sthoulya ss-mys

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

Ayurmitra

TAyComprehended

vii

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.

x

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

xi

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

xx

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


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


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


OBJECTIVES OF THE STUDY

The study is partly conceptual and partly observational.

The conceptual part deals with the following objectives:



To validate the statement of Charaka Samhita “Shukra abahutvat medasaavruta

margatvat cha krucchra vyavayata”.

The observation part deals with the following objective:



5


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


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 mÉÏlÉmÉÏ³uÉÏ 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


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


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


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


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


ÌuÉÍzÉ¹ AÉWûÉU uÉzÉÉiÉç- due to intake of specific diet which is conducive to

medodhatu.

ASØ¹ 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


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


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


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


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


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


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

aÉÑÂ 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.

18


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.

19


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


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.

21


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.

22


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.

23


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

24


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


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 socioeconomic 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

26


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

27


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

28


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.

29


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

30


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

31


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

32


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.

33


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.

34


Flow Chart .No.1. Showing Pathogenesis of Obesity

35


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)

36


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%.

37


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

38


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.

39


Synonyms

aÉëÉqrÉkÉqÉï: qÉæjÉÑlÉÇ ÌlÉkÉÑuÉlÉÇ UiÉqÉç | A.K94

urÉuÉÉrÉ: xÉÑUiÉå AliÉkÉÉæï mÉÑÇxÉÏ YsÉÏoÉÇ iÉÑ iÉãeÉÍxÉ | M.K

AoÉë¼cÉrÉï x§ÉÏaÉqÉlÉÇ aÉëÉqrÉkÉqÉï mÉëuÉ×Ì¨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

40


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.

41


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.

42


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.

43


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.

44


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.

45


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

46


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.

47


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.

48


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

49


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

50


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.

51


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.

52


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.

53


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.

54


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)

55


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.

56


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.

57


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.

58


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.

59


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

60


(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.

61


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

62


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.

63


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.

64


Methods

Aim: To validate the statement of Charaka Samhita “Shukra abahutvat medasaavruta

margatvat cha krucchra vyavayata in sthoulya”.

Objectives of the study



To validate the statement of Charaka Samhita “Shukra abahutvat

medasaavruta margatvat cha krucchra vyavayata”.



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.

65


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)

66


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:






9-10 No dysfunction

67


III. Sexual desire total scores can be interpreted as follows:






9-10 No dysfunction

IV. Intercourse satisfaction total scores can be interpreted as follows:

V. Overall satisfaction total scores can be interpreted as follows:






13-15 No dysfunction






9-10 No dysfunction

68


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


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.


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.


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


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.


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


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


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.


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.


No exercise 23 69.7

Does exercise 10 30.3

Exercising

Practice

Total 33 100.0

0.024

72


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.


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


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.


Madhura 5 15.2

Katu 8 24.2

All 20 60.6

Predominant rasa

preferred

Total 33 100.0

0.003


Poor 3 9.1

Moderate 7 21.2

Good 22 66.7

Severe 1 3.0

Appetite

Total 33 100

0.000

74


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.


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


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


Satisfactory 28 84.8

Unsatisfactory 5 15.2

Nature of

sleep Total 33 100.0

0.000

75


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.


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.


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.


P

value

Madhyama 30 90.9

Pravara 3 9.1

Samhanana

Total 33 100.0

0.000

76


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.


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



Avara 2 6.1

Madhyama 24 72.7

Pravara 7 21.2

Sattva

Total 33 100.0

0.000


P

value

Avara 1 3.0

Madhyama 32 97

Abhyavaharana

Shakti Total 33 100.0

0.000

77


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.


Avara 1 3.0

Madhyama 29 87.9

Pravara 3 9.1

Jarana

Shakti

Total 33 100.0

0.000


Avara 13 39.4

Madhyama 20 60.6

Vyayama

Total 33 100.0

0.223


Madhyama 32 97.0

Kroora 1 3.0

Koshta

Total 33 100.0

0.000

78


RESULTS

Table No .32. Showing the scores of IIEF related to Erectile Functions in the



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


Out of 33 individuals,2 individuals (6.1%) had Severe orgasmic Dysfunction.5



individuals (30.3%) had no orgasmic dysfunction.







