Introduction

Charak has described Sthaulya in Sutra Sthana 21st chapter. He has considered Sthaulya as Kaphaja Nanatmaja Vikara, [1] Sthaulya has been mentioned in Santarpana Nimittaja Vikara. [2] Charak has explained the list and symptoms of disease in which Dosha are dominant, in such disease Charak indicated that Shodhana Should be administered. Sthaulya has been enlisted. [3] The entire Nidana - Panchaka of Sthaulya has been described by Charak. [4] According to Charak consequences of excessive Brihana is Sthaulya. [5] With respect to treatment protocol Svedana [6] and Vamana [7] is contraindicated in Atisthula. Sushrut has described the Nidana, Purvarupa, Samprapti, Rupa etc. of Sthaulya. [8] He describes Sthaulya as Rasa Nimittaja Vyadhi [9] and Sushrut highlighted his views that, if excessive nourishment of Rasa Dhatu because of different causes produces excessive Meda Dhatu, in consequences excessive production of Apachit or Vikrit Meda causes Sthaulya. He considered vitiation of Meda as the etiological factor. Dalhan termed Sthaulya as Jatharya. [10]

Vagbhat has classified Sthaulya with respect to treatment protocol. Dominant Dosha involved are Kapha and Pitta. [11] Bahu Sthaulya, Madhyam Sthaulya and Hina Sthaulya are categorized and are treated respectively by Shodhan, Pachan, Dipan, Kshudha and Trishna Nigraha. Indu commented that Bala of Sthaulya patient must be envisaged. [12] Same opinion has been expressed by Arundatta. [13] Arundatta referred Sthaulya as ‘Sthavima’ can be said as synonym which means “Sthulatvam.” [14] While describing its management Vagbhat explained that Karshya is better than Sthaulya. [15]

Obesity and overweight are the fifth leading risk of global deaths. He expressed his views that at least 3.4 million adults die each year as a result of being overweight or obese. In addition, 44 percent of diabetes burden, 23 percent of ischemic heart disease burden and between 7 to 41 percent burden of certain cancer are attributed to overweight and obesity. [16] WHO in 2016, published more than 1.9 billion adults, 18 years and older, were overweight, of these over 650 million were obese, Obesity in India has reached epidemic proportion in the 21st century with morbid obesity affecting 5% of countries population.[17] In spite of advanced technology and researches, the modern medicine is failing to give the best result for obesity, due to its multifactorial nature. There are fewer drugs used for treatment of obesity in modern medicine. the side effect profile has limited the use of many agents, but few drugs are currently licensed but having large side effects, drugs are as like orlistat, sibutramine, amphetamine, rimonabant, fluoxatine, exenatide and metformin, almost all these drugs have different side effects such as, orlistat inhibits pancreatic and gastric lipase, in consequence reducing dietary absorption by 30% of ingested, these causes side effects like loose motion, malabsorption of oil from gut, flatus and malabsorption of soluble vitamins. sibutramine causes excess cardiovascular mortality, others drugs are also not used because of their toxicity. [18]

The role of surgeries like bariatric surgery, gastric bypass surgery, gastric banding is only restricted to morbid obesity (BMI>40) hence in modern medicine, its management aspect remains symptomatic and restricted use of drugs with serious side effects and greater chances of recurrence.

Now the people of this era are looking forward for alternative medicine specially Ayurveda to have beneficial treatment in obesity termed as Sthaulya in Ayurveda which is cost effective, less chances of recurrence and with less side effects.

Discussion

Chikitsa of Sthaulya, Charak has said that it is very difficult to treat Atisthula Purush because, Karshana therapy leads to further aggravation of already aggravated Jathragni and Vayu. Brimhan Chikitsa is applied it further increase the Meda. General principles of management of any disorder include Shodhanam Shamanam and Nidan Varjana. [19] Thus, in any disorder management is divided into 3 parts.

1. Shodhana   2. Shamana and 3. Nidana Parivarjana

 The Chikitsa of Sthaulya is also explained in detail as follows-

Bahya Chikitsa: In the management of Sthaulya Ruksha Udvartana is indicated as Bahir- Parimarjana Chikitsa.[20] Charak has also mentioned Ruksha Udavartana [21] for Sthaulya. Vaghbhata has mentioned the benefits of Ruksha Udvartana in general as Kaphahara and Medahara. [22]

Shodhana Therapy: Prakupita Dosha are eradicated from body via nearby external route as Urdhva or Adha Marga with the help of Shodhan therapy. Dosha are mobilized from Dhatu invoved to nearest Koshth by Vriddhi, Vishyandana, Paka of Dosha, Strotomukha Vishodhana and alleviating Vayu. To serve the purpose Snehan and Svedan are administered [23] Sthaulya, being a metabolic syndrome, having Bahudosha Lakshana, Shodhana Chikitsa is recommended by Charak. According to Vagbhat, Atisthaulya patients having dominance of Dosha and more Bala, should be treated by Shodhana therapy. [24]

