029
79
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .34. Showing the scores of IIEF related to Sexual Desire in the
individuals of Sthoulya.
Out of 33 individuals, none of the individuals had Severe sexual desire Dysfunction.5
individuals (15.2%) had Moderate Dysfunction,9 individuals (27.3%) had Mild –
Moderate Dysfunction, 14 individuals(42.4%) had Mild Dysfunction and 5
individuals (15.2%) had no sexual desire dysfunction.
Table No. 35. Showing the scores of IIEF related to Intercourse Satisfaction in
the individuals of Sthoulya
Out of 33 individuals,4 individuals(12.1%) had Severe Dysfunction in Intercourse
Satisfaction.4 individuals (12.1%) had Moderate Dysfunction,9 individuals (27.3%)
had Mild –Moderate Dysfunction, 11 individuals(33.3%) had Mild Dysfunction and
5 individuals (15.2%) had no dysfunction in Intercourse Satisfaction.
Frequency Percentage P value
Severe Dysfunction 0 0
Moderate Dysfunction 5 15.2
Mild –Moderate Dysfunction 9 27.3
Mild Dysfunction 14 42.4
No Dysfunction 5 15.2
Scores of
IIEF
related
Sexual
Desire Total 33 100.0
0.084
Frequency Percentage P value
Severe Dysfunction 4 12.1
Moderate Dysfunction 4 12.1
Mild –Moderate Dysfunction 9 27.3
Mild Dysfunction 11 33.3
No Dysfunction 5 15.2
Scores of
IIEF related
Intercourse
Satisfaction
Total 33 100.0
0.182
80
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .36. Showing the scores of IIEF related to Overall Satisfaction in the
individuals of Sthoulya.
Out of 33 individuals,1 individual (3.0%) had Severe Dysfunction in Overall
Satisfaction.2 individuals (6.1%) had Moderate Dysfunction,7individuals (21.2%) had
Mild –Moderate Dysfunction, 17 individuals(51.5%) had Mild Dysfunction and 6
individuals (18.2%) had no dysfunction in overall Satisfaction
Table No.37. Showing the Semen volume in the individuals of Sthoulya.
Frequency Percentage P value
<1.5ml/eja 7 23.3
>1.5-2 ml/ej 11 36.7
Above 2ml/eja 12 40.0
Semen
volume
Total 30 100.0
0.497
Out of 33 individuals, 7 individuals (23.3%) had semen volume <1.5ml/ejaculate, 11
individuals (36.7%) had semen volume >1.5-2 ml/ejaculate and 12 individuals
(40.0%) had semen volume above 2ml/ejaculate.
Frequency Percentage P value
Severe Dysfunction 1 3.0
Moderate Dysfunction 2 6.1
Mild –Moderate
Dysfunction
7 21.2
Mild Dysfunction 17 51.5
No Dysfunction 6 18.2
Scores of
IIEF related
Overall
Satisfaction
Total 33 100.0
0.000
81
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .38. Showing the Liquefaction time of Semen in the individuals of
Sthoulya.
Frequency Percentage P value
Normal 25 83.3
Abnormal 5 16.7
Liquefaction time
Total 30 100.0
0.000
Out of 33 individuals, the Liquefaction time of semen was normal in 25 individuals
(83.3%) and abnormal in 5 individuals (16.7%).
Table No .39. Showing the Viscosity of Semen in the individuals of Sthoulya.
Frequency Percentage P value
Normal 27 90.0
Abnormal 3 10
Viscosity
Total 30 100.0
0.000
Out of 33 individuals, the viscosity of semen was normal in 27 individuals (90%) and
abnormal in 3 individuals (10%).
Table No .40. Showing the Sperm count in the individuals of Sthoulya.
Frequency Percentage P value
Normal 24 85.7
Borderline 2 7.1
Abnormal 2 7.1
Sperm count
Total 30 100.0
0.000
Out of 33 individuals, the normal Sperm count was noticed in 24 individuals (85.7%),
it was borderline in 2 individuals (7.1%) and abnormal in 2 individuals (7.1%).
82
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .41.Showing the Motility of Sperms in the individuals of Sthoulya.
Frequency Percentage P value
<25% 9 30.0
>25% 21 70.0
Motility of Sperms
Total 30 100.0
0.028
Out of 33 individuals, Motility of Sperms was <25% in 9 individuals (30.0%) and
>25% in 21 individuals (70.0%).
Table No.42. Showing the Motility of Sperms (class a & class b) in the
individuals of Sthoulya.
Frequency Percentage P value
Normal 19 63.3
Abnormal 11 36.7
Motility of Sperms( class
a & class b ) Total 30 100.0
0.144
Out of 33 individuals, Motility of Sperms (class a & class b) was normal in 19
individuals (63.3%) and abnormal in 11 individuals (36.7%).
Table No .43. Showing the Morphology of Sperms in the individuals of Sthoulya.
Frequency Percentage P value
Normal 25 83.3
Abnormal 5 16.7
Morphology of Sperms
Total 30 100.0
0.000
Out of 33 individuals, Morphology of Sperms was normal in 25 individuals (83.3%)
and abnormal in 5 individuals (16.7%).
83
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .44. Showing the Impression of Semen Analysis in the individuals of
Sthoulya.
Frequency Percentage P value
Normal 19 63.3
Abnormal 11 36.7
Impression of Semen
Analysis Total 30 100.0
0.144
Out of 33 individuals, the impression of the semen analysis was normal in 19
individuals(63.3%) and abnormal in 11 individuals(36.7%)
Table No .45. Showing the Correlations of BMI with Erectile Functions in the
individuals of Sthoulya
There is no significant relation observed between BMI and erectile functions.
V1 V2 Correlation
co-efficient
Sig
BMI Erectile function -.025 .891
BMI Orgasmic Function .031 .862
BMI Sexual Desire -.042 .815
BMI Intercourse
Satisfaction
.056 757
BMI Overall Satisfaction .105 .560
84
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .46. Showing the Correlations of BMI with Semen Analysis in the
individuals of Sthoulya
There is no significant relation observed between BMI and semen parameters.
Table No .47. Showing the Correlations of waist hip ratio with Erectile Functions
in the individuals of Sthoulya
There is significant relation observed between Waist Hip ratio and erectile function
with significant P value0.017. There is no significant relation observed between Waist
Hip ratio and Orgasmic Function, Sexual Desire, Intercourse Satisfaction and Overall
Satisfaction.
V1 V2 Correlation
co-efficient
Sig
BMI Semen volume 0.124 0.514
BMI Sperm count 0.278 0.137
BMI Motility 0.234 0.213
BMI Morphology 0.001 0.994
V1 V2 Correlation
co-efficient
Sig
Waist Hip ratio Erectile function -.413 0.017
Waist Hip ratio Orgasmic Function -.203 0.256
Waist Hip ratio Sexual Desire -.290 0.102
Waist Hip ratio Intercourse
Satisfaction
.-.305 0.084
Waist Hip ratio Overall
Satisfaction
-.225 0.207
85
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Table No .48. Showing the Correlations of waist hip ratio with Semen Analysis in
the individuals of Sthoulya
There is no significant relation observed between Waist Hip ratio and semen
parameters.
V1 V2 Correlation
co-efficient
Sig
Waist Hip ratio Semen volume -.148 0.436
Waist Hip ratio Sperm count -.199 0.291
Waist Hip ratio Motility -.147 0.437
Waist Hip ratio Morphology -.308 0.098
86
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.1. Showing the incidence of Age
Graph No.2. Showing the incidence of marital status
87
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.3. Showing the incidence of Educational level
Graph No.4. Showing the incidence of socio-economic status
88
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.5. Showing the incidence of Cardinal symptoms of Sthoulya
Graph No.6. Showing the incidence of Cardinal symptoms of Sthoulya
89
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.7. Showing the incidence of Nature of work
Graph No.8. Showing the incidence of Duration of Excercise
90
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.9. Showing the incidence of Nature of Diet
Graph No.10. Showing the incidence of Nature of food
91
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.12. Showing the incidence of Nature of appetite
Graph No.11. Showing the incidence predominant taste Preferred
92
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.13. Showing the incidence of Nature of Sleep
Graph No.14. Showing the incidence of Duration of Day sleep
93
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.16. Showing the incidence of Prakruti
Graph No.15. Showing the incidence of Duration of sleep at night
94
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.17. Showing the incidence of Sattva
Graph No.18. Showing the incidence of Koshta
95
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.20. Showing Scores of IIEF related to Orgasmic Functions
Graph No.19. Showing Scores of IIEF related to Erectile Functions
96
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.22. Showing Scores of IIEF related to Intercourse Satisfaction
Graph No.21. Showing Scores of IIEF related to Sexual Desire
97
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.23. Showing Scores of IIEF related to Overall Satisfaction
Graph No.24. Showing Semen volume
98
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.26. Showing Viscosity of Semen
Graph No.25. Showing Liquefaction time of Semen
99
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.28. Showing Motility of sperms
Graph No.27. Showing Sperm Count
100
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Graph No.30. Showing Impression of Semen Analysis
Graph No.29. Showing Morphology of sperm
101
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
DISCUSSION
Any hypothesis needs to be analyzed by proper reasoning in order to arrive at
any conclusion. In this part the conceptual and observational studies are discussed.
Discussion on title
Obesity has been a health problem since the inception of the civilization.
However, the present era has seen a drastic increase in the rate and severity of the
problem. Changing lifestyle with regards to food habits and lack of physical activities
are considered as the important causes for this. As a result of this obesity is
considered as the most important lifestyle disorder of the modern age. WHO has
shown the severe concern about the growing rate of puberty onset obesity in
metropolitan Population. It is estimated that every year 3 lakh people die of the
complications of obesity.
The gravity of the problem is alarming in India also especially because of
growth in economy and technology. These factors have changed the lifestyle of
Indians considerably. Now a days more people are addicted to the complex high
calorie food habits, television and computer, private mode of transportations and other
such comforts which leads to reduced physical activity and sedentary lifestyle.
One among the many complications or limitations experienced by obese
people is the difficulty experienced during their sexual act. Even though the western
science is yet to recognize the exact mechanism and the impact of obesity on the
quality of sexual life, researchers and clinicians have taken a keen interest in this
regard. Presently a good number of studies are being conducted focusing on the
subject.
In this regard it is interesting to notice that Ayurvedic classical literature has
recognized this problem long ago. “Krucchra vyavayata” was recognized as one of
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the limitations of Sthoulya144. Not only the relationship between obesity and the
quality of sexual life but also the pathophysiology for the same was also hypothesized
in the form of “shukra abahutvat” (alpa shukra) and “margavarodha”.
The current study is conducted to understand, analyze and validate the hypothesis
“shukra abahutvat medasavruta margatvat cha krucchra Vyavaya”
Discussion on Sthoulya:
Sthoulya represents the condition obesity described in the contemporary medical
science. Obesity is defined as state of increased body weight due to adipose tissue
accumulation i.e of sufficient magnitude to produce adverse health effects The
definition of Sthoulya “Sthoolasya bhavaha sthoulyam” (xjÉÔsÉxrÉ pÉÉuÉÈ xjÉÉæsrÉqÉç |)
also implies the same meaning. By definition in obesity there is abnormal growth of
adipose tissue due to an enlargement in fat cell size or an increase in fat cell number
or combination of both which is similar to the cardinal feature of Sthoulya i.e., ayatha
upachaya of medas as stated in Charaka Samhita.
Charaka Samhita has considered Sthoulya as a complicated health condition and has
duly recognized it as a condition of “Nindita” i.e., undesirable. It is not only one
among the eight undesirable physical status (Ashta nindita purusha), but also the most
severe and untreatable form of them. The other classical text books of Ayurveda have
also recognized Sthoulya and its health consequences. Sushruta Samhita has
considered it as a “rasa nimittaja vyadhi”. However the subject of Sthoulya finds a
lucid description in the classical text book of Ayurveda. Madhava nidana is the first
text book which has dedicated a separate chapter for the discussion of obesity under
the label “Medoroga”. Bhavaprakasha and other later text books of Ayurveda have
also discussed this subject in detail. The significance of Sthoulya as a pathological
condition has changed over years from the time of Charaka Samhita to the later
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authors. This may be due to the prevalence of the disease which gradually increased
in the course of time. Understanding this disease from Ayurvedic perspective is the
most important need of the present era as it is reaching pandemic levels and has a
great influence on the mortality and morbidity.
