sthoulya sw06 has

DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITTA

SHRI DHARMASTHALA MANJUNATHESHWARA

COLLEGE OF AYURVEDA & HOSPITAL

HASSAN - 573 201.

Certificate

This is to certify that the thesis entitled “EFFECT OF

UDVARTHANA IN STHOULYA” is the record of research work

conducted by ‘PRASANNA KUMAR K’ under my direct supervision and

guidance as a partial fulfillment for the award of the degree of M.D.(Ayu)

in Swasthavritta.

Some of the observations made in this elaborative clinical

study are original and have definitely contributed in the advancement of the

existing knowledge of the subject.

The candidate has fulfilled all the requirement of ordinances

laid down in the prospectus of Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka for the award of Degree of Doctor of Medicine

(Ayu.) Swasthavritta.

I am fully satisfied with his work and recommend this thesis to

be submitted for adjudication.

Guide HOD

.

Date: 28-03-04

Place: HASSAN

Dr. Sajitha.K M.D.(Ay)

Asst. Prof.

Dept. of PG studies in Swasthavritta

SDM College of Ayurveda & Hospital HASSAN.

Prof. Ramana. G.V M.D (Ay)

Prof. & HOD Dept. of PG studies in Swasthavritta

SDM College of Ayurveda & Hospital

HASSAN.

Ayurmitra

TAyComprehended

CONTENTS

I. Introduction 1-4

II. Literary review

1. Sthoulya 5-32

a. Paribhasha 6

b. Historical Background 7-9

c. Physiological consideration of Meda Dhatu 10-11

d. Nidana 12-16

e. Samprapthi 17-21

f. Poorvaroopa 22

g. Roopa 23-25

h. Upadrava 26-27

i. Sadhyasadhyata 28

j. Chikitsa 29-33

2. Obesity

a. Lipids 34-41

b. Definition 42-43

c. Etio-Pathogenesis 44-50

d. Assessment 51-54

e. Morbidity- Mortality 55

f. Complication 55

g. Treatment 56-59

3. Udvartana

h. Paribhasha 60

i. Concept of Rookshana 61-63

j. Historical Background 64

k. Classification 65

l. Benefits 66

m. Procedure and mode of Action (rubbing) 67-70

III. Clinical study

a. Study design 71

b. Reason for selecting Study Design 72

c. Objectives of Study 74

d. Selection criteria 74

e. Objective Parameters 75

f. Subjective Parameters 75-78

g. Drug Review 79-80

i. Treatment Procedure 81-82

IV. Observation and Results 83-109 V. Discussion 110-124

VI. Summary and Conclusion 125-129

VII. List of Reference 130-131

VIII. Bibliography 132-133

IX. Annexure I-XIV

Acknowledgement

Effect of Udvarthana in Sthoulya

Acknowledgement

I offer my prayers to Lord Aanjaneya and Sri Raghavendra Swamiji

who gave me strength to overcome all the difficulties during this Thesis work.

I bow my head on the foot of Dr. Virendra Hegdeji, the founder

president of SDMCA, Hassan for his endless service to society.

I am very much thankful to Prof. Prasanna .N. Rao, Principal, who

provided the necessary facilities for the completion of this work.

I express my sincere gratitude to most honourable and esteemed teachers

Dr. Ramana.G.V, HOD and Dr. Sajitha .K, Guide, for their unforgettable

parental affection and patience cooperation to give suggestions at every step in

accomplishing the present work.

My most respects and indebtedness to Dr. Sekhar, Dr. Bhaskar Rao,

Dr. Mallika, Dr. Muralidhar Pujar, Dr. Prasanna Kerur, Dr. Sanjay Das

and Statistician Dr. Mahadevappa for their valuable suggestions.

I take this opportunity to thank Prof. B.G. Gopinath, Dr. B. Srinivas

Prasad, Dr.Chandrashekar, Dr. Prakash Mangalasseri Dr. kishore

Patwardan and Dr. Kiran Gowda who taught me the science and arts of

medicine.

My vocabulary falls short of suitable words to express my deep sense of

gratitude to my friends Dr. Sairam, Dr. Krishna, Dr. Sudheer and Dr. Suhas

for their timely support and brotherly care.

I am greatfull to Dr. Manjunath N.S, Dr. Guruprasad. K and

Dr.Vijaya Lakshmi for their constant help.

It is a privilege for me to express my thanks to Dr.Srinibash Sahoo,

Dr.AshwinKumar, Dr.Raju, Dr.Prasanna Aithal, Dr.Ashwini MJ,

Dr.Gururaj, Dr.Srinivas GK, Dr.Amit Deshmukh, Dr.Vijay Biradar,

Dr.Gopikrishna, Dr.Dheeraj, , Dr.VishalAgarwal, and Dr.Manjunath NP.

I express my best wishes to Dr. Sudheendra, Dr. Shivakumar,

Dr.Guhesh, Dr. Monilal, Dr. Srikanth, Dr. Adithi, Dr. Manish and Dr.Uday.

Acknowledgement


I am thankful to internees Raghavendra, Poornima, Sudarani,

Shivananda, Nalina and Usha who helped me for survey work.

It was not possible to complete this work without Patients therefore I am

very much greatfull to each and every patient who cooperated me for this work.

I fail in my duty if I don’t recall Dr. Srikanth PL, Dr. Madhav Diggavi,

Dr. Srinivas T, Dr. Vishala, Dr. Anupama, Dr. Gurubasavaraj and Shobha

for their inspiration to join MD.

I take this opportunity to thank whole heartedly to Mr.

Raghavendrachar.B and Mr.Ramachandra who helped me for getting MD

seat.

This work has not been completed if Mr. Venugopal K and

Mr.Venugopalachar had not supported and blessed me. I am greatfull to Smt.

Shantha bai- my grand maa, Smt.Shashikala, Sri.Muralidhar Rao,

Smt.Chayya Kulkarni, Smt.Sudha shyati and Sri Eranna Pathrimath for

their encouragement and blessings.

This world of words failed to provide me a word just capable of

expressing my feelings to my friend late Preethi for her long-lasting inspiration.

I heartly acknowledge my love and affection to my brother Praveen,

sisters Poornima and Pallavi, Mr. Satish and my sweet Shreya.

On this occasion with a great reverence I humbly offer my pranamas at

the lotus feet of my mother Smt. Rekha Kulkarni and father Sri. K. Satya

Prakash, who have shaped me into what I am today. All the credit of this work

goes to them.

May Lord Dhanwanthri bless all with Hitayu and Sukhayu who helped

me directly and indirectly in completing this work.

Prasanna Kumar K


List of Tables

Table no.

Content Page no.

1 Paryaya of Sthoulya 06 2 Direct Aharatmaka Nidana 14 3 Indirect Aharatmaka Nidana 15 4 Viharatmaka Nidana 15 5 Manasika Nidana 15 6 Anya Nidana 16 7 Important Nidana with its features 16 8 Sthoulya Lakshana 25 9 Sthoulya Upadrava 27 10 Ahararupi Pathya – Apathya 32 11 Vihararupi Pathya – Apathya 33 12 Different constituents of lipoprotein 36 13 Normal limits of blood cholesterol 39 14 Distribution of adipose tissue. 40 15 Role of different genes 46 16 Interpretation of BMI 52 17 Drugs, there mode of action and adverse effects 58 18 Difference between Langhana and Rookshana 60 19 Effects of Rookshana karma: 61 20 Samyak Rookshana Lakshana 61 21 Rookshana athi yoga lakshana 61 22 Rookshana Ayoga Lakshana 63 23 Benefits of Udvarthana 66 24 Sthoulya cases as per Age-wise Distribution 83 25 Sthoulya cases as per Sex wise distribution 83 26 Sthoulya cases according to their Religion 84 27 Sthoulya cases according to their Socio-economical status 84 28 Sthoulya cases according to their occupation 84 29 Sthoulya cases according to their Prakruthi 84 30 Sthoulya cases according to chronicity of disease 85 31 Sthoulya cases according to Family history 85 32 Sthoulya cases according to quantity of food consumption 85 33 Sthoulya cases according to frequency of food consumption 86 34 Sthoulya cases according to their Pana 86 35 Sthoulya cases according to Rasa preferred 86 36 Sthoulya cases according to Nidra kala 86 37 Sthoulya cases according to their Adhyatana Agni 87 38 Sthoulya cases according to their Poorvagni 87 39 Sthoulya cases according to their Abhyahvarana shakthi 87 40 Sthoulya cases according to their Jarana shakthi 87 41 Sthoulya cases according to their Jatha Desha 88 42 Sthoulya cases according to their Samvrudha Desha 88 43 Sthoulya cases according to their Vyadhitha Desha 88


Cont…

Table no. Content Page no. 44 Sthoulya cases- Body frame 89 45 Sthoulya cases- Educational status 89 46 Sthoulya cases as their per Associated Features 89 47 Sthoulya cases as per their Vihara 90 48 Changes in chala spik, sthana and udara lambana 90 49 Changes Ayathaupachaya utsaha hani 90 50 Changes in Swedadhikyata 91 51 Changes in Ayase Swasa 91 52 Changes in Nidradhikya 91 53 Changes in Adhika Kshuda 92 54 Changes in Ahara matra 92 55 Changes in Ahara kala 92 56 Changes in Athi Pipasa 93 57 Changes in Kshuda sahatva 93 58 Changes in kshuda souhitya 93 59 Changes in Alpa vyayama 94 60 Changes in Anga gourava 94 61 Changes in Anga sithilatha 94 62 Changes in Gatra sada 95 63 Statistical analysis of Subjective assessment 95 64 Changes in weight 97 65 Response in weight 97 66 Changes in BMI 98 67 Response in BMI 98 68 Statistical analysis of changes in weight and BMI 99 69 Response in chest circumference 100 70 Response in abdomen circumference 100 71 Response in hip circumference 100 72 Response in Mid-arm circumference 101 73 Response in Mid-thigh circumference 101 74 Statistical analysis of Circumference of Chest,

Abdomen, Hip, Mid-arm, Mid-thigh 102

75 Decrease in Total cholesterol level 102 76 Changes in Total cholesterol 103 77 Changes in HDL 103 78 Increase of HDL level 104 79 Changes in LDL 104 80 Decrease of LDL level 105 81 Changes in Triglycerides 105 82 Decrease of Triglycerides level 106 83 Statistical analysis lipid profile 106


Contd..

Table no.

Content Page no.

84 Age wise distribution of survey patients 107 85 Sex wise distribution of survey patients 107 86 Religion wise distribution of survey patients 107 87 Nature of work wise distribution of survey patients 108 88 Diet wise distribution of survey patients 108 89 Height wise distribution of survey patients 108 90 Weight wise distribution of survey patients 109 91 B.M.I wise distribution of survey patients 109 92 Synonym of Sthoulya with modern interpretation 110 93 Common Indian preparation with kcal.of energy IX 94 Activities and caloric burn for different weight X 95 Recommended energy intake for age, height, & weight X 96 Height and weight for women of different ages XI 97 Height and weight for men of different ages XI 98 Common Indian cereals with their nutritive value XII 99 Common Indian vegetables with nutritive value XII 100 Miscellaneous Indian foodstuff with nutritive value XIII 101 Reducing and weight maintenance diet of high cost XIII 102 Reducing & weight maintenance diet of medium cost XIV 103 Reducing and weight maintenance diet of low cost XIV

Abbreviations


Abbreviations

(1) Cha. sam - Charaka samhita

(2) Su. sam - Sushruta samhita

(3) As. San - Astanga sangraha

(4) As.Hr. - Astanga hridayam

(5) Sha. sam. - Sharangadhara samhita

(6) Bh.Pr. - Bhava Prakasha

(7) Ma.Ni. - Madava Nidana

(8) Yo.Ra. - Yogarathnakara

(9) Ka. san - Kashapa samhita

(10) Ra. vai - Rasa vaisheshika

(11) su - Sutrasthana

(12) vi. - Vimanasthana

(13) sha - Shareera

(14) ni - Nidanasthana

(15) si. - Siddisthana sthana

(16) chi. - Chikitsasthana

(17) khila - Khilasthana

(18) Ut. - Uttarasthana

(19) BT - Before treatment

(20) AT - After treatment

(21) Dif. - Difference

Introduction


1

Scientific and technological progress has made man highly sensitive and

critical; there by giving rise to different types of health problems. The

advancement of industrialization and communication is contributing towards

sedentary life styles, in turn causing chronic non- communicable diseases like

diabetes mellitus, hypertension, cancer, ischemic heart disease, cerebro-vascular

accidents, atherosclerosis, varicose veins etc. Obesity being the risk factor for

these diseases and hence prevention of obesity will decrease the chances of such

diseases. Excess of fat is a disadvantage rather then an asset; it may “lengthen

the waist line” but “shortens the life line” of the individual by imposing an extra

burden on all the systems of body.

Inspite of advanced technology and researches, the modern medicine is

failing to give the best result for obesity, due to its multifactorial nature. Like

other diseases, obesity is mostly the result of factors like heredity, environment

or food, but it is difficult to decide the involvement of prime factor. It is not

possible to change heredity; it is difficult to change environment, but relatively

easy to change food habits and life styles. Hence intervention at this level is need

of the hour.

Obesity is a major health problem in both developed and developing

countries. The exact estimation of prevalence is difficult as the standardized

definition is lacking. In countries like USA, approximately 55% of population in

the age group of 20-70 years is suffering from this problem. A study conducted

in Delhi shown that approximately 25% of populations are obese in urban areas.

Another study conducted in United States, showed increase in sudden death rate

among men and women with at least 20% overweight, which clearly shows the

reduced life span due to its incidence.

Ayurveda, the science of life, had given much importance to primary and

secondary preventions of diseases. Acharya’s have explained at length the

various procedures that are to be implemented under Dinacharya and Ritucharya.

These are advocated under a branch – Swasthavritta, which explains the

prevention of diseases at different levels. The procedures like Abhyanga,

vyayama, Udvarthana are explained in Dinacharya with an aim of maintaining

Introduction


2

one’s own physique in moderation. In Dasha vidha pareeksha, samhanana

pareeksha is to be examined to determine the compactness of dhatu i.e. the frame

of the body, which is essential in the treatment context.

Sthoulya is the nearest clinical entity for obesity in Ayurveda. For

causation of Sthoulya, excessive intake of calories with a decreased expenditure

is the main reason. With a view of preventing excessive consumption, only two

Annakala are specified with intermediate period of 8-10 hours. While deciding

the Ahara to a person, the 8 factors (Ashta vidha Ahara Vishesha ayathana) are

prescribed which includes the assessment of quantity, quality and composition.

These eight principles incorporate all the modern parameters described in the

context of nutrition. Considering the difficult nature of disease, obesity can be

better prevented rather than treated. In ayurveda, obese persons are included

under Asta Nindita purusha (Athi Deerga, Athi Hraswa, Athi Stoola, Athi

Krusha, Athi Goura, Athi Sweta, Athi Roma and Aroma). The reason for

difficult nature being the involvement of Tridosha and affliction of sapta dhatu.

It is also mentioned that the preferred constitution for an individual should be

emaciated rather than obese.

The existing obesity treatment options, in modern medicine includes

drugs like Fenfluramine, Dexfenfluramine and Sibutramine which acts as

appetite inhibitors have with of adverse effects and cannot be used for more than

three months. The diuretic and purgatives drugs are also used to treat obesity,

but the action is for shorter term, and the patients again put on weight after

cessation of treatment. Some devices like vibrators are being used for local

lipolytic action. Nutritional combinations (synthetic nutritional compounds) are

expensive and they too have untoward effects.

In the present context Ayurveda offers a ray of hope in treatments like lekhana

basti, virechana, Udvarthana along with some internal medicines like Navaka

guggulu, trayodashanga guggulu etc. The periodical Shodhana has also proven

its efficacy. Among these therapies, the internal administration of guggulu has

certain limitations like gastric irritation, constipation etc. The administration of

lekhana basti is to be undertaken for prolonged period and administration of

Introduction


3

which requires medical supervision. On contrary, Udvarthana is a procedure

which can be undertaken daily with a preliminary training to the individual. It’s

efficacy has been proved in reduction of Hyperlipidemia in the earlier studies;

but its efficacy in reducing body weight has not yet studied. The observation at

our hospital-conducted studies on the same over considerable samples shows

significant reduction in body weight in a very short duration of time with no

adverse effects. Before and after Udvarthana, purgation was given.

To document and analyze this procedure for statistical interpretation, the

study entitled “ Effect of Udvarthana in Sthoulya” was undertaken. The effect of

Udvarthana in reducing weight and its relationship with serum lipid values was

also considered.

The whole dissertation consists of three studies under the following

headings.

Conceptual study

Clinical study and

Survey study

Conceptual study

This part of the study deals with the literary review of sthoulya as

explained in classics with spatial reference to its Paribhasha, Nirukti, Historical

background, Nidana panchaka and Chikitsa etc.

In further, the concept of obesity is explained considering from lipids to

etymology, etiopathogenisis and treatment etc. No correlation was made in

between and so that it can be interpreted in discussion chapter.

The last part of this conceptual study includes the review of Udvarthana.

It includes the Nirukthi, Paribhasha, etc of Udvarthana. For better understanding

of this procedure, the principles of Rookshana are considered, as it is one among

the Rookshana karma. Hence Rookshana is also explained in brief giving

importance for its practical approach.

Introduction


4

Clinical study

This part of the study deals with the materials and methods. The methods

include the study design, reason for selecting design, objectives, selection

criteria, subjective and objective parameters for assessments.

The materials include the drug review, method of preparation of

Udvarthana dravya, procedure etc.

Survey study

As exact incidence and prevalence rates of obesity are not available, an

attempt is made to survey the patients attending the OPD to assess the incidence

rate. The study was carried out for thirty working days.

All the observations, data and results are tabulated in the observations and

results section along with pictorial presentation. Based on the conceptual study

and results, a critical analysis was made in discussion part. In this chapter right

from the review of literature to clinical and survey study, discussions are carried

out. It also includes the probable mode of action of Udvarthana on sthoulya and

also on lipid profile.

In conclusion and summary chapter the dissertation is concluded. Here the whole

of the work is sum up with few important outcomes.

Last but not least this dissertation include bibliography and appendix

where some of the tables which are important for clinical study are enclosed,

which includes case sheet, master chart, diet chart etc, helping the reader to

verify the things wherever required.

Review of literature-Sthoulya


5

Sthoulya Paribhasha

The word “Sthoola” is derived from root “Sthu” with suffix “ach” which

stands probably for “Thick” or “Solid” or “Strong” or “Big” or “Bulky”. The

different meanings denoted by various Granthakara’s can be summarized as

below-

Shtulasya bhavam Sthoulyam – vachaspathyam (6/358)

Sthulayathi te cha athaha Sthoulyam- vachaspathyam (6/358)

Sthula paribhrane- Amarakosha (Nanartha varga 204)

Sthulayathi Sthula Brumhane ach- Hemachandra

Sthula sthiryate barhi asmavat- Bruhaspathi

Sanchaya Pravachana madhyam trike Sthulatha- Koutilya

(patala 1/10)

Medini opines Sthoola as “koota” or “samuha” which means the cluster.

The human with large frame is known as “Sthoola” and “Sthoulya” is an

adjective of the word “Sthoola”.

Dictionaries give the meaning of “Sthoola” as:

Large Great

Bulky Huge

Fat Corpulent

The word “Sthoola” is also used as synonym for some drugs like Khanda,

Priyangu, Rakta lashuna, Ikshu etc.



6

Sthoulya Nirukthi

Different scholars had given their contribution in defining Sthoulya.

Among them are:

A person having heaviness and bulkiness of the body due to extensive

growth especially in Udaradi region is termed as “Sthoola” and this state

(Bhava) of Sthoola is called as “Sthoulya”1.

Athi Sthoola has been defined as a person who on account of the

inordinate increase of fat and flesh is distinguished with pendulous

buttocks, belly and breasts and whose increased bulk is not matched by a

corresponding increase in energy2.

Sthoulya Paryaya

Table no.01 showing Paryaya of Sthoulya as per different texts:

Sl. No

Paryaya Ch. Sam

Su. Sam

As. San

Ka. Sam

Ma. Ni

Sha Sam

Bh. Pra

Yo. Ra

1 Sthoulya + + + + - - + + 2 Athi Sthoulya + + + - - - + + 3 Sthoolata - + + - - - - - 4 Sthoolatwa - - + - - - - - 5 Sthavima - - + - - - - - 6 MedoRoga - + + - + + + + 7 MedoDosha + - - - - + + + 8 Medovriddhi - - - - - - + + 9 Medovikara - - - - - - + - 10 Medogada - - - - - + + - 11 Medopushti - - - - - - - + 12 Medadushti - - - - - - - + 13 Athipushti - - + - - - + - 14 Pushti + + + + - + + + 15 Upachaya + + + + - + + + 16 Jathasya - + - - - - - - 17 Brumhana + - + + - - - - 18 Medaswita - - - - - - - + 19 Medurata - - - - - - - +



7

Historical background

I) Reference in Vedas:

Ayurveda is known to be upaveda of Artharvana Veda. We find some

scattered reference of sthoulya in this Veda like:

“Pivasi ……. Naiva Majja svahatam” | 1/11/4

MEDASI :

“ye kilaarlana tarpayanthi ye dhatena ye va kyo Medasicha si mam”| 4/27/5

II) Reference in samhita:

a. Brihatrayi;

In the big triads of Ayurveda i.e. Charaka samhita, Sushrutha samhita and

Astanga sangraha, we find many reference regarding sthoulya.

1.Charaka Samhita

Acharya Agnivesha has explained sthoulya under the heading of Ashta

Nindita in Sutra Sthana 21st chapter. Here the descriptions of Etiology,

pathogenesis, symptomatology, along with its treatment and diet have been

explained. Athi sthoulya is also mentioned as one of the Kaphaja Nanatmaja

vikara.

2. Sushrutha Samhita

In Sutrasthana 15th chapter “Dosha Dhatu Mala Vignana” the description

of sthoulya has been explained which includes causes, symptoms, signs and

treatment. In Sutra sthana 35th chapter the treatment principles of sthoulya has

been explained3.

3. Ashtanga Sangraha

It has been described the different aspects of sthoulya in Sutrasthana

“Dwividhopakramaniya” chapter. It is also explained that sthoulya is “Athi

Brumhanajanya” Vyadhi.



8

b. Laghutrayi

1. Madhava Nidana:

He is the first author to describe this disease under separate heading

called “Medo Roga” in 34th chapter. He has mentioned Nidana, Lakshana and

Samprapthi of this disease.

2. Sharangadhara Samhita:

This textbook is known for its many unique things like Nadi pareeksha,

clear definition of pharmacological terms etc. this author has explained madhu

as the single drug treatment for Medovriddhi4.

3. Bhava Prakasha:

Author has stressed more on the treatment aspects compared to

Brihatrayi. Acharya Bhava mishra has explained regarding a popular Dhupa

called “Malayanila Dhupa” in 39th chapter of Chikitsa sthana. He has also

explained regarding various Lepa and Udvartana to treat sthoulya. This author

has explained sthoulya in separate chapter.

c. Other Classical Texts:

1. Bhela Samhita:

It is one of the popular texts of Ayurveda. In 11th Chapter of sutrasthana,

various aspects of Sthoulya have been explained.

2. Vangasena Samhita:

In this classical textbook, Medo Roga Chikitsa is explained in 16th chapter.

3. Yogaratnakara:

Sthoulya is explained under a separate chapter. Many of the formulations

to treat Sthoola are explained.



9

4. Chakradatta:

Acharya Chakrapani datta has explained treatment of Sthoulya in 36th

chapter.

5. Kashyapa Samhita:

As this book gives more importance for “Koumarabruthya” and “Prasuthi

tantra”, hence Acharya Kashyapa have described “Medasvi Dhatri Chikitsa”5.

Another specialty of this text is that Rakta mokshana is explained as Chikitsa for

Sthoulya.

6. Bhaishajyaratnavali:

It is famous for various treatment and preparations of medicines. In 39th

chapter Sthoulya Chikitsa is explained.

7. Gada Nigraha:

In 31st chapter, Sthoulya Roga and its Chikitsa is explained.

8. Rasaratna Samucchaya:

This book of Rasashastra, has explained Sthoulya in 18th chapter.

9. Nidana Chikitsa Hastamalaka:

This book of Ayurveda has been written in modern times by Vaidya

Ranajit Ray Desai. Here Sthoulya is explained in second volume.



10

Physiological consideration of Meda Dhatu:

Utpathi:

When the sukshma bhaga of Mamsa dhatu comes in contact with

Medodhatwagni then Meda dhatu is formed. Due to ambu guna present in

Medas, sneha guna is increased. Mamsa dhatu gets paka due to its Agni and

ambu guna present in it forms Medo dhatu6.

Guna – Karma:

Medo dhatu is having the guru and Snigdha guna. It gives bala and

bhrumanatva to the body7. It produces sneha and sweda in the body; it makes

drudata of shareera and gives poshana to Asthi dhatu8. Sneha in the body is of

three types:

1.In the form of Medas which is Sandra & like Ghrutha

2. In the form of Vasa, which is present in Mamsa

3. In the form of Majja, which is present in Asthi9.

Medodhara Kala:

It is the third Kala, present in Udara and sukshma Asthi10.

