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Introduction

Langhana is a term which is ‘A’ karanta napumsaka linga. It is derived from the root ’Laghi’ with the pratyaya ‘Lyaut’. This means to pass over meals/ abstain from food/ fast.[1] Upakrama is ‘A’ karanta pullinga pada derived out of ‘Kramu’ dhatu with the upasarga ‘Upa’ and ‘Ghan’ pratyaya, which means anything leading to a result/ treatment, practice or application of medicine, to treat, attend on.[2] Langhana upakrama incorporates various procedures/ medications by the use of which laghavata of the body is achieved. It also called as Apatarpana, in the context of dvividhopakrama, the words langhana and apatarpana are used synonymously in astanga hridaya.[3] Charaka samhita classifies langhana upakrama into ten types which include Vamana, Virechana, Asthapana, Nasya, Pipasanigraha, Atapa sevana, Maruta sevana, Pachana, Upavasa and Vyayama.[4] Astanga hridaya classifies langhana into two types i.e., shamana and shodhana. Shamana rupi Langhana includes Pachana, Deepana, Kshut, Trut, Vyayama, Atapa and maruta sevana. Shodhana rupi langhana is further classified into five types i.e. Niruha, Vamana, Virechana, Shiro-Virechana, Raktamokshana.[5] Langhana upakrama is indicated in individuals who are afflicted with twak dosha, pramudhata (unconscious) when there is predominance of snigdha and abhishyandi gunas, and in atibrumhita persons (over nourished). Langhana is also advocated in sishira and hemanta rutus and in vata vikaras.[6]  Indications of langhana upakrama as per Astangahridaya include conditions such as meha, ama dosha, atisnigdha, jwara, urusthamba, kushta, visarpa, vidradhi. Pleeha, shiro roga, kantha and akshi roga.[7]

Sushrutha samhita advocates, langhana as the main line of treatment in Atinidra especially samshodhana rupi langhana. Individuals who are Sthoola need to undergo langhana everyday. In general, langhana is indicated in sishira and hemanta rutus.[8] Langhana is indicated in jwara and is considered as the first line of treatment.[9]

Apatarpana and Sthaulya

All the treatment modalities can be classified under two headings, santarpana and apatarpana. Apatarpana is the main line of treatment when the disease is santarpana nimittaja and ama nimittaja. Whereas santarpana is indicated in apatarpana nimittaja vyadhis and vata pradhana vyadhis. As pitta and kapha are Drava dhatus, apatarpana is to be advised in santarpanottha vikaras like sthaulya. It is evident from the definition of langhana upakrama that it incorporates various procedures/ medications by the use of which laghavata/ lightness of the body is achieved. The indication for such an upakrama sthaulya  chiefly.[10] Langhana or laghuta can be achieved in the body if vayu, Agni and akasha mahabhuta dominance is achieved for which various types of langhana are advocated depending on the atura bala, vyadhi bala and avastha of vyadhi. For the management of such diseases, the gunas and dravyas which are opposite to the aetiological factors are needed. All the management strategies which aim to counteract Santarpana are grouped under the heading Apatarpana/ Langhana. The gurvadi gunas which are related with both santarpana and apatarpana can be grouped as follows: The dravyas (ahara and aushadha) which have apatarpaka gunas should be made use of to achieve langhana. The dravyas which possess gunas opposite to it are apathya and hence to be avoided.

 

Dashvidh Langhana Upakrama

Vyayama, atapa and maruta seva: [11]

These three varieties of langhana indicate modification in the lifestyle of the individuals. Altered lifestyle plays an important role in the manifestation of santarpana janya vyadhis which are evident from the nidanas like Aasya sukha, swapna sukha, divasvapna, avyayama which are implicated as the major culprits in the genesis of Santarpanaottha vikaras.  Modification in lifestyle (vyayama, atapa and maruta seva) can be the chief management strategy when the individual is strong and the disease is not severe (alpa vyadhi bala). Otherwise this variety of langhana has probably a supporting role with other treatment modalities. Hence in a santarpanottha vyadhi, during its initial stages adopting a healthy

lifestyle could prevent the progression and further complications of the disease. During moderate to heavy exercise there will be dramatic increase in fat utilization due to the influence of epinephrine and nor epinephrine. This is due to sympathetic stimulation during      exercise which activates hormone sensitive triglyceride lipase present in fat cells in abundance directly. This causes rapid breakdown of triglycerides and mobilization of fatty acids. Also, the use of free fatty acids for energy by muscles during exercise increases eight-fold.[12]

Upavasa and Pipasa nigraha:

Dietary modification is an important component in the management of all diseases in general and Santarpanottha vyadhis in particular When the strength of the disease and the diseased are less (alpa bala rogi and alpa bala roga) then, upavasa and pipasa nigraha are to be resorted to. As the bala of the patient is not strong vyayama and atapa seva cannot be advised. The severity of the disease is also not much to advice shodhana. Hence upavasa and pipasa nigraha are to be advocated. Avoiding snigdha, guru, the food having these qualities can also be considered as upavasa along with total abstinence from food in this context. Dietary fat and excess carbohydrates are the main culprits in the pathology of various santarpanottha vyadhis. Lack of availability of sufficient carbohydrates automatically increases the rate of removal of fatty acids from adipose tissues which are made available to the peripheral tissue cells to be used for energy during periods of starvation.[13]