Not only the definition but also the classification of Sthoulya has a good similarity
with the western classification of obesity which can be compared as below:
Sl.No Classification of Sthoulya145 Classification of obesity
1 Heena Sthoulya Obese class I (BMI – 30 to
34.9)
2 Madhya Sthoulya Obesity class II (BMI 35 to
40)
3 Adhika Sthoulya Obesity class III (BMI > 40)
The etiological factors mentioned for Sthoulya and obesity are also strikingly similar.
Beejaswabhava or hereditary factor has been emphasized as the intrinsic factor. The
other etiological factors are exogenous in nature.
Diet a causative factor
Ahara rasa plays a major role for the increase of “medodhatu”. Sushruta Samhita
describes both Sthoulya and karshya as two opposite conditions which mainly
depends on the quality and quantity of the ahara rasa146, which is again
interdependent on the nature and quantum of food consumed.
The role of diet in the manifestation of Sthoulya can be better understood with the
help of Samanya Vishesha Siddhanta. Foods that have madhura rasa, guru, sheeta
and snigdha guna increase medodhatu and kapha dosha which have similar qualities.
Similarly, food habits like adhyashana and atisampoorana acts as the causative
factors for obesity by virtue of dravya samanya.
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In the process of dhatu poshana krama, it is anticipated that the food consumed
should invariably result in the increase of subsequent dhatus i.e. from rasa to rakta,
rakta to mamsa, mamsa to medas and so on . But the process of nutrition of dhatus is
also selective causing the increase of an isolated dhatu. The reason for this is well
explained in Shashilekha commentary on Ashtanga Sangraha. It states that the food
articles which act as causative factors for the increase in medas are specific to that
particular dhatu and not to other dhatus because of the similarity and dissimilarity in
qualities respectively. Nibandha sangraha commentary of Dalhana on Sushruta
Samhita endorses the same by quoting vishishta ahara (ÌuÉÍzɹ AÉWûÉU) as one of the
cause for increase in medodhatu.
Contemporary science also highlights the role of dietary factors in causing obesity.
Fats and sugars are considered as energy dense food but low in bulk which increase
energy intake substantially. It can be interpreted that, these food items are of guru,
madhura and snigdha gunas.
Vihara as a causative factor
The role of activities (vihara) is also significant in Sthoulya. Sedentary lifestyle
consisting of minimum physical activity (Avyayama), abstinence (Avyavaya) and day
sleep (Divaswapna) promote weight gain through medovruddhi. Contrary to this
regular physical activity (vyayama), regular sexual activities and proper sleep
schedule promotes good health and controls the probability of developing Sthoulya.
Avyayama causes reduction in energy expenditure and calories burnt, as a
consequence of this there is accumulation of calories in the body in the form of medas
which ultimately leads to Sthoulya. Bhavaprakasha states that avyvaya leads to
medovruddhi, as abstinence reduces physical activities and there is a great intensity of
energy expenditure during the sexual act. On the other hand divaswapna leads to
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Sthoulya which is mediated through the quantitative and qualitative increase of kapha.
Concurrently the abhishyandi guna of divaswapna also results in srotorodha in
general and medovaha srotas in particular. All these factors collectively promote
Sthoulya. The reduced metabolic rate during the increased sleeping period also acts as
a contributory factor for the excessive accumulation of medodhatu.
Psychological factors as a causative factor
Charaka Samhita has considered harshanityata and achintana as Psychological
factors which are responsible for Sthoulya. These factors enhance tamas at the
psychological level and kapha in the physiological level.
A recent study reveals that stress induces obesity. This may be due to the fact that a
person under stress tends to eat more to tide over that situation. One who frequently
gets stressed gets accustomed to take frequent food which is nothing but Adhyashana,
one of the nidana /aetiological factor for Sthoulya.
Beejadosha as a causative factor:
Charaka Samhita has mentioned Beejadosha as one of the cause for Sthoulya147.
Defect of Beejabhaga avayava i.e. part of Beeja, may lead to defective development
of medas. Increased proportion of Meda and decreased proportion of Shukra in Beeja
at the time of conception predisposes towards development of an individual who is
stout (stoola, snigdha and supushta shareera) and bala heena148.This hypothesis is
also supported by the contemporary medical science. It stresses the role of genetic
factors in obesity. Western medical literatures considers melanocortin – 4 receptor
(MC4R) as a responsible factor for obesity.
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Other factors as a causative factor
The constitution of the child also depends on the maternal dietary factors. The Excess
intake of Madhura Rasa during pregnancy is considered as a causative factor for birth
of obese child, which indicates that the maternal dietary factors influence the child in
later life hood149.
Alcohol consumption promotes weight gain which is supported by considering Varuni
madya as one of the medodushti nidana150.
Smoking cessation increases appetite, which inturn results in excessive intake of food
which becomes one of the nidanas of Sthoulya ie. Atisampoorana.
Excessive administration of treatment procedures like snehana, sneha basti, utsadana,
swapna leads to Sthoulya due to atibruhmana.
Hence it can be considered that obesity is a condition which is caused by
heterogeneous factors including hereditary factors, dietary factors, level of physical
activities and habits. Most of the times it is due to the combination of more than one
factor mentioned above.
Samprapti
Discussion on Samprapti Ghatakas
Dosha - Tridosha, Samanavayu, Apanavayu, Vyanvayu, Pachaka pitta,
Kledaka kapha.
Dushya - Rasa and Meda( primary ),
Agni - Medodhatvagnimandya, Jatharagnimandya
Ama-Jataragnimandyjanya ama in initial phases, Medodhatvagnimandyajanya
ama in later phase
Srotas - Annavaha, Rasavaha, , Medovaha
Udabhavasthana - Amashaya
Sanchara - Rasayani
Vyakta - Whole body specifically udara, sphika, stana
Adhisthana – Medo dhatu
Srotodushti - Sanga, Vimargagamana
Swabhava – Chirakalina
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Dosha as a samprapti ghataka:
Sthoulya involves all the three doshas in its manifestation at various levels. However
kapha can be considered as the most predominant dosha involved.
Sthoulya is basically considered as Kaphaja nanatmaja Vyadhi. The aharatmaka and
viharatmaka nidanas such as Guru, Snigdha, Madhura, Sheeta, Picchila and
Abhishyandi Ahara and Vihara like Divaswapna, Achintana are more favourable for
vitiation of kapha rather than any other. Most of the symptoms of Sthoulya come
under the category of Kaphavriddhi.
The role of pitta in Sthoulya can be understood by the state of teekshnagni which is
persistant in the condition. The teekshnagni is an effect of the involvement of pachaka
pitta which is present in the koshta. Pitta acts as an important cause in maintaining
Sthoulya.
The involvement of vata dosha can be well appreciated at two levels. First is the state
of Avruta Vata which stimulates Agni and ultimately increases the demand for the
food (Abhyavaharana Shakti). Second is inactiveness of Vyana Vayu. Vyana vayu is
responsible for proper circulation and distribution of nutrients to Dhatus151. Due to
Sanga in Medovaha srotas the nutrients cannot be carried by Vyana vayu to their
respective dhatus resulting in the undernourishment of all the dhatus other than
medas.
Dushya as a samprapti ghataka
Sushruta Samhita has mentioned Sthoulya as a rasa nimittaja vyadhi. The
involvement of medas in the form of its overproduction is the most important step in
the pathogenesis of Sthoulya hence medas is the predominant dhatu involved in
Sthoulya.
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Agni
Jatharagni
In Sthoulya the Agni is teekshna. This is the result of avarana of vayu by medas
which confines vayu in the koshta, resulting in the exaggerated speed of digesion.
Dhatvagni
As a general principle dhatvagni is considered as a part of jatharagni. The
quantitative increase and decrease of a particular dhatu depends on the kshaya and
vruddhi of the concerned dhatvagni. In case of sthoulya also, there is medodhatvagni
mandya resulting in an increased production of medo dhatu.
Ama
The cause for the formation of ama in Sthoulya is dhatvagnimanya and adhyashana
respectively. Even though obese people have strong digestive strength, the
dhatvagnimandya eventually result in the production of ama. At the same time
adhyashana is the other cause for the formation of ama in people who are obese.
Srotas as a samprapti ghataka
The three important srotas that are involved in Sthoulya are annavaha, rasavaha and
medovaha srotas.
Formation of ama which is in the form of apakva anna rasa (amarasa) and
predominantly madhura rasa is the initial step in the samprapti involving annavaha
srotas. The resultant apakva anna rasa impairs the nourishment of rasa dhatu
involving the rasavaha srotas. Medo dhatvagnimandya resulting in the vruddhi of
medo dhatu indicating the involvement of medovaha srotas.
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Discussion on Samprapti
The samprapti of Sthoulya narrated in the classical literature of Ayurveda focuses on
key factors avarana of vayu by medas, the state of agni or koshta and the formation of
madhura annarasa. It is stated that the pathophysiology of Sthoulya is directed
towards increase in the medodhatu at the cost of other dhatus.
The samprapti that is explained in different classical text books of Ayurveda can be
conveniently analyzed and understood by arranging the process of pathogenesis in the
following stages.
Formation of Ama
Formation of ama which is in the form of apakva anna rasa (amarasa) and
predominantly madhura rasa is the first stage of Samprapti. Intake of specific
nidanas such as guru, Madura sheeta ahara which are kapha and medo vardhaka
causes impairment in agni and initiate the pathogenesis in vulnerable individuals.
Medovruddhi
The next stage of pathogenesis is the actual increase of the bulk of medas. The apakva
annarasa formed during the previous stages of pathogenesis circulates all over the
body in its apakva stage itself. The jataragnimandya and the subsequent
dhatvagnimandya of medas results in the production of apakva medas.At this stage
there is a unilateral increase of medo dhatu at the cost of other dhatus. This is a result
of two factors. Firstly, medo dhatvagnimandya resulting in the vruddhi of that
particular dhatu. Secondly the continued intake of nidanas which have more affinity
towards medodhatu. Thus the resultant medodhatu which is over produced circulates
all over the body and gets deposited in places such as udara,stana, and spik resulting
in Sthoulya.
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Srotorodha by medas
The pathophysiology of Sthoulya is a continuous process as it is a vicious cycle
including increased jatharagni and production of medas. When there is an increase in
medodhatu, it starts obstructing the channels all over the body resulting in vata
vruddhi. The resultant vata vruddhi is confined to koshta. As a consequence of this
there is an increase in the bala of jatharagni. The increased appetite results in
consumption of higher quantity of food. The major part of which is again converted
into medodhatu. This process is metaphorically described in Charaka Samhita giving
the example of a forest fire. Irrespective of food consumed, it will be digested
quickly. Added to this, there will be upalepa of annavaha srotas by madhura rasa, as
a result of which whatever food is consumed it ultimately attains the madhura bhava
which promotes the formation of medas and kapha which are the two important
factors for the maintainance of Sthoulya as a condition.
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Flow chart No.2. Showing the Samprapti of sthoulya
Discussion on Poorva roopa
As the specific purvarupa of Sthoulya are not enumerated in the literature of
Ayurveda, the general rule of considering the subtle form of rupa itself as the
purvarupa stage of the disease is to be applied in Sthoulya. Hence increase in weight
and other factors in the initial and milder form are to be considered as the purvarupa
of Sthoulya.
Nidana sevana
Jataragnimandya
Amotpatti
Ama annarasa
Medodhatvagnimandya
Medovruddhi
Sthoulya
Madhuropalipta annavaha srotas
Medasavrutamarga
Conversion of ahara into madhura rasa irrespective of
rasa consumed
Circulates all over the body
Produces sneha & meda
Vata is confined to koshta
Increases Agni
Atikshudha
Ati Bhojana
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Discussion on Roopa
Ayushohrasa, Javoparodha, KrucchraVyavayata, Dourbalya, Dourgandhya,
Swedabadha, Kshut atimatra, pipasa atiyoga, Chala spik udara stana,
Ayathopachaya and Ayatha utsaha are considered as the cardinal features of
Sthoulya.
Physical activity clearly modulates overall calorie balance and obese individuals tend
to be less active. This can be a contributory factor in the causation and maintainance
of excess weight. Obesity induces inactivity and inactivity further promotes weight
gain. This vicious cycle leads to symptoms such as javoparodha, jadya, ayatha
utsaha and dourbalya.
Overall energy expenditure depends on resting metabolic rate, exercise induced
thermogenesis and dietary thermogenesis, all of which are impaired in obese people.
This leads to decreased calorie expenditure and over efficient calorie utilization.
Which inturn leads to excess thirst and hunger (pipasa and kshut atimatra).
In obese people the sweat glands work overtime to dispose off the excess minerals
from the body. Hence there will be excessive sweating (Swedabhada), which inturn
produces bad odour (dourgandhya).