Medovaha Srotas and its Vidha Lakshana:

These srotas are two in number. The moola is kati and vrukka. Vidha

lakshana are Sweda (sweating), Snigdhata in anga (oily body), talu shosha

(dryness of palate), stoola shopha (large swelling) and Pipasa (thirst).11

Meda Dhatu Mala:

Sweda is the mala of Meda dhatu12.

Meda Dhatu Upadhatu:

Snayu is the upadhatu of Medas13.



11

Meda Dhatu Pramana:

Two anjali is said to be the quantity of Meda dhatu.

Meda sara purusha lakshana:

Adhika snehansha in varna , swara, netra, kaksha, loma ,nakha, danta,

oushta, mutra and pureesha. The person will have Dhana, Ishwarya, Sukha,

Upabhoga. He will be Daana-sheelata, Saralata, Komalatha and Bhavaka

suchaka14.

It is also mentioned that these persons will have large body and unable to

perform heavy work15.

Meda Dhatu Vridhi Lakshana:

Snigdhata of Shareera, vridhi of Udara and parshwa, kasa, swasa, hikka,

dourgandha of shareera are seen as Meda vridhi lakshana16. It is also mentioned

that these persons will have Srama and increase in size of Spik, sthana and

Udara17.

Meda Dhatu Kshaya Lakshana:

The depletion of this dhatu are seen as Plehavridhi, Sandhi Shunyatha,

Rukshyata and Iccha of Athisnigdha and Mamsa18. The other symptoms are

Shunyata of Kati, Krusha shareera19.



12

Sthoulya Nidana

Nidana is an important factor for manifestation of any disease. Many a

times a disease can be diagnosed on the basis of nidana itself as in case of

“Mrudbhakshanajanya Pandu”.

The synonyms of nidana are Nimitta, Hetu, Ayatana, Prathyaya, Uttana,

and Karana. Nidana can be broadly classified as Bahya nidana, which includes

ahara and vihara, and Abhyantara nidana being the Dosha and Dushya.

Abhyantara nidana will be discussed in the context of Samprapthi.

Bahya nidana can be compared with etiological factors in contemporary

science. The etiological factors are scattered in classical textbooks of Ayurveda

under different heading like:

1. santarpana karaka nidana20

2. Medo Roga hetu21

3. Athi sthoulya hetu22

4. Medo Mamsavaha srotodusti hetu23

5. Prameha Hetu24

6. Kapha Vruddhikara Hetu25

All of these can be summarized as follows:

1. Aharatmaka nidana

2. Viharatmaka nidana

3. Manasika nidana

4. Sahaja nidana

5. Anya nidana

1. Aharaja nidana:

Food plays a major role in formation of Sthoulya and hence it is rightly

said that wholesome and unwholesome foods are responsible for happiness and

misery.



13

Aharaja nidana are wide spectrum of etiological factors, which is having

variation in Ahara krama at one end, and Rasadi factors at another end. The

following are the Aharaja Hetu:

1. Adhyashana

2. Athi matra ahara

3. Athi sampurana

4. Guru, sheeta, pichila, snigdha guna ahara

5. Madhura Rasapradhana ahara

6. Specific dravya pradhana ahara

Adhyashana:

Food that is consumed before the digestion of previous meal is called as

Adhyashana. Here the patient will be not following the ahara ashta vidha

visheshayatana.

Athi matra Ahara:

Excess consumption of food is called as Athi matra Ahara sevana. Here

the consumption of food is related not only for quantity of intake but also the

frequency of intake. As the formation of Rasa is more, it over- nourishes the

Dhatu of the body; there by leading to Brihath Shareera.

Athi sampurana:

Intake of food up to ones full belly is called as Athi sampurana. To assess

the quantity of food in take the parameters had been explained in the classics26.

Guru, sheeta, pichila, snigdha guna ahara:

All these guna have an affinity towards the Kapha and the Medas there by

leading to increase in their quality and quantity. More over due to Picchila and

Snigdha guna, it causes the obstruction of the Vata in the srotas, in turn leads to

sandukshana of Agni.



14

Madhura Rasapradana ahara:

This Madhura Rasa is having the Kapha prakopaka property because of

which there will be increase of Kapha and Medas. When the Madhura Rasa is

added to Snigdha guna then there will be more vitiation of Dosha.

Table no.02 showing Ahara, which directly cause Sthoulya:

Sl No

Nidana Ch. Sam

Su. Sam

As San

As Hru

Ma Ni.

Bh Pr

Yo Ra.

1 Adhyashana - + - - - - -

2 Athi sampurana + - + - - - -

3 Athi brumhana - - - + - - -

4 Guru ahara + - + - - - -

5 Madhura ahara + + + - + + +

6 Kaphakara ahara - + - - + + +

7 Snigdha ahara + - + - - - -

Some of the Nidana explained in different context can be considered for

understanding Sthoulya Nidana.

Table no 03 showing indirect Aharatmaka Nidana of Sthoulya:

Sl No

Nidana Ch. Sam

Su. Sam

As San

As Hru

Ma Ni.

Bh Pr

Yo Ra.

1 Athibhojana + - - - - - -

2 Sheeta ahara + - - - - - -

3 Navanna + - - - - - -

4 Navamadya + - - - - - -

5 Gramya Rasa + - - - - - -

6 Paya vikara + - + - - - -

7 Dadhi + - - - - - -

8 Sarpi + - + - - - -

9 Ikshu + - + - - - -

10 Guda + - - - - - -

11 Mamsa + - - - - - -

12 Godhuma + - - - - - -



15

Table no.04 showing viharatmaka Nidana of Sthoulya:

Table 05 showing Manasika Nidana of Sthoulya:

Sl No

Nidana Ch. Sam

Su. Sam

As Hru

Ma Ni.

Bh Pr

Yo Ra.

1 Harsha Nitya + - + - - -

2 Achintana + - + - - -

3 Priyadarshana + - - - - -

Table 06 showing Anya Nidana of Sthoulya:

Sl No

Nidana Ch. Sam

Su. Sam

As Hru

Ma Ni.

Bh Pr

Yo Ra.

1 Ama Rasa - - - - + -

2 Snigdha Madhura basti + - - - - -

3 Tailabhyanga + - + - - -

Sl no Nidana Ch. Sam

Su. Sam

As Hru

Ma Ni.

Bh Pr

Yo Ra.

1 Avyayama + + - + + +

2 Avyavaya + - - - - -

3 Divaswapna + + - + + +

4 Sukha shayya + - + - - -

5 Gandhamala dharana + - - - - -



16

Table no.07 showing important Nidana of Sthoulya with its features:

Sl. No

Nidana Mahabhuta Predominance

Rasa/Guna/ Veerya/Vipaka

Vitiation

1 Guru ahara Pruthvi +Ap Madhura Rasa Kapha-Meda

2 Snigdha ahara Pruthvi +Ap Madhura Rasa Kleda

3 Picchila ahara Pruthvi +Ap Madhura Rasa Kapha-Meda

4 Sheeta ahara Ap Madhura Rasa Vata-udaka

5 Madhura Rasa Pruthvi +Ap Snigdha, guru Kapha-Meda

6 Go ksheera Ap Madhura KaphaMeda

7 Mahisha ksheera Ap + Pruthvi Athi sneha Kapha-Meda

8 Dadhi Ap + Pruthvi Kapha-Meda

9 Ghritha Agni + Ap Snigdha Kapha-Meda

10 Ikshu Ap+ Madhura Kapha

11 Phanitha Pruthvi + Ap Guru TriDosha

12 Guda Pruthvi Madhura, kashaya Kapha-Meda

13 Anupa Mamsa Ap + Pruthvi Madhura Rasa Kapha

14 Athi Nidra - Tamo guna Kapha

15 Sukha shayya - Tamo guna Kapha

16 Divaswapna - Tamo guna Kapha

17 Avyayama - Tamo guna Kapha

18 Athi vyayama - Rajo guna Vata

19 Jagarana - Rajo guna Vata

20 Anashana - - Vata



17

Sthoulya Samprapti

It is defined as “the description of the evolution of the disease in

sequential order, commencing with Dosha-Dushya vaishyamya till the disease

manifests completely. For the manifestation of a disease various deranged

structural and functional elements of the body are responsible and all such things

are studied under Samprapti. The knowledge of Samprapti (also called as jathi

and agathi) is very helpful to the physician both for accurate diagnosis and also

for planning appropriate treatment. It is essential to know about “Ghataka” of

the Samprapti because Samprapti vighatana itself is Chikitsa.

Samprapti of sthoulya is understood as follows:

1. Samanya Samprapti of sthoulya

2. Samprapti Ghataka of sthoulya

3. Role of Ama in sthoulya

4. Analysis of important features of sthoulya

Samanya Samprapti of sthoulya:

The nidana of sthoulya will produces the Ama when there is an

atmosphere in favour of them and prior to which there will be production of

reversible bond between Nidana- Dosha- Dushya27, which is must for the

manifestation of the disease. This Ama after acquiring Madhuratwa along with

snehamsha, present in the body will produce vikrutha Medas. This will become

obstacle for the nourishment of uttarottara dhatu resulting in under development

of those dhatu. Accumulation of Medas resulting in Vata vridhi at koshta leads

to Athi sandukshana of Jataragni. This pradeepta Agni will be always in wants of

food there by it makes a person to feel more of hungry otherwise leading to

various derangements, but if food is taken it will nourish only the Medas. Thus

this vicious cycle results in the vridhi of certain anatomical region or all body

parts.



18

Ati ahara sevana

Jataragni ati sandhukshana

Vata vrudhi in kosta

Ati Meda avarana

Anya dhatu asamyak upachaya

Ati vrudha Meda dhatu causes anya dhatu

dh

STHOULYA

Kostagni dusti

Ama

Nidana sevana Ahara, Vihara, manasika

Madhuratara anna Rasa

Medo Dhatwagni d t

Atisneha utpatti

Meda dhatu ati upachaya

Beeja

Samprapthi chakra



19

Samprapthi Ghataka Dosha:

Kapha – Kledaka Vata - Samana, Vyana, Prana Pitta - Pachaka

Dushya: - Rasa, Mamsa, Medha Agni:

Jataragni - Pradeeptha Dhathwagni - Medadhathwagni manda.

Ama: - Medadhathwagni manda janya Srotas: - Medovaha, Rasavaha Dusti prakara: - Sanga Udbhava sthana: - Amashaya Adhistana: - Vrukka, Vapa Sanchara sthana: - Sarva daihika Vyaktha sthana: - All over body but mainly in Spik, Sthana, Udara. Vyadhi prakara: - Chirakari, Sadyasadyatha - Krucchrasadhya Roga marga: - Bhahya and Abhyantara



20

Brief description about important Lakshana:

1. Meda- Mamsa Vrudhi:

As it is a Meda Dhatwagni mandya janya vikara, the excess of

formation of Medas along with its immediate poorva dhatu i.e. Mamsa

dhatu is seen. The nidana like guru, picchila ahara and divaswapna and

athi nidra will contribute to the vikara of Kapha. This Kapha is having the

same qualities of Medas and hence Dosha-Dushya sammurcchana takes

place leading for Vrudhi of Mamsa and Medas, which are Ama roopi.

2. Chalatwa of Spik Sthana and Udara:

This is seen when more of Meda dhatu is present relatively more

than Mamsa dhatu. Chalatwa is mainly appreciable in the Anatomical

regions like Spik, Sthana and Udara. Here Medas is not properly adhered

to the Mamsa dhatu and hence it moves freely giving rise to above

condition.

3. Ayatopachayotsaha:

Because of the guru guna present in Kapha and Medas, it gives

raises to vrudhita of tamasika guna of Manas in turn giving raise to

sluggish movements to the body, and also due to Anga gurutwa this

feature is seen.

4. Ayusrhasa:

This lakshana is explained as one of the ashta Dosha of Sthoulya.

The less span of life is seen, as it is one of the ashta nindita Vyadhi where

Bahu Dosha are involved. When uttarottara dhatu formations are

hampered, the Oja kshaya takes place, which is responsible for

maintenance of ayu. Hence we see decreased lifespan in Sthoola purusha.



21

5. Krucchra vyavaya:

Shukra dhatu is responsible for vyavaya. When its rate of

formation is reduced due to mandata of Meda Dhatwagni, there will be

difficult in sexual act.

6. Athi Sweda and Dourgandhya:

Sweda is said to be mala of Medas. When there is increase in

Meda dhatu, formation of its mala is also increased leading for excessive

sweating. Due to excessive sweating, the Medasvi will have Durghanda in

their body.

7. Athi kshut and Pipasa:

In sthoulya, vikrutha Vata will carry Agni from the Meda dhatu to

amashaya, due to obstruction for the moment of Vata by picchilatha of

Medas in the srotas of shakha. Hence pradeepthata of Jataragni is seen

leading for the symptoms like excessive thirst and hunger40.



22

Poorvaroopa

It refers to the features, which indicates the forth-coming disease. It

usually happens during (this corresponds with) fourth kriya kala called “Sthana

samsraya”. Clinically, this is important for early diagnosis, treatment and

prognosis. Mild exhibition of actual features of disease itself can be considered

as Poorvaroopa.

Poorvaroopa is of two types:

1. Samanya poorvaroopa

2. Vishesha poorvaroop

Samanya poorva rupa gives the knowledge about forthcoming disease, but

not regarding the exact disease, where as Vishesha Poorvaroopa gives the

knowledge regarding Dosha as well as the disease.

In the context of present disease, none of the Acharayas have stressed

upon the poorva rupa, but it doesn’t mean that they are absent; in turn it is very

difficult to identify the features of poorva rupa during the process of disease

manifestation. As per the directions given in Vata Vyadhi28, Urakshata29,

Thrushna30 chapters, the initial manifestations of Sthoulya related symptoms

could be considered as the premonitory symptoms or Poorva Rupa of Sthoulya31.

Bahu Drava Sleshma and abhada Meda are two morbid components involved in

pathogenesis of Prameha32, which are found vitiated in Sthoulya also. So Kapha

Sanchaya and Meda Dusti lakshana related Poorvaroopa of Prameha and

Medovaha Srotodusti lakshana described by Acharya Sushrutha33 can be

considered as poorva rupa of Sthoulya.

In contemporary science this is termed as “Premonitory features” as seen

in the conditions like leprosy etc.



23

Rupa

When the Vyadhi kriya kala is in fifth stage (Vyakthavastha), the disease

will produces the features called as “Rupa”. These rupa will indicate the

manifestation of disease34. Rupa is having synonyms like Samsthana, Vyanjaka,

Linga, Lakshana, Chinna, and Akruthi35. Rupa includes both subjective

symptoms as well as objective signs.

This is the stage when Dosha -Dushya Sammurcchana is completed.

Dosha -Dushya Sammurcchana is of two types:

1) Prakruthi Sama Samavetha:

Here the nature of mixing up of Dosha and Dushya is not intensive and

hence both involved in a particular disease continue to maintain some degree of

their identity in resultant disease. Therefore, clinically it is not difficult to

identify the involved Dosha and Dushya based on lakshana.

2) Vikruthi Vishama Samavetha:

The nature of mixing up of Dosha and Dushya are so much intensify that, it

will be very much difficult to assess the Dosha and Dushya involved on the basis

of the lakshana of disease. Ex. In Prameha, “Prabhuta Avila Mutrata” is neither

the feature of Kapha nor the Medas.

Sthoulya is a disease where inspection itself is suffixes for the diagnosis.

In spite of that our Acharayas have explained some of the signs and symptoms,

based on which it can be differentiated from other disorders where enlargement

of body is seen as in case of Sarvanga shotha.



24

The lakshana of Sthoulya had been described under different headings

like:

1. Sthoulya Lakshana36

2. Medo Roga Lakshana37

3. Sthoulya Ashta Dosha37

4. Medo Vrudhi Lakshana38

5. Medovaha Sroto Dusti Lakshana39

All the lakshana can be broadly classified as:

1. Sthoulya Pratyatmaka Lakshana

2. Sthoulya Samanya Lakshana

1. Sthoulya Pratyamtaka Lakshana: The following are the diagnostic features of

Sthoulya:

a) Medo Vridhi (increase in fat)

b) Mamsa Vridhi (increase in flesh)

c) Chala Spik (Pendulous buttocks)

d) Chala Udara (Pendulous abdomen)

e) Chala Sthana (Pendulous breast)

f) Ayatopachayotsaha (sluggish movement of body)

2. Sthoulya Samanya Lakshana:

Rest of the symptoms present in the table shows Samanya lakshana of

sthoulya.



25

Table no.08 Showing Sthoulya lakshana given by different authors:

Sl.No

Lakshana Ch. Sam

Su. Sam

Ma Ni

Yo.Ra

Bh.Pr

Chi. San

Bas. Raji

1 Medo Vridhi + - + + + + + 2 Mamsa Vridhi + - + + + + + 3 Chala Sphik + - + + + + + 4 Chala Udara + - + + + + + 5 Chala Sthana + - + + + + + 6 Ayatopachayotsaha + - + + + + + 7 AyushahRasa + - - - - - - 8 Javaparoda + - - - - - - 9 Krucchra vyavaya + - + + + + + 10 Dourgandha + + + + + + + 11 Dourbalya + - + + + - + 12 Swedadhikyata + + + + + + + 13 Athi kshut + + + + + + + 14 Athi pipasa + + + + + + + 15 Kshudra swasa - + + + + + + 16 Krathana - + + + + + - 17 Gatra sada - + - - - + - 18 Gadgada - + - - - - - 19 Moha - - + + + + - 20 Swapnadhikya - + + + + + - 21 Alpa prana - - - - - + -



26

Upadrava

This manifests in last kriya kala. The condition in which further

development of disease takes place after Rupavastha is called as “Bhedavastha”

or “Upadrava”. 41

Upadrava is mainly due to the chronicity of the disease in which a proper

treatment is not given. Sometimes due to virulence of Dosha-Dushya

sammurcchana, with in a short period, this state is seen.

It is sequel of the main disease. The sequel is so called because it is

consequent of the disease. The main disease is the primary and upadrava are

being secondary. Upadrava may be major or minor ailment when compared with

primary disease. Usually, these will disappear when the primary disease is

treated, but sometimes a separate treatment may require for upadrava due to its

more virulence than the primary disease. Hence, a physician should always be

capable of eliciting upadrava from the Roga and should give a proper treatment

for what so ever is required.

As Sthoulya is an Asadhya Vyadhi, it will always have the tendency to

exhibit upadrava. The concept of Sthoulya Ashta Maha Dosha42 can be

considered as upadrava itself. Here Agni and Vayu are important factors for

upadrava. Prakupita Vata due to its obstruction by Medas will make the

Sandukshana of Agni. This Pradeepta Agni digests the food as quick as fire

burning the forest. Hence there will be Athi kshudha in the Sthoola. If the proper

quality and quantity of food is not supplied to this Teekshnagni, it will produce

hazardous effect, which may cause even death.

Shiva Das Sen commenting on Charaka samhita states that “Vikaram

daruna” should be considered as Prameha, Pidaka, Jwara, Bhagandara, Vidradhi

and Vata Roga.

Dalhana opines that among the said Upadrava any one or all of them may

present while commenting on “Vikarana anyatamam”. Same author on

commenting “Prapya panchatwam upayati” says that the person dies due to



27

upadrava. Bhava mishra and Yogaratnakara have used the word “Sudustara” in

the place of upadrava shabda.

Table no.09 showing the Sthoulya upadrava:

Sl.No

Upadrava Ch.Sam

Su. Sam

As. Hr

Bh. Pr

Yo. Ra

Ba. Raji

Chi.San

1 Prameha + + + + - + + 2 Pidaka + + + + - - - 3 Jwara + + + + - + + 4 Bhagandara + + + + - + + 5 Vidradi + + + + - - - 6 Vata Roga + + - + - - - 7 Udara - - + - - - - 8 Urusthamba - - + - - - - 9 Kusta - - - + - + + 10 Visarpa - - - + + - + 11 Athisara - - - + + - + 12 Arshas - - - + + - + 13 Slipada - - - + + - + 14 Apachi - - - + + - + 15 Kamala - - - + + - + 16 Krimi - - - + - - + 17 Thrushna - - - - - + - 18 Moha - - - - - + - 19 Vrana - - - - - + - 20 Mutra krucchra - - - - - + - 21 Kasa - - - - - + -



28

Sadhyasadhyata

Ancient scholars keeping in view of success rate of treatment have

explained the concept of Sadhyasadhyata. The prognosis of the disease depends

upon the factors like Nidana, Kala, Desha, Bala, Ashraya, and Lakshana etc. If

ritu and Dosha (ritu swabhava Dosha and Vyadhi utpadaka Dosha) are similar

then the disease will be of bad prognosis (few exceptions like Jwara). If Dosha

and Dushya are of similar nature then the disease is Asadhya43 (exceptions like

Kaphaja Prameha). Hence the wise physician must analyze samprapthi ghataka

first, and then start the treatment after explaining the prognosis of the disease to

the patient, or else if he handles the patient with bad prognosis he will lose both

name and fame44. So the knowledge of sadhyasadhyata is essential while

selecting medicine and therapy for the particular disease.

Considering the above general principles, Sthoulya is treated as an

Asadhya Vyadhi as there will be involvement of similar Dosha (Kapha) and

Dushya (Medas). As it is a slow progressive condition continuous medicament

along with general instruction are required. Hence the obese patients are rightly

described under “Ashta nindita purusha”.

Brihatrayi opines that when comparison is made between Krusha and

Sthoola, the Krusha is better for the treatment, because it is difficult to bring

back the Agni, Vata and Medas to equilibrium in case of Sthoulya45.

As it is one of the Beeja swabhavaja Vyadhi, classical texts have considered it as Asadhya for Chikitsa46.



29

Sthoulya Chikitsa

The process by which dhatu samyatha is achieved that is called as

“Chikitsa”. As Sthoulya is a Santarpanajanya Vyadhi, Apatarpana Chikitsa

should be given. To achieve the same our Acharayas have explained different

types of treatment modalities. As Vata, Kapha and Medas are important vitiated

factors in Sthoulya, correction of these should be the main line treatment.

Sthoulya is a multifactorial disease having involvement of factors like guru

Bhojana, athi Nidra etc., which will cause mandata of Meda Dhatwagni and

vridhi of Jataragni, as a result of formation of uttarottara Dhatu will be

hampered. Moreover due to presence of Ama this disease requires holistic

approach to bring the Dosha and dhatu to their samyavastha, which is seen as

“Laghavatha of Shareera”.

The following are the different type of Chikitsa which are applied to treat

Sthoulya

1. Santarpanajanya Vyadhi Chikitsa

2. Satatakarshana Chikitsa

3. Guru cha Atarpana

4. Langhana Chikitsa

5. Pathyapathya with special importance to nidana parivarjana.

Santarpanajanya Vyadhi Chikitsa:

Procedures like Vamana, Virechana, Rakta mokshana, Vyayama,

Upavasa and Swedana are been explained for all the disease, which are

originated because of Santarpanakaraka ahara and vihara. Apart from the above,

other medicines like honey with Haritaki choorna Rooksha Annapana,

Triphaladi quatha, Musthadi quatha and Kustadi choorna47 are also advised to

tackle with Sthoulya.



30

Satatakarshana Chikitsa:

For the Sthoola rogi, karshana should be done continuously. Because of the

karshana there will be depletion of Mamsa as well as Meda dhatu, resulting in

Laghavatha of Shareera48.

Guru cha Atarpana:

This is one of the basic line of treatment, which is mainly adopted, in the

selection criteria dietary drugs for Medasvi. Meaning of “Guru Cha Atarpana” is

that those drugs which are heavy for digestion and having the Atarpana Guna.

As the Jataragni is in Pradeepta avastha, hence guru guna dravya should be

prescribed and at the same time these drugs should not nourish the dhatu. Drugs

having above properties are Prashatika, Priyangu, Shyamaka, Yava, Kodrava,

Mudga, Kulatha Patola, Madhudaka etc.49

Langhana Chikitsa

Acharya Charaka is explained about 10 different types of Langhana,

which can broadly classify as

1. Shodhana rupi langhana

2. shamana rupi langhana

1. Shodhana rupi langhana:

Acharya Charaka has explained about the four types of Shodhana that can

act as Langhana. They are:

a. Vamana

b. Virechana

c. Niruha Basthi

d. ShiroVirechana



31

a. Vamana:

This is the procedure done to expel out the utklista Kapha from the body.

This procedure will aggravate Vata hence application of the same may not be

choice of therapy in Sthoulya.

b. Virechana

This is the choice of treatment for Pittaja vikara and also for Pitta

sthanagata Vata vikara as its action is seen in Pakvashaya also in the form of

Vatanulomana. Hence this can be adoptable in the Sthoola.

c. Niruha Basthi:

To check the vikrutha Vata that is present all over the body, classical texts

have explained about Basthi therapy, as it acts at the root level of Vata. This

Basthi is of two types (Anuvasana Basthi & Niruha Basthi) depending on the

drugs used. In the context of Sthoulya, ancient scholars have explained about the

administration of Niruha Basthi. Among all varieties of Basthi, Lekhana Basthi

stands in the first place to tackle the condition of Sthoulya.

d. Shiro Virechana:

This is done to expel the vikrutha Kapha present above neck. As it is

explained that “Nasa hi shiraso dwaram…” This may not have direct action over

Sthoulya, but it can defiantly helps to overcome some of the features of Sthoulya

like “Athi kshudha”.



