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Introduction

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. [1] Ayurveda has proved it that it is the genomic variation that regulates the range of body weight at which set point is set. This is concept of Prakruti. Prakruti along with Agni and condition of body channels i.e. Srotas are responsible for setting weight at certain range. [2] Changes in food, lifestyle and psychological changes for short duration and on a smaller scale do not affect body weight on a wider range. But, if drastic changes in Charya are there continuously for length of time, then homeostasis is lost and gaining of weight or weight loss starts. Weight gain initially leads to condition of overweight and further to obesity. Sthoola is considered as Nindita pertaining among 8 physical deformities .[3] Non-practice of  physical exercise or absence of physi­cal exercise,   day-sleep and in­take of food increasing Shleshma, sweat and unctuousness (Snigdha), which resulting cause and pro­duce fat in excess. [4] Consequently, Meda obstructs channels causing Srotoavarodha and other body tissues-dehadhatus do not get nourishment or remain neglected for enhancement or growth and ultimately, Meda only continues to develop constantly resulting in growth of meda in excessive amount, extra ordinarily. As the result (excessive growth, production and higher amount of Meda(fat-excessiveness), one finds himself incapable for physical activities and body movements, becomes, thus, unable in any action  on account of extra deposit of fat. Management of Sthaulya is difficult as long term, consistent, troublesome treatment along with lifestyle modification with diet and exercise is mandatory. Need of the hour is to treat rationally so that complications can be reduced or prevented. In this regard, approach of Ayurveda is more safe, comprehensive and rational.

Ayurvedic view on management of Obesity

Ayurvedic approach in achieving ideal weight, is based on taking a realistic look at our body type and then nourishing it back to natural health. It is about getting to know your body and becoming in tune with its rhythm. Permanent resetting of mind- body’s ability to regulate itself by calming nervous system, enhancing digestive fires and regulating storage of energy and fat is done. In Ayurveda, rather than universal approach to solving problems, it is always patient specific, towards all diseases and obesity in particular. Strategies are designed for each person after a careful analysis of condition of person’s body, mind, soul, dosha status and constitution. Lifestyle modification as per constitution is advised especially regarding diet and exercise. Increase in intake of foods that enhance digestive fire like ginger, bitter melons, dark bitter greens etc. is advised. Management of Sthaulyais quite difficult because both Agni and Vayu are in aggravated  state.  If Apatarpana is  done Vayu gets Vriddha and Agni starts  burning  other Dhatus and  if Santarpana is  done  the  disease  will  be aggravated. The treatment principle of the disease is  well  explained  in  Charaka  Samhita. Administration  of  Guru  and Apatarpaka articles which possess additional Vata, Shleshman and Medonashaka properties  is  considered  as an ideal shaman therapy for Sthaulya.[5]

Elimination of Aama

Aama is byproduct of inefficient or incomplete digestion. It tends to clog up circulatory, lymph and other channels of body. Getting rid of Aama is primary strategy. It’s highly impossible to treat any imbalance of physiology when Ama is present and it is extremely difficult, perhaps impossible to lose wt. This is why so many people who have limited their diets to the point of virtual starvation still have failed to accomplish their goals. So, it’s essential to take practical steps to eliminate Aama in order to lose wt. and keep it off permanently. Aama is, quite simply, a key in the pathogenesis of obesity. Simple regimen such as sipping of warm water processed with powders of dry Ginger, Khus, and Musta or Turmeric + Triphala+ Trikatu +Honey with warm water gives wonderful result in pacifying vitiated Aam. In general, two types of therapies are to be formulated for treating the over-obese (Atisthula) and over-lean (Atikrisa) persons. For reducing the bulk of the obese (Sthulanam karsanam parti) heavy (Guru) and non-saturating (Atarpanam), while for promoting the bulk of the lean (karsanam brinhanrtham), light (laghu) and saturating therapy (santarpana) is prescribed.

Treatment plan for Obesity

The Ayurvedic management of Obesity (Sthaulya) can be categorized as Nidanasya Parivarjarna – Find And Nullify Cause, Satata Karshana Chikitsa – Continuous/ Repeated/ Periodic Treatment, Guru Apatarpana Ahar- Diet Regulation, Langhana Chikitsa, Shodhana Rupi Langhana – Panchkarma,  Shamana Rupi Langhan- Pharmacotherapy and Pathyapathya – Do’s And Don’ts to be advocated for better outcome.

Similarly, BMI is one of the important criterion for designing treatment plan.

Table 1: Plan of treatment based on BMI

Shodhan Chikitsa in Management of Obesity

Panchkarma therapy should be done as Primary Treatment for Heredity of obesity, genetically obese, repeated weight gain after weight loss, Lifestyle Disorder, Physically unfit for vigorous exercise and in those who need of speedy weight loss for some reason.

Plan of treatment

1) Shodhan Chikitsa- (Purificatory measures)- These Panchkarma are primarily aimed to remove accumulated toxins out of body, to cleanse channels to facilitate circulation of nutrients, to increase body’s receptibility for drugs and diet and to modify, improve Digestion and Metabolism.