Obesity has a great impact on the quality of life. It can also lead to many
complications including Coronary heart disease, Hypertension, Hyper lipidaemia and
others. Hence the morbidity and mortality rate of obese individuals is higher than non
obese individuals. For this reason Ayushohrasa, Alpaayu, Alpabala and Alpa prana
are considered as the features of Sthoulya.
Khudrashwasa is one of the lakshanas of Sthoulya which is due to excessive
mechanical load caused by obesity imposing a great burden on the inspiratory
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muscles. This may predispose the susceptible individual to the weakness of
respiratory muscles resulting in exertional dyspnoea.
Excessive sleep and daytime sleep is associated with Sthoulya is due to involvement
of kapha, medas and tamas in the pathogenesis.
Sushruta Samhita has mentioned krathana as an outcome of Sthoulya. The reason is
that people who are overweight have thicker necks. When they gain weight they also
gain it in the neck area and that extra bulkiness in the throat constricts the air way and
makes it more difficult to breathe. At night the constriction increases the likelihood of
snoring. Another reason is that overweight people tend to lose muscle tone, even in
their neck. At night these loose muscles are likely to sag and cause airway obstruction
which result in snoring.
Chala sphik udara stana is one of the cardinal features of Sthoulya. Adipose tissue is
found in specific locations, which are referred to as 'adipose depots’ and Udara,
sphik, stana are one among the adipose depots. Fat in the lower body, as in thighs and
buttocks, is subcutaneous, whereas fat in the abdomen is mostly visceral. Visceral fat
is composed of several adipose depots including mesenteric, epididymal white
adipose tissue (EWAT) and perirenal depots. This is the reason for fat accumulation
in specific regions on the body in obese individuals.
Upadravas
The upadravas of Sthoulya are Prameha pidakas, Meha, Jwara, Bhagandara,
Vidradhi Vatavikaras, Shwasa, Urustamba, Pitaka, Kushtha, Visarpa, Moha, Arsha,
Shleepada, Apachi, Kamala and Jantava (krimi). These upadravas can be classified
into following pattern:
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Upadravas such as Ajirna, Atisara, Arsa, Udararoga Visarpa Apachi,
Vidradhi, Shleepada can emerge due to malfunctioning of Agni.
Upadrvas namely Prameha and Prameha pidika, may result due to Abaddha
Meda. Due to the similarities in the causative factor and the involvement of
dosha and dushya, Sthoulya and Prameha coexist in majority of the
individuals. For the same reason Prameha can also be considered as the most
frequent complication of Sthoulya. In support to this, Sushruta Samhita has
mentioned Apathya Nimitaja Prameha as result of over eating by obese
individual152.
Complications such as Urustambha, Vata vyadhi, may occur due to Avarana
of vata by meda.
Complications such as krimi and Kushtha may occur due to swedabadha and
vitiated Medas.
The upadravas of Sthoulya are similar to the complications mentioned in obesity,
which are enumerated in the table no (3).This can be analyzed as follows:
Prameha and Pramehapidika are the complications of Sthoulya which are
similar to the type 2 diabetes associated with obesity as a metabolic syndrome.
Kamala and Udara are the complications of Sthoulya which are similar to
fatty liver, cirrhosis caused in obesity due to the excessive accumulation of fat
in the liver causing liver dysfunction.
Shwasa or excertional dyspnoea is caused due to restricted ventilation.
The western literature on obesity lists out the possibility of recurrent skin
infection especially in the groin and sub mammary areas. Ayurvedic literature
also mentions such similar skin conditions by mentioning Apachi, Kushtha,
Vidradhi and Bhagandara as the upadrvas of Sthoulya.
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Sadhyasadhyata
Classical literature of Ayurveda including Charaka Samhita considers
Sthoulya as the krucchra sadhya condition. This view can be understood and justified
because of the complexity involved in the management, wherein either santarpana
chikitsa or apatarpana chikitsa have a serious short coming. This is summarized in
the statement of Ashtanga Hrudaya “ na hi atistoolasya bheshajam”.
Chikitsa
The line of treatment of Sthoulya incorporates different modalities of management
such as Ahara, Vihara and Oushadha.
Foods which are guru but apatarpana should be prescribed. Guru ahara refers to the
food which are heavy and takes longer duration for digestion. At the same time
apatarpana refers to the quality contained in the food which reduces medas. Similarly
the management of obesity involves low calorie diet with lower levels of fat,
carbohydrate and higher levels of proteins.
With regards to physical activities, both Ayurveda and the contemporary medical
science stress the importance of increased physical activities in the form of exercise
and other such lifestyle measures.
The pharmacotherapy of obesity consists of anorectic group of drugs namely
sibutramine, orlistat, rimonabant and others which reduces appetite and induce
anorexia thereby helps in reducing calorie intake and hence used in obesity. There are
many side effects associated with the use of these medications which limits the use of
such drugs in routine management of obesity. Some of the side effects include
increase in heart rate, blood pressure with the use of sibutramine, oily stools,
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flatulence, and diarrhoea with the use of orlistat and nausea, diarrhoea, anxiety,
depression with the use of rimonabant.
Considering these limitations the western medicine emphasizes the significance of
behavioural and lifestyle modification. These lifestyle modifications are also
highlighted as the primary mode of management of Sthoulya. Along with these
specific therapeutic measures such as Virechana, basti, udvartana and raktamokshana
are also indicated. Many drug formulations which probably have lesser side effects
are also enlisted in different text books in chikitsa.
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DISCUSSION ON KRUCCHRA VYAVAYA
The literal meaning of the term krucchra vyavaya is “difficulty in sexual intercourse”.
The term broadly represents different difficulties experienced during the various
stages of sexual act. The knowledge of Sexual physiology is an essential prerequisite
for understanding krucchra vyavaya.
Physical indulgence in sexual act is called as vyavaya in Ayurvedic literature. The
physiology of vyavaya has been explained in detail in the literatures of Ayurveda.
Vyavaya and brahmacharya; indulgence in sex and its regulation are considered to be
the key factors for the maintenance of health. Sex with a proper regulation (vyavaya
with samyama) will result in the enhancement of longevity and also retards ageing. It
will also help to improve the complexion, strength, firm and healthy musculature153.
Sexual physiology is explained in detail in Ayurvedic literatures. Normal
sexual physiology includes four distinct phases namely Sankalpa, Cheshta, Nishpeeda
and Shukra chyuti. The descriptions of the various physical and emotional changes
that occur during each stage of these four phases have a good correlation with the
“normal human sexual response cycle” described in Western sexology.
A good state of health is considered to be a prerequisite for fulfilling all the
purusharthas including kama , which represents desire in general and sexual desire
and performance in particular154. Sexual act is both a physical act and a mental
phenomenon. The role of mind in sexual act has been emphasized in Charaka samhita
by the statement that “anything that causes harsha of mind will act as vrushya”155.
This statement has been further analyzed by Chakrapanidatta by stating that the
absence of harsha will result in loss of ability to perform intercourse.
Charaka Samhita has explained in detail about the measures which help to keep the
mind in cheerful state which enhances pleasure and ability of sexual act. It includes
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musical melodies, sounds of ornaments of women, fragrance etc. Even the
environment plays an important role in keeping the mind in a pleased state i.e., the
environment which is pleasing removes stress and anxiety and induces happiness of
mind which in turn acts as sexual enhancer. So sexual excitement depends on the
pleasant state of mind.
Considering the role of psychological factors in sexual act Sushruta Samhita
highlights the need of a pleasant state of mind (prasannata of manas) as the
prerequisite for the act. Suprasannata of manas with respect to sexual act includes the
visual, the auditory and tactile stimulations. The stimulii can also occur through the
rehearsal of sexual activities with a desired partner. Along with these positive stimuli
the absence of negative emotional stimuli in the form of anger (krodha), envy (Irshya)
are also factors, which has an impact on the quality of sexual act. These factors can
act as the blocking forces both in the psychological level and physiological level. In
the psychological level they retard the sankalpa and in the physiological level they
cause shukra dushti156.
The state of mind has no doubt has an impact on all the stages of sexual act but it has
a great impact on the first phase of vyavaya namely sankalpa.
Among the eight contributing factors of ejaculation Harsha and Tarsha are the
psychological factors. Harsha is a state of excitement which results in dhwajocchraya
a process of dilatation of shukravaha sira (sputatvam)157. Tarsha is a component of
Sankalpa which develops desire towards female partner.
Vaidyakeeya subhashita sahitya explains Ashtanga maithuna which includes
smarana, keertana, keli, prekshana, guhya bhashana, sankalpa, adhyavasaya and
kriya nivrutti. Among these most of them viz smarana, keertana, prekshana, guhya
bhashana and sankalpa are related to psychological aspects.
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Deha bala is the other important factor for the sexual act. Lack of physical strength
which can occur because of various reasons which includes diseases, composition of
the body and hereditary factors158 results in the abhava of Harsha (excitement) which
in turn will affect the sexual performance159.
The sankalpa stage described in Ayurvedic literature has similarities with the appetite
phase described in western sexology.
Cheshta is the second phase which includes the activities carried out during vyavaya.
During this phase sparshanendriya has a significant role since shukra pervades
throughout the body and is sensitive to sparshanendriya which also exists throughout
the body. Touching and being touched are physical expressions of love. So by cheshta
the stimulations are carried through sparshanendriya which in turn helps in shukra
chyuti.
There are some specific parts of the body, by the stimulation of these parts, one can
get optimum arousal. Also specific actions in specific parts of the body are mentioned
to get maximum arousal. The response to the stimulus in particular parts is due to the
high sensitivity of the parts for the particular action. For ex. the act of scratching with
nails is advocated in specific areas such as seemanta, kukshi and kanta pradesha.
Hence specific action in particular parts result in optimum arousal and thereby
influences shukra chyuti.
The phase of Cheshta and Excitement are similar as both highlight foreplay during the
stage.
Nishpeedana, the third phase refers to union of male and female. Also it refers to the
peedana of yoni, shepha and upastha. Twacha is the sthana of vata160. Hence during
the process of copulation, by the sangharsha of medra and yoni, there is stimulation
(uttejana) of vayu. This stimulation is both local i.e. genital stimulation and systemic
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i.e. central stimulation. This stage is known as ‘tejodeerana’, wherein there will be
udeerna of teja which is experienced throughout the body. Similarly this type of
udeerna of teja is seen in medra resulting in shukra chyuti161.
During this phase the position of male and female plays an important role. Vatsyayana
Kamasutra and Nafzavis162 ‘The perfumed garden’ have described and illustrated
many positions that are used for intercourse. There are dozens of positions, with a
profound symbolism attached to each in popular mythology. But all these can be
boiled down to four basic positions and each can be varied infinitely. The four basic
positions are:
1. Face to face positions vs front to back
2. Man on top position vs woman on the top
3. Penis vagina position vs manual and oral genital positions
4. Lying down vs sitting or standing positions.
Many positions are interchangeable. Charaka Samhita also explains four different
positions. The couple may indulge in any of the position for sexual pleasure as each
position varying opportunities for physical and emotional expression. But uttana
position is considered to be the best when the intension of copulation is conception.
The Nishpeedana phase is the stage in sexual act wherein the actual copulation takes
place. This phase is followed by orgasm and ejaculation which is represented by the
term “Shukra chyuti”
The shukra which is present in the entire body is just like ghee present in milk and
jaggery in sugarcane163.During sexual act, because of harsha and prasannata of
manas the shukra which is present in the entire body comes out through mutra marga.
Though the sthana of shukra is sarvadehika, medhra and vrushana are considered as
the vishesha sthana164.
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Therefore sexual response is an example of amalgamation of various psychological
and physiological experiences. The excitation stimuli, the experiences and the peak
reaction of orgasm all have both psychological and physical components.
Krucchra Vyavaya
Krucchra vyavaya or difficultly in sexual act is appreciated at any of these phases of
vyavaya. The disorders which manifest in the appetite phase /sankalpa are
amotivation, disinterest and lack of desire for sexual activity. The most important
cause for difficulty in sexual act is loss of desire towards the sexual act. The lack of
desire towards sexual activity may be total or partial. It may also be primary or
secondary problem. Commonly it occurs secondary to erectile dysfunction,
dyspareunia or depressive disorders. Sexual aversion is another disorder where the
prospect of sexual activity is associated with strong negative feeling and produces fear
and anxiety.