32

Pathyapathya

This is the unique contribution of Ayurveda and explained for almost all

diseases. It plays an important role as much as of medicine and it is rightly

mentioned that “if one follow Pathya, than there is no need of medicine and if

not than also there is no use of therapeutic measures”.

Acharya Charaka has stressed upon the Guru and Atarpana drugs as a

special diet for Sthoola, which is already described. Commentators like

Chakrapani50 and Gangadhara51 had mentioned that “sthoka bojana” or “Alpa

bojana” as the best karshana. They have also given weight-age for laghu and

rookshana ahara. Ahara dravya should be used after converting it in guru

through samskara52. The following tables show various Pathya and Apathya

prescription for Sthoola.

Table no.10 showing Ahararupi Pathya - Apathya for Sthoulya:

Ahara varga Pathya Apathya Shuka dhanya Yava, Kodrava Godhuma, Navanna,

shali

Shami dhanya Mudga, Rajamasha, Kulatha, Chanaka

Masha, Tila

Shakha varga Patola, vrunthaka Madhura phala

Dravya Takra, Madhu, ushnodhaka, Sarshapa Taila, Arista, Asava, Jeerna Madya

Dugda, draksha, navaneeta, grutha, dadhi

Mamsa Rohita matsya Anupa, gramya



33

Table no.11 showing Vihararupi Pathya - Apathya for Sthoulya:

Pathya Apathya Srama Jagarana Vyayama Chintana Shoka Krodha Nitya bramana

Divaswapna Avyayama Avyavaya Sukha shayya Nitya harsha Achintana Sheetala jalapana

Review of literature-Obesity


34

Lipids

The term “lipids” is applied to a group of naturally occurring substances

(plant and animal origin) characterized by their insolubility in water, greasy feel

and solubility in some organic solvents.

Lipid in diet:

Lipids are consumed in the form of neutral fats, which are also known as

Triglycerides. Triglycerides are made up of a glycerol nucleus and three fatty

acids. These lipids form the major constituent in food of animal origin and much

less in food of plant origin.

Apart from neutral fats, the usual diet also contains small quantities of

cholesterol and cholesterol esters.

Digestion of lipids:

The enzymes involved in the digestion of lipids are known as lipolytic

enzymes. The tributyrase or gastric lipase present in gastric juice is not sufficient

to digest the lipids due to its weak in terms of quality as well as quantity. The

lipids are actually digested in small intestine. Bile salt takes key role in the

digestion. The other enzyme is pancreatic lipase1.

Role of bile salts:

The lipid molecules are insoluble in water due to its surface tension. So

these molecules are not digested by any of the lipolytic agent. Due to the

detergent action of the bile salts, the lipids are made water-soluble and this

process is called as “Emulsification”. During this process the bile salts cause

formation of aggregation of lipid in the form of “micelles”. The micelles contain

cholesterol, monoglycerides and fatty acids.

Role of Pancreatic Lipase:

It can digest only emulsified fat molecules. Pancreatic Lipase converts

most of the Triglycerides into free fatty acids and monoglycerides but only a



35

small part remains as diglycerides. The action of Enteric Lipase, present in small

intestine mucosa is negligible.

Absorption of lipids:

From the micelles, fatty acids, cholesterol and monoglycerides diffuse

into epithelia; cells in the mucosa of small intestine. The fatty acids with less

than 12 carbon atoms diffuse directly into blood, which transports them through

portal vein to liver as unesterified fatty acids. The fatty acids with more then 12

carbon atoms are converted into triglycerides by re-esterification. Now, the

lipids remaining in the small intestine are aggregated into the chylo-microns by

the activity of Endoplasmic reticulum of the epithelial cells in the intestinal

mucosa. Chylomicrons are mainly formed by Triglycerides and cholesterol

esters and, are coated with layer of cholesterol, Phospholipids and some proteins.

Chylomicrons cannot pass through the blood capillaries because of the larger

size. So these lipid materials enter the lymph vessels and, are transported into

blood from lymph.

Applied physiology:

When digestion and absorption of lipids are affected, the stools become

fatty and bulky. This is called as “steatorrhea”. This occurs due to lack of

pancreatic enzyme during the disorders of exocrine part of pancreas. This

condition is also seen due to the absence of bicarbonate ions in pancreatic juice.

Due to lack of bicarbonate ions, the bile salts are precipitated by the acidity of

the chyme. So the lipids are not digested leading to “steatorrhea.”

Transport of lipids:

Most lipids, such as cholesterol and Triglycerides, are monpolar and

therefore very hydrophobic- molecules. To be transported in watery blood, such

molecules are first made water-soluble by combining them with proteins

produced by the liver and intestine. The combination thus formed is



36

“Lipoprotein”. These are spherical particles that contain hundreds of molecule.

In a lipoprotein, an outer shell of polar proteins plus amphipathic Phospholipids

and cholesterol molecules surrounds an inner core of hydrophobic Triglycerides

and cholesterol ester molecules. The protein in the outer shell are called

“Apoprotein (apo) and are designated by letters A, B, C, D and E plus a number.

Besides helping to solubilize the lipoprotein inn body fluids, each Apoprotein

also has specific functions2.

There are several types of lipoproteins, each having different functions,

but all essentially are transport vehicles: Lipoproteins are categorized and named

mainly according to their density, which varies with the ratio of lipids (which

have a low density) to proteins (which have a high density). From largest and

lightest to smallest and heaviest, the four major classes of lipoprotein are

Chylomicrons, very low-density lipoprotein (VLDL), low –density lipoprotein

(LDL), and high-density lipoprotein (HDL).

The following table no.12 shows different constituents of lipoproteins:

Lipoprotein Protein Triglycerides Phospholipids Cholesterol Chylomicrons 1 – 2 % 85 % 7 % 6 – 7 % VLDL 10 % 50 % 20 % 20 % LDL 25 % 5 % 20 % 50 % HDL 40 – 45% 5 – 10 % 30 % 20 %

Chylomicrons:

These form in mucosal epithelial cells of the small intestine and contain

exogenous (dietary) lipids. They contain small amount of fat-soluble vitamins.

These enter lacteals of intestinal villi and are carried by lymph into venous

blood (hence the milky appearance for plasma), and then into systemic

circulation.

Very low-density lipoprotein (VLDL):

These forms in hepatocytes and contain endogenous Triglycerides. They carry

Triglycerides, which are synthesized in hepatocytes to adipocytes. After



37

depositing some of their Triglycerides in adipose cells VLDL are converted to

LDL

Low-density lipoprotein (LDL):

They carry about 75 % of total cholesterol in the blood and deliver it to

cells through out the body for use in repair of cell membranes and synthesis of

steroid hormones and bile salts. The only Apoprotein LDL contain is apo

B100, which binds to LDL receptors for receptor – mediated endocytosis of

LDL into a body cell. Within the cell the LDL is broken down, and the

cholesterol is released to serve the cell’s needs. Once a cell has sufficient

cholesterol for its activities, a negative feed back system inhibits the cells

synthesis of new LDL receptors. When present in excessive numbers, LDL

will also deposit cholesterol in and around smooth muscle fibers in arteries,

forming fatty atherosclerotic plaques that increase the risk of coronary artery

disease. For this reason, this cholesterol of LDL is called as ‘bad’ cholesterol.

As some people have too few LDL receptors, their body cells cannot remove

LDL from the blood; as a result their plasma LDL level is abnormally high and

they are more likely to develop vascular diseases. Moreover eating high fat diet

increases production of VLDL inturn results in elevated LDL levels.

High-density lipoprotein (HDL).

It removes excess cholesterol from body cells and transports it to the liver

for the elimination. As this HDL prevents accumulation of cholesterol in the

blood, a high HDL level is associated with decreased risk of coronary artery

disease and hence it is rightly termed as ‘good cholesterol’.

Source and significance of blood cholesterol:

There are two source of cholesterol:

1. Food

2. Synthesized by liver



38

Food products like eggs, milk products, meat, beef, and pork. Etc. are the

rich source of cholesterol. Fatty foods in spite of devoid of any cholesterol will

still dramatically increase blood cholesterol level in two ways. First, a high

intake of dietary fats stimulates reabsorption of cholesterol containing bile back

into the blood, so less cholesterol is lost in the feces. Second, when saturated fats

are broken down in the body hepatocytes use some of the breakdown products to

produce cholesterol.

Liver and lipids:

Function of liver in fat metabolism3:

A very high rate of oxidation of fatty acids to supply energy for other

bodily functions

Formation of most of the lipoprotein.

Synthesis of large quantities of cholesterol and Phospholipids.

Conversion of large quantities of carbohydrates and proteins into fat

80% of cholesterol is synthesized in liver is converted into bile salts which

in turn are secreted into the bile. The remainder is transported in the lipoprotein,

which are carried by blood to the tissue cell everywhere in the body.

Exercise and lipids:

Most of the energy is derived from carbohydrate during the first few

seconds or minutes of exercise, but at the time of exhaustion, as much as 60-85%

of energy is derived from fats rather than carbohydrates.

Assessment of blood cholesterol:

In Laboratory blood cholesterol are assessed under lipid profile test.



39

The following table no.13 shows the normal limits of blood cholesterol.

Sl.No. Blood Cholesterol Normal (Mg/Dl) High Risk 1 Total cholesterol < 200 > 239 2 LDL <130 > 159 3 HDL > 40 - 4 Triglycerides 10 - 190 -

LDL cholesterol is calculated as follows:

LDL = TC – HDL – (Triglycerides / 5)

If the above mentioned normal range is exceeded then the condition is

termed as Hyperlipidemia.

Treatment for Hyperlipidemia:

The following are the types of treatment for the Hyperlipidemia

Non-pharmacological measures, which includes low-fat diet exercise.

Pharmacological measures by using the drugs like Lovastatin (which

block a key enzyme needed for the cholesterol synthesis.), colestipol (it

promotes the excretion of bile in the feces.)

The fate of lipids:

Lipids, like carbohydrates, may be oxidized to produce ATP. If the body

has no immediate need to use lipids in this way, they are stored in adipose tissue

(fat depots) through out the body and in the liver. A few lipids are used as

structural molecules or to synthesize other essential substances like

Phospholipids (constituents of plasma membrane), lipoproteins (to transport

cholesterol) and thromboplastins (for blood clotting).

Triglycerides storage:

A major function of adipose tissue is to remove Triglycerides from

Chylomicrons and VLDL and to store them until they are needed for ATP

production in other parts of the body.



40

The following table (no.14) shows the distribution of adipose tissue.

SL.NO STORAGE SITE OF TRIGLYCERIDES PERCENTAGE 1 Subcutaneous layer 50 % 2 Around kidneys 12 % 3 In omenta 10 – 15 % 4 In genital area 15 % 5 Between muscles 5 – 8 % 6 Behind eyes 5 %

Triglycerides in adipose tissue are continually broken down and re-

synthesized. Thus the Triglycerides stored in adipose tissue today are not the

same molecule that were present last month because they are continually

released from storage, transported in blood, and re-deposited in other adipose

tissue cells.

Regulation of energy release from Triglycerides:

When excess quantities of carbohydrates are available in the body

carbohydrates are used preferentially over Triglycerides for energy. There are

several reasons for this “Fat-sparing” effect of carbohydrate.

Lipid catabolism- lipolysis:

Triglycerides stored in adipose tissue constitute 98% of all body energy

reserves. They are stored more readily than is glycogen, in part because

Triglycerides are hydrophobic and do not exert osmotic pressure on cell

membranes. Several tissues (muscle, liver and adipose tissue) routinely oxidized

fatty acids derived from Triglycerides to produce ATP; they must be split into

glycerol and fatty acids. This process is called as “lipolysis” (li-pol-i-sis) i.e.

catalyzed by enzymes called lipases. Two hormones that enhance Triglycerides

break down into fatty acids and glycerol, are “Epinephrine” and

“Norepinephrine”, which are realized when sympathetic tone increases, as

occurs during exercises. Other lipolytic hormones are cortisol, thyroid hormones

and insulin like growth factors. Insulin itself inhibits lipolysis.



41

The glycerol and fatty acids that result from Liposis are catabolised via

different pathways. Glycerol is converted to glyceraldehyde 3-phosphate by

many cells of the body; one of the compounds also forms during the catabolism

of glucose. If ATP supply in a cell is high, glyceraldehyde 3- phosphate is

converted into glucose, an ex of gluconeogenesis.

Even collectively all of the manipulations to increase the blood glucose

are inadequate to provide energy supplies for prolonged fasting periods. Luckily

the body can adopt to burn more fats and proteins, which enter the Krebs cycle

along with glucose, break down products. The increased use of non-carbohydrate

fuel molecules (especially Triacylglycerols) to conserve glucose is called as

“glucose sparing’ 3. As the body progress from the absorptive to the post-

absorptive state, the brain continues to take its share of blood glucose but

virtually every other organ switches to fatty acids as its major energy sources,

thus sparing glucose for the brain. During this transition phase, lipolysis begins

in adipose tissues and realized fatty acids are picked up by tissues cells and

oxidized for energy. In addition the liver oxidizes fats to ketones and releases

them into the blood for use by tissues cells. If fasting continues for longer then 4

or 5 days the brain too begins to use large quantities of ketones bodies as well as

glucose as its energy fuels.

Lipid anabolism: Lipogenesis:

Liver cells and adipose cells can synthesis lipids from glucose or amino

acid through Lipogenesis, which is stimulated by insulin. Lipogenesis can occur

when a person consumes more calories than are needed to satisfy their ATP

needs. Excess dietary carbohydrates, proteins and fats all have the same fate.

They are converted into Triglycerides. The glycerol and fatty acids can undergo

anabolic reactions to become Triglycerides that can be stored or they can go

through a series of anabolic reactions to produces other lipids such as

lipoproteins, Phospholipids, and cholesterol.



42

Etymology

The word Obesity is derived from Latin term “obesus” which means:

Ob → by reason of

Edo → I eat

Obesus → having eaten or having eaten until fat

Obesity → grossly fat

Definition:

It is defined as “an abnormal growth of the adipose tissue due to an

enlargement of fat cell size (hypertrophic) or an increase in fat cell number

(hyperplastic) or a combination of both.

Other definitions of obesity are as follows:

It is a state in which there is a generalized accumulation of fat in the body

leading to more than 20% of the desirable weight.

Obesity is defined as BMI (Body Mass Index) above 25.

Obesity is a pathological condition characterized by an accumulation of

body fat much in excess than that of necessary for optimal body function.

It implies an excess storage of fat.

Most patients suffer from simple obesity but in certain conditions, it is an

associated feature. Even in later situation the intake of calories must be

exceeding expenditure. Hormonal imbalance is often incriminated in women (ex.

Post menopause or when taking contraceptive pills), but most of the weight gain

in such cases is usually small and due to water retention.



43

Synonyms of obesity Synonyms of obese

Plumpness Fatty

Stoutness Stout

Fatness Corpulent

Over Weight Buxom

Adiposity Pert

Adiposis Pulp

Liposis. Rotund

Prevalence:

It is most prevalent form of malnutrition in developed countries affecting

adults as well as children. Obesity is a major public health problem in the

industrialized countries. It is extremely difficult to assess the size of the problem

and compare the prevalence rates among the countries, as no exact figures are

available4. The other reason for the same is lacking of standardization of

definition of obesity. However it has been estimated that twenty to forty percent

of adults suffer from this disease in the developed countries like USA, UK. It is

shown that fifty three percent of men aged twenty to seventy four and 1.3 to 1.5

times women are obese in USA. These people spend 30-40 billion dollars every

year on weight loss treatment.

In developed countries this disease is more commonly seen in low socio-

economic people where as in developing countries it is seen in higher socio-

economical groups. A small study conducted recently in urban Delhi5 shown

20% of men and 27.1% of women are obese (BMI > 25).



44

AETIO-PATHOGENSIS

The causes of obesity can be studied under three heading as it is usually done

while dealing with the prevention of communicable as well as non-

communicable disease. The three causative factors are referred to as

“Epidemiological Triad”. They are:

1. Agent factor

2. Host factor

3. Environmental factor.

In the disease Obesity, it is very difficult to separate all of these factors under

different headings, as they are inter-related with each other. An attempt is made

to understand these things as separate entities as much as possible.

1. Agent factor:

In the disease the agent is defined as “a substance, living or non-living, or a

force, tangible or intangible, the excessive presence or relative lack of which

may initiate or perpetuate a disease process”4.

The disease agents of obesity can be classified as follows:

a) Nutrient agents:

The eating habits of obese people are variable. Some eat three large meals a

day, while other eats frequently five to six times a day. In both the cases

excessive food intake is the cause for obesity. Not all obese patients eat more

than average person, but all obviously eat more than they need. The foodstuff

rich in fats are the key factor in the development of the disease. Even diets rich

in simple sugars are also have definite role in the manifestation.



45

It has been shown that obese patient eat more than they admit to eating, and

over the years very small daily excess can lead to a large accumulation of fat.

For example, 10.5 kcal excess would lead to a 10 kg weight gain over 20 years.

b) Social agents:

This disease is present more in effluent class of people in developing

countries and in low socio-economic group in developed countries. As the poor

people in developed countries can’t offer balanced diet, they are more prone to

get affected. Due to increased sedentary life styles and frequent social kitty

parties the people of economically rich group are affected in developing

countries.

2. Host Factor:

This is the intrinsic factor and is broadly classified as:

I. Demographic characteristic like age, sex and ethnicity.

II. Biological characteristic such as genetic factors, bio-chemical levels

of blood and enzymes, physiological function of different organ

systems of the body.

III. Social and economic characteristic like socio-economic status,

education, occupation, stress etc.

IV. Life style factors such as living habits, physical exercises, use of

alcohol, drugs and smoking, behavioral patterns etc.

☻Age and sex:

Obesity can occur at any age and generally increase with age. It has been

well established that most adipose cells are formed earlier in life. Over feeding

during infancy and early childhood by over enthusiastic mothers can be an

important cause of obesity in adolescence and adults. It occurs in either sex and

it is found that men gain weight between the ages of 29-35 while women gain

most between 45-49 years of age. Women are more prone than men in gaining

weight.



46

☻ Genetic factors:

It is very difficult to assess the role of genes in the manifestation of

obesity. But it is seen commonly in families. Re-feeding experiments in

monozygotic and dizygotic twins feed together or apart, suggest that genetic

influences account for 70% of the difference in Body Mass Index (BMI) later in

life. Genetic factors have led to the discovery of a mutative gene, firstly in the

obese (ob ob) mouse and now in humans. The ob gene was shown to be

expressed solely in both white and brown adipose tissues. The ob gene is found

on chromosome 7 and produce 16kDa protein called Leptin. In animal

experiment it has been proved that massively obese mouse; Leptin mRNA in

subcutaneous adipose tissues is 80% higher than in controls. There are a number

of known genetic conditions such as Prader-willi syndrome and mutation in the

Leptin gene, which produce a syndrome complex associated with obesity.

The following table (no.15) shows the role of different genes in

manifestation of obesity6:

GENE GENE PRODUCT MECHANISM Lep Leptin, a fat-derived hormone Mutation prevents Leptin from

delivering satiety signal; brain receives starvation

LepR Leptin receptor As above

POMC Proopiomelanocortin, a precursor of several hormones and neuropeptide

Mutation prevents synthesis of melanocytes-stimulating hormone(MSH) as satiety signal

MC4R Type 4 receptor for MSH Mutation prevents reception of satiety signal from MSH

PC-1 Prohormone convertase 1, a processing enzyme

Mutation prevents synthesis of neuropeptide, probably MSH

Whatever the role of genes may be, it is clear that environment plays an

important role, as evidenced by the fact that famine prevents obesity even in the

most obesity prone individual.



47

☻Bio-chemical levels of blood and enzymes:

a). Leptin:

Plasma levels of Leptin are also very high, correlating with BMI. But in

human experiments have proved that abnormalities in Leptin are not the prime

cause of human obesity. Leptin secreted from fat cells could act as a feed back

mechanism between the adipose tissue and the brain, acting as a “Lipostat”

(adipostat), controlling fat stores by regulating hunger and satiety7.

Leptin is a 16-kD protein that plays a critical role in the regulation of

body weight by inhibiting food intake and stimulating energy expenditure.

Defects in Leptin production cause severe hereditary obesity in rodents and

humans. In addition to its effects on body weight, Leptin has a variety of other

functions, including the regulation of haematopoiesis, angiogenesis, wound

healing, and the immune and inflammatory response. The LEP gene is the

human homolog of the gene (ob) mutant in the mouse 'obese' phenotype.

A Leptin receptor has been found in the ventromedial nucleus of the

hypothalamus and it is possible that changes in this receptor impair the effect of

Leptin. This would lead to a decrease in the release of transmitters such as

neuropeptide Y, so that appetite would not be suppressed, interfering with the

feedback mechanism.

b). Control of appetite:

This is complex and depends partly on external stimuli, such as the

company, the type of food, the surroundings and the person’s habitual behavior.

Appetite is the desire to eat and this usually initiates food intake. Following a

meal, satiation occurs. This depends on gastric and duodenal distention and the

release of many substances. Following a meal, cholecystokinin (CCK),

Bombesin and Somatostatin are released from the small intestine and glucagons

and insulin from the pancreas. All of these hormones have been implicated in the

control of satiety. Centrally the hypothalamus – particularly the Para ventricular

nucleus and the ventromedial wall – is thought to be the main satiety center.

Numerous neurotransmitters (like CCK, opioids, serotonin, corticotrophin-



48

releasing hormone and particularly neuropeptide Y) have a role in the central

control of satiation.

c). Thermogenesis:

Brown adipose tissue in animals8, when stimulated by cold or food,

dissipates in the form of heat the energy derived from ingested food. This can be

a major component of overall energy balance and it has been suggested that this

may also apply to humans.

A β3-Adrenergic receptors6 are the principle receptors mediating

catecholamine- stimulated lipolysis in brown and white fat tissue. After a meal

or exposure to cold, relatively high concentrations of noradrenalin are released,

stimulating the low-affinity receptors in brown adipose tissue. Low β3-

Adrenergic receptor activity would decrease Thermogenesis and this can explain

why most obese patients require a very low calorie intake to maintain any weight

loss, and gain weight easily after only small calorie increases. Decreased

function of the receptors in white adipose tissues could slow lipolysis-causing

retention of lipid in fat cells. As β3-Adrenergic receptors are more frequent in

visceral adipose tissues, this would explain the regional distribution of fat in

obese subjects.

☻Occupation:

Obesity is seen more in the people associated with sedentary life style

occupations such as clerks, managers, housewives etc.

☻ Life style factors -Physical activity:

Obesity is rarely seen among persons who lead active lives. It is very

common in those who lead sedentary lives. With extensive use of transport

facilities and mechanization of industry, the proportion of people who take

adequate exercise has decline and the number of persons leading sedentary lives

has been increasing. Obese patients tend to expend more energy during physical

activity as they have a larger mass to move. On the other hand, many obese



49

patients decrease their amount of physical activity. The energy expended on

walking at three miles per hour is only 3.7 kcal/min and therefore increase in

xercise plays only a small part in loosing weight. Uses of alcohol frequently will

cause deposition of adipose as one gram of alcohol gives 7 kcal of energy.

☻ Drugs:

Some of the drugs like Corticosteroids; Sulphonilureas etc. will cause

obesity in long-term use. The drugs, which are used to treat psychological

diseases like Carbamazepine, Phenobarbitone plays a key role in the

manifestation of the disease- obesity.

3. Environmental factors:

This is an extrinsic factor that includes all that which is external to the

individual human host, living and non-living and with which he is in constant

interaction. This factor is again divided into:

Physical environment:

This includes air, water and food. In Obesity only food factor is

applicable which is already discussed.

Biological environment:

It includes universe of living things, which surrounds man like microbes,

insects, animals and plants. All theses may not be applicable for Obesity.

Psycho-social environment:

It covers a complex of Psychosocial factors which are defined as “those

factors affecting personal health, health care and community well being”. These

are cultural valves, customs, habits, beliefs, attitudes, morals, religion,

education, lifestyles, social and political organization.

During some of the religious fests, sweets and oily rich recipes will

provide additional calories to man and will make him to suffer from Obesity in



50

future. The country like India is rich in many customs and religious festivals and

people of this country are more prone to get this disease when compared with

other countries.

Types of obesity

In simple the Obesity can be classified as:

1. Exogenous obesity: A common form due to excessive intake of food. The

distribution of fat is uniform, although somewhat excessive under the chin

(double chin) and the abdomen. This is also termed as simple obesity or

primary Obesity.

2. Endogenous or glandular obesity: when being overweight is the primary

complaint, an endocrine disorder is seldom the cause. This is also known as

secondary Obesity9.

Obesity may be mild, moderate or severe, or as described by one author,

“enviable”, “regal” or “pitiable”.

The manner of distribution of fat may be of some diagnostic value.

Distribution of fat:

1) Generalized type usually seen in alimentary or exogenous type.

2) Central or trunk type, involving only the trunk and neck. Ex: Cushing’s

syndrome and Hypothyroidism.

3) Superior or buffalo type, involving the face, neck, arms and upper part of

trunk. Ex Cushing’s syndrome and Hypothyroidism.



51

4) Inferior type, involving the lower part of trunk and legs (called

lipodystrophia when accompanied by wasting of upper half of the body)

5) Girdle type, involving the hips, buttocks, abdomen and with a “fatty

apron”, seen in pituitary or hypothalamic disorders.