Pachana:

Charaka Samhita advocates pachana rupi langhana in conditions like chardi, atisara, jvara, gourava which predominantly involve kapha and pitta and the bala is madhyama. Due to the bala of vyadhi, pipasa nigraha and upavasa cannot be resorted to for ama pachana and may need dravyas which possess ama pachaka effect. Shodhana rupi langhana.[14]

 Shodhana:  this langhana incorporates Vamana, Virechana, Shiro Virechana, Asthapana basti, Raktamokshana. It is indicated when the patient can withstand the pharmacotherapy and when the other management modalities fail due to the severity of the Disease. When the rogi and roga bala is pravara then shodhana rupi langhana is advocated. When there is involvement of excessive sleshma, pitta, rakta and malas in the pathology and when there is samsrushta maruta (Vata associated with other doshas/ dhatus) then one has to resort to shodhana rupi langhana rather than any other type of langhana. The Shodhana chikitsa, advocated in such conditions incorporates dietary restriction too along with the procedure. The aim being correction of Agni, ama pachana, preparing the body for pharmacotherapy. Specific shodhana is advocated based on dosha and rogi bala. By samshodhana there will be dosha nirharana from the body resulting in kostha shuddhi. Due to koshta shuddhi there will be jaatharagni vruddhi and Dhatvagni vruddhi which to brecks the Samprapti of sthaulya.[15]

Discussion

Obesity is a state of increased body weight due to adipose tissue accumulation. number or combination of both resulting in disproportionate weight to specific height which is similar to the pathology mentioned in Sthoulya i.e., ayatha upachaya of medas as stated in Charaka Samhita. Sthoulya is considered as a rasanimittaja vyadhi in Sushruta Samhita, the management of which is primarily through langhana. Sthoulya is a santarpanottha  vyadhi which is to be treated on the lines of Apatarpana which is synonymous to Langhana. Ten  varieties of langhana upakrama can be understood under the following broad headings.

1. Shodhana, Pachana and Deepana- Pharmacotherapy

2. Upavasa, Trushna nigraha - Dietary management

3. Vayama, Atapa Maruta seva - Exercise/ lifestyle management

Effect of Dashvidh Langhana Upakrama on Sthaulya:

Regular physical activity (vyayama), regular sexual activities and proper sleep schedule promotes good health and controls the probability of developing Sthoulya. Vyayama, atapa and maruta seva also have a significant impact on plasma lipid levels and should be encouraged in individuals who can tolerate moderate to high levels of exercise. Reduction in plasma triglyceride levels, increase in HDL levels result out of this variety of langhana. All these effects are due to sympathetic medicated activation of hormone sensitive triglyceride lipase present in fat cells which accelerate breakdown of triglycerides and mobilization of fatty acids. Hence in a balavan rogi, if the vyadhi bala is madhyama (Madhya sthoulya) then vyayama, atapa and maruta seva can be the choice to achieve langhana. The concept of ‘Guru cha Atarpana’ in the management of sthoulya is aimed at restricting the total calorie intake without absolute starvation. Diets containing low-energy dense and high fiber content like oats, unrefined flours, greens leafy vegetables and fruits have been shown to control hunger (due to guru guna) and also give a sense of satiety resulting in decreased caloric intake and weight loss (atarpana).  Management of obesity chiefly involves dietary modification to decrease energy intake[16]  which can achived by Upavasa and Pipasa Nigraha. When the strength of the disease and the diseased are less (alpa bala rogi and alpa bala roga) then, upavasa and pipasa nigraha are to be resorted to. As the bala of the patient is not strong vyayama and atapa seva cannot be advised. The severity of the disease is also not much to advice shodhana. Hence upavasa and pipasa nigraha are to be advocated in conditions of Madhya sthoulya. [17]

Langhana, langhana – Pachana, Doshavasechana are the three means of achieving apatarpana as detailed in vimana sthana of charaka samhita. Depending on the involvement of doshas and severity of the disease these three are to be advocated. Sthoulya is a condition enlisted under Bahudosha avasthas wherein shodhana is to be performed to get better results. In sthoulya, when the other management strategies fail due to the involvement of prabhuta doshas then shodhana is to be advised. Shodhana is helpful in clearing the margavarana which is responsible for prabhuta koshta vayu in sthoulya.  The choice of the type of shodhana depends on the condition of the patient and avastha of the disease. Vamana is Kaphaja vyadhi and has significant role in sthaulya. Virechana is advocated in santarpanottha vyadhis like sthoulya. Though pachana chikitsa is beneficial in treating Ama, which is the prime factor in the genesis of the disease sthoulya, concurrent shodhana is needed as agnimandya is at the level of dhatus which has to be corrected to ensure proper dhatuparinamana.  The type of basti indicated in sthoulya is Asthapana basti. bastis with ruksha, ushna, teekshna dravyas, lekhana bastis are recommended.[18]

Conclusion

Balancing the energy intake and expenditure is the idea behind various Langhana  upakramas. Dashvidh Langhana should be indicated in Sthaulya. Because there is involvement of kapha, medas, ama dosha, snigdha and abhishyandi gunas in the pathogenesis, langhana upakrama is advocated. The choice of the nature of langhana depends again on the condition of patient and stage of the disease.