The disorders which manifest in the excitement phase are erectile disorders. Erectile
disorders are due to psychological or non psychological factors. Charaka Samhita
highlights the importance of erection (dhwajocchraya) for shukra chyuti. For
dhwajocchraya to occur sankalpa and harsha are needed invariably. This suggests that
the psychological disturbances cause erectile disorders. Also, in the process of
dhwajocchraya, there is dialatation of shukravaha siras. Any impairment in this
process results in erectile disorders. To conclude, erectile disorders may occur due to
psychological or non psychological factors.
The difficulty which occurs in the Nishpeedana phase is due to the improper positions
of male and female during the act. Because, in some positions the partners will have
greater freedom to initiate and control the tempo, angle or style of movement to create
arousing stimulations. Both verbal and non verbal communication about preferences
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of position, tempo and movement can enhance the pleasure and arousal for both
partners. The desirability of a particular position may change with one’s mood at the
moment, alteration in health, age, weight, pregnancy or partner may create different
situations.
Nishpeedana results in Shukra chyuti. The difficulty that occurs during orgasmic
(shukra chyuti) phase is the premature ejaculation. Premature ejaculation may be
primarily due to psychological factors or combined factors including psychological
and organic factors.
Among the eight contributing factors, six factors namely Saratva, Paicchilya,
Gaurava, Anu bhava, Pravana bhava and Drutatva of maruta can be considered as
the physical factors. They play an important role in shukra chyuti. If the shukra
produced does not possess shuddha shukra lakshanas, then it lacks in above
mentioned factors which invariably becomes a cause for krucchra vyavaya. In this
context, saratva represents the fluid nature of shukra i.e. the consistency of which is
like madhu, taila or ghruta. Paicchilya represents the sliminess of Shukra. Gurutva
indicates parthivatatva and anu bhava represents the subtleness of Shukra. Because of
these qualities the pravana bhava i.e. downward movement of shukra takes place.
Hence these qualities enable easy flow of shukra. If the shukra produced does not
possess these qualities, then it affects the flow of shukra resulting in krucchra
Vyavaya.
During sexual act, vata plays an important role because vata controls the functions of
senses, regulates the mind, initiates and regulates various movements in the body.
Hence impairment in the functioning of vata in general and Apana vata in particular
will invariably result in krucchra Vyavaya, as apana vata is responsible for shukra
nishkramana.
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Any obstruction in shukra marga affects the flow of shukra resulting in krucchra
Vyavaya, as for the easy movement of shukra the marga has to be clear.
In a nutshell, krucchra vyavaya is nothing but the difficulty experienced at different
stages of vyavaya which may be due to psychological and physical causes.
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DISCUSSION ON RELATIONSHIP OF STHOULYA WITH KRUCCHRA
VYAVAYA
Charaka Samhita gives a clear cut statement regarding the relationship that exists
between the difficulty experienced during sexual intercourse and the weight of the
body. Two specific causes have been attributed for the said difficulty. First one is
reduction of Shukra (Shukra Abahutvat) and the second one is the obstruction for the
passage of Shukra by medas.
Sushruta Samhita opines that the obstruction to the marga by both kapha and medas
is the cause for difficulty experienced by the obese people during the intercourse.
The relationship between Shukra abahutva which is also called as Alpa Shukra165 and
krucchra Vyavaya can be analyzed as follows:
In obese people the upachaya of medodhatu takes place, at the cost of other dhathus.
Among all the other dhatus probably shukra dhatu is the most affected one. The
reason for this can be analysed as follows:
In dhatu poshana krama the possibility of impairment of the uttara dhatu is higher
than that of purva dhatus. Hence the possibility of impairment of the dhatus which are
nourished after medas is higher than that of rasa, rakta and mamsa. Again among
three uttara dhatus nourished after medas, shukra is the most affected as it has a
qualitative resemblance with medo dhatu. Qualities such as guru, snigdha, madhura,
are similar in both dhatus. Hence the poshakamsha of both medodhatu and shukra
dhatu are similar. As shukra dhatu upachaya takes place after medo dhatu upachaya,
majority of poshakamshas are utilized by medo dhatu itself causing the depletion in
nourishment of shukra dhatu.
This depletion in nourishment of shukra dhatu results in impairment in normal
functioning of Shukra dhatu which may be appreciated at the following levels:
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Formation of Shukra
Quality of Shukra
Function of Shukra
There are certain factors which lead to shukra kshaya among which roga (diseases) is
one which leads to shukra alpata166. Sthoulya is a disease entity which in turn leads to
alpa shukra. Also in Sthoulya the nourishment of shukra dhatu is impaired resulting
in alpa shukrata (Shukra abahutvat) which is clearly stated in charaka Samhita.
The normal quality of shukra is bahala, madhura, snigdha, avisra, guru, picchila,
shukla varna, resembles ghruta, makshika, taila167,168. Among these qualities guru,
sara, paicchilya, anu bhava, pravana bhava are considered as the contributing factors
for shukra chyuti. Any deviations from the normal quality result in early ejaculation/
delayed/ difficult ejaculation which can be considered as the cause for krucchra
Vyavaya.
The normal functions of shukra include dhairya, chyavana, preeti, harsha, deha bala
and garbhotpadana. Among these dhairya, preeti, harsha represent the psychological
factors. Dhairya is a factor which is essential for chyavana and maithuna. Preeti is
affection towards opposite sex and harsha is the stage of excitement. All these
together helps in shukra chyuti. Another function dehabala refers to upachaya of
shareera especially it gives strength during sexual act.
In Sthoulya, alpa shukrata may result in the diminished function of shukra dhatu.
This may be one of the causes for difficulty in sexual act. The functions of shukra
such as dhairya, preeti, harsha may be diminished resulting in loss of sexual desire
which is considered as the major cause for krucchra Vyavaya. If deha bala is
diminished, the individual finds difficulty in performing the sexual act itself which is
one of the causes for krucchra Vyavaya.
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Another reason for krucchra Vyavaya in sthoulya is medasavruta marga ie.
Obstruction of the channels by medas alone or medas and kapha together.
In Sthoulya there will be medo dhatvagni mandya resulting in excessive production of
medas which is abaddha in nature. This abaddha medas obstructs different channels
of the body including shukra vaha srotas. The obstruction to the channels may also
cause vata vruddhi particularly the apana vata which is situated in shroni and
medhra. Shukra nishkramana kriya or ejaculation of Shukra is one of the normal
functions of apana vata which is disturbed because of avarana resulting in krucchra
Vyavaya.
Flow Chart No.3. Showing the samprapti of krucchra vyavaya in Sthoulya
Difficulties experienced at different stages of Vyavaya in Sthoulya:
Sankalpa
It is the stage of mental preparation for sexual act. The cardinal features of Sthoulya
such as chala sphik, udara, sthana, ayathopachaya, ayathotsaha, dourbalya,
Atikshudha
Medasavrutamarga
Vata is confined to koshta
Increases Agni
Krucchra Vyavaya
Vata Vruddhi
Sthoulya
Ati vruddha Meda Dhatu
Causes Shukra Dhatu Margavarodha
Shukra Dhatu asamyak Upachaya
Alpa Shukra
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dourgandhya, sveda badha, ati kshut, and ati pipasa will hamper the routine of the
individual resulting in depression, stress, anxiety and other psychological
disturbances. These disturbances may cause apprehension about the sexual act and
subsequently decrease the sexual appetite.
Cheshta
These are the activities which are carried out during Vyavaya. In Sthoulya there will
be javoparodha (sluggish movements) and dourbalya because of this obese individual
finds difficulty in performing activities during the sexual act.
Erectile disorders manifest during this phase. Even the recent studies suggest that one
third of obese men with Erectile Dysfunction (ED) regain their sexual activity after
reducing weight. The cause for ED may be psychological or physical factors. In
Sthoulya ED may occur both due to psychological or physical factors.
Erection (dhvajochraya) is a process which occurs mainly due to harsha. Harsha is a
psychological factor which is impaired in obese individual. Because of this ED can
occur. Also in Sthoulya there will be medasavruta marga because of this dilatation of
shukra vaha srotas is improper as dilatation is invariably needed for erection resulting
in ED which is considered as the physical factor.
Shukra chyuti and Nishpeedana
The difficulties experienced by obese individuals during the stage of Nishpeedana and
Shukra chyuti may be in the form of premature ejaculation, delayed ejaculation and
painful orgasm. All these difficulties are again the impact of either decreased volume
or obstruction to the passage. The position of male and female is one of the important
key factors for sexual pleasure. In obese people the sexual pleasure may be decreased
because of their inability to perform in different postures. The restricted movement of
the body acts as a blocking factor for a comfortable sexual act. Premature ejaculation
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and delayed ejaculation are also the difficulties faced during orgasmic phase, as a
result of apana vata vikruti caused by margavarodha. Pain and other discomforts
experienced during Vyavaya in obese people may be because of the decreased volume
or apana vata vikruti. Most of the times, it may be a combination of both.
From the above analysis, it can be inferred that the people who are obese are more
prone to have sexual difficulties during the different phases of Vyavaya.
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DISCUSSION ON MATERIALS AND METHODS
The present study was conducted on a single group. All the subjects were given a
questionnaire to assess erectile function; consequently semen analysis was done in 33
individuals.
Reason for selection of IIEF questionnaire:
The questionnaire selected was IIEF. It is approved by an international panel of
experts, with linguistic validation in 10 languages. IIEF questionnaire was selected
because it helps in assessing the overall sexual function of an individual including
erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall
satisfaction.
Reason for semen analysis:
Semen analysis was done to find out the qualitative and quantitative changes in the
semen as alpa shukrata is considered as one of the causes for Krucchra Vyavaya in
Sthoulya.
Inclusion criteria
The individuals selected for the study belong to the age group of 30-60 years. The
people of this age group represent youvana avastha in which any sexual problems
related to obesity can be easily made out.
Exclusion criteria
Obesity secondary to endocrinal disorders is excluded as the study is aimed at
primary obesity.
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Patients with other systemic disorders that interfere with the study and
individuals with congenital anomalies of uro-genital tract are excluded. As the
study is aimed at evaluating the sexual function related to obesity.
Patients who have undergone Vasectomy and other surgical interventions
which interfere with sexual activity /performance are excluded as these
conditions interfere either with sexual function or parameters assessed in
semen analysis.
Individuals having Infection or anomalies of genital organs were excluded. As
these conditions may be a cause for sexual dysfunction or variation in semen.
Diagnostic criteria
The primary diagnostic criteria for Sthoulya are BMI and Waist Hip ratio. BMI was
taken as diagnostic criteria as it takes into account both height and weight of an
individual. Waist to hip ratio is also considered as the BMI does not account for
weight distribution.
Semen analysis
Semen was collected after 48 hours of abstinence and was subjected to analysis. The
following parameters were assessed.
Volume
Liquefaction time
Viscosity
Alkalinity
Sperm count
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Motility
Morphology
Statistical methods
Descriptive statistics
The descriptive procedure displays univariate summary statistics for several variables
in a single table and calculates standardized values (z scores).
Frequencies
The Frequency procedure provides statistics and graphical displays that are useful for
describing many types of variables. The Frequency procedure is a good place to start
looking at data.
Chi-square test: This test is used so as to quantify the qualitative data and find out
the test of significance in small sample.
Pearson’s product moment correlation:
Pearson product-moment correlation coefficient (sometimes referred to as the PMCC,
and typically denoted by r is a measure of the correlation (linear dependence) between
two variables X and Y, giving a value between +1 and −1 inclusive. It is widely used
in the sciences as a measure of the strength of linear dependence between two
variables.
Observations
Among the 33 individuals who have completed the study, semen analysis could not be
done in 3 individuals. Semen analysis was done in rest of 30 individuals. In two
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individuals it was not possible because of low sample volume. In another individual
there was an obvious erectile dysfunction.
Observations Regarding the Incidence of obesity:
Age
In the present study, 17 individuals (51.5%) were in the age group of 30-35, 6 were in
(18.2%) the age group of 36-40, 5 were in (15.2%) the 41-45 age group , 3 were in
46-50 age group, 1(3.0%) in 51-55 age group and 1(3.0%) in 56-60 age group.
The statistical value is highly significant (p value .000). In the present study 51.5% of
the individuals are in the age group of 30-35 years which suggests the fact that the
incidence of obesity is more in this age group.
Marital status
In the present study out of 33 individuals, 32 individuals (97%) were married and 1
individual (3%) was unmarried. As majority of the individuals are married the
statistical value is highly significant (p value .000).
Religion
In the present study, 29 individuals (87.9%) were Hindus and 4 individuals (12.1%)
were Muslims. The statistical value is highly significant (p value .000) as the majority
of the individuals are Hindus.