6) Breeches or Trochanteric type, involving only the buttocks, as in the

“Hottentots negro”, seen in Hypogonadal obesity.

7) Lipomatous type or multiple lipomataosis, with localized deposits of fat

over the body (called Dercum’s disease or adiposis dolorosa when

associated with tenderness and pain over the fatty lumps).

Assessment of obesity

For the assessment of Obesity many formulations had been put forward.

The following are different methods to assess the obesity in terms of weight and

fat.

1. Body weight:

It is not an accurate measure to calculate excess fat, but is widely used

index. In epidemiological studies it is conventional to accept +2 S.D (standard

deviation) from the median weight for height as a cut-off point for obesity.

For adults, various other indicators are mentioned as follows:

a.) Body Mass Index (Quetelet’s Index):

= Weight in Kg / height in meter square. (Kg / m2)



52

Table no. 16 showing the interpretation of BMI4:

SL. NO.

BMI STAGE COMMENTS

1 < 16.00 Grade III thinness High mortality 2 16.0-16.99 Grade II thinness High mortality 3 17.0-18.49 Grade I thinness Moderate mortality 4 18.5-24.99 Normal range Healthy 5 25.0-29.99 Grade I obesity Moderate mortality 6 30.0-39.99 Grade II obesity High mortality 7 > 40 Grade III obesity High mortality

b). Ponderal index10:

= Height in centimeters / cube root of body weight i.e. cms / kg1/3

c.) Broca index:

= Height in centimeters minus hundred (i.e. cms-100)

d.) Lorentz’s formula:

= Height in centimeters – 100 - height in centimeters – 150

Divided by 2 for women and 4 for men.

For women: Cms-100- Cms-150

2

For men: Cms-100- Cms-150

4

e.) Corpulence index:

= Actual weight divided by desirable weight.

This should not exceed 1.2

The B.M.I and the Broca index are widely used. A recent

FAO/WHO/UNO reports gives the much needed reference tables for B.M.I,

which can be used internationally as reference standards for assessing the

prevalence of obesity in a community. BMI is better index of obesity compared

with percent weight chart because it obviates the need for weight-height chart



53

and unlike the later, is not affected by type of body built like light, medium and

heavy.

2. Skin Fold Thickness (SFT):

A large proportion of total body fat is located just under the skin. Since it

is most accessible, by measuring skin fold thickness obesity can be measured. It

is a rapid and “non-invasive” method for assessing body fat. Several varieties of

calipers like Harpenden skin calipers are available. But considering its cost,

Vernier calipers are used compromising for slight variation. The measurements

are taken at following sites11:

a. Mid triceps

b. Biceps

c. Sub scapular and

d. Suprailiac region.

The sum of the measurements should be less than 40 millimeters in boys

and 50 millimeters in girls or Triceps SFT alone is considered for assessment

and >18 and >32 mm in men and women respectively denotes obesity. Recent

evidence indicates that SFT used in west is not applicable in India.

Unfortunately standards for subcutaneous fat do not exist for comparison. More

over in extreme obesity measurement may not be possible and main draw back is

its poor repeatability.

3. Waist – hip ratio (WHR):

This is the waist circumference in centimeters divided by the hip

circumference in centimeters. The waist circumference is usually measured

halfway between the superior iliac crest and the rib cage in the mid-axillary line.

Where as the hip circumference is measured one-third of the distance between

the superior iliac spine and the patella.

WHR in central distribution of body fats i.e. a waist hip circumference

ratio of more than 1 in men and more than 0.9 in women is associated with a



54

higher risk of morbidity and mortality than is a more peripheral distribution of

body fat i.e. WHR less than 0.85 in men and less than 0.75 in women.

The ratio of waist circumference to height or measuring the sagittal

diameter of the abdomen at the level of L4 / L5, provides a useful index of intra-

abdominal fat content. The diseases associated with abdominal obesity include

hypertension, Hyperlipidemia, insulin resistance, diabetes mellitus and cardio-

vascular diseases

4. Others:

In addition to above, three well established and more accurate

measurement is used for estimation of body fat. They are measurement of total

body water, measurement of total body potassium, measurement of body density

and index of lean (non-fat) mass, or impedance analysis. This impendence

depends on the difference in electrical resistance between lean tissue and fat.

Normal body fat content of an adult is 10-20% in men and 20-30% in

women.

The techniques involved are relatively complex and cannot be used for

routine clinical purpose or for epidemiological studies. Abdominal fat can be

measured using CT or MRI.

The introduction of measuring fat cells has opened up a new field in

obesity research.

Above all just a simple look towards an undressed patient is sufficient to

diagnosis the condition.

Morbidity and Mortality:

Greater the obesity higher the morbidity and mortality rates8. For

example, men who are 10% over weight have 13% increased risk of death, while

increase in mortality for those 20% over weight is 25%. The raise is less in

women and in men over 65 obesity is not an independent risk factor. Weight

reduction reduces this mortality and therefore should be strongly encouraged.



55

Complication of Obesity

The following are the list of complications of Obesity11:

Type 2 diabetes mellitus

Hypertension

Stroke

Hyperlipidemia

Coronary heart diseases

Gall stones

Arthritis of hip, knee and foot

Varicose veins

Breathlessness

Sleep apnoea

Infertility

Hirsutism

Abdominal hernia

Depression

Cancers of breast, endometrium, ovaries etc.



56

TREATMENT

The treatments of Obesity can be studied under the following heading:

1. Non-pharmacological measures including dietary control and Behavioral

Modification

2. Pharmacological measures

3. Surgical measures.

1. Non-pharmacological measures:

☻Dietary control:

This largely depends on a reduction in calorie intake. The most common

diets allow a daily intake of approximately 4200 k joules (1000 k cal), although

this may need to be nearer 6300 k joules (1500 k cal) for someone engaged in

physical work12. A diet that is too low in total calories will usually result in the

patient cheating and keeping to the diet only for short periods. Patients must

realize that prolonged dieting is necessary for large amounts of fat to be lost. A

permanent change in eating habits is required to maintain the new low weight. It

is relatively easy for most people to lose the first few kilograms, but long-term

success in moderate obesity is poor, with an overall success rate of no more than

10%.

The aim of any dietary regimen is to lose approximately 1 kg per week.

Weight loss will be greater initially owing to accompanying protein and

glycogen breakdown and consequent water loss. After 3-4 weeks, incremental

weight loss may be very small because only adipose tissue is broken down and

there is no accompanying water loss.



57

Patients must understand the principles of energy intake and expenditure.

The best results are obtained in educated, well-motivated patients.

An increase in exercise will increase energy expenditure and should be

encouraged - provided there is contra-indication – since weight is usually not

achieved without exercise. Weight cannot be lost by exercise alone. Regular

exercise, however, will improve general health and often enables patients to

control their diet.

The diet should contain adequate amount of each nutrient. A diet of 1000

kcal per day should be made up of approximately 100 gm of carbohydrate, 50

gm of protein and 40 gm of fat. The carbohydrate should be in the form of

complex carbohydrate such as vegetable and fruit rather than simple sugars.

Alcohol contains which provides 7 kcal per gm, should be discouraged. A

balanced diet, attractively presented, is of much greater value and safer than any

of the slimming regimens.

☻ Exercise:

An increase in exercise will increase energy expenditure and should be

encouraged - provided there is contra-indication – since weight is usually not

achieved without exercise. Weight cannot be lost by exercise alone. Regular

exercise, however, will improve general health and often enables patients to

control their diet.

☻Behavioral Modification:

Behavior therapy is a term, which covers wide variety of treatment at

approaches. This therapy is based on an attempt to produce permanent changes

in behavior by involving the patient in his own management. Obese persons are

addicted by some behavioral pattern. This living pattern invites obesity, so that

this therapy guides the patients to observe his current life style, eating habit,

activities etc, and encourage changing it. The programs includes monitoring



58

intake, modifying causes that signal “inappropriate eating”, modifying the act of

eating itself, increasing exercise and self reward for more appropriate behavior.

Self monitoring means keeping a written record of every thing eaten, the

circumstances in which it was eaten.

Elimination the case that signal inappropriate eating including controlling

the environment in which the person is e.g. changing habit such as watching TV

or studying, eating at late nights. These are all common problems of an obese

person.

Most obese people oscillate in weight; they often regain the lost weight,

but many manage to lose weight again. This cycling in body weight may play a

role in the development of coronary artery disease.

2. Pharmacological measures:

The following table (no.17) shows the drugs, their mode of action and

adverse effects:

DRUG ACTION ADVERSE EFFECTS Fenfluramine Acts through serotinergic

system in brain Primary HTN Valvular heart disease

Dexfenfluramine As above As above

Phentermine Acts centrally by reducing appetite

As above

Sibutramine Reuptake inhibitor of Norepinephrine

Cannot be used for long term

Orlistat Inhibition of intestinal lipase- malabsorption of fat

Cannot be used for long term

All these drugs can be used in the short term (max. of three months) as an

adjunct to the dietary regimen6.



59

Some of the researches are going on β3-Adrenergic receptors agonists

may provide a new ray of hope for obese patients.

Surgical Measures:

Surgery to obese patients is indicated when their BMI exceeds 40.

Operations that involve bypassing parts of the small intestine have fallen out of

favour because of their side effects. Three procedures are in practice in the

condition of morbid obesity.

1.Wiring the jaws to prevent eating by which only liquids are allowed to

consume.

2.Gastric plication through which a pouch is constructed by stapling across

the wall of the stomach.

3.Gastric balloon is placed endoscopically inside the stomach and inflated.

Review of literature-Udvarthana


60

Nirukthi:

The word Udvarthana is derived from the root

ud + vrith + bhavae + karaneva lyud

This means vilepana or Gharshana.

Paribhasha:

In simple words, Udvarthana means rubbing of the body. It is a cleaning

procedure. It cleans Mala of skin by using drugs of fragrance.

It is described as one of the Rookshana karma. The word meaning of

Rookshana is making thin or the art of making thin. Acharya Charaka explains

this Rookshana as one among the Shadvidhopakrama. The drugs having the

qualities of Rooksha, Laghu etc are used for the procedures of Rookshana1. The

characteristic feature of Rookshana karma is that it surely prevents the outflow

of substance irrespective of the nature of their mobility1a.

Many a times Langhana karma is confused with Rookshana karma

because of much similarity of guna of both the dravya and similarities in the

treatment effects.

Table no.18 shows the difference between Langhana and Rookshana

Langhana Rookshana Gourava abhava Sneha abhava

Laghu guna pradhana Rooksha guna pradhana

Dravya & adravya bhuta(ex.upavasa) chikitsa Only dravya bhuta chikitsa

Sara guna present in drugs Sthira guna present in drugs

The dravyas of Rookshana karma will be dominated with Vayu pradhana,

Agni and pruthvi mahabhuta2 and it is having kashaya pradhana, katu tikta rasa.

The examples are yava and takra.



61

Table no 19 showing various effects of Rookshana karma:

Effects

Dosha Vata vardhaka, Kapha nashaka

Dhatu Vikruta Dhatu soshana, Balya, Varnya

Mala Shoshana (dravamsha of mala)-performs sthambhana karma

Table no.20 showing Samyak Rookshana Lakshana

Lakshana Cha.sam3 Su.sam4 As.hr5 As.Sa6

Samyak vata, mutra, mala Pravritti + + - -

Hridaya Shuddhi + - + +

Udgara Shuddhi + - + +

Kanta Shuddhi + - + +

Aasya Shuddhi + - - -

Indriya Prasannatha - + + +

Tandra Nasha + - + +

Klama Nasha + - - -

Sweda + - - -

Ruchi + - + +

Kshuth Sahodaya + + + +

Pipasa Sahodaya + + + +

Vyadhi Mardhava - - + +

Utsaha - - + +

Nirvyathe Antharatma + - - -

Gatra Laghuta + + + +

Table no.21 showing Rookshana athi yoga lakshana.

Lakshana Ch.sam7, 8 Su.sam9 As.hr10 As.sa 11

Parva Bheda + - - -

Anga Marda + - - -

Kasa + + + +

Mukha Shosha + + - -

Kshuth Pranasha + - + +

Aruchi + - - -

Trishna + + + +

Shrotra Netra Dourbalya + - + +



62

Urdva Vata + - + +

Tamo Vrudhi + - - -

Deha Bala Nasha + + - -

Agni Bala Nasha + - + +

Tandra - + - -

Anidra - + + +

Bhrama - + - -

Klama - + - -

Swara Kshaya - + - -

Chardi - + + +

Hikka - + + +

Swasa - + + +

Arochaka - - + +

Sneha Kshaya - - + +

Shukla Kshaya - - + +

Oja Kshaya - - + +

Swara Kshaya - - + +

Basti Rukh - - + +

Hridaya Rukh - - + +

Murdha Rukh - - + +

Jangha Rukh - - + +

Uru Ruja - - + +

Trika Ruja - - + +

Parshva Ruja - - + +

Jwara - - + +

Pralapa - - + +

Glani - - + +

Para Asthi Bhedana - - + +

Varcho Mutra Graha - - + +

Jrumbha - - + +



63

Table no.22 showing Rookshana Ayoga Lakshana12, 13

Lakshana Ch.sam

AOUSHADANAM DHATUNAM ASHAMO (No relief from the diseases treatable from upakrama)

+

ROGA VRIDHI (Aggravation of diseases) +

Shodhana Ayoga +

Ruthu Anusara Rookshana:

Rookshana is indicated in Vasantha Ruthu in which Udvarthana with

Rooksha dravya, which are having kaphagna property, is beneficial14,15 .

Modes of administration of Rookshana can be broadly classified as:

1.Bahya Rookshana 2. Abhyantara Rookshana

Bhahya Rookshana can be achieved by doing Udvarthana, Lepa etc.

Abhyantara Rookshana can be achieved by administering:

Pana – Takrapana etc.

Anna – Yavanna etc.

Beshaja – Triphala Kwatha, Takrarishta etc. and

Beshaja upakrama – Rookshana / Lekhana Basti.

In this way the concept of Udvarthana is understood through Rookshana

karma.



64

Historical background

The concept of Udvarthana is as explained right from the oldest textbook

charaka samhita and all most all the other authors had explained this Rookshana

karma.

1. Charaka Samhita:

Basically Acharya Charaka explains this Udvarthana in the context of

Dinacharya as Shareera Parimarjana. He says that it destroys Shareera

Dourgandhya, Gurutwa, Tandra, Kandu, Arochaka, Sweda, etc. He advocates

that Udvarthana karma should be done before Abhyanaga so as to maintain

health.

2. Sushruta Samhita:

Acharya Sushruta explains that Udvarthana helps to bring back the

Vikrutha Vayu to its normalcy. It decreases the fat and Vikrutha Kapha. It also

provides smoothness and cleans to the skin and gives firmness to the body. He

further mentions that it also dilates the orifices of Sira and stimulates Brajaka

Pitta. He is the first person to document the types of Udvarthana.

3. Astanga Hrudaya:

As per Acharya Vagbhata Udvarthana normalizes Vikrutha Kapha and

liquefies the Medas. It provides firmness to body, smoothness to skin and

increases the complexion of the skin.

In Sarvanga sundari vyakhya it is described that Pravilayana refers to the

dravikarana of Medas followed by making it Shoshana. The commentator has

also mentioned about the usage of Kashaya choorna for Udvarthana, hence he

defines Udvarthana as “ Udvarthanam kashayadi choorna Gatra karshanam”

i.e. giving friction to the body by kashaya choorna is called as Udvarthana.

4. Yogaratnakara:

In the context of “Nitya pravruthi prakarana” author has mentioned that

Udvarthana normalize the increased Kapha and diminishes Medo dhatu. It



65

increases Shukra dhatu, gives strength to body, increase blood formation,

increases body complexion and makes skin smooth. The text also explains

about “Mukhodvarthana”.

Classification:

Udvarthana can be classified as two types:

1. Udgharshana

2. Utsadana

1. Udgarshana (Reinforced friction):

“Ud + Grashana gathradi karshanam”

Acharya Dalhana says that “rubbing the body with powdered medicine

without mixing oil or other Drava dravya is called as Udgarshana”16.

Benefits: Vata Shamana, Kandu- Spota- Pidika nashaka, Sira shodhaka, Twak

gata Agni vardaka, stimulates Brajaka Pitta.

Friction of body with brick powder excites the heat of skin, destroys

itching and rashes etc.

2. Utsadana (Rubbing):

It is defined as: “Sasneha Kalkenodgarshanam Utsadanam”

i.e. friction of body with drugs containing sneha or medicine mixed with oil or

other dravya in the form of kalka is called as Utsadana. The benefits of this are:

it improves complexion of females, gives good appearances, cleanliness, and

beautification.

Difference between Abhyanga and Udvarthana:

The main difference of Udvarthana from Abhyanga is that Udvarthana is

done in upward direction (prathiloma gathi) and Abhyanga is done in downward

direction (anuloma gati). However the main intention behind Udvarthana is to

bring the Rookshana in the body.



66

The procedure that mimics the Udvarthana is Mardhana:

Acharya Dalhana comments Mardhana as:

“ Mardhanam tu gatam padabyama arambham kati parayatham”.

i.e. Mardhana is a process of giving deep pressure from foot to waist, which is in

prathiloma gathi. However Mardhana is being considered as a type of Abhyanga

(as sneha dravya are used).

Over all the benefits of Udvarthana as mentioned in different classical

texts are as follows:

Table no.23 Showing benefits of Udvarthana:

Sl. No.

Benefits Cha. Sam

Su Sam

As. Hr.

Yg. Ra

1 Dourgandya hara + - - -

2 Gourava hara + - - -

3 Tandra hara + - - -

4 Kandu hara + - - -

5 Mala hara + - - -

6 Aruchi hara + - - -

7 Vata hara - + - -

8 Kapha vilayana - + - -

9 Meda vilayana - + + -

10 Anga sthirikarana - + + -

11 Twak prasadakara - + + +

12 Kapha hara - - + +

13 Meda hara - - - +

14 Shukrada - - - +

15 Balya - - - +

16 Kanthi - - - +

17 Twak mrudutwa - - - +



67

Rubbing – Mode of Action

Rubbing helps in the absorption of effusions, relief of blood stasis and

carrying away the morbid products in the system. Deep pressure massage helps

the interchange of tissue fluids by increasing the circulation in the superficial

vein and lymphatics. The pressure helps the contents of the vessels move

towards the heart, if applied strongly and quickly, it has a stimulating effect. It

increases nutrition in all tissues. It removes fatigue, carrying away the increased

products of combustion. Also it assists the reabsorption of serous fluid.

Important qualities of rubbing are –

It has got great influence on the muscles. It gives them a mechanical

stimulation causing them to contract

It increases circulation mainly in the veins. The alternate pressure and

relaxation brings fresh blood to the part

It improves the nutrition of the particular area

It raises temperature locally

It increases elimination of waste products

It increases secretion and absorption

It improves the condition of the nervous system by stimulating the cutaneous

nerve endings

It influences the general metabolism when applied on large areas

Helps to breakdown thickening and adhesions in subacute and chronic

conditions

Also helps in the reabsorption of inflammatory products and absorption of fat

in fatty tissues.

When rubbing is done lightly on the nerves for a short time it stimulates them.

If applied down on each side of the spinal column, stimulates the spinal nerves and

in a reflex way strengthens the heart. It affects the vasomotor nerves and there by

widens the blood vessels also influences the secretary nerves for increasing their

function.



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Physiological effect of rubbing

The pressure of deep massage exerts a simultaneous influence up on all

the tissue of the body with in it reach up on the skin, fasciae, muscles, peripheral

nerves, blood vessels, lymphatic and central nervous system. Further it

accelerates the activity of the heart, helps the assimilation of food and influences

general metabolism of the body. As the skin covers nearly the whole body its

surface is affected by massage as well as the structures, which lie beneath it. It

increases the cutaneous circulation and benefits the sensory nerve ending and

influences the vasoconstrictors and vasodilators in the skin.

The effect of rubbing up on muscle tissue is of vast importance. This

effects removal of fatigue products. Muscles in action exert a kind of massage up

on each other. Ordinary movements of the voluntary muscle are a means of

accelerating the blood by their alternate contractions and relaxations. At every

contraction blood is pressed out of the muscle, at the same time it receives an

impulse to return to the heart, while during each relaxation fresh blood comes to

the muscle. Muscular fatigue from over exertion is relieved by massage. Toxic

materials must be removed from the tissues in order to restore the normal

functions of the body and this can be accomplished by rubbing.

Influence of rubbing up on the circulation of fluid is also of great

importance. Both the venous and lymphatic circulations are accelerated towards

the heart. Deep manipulations cause the veins and lymphatic to be mechanically

emptied and the fluid cannot return on account of the valves within the vessels.

More space is thus made for blood returning from the deeper parts.

The rubbing may be said to act both by pressure and by suction. Massage

diminishes the blood pressure without increasing the activity of the heart. But

the blood vessels are relaxed, distended and stretched by this. After a course of

this treatment blood has been found to contain more red blood corpuscles and



69

hemoglobin. These are not manufactured by rubbing. But brings them into

circulation instead of them remaining dormant in the system.

Lymph flow is helped by rubbing exercises for the limbs both passive and

active increases the lymph flow. But prolonged inactivity tends to impend

normal nutrition because of defective drainage by lymphatic.

Rubbing stimulates both motor and sensory nerve endings to various parts

of the body. This stimulation is carried along the sensory fibers of a nerve to the

spinal cord and hence to the brain. There it is transmitted through another set of

fibers to the same part and this is the reflex action of the nerve or spinal cord is

diseased or impaired. So that the communication is completely cut off, no such

action results. The activity of motor nerves is increased by strong pressure. It is

diminished or destroyed. A strong stationary pressure on the affected muscle

may stop cramps. Rubbing stimulates secretary nerves. This also influences

vasomotor neurons. A short gentle stimulation applied to nerves containing both

vasoconstrictors and vasodilators tends to produce a contraction of blood vessels

but a strong and continuous stimulation will produce dilatation, the skin becomes

red and the part feels warms. Rubbing is an excellent form of passive exercise. It

is a part of physiotherapy, which will relieve pain, improves the strength and

mobility.

Motion of the molecules participates in chemical activity. It is known that

all materials participating in nutrition and support of the vital powers undergo

radial chemical changes in their course through the organism and that it is only

by and through these chemical process of composition and decomposition that

the evolution of vital power in any of its form is possible. The motion of the

circulating fluids, vascular and intervascular is necessary to bring the elements

for chemical change. Motions secure impact between the separate and distinct

molecules. This impact converts motor into chemical energy. The special and

energetic use of pressure motions is therefore the first and natural means adapted

to overcome the effects. Ill health co-exists with the presence of sub-oxides, and



70

that the degree of health, is measured by degree in which the oxidizing purpose

of the system is attained. The true remedial relevancy of rubbing is readily seen,

since its purpose and effects is to increases the degree of oxidation, to convert

sub-oxides into complete oxides, which only are compatible with health.

Procedure of Udvarthana

The best time for Udvarthana is in the early morning between five and nine.

Because in daily regimen it is mentioned before snana.

Before doing Udvarthana, bladder and bowel should be emptied.

Blood pressure, pulse rate, heart rate and respiratory rate should be recorded

before doing Udvarthana.

Udvarthana is started from legs, arms, chest, abdomen, back and gluteal

region and is done in upward direction.

Generally, duration is 30 to 45 minutes.

After Udvarthana, patient should take rest for 5 to 10 minutes, which helps

the patient to relax.

After relaxation, hot water bath is taken.

Clinical Study


71

Research Design:

Present study is a two group clinical study with pre-test and post-test

design.

Setting for the Study:

The scholar had selected the out patient department of Sri Dharmasthala

Manjunatheshwara Ayurveda Hospital, Hassan as the setting for the study.

Population:

Obese patients from all over Hassan district and other neighbouring

districts and states who attended the Hospital were included in the study.

Sample:

The samples were selected from the population consisting of adult

patients of either sex, irrespective of religion, race, socio-economic status and

education, satisfying the inclusion criteria.

Grouping:

A total number of 30 samples were selected and randomly allocated into

following groups.

Group - A: Control group consisted of 15 patients, who were instructed to

follow the advised exercises and a calorie calculated dietary chart. The patients

were given Rechana (Purgation) with Trivruth lehya.

Group-B: Experimental group consisted of 15 patients, who were given

Rechana with Trivruth lehya followed by Udvarthana with Triphaladi choorna

for 7 days. The method of preparation of Triphaladi choorna is discussed in drug

review context. After completion of Udvarthana again Rechana was given with

Trivruth lehya. Here also the patients were asked to follow exercises and a

Clinical Study


72

calorie calculated dietary chart similar to that of Group A, except on the days of

purgation.

The samples were under direct observation of the investigator for the first

9 days of their hospital stay and then onwards they were asked to visit hospital

after 1 month for follow-up.

Hypothesis:

Null-hypothesis: Udvarthana is not effective in reducing weight.

Alternate –hypothesis: Udvarthana is effective in reducing weight

Reasons for selecting the Research design:

For a scientific trial, proper design is required so as to assess the efficacy

of the therapy, in turn to meet the objectives. Here two groups i.e. Group-A and

Group-B have been selected. Except Udvarthana, all the treatment modalities

like purgation, physical exercise and diet were common for both the groups.

Hence Group-B will highlight the efficacy of Udvarthana.