Vamana Karma: Most of the texts have prohibited the use of Vamana Karma [7] in Sthaulya due to inability to bear the potency of medicine and therapy causing Prana-Aparodha. (life threatening condition) [7] Medo Dhatu and Kapha Pradhan Dushti is main part of pathology of Sthaulya.  Therefore, best Shodhana Chikitsa for Kapha Pradhan Vyadhi in general is Vamana Karma. As on counting Pros and Cons we preferred to give Vamana Karma to Balavan Sthula Rugna only. [12]

Virechana Karma: As Charak and Vagbhat recommended Shodhan as Prime line of Management in Sthaulya patients. [12] Virechana is one of the Shodhana Karma hence we prefer it for patients of Sthaulya as well as Virechak Dravya mentioned in Ayurvedic texts like Haritaki, Katuki, Aragvadha, Trivruta, Danti Dravanti etc., which have Medonashaka property and could be applied to the patients of Sthaulya. Practically also Virechana Karma seems to be fruitful for the management of Sthaulya.

Basti Karma: Ruksha, Ushna and Tikshna Basti are suggested by Charak for Sthaulya Chikitsa. [21] A number of Basti Kalpa are also mentioned in Ayurvedic texts but Lekhana Basti is considered as the best therapy for Sthaulya. [25] Sharangdhara has given a clear description regarding the properties of Lekhana Dravya and characteristics of Lekhana Basti. [26]

Rakta-Mokshana: Kashyapa and Bhavamishra have recommended Rakta Mokshana for the treatment of Sthoulya in Chikitsasthana, Medasvi Dhatri Chikitsa. [27] Charak has also mentioned Raktamokshana for treatment of Santarpana Janya Vyadhi including Atisthaulya. [28]

Nasya: Sushruta has recommended the use of Triphaladi Taila Nasya in the patients of Medovriddhi. [29]

Shamana Therapy:

Shaman Chikitsa can be defined as the Chikitsa which brings the Visham Dhatu into Sama Avastha without removal of Dosha and further balanced state of Dosha is not deranged. [30]

All ten types of Langhana can be applied for the patients of Sthaulya according to Rogi-Roga Bala. Charak has given treatment of Sthaulya in following words. [21]

Guru Cha Atarpanam Cheshtam Sthulanam Karshanam Prati | Vataghnanyanaapanani Sleshma Medo Harani Cha ||

i.e., Administration of Guru and Atarpana Dravyas which are heavy to digest and possess additional Vata, Shleshma and Medonashaka properties are considered as ideal for Shamana therapy in Sthaulya. Chakrapani has explained that Guru property is required to suppressing the Atikshudha. Along with Guru Dravya, Atarpana Dravya provides non-nourishment and thus leads to depletion of Meda Dhatu. [31]

Gangadhar has interpreted that Guru property is suitable to treat Tikshnagni and vitiated Vata especially Kosthagata Vata and thereby Atikshudha, and Atarpana property is that which does not provide Tarpana and cause reduction of Meda. [31]

The drugs planned for Sthaulya should have Dipana and Pachana property to augment Agni (Dhatvagni). They should also have properties of Amapachaka as obstruction of Medovaha Strotas by Ama is main factor for Sthaulya. Again, it is told that the Hetus of Karshya i.e. Ruksha Annapana Sevana, Langhana, Pramitashana, Shoka, Nidra Vega Vinigraha, Ruksha Udvartana, Krodha etc. can be practiced as line of treatment for Sthaulya. [32]

Some important references about Shamana Chikitsa of Sthaulya are mentioned as follows:

Some Samshamana Yogas which are Rukshana and Pachana in nature like Guduchi, Musta, Triphala, Takrarishta, Mukshika, Vidangadi Lauha, Bilvadipanchmula and Shilajatu with Agnimantha Svarasa are advised for prolonged period. [21]

In Charak Samhita, drugs and preparations like Karshana Yavagu of Gavedhuka, Lekhaniya Mahakashaya, Bibhitaka, Yava and Madhudaka are advocated as Medonashaka and Lekhana [33][34][35][36]. Akasha and Vayu Mahabhuta Pradhan Dravyas are attributed to have Laghavakar action [37], so these can be used for management of Sthaulya.

Rasa Sevana particularly Katu and Kashaya Rasa are having Karshana, Upachayahara properties, while Tikta Rasa is having Lekhana and Medo Upshoshana Karma [38], hence Katu, Tikta and Kashaya Rasa dominant drugs can be used for treatment of Sthaulya.