Education
In the present study, 1 individual had studied till Primary (3.0%), 1 individual had
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studied till Middle School (3.0%), 15 individuals had studied till High School
(45.5%), 13 individuals were Graduates (39.4%) and 3 individuals were Post
graduates (9.1%). The statistical values are highly significant (p value .000) as most
of the individuals under study were educated.
Socio economic status
In the present study ,4 individuals belonged to Lower middle class (12.1%), 23
individuals belonged to middle class ( 69.7%), 5 individuals belonged to Upper
middle class (15.2%) and one individual belonged to Rich ( 3.0%). The statistical
values are highly significant (p value .000) as the prevalence of obesity is more in
middle class. It is evident from the study that the incidence is due to faulty habits and
not with the socio economic status of the individual.
Cardinal symptoms
In the present study, the symptom Chala Sphik udara stana was present in all
individuals (100%). Only 9 individuals (27.3%) presented with alasya, utsahahani
(p value 0.009), 8 individuals with dourbalya (p value 0.003), 10 individuals (30.3%)
with dourgandhya and snigdhangata (0.024) and 4 individuals (12.1%) with atipipasa
and atikshuda (p value 0.000) with statistically significant values.
21 individuals (63.6%) suffered from kshudra shwasa and swedadhikya (p value
0.117), 15 individuals (45.5%) suffered from nidradhikya (p value 0.602), 15
individuals (45.5%) from Alpavyavaya (p value 0.602) and 11 individuals (33.3%)
suffered from gatrasada (p value 0.056) which is statistically insignificant, suggesting
that the distribution is similar. This can also be interpreted that most of the individuals
presented with above symptoms.
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Nature of work
In the present study, 11 individuals were doing Sedentary work (33.3%), 4 individuals
were doing Mild work (12.1%), 17 individuals were doing Moderate manual work
(51.5%) and 1 individual was doing Hard Manual work (3.1%), with statistically
significant p value 0.000. This suggests that the incidence of Sthoulya was found to be
more in individuals involved in Moderate manual work (51.5%). The incidence was
least in individuals involved in hard manual work (3.1%).
Duration of exercise
In the present study, 23 individuals did not involve in Exercise (69.7%) and 10
individuals involved in Exercise (30.3%).The incidence was more in individuals who
are not involved in any kind of exercise (P value .000) which is statistically highly
significant; supporting the fact that avyayama is one of the causative factors for the
development of Sthoulya.
Diet
In the present study, Diet of 25 individuals (75.8%) was mixed type and is statistically
significant with p value 0.003 suggesting that the prevalence of obesity in individuals
on mixed diet (Guru ahara).
Nature of Diet
Regarding the nature of food, intake of heavy food was noticed in 9 individuals
(27.3%), 2 individuals (6.1%) were taking Normal food with increased frequency, 21
individuals (63.6%) were having the habit of taking Small quantity with regular
interval, 8 individuals (24.2%) were having the habit of taking snacks between the
meals and none of the individuals were on excessive diet.
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Deviation from regular dietary pattern was noticed in all the individuals (33). Though
the incidence of obesity is more in individuals who consume small quantity with
regular interval but it is statistically insignificant (p .117). Whereas incidence of
obesity in individuals who consume heavy food (p.009), normal food with increased
frequency (p .000), use of snacks between the meals (p .003) comparatively less but
statistically it is significant.
The incidence of Sthoulya is found to be more in people who are accustomed to
untimely and heavy food which is evident from the classical reference.
Predominant rasa
In the present study, 5 individuals (15.2%) preferred predominantly Madhura rasa, 8
individuals (24.2%) preferred predominantly katu rasa and 20 individuals (60.6%)
preferred all the rasas.
It was found that 20 individuals (60.6%) preferred all the 6 rasas which is statistically
significant (p .003). Though it may imply from the above results that the incidence of
obesity is independent of the rasa consumed, it is evident from the classics that once
the disease is manifested, irrespective of the rasa consumed it will attain madhua
bhava further initiating the pathogenesis of Sthoulya.
Appetite
In the present study, 3individuals (9.1%) were having poor appetite, 7 individuals
(21.2%) were having moderate appetite, 22 individuals (60.7%) were having good
appetite and 1 individual (3.0%) was having severe appetite, which is statistically
significant (p .000).
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In Sthoulya the Agni will be good which is evident from the present study as
maximum number of individuals (22) had good appetite
Nature of sleep
In the present study 28 individuals (84.8%) were having satisfactory sleep, 5
individuals (15.2%) were having unsatisfactory sleep.
Prasannata of manas, harsha nityatva ensure sound sleep which is evident from the
present study as 28 individuals (84.8%) had satisfactory sleep which is statistically
significant (p .000).
Day sleep
In the present study 11 individuals were in the habit of Day sleep of which 1
individual (3.0%) sleeps for 30minutes, 8 individuals(24.2%) sleep for 1hour and 2
individuals (6.1%) sleep for 2hours and 22 individuals (66.7%) were not having the
habit of day sleep with statistically highly significant (p .000) value.
Habits
In the present study, out of 33 individuals, 2 individuals (6.1%) had the habit of
smoking, 5 individuals (15.2%) had the habit of taking alcohol and all the individuals
had the habit of taking tea and coffee indicating statistical insignificance in relation to
sthoulya.
Discussion on Dasha vidha pareeksha
Prakruti
In the present study out of 33 individuals, 1 individual is of vata- pitta prakruti, 22
individuals were of kapha-pitta and 10 individuals were of kapha-vata prakruti, with
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statistically significant p value 0.000. This suggests that the Incidence of Sthoulya is
more in kapha pitta prakruti persons
Sara
All the individuals under study had madhyama saara.
Samhanana
In the present study Out of 33 individuals, 30 individuals (90.9%) were of madhyama
samhanana, 3 individuals (9.1%) were of Pravara samhanan, suggesting that most of
the individuals had madhyama samhanana (p .000) which is statistically significant.
Saatmya
In the present study, 5 individuals (15.2%) were of avara satmya, 1 individual (3.0 %)
was of madhyama satmya, 27individuals (81.8%) were of Pravara satmya, suggesting
that the incidence of Sthoulya was more in persons with pravara saatmya which is
statistically significant (p .000).
Sattva
In the present study, 2individuals (6.1%) were of avara sattva, 24 individual (72.7 %)
were of madhyama sattva, 7 individuals (21.2%) were of Pravara satmya.
Most of the individuals in the present study had madhyama sattva (p .000) which is
statistically significant indicating that the incidence is frequent with the people of
madhyama sattva.
Abhyavaharana Shakti
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In the present study, 1 individual (3.0%) had avara abhyavaharana Shakti and 32
individuals (97%) had madhyama abhyavaharana Shakti. Most of the individuals in
the present study had madhyama Abhyavaharana shakti (p .000) which is statistically
significant.
Jarana Shakti
In the present study, 1 individual (3.0%) had avara jarana Shakti , 29 individuals
(87.9%) had madhyama jarana Shakti and 3 individuals (9.1%)had pravara jarana
Shakti. Most of the individuals in the present study had madhyama jarana Shakti (p
.000) which is statistically significant.
Vyayama Shakti
In the present study, 13 individuals (39.40%) had avara vyayama Shakti and 20
individuals (60.6%) had madhyama vyayama Shakti with statistically insignificant
with p value 0.223, as the distribution of the data is similar. Most of the individuals in
the present study had madhyama Vyayama Shakti suggesting that incidence of
Sthoulya is frequent with people of madhyama Vyayama Shakti.
Koshta
In the present study 1 individual (3.0%) had kroora koshtha and 32 individuals (97%)
had madhyama koshtha. Most of the individuals in the present study had madhyama
koshta (p .000) which is statistically significant.
From all these observations it is evident that obesity is caused by heterogeneous
factors including dietary factors and level of physical activity. By this study it is
evident that chala sphik udara stana is the cardinal symptom as it is present in almost
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all the individuals. Rest of the lakshanas depends on the pathogenesis and the srotas
involved.
Observation Regarding obesity and Sexual dysfunction
Erectile Functions
In the present study, Out of 33 individuals, 4 individuals (12.1%) had Severe Erectile
Dysfunction, 3 individuals (9.1%) had Moderate Dysfunction, 7 individuals (21.2%)
had Mild –Moderate Dysfunction, 5 individuals (15.2%) had Mild Dysfunction and
14 individuals (42.4%) had no erectile dysfunction. It is statistically significant with p
value .020, as 14 individuals had no erectile dysfunction. Suggesting that in obesity,
there is no erectile dysfunction.
From the data it is evident that 57.6% of individuals had some degree of erectile
dysfunction ranging from severe to mild, though statistically insignificant i.e. among
33 individuals only 14 individuals has no erectile dysfunction. Remaining 19
individuals had some amount of erectile dysfunction though only 4 individuals had
severe dysfunction. This suggests that in obese individuals there will be some amount
of erectile dysfunction though the severity may vary.
Orgasmic function
Out of 33 individuals, 2 individuals (6.1%) had Severe orgasmic Dysfunction, 5
individuals (15.2%) had Moderate Dysfunction, 4 individuals (12.2%) had Mild –
Moderate Dysfunction, 12 individuals (36.4%) had Mild Dysfunction and 10
individuals (30.3%) had no orgasmic dysfunction. It is statistically significant with p
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
value .029, as 12 individuals had Mild Dysfunction. This Suggest that in obesity,
there is mild orgasmic dysfunction.
Sexual desire
Out of 33 individuals, none of the individuals had Severe sexual desire Dysfunction. 5
individuals (15.2%) had Moderate Dysfunction, 9 individuals (27.3%) had Mild –
Moderate Dysfunction, 14 individuals (42.4%) had Mild Dysfunction and 5
individuals (15.2%) had no sexual desire dysfunction. It is statistically insignificant
with p value .084, as the distribution of the data is similar.
But when the percentage of abnormality is considered, 84.8% of individuals had
problems with sexual desire which includes variation from severe to mild degrees.
15.2% of the individuals did not have any problem with sexual desire. This suggests
that in obese individual there will be some amount of dysfunction seen in Sexual
desire though the severity may vary.
Intercourse satisfaction
Out of 33 individuals, 4 individuals (12.1%) had Severe Dysfunction in Intercourse
Satisfaction, 4 individuals (12.1%) had Moderate Dysfunction, 9 individuals (27.3%)
had Mild –Moderate Dysfunction, 11 individuals (33.3%) had Mild Dysfunction and
5 individuals (15.2%) had no dysfunction in Intercourse Satisfaction. It is statistically
insignificant with p value .182, as the distribution of the data is equal.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
But when the percentage of abnormality is considered, 84.8% of individuals had
problems with intercourse satisfaction which includes variation from severe to mild
degree and 15.2% of the individuals do not have any problem with intercourse
satisfaction. This suggests that in obese individual there will be some amount of
dysfunction seen in Intercourse satisfaction though the severity may vary.
Overall satisfaction
Out of 33 individuals, 1 individual (3.0%) had Severe Dysfunction in Overall
Satisfaction, 2 individuals (6.1%) had Moderate Dysfunction, 7individuals (21.2%)
had Mild –Moderate Dysfunction, 17 individuals(51.5%) had Mild Dysfunction and 6
individuals (18.2%) had no dysfunction in overall Satisfaction. It is statistically highly
significant with p value .000 as 17 individuals had Mild Dysfunction related with
overall satisfaction, indicating that in obesity there will be Mild Dysfunction related
with overall satisfaction.
Semen analysis
Semen volume
Out of 33 individuals, 7 individuals (23.3%) had semen volume <1.5ml/ejaculate, 11
individuals (36.7%) had semen volume >1.5-2 ml/ejaculate and 12 individuals
(40.0%) had semen volume above 2ml/ejaculate. It is statistically insignificant with p
value .497 as the distribution of the data is equal.
But when the results are observed, 7 individuals had semen volume less than 1.5ml/
eja, 11 individuals had semen volume between 1.5ml/eja to 2ml/eja and 12 individuals
had semen volume more than 2ml/ eja. In total, 18 individuals had semen volume less
than 2ml/eja.i.e. In 60% individuals the semen volume is less than 2 ml suggests that
there will be some amount of abnormality observed in the volume of semen.
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Liquefaction time of Semen
Out of 33 individuals, the Liquefaction time of semen was normal in 25 individuals
(83.3%) and abnormal in 5 individuals (16.7%), with statistically significant p value
0.000, suggesting that there is no much change in the Liquefaction time of Semen in
obese individuals.