As it has already been discussed that sthoulya is a multifactorial disease

and a holistic approach is required for the same, so the modalities like exercise,

Udvarthana and diet have been included in the study. Moreover, no treatment is

completed unless proper Ahara and Vihara are followed along with the

medicine.

Pathya in terms of calorie calculated diet is having its own role. Hence a

diet chart, which provides energy, that is just a little more than that of the Basal

Metabolic Rate (BMR) i.e. 1200 to1400 kcal is allowed to the patients. The

concepts like low fat and high fibers have been considered while preparing the

chart. As the samples were not just restricted to a small geographical area, this

chart was modified keeping in view their Desha, Satmya, kala and udyoga.

Clinical Study


73

However a standard diet chart is enclosed in annexure, considering their nature

of food habits and calorie.

Proper dynamic exercises are required to burn off the calories present in

the body in the form of adipose tissue. All the 30 patients were advised to follow

dynamic exercises for duration of one hour in morning and evening on all the

days of the study in the hospital except on the day of purgation and subjects

were advised to follow the same at their house after discharge. The list of

exercises is enclosed in annexure. The samples underwent Physiotherapy

exercises as advised, which included stepper, tread-mail, shoulder-wheel, pulley,

vibrator, cycle, etc.

Sweda is believed to be the mala of meda dhatu; hence to remove excess

sweda from vikrutha medas, swedana karma in the form of Sarvanga bashpa

sweda has been done to the patients following Udvarthana.

As it is a medavrita vata janya vyadhi, after vilayana of medas through

Udvarthana, to check the vikrutha Vata, Rechana was given for the purpose of

Vatanulomana.

Udvarthana was selected for Group B patients on the basis of the

assumption that it can initiate the process of lipolysis and helps in the

transportation of lipids from the periphery to the liver, where it will be

metabolized into fatty acids to yield energy. On this hypothesis the present study

has been designed.

This study has been designed after conducting sufficient number of pre-

clinical trials and during which no adverse effects were noticed; therefore the

study was taken up for detailed analysis.

No internal medicines were advised for the patients. All the patients of

each Group were asked to come for follow up after one month. Keeping in view

Clinical Study


74

of practical problems and limitations of time, the investigator has bonded

himself for one month observations to check further changes in the weight. The

sample size in both the groups were small i.e. 15 patients, but considering the

time limitation and the technical problems, the scholar had restricted himself for

a total of 30 patients.

Objectives of the Study:

1. To study the concept of sthoulya as per the Ayurvedic texts and their

discussions with current medical prospective.

2. To evaluate the effect of Udvarthana as the therapeutical aid in the

patients of sthoulya (in terms of weights and biochemistry).

3. To see the effect of Udvarthana in relieving the associated symptoms like

Atisweda, Dourgandhya etc.

4. To survey the obese patients attending the O.P.D of S.D.M.C.A&H,

Hassan, irrespective of their complaints.

Selection Criteria:

Inclusion Criteria:

1. Patients complaining of symptoms related to sthoulya as per the classics.

2. Patients who were already diagnosed as obese.

3. Patients not responding to the expectations with textual prescription

irrespective of system of medicine.

4. Patients who’s Body Mass Index is equal or above 30, irrespective of sex.

5. Patients of uncomplicated hypertension and arthritis who are under

control and under treatment were also selected for study.

6. Obese patient detected or diagnosed to be having Hyperlipidemia.

Clinical Study


75

Exclusion Criteria:

1. Obesity due to other disorders like secondary obesity as seen in Cushing

syndrome, Hypothyroidism etc.

2. Patients with previous history of cardiac disorders and other systemic

disorders.

3. Obesity observed since birth were excluded.

Assessment criteria:

Assessment was made based on subjective and objective parameters is as

follows:

Objective parameters:

1. Weight

2. BMI

3. Circumference of Chest, Abdomen, Hip, Mid-arm, Mid-thigh

Subjective parameters:

Various features of obesity had been considered and grading was given to

analyze the results statistically as follows.

1. Assessment of chala spik, stana and Udara

a. Absence of chalatva grade 0

b. Chalatva during fast movement grade 1

c. Chalatva during moderate movement grade 2

d. Chalatva during slight movement grade 3

2. Assessment of Ayata upachaya, utsaha hani (sluggish movement of body)

a. Unimpaired utsaha grade 0

b. On desire can work sluggishly but properly grade 1

c. On desire can work sluggishly but improperly grade 2

d. Even on desire do not like to work grade 3

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76

3. Assessment of Sweda adikyata (At normal condition and at comfortable zone i.e.

temperature of 270 c, humidity of 65%)

a. No sweating grade 0

b. Profuse sweating after moderate work grade 1

c. Profuse sweating after slight work grade 2

d. Sweating even in resting condition grade 3

4. Assessment of Ayase Swasa (dyspnoea on exertion)

a. Absent grade 0

b. Dyspnoea on moderate work grade 1

c. Dyspnoea on slight work grade 2

d. Dyspnoea even at rest grade 3

5. Assessment of Nidradhikya (excessive sleep)

a. Normal sleep of 6-7 hours per day grade 0

b. Normal sleep of 8 hours per day grade 1

c. Normal sleep of 10 hours per day grade 2

d. Normal sleep of more than 10 hours per day grade 3

6. Assessment of Athi kshudha (excessive hunger)

a. Feels hunger at next annakala only grade o

b. Feels hunger for once in between Anna kala grade 1

c. Feels hunger for more than twice grade 2

d. Feels hunger always grade 3

7. Assessment of Ahara matra (total quantity of food intake)

a. Takes food in moderation grade 0

b. Takes one time food up to satiety grade 1

c. Takes two times food up to satiety grade 2

d. Takes food always up to full satiety grade 3

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8. Assessment of Ahara kala (frequency of food intake)

a. Two large meals a day grade 0

b. One small meal and two large meals a day grade 1

c. Three large meals a day grade 2

d. More than three meals a day grade 3

9. Assessment of kshudha souhitya (feeling of satiety after food)

a. Feels comfort after food grade 0

b. Feels discomfort but performs routine work grade 1

c. Feels discomfort and hampers routine work grade 2

d. Feels discomfort and unable to perform work grade 3

10. Assessment of kshudha sahatva (tolerance of hunger)

a. Can tolerate hunger more than two meal time grade 0

b. Cannot tolerate hunger more than two meal time grade 1

c. Cannot tolerate hunger more than one meal time grade 2

d. Cannot tolerate hunger even for one meal time grade 3

11. Assessment of Athi Pipasa (excessive thirst)

a. Normal thirst grade 0

b. Up to one liter excess intake of water / fluids grade 1

c. Up to two-three liter excess intake of fluids grade 2

d. More than three liter excess intake of fluids grade 3

12. Assessment of Alpa vyayama (decreased physical exercises)

a. Can do routine exercises grade 0

b. Can do moderate exercise with difficulty grade 1

c. Can do only mild exercises with difficulty grade 2

d. Cannot even do mild exercises grade 3

Clinical Study


78

13. Assessment of Alpa vyavaya (decreased sexual attitude)

a. Unimpaired libido and sexual performance grade 0

b. Decreased libido but can perform sexual act grade 1

c. Decreased libido, sexual act with difficulty grade 2

d. Loss of libido and cannot perform sexual act grade 3

14. Assessment of Anga gourava (feeling of heaviness)

a. No heaviness in body grade 0

b. Feels heaviness but it doesn’t hampers routine work grade 1

c. Feels heaviness which hampers routine work grade 2

d. Feels heaviness which restricts routine work grade 3

15. Assessment of Anga sithilatha (flabbiness of body)

a. No flabbiness in body grade 0

b. Flabbiness in one anatomical region grade 1

c. Flabbiness in more than one region grade 2

d. Generalized flabbiness in body grade 3

16. Assessment of Gatra sada (fatigue)

a.can perform work without fatigue grade 0

b. can perform work with little fatigue grade 1

c. can perform work with Moderate fatigue grade 2

d. can’t perform any work grade 3

Materials:

The following materials are required for the clinical study:

Triphaladi Udvarthana Choorna

Trivruth lehya

Weighing machine

Measuring tape

Clinical Study


79

Drug Review In the present study some of the drugs, which are having Rookshana property had been selected. The following tables shows the important features of the drug which are used for Udvarthana choorna

Drug Latin name

Kula (Family)

Paryaya Rasa Guna Virya Vipaka

Haritaki Terminali-a

chebula

Haritaki (combretacea

e)

Abhaya Pathya Rohini

Lavana varjitha

pancharas Kashaya

rasa Pradhana

Laghu Ruksha

Ushn Madhur

Amlaki Emblica officinalis

Euphorbiace-ae

Dhatri Amlaja.

Lavana varjitha

pancharas Amla rasa

Pradhana

Guru Ruksha Sheeta

Sheet Madhur

Vibitaki Terminali-a belirica

Combretace-ae

KarshaphalaAksha

Kalidruma

Kashaya Laghu Ruksha

Ushn Madhur

Mudga Vigna radiata

Shimbi (leguminosa

-e)

Kashaya Madhura

Laghu Ruksha

Sheet Katu

Kulatha Cassia absus

(leguminosa-e)

Chakshyus-ya

Kulali

Tikta, Kashaya

Ruksha Sheet Katu

Sarshap Brassica compestri

Ragika (cruciferae)

Katusneha Tantubha

Katu Tikta

Tikshna Snigda

Ushn Katu

Methika Trigonella foenum

Shimbi (leguminosa

-e)

Pitabeeja Katu Laghu Snigda

Ushn Katu

Yava Hordeum vulgarae

(gramineae) Java Madhura Kashaya

Laghu-

Ruksha Sheet Katu

Clinical Study


80

Dravya Chemical Composition

Bhahya Prayoga Dosha -gnata

Rogagnata Prayojya Anga

Haritaki Chebulagic acid, Tannin Corilagin

Shothahara, Vrana Shodhana Vedanasthapana

VPK Srotoshodana Prameha, kusta

Arsha,

Phala

Amlaki Gallic acid Tannic acid, Vit-c

Dahaprashamana Chakshushya Keshya

VPK Prameha, Kusta,

Shotagna

Phala

Vibitaki Tannin Galic acid Ethyl gallate

Shothahara, Raktastambhana Vedanasthapana

VPK Kapha vikara Medo vikara, Rasa vikara

Phala

Mudga Potassium, Vitamin A,B,C,K

- PK Prameha, kusta Beeja

Kulatha Chaksine Isochaksine

Neetra roga

PK Medo roga Ashmari

Beeja

Sarshap Sinalbin, Sulphosianide

Lekhana Varnya Vedanasthapana

VK P

Kusta Beeja Taila

Methika Volatile oil, Calcium

Vedanasthapana Shothahara

VK

Shotha, Vidradhi

Panchang

Yava Protein, Iron Calcium Phosphorus

- PK V

Mutrakruchra Prameha, Kasa

Trishna,Peenasa

Panchang

V-Vata, P-Pitta, K-Kapha, -Prakopa, - Shamana

Table – showing the ingredients and their quantity in Triphaladi choorna.

Ingredients Part used Parts

Triphala Haritaki Choorna Vibhitaki Churna Amlaki Churna

Phala

2 parts

Kulatha Beeja 4 parts

Mudga Beeja 1 part

Yava Beeja 2 parts

Methika Beeja 1 part

Sarshapa Beeja 1/4th part

The drugs and their proportions have been standardized after pilot study.

Clinical Study


81

Source of Drugs

All the raw drugs for the preparation of Udvarthana choorna were

procured from S.D.M College of Ayurveda Pharmacy, Hassan.

Preparation of Udvarthana Choorna

All the ingredients in suitable proportions are made into sukshma choorna

separately then they are mixed together.

Trivruth lehya:

This drug is used for Rechana (purgation) in both the groups.

Table showing the properties of Trivruth:

Latin name:

Family:

Paryaya:

Rasa:

Guna:

Veerya:

Vipaka:

Chemical composition:

Doshagnata:

Rogagnatha:

Operculina turpephum

convolvelaceae

Tribandi, Nishotha

Kashaya, Madhura

Rooksha

ushna

Katu

Turpethin, volatile oils

Kapha- pitta shamana

Jwara, Shotha, Udara, Pleeha, Pandu, Vrana

Trivruth lehya was taken from Arya Vaidya Sala, Kottakkal, Kerala.

Treatment Procedure:

After completion of exercises, the patients were made to lie on table with

minimal clothing. A total of 400 gm of Udvarthana choorna is taken every time.

Massage with this herbal powder was done in ‘pratiloma gati’ i.e. against the

direction of hair follicles. Massage was done in all following seven consecutive

postures for a period of 5 minutes in each, with a total duration of 35 minutes.

Clinical Study


82

1. Sitting

2. Supine

3. Left lateral

4. Dorsal

5. Right lateral

6. Supine

7. Sitting

After Udvarthana, the subjects underwent Sweda karma (Sarvanga bashpa

Sweda with Dasha moola kwatha).

Materials for diagnostic study:

To measure circumference of mid-arm, mid-thigh, abdomen, chest and

hip, measuring tape was used. A standard Weighing machine was used to

measure weight and it is noted in kg.

Materials for laboratory investigations:

The investigations are carried out in an “Auto analyzer”. Lipid profile test

was done before and after treatment, in empty stomach. This test includes

Total cholesterol

HDL

Triglycerides

LDL {= TC – HDL – (Triglycerides / 5)}

The following table shows the name of the reagents used for the study.

Test Name of the reagent Maker

Total cholesterol Total cholesterol liquid kit Diagnostica, Bantwal.

HDL HDL cholesterol precipitating set Diagnostica, Bantwal.

Triglycerides Triglyceride liquid reagent set Diagnostica, Bantwal.

Clinical Study


83

Before Udvarthana

During Udvarthana with Triphaladi choorna

1

2

Observation & Results


83

Technological efficacy of sciences has lead to wide acknowledgement of

effectiveness of its method. Standards of testability, verifiability and more

refined criteria of falsifiability as filters for legitimate knowledge have been

brought about by ceaseless development of science. Ingenuity of science is seen

in its method. It is experiments that give impetus to scientific knowledge.

For any research work, the data should be collected systemically and must

be presented in such a way that the reader can understand the things in a better

manner.

Here onwards the data will be presented in tabulations, graphs and

pictographs. As these are self-explanatory descriptions are given wherever

required.

Observations:

Table no.24 Showing Age-wise Distribution of Sthoulya Cases in Group A & B:

Age Group Group A % Group B % Total % 18-30 05 33.33 03 20.02 08 26.66

31-40 05 33.33 04 26.66 09 30.00

41-50 03 20.01 04 26.66 07 23.34

51-60 02 13.33 04 26.66 06 20.00

61-70 00 00.00 00 00.00 00 00.00

71-80 00 00.00 00 00.00 00 00.00

Total 15 15 30

Table no.25 showing sex wise distribution:

Sex Group A % Group B % Total %

Male 07 46.67 05 33.33 12 40.00

Female 08 53.33 10 66.67 18 60.00

Total 15 15 30



84

Chart- Showing Agewise distribution of obese patients:

0123456789

no.of patients

Group A Group B Total

18-30

31-40

41-50

51-60

61-70

71-80

Chart- Showing sex wise distribution:

75

12

810

18

0 5 10 15 20 25 30 35

Group A

Group B

Total

Male Female

Chart- Showing Distribution of Associated Features in both Groups:

0

5

10

15

20

25

30

35

Group A Group B TotalPipasa Kshuda Swasa Dourgandhya

Athi Sweda Srama Athi Nidra



85

Table no.26 Showing Distribution of Sthoulya Cases in Group A and B

according to Religion:

Religion Group A % Group B % Total %

Hindu 11 73.34 12 73.34 23 76.67

Muslim 03 19.99 03 19.99 06 20.00

Christian 01 06.67 00 06.67 01 03.33

Total 15 15 30


according to Socio-economical status

Status Group A % Group B % Total % Low 00 00.00 00 00.00 00 00.00

Middle 06 40.00 05 33.34 11 36.66

High 09 60.00 10 66.66 19 63.34

Total 15 15 30

Table no.28 Showing Distribution of Sthoulya Cases in both Groups occupation:

Occupation Group A % Group B % Total % House wife 04 26.66 08 53.31 12 40.00

Business 04 26.66 02 13.34 06 20.00

Clerk 03 20.00 01 06.67 04 13.33

Teacher 02 13.34 01 06.67 03 10.00

Engineer 01 06.67 01 06.67 02 06.67

Student 01 06.67 02 13.34 03 10.00

Total 15 15 30

Table no.29 Showing Distribution of Sthoulya Cases in Group A and B as per

Prakruthi:

Prakruthi Group A % Group B % Total %

Vata-Kapha 09 60.00 10 66.67 19 63.34

Pitta-Kapha 06 40.00 05 33.33 11 36.66

Total 15 15 30



86

Table no.30 Showing Distribution of Sthoulya Cases in both Groups according

to chronicity:

Chronicity (In Years)

Group A % Group B

% Total %

Less than 10 10 66.66 10 66.66 20 66.66

11-20 03 20.02 02 13.34 05 16.66

21-30 01 06.66 02 13.34 03 10.00

31-40 01 06.66 00 00.00 01 03.34

41-50 00 00.00 01 06.66 01 03.34

Total 15 15 30

Table31 Distribution of Sthoola in both Groups according to Family history

Family History Group A % Group B % Total %

Negative 02 13.34 02 13.34 04 13.34

Maternal +ve 05 33.34 05 33.34 10 33.34

Paternal +ve 02 13.34 03 19.98 05 16.66

Both +ve 06 39.98 05 33.34 11 36.66

Total 15 15 30


quantity of food consumption:

Quantity of Food

Group A % Group B % Total %

Less 00 00.00 00 00.00 00 00.00

Moderate 04 26.66 06 40.00 10 33.34

More 11 73.34 09 60.00 20 66.34

Total 15 15 30



87

Table no.33 Showing Sthoola in both groups according to frequency of food

consumption:

Frequency of food intake

Group A

% Group B

% Total %

2 times 00 00.00 00 00.00 00 00.00

3 times 03 20.00 07 46.67 10 33.34

4 or more 12 80.00 08 53.33 20 66.34

Total 15 15 30

Table no.34 Showing Distribution of Sthoulya Cases in both Groups as per

Pana”:

Pana Group A % Group B % Total % Sitambu 12 80.00 09 60.00 21 69.99

Fruit juice 13 86.00 10 26.67 23 76.67

Butter milk 02 13.34 04 26.34 06 19.99

Dumra pana 04 26.67 02 13.34 06 19.99

Madhyapana 01 06.67 02 13.34 03 09.99

Total 15 15 30

Table no.35 Showing Sthoola Cases in both Groups per Rasa preferred:

Rasa Group A % Group B % Total %

Madhura 14 93.34 12 80.00 26 86.67

Amla 09 60.00 05 33.34 14 46.67

Katu 07 46.67 11 73.34 18 59.99

Total 15 15 30


according to “Nidra kala”:

Nidra kala in hrs Gr A % Gr B % Total %

10 or more 09 60.00 10 66.67 19 63.34

Less than 10 06 40.00 05 33.33 11 36.66

Total 15 15 30



88


Adhyatana Agni:

Adyatan agni Group A % Group B % Total %

Pravara 15 100 13 86.67 28 93.34

Madhyama 00 00.00 02 13.33 02 06.66

Avara 00 00.00 00 00.00 00 00.00

Total 15 15 30


Poorvagni:

Poorvagni Group A % Group B % Total %

Pravara 08 53.34 14 93.33 22 73.34

Madhyama 07 46.66 01 06.67 08 26.66

Avara 00 00.00 00 00.00 00 00.00

Total 15 15 30


Abhyahvarana shakthi:

Abhyavaran Shakthi

Group A

% Group B

% Total %

Uttama 12 80.00 13 86.67 25 83.34

Madhyama 03 20.00 02 13.33 05 16.66

Hina 00 00.00 00 00.00 00 00.00

Total 15 15 30

Table no.40 Showing Sthoola in both Groups as per Jarana shakthi

Jarana Shakthi Group A % Group B % Total % Uttama 14 93.34 12 80.00 26 86.67 Madhyama 01 06.66 03 20.00 04 13.33 Hina 00 00.00 00 00.00 00 00.00 Total 15 15 30



89

Table no.41 Showing Distribution of Sthoola in both Groups as per Jatha Desha:

Jatha Desha GroupA % Group B % Total % Anupa 01 06.66 01 06.66 02 6.66 Sadarana 01 06.66 00 00.00 01 3.34 Jangala 01 06.66 03 20.00 04 13.34 anupasadarana 05 33.35 06 40.00 11 36.66 jangalasadaran 07 46.67 05 33.34 12 40.00

Total 15 15 30

Table no.42 Showing Sthoola in both Groups as per Samvrudha Desha:

Samvrudha Desha

Group A

% Group B

% Total %

Anupa 02 13.34 03 20.00 05 16.66 Sadarana 01 06.66 04 26.66 05 16.66 Jangala 02 13.34 02 13.34 04 13.34 Anupasadarana 05 33.33 03 20.00 08 26.67 Jangalasadaran 05 33.33 03 20.00 08 26.67

Total 15 15 30


Vyadhitha Desha:

Vyadhita Desha Group A % Group B % Total % Anupa 01 06.66 02 13.34 03 10.0

Sadarana 02 13.34 01 06.66 03 10.0

Jangala 01 06.66 02 13.34 03 10.0

Anupasadarana 05 33.34 07 46.66 12 40.0

Jangalasadaran 06 40.00 03 20.00 09 30.0

Total 15 15 30



90


Body frame:

Frame Group A % Group B % Total %

Small 02 13.33 01 06.67 03 10.00

Medium 13 86.67 14 93.33 27 90.00

Large 00 00.00 00 00.00 00 00.00

Total 15 15 30


Educational status:

Education Group A % Group B % Total % Illiterate 00 00.00 00 00.00 00 00.00

Below 10th 07 46.66 05 33.34 12 40.00

Degree or below 06 40.00 07 46.66 13 43.34

Post graduation 02 13.34 03 20.00 05 16.66

Total 15 15 30


Associated Features:

Associated Features

Group A

% Group B

% Total %

Pipasa 12 80.00 11 73.33 23 76.67

Kshuda 14 93.33 15 100 29 96.66

Swasa 07 46.66 12 80.00 19 63.33

Dourgandhya 08 53.33 09 60.00 17 56.66

Athi Sweda 12 80.00 13 86.00 25 83.33

Srama 05 33.33 09 60.00 14 46.66

Athi Nidra 12 80.00 09 60.00 21 70.00

Kruchravyavaya 00 00.00 00 00 00.00



91

Table no.47 Showing Distribution of Sthoulya Cases in Group A and B as per Vihara:

Vihara Group A % Group B % Total %

Jagara 05 33.34 06 40.00 11 36.67

Vyayama 03 20.00 04 26.67 07 23.34

Avyayama 11 73.34 11 73.34 22 73.34

Divaswapna 09 60.00 08 53.34 17 56.67

Sukhashayya 13 86.67 13 86.67 26 86.67

Chestadwesha 13 86.67 09 60.00 22 73.34

Achintana 09 60.00 11 73.34 20 66.67

Harshanitya 11 73.34 10 66.66 21 70.00

Results

Assessment of subjective criteria in subjects of both the groups:

(Please refer clinical study chapter for grading)

I) Table no.48 showing the changes in chala spik, sthana and udara lambana

before and after treatment in both the groups:

Response Difference in grades Group A % Group B %

Nil 0 13 86.66 09 60.00

Mild 1 02 13.34 06 40.00

Moderate 2 00 00.00 00 00.00

Good 3 00 00.00 00 00.00

86.66% of group A subjects showed no change in above lakshana, where

as in group B 40% (6 pts) had improved.

II) Table no.49 showing the changes Ayathaupachaya utsaha hani before and

after treatment in both the groups:


Nil 0 06 40.00 06 40.00

Mild 1 09 60.00 06 40.00

Moderate 2 00 00.00 03 20.00

Good 3 00 00.00 00 00.00



92

9 patients in group A had mild improvement in symptom

“Ayathaupachaya utsaha hani”. In group B 60%(12 pts) of subjects showed

improvement and 3 patients were not responded for this associated feature.

III) Table no.50 showing the changes in Swedadhikyata before and after

treatment:


Nil 0 15 100 14 93.34

Mild 1 00 00.00 01 06.66

Moderate 2 00 00.00 00 00.00

Good 3 00 00.00 00 00.00

There was no change in Swedadhikyata among the patients of group A.

Only one subject had showed mild improvement in group B.

IV) Table no.51 showing the changes in Ayase Swasa before and after treatment

in both the groups:


Nil 0 13 86.66 10 66.66

Mild 1 02 13.34 04 26.68

Moderate 2 00 00.00 01 06.66

Good 3 00 00.00 00 00.00

Only 2 patients had mild response for Ayase Swasa in group A and 5

patients responded for the same in group B.

V) Table no.52 showing the changes in Nidradhikya before and after treatment

in both the groups:


Nil 0 03 20.00 03 20.00

Mild 1 10 66.66 08 53.32

Moderate 2 02 13.34 04 26.68

Good 3 00 00.00 00 00.00

In both the groups, 6 patients did not respond for nidradhikyata. Rest of

the 24 (12 in both groups) patients responded in the course of treatment.