Scores of

IIEF

related

Orgasmic

Functions Total 33 100.0

0.029

79


Table No .34. Showing the scores of IIEF related to Sexual Desire in the


Out of 33 individuals, none of the individuals had Severe sexual desire Dysfunction.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.


Severe Dysfunction 0 0





Scores of

IIEF

related

Sexual

Desire Total 33 100.0

0.084







Scores of

IIEF related

Intercourse

Satisfaction

Total 33 100.0

0.182

80


Table No .36. Showing the scores of IIEF related to Overall Satisfaction in the


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.


<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.




Mild –Moderate

Dysfunction

7 21.2



Scores of

IIEF related

Overall

Satisfaction

Total 33 100.0

0.000

81


Table No .38. Showing the Liquefaction time of Semen in the individuals of

Sthoulya.


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.


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.


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


Table No .41.Showing the Motility of Sperms in the individuals of Sthoulya.


<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



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.


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


Table No .44. Showing the Impression of Semen Analysis in the individuals of

Sthoulya.


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


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


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


Graph No.1. Showing the incidence of Age

Graph No.2. Showing the incidence of marital status

87


Graph No.3. Showing the incidence of Educational level

Graph No.4. Showing the incidence of socio-economic status

88


Graph No.5. Showing the incidence of Cardinal symptoms of Sthoulya

Graph No.6. Showing the incidence of Cardinal symptoms of Sthoulya

89


Graph No.7. Showing the incidence of Nature of work

Graph No.8. Showing the incidence of Duration of Excercise

90


Graph No.9. Showing the incidence of Nature of Diet

Graph No.10. Showing the incidence of Nature of food

91


Graph No.12. Showing the incidence of Nature of appetite

Graph No.11. Showing the incidence predominant taste Preferred

92


Graph No.13. Showing the incidence of Nature of Sleep

Graph No.14. Showing the incidence of Duration of Day sleep

93


Graph No.16. Showing the incidence of Prakruti

Graph No.15. Showing the incidence of Duration of sleep at night

94


Graph No.17. Showing the incidence of Sattva

Graph No.18. Showing the incidence of Koshta

95


Graph No.20. Showing Scores of IIEF related to Orgasmic Functions

Graph No.19. Showing Scores of IIEF related to Erectile Functions

96


Graph No.22. Showing Scores of IIEF related to Intercourse Satisfaction

Graph No.21. Showing Scores of IIEF related to Sexual Desire

97


Graph No.23. Showing Scores of IIEF related to Overall Satisfaction

Graph No.24. Showing Semen volume

98


Graph No.26. Showing Viscosity of Semen

Graph No.25. Showing Liquefaction time of Semen

99


Graph No.28. Showing Motility of sperms

Graph No.27. Showing Sperm Count

100


Graph No.30. Showing Impression of Semen Analysis

Graph No.29. Showing Morphology of sperm

101


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

102


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

103


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.

104


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 (ÌuÉÍzÉ¹ 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

105


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.

106


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

107


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.

108


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.

109


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.

110


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.

111


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

112


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).

136


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

139


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

140


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.

141


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.

142


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.

143


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


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


144


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.

145


146


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.

147


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

148


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.

149


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Bhavaprakasha, Vol 2 Delhi, Motilal Banarsidas, 1997, PP: 412





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





161


165. Jogindranath Sen, Charakopaskara, 1stVol, Banaras, Culcatta, J.N.Sen

Publications PP: 476.







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


2 -A few times (less than half the time)

vi



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



3 -Sometimes (about half the time)



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





Q5. During sexual intercourse, how difficult was it to maintain your erection to

completion of 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?







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


2- A few times (less than half the time)

viii




Q10. When you had sexual stimulation or intercourse, how often did you have the

feeling of orgasm or climax?