Viscosity
Out of 33 individuals, the viscosity of semen was normal in 27 individuals (90%) and
abnormal in 3 individuals (10%), with statistically significant p value 0.000,
suggesting that there is no much change in the viscosity of Semen in obese
individuals.
Sperm count
Out of 33 individuals, the normal Sperm count was noticed in 24 individuals (85.7%),
it was borderline in 2 individuals (7.1%) and abnormal in 2 individuals (7.1%), with
statistically significant p value 0.000, suggesting that there is no much change in the
sperm count in obese individuals.
Motility of Sperms (class a)
Out of 33 individuals, Motility of Sperms was <25% in 9 individuals (30.0%) and
>25% in 21 individuals (70.0%), with statistically significant p value 0.028,
suggesting that there is no much change in the sperm count in obese individuals.
Motility of Sperms (class a & class b)
Out of 33 individuals, Motility of Sperms (class a & class b) was normal in 19
individuals (63.3%) and abnormal in 11 individuals (36.7%), with statistically
insignificant p value 0.144, suggesting that the distribution of the data is equal.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Morphology of Sperms
Out of 33 individuals, Morphology of Sperms was normal in 25 individuals (83.3%)
and abnormal in 5 individuals (16.7%). with statistically significant p value 0.000,
suggesting that there is no much change in the Morphology of sperms in obese
individuals.
Impression of the semen analysis
Out of 33 individuals, the impression of the semen analysis was normal in 19
individuals (63.3%) and abnormal in 11 individuals (36.7%), with statistically
insignificant p value 0.144, suggesting that the distribution of the data is equal.
Even though the semen analysis results have statistically non –significant values,
when seen from the medical point of view near to 50% of abnormality in semen
analysis proves the variation in semen parameters in obese individuals.
In majority of the individuals there was no significant changes noticed in semen
parameters like liquefaction time, viscosity, sperm count and Motility of Sperms
(class a) , with statistically significant value suggesting that there is no much
qualitative changes in the semen. This may be due to the low sample size of the study.
Correlations of BMI with Erectile Functions
There is no significant relation observed between BMI and erectile function.
Correlations of BMI with Semen Analysis
There is no significant relation observed between BMI and semen parameters.
Correlations of waist hip ratio with Erectile Functions
There is significant relation observed between Waist Hip ratio and erectile function
with significant P value 0.017. There is no significant relation observed between
Waist Hip ratio and Orgasmic Function, Sexual Desire, Intercourse Satisfaction and
Overall Satisfaction.
Correlations of waist hip ratio with Semen Analysis
There is no significant relation observed between BMI and semen parameters.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
Correlation studies suggest the fact that the extent of erectile dysfunction varies
directly with the hip waist ratio (p value .017). Rest of the erectile functions like
orgasmic function, sexual desire, intercourse satisfaction, overall satisfaction, semen
parameters has no statistically significant variation with hip waist ratio. There is no
statistically significant variation in any of the semen parameters or erectile functions
with BMI.
Recommendation for further study
The study can be undertaken involving larger sample size and multiple
centers.
Clinical evaluation of the concept can be undertaken based on the results of
the present observational study.
Studies can be undertaken to evaluate the difficulties faced by obese female in
sexual act.
Studies can be undertaken to understand which component of sexual
dysfunction is more common in obese people.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
CONCLUSION
Sthoulya is caused due to multiple causative factors.
Krucchra vyavaya can be considered as the difficulty encountered in various
stages of vyavaya.
There is a definite relationship between Sthoulya and sexual dysfunction
The difficulty in sexual act in Sthoulya may be due to psychological and
physical causes.
The cause for the difficulty in sexual act may be due to apla shukrata and
medasavruta marga.
Erectile Functions, orgasmic function, sexual desire, intercourse satisfaction
and overall satisfaction are impaired in Sthoulya to varying degrees.
There is marked variations seen in the semen analysis of obese individuals
which is evident from the present observational study.
From the results of the present study the statement of charaka samhita
“Shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” can
be substantiated.
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SUMMARY
The present study entitled A study on “shukra abahutvat medasaavruta
margatvat cha krucchra vyavayata” in sthoulya was aimed at understanding the
relationship between Sthoulya and krucchra vyavaya. To assess this, parameters like
IIEF and semen analysis were used and results were analysed.
The study had two components. The first was a conceptual study which
included various aspects of the subject such as Sthoulya, vyavaya, krucchra vyavaya,
obesity and relationship between obesity and sexual dysfunction. The second
component of the study was an observational study consisting of sample size of 33
obese individuals. The relation between obesity and the sexual function was observed
in these individuals with the help of IIEF questionnaire and semen analysis. All the
individuals were assigneed in a single group. The results were analyzed statistically
based on the scores obtained from the questionnaire and semen analysis results.
In obese individuals based on IIEF questionnaire erectile function, orgasmic
function, sexual desire, intercourse satisfaction and overall satisfaction were assessed.
Significant results were observed in overall satisfaction and orgasmic function
suggesting that there was mild dysfunction observed in these two parameters.
Statistically significant results were observed in erectile functions of obese individuals
suggesting that there is no dysfunction seen in obese individuals. But the degree of
dysfunction from severe to mild is comparatively more in obese individuals. In rest of
the components of IIEF there was no significant findings observed. But some amount
of dysfunction from severe to mild was observed in these two components also.
Statistical results suggest that there were no changes observed in the semen analysis
results. But 60% of the individuals had semen volume less than 2ml suggesting that
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
probability of having a low semen volume is more in obese individuals when
compared to non obese individuals.
Correlation studies suggest that there was no relation of BMI with either erectile
functions or semen analysis. However the studies suggest that Erecile dysfunction
increases proportionately with waist hip ratio. The rest of the components in IIEF and
semen analysis had no relation with hip waist ratio.
By the results it was observed that there is a definite relation between Sthoulya and
krucchra vyavaya
The conclusion derived on the basis of detailed observation & deep study is submitted
under the chapter on Conclusion. Future perspective of the study is highlighted as an
aid for the future research workers.
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
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Prakashana, 2007, PP: 397.
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Choukhambha Publishers, 2002, PP: 2387
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Chowkamba Orientalia, 2003, PP: 309.
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Prakashana, 2007, PP: 397.
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Chowkamba Orientalia, 2003, PP: 310.
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Krishnadas Academy, 1998, PP:68
107. Indradeva Tripati & Dr.Daya Shankar Tripati , Yoga Ratnakara, 1st Ed,
Krishnadas Academy, 1998, PP:69
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Prakashana, 2007, PP: 397.
109. Kaviraja shree Narendranath Sengupta, , Kaviraja shree Balaichandra
Sengupta Charaka samhita of Agnivesha, 2nd Ed, vol 4, Varanasi,
Choukhambha Publishers, 2002, PP: 2387
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Prakashana, 2007, PP: 340, 341.
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Choukhambha Prakashana, 2007, PP: 397.
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Prakashana, 2007, PP: 397.
113. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 397.
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Prakashana, 2007, PP: 397.
115. Kaviraja shree Narendranath Sengupta, , Kaviraja shree Balaichandra
Sengupta Charaka samhita of Agnivesha, 2nd Ed, vol 4, Varanasi,
Choukhambha Publishers, 2002, PP: 2387
116. Vishwanath Dwivedi Shastri, Bhavaprakasha Nighantu of Bhavaprakasha,
Delhi, Motilal Banarsidas, 1997, PP: 25
117. Indradeva Tripati & Dr.Daya Shankar Tripati , Yoga Ratnakara, 1st Ed,
Krishnadas Academy, 1998, PP:70
118. Vishwanath Dwivedi Shastri, Bhavaprakasha Nighantu of Bhavaprakasha,
Vol-1 Delhi, Motilal Banarsidas, 1997, PP: 149
119. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 494.
120. Chakravarti shrinivasa Gopalacharya, Shabdartha Koustubha,Vol 2, 2nd Ed,
Bangalore: Bapuji Publications, 2000; PP :776.
121. Wasudev Laxman Shastri Panshikar, Amara Kosha with short commentary,
7th Ed: Panduranga Jawaj, Bombay, 1934, PP: 53
122. Monier.Monier Williams,sanskri -English dictiponary, Motilal Banasidas
Publishers, Delhi, Reprint;1990 PP :304
123. M S Bhatia, Essentials of psychiatry, 4th Ed, New Delhi CBS Publishers,
2004,PP: 18.10.,18.11
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A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
124. Schiavi RC, segraves RT. The biology of sexual function. Psychiatric clinics
of North America 1995; 18, 1,7-23.
125. M S Bhatia, Essentials of psychiatry, 4th Ed, New Delhi CBS Publishers,
2004, PP: 18.10.
126. M S Bhatia, Essentials of psychiatry, 4th Ed, New Delhi, CBS Publishers,
2004, PP: 18.10.
127. M S Bhatia, Essentials of psychiatry, 4th edition, New Delhi, CBS Publishers,
2004, PP: 18.10.
128. M S Bhatia, Essentials of psychiatry, 4th Ed, New Delhi,CBS Publishers,
2004, PP: 18.10.
129. M S Bhatia, Essentials of psychiatry, 4th Ed, New Delhi, CBS Publishers,
2004, PP: 18.8, 18.11.
130. World health organisation. The ICD – 10, classification of mental and
behavioural disorders. Clinical descriptions and diagnostic guidelines. World
health organisation, Geneva, 1992.
131. World health organisation. The ICD – 10, classification of mental and
behavioural disorders. Clinical descriptions and diagnostic guidelines. World
health organisation, Geneva, 1992.
132. World health organisation. The ICD – 10, classification of mental and
behavioural disorders. Clinical descriptions and diagnostic guidelines. World
health organisation, Geneva, 1992.
133. Anna Moreshwar Kunte .Ashtanga hrudaya of Vagbhata. 7th Ed, Varanasi:
Chowkamba Samskrit Adhishtan, 2002, PP: 144
134. Yadunandan Upadhyaya, Madhava Nidana, 20th Ed, Varanasi, Chowkambha
Sanskrit Bhavan, 1992, PP: 28
135. Vishwanath Dwivedi Shastri, Bhavaprakasha Nighantu of Bhavaprakasha,
Vol 2 Delhi, Motilal Banarsidas, 1997, PP: 405
136. Jogindranath Sen, Charakopaskara, 1stVol, Banaras, Culcatta, J.N.Sen
Publications PP: 476.
159
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
137. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 174.
138. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 516.
139. Anna Moreshwar Kunte .Ashtanga hrudaya of Vagbhata. 7th Ed, Varanasi:
Chowkamba Samskrit Adhishtan, 2002, PP :397
140. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 116.
141. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 73, 74.
142. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 116.
143. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 116.
144. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 116
145. Anna Moreshwar Kunte .Ashtanga hrudaya of Vagbhata. 7th Ed, Varanasi:
Chowkamba Samskrit Adhishtan, 2002, PP 224
146. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 73
147. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 116
148. Hereditay Vishwanath Dwivedi Shastri, Bhavaprakasha Nighantu of
Bhavaprakasha, Vol 2 Delhi, Motilal Banarsidas, 1997, PP: 412
149. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP:344
150. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 516
160
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
151. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 251
152. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 451
153. Indradeva Tripati & Dr.Daya Shankar Tripati , Yoga Ratnakara, 1st Ed,
Krishnadas Academy, 1998, PP:67
154. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 6
155. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 397
156. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 308
157. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 349.
158. Hereditay Vishwanath Dwivedi Shastri, Bhavaprakasha Nighantu of
Bhavaprakasha, Vol 2 Delhi, Motilal Banarsidas, 1997, PP: 412
159. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 397
160. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 42
161. Shree Bhaskara Govinda Ghanekar , Sushruta Samhita of Sushruta, Vol -2 ,
Banaras, Chowkamba Samskrit Series,1950,PP:58
162. Nafzavi.S,The Perfumed Garden.Sir Richard Burton Translator, London,
Neville Spearman,1963
163. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 357.
164. Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 7th Ed., Varanasi:
Chowkamba Orientalia, 2003, PP: 69.
161
A study on “shukra abahutvat medasaavruta margatvat cha krucchra vyavayata” in sthoulya.
165. Jogindranath Sen, Charakopaskara, 1stVol, Banaras, Culcatta, J.N.Sen
Publications PP: 476.
166. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 397
167. Acharya YT, Charaka Samhita of Agnivesha, 5th Ed, Varanasi, Choukhambha
Prakashana, 2007, PP: 397
168. Anna Moreshwar Kunte .Ashtanga hrudaya of Vagbhata. 7th Ed, Varanasi:
Chowkamba Samskrit Adhishtan, 2002, PP :365
i
ANNEXURE -01
CASE SHEET PROFORMA
‘A STUDY ON “SHUKRA ABAHUTVAT MEDASAAVRUTA MARGATVAT CHA KRUCCHRA VYAVAYATA” IN STHOULYA.’