93

VI) Table no.53 showing the changes in Adhika Kshuda before and after

treatment in both the groups:


Nil 0 10 66.66 08 53.34

Mild 1 05 33.34 06 40.00

Moderate 2 00 00.00 01 06.66

Good 3 00 00.00 00 00.00

66.66% of group A patients remained unchanged for Adhika Kshuda

where as in group B 46.66% (7 patients) had improved.

VII) Table no.54 showing the changes in Ahara matra before and after treatment

in both the groups:


Nil 0 00 00.00 01 06.66

Mild 1 11 73.34 08 53.34

Moderate 2 04 26.66 06 40.00

Good 3 00 00.00 00 00.00

All of 15 patients showed improvement in group A and in group B 40%

of subjects improved moderately with respect to their ahara matra.

VIII) Table no.55 showing the changes in Ahara kala before and after treatment

in both the groups:


Nil 0 00 00.00 00 00.00

Mild 1 00 00.00 04 26.67

Moderate 2 15 100.0 07 46.66

Good 3 00 00.00 04 26.67



94

IX) Table no.56 showing the changes in Athi Pipasa before and after treatment

in both the groups:


Nil 0 10 66.66 11 73.34

Mild 1 05 33.34 04 26.66

Moderate 2 00 00.00 00 00.00

Good 3 00 00.00 00 00.00

For 5 patients Athi pipasa was revealed and in group B 73.34% of

subjects showed no change.

X) Table no.57 showing the changes in Kshuda sahatva before and after



Nil 0 00 00.00 00 00.00

Mild 1 07 46.66 05 33.34

Moderate 2 08 53.34 09 60.00

Good 3 00 00.00 01 06.66

8 patients were moderately improved for Kshuda sahatva in control group

and 60.00% (9 pts) of group B subjects had same change in group B.

XI) Table no.58 showing the changes in kshuda souhitya before and after



Nil 0 03 20.00 00 00.00

Mild 1 09 60.00 01 06.66

Moderate 2 03 20.00 12 80.00

Good 3 00 00.00 02 13.34



95

XII) Table no.59 showing the changes in Alpa vyayama before and after



Nil 0 00 00.00 00 00.00

Mild 1 14 93.34 07 46.66

Moderate 2 01 06.66 08 53.34

Good 3 00 00.00 00 00.00

93.34% of subjects in group A had mildly changed their alpa vyayama

pravruthi, where as in group B 53.34% patients moderately improved in their

vyayama pravruthi.

As the patients in both the groups were sensitive towards reveling their

sexual attitude, hence it was not assessed.

XIV) Table no.60 showing the changes in Anga gourava before and after



Nil 0 03 20.00 01 06.66

Mild 1 11 73.34 06 40.00

Moderate 2 01 06.66 08 53.34

Good 3 00 00.00 00 00.00

14 patients had relieved from Anga gourava in group B and in group A

only 3 (20%) patients remained unchanged.

XV) Table no.61 showing the changes in Anga sithilatha before and after



Nil 0 12 80.00 07 46.66

Mild 1 03 20.00 08 53.34

Moderate 2 00 00.00 00 00.00

Good 3 00 00.00 00 00.00



96

There was no change in anga sithilatha among 12 patients in group A and

7 patients in group B.

XVI) Table no.62 showing the changes in Gatra sada before and after



Nil 0 08 53.34 05 33.34

Mild 1 07 46.66 10 66.66

Moderate 2 00 00.00 00 00.00

Good 3 00 00.00 00 00.00

8 patients in group A and 5 patients in group B showed no response with

respect to Gatra sada. But 66.66% (10) patients in group B showed mild change.

Table no.63 showing Subjective assessment (please refer assessment chart for numbers) statistical analysis: ** = Highly significant * = Statistically significant + = Significant ++ = Insignificant

Subjective parameter Gp I II III IV V A 1.53 1.93 1.13 1.33 2.53 Mean BT B 1.80 2.06 1.26 1.46 2.40 A 1.40 1.33 1.13 1.20 1.60 Mean AT B 1.40 1.26 1.20 1.06 1.33 A 0.133 0.60 00 0.133 0.933 Mean dif. B 0.40 0.80 0.06 0.40 1.066 A 8.49 31.08 00 9.77 36.75 Mean % of

Improvement B 22.22 38.83 4.76 27.39 44.16 A 0.339 0.489 0.0 0.339 0.573 S.D B 0.489 0.748 0.249 0.611 0.679 A 0.087 0.126 0.00 0.087 0.147 S.E B 0.123 0.193 0.064 0.157 0.175 A 1.519 4.754 00 1.528 6.349 “t” valve B 3.252 4.142 1.028 2.536 6.081 A < 0.2++ <0.001** 1++ <0.2++ <0.001** “p” value B <0.010* <0.001** <0.4++ <0.02+ <0.001**



97

Subjective parameter Gp VI VII VIII IX X A 1.93 2.66 2.66 2.73 2.8 Mean BT B 1.66 2.60 2.60 2.73 2.60 A 1.60 1.40 0.66 1.00 1.26 Mean AT B 1.13 1.26 0.60 0.56 0.86 A 0.33 1.26 2.00 1.60 1.53 Mean dif. B 0.53 1.33 2.00 2.06 1.73 A 17.09 47.36 75.18 58.60 54.64 Mean % of

Improvement B 31.92 51.15 76.92 75.54 51.15 A 0.471 0.442 0.00 0.489 0.570 S.D B 0.618 0.596 0.730 0.470 0.573 A 0.121 0.114 0.00 0.126 0.147 S.E B 0.157 0.153 0.188 0.121 0.147 A 2.738 11.09 0.00 12.698 10.428 “t” valve B 3.394 8.667 10.615 17.074 11.717 A < 0.025+ <0.001** 1++ <0.001** < 0.001** “p” value B <0.005+ < 0.001** <0.001** < 0.001** < 0.001**

Subjective parameter Gp XI XII XIV XV XVI A 2.20 2.06 1.80 2.20 1.33 Mean BT B 2.13 2.13 2.13 2.40 1.53 A 1.86 1.00 0.93 2.00 0.93 Mean AT B 1.86 0.60 0.66 1.80 0.86 A 0.33 1.06 0.86 0.20 0.46 Mean dif. B 0.26 1.53 1.46 0.53 0.66 A 13.63 51.45 47.77 9.09 34.58 Mean % of

Improvement B 12.20 71.83 68.54 22.08 43.13 A 0.471 0.249 0.498 0.40 0.498 S.D B 0.442 0.498 0.618 0.498 0.491 A 0.121 0.064 0.128 0.103 0.128 S.E B 0.114 0.123 0.159 0.128 0.126 A 2.738 16.656 6.739 1.937 3.626 “t” valve B 2.331 12.463 9.185 4.147 5.285 A < 0.025* <0.001** < 0.001** < 0.1+ < 0.005* “p” value B < 0.025* < 0.001** < 0.001** <0.001** < 0.001**



98

Assessment of objective criteria:

Table no.64 showing changes of weight in both Groups:

S.No. Group A Group B BT AT Dif. BT AT Dif. 1 90 88 2 99 94 5

2 66 65 1 83 77 6

3 89 88 1 60 58 2

4 85 85 0 76 75.5 1.5

5 90 89 1 92.5 88 4.5

6 87 86 1 71 65.5 5.5

7 81 81 0 91 86 4 8 80 78.5 1.5 90 87.5 2.5

9 75 74 1 86 82 4

10 94 91.5 2.5 90 85 5

11 79 79 0 86 82 4

12 78 76.5 1.5 95 92 3

13 70 68 2 96 93 3 14 93 91 2 70 65.5 4.5

15 69 68 1 78 72 6

Total 1226 1208.5 17.5 1263.5 1203 60.5

Table no 65 showing response of weight in both groups:

Weight reduction Response Group A % Group B %

0-2 kg Poor 15 100 03 20.00

3-5 kg Moderate 00 00 10 66.66

6-8 kg Good 00 00 02 13.34

There was maximum of 2.5 and 6 kg difference in group A and B

respectively. 80% of subjects in group B had lost weight of more than 2 kg.



99

Chart- Showing changes of weight in both Groups:

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

reduction in kg

Gr. A

Gr.B

Table no.66 showing changes of BMI in both Groups:

Pt.No. Group A Group B BT AT Dif. BT AT Dif. 1 36.05 35.25 0.80 40.16 38.13 2.03 2 33.19 32.69 0.50 34.45 32.89 1.56 3 31.54 31.17 0.37 31.96 30.90 1.06 4 34.04 34.04 0.00 32.04 31.83 0.21 5 37.94 37.52 0.42 41.12 39.12 2.00 6 32.34 31.97 0.37 30.33 27.98 2.35 7 30.11 30.11 0.00 37.87 35.79 2.08 8 30.48 29.91 0.57 33.05 32.13 0.92 9 30.04 29.64 0.40 36.24 34.54 1.70 10 36.26 35.29 0.97 31.14 29.41 1.73 11 31.24 31.24 0.00 37.22 35.49 1.73 12 32.47 31.84 0.63 32.87 31.83 1.04 13 30.29 29.43 0.86 31.70 30.71 0.99 14 35.43 34.67 0.76 30.17 27.61 2.56 15 31.07 30.62 0.45 32.89 30.35 2.54 Total 492.49 485.39 7.10 513.21 488.71 24.5

Table no.67showing response of BMI in both groups:

Changes in BMI Response Group A % Group B %

No change Poor 03 20.00 00 00

<1 Moderate 12 80.00 03 20.00

>1 Good 00 00.00 12 80.00



100

0.97 was maximum reduction of BMI in group A and in group B 2.56. The least

reduction in group B is 0.21. In group A 80% of subjects reduced <1 BMI and in

group B 80% patients reduction in >1 BMI.

Chart- Showing changes of BMI in both Groups:

0

0.5

1

1.5

2

2.5

3

decrease in BMI

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

pts

Gr.A. Gr.B



101

Table no.68 showing Statistical analysis of weight and BMI after treatment in

both groups:

Group Weight B M I A 81.73 32.83 Mean BT B 84.23 34.21 A 80.56 32.35 Mean AT1

B 80.20 32.58 A 79.13 31.78 Mean AT2

B 78.03 31.76 A 1.16 0.47 Mean dif.1

B 4.03 1.63 A 2.60 1.04 Mean dif.2

B 6.26 2.45 A 1.41 1.43 Mean % of

Improvement1 B 4.78 4.76 A 3.181 3.167 Mean % of

Improvement2 B 7.43 7.132 A 0.745 0.296 S.D1 B 1.347 0.650 A 1.26 0.496 S.D2 B 2.143 0.775 A 0.192 0.076 S.E1 B 0.3477 0.167 A 0.324 0.270 S.E2 B 0.553 0.631 A 6.223 6.223 “t” valve1

B 9.778 9.778 A 8.024 3.844 “t” valve2

B 11.33 3.879 A < 0.001** < 0.001** “p” value1

B < 0.001** < 0.005*

A < 0.001** < 0.005* “p” value2

B <0.001** < 0.005*

** = Highly significant * = Statistically significant + = Significant ++ = Insignificant

In above table, all parameters with “1” denotes value after 8 days of

treatment and “2” denotes value after one month of follow up.



102

Table no.69 showing the response of both groups in chest circumference:

Response Changes in centimeters Group A % Group B %

Nil 0 13 86.66 00 00.00

Mild 1 02 13.34 08 53.34

Moderate 2 00 00.00 03 19.99

Good > 2 00 00.00 04 26.67

2 patients in group B showed maximum decrease of 2 cms in chest

circumference.

Table no.70 showing the response of both groups in abdomen circumference:

Response Changes in cm Group A % Group B %

Nil 0 05 33.33 01 06.67

Mild 1 08 53.33 03 19.99

Moderate 2 02 13.34 01 06.67

Good > 2 00 00.00 10 66.67

Patients of group B had responded well in decrease of abdomen

circumference. Maximum of 7 cms decrease was noticed in that group.

Table no.71 showing the response of both groups in hip circumference:

Response Changes cms Group A % Group B %

Nil 0 06 40.00 03 20.00

Mild 1 09 60.00 03 20.00

Moderate 2 00 00.00 05 33.34

Good > 2 00 00.00 04 26.66

There was good response in decrease of hip circumference in patients of

B group. Maximum decrease of 4 cms was noticed in one patient of group B



103

Table no.72 showing the response of both groups in Mid-arm circumference:

Response Changes in cms Group A % Group B %

Nil 0 14 93.34 10 66.66

Mild 1 01 06.66 04 26.68

Moderate 2 00 00.00 01 06.66

Good > 2 00 00.00 00 00.00

Group A showed no response in 14 patients, where as group B had

responded relatively well. One patient had decrease of 2 cms in trail group.

Table no.73 showing the response of both groups in Mid-thigh circumference:

Response Changes in cms Group A % Group B %

Nil 0 08 53.33 02 13.34

Mild 1 05 33.33 07 46.66

Moderate 2 02 13.34 02 13.34

Good > 2 00 00.00 04 26.66

4 patients in group B had decreased their circumference of mid-thigh over

2 cms. Maximum of 3.5 cms decreased was noticed in that group.

Table no.74 showing Circumference of Chest, Abdomen, Hip, Mid-arm, Mid-

thigh statistical analysis:

Gr. Chest cir. Abd cir. Hip cir. Mid-arm cir

Mid-thigh cir

A 104.8 106.73 111.13 33.73 61.76 Mean BT B 107.93 111 114.36 33.7 61.76 A 104.66 105.93 110.53 33.7 61.26 Mean AT B 106.26 108.33 112.66 33.26 60.13 A 0.13 0.80 0.60 0.03 0.56 Mean dif. B 1.80 3.20 1.76 0.43 1.60 A 0.12 0.74 0.53 0.08 0.90 Mean % of

Improvement B 1.66 2.88 1.53 1.27 2.59 A 0.339 0.652 0.489 0.124 0.703 S.D B 0.909 1.973 1.195 0.654 1.254 A 0.087 0.168 0.126 0.032 0.181 S.E B 0.234 0.509 0.308 0.028 0.323 A 1.528 4.761 4.761 1.0312 3.127 “t” valve B 7.692 6.286 5.733 15.464 4.953 A < 0.2++ < 0.001** < 0.001** < 0.4++ < 0.01* “p” value B < 0.001** < 0.001** < 0.001** < 0.001** < 0.001**



104


The changes observed in lipid profile are as follows:

Table no.75 showing the decrease in Total cholesterol level in both the groups:

Response Level in mg/dl

Group A

% Group B

% Total Patients

%

Mild 5-25 15 100

09 64.26 24 82.75

Moderate 26-45 00 00 03 21.43 03 10.35

Good 46-65 00 00 02 14.31 02 6.90

Total 15 14 29

There was mild response in all the subjects of group A. only one patient

had increase of total cholesterol by 6.4 mg/dl in group B and 14.31% patients

showed good response in that group.

Chart- Showing changes in Total cholesterol:

-10

0

10

20

30

40

50

60

70

mg/dl

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

pts

Gr.A

Gr.B



105

Table no.76 showing changes in Total cholesterol (in mg/dl):

Pt.no

Group-A Group-B

BT AT DIF BT AT DIF 1. 182.4 179.1 3.3 262.6 269 -6.4 2. 133.8 126.4 7.4 186 169 17 3. 138.9 135 3.9 234.7 190 44.7 4 160.4 160.3 0.1 280 254 26 5 161.8 155.1 6.7 170 152 18 6 219.0 210 9 252 190 62 7 200.7 196.7 4 205 194 11 8 221.7 210 11.7 225.5 209 16.5 9 206 200.7 5.3 142.6 132.9 9.7 10 215 210 5 176 160 16 11 178 169.1 8.9 181 147.4 33.6 12 234.7 215.1 19.6 226 170.6 55.4 13 165.8 163 2.8 176 159 17 14 167 165.3 1.7 152.1 142.6 9.5 15 271 262.5 8.5 215 200 15 Total 2856.2 2758.3 97.9 3084.5 2739.5 345

High-density lipoprotein (HDL):

Table no.78 showing increase of HDL level:

Response Level in mg/dl

Group A

% Group B % Total

%

Mild 0-6 15 100 04 40 19 76.00 Moderate 7-13 00 00 03 30 03 12.00 Good 14-20 00 00 03 30 03 12.00

Total 15 10 25

All 15 patients showed mild response in group A where as only 10

subjects showed increase in their HDL levels in group B, but 3 pateints had

responded good in this group.



106

Chart- Showing changes in HDL:

-20

-15

-10

-5

0

5

10

15

20

mg/dl

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

pts

Gr.A

Gr.B

Table no.77showing changes in HDL :

Pt.no Group-A Group-B BT AT DIF BT AT DIF 1. 28.2 28.5 -0.3 40.8 55 -14.5 2. 26.4 28.2 -1.8 60 48 12 3. 61.2 64.4 -3.2 42.6 50.8 -8.2 4 29.2 31.2 -2 63 75 -12 5 28.2 28.9 -0.5 39 44 -5 6 30.6 31.4 -0.8 48 55 -7 7 29 29.7 -0.7 44 60 -16 8 27.4 28.1 -0.7 45.5 52 -6.5 9 48 49.5 -1.5 38.7 33.2 5.5 10 42 45 -3 54 58 -4 11 37 38.1 -1.1 52 36.4 15.6 12 42.6 46.2 -3.6 32.4 30.4 2 13 42.6 46.5 -3.9 42 48 -6 14 38 39.1 -1.1 37.8 29.5 8.3 15 38 40.2 -2.2 42 49 -7



107

Low-density lipoprotein (LDL):

Table no.80 showing decrease of LDL level:

Response Levels in mg/dl Group A % Group B %

Mild 0-25 15 100 09 60.00

Moderate 26-50 00 00.00 04 26.67

Good 51-75 00 00.00 02 13.33

Total 15 15

All the 30 patients responded well for decrease in LDL levels. 40% of

group B patients decreased more than 25 mg/dl of LDL levels.

Chart- Showing changes in LDL:

0

10

20

30

40

50

60

70

mg/dl

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

no.pts

Gr.A

Gr.B



108

Table no.79 showing changes in LDL:

Pt.no Group-A Group-B BT AT DIF BT AT DIF 1. 120.3 117.2 3.1 198 187 11 2. 71 62.2 8.8 126 97 29 3. 54.2 48.58 5.62 175.1 120 55.1 4 119.1 117.2 1.9 185 150.6 34.4 5 106.4 87.16 19.24 110 87.6 22.4 6 161.7 151.6 10.1 177 108 69 7 136.5 133.82 2.68 129 101 28 8 152.1 139.88 12.22 153.8 129 24.8 9 136 130.02 5.98 91.6 87 4.6 10 141.6 134.54 7.06 98.8 81 7.8 11 123 113.26 9.74 106.9 93 13.9 12 175.1 152.00 23.1 100.6 98.8 1.8 13 103.4 96.96 6.44 116 72.2 43.8 14 110 107.22 2.78 96.4 95.5 0.9 15 185 174.88 10.12 141.6 124.2 17.4 Total 1895.4 1766.52 128.88 2005.8 1631.9 363.9

Triglycerides:

Table no.82 showing decrease of Triglycerides level:

Response Level in mg/dl Group A % Group B % Mild ≤ 5 15 100 02 22.21

Moderate 6-20 00 00.00 05 55.55

Good ≥ 21 00 00.00 02 22.24

Total 15 09

Only 9 patients in group B had decreased their Triglycerides levels in

group B, where as all 15 patients responded in group A. maximum of 23mg/dl of

decrease was noticed in group B.



109

Chart- Showing changes in Triglycerides:

-15-10-505

10152025

mg/dl

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

pts

Gr.A

Gr.B

Table no.81 showing changes in Triglycerides:

Pt.no Group-A Group-B

BT AT DIF BT AT DIF 1. 169.7 167 2.7 120 135 -15 2. 182.6 180 2.6 130 120 10 3. 113.9 110.1 3.8 85 96.2 -11.2 4 60.9 59.5 1.4 160 142 18 5 136.1 135.7 0.4 108 112 -4 6 135.7 134 1.7 135 139 -4 7 176.1 170.9 5.2 160 165 -5 8 211.2 210.1 1.1 131.9 110 21.9 9 108 105.9 2.1 61.9 60 1.9 10 157 152.3 4.7 116 105 11 11 90 88.7 1.3 110.9 93 17.9 12 85 84.5 0.5 415 397.5 17.5 13 99 97.7 1.3 90 94 -4 14 98 94.9 3.1 89.5 88.1 1.4 15 240 237.1 2.9 157 134 23 Total 2063.2 2028.4 34.8 2070.2 1990.8 79.4



110

Table no.83 showing lipid profile statistical analysis:

Gp Total chol. HDL LDL Triglycerides A 190.41 36.56 126.36 137.54 Mean BT B 205.63 45.45 133.72 138.01 A 183.88 38.33 117.76 135.22 Mean AT B 182.63 48.28 108.79 132.72 A 6.53 -1.76 8.59 2.32 Mean dif. B 23.01 -2.83 24.26 5.29 A 3.42 % 4.81 % 6.8 % 1.58 % Mean % of

Improvement B 11.19 % 6.22 % 18.64 % 3.83 % A 4.619 1.144 5.826 1.394 S.D B 18.48 11.13 19.17 11.562 A 1.192 0.295 1.504 0.359 S.E B 4.771 2.87 4.949 2.985 A 5.474 5.966 5.712 6.462 “t” valve B 4.822 0.994 4.902 1.773 A < 0.001** < 0.001** < 0.001** < 0.001** “p” value B < 0.001** < 0.4++ < 0.001** <0.1++




111

Survey Study

A survey was conducted during August and September month of 2003 to

see the incidence rate of obesity in the adult patient attending S.D.M college

Hospital for first time irrespective of their complaints. A total of five hundred

and sixteen patients were studied with respect to their age, sex, religion,

occupation, diet, height, weight and B.M.I. Out of total patients one hundred and

ninety three were having B.M.I. above 25 (irrespective of sex) the data is

presented as follows:

Table no.84 showing Age wise distribution:

Age Group Over all patients % No. of obese patients % 18-30 168 32.58 67 34.84

31-40 110 21.32 41 21.32

41-50 120 23.24 52 27.04

51-60 065 12.61 26 13.42

61-70 037 07.16 05 02.34

71-80 015 02.91 02 01.04

81-90 001 00.18 00 00.00

Total 516 193

Chart- Showing Age wise distribution

0

20

40

60

80

100

120

140

160

180

All pts obese

18-30

31-40

41-50

51-60

61-70

71-80

81-90



112

Table no 85 showing sex wise distribution:

Sex Over all patients % No. of obese patients % Male 287 55.62 084 43.52

Female 229 44.38 109 56.48

Total 516 193

sexwise distribution of obese patient

84

109

male

female

Sexwise distribution of all patients

43%

57%

male

female

Table no.86 showing religion wise distribution:

Religion Over all patients % No. of obese patients % Hindu 484 93.79 179 92.76

Muslim 028 05.43 013 06.73

Christian 004 00.78 001 00.51

Total 516 193



113

Chart- Showing religion wise distribution:

484

28 4

179

13 10

50

100

150

200

250

300

350

400

450

500

HINDU

MUSLIM

CHIRSTIAN

Table no.87 showing Nature of work wise distribution:

Nature of work Over all patients

% No. of obese patients

%

Sedentary 308 59.75 136 70.47

Moderate 103 19.40 051 26.42

Hard 105 20.85 006 03.11

Total 516 193

Chart- Showing Nature of work wise distribution

0

50

100

150

200

250

300

350

All pts Obese

Sedantary

Moderate

Hard



114

Table no.88 showing Diet wise distribution:

Diet Over all patients

% No. of obese patients %

Vegetarian 197 38.19 67 34.71

Irregular mixed 046 08.91 23 11.92

Regular mixed 273 52.90 103 53.37

Total 516 193

Chart- Showing Diet wise distribution

All patients

38%

9%

53%

vegetarian irregular mixed regular mixed

Obese patients

35%

12%

53%

vegetarian irregular mixed regular mixed



115

Table no.89 showing Height wise distribution:

Height in cms

Over all patients % No. of obese patients %

130-140 002 00.39 00 00.00

141-150 080 15.51 41 21.24

151-160 168 32.45 74 38.34

161-170 177 34.31 59 30.57

171-180 085 16.57 19 09.85

181-190 004 00.77 00 00.00

Total 516 193

Chart- Showing Height wise distribution

0

20

40

60

80

100

120

140

160

180

All pts obese

131-140

141-150

151-160

161-170

171-180

181-190

Table no.90 showing Weight wise distribution:

Weight in Kg

Over all patients % No. of obese patients %

30-40 32 06.20 00 00.00

41-50 109 21.14 00 00.00

51-60 148 28.71 06 03.10

61-70 138 26.77 98 50.78

71-80 053 10.28 53 27.46

81-90 024 04.58 24 12.44

91-100 010 01.94 10 05.18

101-110 002 00.38 02 01.04

Total 516 193



116

Chart- Showing Weight wise distribution

020406080

100120140160

All pts obese

31-40 41-50 51-60 61-70

71-80 81-90 91-100 101-110

Table no.91 showing B.M.I wise distribution:

B.M.I Over all patients % No. of obese patients % 10-14 003 00.58 - -

15-19 106 20.58 - -

20-24 214 41.45 - -

25-29 136 26.34 136 70.58

30-34 044 08.53 044 22.74

35-39 011 02.13 011 05.64

40-44 002 00.39 002 01.04

Total 516 193

Chart- Showing B.M.I wise distribution:

0

50

100

150

200

250

All pts obese

10-14.