Panchakarma – These are fivefold therapies (Vamana, Virechan, Basti, Nasya and Raktamokshan) have been advocated before pharmacotherapy and other treatments give better, fast and long standing results in obesity management. Out of 5, three are proved to be more beneficial for Obesity such as Vaman (medicated vomiting), Virechan (medicated purgation), Basti(enema therapy-particularly Lekhan Basti). Swedan (fomentation) and Udvartan (massage with herbal powder) also play a major role in treatment. Out of various Basti , Lekhan, Vaitaran, Ardhamatrik, Yog Basti are more beneficial. Other useful purificatory measures are-Dhumpan (medicated smoking), Swedan (Sudation therapy- especially Kuti Sweda, Ruksha sweda, Anagni sweda) and Udvartana (herbal powder massage- Rubbing of dry powders with or without friction is helpful especially for fat deposits at subcutaneous level). Herbs for Udvartana-Triphala, Musta, Neem, Haridra, Daruharidra, Tulsi, Ashwagandha, Musterd, Lodhra, Vacha etc.

Discussion

Lekhan Basti- This is a medicated enema that contains drugs that are having lipolysing capacity.  Enema is given on alternate fortnights for 3 cycles.

300-400 ml decoction of Triphala, 10 gm of powder of Ushak, Saindhav, Shilajatu, Kasis, Hing, Tuttha mixed with Moorchchita sarshap oil, 100 ml of cow urine, 80 ml of honey and 5 gm of yavakshar.[6]

Exrernal treatment:

Udvartan- Retrograde powder massage by rubbing( with pressure). Drugs used are having penetrating, scraping capacity. Powders of Triphala, Nimb, Nagarmotha, Vacha, Shunthee, Agaru, Haridra, Daruharidra, Shirish, Khus, Lodhra, Nagkeshar, Arkapatra kshar, White clay,Ash of cow dunk.

Lepa- Local application of medicated paste

Snehan and Mardan- Oil application with variable pressure and in direction from distal to proximal end.

Swedan- Sudation especially Kuti swed.

There are certain rules and protocol to be followed while performing these procedures such as  Snehan and Swedan should be done before advocating Panchkarma Therapies and all the   applications should be from distal to proximal end. Drugs and technique of therapy are equally important in the procedure.

2) Shaman Chikitsa- These are pacificatory measures that are advocated generally after purificatory procedures. Shaman chikitsa is aimed to pacify vitiated Dosha responsible for existing obesity, to tone up fat by removal (lekhan- scraping ) of abnormal, excess fat from areas where it has got accumulated in abundance. Conservative herapy with herbs, diet, exercises and lifestyle, use of Bitter, pungent astringent taste, drugs of Dry, hot, sharp, scraping qualities with   Anupan- luke warm water and honey is very important. The Dhatutarpan chikitsa refers to providing adequate nourishment to make you feel satisfied but not in excess to be stored as fat. Similarly, Agnimandyahara chikitsa improves Digestion and Metabolism and Apunarbhav Chikitsa measures those are undertaken to avoid regain of lost weight, maintenance of health and healthy wt. toning up of body constituents. Hence, not to allow fat to accumulate within lax tissues.

Drugs for Obesity

Especially for Abdominal Obesity-

1. Lauha rasayan, lohasav, loharishta
2. Varunadi kwath
3. Chitrak, kutaki, trikatu combination.
4. Musta+ Shunthee Jal
5. ½ tsp honey + ½ tsp basil leaves - paste in 1 glass of luke warm water to drink.
6. 1 glass of water + soak 2 tablespoon of horse gram & keep it for a day. -Drink early morning on empty stomach.
7. Arogyavardhini, Chandraprabha, Punarnava mandur, Gomutra Haritaki, Medohar Guggulu, Navak Guggul, Trivang bhasma.

To reduce fat and for getting relief from obesity-one should follow certain measures, for instance:

1. Upavasa (fasting and dieting or abandoning food-abstinence from heavy cereals and edible in high quantity and high calories or much nourishing food etc.).
2. An obese person should always use following cereals and food articles as well as suitable measures:
3. Purana Sali (old-not freshly harvested rice esp; Sali), Mudga, Kulattha, Uddalaka (vankodrava), Kodrava.
4. Asukha shayya (sleeping on uncomfortable bed or avoiding luxurious, highly comfortable bed using modern amenities for making it softer and bulky etc.)
5. Sattvoudarya (psychic generosity and courtesy);
6. Tamojaya (countering sleep and adverse effects and characteristics of temoguna)

The obesity caused by Santarpana (saturation) should be checked by following measures: As obese person who is inclined to practice these measures as his favorites and prefers to consume Yava (barley) and Shyamaka cereals as food articles, definitely succeeds in getting rid of obesity. Dhumapana (medicated smoking), Krodha (anger) and Raktamoksana (bloodletting) are beneficial to obese condition. After digestion of food once ingested, one should use barley (Yava) and wheat (Godhuma) regularly for food preparations which should be consumed by patient in routine diet.

Conclusion

Judicious and genuine management of Sthaulya is done with treatment triad i. e. Drugs, Diet regulation and Exercise. Scientific elaboration of these along with small tips about the same is mentioned so as to make it more applicable rather than mere theoretical. Enlisting of herbal drugs and herbal and herbo-mineral combinations is done so as to have wide scope for selection of drugs as per constitution, dosha vitiation and specific for the patient and condition. This is a humble effort to compile information as well as sharing of views and eventually formulate a Sthaulya chikitsa upakrama- a holistic plan for prevention and management of Obesity.