HEAD OF THE DEPARTMEN : Dr. Anjaneya Murthy M.D., (Ayu) /Dr.Shakunthala.G.N M.D., (Ayu)
GUIDE : Dr. Naseema Akthar M.D., (Ayu)
CO-GUIDE : Dr. Rajendra. V. M.D., (Ayu)
RESEARCHER : Dr. Geetha.P, B.A.M.S
Sl.No:
I. ATURA VIVARANA:
Name: Date:
Age: yrs.
Marital Status: M / UM / W / D.
Religion: H / M / C / Others.
Education: UE / PS / MS / HS / G / PG.
Socio-Economic Status: VP / P / LM / M / UM / R.
Address:
Phone No :
II. DETERMINATION OF THE GRADES OF STHOULYA A. PRIMARY CRITERIA: Body Weight:
B M I:
Hip Waist Ratio:
Height Weight Ratio:
Skin Fold Thickness:
ii
SECONDARY CRITERIA: DURATION
Chala Spik Udara Stana :
Kshudra Swasa / Ayasena Swasa :
Alasya Utsaha Hani :
Daurbalyata [ Alpa Vyayam] :
Nidradhikya :
Daurgandhata :
Snighangata:
Atipipasa :
Atikshudha :
Alpa Vyavaya :
Gatra Sada :
Agnibala :
Swedadhikya:
III. HISTORY OF PRESENT SEXUAL ACTIVITIES
IV. FAMILY HISTORY
V. PERSONAL HISTORY
A. Nature of work: Hard manual work / Moderate manual work / Mild Work/ Sedentary
work
B. Duration of exercise:
Nature of exercise:
C. Diet: Veg/ Mixed
If Cosumes Non-veg : Regular / Occasional /how frequently
D. Nature of food:
Intake of Heavy food regularly : Yes / No
Normal quantity with increased frequency: Yes / No
Small quantity with regular frequency: Yes / No
Use of snacks between meals: Yes / No
Excessive dieting : Yes / No
Predominant taste Prefered /cosumed :
E. Appetite: Poor / Moderate / Good / Severe
iii
F. Sleep
Nature: Satisfactory/ Unsatisfactory/ Excess
Duration: Day:
Night:
G. Habits: Beedi / Cigarette / Beetle leaf / Tobacco chewing / Supari /
Alcohol / Drugs / Tea / Coffee / Other
H. Sexual History:
A. Secondary Sexual Characters :
B. Psychosexual Disorders:
C.
VI. TREATMENT HISTORY:
VII. ASHTASTHANA PAREEKSHA
Nadi:
Mutra:
Mala:
Jihva:
Shabda:
Sparsha:
Druk:
Akruti:
VIII. DASHAVIDHA PAREEKSHA
Prakriti:
Vikriti:
Sara: Avara / Madhyama / Pravara
Samhanana: Avara / Madhyama / Pravara
Pramana: Ht: Wt:
iv
Satmya:
Sattva: Avara / Madhyama / Pravara
Aharashakti: a. Abhyavaharana : Avara / Madhyama / Pravara
b. Jarana: Avara / Madhyama / Pravara
Vyayamashakti: Avara / Madhyama / Pravara
Vaya: Yrs. Baalya / Yauvana / Vaardhakya
IX. KOSTA : Mrudu/Madyama/Krura
X. SPECIFIC INVESTGATION: Semen Analysis
XI. SPECIAL INVESTIGATIONS DONE [ IF REQUIRED] :
SIGNATURE OF RESEARCHER SIGNATURE OF CO-GUIDE
SIGNATURE OF GUIDE SIGNATURE OF H.O.D.
v
ANNEXURE -02
PATIENT QUESTIONNAIRE
These questions ask about the effects that your erection problems have had on your
sex life over the last four weeks. Please try to answer the questions as honestly and as
clearly as you are able. Your answers will help your doctor to choose the most
effective treatment suited to your condition. In answering the questions, the following
definitions apply:
-Sexual activity includes intercourse, caressing, foreplay & masturbation
- Sexual intercourse is defined as sexual penetration of your partner
-Sexual stimulation includes situation such as foreplay, erotic pictures etc.
-Ejaculation is the ejection of semen from the penis (or the feeling of this)
-Orgasm is the fulfillment or climax following sexual stimulation or intercourse
Over the past 4 weeks: Please check one box only
Q1. How often were you able to get an erection during sexual activity?
0- No sexual activity
1 -Almost never or never
2- A few times (less than half the time)
3- Sometimes (about half the time)
4 -Most times (more than half the time)
5- Almost always or always
Q2. When you had erections with sexual stimulation, how often were your erections
hard enough for penetration?
0 -No sexual activity
1 -Almost never or never
2 -A few times (less than half the time)
vi
3- Sometimes (about half the time)
4 -Most times (more than half the time)
5 -Almost always or always
Q3. When you attempted intercourse, how often were you able to penetrate (enter)
your partner?
0 -Did not attempt intercourse
1 -Almost never or never
2 -A few times (less than half the time)
3 -Sometimes (about half the time)
4 -Most times (more than half the time)
5 -Almost always or always
Q4. During sexual intercourse, how often were you able to maintain your erection
after you had penetrated (entered) your partner?
0- Did not attempt intercourse
1- Almost never or never
2 -A few times (less than half the time)
3- Sometimes (about half the time)
4 -Most times (more than half the time)
5 -Almost always or always
Q5. During sexual intercourse, how difficult was it to maintain your erection to
completion of intercourse?
0 -Did not attempt intercourse
1 -Extremely difficult
2 -Very difficult
3 -Difficult
4 -Slightly difficult
5 -Not difficult
vii
Q6. How many times have you attempted sexual intercourse?
0 -No attempts
1 -One to two attempts
2 -Three to four attempts
3 -Five to six attempts
4 -Seven to ten attempts
5- Eleven or more attempts
Q7. When you attempted sexual intercourse, how often was it satisfactory for you?
0 -Did not attempt intercourse
1- Almost never or never
2 -A few times (less than half the time)
3- Sometimes (about half the time)
4 -Most times (more than half the time)
5 -Almost always or always
Q8. How much have you enjoyed sexual intercourse?
0- No intercourse
1 -No enjoyment at all
2- Not very enjoyable
3 -Fairly enjoyable
4 -Highly enjoyable
5- Very highly enjoyable
Q9. When you had sexual stimulation or intercourse, how often did you ejaculate?
0 -No sexual stimulation or intercourse
1 -Almost never or never
2- A few times (less than half the time)
viii
3 -Sometimes (about half the time)
4 -Most times (more than half the time)
5 -Almost always or always
Q10. When you had sexual stimulation or intercourse, how often did you have the
feeling of orgasm or climax?
1- Almost never or never
2 -A few times (less than half the time)
3 -Sometimes (about half the time)
4 -Most times (more than half the time)
5- Almost always or always
Q11. How often have you felt sexual desire?
1- Almost never or never
2 -A few times (less than half the time)
3 -Sometimes (about half the time)
4 -Most times (more than half the time)
5- Almost always or always
Q12. How would you rate your level of sexual desire?
1- Very low or none at all
2 -Low
3- Moderate
4 -High
5 -Very high
Q13. How satisfied have you been with your overall sex life?
1 -Very dissatisfied
2 -Moderately dissatisfied
ix
3- Equally satisfied & dissatisfied
4 -Moderately satisfied
5 -Very satisfied
Q14. How satisfied have you been with your sexual relationship with your partner?
1 -Very dissatisfied
2- Moderately dissatisfied
3 -Equally satisfied & dissatisfied
4- Moderately satisfied
5 -Very satisfied
Q15. How do you rate your confidence that you could get and keep an erection?
1 -Very low
2 -Low
3 -Moderate
4- High
5- Very high
x
ANNEXURE -03
SHLOKAS
Sthoulya
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20. WûwÉÉïiÉç CÌiÉ qÉlÉxÉÉå UÌiÉ EkSÏmÉlÉ ÌlÉÍqɨÉqÉÉåSÉiÉç | aÉÇaÉÉkÉU 21. xɃ¡ûsmÉmÉÔuÉïMü zÉÑ¢üÉåSìåMü kuÉeÉÉåcNíûÉrÉÉÌSMüÉUÏcNûÉ | cÉ¢ümÉÉÍhÉ 22. iÉwÉïÈ uÉÌlÉiÉÉÍpÉsÉÉwÉÈ | cÉ¢ümÉÉÍhÉ 23. xÉUiuÉqÉç AxjÉærÉïqÉç | cÉ¢ümÉÉÍhÉ 24. AlÉÑmÉëuÉhpÉÉuÉÈ AhÉÑiuÉå xÉÌiÉ oÉÌWûÌlÉïaÉqÉlÉ xuÉpÉÉuÉÈ | cÉ¢ümÉÉÍhÉ 25. SìÓiÉiuÉÉlqÉÉÂiÉxrÉ cÉåÌiÉ zÉÑ¢ümÉëåUMüxrÉ uÉÉrÉÉåUÍpÉSìuÉlÉzÉÏsÉiuÉÉÌSirÉjÉïÈ | cÉ¢ümÉÉÍhÉ 26. GiÉÉæ x§ÉÏmÉÑÇxÉrÉÉåïrÉÉåaÉå qÉMüUkuÉeÉuÉåaÉiÉÈ ||
qÉåRíûrÉÉålrÉÍpÉxɆ¡ûwÉÉïcNûUÏUÉåwqÉÉÅÌlÉsÉÉWûiÉÈ || mÉÑÇxÉÈ xÉuÉïzÉUÏUxjÉÇ UåiÉÉå SìÉuÉrÉiÉåÅjÉ iÉiÉç || uÉÉrÉÑïqÉåïWûlÉqÉÉaÉåïhÉ mÉÉiÉrÉirÉ…¡ûlÉÉpÉaÉå ||
xvii
iÉiÉç xÉÇzÉ×irÉ urÉɨÉqÉÑZÉÇ rÉÉÌiÉ aÉpÉÉïzÉrÉÇ mÉëÌiÉ | iÉ§É zÉÑ¢üuÉSÉrÉÉiÉålÉɨÉïuÉålÉ rÉÑiÉÇ pÉuÉåiÉç || pÉÉ.mÉë. mÉÔuÉïZÉÉQû 3/28-30