15-19

20-24

25-29

30-34

35-39

40-44

Discussion


110

For every research work, rational interpretation and useful discussion

should be made, so that it contributes at least “squirrel service” to the medical

field, inturn serving the society. Here an attempt is made to discuss the concepts

with respect to literary as well as on clinical work.

Discussion on review of literature

Discussion on definition of Sthoulya:

All the definitions, which are mentioned in contemporary science, have

one or the other drawback. For instance, a person accustomed with regular

exercises, may weigh relatively more and as per the definitions he should be

termed as obese person inspite of his active routine works and lack of symptoms

and hence one feels difficult to define obesity. But the definition given by

Ayurveda holds good in this regard. i.e. unless until irrespective of body weight

if a person have “Chala Spik sthana and Udara lambana” he cannot be termed as

obese. More over excess of fat is threat to life rather than weight alone. Hence

assessment of fat is important and for that instead of measuring it in terms of

laboratory parameters and calculations, it is better to stick on to the definition as

mentioned in the classics for the diagnosis of the disease, however to grade and

to assess the results one can take the help of BMI calculations.

Discussion on synonyms:

Various synonyms had been given in the ancient textbooks for Sthoulya,

which includes from over weight to morbid obesity. Recent scholars had tried to

classify the synonyms based on modern criteria as follows:

Table n0.92- Synonym of Sthoulya with modern interpretation:

Synonym Comment BMI < 27 Pusti, mamsalata, piñata Well nourished deposition of fat with

mild degree of overweight BMI 27-30 Medasvita, Medovridhi,

Medurata, Medopusti For extensive growth of Meda dhatu without risk factor.

BMI> 30 Athi Sthoulya, Medo vikara, Medodosha, Medodusti

Morbid obesity

WHR > 0.9 Tundika, Mahodara, Sthulodara Android obesity

Discussion


111

Discussion on physiological consideration of Meda Dhatu:

There is very thin line difference between Medo vridhi and Meda roga.

Many a times both of these terms are used synonymously. The only difference

one can find is that Meda vridhi person will have lambana of Spik, Sthana and

Udara, where as Meda rogi will have Chalatwa due to increased lambana in the

same parts.

It is very difficult to understand the concept of dhatu pramana. Hence 2

Anjali of Medas is very difficult to correlate with any of the modern

Physiological entities.

Sweda is said to be the excretory product of Medas, and it is practically

seen in all most all subjects suffering with obesity will have excessive sweating.

Vrikka and vapavaha are the moola sthana of Medas. It is described in

contemporary literature that Triglycerides are stored around kidneys and

omentum (about 25%). This shows that ancient scholars had an idea about

microelements also. In classics ‘Vrukka’ is found intimately related with fat and

attributed the acquiring of fat to it. “Vrukkwo pustikaro proktho jatarasya

medasa”. By the reference available, it is found to be placed on either side of the

body, apparently inside the abdomen and fat originates from it which appears to

resemble the supra renal glands. With regard to the medodhatu, it is necessary to

look into the action of a hormone produced by the adrenal gland on the fat

metabolism. Cortisol, a glucocorticosteroid produced by the cortex of the

adrenal gland causes a moderate degree of fatty acid mobilization from adipose

tissue but persons with excess cortisol secretion frequently develop obesity.

Discussion on Nidana:

Role of Beeja dosha a having its own part in the manifestation of the

disease. However unless and until the combination of dosha-dushya-nidana takes

place, Sthoolata in the body is not seen.

The etiological factors that are found in both the classics are almost

same. The concept of Santarpaka Ahara and Vihara, when viewed with modern

science, than it can be concluded that the nidana, which are explained, are

Discussion


112

nothing but the high caloric foods and sedentary life styles. For ex. If a person

sleeps in afternoon then due to increased resting hours the calories will be

spared, resulting in fat accumulation. Hence the day sleep is totally

contraindicated in all individuals (expect in greshma ritu) for the maintenance of

health.

Usually obese patients will have inactiveness. The following cycle

shows the reason for the same

Discussion on Lakshana:

Ayushohrasa – decreased life span:

The life span of an obese person decrease proportionally with increase of

BMI. As a result it will be increase chances of inviting the dead full

complications like Stroke, IHD etc. Hence an obese person dies after meeting

with the complications.

Javoparoda- hampering the movements:

As the skeleton is not customized with bearing extra burden in the form

of fat, there will be hampering of movements.

Meda Vridhi in Spik, Sthana and Udara:

Every cell is designed in such a way that it can store excess of energy and

utilize it during starvation or relatively decrease supply of energy. Due to

advancement in modern technology most of the population will hardly suffer

from non-availability of food due to natural causes. Hence there will be always

In activity Weight gain

Decreased fitness

Reduced exercise tolerance

Discussion


113

positive energy balance in the body to which our body is not programmed to

maintain this condition. This excess of energy, irrespective of its form like

carbohydrates, fats and proteins are mostly stored as fat in the adipose tissues.

The deposition of these fats are mainly seen in anterior abdominal wall, flanks,

chest and buttocks will give rise to increase of these structures and hence the

above condition.

3. Athi kshuda / Pipasa:

Usually obese patients will have impaired levels of leptine, which is

responsible to cause satiety. Moreover due to increased basal metabolic rate,

obese patients have to consume more energy; hence they come across above

feature.

Discussion on Upadrava:

Some of diseases like Prameha (Type II diabetes mellitus) & Vata vyadhi

(CVA) can be seen complication of obesity. Here Vata vyadhi will be of avarana

type.

Discussion on Action of Udvartana:

As it is mentioned that ambu is present in Meda dhatu, to flush to the

excess of ambu dhatu, which is present either intercellular or intracellular,

purgation is given with Trivruth lehya. This removes the excess of water, which

represents excess weight in the body. There are five basic principles to bring

dosha from shakha to kosta:

Vrudha – increasing the dosha

Vishyanda –liquefaction

Pakat – due to the paka of dosha

Srotomukha vishodanat – due to Shodana of sroto mukha

Vayu nigraha – due to control over Vata

Discussion


114

Udvartana is having the gunas of Kapha – Meda vilayana property. Due

to ushna and teekshna guna of dravya and forceful massage effect on romakupa,

the Veerya of drug enters into body through, there after it opens the mukha of

siras, there by making paka of Kapha and Medas. Due to this, there will be

dravatha Vrudhi of Kapha and Medas. Swedana, which is given after

Udvarthana will further makes paka of the same. It also makes sweda

pravrathana and due to Sweda karma, which is given after Udvarthana, acts as

Sthambhana, Gouragna and Sheetagna. When the Doshas enters kosta, via above

methods, they should be flushed out of the body. To evacuate these vikrutha

Dosha and Dushya, purgation is given with Trivruth lehya after completion of

sevan days of Udvarthana therapy. By all of these nirharana of Vikruth Vata,

Kapha, aap dhatu along with Medas will takes place ultimately resulting in

Laghavata of Shareera.

Mode of action of Udvarthana on lipids:

As it is seen that Udvarthana is having good efficacy over lipid levels.

The probable mode of action can be explained as follows:

Due to increased friction to all the parts of the body, the Triglycerides

present in the subcutaneous tissues will break down into fatty acids. These fatty

acids are carried out to the liver due to the effect of centripetal massage, which

increase circulation to internal organs for the conversation of these fatty acids

into bile. As less caloric food is supplied along with heavy exercises, the body

needs more of energy to meet the same. In the absence of carbohydrate, fats are

utilized for the purpose of energy production. The bile that is formed in liver, on

the day of purgation will be expelled out in excess. Hence the reabsorption of the

bile will be decreased, inturn further utilizing the lipid which is circulating in the

blood. Promotion of excretion of bile in the feces is used as one of the treatment

principle to treat Hyperlipidemia eg. Colestipol.

Discussion


115

Here is the explanation for the various benefits of Udvarthana:

Twak prasadakara: This beneficial effect of Udvarthana is used to increase

beauty. Improvement in the complexion is the best criteria to assess the cosmetic

property. The colour of skin depends on level of melanocytes, blood circulating

beneath the skin and carotinoids. Colour given to skin by blood is mainly

depends upon the quantity of haemoglobin. By performing Udvarthana, the

amount of blood circulation beneath the skin increases due to friction. Due to

this change the cells of the skin are supplied with more oxygen, there by

changing the colour at least to some extant. In all 15 patients the investigator had

observed no changes with respect to their skin colour, but if this procedure is

conducted as a routine practices there are chances to prove above hypothesis.

Anga sthirikarana (stability of the body): There will be increase in the fat

cells either in number or in size or both in obese person. By performing

Udvarthana these fat cells get lipolysed then the cells get shrunken causing

compactness. Thus one can appreciate the above benefit.

Gourava hara (depletion of heaviness): Gourava is feature due to increase in

Kapha and Medas. Udvarthana enhances transport of Cholestrol from the

periphery to the liver. This cholesterol is utilized for formation of bile (bile

salts). Hence due to decrease of fat one feels lightness.

Dourgandhya hara (removal of body odour): Dourgandhya is the resultant of

Sweda, which is mala of Medas. Due to Udvarthana there will be decrease in

Mala of Medas, hence formation of excess sweat is reduced, resulting in above

benefit.

Tandra hara (removal of drowsiness): Tandra is due to tamo guna, which is

increased by vikrutha Kapha. Udvarthana will reduce Kapha, hence relieves

Tandra. All the patients who received Udvarthana got this benefit.

Discussion


116

Kandu hara (removal of itching): One of the reasons for Kandu is obstruction

in the Swedavaha srotas. As Udvarthana clears the orifices of Sweda vaha srotas

by its Sira mukha vishodhana guna, it reduces itching. Udvarthana choorna

contains ingredients that have Kandu hara property like Sarshapa.

Mala hara (removal of excretory products): In general, mala includes

Pureesha, Mootra and Sweda. Here the term mala indicates only Sweda. Sweda

is the mala, which is excreted through orifices of the skin by Udvarthana.

Vata hara: In sthoulya, Medas and Kapha obstruct Vata. Udvarthana reduces

Kapha and Medas and there by normalizing the movement of Vata.

Shukrada: Due to mandata of Medodhatwagni, the uttarotara poshana of dhatu

gets hampered. Udvarthana corrects Medodhatwagni and hence formation of

consecutive dhatu takes place, there by increasing the level of last dhatu- Shukra.

It is mentioned in the modern literature “fat binds the testosterone”. i.e.

high levels of lipids in blood will decrease Testosterone. Udvarthana reduces

the cholesterol there by hindering the testosterone binding thus making more

availability of testosterone.

Twak mriduta (softness of skin): By performing the Udvarthana, expulsion of

debris of dermis and epidermis take place due to friction. It also increases blood

circulation to layers of skin, there by supplying maximum oxygen to the dermal

cells. Hence softness of the skin is observed. Moreover massaging effect on

sebaceous glands stimulates sebum production and there by brings softness and

texture to the skin.

Discussion on Results:

Discussion on subjective parameters:

All the patients had responded for most of the subjective features. Over

all fifteen parameters had been assessed. “Krucchra vyavaya” was not analyzed,

Discussion


117

as most of the patients were sensitive to reveal their sexual performance and

their desire towards sex (more over most of the subjects were females and had

attained menopause). Some of the parameters like Chalatwa of Spik, Sthana and

Udara, Swedadhikyata, Ayase swasa, Anga sithilatha were responded

significantly by the patients of group B than group A. This shows Udvarthana is

having its efficacy over relieving associated features.

Discussion on subjective parameters:

On weight:

Patients of both the groups had decreased weight with an average of 1.16

0.74 kg in group A and 4.03 1.347 kg in group B after completion of

treatment. The maximum decrease was 2.5 kg and 6 kg in group A and B

respectively. After one month of follow-up, average weight lose was 2.6 1.26

kg in group A and 6.26 2.14 kg in group B with ‘t’ value of 8.024 (p<0.001) in

group A and 11.33 (p<0.001) in group B.

On BMI:

In group A maximum decrease was 0.97 with average decrease of 0.47

0.29 which shows its high significance (p<0.001) after completion of treatment.

In group B minmum decrease was 0.21 and maximum decrease was 2.56 with an

average of 1.63 0.296 with ‘t’ value of 9.778 (p<0.001).

After one month of follow-up the average decrease of BMI was 1.04

0.27 in group A and 2.45 0.775 in group B.

On lipid profile:

Lipid profile was done for the subjects of both the groups. Both the group

had shown some or the changes in the values.

Total cholesterol: All the 29 patients had decrease in cholesterol level except in

one case where there was increase of 6.4 mg/dl.

Discussion


118

In Group A:

All fifteen patients got decrease in their total cholesterol.

Average decrease → 6.53 4.61 mg/dl

Minimum decrease → 0.1 mg/dl

Maximum decrease → 19.6 mg/dl

In Group B:

Out of fifteen patients fourteen got decrease in their total cholesterol.

Average decrease → 23.01 18.48 mg/dl.

Minimum decrease → 11 mg/dl

Maximum decrease → 62 mg/dl

Only one patient has gained by 6.4 mg/dl

Both the groups had shown highly significant response over Total cholesterol.

One patient in Udvarthana group inspite of following regular diet and exercise

had gain in this lipid. It was difficult to analyze the reason behind the same.

HDL: There is mean increase in HDL by 1.76 1.144 mg/dl and 2.85 11.13

mg/dl in group A and B respectively.

In Group A

Out of fifteen subjects all patients had increase in HDL levels.

Maximum increase → 3.9 mg/dl

Minimum increase → 0.3 mg/dl

In Group B

Out of fifteen subjects ten patients had increase in HDL levels.

Minimum increase → 4 mg/dl

Maximum increase → 16 mg/dl

Average increase → 8.62 mg/dl

Out of fifteen subjects five patients had decrease in HDL levels

Minimum decrease → 2 mg/dl

Maximum decrease → 15.6mg/dl

Average decrease → 8.68 mg/d

Discussion


119

The reason for decrease in HDL of 5 patients is not known.

Group A showed highly significance (p<0.001) whereas group B showed

insignificance (p<0.4) in HDL increase. Further research works are required in

this regard.

LDL: There was decrease in LDL levels in Group A & B with an average of

8.59 5.826 mg/dl and 24.26 19.17 mg/dl respectively.

In Group A:

All the fifteen patients had decrease in their LDL levels



In Group B:

All the fifteen patients had decrease in their LDL levels



When the results of both the Groups were compared, there was considerable

reduction of LDL level in experimental group with highly significance ‘p’ value

(<0.001). Hence Udvarthana can be advised as treatment of choice in patients

with high LDL levels.

Triglycerides: There was considerable variation in Triglycerides levels in

Group A and Group B.

In Group A:

All the 15 patients had decrease in Triglycerides level.



Average decrease → 2.18 1.394 mg/dl

In Group B:

Nine out of fifteen patients had decrease in their Triglycerides level.



Discussion


120

Six patients among 15 subjects had increase in Triglycerides level.

Minimum increase → 4 mg/dl

Maximum increase → 15 mg/dl

Overall there was a decrease of 5.29 11.56 mg/dl in all 15 patients.

Group A patients showed highly significance (p<0.001) where as group A

showed insignificance (p<0.1) statistically. However considering overall results,

it can be stated that Udvarthana had better action over lipid profile.

Discussion on patients:

Case – 1:

A female Hindu patient, aged 35 years, was suffering from increased

weight since 9 years. She had associated features of Athi Pipasa, Athi kshudha,

Swasa, Athi Nidra, and Srama. Family history reveals that her parents were

obese. There was no history of Hypertension, Diabetes mellitus and long-term

use of drugs. She was vegetarian and takes food 4 times in a day. She preferred

cold drinks and Madhura Amla yukta ahara. Subject also revealed that she was

habituated with Avyayama, Divaswapna, Sukha shayya, Chestadwesha and

Achintana. She used to sleep for more than 10 hours in a day. Her Prakruthi was

analyzed as Kapha Vataja with Medasara Lakshana. Her Agni status (poorva and

adyatana) was in pravaravastha. She was born and brought-up in Anupa-Jangala

and diseased in Anupa-Sadharana Desha.

Her B.P, pulse and other general features were within normal limits.

Patient frame was medium with height of 158 cm and 90 kg of weight with BMI

36.05 on the day of admission. She had been allocated to group A, where she

took Trivrith lehya on 1st day and passed 9 Vegas. From 2nd day, she started

dynamic exercise and physiotherapy along with prescribed diet chart. Her body

circumference and lipid profile values were taken before and after treatment.

On 9th day, changes were noticed in subjective parameters. There was

decrease of Total cholesterol by 3.3mg/dl, increase in HDL by 0.3 mg/dl, LDL

decreased by 3.1mg/dl, and decrease in Triglycerides by 2.7 mg/dl. She reduced

her body weight by 2 kg and BMI decreased by 0.08. There were no changes in

Discussion


121

Chest, Abdomen and Mid-arm circumference. But Hip and Mid-thigh

circumference were reduced by 1 cm.

Case – 2:

A female Hindu patient, aged 38 years, was suffering from increased

weight since 10 years with positive family history. She had associated features

of Athi Pipasa, Athi kshudha, Swasa, Athi Nidra, Athi Sweda and Srama. There

was no history of long-term drug use, Hypertension and Diabetes mellitus. She

used to take vegetarian diet for 4 times a day. She preferred fruit juice, cold

drinks and Madhura Amla yukta ahara. Subject also revealed that she was

habituated with Avyayama, Divaswapna, Sukha shayya, Chestadwesha and

Harshanitya. Her Prakruthi was analyzed as Kapha Pittaja with Medasara

Lakshana. Her Agni status (poorva and adhyatana) was in pravaravastha. She

was born, brought-up and diseased in Anupa-Jangala Desha.

Her B.P, pulse and other general features were normal. She was of

medium frame with height of 155 cm and 91 kg of weight with BMI 37.87 on

the day of admission. She had been allocated to group B, where she took

Trivruth lehya on 1st day and passed 7 Vegas. From 2nd day, she underwent

Udvarthana treatment with Triphaladi choorna followed by Sarvanga bashpa

sweda with Dashamoola kwatha. After 7 days of Udvarthana, she was given

Trivruth lehya on last day of her hospital stay. She passed 6 Vegas. Snigdhata

was noticed in stools after first 3 Vegas. The patient was on low-calorie diet and

performed prescribed dynamic exercises and physiotherapy. Her body

circumference and lipid profile values are taken before and after treatment.

On 9th day, changes were noticed in subjective parameters. There was

decrease of Total cholesterol by 11mg/dl, increase in HDL by 16mg/dl, LDL

decreased by 28 mg/dl, but there was increase in Triglycerides by 5 mg/dl. She

reduced her body weight by 5 kg and BMI showed reduction by 2.08. There was

decrease of 1cm in chest, abdomen and hip circumference. No changes were

seen in Mid-arm and Mid-thigh circumference.

Discussion


122

Discussion on survey:

A total number of 516 adult subjects were surveyed, who had attended the

OPD of SDMCA & hospital Hassan for first time. The system of Hospital is

maintained in such away that every new patient after getting their registration,

has to go to Screening room, from where they will be sent to different OPD with

respect to their complaints. But the old cases will not be in contact with

screening room on their follow up. Hence the investigator had decided to select

the screening room for his survey study.

The objective of the study was to assess the incidence rate of obesity in

patients attending the above-mentioned OPD irrespective of their complaints.

BMI parameter was selected to assess the obese patients (BMI> 25). Hence with

the help of measuring tape (in cms) and weighing machine the height and weight

were noted. Few other vital data age, sex, religion, life styles and diet were noted

which are helpful for analysis. The survey was done on 30 working days in

between 16th August to 21st of September of 2003. There were total of 193

obese out of 516 patients in the study. The following are the out come of the

study.

Discussion on Age:

Out of 516 patients, 168 patients were belonging to age group between

21-30 years and there was only 1 patient in the age group between 81-90. These

data show that the younger age group patients are more aware of their health

problems.

Out of 193 obese patients 67(34.84%) were belonging to the age group of

21-30.

As the population was more in that age group, hence the prevalence rate

of obesity was more in the same.

Discussion


123

Discussion on sex:

A total number of 287 (55.62%) males and 229(44.30%) females were

present in the population, out of which obese patient were 84(43.52%) males and

109(56.48%) females which reveals that females are more prevalent for obesity.

Discussion on religion:

Survey was done in Hindu dominated area; hence the number of Hindu

cases was more in the study. Out of 484 Hindu patients, 179(92.76%) were

obese.

Discussion on life style:

308 patients were habituated to sedentary life styles, out of which 136

patients (70.47%) had obesity. This shows that, sedentary type of life style have

definite role in the causation of disease.

Discussion on diet:

Out of 516 patients, 316(61.83%) were consuming mixed diet (including

regular and occasional non-veg diet). 53.37% of regular mixed diet (non-veg > 4

times a month) and 11.92% of irregular mixed diet (<4 times a month) suffered

from obesity. This shows that non-vegetarian diet is one of the triggering factors

for obesity, avoidance of which (except fish which contains omega 3 fatty acids)

is believed to decrease BMI.

Difficulties and limitation of the study:

The major problem with the investigator was to allocate the patients into

control group. As the study was conducted in an Ayurvedic Hospital, the obese

patients attended the OPD, expecting some Ayurvedic remedy for their problem,

but when they were asked to undergo purgation and Exercises along with diet

many patients agreed after proper convincement. Once they started realizing that

Discussion


124

their problem is due to sedentary life style with high calorie intake, they pleased

and actively participated in the study. However this problem was not

experienced in case of trail group patients, as many of the patients visit Hospital

requesting to undergo Udvarthana.

The second difficulty was monitoring the diet of patients. During their

stay at Hospital some how they managed with great enthusiasm, but when they

lost their weight and after discharge patients were again attracted by sweets and

such other obesity predisposing foods and activities. However, it was

investigators out of reach to observe each patient after discharge from Hospital.

Many of the obese patients were attracted towards the products, which are

experimented in abroad, were brought to India to exploit the innocent citizens.

Many of such products were telecasted right from local TV channels to

international channels. Almost all magazine will publish one or the other such

products showing before and after treatment photos. Some of the patients in the

study were undergone such products and met with adverse effects. It is the

responsible of the government to take strict action over such things and help the

public for avoiding such mistakes.

As the sample size was small, a pinpoint conclusion cannot be drawn.

Hence it is suggested to conduct the same study over large samples. The follow

up period was restricted for one month keeping in view of study period. In

future, the same study should be carried out to check the regain of weight for a

considerable period.

Further recommendation of study:

1. Same study on secondary obesity.

2. Continuation study with Yavamalaka choorna during follow-up.

3. Survey study in healthy population to assess its prevalence rate.

Conclusion-summary


125

The present study was carried out, giving importance to literary,

diagnostic and therapeutic aspect considering the ancient as well as

contemporary views. The following conclusion along with summary is drawn

after considering the clinical and conceptual study.

This study has done giving equal importance for conceptual as well as

clinical aspects. One should agree the fact that the modern medicine

advanced a lot in this aspect in terms of assessment for weight as well as fat

parameters. Inspite of that there are lacuna in some aspects like defining

obesity, its treatment etc.

The lipid in modern parlance is correlated to Medas with a thought that

Medaja upakrama can be adopted in treating lipid disorders. At the same time

a brief review regarding the lipids and Hyperlipidemia was done.

The Lakshana described in Ayurvedic literature are more worthwhile

than the disease features explained in contemporary science. Ayurveda gives

importance to the bulk of the body; hence to assess the same one should take

the help of Anguli pramanas so as to assess the normal size of the body and

to compare the same with increased bulk of diseased.

The drugs that are described as Pathya for sthoola are rich source of

fibers and hence they can be used, so that patient feels the fullness of

stomach. Fibers stimulates satiety center.

Classification done on nidana like Aharaja, Viharaja, Manasika and anya

holds good for sthoulya. Because each of them have its own role to play but

above all samanyaja stands first. If that is not in favour of sthoulya than

disease cannot manifest. Hence it can be concluded that it is the

Vikaravighatakara bhava.

Conclusion-summary


126

The degrees of obesity like mild, moderate and morbid can be correlated

with vagbhatacharya’s classification like Avara, Madhyama and Pravara Sthoola

respectively.

The concept behind explaining Sthoola as one among the Ashta Nindita is

mainly due to symptoms like Ayushohrasa, complicated pathology and long-

term management.

Among genetic and environmental factors, it is very difficult to judge, which

is having a key role in the manifestation. In the survey study, some of obese

cases reveal the family history and food that they consume, which are also

predisposing factors that are commonly observed. Hence it is difficult to separate

these two entities.

Exercise is having its own role to play in reducing and maintaining the

weight. These patients should be advised to stay active through out the day and

minimize some of the sedentary activities like watching television, using vehicle

etc. They always require continuous encouragement and motivation to perform

physical activities.

Udvarthana should be practiced as a daily regime especially for obese

patients. In classics, it is described to perform Udvarthana after vyayama and

before snana, but if it is done before vyayama then it will be helpful to utilize the

peripheral fatty acids for energy, there by increasing the lipolytic action.

Synonyms described in the text should be used as and when required instead

of using them in broader sense. For example to describe a person of mild obesity

the terms like Medasi, Medurata are suitable whereas to point out morbid obese

person using the term like athi sthoulya etc. by doing so it will be helpful to

choose the therapy with quality and quantity of Pathya merely by looking at the

diagnosed term.