Q11. How often have you felt sexual desire?






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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xv

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xvi

14. mÉÏQûlÉqÉç lÉÉUÏ mÉÑÂzÉrÉÉãÈ mÉUxmÉU xÉÇqÉÔNïûlÉÇ A§É cÉ lÉÉUÏ mÉÑÂzÉ xÉÇrÉÉåaÉÈ mÉëkÉÉlÉ MüÉUhÉÇ iÉiÉç xÉWûMüÉUÏÍhÉ cÉå¹ÉSÏÌlÉ | cÉ¢ümÉÉÍhÉ

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17. zÉÑ¢Çü mÉëcrÉuÉiÉå xjÉÉlÉÉ‹sÉqÉÉSìÉïiÉç mÉOûÉÌSuÉ || cÉ.ÍcÉ.2/4/47

18. UxÉ C¤ÉÉæ rÉjÉÉ SÎlbÉ xÉÌmÉïxiÉæsÉÇ ÌiÉsÉå rÉjÉÉ |

xÉuÉï§ÉÉlÉÑaÉiÉÈ SåWåû zÉÑ¢Çü xÉÇxmÉzÉïlÉå iÉjÉÉ || cÉ. ÍcÉ.2/4/46 iÉiÉç x§ÉÏmÉÑÂwÉ xÉÇrÉÉåaÉå cÉå¹ÉxÉÇMüsmÉmÉÏQûlÉÉiÉç | zÉÑ¢Çü mÉëcrÉuÉiÉå xjÉÉlÉÉ‹sÉqÉÉSìÉïiÉç mÉOûÉÌSuÉ ||

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20. WûwÉÉïiÉç CÌiÉ qÉlÉxÉÉå UÌiÉ EkSÏmÉlÉ ÌlÉÍqÉ¨ÉqÉÉåSÉiÉç | aÉÇaÉÉkÉU 21. xÉƒ¡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 ||

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xvii

iÉiÉç xÉÇzÉ×irÉ urÉÉ¨ÉqÉÑZÉÇ rÉÉÌiÉ aÉpÉÉïzÉrÉÇ mÉëÌiÉ | iÉ§É zÉÑ¢üuÉSÉrÉÉiÉålÉÉ¨ÉïuÉålÉ rÉÑiÉÇ pÉuÉåiÉç || pÉÉ.mÉë. mÉÔuÉïZÉÉQû 3/28-30

27. xlÉÉlÉÉlÉÑsÉåmÉlÉÌWûqÉÉÌlÉsÉZÉhQûZÉÉ± zÉÏiÉÉqoÉÑSÒakÉUxÉrÉÔwÉxÉÑUÉmÉëxÉ³ÉÉÈ | xÉåuÉåiÉ cÉÉlÉÑzÉrÉlÉÇ ÌuÉUiÉÉæ UiÉxrÉ iÉxrÉæuÉqÉÉzÉÑ uÉmÉÑwÉÈ mÉÑlÉUåÌiÉ kÉÉqÉ || rÉÉå.aÉ 45 xlÉÉlÉÇ xÉzÉMïüUÇ ¤ÉÏUÇ pÉ¤rÉqÉæ¤ÉuÉxÉÇxM×üiÉqÉç | iÉiÉÉå qÉÉÇxÉUxÉÈ xuÉmlÉÉå urÉuÉÉrÉÉliÉå ÌWûiÉÉ AqÉÉæ || rÉÉå.aÉ 46 pÉÉ.mÉë 298

28. pÉ¤rÉÉÈ 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 EÂ 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 ÌuÉ¤ÉåmÉÉåÍcÉiÉMüqÉïhÉÉ | rÉÑaÉmÉiÉç xÉuÉïiÉÉåÅeÉxÉëÇ SåWåû ÌuÉÍ¤ÉmrÉiÉå xÉSÉ || cÉ.ÍcÉ. 15/36

xviii

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

sthoulya ss-mys

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