27. xlÉÉlÉÉlÉÑsÉåmÉlÉÌWûqÉÉÌlÉsÉZÉhQûZÉɱ zÉÏiÉÉqoÉÑSÒakÉUxÉrÉÔwÉxÉÑUÉmÉëxɳÉÉÈ | xÉåuÉåiÉ cÉÉlÉÑzÉrÉlÉÇ ÌuÉUiÉÉæ UiÉxrÉ iÉxrÉæuÉqÉÉzÉÑ uÉmÉÑwÉÈ mÉÑlÉUåÌiÉ kÉÉqÉ || rÉÉå.aÉ 45 xlÉÉlÉÇ xÉzÉMïüUÇ ¤ÉÏUÇ pɤrÉqÉæ¤ÉuÉxÉÇxM×üiÉqÉç | iÉiÉÉå qÉÉÇxÉUxÉÈ xuÉmlÉÉå urÉuÉÉrÉÉliÉå ÌWûiÉÉ AqÉÉæ || rÉÉå.aÉ 46 pÉÉ.mÉë 298
28. pɤrÉÉÈ xÉzÉMïüUÉÈ ¤ÉÏUÇ xÉÍxÉiÉÇ UxÉ LuÉ cÉ | xlÉÉlÉÇ xÉurÉeÉlÉÇ xuÉmlÉÉå urÉuÉÉrÉÉliÉå ÌWûiÉÉÌlÉ iÉÑ || xÉÑ.ÍcÉ. 132
xjÉÉæsrÉ - M×ücNíûurÉuÉÉrÉ
29. zÉUÏUå eÉÉrÉiÉå ÌlÉirÉÇ SåÌWûlÉÈ xÉÑUiÉxmÉ×WûÉ | AurÉuÉÉrÉlqÉåWûqÉåSÉåuÉ×ÎkSÈ ÍzÉÌiÉsÉiÉÉ iÉlÉÉåÈ || pÉÉ.mÉë. ÌSlÉcÉrÉï /266
30. pÉëqÉ YsÉqÉ E SÉæoÉïsrÉ oÉsÉkÉÉÎiuÉÎlSìrÉ ¤ÉrÉÉÈ | AmÉuÉïqÉUhÉÇ cÉ xrÉÉSlrÉjÉÉ aÉcNûiÉÈ Îx§ÉrÉqÉç || A.WØû. xÉÔ.7/64
31. zÉÑ¢üxrÉ AsmÉiuÉÉiÉç qÉåSxÉÉÅuÉ×iÉ qÉÉaÉïiuÉÉiÉç cÉ M×ücNíåûhÉ urÉuÉÉrÉÈ qÉæjÉÑlÉÇ rÉxrÉ iÉxrÉ pÉÉuÉÈ M×ücNíûurÉuÉÉrÉiÉÉ || eÉÉåÌaÉlSìlÉÉjÉ xÉålÉç on cÉ.xÉÔ,21/3
32. urÉÉlÉålÉ UxÉkÉÉiÉÑÌWïû ÌuɤÉåmÉÉåÍcÉiÉMüqÉïhÉÉ | rÉÑaÉmÉiÉç xÉuÉïiÉÉåÅeÉxÉëÇ SåWåû ÌuÉͤÉmrÉiÉå xÉSÉ || cÉ.ÍcÉ. 15/36
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Master Chart
Sl No Age M.Sta Reli Ed. SES BMI W.H.R C.S.U. K.S A.uh Doub Nidr.A Dour snig Ati.Pip Ati.Ks Alp.Vya G.S
Swed
1 38 M H G MC 31 1.01 P Ab Ab Ab Ab Ab P Ab Ab Ab Ab P
2 48 M H G UM 30.46 1.01 P P Ab P Ab Ab P P Ab P P P
3 40 M H MS MC 33 1.08 P P Ab Ab Ab Ab Ab Ab Ab P Ab Ab
4 38 M H PG Rich 30.44 1.01 P P Ab Ab Ab Ab Ab Ab Ab Ab Ab Ab
5 34 M Mu HS MC 32.69 1.01 P Ab P Ab P P P Ab Ab P P P
6 31 M H HS MC 33.53 1.05 P P Ab Ab Ab P P Ab Ab P Ab P
7 60 M H G MC 30.85 1.02 P P P Ab P Ab Ab Ab Ab P P Ab
8 32 M H HS MC 31 1.02 P P P Ab Ab Ab Ab Ab P Ab P P
9 42 M H HS MC 30.24 1.05 P Ab Ab Ab P Ab Ab Ab P P Ab Ab
10 31 M H PG MC 30.22 1.02 P P Ab Ab P Ab Ab Ab Ab Ab Ab P
11 37 M H G UM 31 1.02 P Ab Ab P P Ab Ab Ab Ab P P Ab
12 32 M H G MC 30.1 1.01 P Ab Ab Ab Ab Ab P Ab Ab Ab Ab P
13 52 M H G UM 31.94 1.01 P Ab Ab Ab Ab Ab Ab Ab Ab P Ab Ab
14 42 M H HS LM 31.22 1.04 P P P Ab Ab Ab Ab Ab Ab Ab Ab Ab
15 46 M H PG MC 30.24 1.02 P P Ab Ab P Ab Ab Ab Ab P P Ab
16 33 M H HS MC 32.14 1.03 P P Ab P Ab P Ab Ab Ab P Ab P
17 31 M H HS MC 30.69 1.01 P Ab P P Ab P Ab Ab Ab Ab P Ab
18 45 M H G MC 30.24 1.03 P P Ab Ab P Ab Ab Ab Ab Ab P Ab
19 43 M H PS MC 32.19 1.03 P P Ab P Ab Ab Ab Ab Ab Ab Ab P
20 48 M H G MC 31.22 1.03 P P Ab P Ab P Ab Ab Ab P Ab P
21 35 M H HS MC 31.58 1.03 P P P P P P Ab Ab Ab Ab P P
22 33 U.M H HS LM 32.19 1.03 P P P Ab Ab Ab P P Ab Ab P P
23 30 M H HS MC 30.68 1.08 P Ab Ab Ab P P Ab Ab P P Ab P
24 44 M Mu G UM 34 1.02 P P Ab Ab P Ab Ab Ab Ab P Ab P
25 31 M H HS MC 30.22 1.03 P P Ab Ab P Ab Ab Ab Ab P Ab P
26 36 M H HS LM 30.22 1.01 P Ab Ab Ab Ab P P Ab Ab Ab Ab P
27 32 M H HS LM 30.3 1.01 P Ab Ab Ab P P P Ab Ab Ab Ab P
28 30 M H G MC 30.45 1.01 P P Ab Ab P Ab Ab Ab P P Ab Ab
29 32 M Mu HS MC 30.81 1.03 P P Ab Ab Ab Ab Ab Ab Ab Ab Ab P
30 37 M Mu HS MC 38.06 1.01 P P P P Ab Ab P P Ab Ab Ab Ab
31 32 M H G MC 30.85 1.01 P Ab Ab Ab P P Ab Ab Ab Ab Ab P
32 31 M H G MC 30.1 1.01 P P P Ab Ab Ab Ab Ab Ab Ab P P
33 35 M H G UM 30.48 1.02 P Ab Ab Ab P Ab P P Ab Ab Ab P
xix
Sl No Nat.W Dt In.H.F N.I.F S.R.F U.S.M Ex.Dt Pre.Tast Appetite Sl.Nat Prakruti Samhana satmya sattva Abh.Sha Ja.Sha Vya.Sha Koshta
1 Mod. M.W mix N N Y N N All good satis K P Ma Pr Ma Ma Ma Ma Ma
2 Mod. M.W veg N N Y N N Katu poor unsat K P Ma Ma Pr Ma Ma Ma Ma
3 Mod. M.W mix Y N N Y N All mod satis K P Ma Pr Pr Ma Ma Ma Ma
4 Mod. M.W mix N N Y N N All good satis K V Ma Pr Pr Ma Ma Ma Ma
5 Mod. M.W mix N N Y Y N Sweet good satis K P Ma Av Ma Ma Ma Ma Ma
6 Mild.W mix Y N N N N Katu good satis K P Ma Av Ma Ma Ma Av Ma
7 Sed.W veg N N Y N N All good satis K P Ma Pr Ma Ma Ma Ma Ma
8 Mild.W veg N Y N N N Katu good unsat K V Ma Av Pr Ma Ma Av K
9 Mod. M.W veg N N N Y N Sweet good satis K P Ma Pr Pr Ma Pr Av Ma
10 Mod. M.W mix N N Y N N Sweet Mod satis K V Ma Pr Ma Ma Ma Ma Ma
11 Sed.W mix N N Y N N Katu poor satis K V Pr Pr Ma Ma Ma Ma Ma
12 Mod. M.W mix N N Y N N Sweet mod satis K V Ma Av Pr Ma Pr Ma Ma
13 Mod. M.W mix N N Y N N Katu good satis K V Pr Pr Pr Ma Ma Ma Ma
14 Sed.W mix N N Y N N All good unsat K P Ma Pr Ma Ma Ma Av Ma
15 Sed.W mix N N Y N N All Mod satis V P Ma Pr Ma Ma Ma Av Ma
16 Mod. M.W mix Y N N N N All Mod unsat K P Ma Pr Ma Ma Ma Ma Ma
17 Sed.W mix N N Y N N Katu Mod satis K P Ma Pr Ma Ma Ma Av Ma
18 Mod. M.W mix N N Y N N All good satis K P Ma Pr Ma Ma Ma Av Ma
19 Sed.W mix N N Y N N All poor satis K P Ma Pr Ma Av Av Av Ma
20 Sed.W mix Y N N N N All good satis K P Ma Pr Ma Ma Ma Av Ma
21 Mild.W veg N N Y N N Katu good satis K V Ma Pr Ma Ma Ma Av Ma
22 Sed.W veg N N Y N N Sweet good unsat K P Ma Av Av Ma Ma Av Ma
23 Mild.W mix N N Y N N All good satis K P Ma Pr Ma Ma Ma Ma Ma
24 Sed.W mix Y N N Y N All good satis K P Pr Pr Ma Ma Ma Ma Ma
25 Mod. M.W mix N N Y N N All good satis K V Ma Pr Ma Ma Ma Ma Ma
26 H.manual mix Y N N N N All good satis K P Ma Pr Av Ma Ma Ma Ma
27 Mod. M.W mix N N Y N N All good satis K P Ma Pr Ma Ma Ma Ma Ma
28 Sed.W mix Y N N Y N All sev satis K P Ma Pr Ma Ma Pr Ma Ma
29 Mod. M.W mix N N Y Y N All good satis K V Ma Pr Ma Ma Ma Ma Ma
30 Mod. M.W veg Y N N Y N All good satis K P Ma Pr Ma Ma Ma Ma Ma
31 Mod. M.W mix Y N N N N All good satis K V Ma Pr Ma Ma Ma Ma Ma
32 Mod. M.W mix N N Y N N All good satis K P Ma Pr Ma Ma Ma Av Ma
33 Sed.W veg N Y N Y N Katu Mod satis K P M P M M M A M
xx
S.No E.F Org.F SexD I.Sat OvSat E.F Org.F Sex.D I. Sat Ov.Sat Semvol Liqu Vis Count Mot.a Mot.ab Morp Imp
1 27 10 9 15 10 no dys no dys no dys no dys no dys <1.5 N N N N N N N
2 19 7 6 9 7 mild mild md to mod mid to mod mild <0.5 . . . . . . .
3 6 4 5 4 6 severe mod md to mod mod md to mod <1.5 N N Abn Abn Abn Abn Abn
4 30 10 9 14 10 no dys no dys no dys no dys no dys 1.51-2 N N N N N N N
5 22 7 7 10 8 mild mild mild mild mild 1.51-2 N N N N N N N
6 24 8 10 11 10 mild mild no dys mild no dys <1.5 Abn N N N N N N
7 11 4 4 5 6 mod mod mod mod md to mod 1.51-2 N N . Abn Abn Abn Abn
8 26 8 7 12 8 no dys mild mild mild mild 1.51-2 N N N N N N N
9 16 5 4 5 7 md to mod md to mod mod mod mild . . . . . . . .
10 29 10 8 13 8 no dys no dys mild no dys mild 1.51-2 N N N N N N Abn
11 17 8 5 11 7 md to mod mild md to mod mild mild abv 2 Abn Abn . Abn Abn Abn Abn
12 4 0 5 0 7 severe severe md to mod severe mild 1.51-2 N N N N Abn N N
13 30 10 8 14 10 no dys no dys mild no dys no dys abv 2 Abn N N Abn Abn N Abn
14 27 10 9 13 9 no dys no dys no dys no dys no dys abv 2 N N N N N N N
15 17 10 7 5 4 md to mod no dys mild mod mod 1.51-2 N N N Abn Abn N N
16 11 4 5 3 8 mod mod md to mod severe mild . . . . . . .
17 27 9 9 10 9 no dys no dys no dys mild no dys 1.51-2 N N N N N N N
18 24 8 8 10 8 mild mild mild mild mild 1.51-2 N N N N N N N
19 15 4 6 7 8 md to mod mod md to mod md to mod mild abv 2 N N N Abn Abn N N
20 18 6 5 7 6 md to mod md to mod md to mod md to mod md to mod abv 2 N N N N N N N
21 12 6 4 7 6 mod md to mod mod md to mod md to mod abv 2 N N N N N N N
22 2 0 4 0 4 severe severe mod severe mod abv 2 Abn Abn N N N N N
23 15 8 6 7 6 md to mod mild md to mod md to mod md to mod <1.5 N N N N N N N
24 14 7 6 7 6 md to mod mild md to mod md to mod md to mod abv 2 N N N N N N N
25 5 4 4 3 2 severe mod mod severe severe abv 2 N N N N N N N
26 24 8 8 8 8 mild mild mild md to mod mild <1.5 N N N N N Abn Abn
27 28 9 8 12 8 no dys no dys mild mild mild <1.5 N N N Abn Abn N Abn
28 26 5 8 7 5 no dys md to mod mild md to mod md to mod 1.51-2 N N N N N N Abn
29 27 8 8 11 8 no dys mild mild mild mild abv 2 N N Abn Abn Abn Abn Abn
30 29 10 7 12 8 no dys no dys mild mild mild abv 2 N N N N N N N
31 27 9 8 11 8 no dys no dys mild mild mild <1.5 N N B.line N Abn N Abn
32 29 8 8 11 8 no dys mild mild mild mild 1.51-2 N Abn N N N N N
33 26 8 8 9 8 no dys mild mild md to mod mild abv 2 Abn N B.line Abn Abn N Abn
xxi
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