In Sushrut Samhita, administration of Virukshana and Chhedaniya Dravya especially Shilajatu, Guggulu, Gomutra, Triphala, LohaRaja, Rasanjana and Madhu in proper dose and duration are advised. [39] Here, Dalhan has clarified that Virukshana property helps to reduce Meda and Chhedaniya property helps to remove obstruction from body channel, particularly from Medovaha Strotas by its Strotovishodhana property.

In Sushrut Sutrasthana 38th chapter various groups of drugs like Varunadi Gana, Salasaradi Gana, Rodhradi Gana, Arkadi Gana, Mushkadi Gana, Trayushnadi Gana etc. are mentioned as Medonashaka. [40]

Haritaki is advised for the treatment of Santarpana Janya Roga and Amalaki is mentioned as Medopaham. So, Haritaki and Amalaki can be used for treatment of Sthaulya. [41]

In Ashtanga Sangraha, Madanphaladi Churna, Kutajadi Churna, Hingvadi Churna and Vidangadi Mantha are added in line of treatment of Sthaulya. Krishna Lauha, Shankha and Samudraphena, Tuttha, Manahsila, Anjana and Silajatu are Dhatu described as Lekhana and Medonashaka. [42][43][44]

Rasanjana is mentioned as the best for the treatment of Sthaulya while Guggulu is mentioned as the best for the disorders of Meda and Vata [45], so Guggulu can be used for the treatment of Sthaulya.

In Ashtanga Hridaya, Gomutrapaki Haritaki [46], Rodhrasava [47], Vardhamana Bhallataka Rasayana [48] etc. are the various preparations added for the management of Sthaulya.

Navaka Guggulu, Amrutadyaguggulu are indicated in management of Sthaulya in Bhaishajya Ratnawali. [49]

Bhavaprakash [50] has mentioned the remedies for Medohara purpose like Chavyadi Saktu (39/15), Triphaladya Churna (39/16), Erandpatra Kshara (39/23), Badaripatra Peya (39/25), Amritadi Guggulu (39/27), Dashanga Guggulu (39/28), Trayusnadi Guggulu (39/29), Lauha Rasayana (39/30-40), Lauharishta (39/41-48) etc. (B.P. 39/15,16, 23, 25, 27, 29, 40, 41-42). Besides these, various type of Churna, Kvatha and herbal as well as herbo-mineral Yoga are mentioned.

Aushadha Sevana Kala:

According to Ashtanga Sangraha, the Pragbhakta Kala i.e., administration of medicine before meal is insisted for doing Karshana [51]. It has been further elaborated by Sharangadhara, and he advised to take Lekhana drug on empty stomach in early morning and before a meal [52].

Nidana Parivarjana:

Ancient Acharyas have laid great emphasis on the principle of Nidana Parivarjana. Sushrut in particular has recommended Nidana Parivarjana as an essential component in the management of any disorder. Charak elaborated about Nidan Parivarjan as prohibition of indulgence in Visham Hetu and indulgence in Sama Hetu will lead to equilibrium of Dhatu. It will lead to Svastha Purush. [53]

This can be well interpreted by following Sutra,

“Sankshepta Kriyayoga Nidana Parivarjanam.” (Su.U. 1/25) [54]

Nidana Parivarjana Chikitsa means avoiding all the Aharatmaka, Viharatmaka Manasika and Anya Nidana responsible for the manifestation of a disease. All the Nidana mentioned earlier, such as Ati Madhura, Guru Snigdha Ahara Sevana, Divaswapna, Atiharsha etc. should be avoided in case of Sthaulya.

Pathya-Apathya of Sthaulya

Ancient Ayurvedic classics had given much more importance on Pathya Apathya in the management of a disease. Without obeying the rules of Pathya Apathya, a patient will never get satisfactory result; rather a disease may aggravate by Apathya Sevana. All those dietary items and physical activities that are best for Strotas and are also liked by Mana or in other words are beneficial (Hitakaraka) for both Sharira (body) and Mana (mind) are called Pathya and those with opposite qualities are called Apathya. Charak (C.S.21/25-28) [55] Astanga Hridaya (A.H.S. 14/36) [56]  

Yogratnakar (Y.R. Medorog.13) [57]

Conclusion

Sthaulya is predominant metabolic disorder, which is described in Ayurvedic Samhitas. Sedentary lifestyle, lack of exercise, fatty food habits, urbanization, psychological factors along with genetic predisposition play a major role in aetiopathogenesis of Sthaulya. In Ayurveda some herbal drugs, classical preparations Panchakarma procedures and Adravya Chikitsa are mentioned in the management of Sthaulya. By adopting the simple life style and healthy food habits (Pathya-Apathya) anyone can enjoy the life optimally without having lifestyle diseases. Excessive accumulation of Kapha and Meda with other factors eventually leads to Sthaulya Roga, so specific diet management as discussed above should be followed to combat Sthaulya Roga.