Conclusion-summary


127

Some of the scholars make differential diagnosis of Sthoola person with the

patients of Sarvanga shotha and Udara, but thorough inspection itself

differentiates these conditions.

Sthoulya is not just a physical weight burden but the patient also faces many

psychological problems right from wearing tight cloths till insult in the society.

A clinical study was done on 30 patients. The patients were divided into

two groups namely group A and group B and were advised to follow exercise

and prescribed diet for 1 week, before to which they had been given purgation

with Trivruth lehya. This was common for both the groups. Apart from this

group B underwent Udvarthana and purgation after complication of Udvarthana.

Swedana was given after Udvarthana on every day. Lipid profile was done

before and after treatment. Other objective parameters like weight, BMI and

anthropometrics reading were considered. The associated features were also

graded and compared before and after treatment. The duration of the treatment

was 9 days and after that the patients were asked for follow up after one month.

The results (subjective and objective) were encouraging in trail group (B). The

observation and results were tabulated and statistically analyzed with relevant

parameters.

With respect to reduction in weight, group A patients shown 1.16 0.74

kg where as in group B 4.03 1.34 kg. Mean decrease of BMI was 0.47 0.29

and 1.63 0.65 of BMI in group A and B respectively.

The serum lipids had also responded well for the treatment. Total

cholesterol levels increased with an average of 6.53 and 23.01 mg/dl in A & B

groups respectively. There was mean increase of HDL by 1.76 and 2.83 mg/dl,

however in some cases the levels decreased in group B. LDL levels were

decreased by 8.6 and 24.93 mg/dl and Triglycerides also decreased by an

average of 2.18 and 5.29 mg/dl in group A and B respectively. Over all the

patients of Udvarthana group responded well compared to the subjects of control

group.

Conclusion-summary


128

The patients also showed marked difference in body circumferences

especially in abdominal circumference. Here also group B patients responded

well than control group subjects. There was a relative improvement in subjective

criteria in both groups. It can be concluded that Udvarthana is having significant

effect in Sthoulya.

To know the incidence rate of obesity, a survey was conducted and it is

discussed in observation chapter.

After completion of study, it can be concluded that environmental factors

plays an important role in the causation of the disease and a holistic approach is

required to tackle this multifactorial disease.

Approach to an obese patient:

History:

☻ Smoking habit

☻ Current drug therapies that affect weight

☻ Alcohol intake

☻ Risk factors like angina, stroke

Examination:

☻ BMI

☻ Waist circumference

☻ Blood pressure

Psychological:

☻ Depression

☻ Eating disorder

Investigation:

☻ Lipid profile

☻ Thyroid hormone analysis

☻ Blood glucose

Conclusion-summary


129

Principals of behavioral modification:

Issues to be discussed in-group behavioral therapy are:

Self-monitoring using a food diary

Need for long-term life style change

Need to modify eating habits

Need to assess present exercises level and ideas to increase this if

necessary

Importance of restricting occasions and situation when inappropriate

types or amounts of food are eaten

Separation of eating from other activates

Planning of daily food intake

Understanding of food levels and adopting recipes with regard to fat,

salt, sugar and fiber.

Possibility of changes to individual eating style

Identification of the causes of negative emotions and stress

Recognition that eating may be related to stress

Need to self-monitor feeling and emotions

Dealing with situations that interfere with every day food choices.


130

List of reference: Review of literature- Sthoulya:

1. Bh. Pr. Madhyama 39 2. Ch. su.21/19 3. Su. su 35/34 4. Sha. Madhyama 7/68 5. Ka. khila 6. Ch. chi 15/35 7. Bh. Pr 8. Su. su 15/7 9. Pratyaksha Shareera pg-10 10. Su. sha 4/12 11. Su. sha 9/12 12. Ch. chi 15/18 13. Ch. chi 15/17 14. Ch. vi 8/106 15. Su. su 35/16 16. Su .su 15/14 17. As. Hr. su 11/11 18. Su. su 15/9 19. As. Hr .su 11/18 20. Ch. su. 23/3-6 21. Ma. Ni 31/1-2 22. Su. su 15/32 23. Ch. vi 5/15-16 24. Ch. ni 4/5 25. Ch. chi 6/4 26. Ch. vi 3/ 27. Ch. ni 4/4 28. Ch. chi 28/9 29. Ch. chi 11/12 30. Ch. chi 22/18 31. Ch. su 28/15 32. Ch. ni 4/8 33. Su. sha 9/12 34. As. Hr. ni 1/2 35. Ma. Ni 1/5 36. Su. su 15/32 37. Ch. su 21/4 38. As. Hr. su 11/10-11 39. Ch. vi 5/ 40. As. Hr. su 41. Ch. chi 21/40 42. Ch. su 21/5 43. Ch. su 10/8 44. Ch. su 10/10-13 45. As. Hr. su 14/31 46. Ch. chi 6/57


131

47. Ch. su 23/8-13 48. Ch. su 21/16 49. Ch. su 21/15 50. Ch. su 21/10 51. Ch. su 25/40 52. Ch. su 21/17

Review of literature- Obesity:

1. Essentials of Medical Physiology- K Shambhulingam 2. Principles of Anatomy and Physiology- Tortora & Grabowski 3. Textbook of Physiology – Guyton 4. Textbook of Preventive and Social Medicine – K Park 5. Textbook of Preventive and Social Medicine – Gupta & Mahajan 6. Harrison’s Principles of Internal Medicine 7. Pathologic Basis of Disease- Robbins 8. Clinical Medicine – Kumar & Clark 9. Physical Diagnosis – Vakil & Golwalla 10. Principles of Community Medicine – Sridhar Rao. 11. Principle and Practice of Medicine – Davidson 12. Clinical Dietetics & Nutrition – Antia & Philip

Review of literature- Udvarthana:

1. Ch. su 22/14 1a. Ch. su 22/14: chakrapani 2. Ra. vai.30/14 3. Ch. su 22/34-35 4. Su. ut. 39/104 5. As. San. su 24/12 6. As. Hr. su.14/17 7. Ch. su 22/37 8. Ch. su 21/13-14 9. Su. ut 39/105 10. As. Hr. su 14/18 11. As. San. su 21/16 12. Ch. su 22/41 13. Ch .su 16/7-8 14. Yo. Ra. ritucharya 15. As. Hr. su 3/19 16. Su. chi 24/54-56: Dalhana

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28. Social and Preventive Medicine by Yash Pal Bedi, 15th edition, published by Atma Ram and sons, Delhi.

29. Principles of anatomy and Physiology by GJ Tortora and SR Grabowski, 9th edition, 2000, published by John wiley and Sons INC. page 908.

30. Physiology by Berne, Levy, Koeppen & Stanton, 5th edition, 2004, published by Missouri, page 946.

31. API Text Book of Medicine edited by G S Sainani & co.6th edition 1999. Published by Association of Physicians of India, Bombay, page 208-210.

32. Harrison’s Principles of Internal Medicine, edited by Braunwald,15th edition, 2001, published by Mcgrawhill Medical publishing division New Delhi, page 479-485.

33. Davidson’s Principles and Practice of Medicine, edited by Cristopher R W Ewards 17th edition, 1995, published by ELBS with Churchill livingstone, page 578-584, 886-888.

34. Robbins Pathologic Basis of Disease, by Cotran, Kumar & Robins, 5th edition, 1994, Published by W.B.Sounders & co. Bangalore, page 425-427

35. Clinical Medicine by Praveen Kumar & Clark, 4th edition, 1999, Published by W.B.Sounders, page 207-210.

36. Oxford Clinical Dietetics & Nutrition by F.P.Antia & Philip Abraham, 4th edition, 2002, pubished by oxford university press, page 176,336-346.

37. Nutrition- A health promotion approach by Geoffrey P webb, 2nd edition, London.

38. Grey’s Anatomy edited by Henry Gray, Peter L Williams, Laurence Bannister, 38th edition, 1995, Churchill livingstone, New York.

39. Advanced Textbook on Food and Nutrition by Swaminathan M, The Bangalore Printing and Publishing co. ltd.

Annexure

Ef Effect of Udvarthana in Sthoulya

I

Department of Post-Graduate studies in Swasthavritta, SDM College of Ayurveda, Hospital, Hassan.

Clinical Trail: “Effect of Udvarthana in Sthoulya” Candidate: Dr.Prasanna Kumar.K M.D scholar

Guide: Dr.Sajitha.K M.D (Ayu) HOD: Dr.Ramana.G.VM.D (Ayu)

--------------------------------------------------------------------------------------------------------------------------------------------------------------

CASE SHEET PROFORMA FOR STHOULYA Name of the patient: Date: Age: O.P. No: Occupation: I.P. No: Sex: Group: Religion: Clinical trail No: Marital status Date of admission: Socio Economic: Date of discharge: Education: Result: Occupation: Address: Pradhana vedana and avadhi: Anubandha vedana:

Atipipasa / Atikshudha/ Dourgandhya / Swedabhada / Kasa/ Kshudrashwasa /

Krantana / Atinidra / Kruchra Vyavaya / Moha / Shrama / Sandishoola /Others. Pradhana vedana vrittanta: Poorva vyadhi vrittanta:

Annexure


II

Chikitsa vrittanta: Koutumbika vrittanta: Atura charya: Personal history: Bowel: Micturition: Habits: Exercise: Occupational history: Menstrual history: Dietic history: Appetite: Type of food: Quantity of food: Frequency of food intake: Preferred taste: Preferred fluids: Vihara: Nidra kala: Type of Nidra: General condition: B.P: Pallor: Pulse: Edema: Cyanosis: Icterus: Swasa gathi: Dehoshma: Adyathana Agni: Poorva Agni: Abhyavara shakthi: Jarana shakthi:

Annexure


III

Mala pravruthi: Mootra pravruthi: Jihwa: Lymph node: Prakrutyadi pareeksha: Prakruthi: Saara: Sareerika: Manasika: Samhanana Desha: Jatha/ samvrudha / vyadhita Pramanata: Height:

Parameters Before treatment After treatment Weight: BMI: Chest circumference Abdomen circumference Hip circumference Mid-arm circumference Mid-thigh circumference Satmaya: Satwa: Kala: Bala: Routine examination: Hair: Amount: Texture: Distribution: Skin: Texture: Moisture: Pigmentation: Face:

Annexure


IV

Eyes: Visual acuity: Exopthalmos: Retinopathy: Nose: Polyps: Nasal mucosa: Septum: Mouth: Lips: Tongue: Teeth: Gums: Buccal mucosa: Pharynx: Neck: JVP: Thyroid glands: Larynx:

Trachea: Lymph glands: Movements:

Nails: Joints: Thorax: Upper limbs: Abdomen: Lower limbs: Neurological changes: Mental changes: Stupor: Tremor: Reflux:

Annexure


V

SYSTEMIC EXAMINATION (Including srotas pareeksha) Cardio vascular system: Respiratory system: Gastro-intestinal system: Nervous system: Locomotor system: Uro-genital system: Other systems:

Srotas pareeksha

Pranavaha srotas: Udakavaha srotas: annavaha srotas: Rasavaha srotas: Raktavaha srotas: Mamsavaha srotas: Medovaha srotas: Asthivaha srotas: Majjavaha srotas: Shukravaha srotas: Mutravaha srotas: Pureeshavaha srotas: Swedavaha srotas: Proyogalaya pareeksha: Blood for: TC, DC, ESR, Hb%, RBS, Lipid profile. Urine for: Sugar, Albumin, Micro.

Lipid profile Before treatment After treatment Total cholesterol HDL LDL Triglycerides

Annexure


VI

VIKRUTI PAREEKSHA: (1) Hetu:

Beeja dosha: Ahara: Vihara: Manasika: Anya:

(2) Poorvaroopa: (3) Roopa: (4) Upashayanupashaya: (5) Samprapti:

Dosha samanya: vishesha:

Dushya 1. Dhatu: 2. Upadhatu: 3. Mala: 4. Srotas: 5. Dustiprakara: 6. Agni: 7. Ojus: 8. Rogadhistana: 9. Roga marga: 10. Vyadhi prakara:

(6) Sapeksha nidana: (7) Vyavachchedhaka nidana: VYADHI VINISCHAYA: Rogi bala: Roga bala: Upadrava:

Annexure


VII

Arista: Sadhyasadhyata: CHIKITSA: Group selected for the treatment: 1. Control group- A

2. Experimental group- B CHIKITSA KRAMA for group-A: OBSERVATIONS Day-1

Purgation Day: 2-8 Exercises

Day-30 Follow-up

Subjective parameters

Objective parameters

Laboratorial parameters

CHIKITSA KRAMA for group-B: OBSERVATIONS Day-1

Purgation Day: 2-8 Exercises With Udvarthana

Day: 9 Purgation

Day-30 Follow-up

Subjective parameters

Objective parameters

Laboratorial parameters

Pathya-Apathya: Pathya: Apathya: Signature of the Investigator Signature of the guide

Annexure


VIII

Department of Post-Graduate studies in Swasthavritta,

SDM College of Ayurveda, Hospital, Hassan.

Clinical Trail: “Effect of Udvarthana in Sthoulya”

Diet chart for Sthoola Morning – 7:00-7:30 AM: Honey with water / Punarpuli juice – 75 ml. 9:00-10:00 AM:

Breakfast: Vegetables salad- 100 gm + Sprouts-50 gm or 2 idly with chatni or 1 Dosa (oil less) with chatni or 1-cup upma

11:30 AM: Carrot juice / Lemon juice- 200 ml Noon: 1:00 – 2:00 PM: Lunch: 1-2 dry Chapatti / 1 Ragi ball / 1-2 Ragi roti + 1 small cup Rice with sambar + Unlimited raw / cooked vegetables 4:00 – 5:00 PM: Buttermilk / Lemon juice- 200 ml Night: 8:00 – 9:00 PM: Dinner: 1-2 dry Chapatti / 1-2 Ragi rotti

+ Vegetable salads including cucumber, carrot, tomato, radish + buttermilk - 200 ml.

General Instruction: If there is uncontrolled appetite in between meals then, carrot, cucumber,

mosambi, orange, sprouts can be taken in moderate quantity. Avoid sweets, oily foods, ghee, curds, potato, banana, mango and other foods

that contain more of carbohydrate. Avoid mutton, chicken, pork and other non-vegetarian foods except fish. Foods stuffs prepared of rice in moderate quantity. Avoid using coconut / ground nut oils and use refined oil for cooking. Avoid bakery items, chocolates, cold drinks, milk and milk products except

buttermilk, alcohol. Perform exercises atleast for 1 hour / day, brisk walk, jogging, Yogasana Avoid day sleep, TV watching and such other sedentary works.

Annexure


IX

List of Dynamic exercises

Jogging: Forward /Backward / Sideward Neck rotation

Flexion and extension of all joints Twisting

Bending: Forward / Backward / Sideward Toe touching

Heal touching Hip rotation

Knee rotation: Inward / Outward / Both Back swing

Rocking and Rolling Lumbar stretch

Alternate knee touching Straight leg raising

Side leg arising Free walk

Baby walk Camel walk

Crow walk Step climbing

Spinal twist

Table no.93-Common Indian preparation with kilocalories of energy:

Food

preparation

Wt/serving

in gm

kcal Food

preparation

Wt/serving

in gm

kcal

Plain rice 504 595 Idli (2) 136 130

Sambar bath 485 405 Plain dosa(2) 100 216

Curd bath 253 221 Masala dosa(1) 100 212

Uppuma 128 163 Puri(2) 32 136

Chappatis (2) 57 193 Parota (1) 66 304

Ragi ball 336 446 Ragi roti (2) 185 460

Jowar roti(2) 150 252 Bengal gramdal 151 284

Tea 100 36 Coffee 100 52

Meat curry 128 220 Fish fry 100 220

Annexure


X

Table no.94- showing activities and caloric burn with respect to different weight:

APPROXIMATE CALORIE BURNED/

HOUR IN DIFFERENT PERSONS

ACTIVITY

50 kg 60 kg 70 kg 80 kg

Cycling 20 miles/hour 990 1188 1386 1584

Running 12min/mile 510 576 672 768

Walk / jog – 10 min 360 432 504 576

Walk 17 min/ mile 240 288 336 184

Swimming 360 432 504 576

Stretching yoga 240 288 366 384

Weight lifting 180 216 252 288

Dancing disco 330 396 462 528

Gardening 270 324 378 432

Sitting/reading/watching TV 68 81 95 108

Sleeping 38 45 53 60

(Source: “The week” Feb 24, 2004)

Table no.95-Recommended energy intake according to age, height, and weight:

Category

Age In yrs

Weight In kg

Height In cm

Average energy allowance (kcal)

Per kg per day Infants 0.0-0.5

0.5-1.0 6 9

60 71

108 98

650 850

Children

1-3 4-6 7-10

13 20 28

90 112 132

102 90 70

1300 1800 2000

Men

11-14 15-18 19-24 25-50 51+

45 66 72 79 77

157 176 177 176 173

55 45 40 37 30

2500 3000 2900 2900 2300

Women

11-14 15-18 19-24 25-50 51+

46 55 58 63 65

157 163 164 163 160

47 40 38 36 30

2200 2200 2200 2200 1900

Annexure


XI

Table no.96-showing height and weight for women of different ages:

Weight in kg for different ages in years Height

in cms 20 25 30 35 40 45 50

148 38.6 41.0 42.6 44.0 45.1 46.3 47.1

150 40.3 41.6 43.5 44.8 46.0 47.0 47.7

153 41.9 43.5 45.3 46.6 47.9 48.4 49.5

155 42.8 44.3 46.2 47.7 48.8 49.5 50.1

158 44.9 46.3 48.1 49.5 50.4 51.6 52.1

160 46.0 47.3 49.1 50.6 51.5 52.4 53.0

163 47.3 48.8 50.8 52.1 52.2 54.1 54.9

165 49.1 50.6 52.6 54.1 55.3 56.0 57.3

168 50.0 52.1 53.8 55.6 56.8 57.7 59.0

Table no.97- showing height and weight for men of different ages:

Weight in kg for different ages in years Height

in cms 20 25 30 35 40 45 50

148 42.7 44.2 46.2 47.6 48.8 50.0 50.9

150 43.6 44.9 46.9 48.5 49.7 50.8 51.5

153 45.4 47.0 49.0 50.4 51.7 52.3 53.5

155 46.3 48.1 49.9 51.5 52.7 53.5 54.2

158 48.6 50.0 52.0 53.5 54.5 55.7 56.3

160 49.7 51.1 53.1 54.7 55.6 56.7 57.4

163 51.1 52.7 54.9 56.3 57.6 58.5 59.4

165 53.1 54.7 56.9 58.5 59.7 60.6 62.0

168 54.0 56.3 58.1 60.1 61.5 62.4 63.7

170 56.5 57.9 60.3 62.2 63.7 64.7 65.8

173 58.1 60.1 62.2 64.0 65.8 67.0 68.3

175 60.1 62.2 64.2 66.0 68.1 69.7 71.0

178 61.9 64.0 66.3 68.5 70.6 71.9 72.4

180 64.0 66.2 68.5 71.0 73.3 74.4 75.1

Annexure


XII

Table no.98-showing common Indian cereals with their nutritive value

Food Protein (gm)

Fat (gm)

CHO(gm)

Calories

Fiber (gm)

Ca (mg)

B1

(mg) Niacin(mg)

Barley 11.5 1.3 69.4 335 3.9 0.03 0.47 4.7 Jawar 10.4 1.9 72.4 349 1.6 0.03 0.37 1.8 Maize 4.3 0.05 15.1 82 - 0.01 0.11 0.6 Ragi 7.1 1.3 72.7 331 3.6 0.33 0.42 1.1 Rice 13.5 16.2 48.4 393 4.3 0.07 2.70 28.0 Wheat floor 11.8 1.5 71.2 348 1.2 0.05 0.35 5.0 Bengal gram

20.8 5.6 59.8 372 1.2 0.06 0.48 2.4

Black gram 24.6 1.4 60.3 350 0.9 0.20 0.42 2.0 Cow gram 24.0 0.7 55.7 327 3.8 0.07 0.50 1.3 Green gram 24.0 1.3 56.6 334 4.1 0.14 0.47 2.0 Horse gram 22.0 0.5 57.3 322 5.3 0.28 0.42 1.5 Peas 19.7 1.1 56.6 315 4.3 0.07 0.45 2.3 Red gram 22.3 1.7 55.7 327 1.5 0.14 0.45 2.4

Table no.99-showing common Indian vegetables with their nutritive value:

Food Pro gm

Fat gm

CHO gm

Calories

Fiber gm

Ca mg

B1

mg Vit-c mcg

Niacin(mg)

Cabbage 1.8 1.0 6.3 33 1.0 0.08 0.06 124 0.4 Coriander 3.3 0.6 5.3 40 1.2 0.14 0.05 135 0.8 curryleaves 6.1 1.0 16.0 97 6.4 0.81 0.08 004 2.3 Spinach 1.9 0.9 3.4 30 0.6 0.06 0.05 28 0.5 Beet root 1.7 0.1 13.6 62 0.8 0.20 0.04 10 0.4 Carrot 0.9 0.2 10.7 47 1.1 0.08 0.04 03 0.4 Onion 1.8 0.1 13.2 61 0.6 0.04 0.08 02 0.5 Potato 1.6 0.1 22.9 99 0.4 0.01 0.10 17 1.2 Radish 0.6 0.3 7.4 35 0.6 0.05 0.06 17 0.4 Cucumber 0.4 0.1 2.8 14 0.4 0.01 0.03 07 0.2

Annexure


XIII

Table no.100- showing miscellaneous Indian foodstuff with their nutritive value:

Food Progm

Fat gm

CHO gm

Calories

Fiber gm

Ca mg

B1

mg Vit-c mcg

Niacin(mg)

Almond 20.8 58.9 10.5 655 1.7 0.23 0.24 00 4.4 Cashew nut 21.2 46.9 22.3 596 1.3 0.05 0.63 00 1.2 Groundnut 26.7 40.1 20.3 549 3.1 0.05 0.90 00 14.1 musteredseed 22.0 39.7 23.8 541 1.8 0.49 0.65 00 4.0 Sesameseed 18.3 43.3 25.2 564 2.9 1.45 1.01 00 4.4 Lemon 1.0 0.9 11.1 57 1.7 0.07 0.02 39 0.1 Orange 0.9 6.3 10.6 49 - - 0.12 68 0.3 Papaya 0.5 0.1 9.5 40 - - 0.04 57 0.2 Fish 17.6 3.1 1.0 86 - - - - - Egg 13.3 13.3 - - - - - 02 - Mutton 18.5 13.3 - - - - - - - Pork 18.7 4.4 - - - - - 02 - Milk 4.3 8.8 5.1 - - - - 05 - Curds 2.9 2.9 3.3 - - - - 01 -

Table no.101-Reducing and weight maintenance diet of high cost (gm/day)

Reducing diet Weight maintenance diet Diet I (1100 k.cal)

Diet II (1300 k.cal)

Diet III (1500 k.cal)

Diet IV (1800 k.cal)

Foodstuff Veg N.veg Veg N.veg Veg Non.veg Veg Non.veg

Cereals 80 80 100 100 100 100 150 150 Legumes 50 50 60 60 60 60 80 80 Milk 1000 500 1000 500 1000 500 1000 500 Eggs 1 - 1 - 1 - 1

Meat/ fish 100 - 100 - 150 - 200 Green leafy. 200 200 200 200 200 200 200 200 Other veg 200 200 200 200 200 200 200 200 Roots/tubers 50 50 50 50 50 50 50 50 Fruits 50 50 50 50 50 50 50 30 Fats / oils 15 15 20 20 30 30 30 30

Annexure


XIV

Table no102-Reducing and weight maintenance diet of medium cost (gm/day)

Reducing diet Weight maintenance diet Diet I Diet II Diet III Diet IV

Foodstuff Veg N.veg Veg N.veg Veg N.veg Veg N.veg Cereals 100 100 150 150 150 150 220 220 Legumes 100 100 100 100 100 100 100 100 Milk 500 300 500 300 500 300 500 300 Nuts 30 - 30 - 60 30 60 30 Meat, fish - 50 - 50 - 50 - 50 Green leafy 200 200 200 200 200 200 200 200 Other veg. 200 200 200 200 200 200 200 200 Roots/tubers 50 50 50 50 50 50 50 50 Fruits 50 50 50 50 50 50 50 50 Fats / oils 15 15 15 15 15 15 15 15

Table no 103-Reducing and weight maintenance diet of low cost (gm/day)

Reducing diet Weight maintenance diet Diet I (1100 k.cal)

Diet II (1300 k.cal)

Diet III (1500 k.cal)

Diet IV (1800 k.cal)

Foodstuff Veg N.veg Veg N.veg Veg N.veg Veg N.veg

Cereals 120 120 170 170 170 170 240 240 Legumes 100 100 100 100 100 100 100 100 Milk 300 200 300 200 300 200 300 200 Nuts 30 - 30 - 60 30 60 30 Meat, fish - 30 - 30 - 30 - 30 Green leafy 200 200 200 200 200 200 200 200 Other veg. 200 200 200 200 200 200 200 200 Roots/tubers 50 50 50 50 50 50 50 50 Fruits 50 50 50 50 50 50 50 50 Fats / oils 15 15 15 15 15 15 15 15

sthoulya sw06 has

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